Identifying the Incidence of and Risk Factors for Reamputation Among Patients Who Underwent Foot Amputation

doi:10.1016/j.avsg.2012.02.011

Annals of Vascular Surgery

Volume 26, Issue 8, November 2012, Pages 1120-1126

https://doi.org/10.1016/j.avsg.2012.02.011 Get rights and content

Background

Many patients who have lower-extremity amputations secondary to peripheral vascular disease or diabetes require reamputation eventually. This study was designed to identify the incidence of and risk factors for ipsilateral reamputation after forefoot amputation, to evaluate whether postoperative infection increases the risk of reamputation, and to evaluate whether the risk of reamputation was reduced by the duration of antimicrobial therapy after amputation.

Methods

A retrospective analysis of patients who underwent foot amputation for nontraumatic reason from January 2002 to December 2004 at the Veterans Affairs Pittsburgh Healthcare System was performed.

Results

Among 116 patients, 57 (49.1%) had ipsilateral reamputation within 3 years after their first surgeries; 78.9% received reamputation in the first 6 months; 53 (45.7%) died within 3 years; and 16 (13.8%) developed postoperative infections. Upper level of amputation, long duration of hospitalization, insulin-dependent diabetes, and gangrene on physical examination on admission were risk factors for reamputation in univariate analysis. Gangrene (odds ratio: 3.81, 95% confidence interval: 1.60–9.12, P = 0.003) and insulin-dependent diabetes (odds ratio: 2.93, 95% confidence interval: 1.26–6.78, P = 0.012) were risk factors in multivariate analysis. Postoperative infection did not increase the risk of reamputation. Longer than 2-week course of antibiotic use after amputation did not prevent reamputation.

Conclusions

Approximately one-half of patients required ipsilateral reamputation and died in 3 years. Gangrene on admission and history of insulin-dependent diabetes were significant risk factors (P = 0.003, P = 0.028). Long duration of antibiotic use after amputation and postoperative infection did not change the risk of reamputation.

Introduction

In 2006, 66,000 patients were admitted for nontraumatic lower-extremity amputation with diabetes in the United States.¹ Unlike patients who undergo trauma- or cancer-related amputations, in patients with peripheral vascular disease or diabetes, progress of their underlying disease can lead to ipsilateral reamputation.2, 3, 4 Izumi et al.³ reported that reamputation rate was 60% at 5 years. The mortality rate was also high. Long-term survival among patients who had above-the-knee or below-the-knee amputation was 62% at 1 year and 29% at 5 years.⁵

Regarding the risk factors for reamputation, Skoutas et al.⁶ reported age and heel lesions were associated with reamputation. Stone et al.⁷ noted that end-stage renal disease and severe ischemia were the risk factors for a nonhealing wound.

Few studies identified similar factors as being associated with an increased risk of reamputation. Whether postoperative infection increases the risk of amputation has never been studied, nor has the effect of the duration of postoperative antimicrobial therapy.

In this observational cohort study, we aimed to 1) identify the incidence of and risk factors for ipsilateral reamputation after forefoot amputation; 2) evaluate whether postoperative infection increases the risk of reamputation; 3) evaluate whether the risk of reamputation was reduced by the duration of antimicrobial therapy after amputation.

Section snippets

Subjects

With approval from the Veterans Affairs Pittsburgh Healthcare System Institutional Review Board, the medical records and imaging data of the patients who had foot amputation for nontraumatic reason from January 2002 to December 2004 at the Veterans Affairs Pittsburgh Healthcare System (146 beds) were reviewed retrospectively. Patients who died within 1 month after amputation or were lost to follow-up within 6 months were excluded. If patients had multiple amputations in 3 years, only the

Patient Population

Among 123 patients who had foot amputations from January 2002 to December 2004, 116 were identified following the inclusion criteria (Table I). One patient died, and six patients were lost to follow-up. One hundred fifteen patients (99.1%) were male, and the average age (± standard deviation) of all patients was 66.8 ± 11.0 years. Ninety-three patients (80.2%) had diabetes.

Fifty-seven patients (49.1%) had ipsilateral reamputation within 3 years after their first surgeries. Fifty-three patients

Discussion

This study demonstrated the incidence of and risk factors for ipsilateral reamputation after forefoot amputation. Fifty-seven patients (49.1%) had ipsilateral reamputation within 3 years after their first surgeries. The previous studies reported a 21.5% incidence of reamputation in 18 months⁶ and 60% in 10 years.² In all, 78.9% patients received reamputation within 6 months after their first amputation, which is consistent with the study by Skoutas et al.,⁶ and 59.6% of patients with

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Minor lower extremity amputations (LEAs) have become an important part of the limb salvage approach but are not as benign as previously thought. This study investigates the difference in outcome between toe/ray versus midfoot amputations and the risk factors for major amputation conversion associated with each procedure.
We performed retrospective chart review of foot amputation patients at a single tertiary care medical center with a primary end point of conversion to major amputation and secondary end points of 1-year wound healing and mortality rate. We collected data on relevant medical comorbidities, noninvasive vascular imaging, revascularization, repeat amputations, wound healing rate, and 1-year mortality. Patients were separated into toe/ray amputations versus midfoot amputation groups and compared using descriptive statistics, Chi-squared tests, Cox proportional hazards, and a multivariate logistic regression model.
A total of 375 amputations were included in the analysis. 65.3% (245 patients) included toe/ray amputations and 34.7% (130 patients) included midfoot amputations. We compared these 2 cohorts with regard to their rate of conversion to repeat minor and/or major amputation in addition to overall mortality. The toe/ray group underwent more repeat minor amputations within 1 year after index amputation (34.7% vs. 21.5%, P = 0.008) and wound healing (epithelization) at 90 days was also higher in this group. The midfoot group had a higher conversion to major LEA within 1 year on univariate analysis (20.8 vs. 6.9%, P < 0.001). Overall 1-year mortality was 6.17% and there was no significant difference between groups.
While there is a consistency with previous studies that found no significant overall difference in mortality between types of minor LEA, we have extended this previous work by demonstrating the independent risk factors for conversion to major amputation between types of minor LEA. Comparing these 2 groups will assist surgeons in choosing the appropriate level of amputations and will enhance patient's understanding of their chance of wound healing and risk of repeat amputation.
Risk factors for reamputation in patients with diabetic foot: A case-control study
2023, Foot and Ankle Surgery
Reamputation as a complication of diabetic foot ulcers presents a high economic burden and represents a therapeutic failure. It is paramount to identify as early as possible patients in whom a minor amputation may not be the best option. The purpose of this investigation was to do a case-controlled study to determine risk factors associated with re-amputation in patients with DFU (diabetic foot ulcers) at two University Hospitals.
Multicentric, observational, retrospective, case-control study from clinical records of 2 university hospitals. Our study included 420 patients, with 171 cases (re-amputations), and 249 controls. We performed a multivariate logistic regression analysis and time-to-event survival analysis to identify re-amputation risk factors.
Statistically significant risk factors were artery history of tobacco use (p = 0.001); male sex (p = 0.048); arterial occlusion in Doppler ultrasound (p = 0.001); percentage of stenosis in arterial ultrasound>50 % (p = 0.053); requirement of vascular intervention (p = 0.01); and microvascular involvement in photoplethysmography (p = 0.033). The most parsimonious regression model suggests that history of tobacco use, male sex, arterial occlusion in ultrasound, and percentage of stenosis in arterial ultrasound>50 % remained statistically significant. The survival analysis identified earlier amputations in patients with larger occlusion in arterial ultrasound, high leukocyte count, and elevated ESR.
Direct and surrogate outcomes in patients with diabetic foot ulcers identify vascular involvement as an important risk factor for reamputation.
III
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This study aims to identify risk factors as well as proper indications for forefoot or midfoot amputations at the transmetatarsal, Lisfranc or Chopart level as a potential avenue for distal limb salvage and avoid below knee amputation (BKA).
This study utilized the PearlDiver national database encompassing 91 million unique patients from 2010 to 3/31/2020 to identify patients who underwent foot amputation (CPT-28800, CPT-28805). The primary endpoint is conversion to BKA within 6 months. Propensity matched cohorts were created using age, gender and common comorbidities. Logistic regression utilizing the matched cohorts determined odds ratios for conversion to BKA based on indication. Indications included abscess, gangrene, osteomyelitis, and diabetic wounds. Analysis was repeated at 1, 2 and five years. Chi-square analysis was used to assess the impact of comorbid peripheral vascular disease (PVD) in a subgroup of patients with osteomyelitis. Time to conversion to BKA was tabulated.
The database identified 17,875 patients who underwent forefoot or midfoot amputation . Conversion to BKA occurred in 2400 patients with median time of 71 days. Logistic regression of the matched cohorts revealed that gangrene was a significant risk factor for conversion to BKA, while osteomyelitis was protective. Subgroup analysis of the osteomyelitis cohort revealed a higher rate of conversion to BKA for patients with concomitant PVD (OR 1.44; P = 0.01).
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IV.
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Citation Excerpt :
Furthermore, postoperative health-related quality of life was better than preoperatively (see videos), supporting the favorable outcome documented in a previous report using TTT [19]. On the other hand, patients with DFUs usually are older and with multiple comorbidities, and thus the rates of re-amputation, contralateral amputation, and premature mortality are relatively high after major amputation [51,57,59]. Thus, limb salvage using TTT may be more suitable than major amputation for patients with recalcitrant DFUs.
Management of recalcitrant diabetic foot ulcer (DFU) remains difficult. Distraction osteogenesis mediates new bone formation and angiogenesis in the bone itself and the surrounding tissues. Recently it was reported that tibial cortex transverse transport (TTT) was associated with neovascularization and increased perfusion at the foot in patients with recalcitrant DFUs and facilitated healing and limb salvage. However, the findings were from several single-center studies with relatively small populations, which need to be confirmed in multicenter cohort studies with relatively large populations. Furthermore, the effect of this technique on patient's health-related quality of life is still unclear.
We treated patients with recalcitrant (University of Texas wound grading system 2-C to 3-D and not responding to prior routine conservative and surgical treatments for at least 8 weeks) DFUs from seven centers using TTT (a 5 cm × 1.5 cm corticotomy followed by 4 weeks of medial and lateral distraction) between July 2016 and June 2019. We analyzed ulcer healing, major amputation, recurrence, health-related quality of life (physical and mental component summary scores), and complications in the 2-year follow-up. Foot arterial and perfusion changes were evaluated using computed tomography angiography and perfusion imaging 12 weeks postoperatively.
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With challenges in adjusting for variables, previous clinical studies on diabetic foot evaluated the risk factors for recurrence and reamputation [6–8]. Despite controversies, the well-known risk factors for diabetic foot recurrence and reamputation are type 1 diabetes, diabetic polyneuropathy, infection, gangrene, smoking, peripheral arterial disease, chronic renal failure, and dialysis [9–15]. Patients that underwent a previous amputation have a higher risk of recurrence of diabetic foot diseases, such as ulcer, gangrene, and infection.
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Clinical ResearchIdentifying the Incidence of and Risk Factors for Reamputation Among Patients Who Underwent Foot Amputation

Background

Methods

Results

Conclusions

Introduction

Section snippets

Subjects

Patient Population

Discussion

J Foot Ankle Surg

Eur J Vasc Endovasc Surg

Ann Vasc Surg

Arch Phys Med Rehabil

Clinical Research
Identifying the Incidence of and Risk Factors for Reamputation Among Patients Who Underwent Foot Amputation