Elsevier

Surgery

Volume 152, Issue 4, October 2012, Pages 685-696
Surgery

Central Surgical Association
Preoperative factors predict mortality after major lower-extremity amputation

Presented at the 69th annual meeting of the Central Surgical Association in Madison, WI, March 1–3, 2012.
https://doi.org/10.1016/j.surg.2012.07.017Get rights and content

Background

The objective was to develop a preoperative mortality risk stratification tool for patients facing major amputation.

Methods

Patients who underwent above-knee (AKA) or below-knee amputation (BKA) from 2005 to 2010 were identified from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. Univariate and multivariate analyses were performed to determine the association of preoperative factors with 30-day mortality. Multivariable models were used to create a computerized prediction tool.

Results

Of 9,368 patients, 4,032 underwent AKA and 5,336 BKA. The 30-day mortality rate after AKA was 12.8%, almost double that of BKA (6.5%, P < .001). The complication rate was statistically greater after AKA although numerically similar (28.5% vs 26.6%, P = .020), whereas the rate of reoperation was substantially greater after BKA (22.7% vs 11.7%, P < .001). Preoperative factors that predicted mortality after both procedures included older age, dependent functional status, dialysis, steroid use, preoperative sepsis, delirium, thrombocytopenia, increased international normalized ratio, and azotemia. Prediction tools were developed and validated, and their concordance indices were 0.75 for AKA and 0.81 for BKA, indicating good predictive accuracy.

Conclusion

Preoperative factors predict mortality after major amputation, and the risk calculator that we have developed may facilitate informed decision-making and provide realistic expectations for surgeons and patients faced with limb-threatening disease.

Section snippets

Methods

Patients were identified within the participant use data files of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP), which in 2010 included more than 250 community and academic hospitals throughout the United States. The program collects perioperative clinical data on patient demographics, medical history and comorbidities, laboratory values, operative factors, and 30-day postoperative outcomes, including complications, duration of stay, reoperation, and

Characteristics of patients who underwent major amputation

Of 9,368 patients who underwent major amputation, 4,032 (43%) underwent AKA and 5,336 (57%) BKA. Patients who underwent AKA were on average slightly older (70.5 ± 13.3 years) compared with the BKA group (65.0 ± 13.7 years, P < .001). Besides age, other statistically significant differences between the AKA and BKA groups included being underweight (9.6% for AKA vs 4.5% for BKA), black race (30.0% AKA vs 26.1% BKA), dependent functional status (73.1% AKA vs 52.7% BKA), diabetes mellitus (52.0%

Discussion

We used a large multi-institutional database to determine the predictors of 30-day morbidity and mortality after major amputation and created and validated a prediction tool for preoperative risk estimates. The rates of mortality that we observed—12.8% for AKA and 6.5% for BKA—were similar to those from historical reports,2, 3, 4, 5, 14, 15, 16 indicating that advances in perioperative care have not had a major survival impact in this patient population. Interestingly, despite the large

Maintenance of certification (Moc) questions

Question 1:

Which of the following correctly describes the relative frequency of 30-day outcomes after AKA and BKA?

  • a.

    Mortality, morbidity, and reoperation are more frequent after AKA compared with BKA.

  • b.

    Mortality and morbidity rates are higher after BKA; reoperation is more frequent after AKA.

  • c.

    Mortality and morbidity rates are higher after AKA; reoperation is more frequent after BKA. [correct answer]

  • d.

    Mortality, morbidity, and reoperation are more frequent after BKA compared to AKA.

Question 2:

Which of

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