An enhanced treatment program with markedly reduced mortality after a transtibial or higher non-traumatic lower extremity amputation

Abstract

Background and purposeHistorically, high 30-day and 1-year mortality post-amputation rates (> 30% and 50%, respectively) have been reported in patients with a transtibial or higher non-traumatic lower extremity amputation (LEA). We evaluated whether allocating experienced staff and implementing an enhanced, multidisciplinary recovery program would reduce the mortality rates. We also determined factors that influenced mortality rates.Patients and methods129 patients with a LEA were consecutively included over a 2-year period, and followed after admission to an acute orthopedic ward. Mortality was compared with historical and concurrent national controls in Denmark.ResultsThe 30-day and 1-year mortality rates were 16% and 37%, respectively, in the intervention group, as compared to 35% and 59% in the historical control group treated in the same orthopedic ward. Cox proportional harzards models adjusted for age, sex, residential and health status, the disease that caused the amputation, and the index amputation level showed that 30-day and 1-year mortality risk was reduced by 52% (HR =0.48, 95% CI: 0.25–0.91) and by 46% (HR =0.54, 95% CI: 0.35–0.86), respectively, in the intervention group. The risk of death was increased for patients living in a nursing home, for patients with a bilateral LEA, and for patients with low health status.InterpretationWith similarly frail patient groups and instituting an enhanced program for patients after LEA, the risks of death by 30 days and by 1 year after LEA were markedly reduced after allocating staff with expertise.

Development and psychometric properties of the Basic Amputee Mobility Score for use in patients with a major lower extremity amputation

“…Mortality rates among diabetic and arteriosclerotic (dysvascular in the following) amputee patients are to our knowledge the highest reported in orthopedic patients and are associated with older age and the pre‐amputation health status . However, the influence of the post‐amputation ambulatory level to mortality seems less studied.…”

“…A total of 106 consecutive patients with a major non‐traumatic dysvascular LEA, who all followed an enhanced perioperative recovery program in an acute orthopedic amputee unit, were available for the validation part . An additional convenient sample of 30 patients who followed the same program was included for the reliability part.…”

Does closed incision negative wound pressure therapy in non‐traumatic major lower‐extremity amputations improve survival rates?

“…15 The increase seen over the last 4 years is mainly for the consumption of novel oral anticoagulants. [9][10][11] Patients with repeated revisions at the OR undergoing general anaesthesia are known to be at a significant risk of developing postoperative pulmonary complications and cardiac arrhythmias. Another time trend reflected in our data is the development in the last decade of a significant rise in patients amputated using spinal anaesthesia to reduce postoperative complications and the need for opioid medication.…”

“…7,8 In Denmark, 30-day mortality has been reported to be 16% to 35% and 1-year mortality to be 37% to 59% [9][10][11] in this frail group of patients. They suffer from long-term complications of atherosclerosis and diabetes resulting in ischaemia and infected and necrotic wounds.…”

Tourniquets do not increase the total blood loss or re-amputation risk in transtibial amputations

“…The decision to use a tourniquet relied on the surgeons. Standardized care was provided for all patients regarding bandages, pain management, rehabilitation, fluid replacement, pausation of antiplatelet drugs, treatment with blood transfusions and thromboprophylaxis[9]. Tranexamic acid was not administered.…”