Major lower extremity amputation: a contemporary analysis from an academic tertiary referral centre in a developing community

Abstract

BackgroundWe aimed to explore the surgical outcomes of major lower extremity amputation (MLEA) and influencing factors at an academic tertiary referral centre in north Jordan, optimistically providing a platform for future health care policies and initiatives to improve the outcomes of MLEA in Jordan.MethodsClinical records of patients who had undergone MLEA between January 2012 and December 2017 were identified and retrospectively reviewed. International Classification of Diseases codes were used to identify the study cohort from a prospectively maintained computerised database. We included adult patients of both genders who underwent amputations for ischemic lower limb (acute and chronic) and diabetic foot syndrome (DFS). We excluded patients for whom MLEA surgery was performed for other indications (trauma and tumors). Outcomes of interest included patient demographics and comorbidities, type of amputation and indications, length of hospital stay (LOS), the need for revision surgery (ipsilateral conversion to a higher level of amputation), and cumulative mortality rate at 1 year. The impact of the operating surgeon’s specialty (vascular vs. non-vascular surgeon) on outcomes was evaluated.ResultsThe study cohort comprised 140 patients who underwent MLEA (110 below-knee amputations [BKA] and 30 above-knee amputations [AKA]; ratio: 3:1; 86 men; 54 women; mean age, 62.9 ± 1.1 years). Comorbidities included diabetes, hypertension, dyslipidaemia, ischaemic heart disease, congestive heart failure, chronic kidney disease, stroke, and Buerger disease. The only associated comorbidity was chronic kidney disease, which was more prevalent among BKA patients (p = 0.047). Indications for MLEA included DFS, and lower limb ischaemia. Acute limb ischaemia was more likely to be an indication for AKA (p = 0.006). LOS was considerably longer for AKA (p = 0.035). The cumulative mortality rate at 1 year was 30.7%. Revision surgery rates and LOS improved significantly with increased rate of vascular surgeon-led MLEA.ConclusionsIn developing countries, the adverse impact of MLEA is increased because of limited resources and increased prevalence of diabetes-related foot complications. Vascular surgeon-led MLEA is associated with decreased revision rates, LOS and possibly improved outcomes, particularly when it is performed for vascular insufficiency. It is important to formulate national health care policies to improve patient outcomes in these countries.

Epidemiology of Major Lower Extremity Amputations in Individuals With Diabetes in Austria, 2014-2017: A Retrospective Analysis of Health Insurance Database

“…In line with other studies, 87.3% of individuals in our cohort had a PVD and were older (73.6 versus 69.0 years, p < 0.001) with a signi cantly higher burden of comorbidities such as renal disease (40.6% versus 23.7%, p < 0.001), CHF (31.1% versus 13.1%, p < 0.001), stroke (28.9% versus 15.0%, p < 0.001), and the mean ACCI score (6.3 versus 4.1, p < 0.001) than those without PVD. In agreement with our results, a study found a high proportion of ischemic heart disease (46.0%), CHF (31.6%), stroke (27.7%), and chronic kidney disease (25.0%) among patients with arteriopathy [27]. Research has also shown a strong association between the accumulating burden of comorbidities and the risk of LEA.…”

A predictive score for 30-day survival for patients undergoing major lower limb amputation for peripheral arterial obstructive disease

“…Year after year, many studies have reported consistently high mortality rates after mELAs, notwithstanding a more aggressive policy toward peripheral revascularization, better medical management, and preoperative optimization, in addition to anesthetic improvements [2,[17][18][19]. In our experience, early mortality remained unchanged for the past decade and is consistent with the 7.6-22.5% reported in several real-world experiences, not falling below 14% in the four quartiles of the period of study (Table 6) [3,[5][6][7][17][18][19][20][21][22][23][24][25][26][27]. Our results are similar to Jones et al [3], who analyzed 186,338 older patients with identified PAOD who underwent mLEA, namely the largest cohort published up to date.…”

“…However, while prior investigators have reported that an increased perioperative mortality rate in AKA patients was associated with the presence of advanced ischemia, the most determining factor for AKA in our experience was older age [5,19]. On one hand, it further underlines the impact of age on mLEA outcomes as BKA patients had a higher incidence of diabetes, chronic kidney disease, or hemodialysis [17,26,30,31]. The association of these comorbidities with BKA is the main rationale as to why a BKA was significantly associated with postoperative complications, and more frequently required proximal revision surgery because of stump failure [17].…”

A population-based assessment of the post-operative complications rates and 30-day mortality associated with lower limb amputations at a tertiary care center in Riyadh, Saudi Arabia

“…Whether or not various risk factors are associated with increased mortality and morbidity rates after LLA remains to be elucidated because there is no consensus on this in the literature. [31,32] In our study, amputees with pre-existing infections and renal, neurological, respiratory, cardiac, vascular, endocrine, and gastrointestinal disorders were significantly associated with higher 30-day mortality and rate of complications. Moreover, patients with continuous tobacco smoking habits, a major level of amputation, and PVD or trauma as the primary indication for surgery had higher rates of complications and consequently worse outcomes; this finding is in line with published studies.…”