PC060 Reoperation Following Lower Extremity Amputation

Wooster, Mathew; Binner, M.; Wilson, Chelsea H.; Tanious, Adam; Brooks, James D.; Armstrong, Paul A.; Shames, Murray L.; Patel, Shivangi

doi:10.1016/j.jvs.2017.03.294

Cited by 2 publications

(3 citation statements)

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“…Previous studies have suggested the role for expanded follow-up after lower extremity amputations after finding increased risk of revision surgery within 1 year of BKA (26% to 38%). 4,5 Patients who undergo BKA had nearly a 50% competing risk of death, which did not reach a steady incidence rate in our cohort—both reflective of the high risk of mortality and overall compromised health of male vasculopathic patients. A recent meta-analysis of 61 studies evaluating nontraumatic major lower extremity amputation (BKA, AKA, and knee disarticulation) survival outcomes found a commensurate mortality risk of 56.6% at 5 years in 11,320 BKAs.…”

Section: Discussionmentioning

confidence: 71%

“…Although there is increasing evidence that BKA postoperative surveillance should be maintained for at least 1 year, the time frame for conversion to AKA is not well established. 4,5 To better understand why patients require conversion to AKA, we analyzed the cumulative probability of and risk factors for conversion to AKA within 5 years of BKA within the Veterans Affairs (VA) population, with death as a competing risk.…”

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confidence: 99%

“…3 Patients with poorly managed comorbidities often require additional procedures or revisions after BKA, with 26% to 38% having a revision surgery within 1 year. 4,5 Risk of conversion from BKA to AKA within 30 days ranges from 3.5% to 9.4% in vascular surgery literature. 3,6 In addition to using follow-up periods less than 1 year, 3,6 these previous studies have used survival analysis methods (eg, Kaplan-Meier and Cox proportional hazards) in which patients who die and those who are lost to follow-up both are censored together despite being importantly different.…”

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confidence: 99%

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Mortality and Conversion to Transfemoral Amputation After Transtibial Amputation in the Veterans Affairs Health System

Wong

Woelber

Madison

et al. 2022

J Am Acad Orthop Surg

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Introduction:Transtibial below-knee amputation (BKA) is associated with considerable morbidity, particularly in the vasculopathic population. The purpose of this study was to determine the cumulative probability of undergoing transfemoral above-knee amputation (AKA) conversion within 5 years of BKA and associated risk factors while accounting for the competing risk of death.Methods:This is a retrospective, national database study with structured query of the Veterans Affairs (VA) database for patients who underwent BKA from 1999 to 2020, identified by Current Procedural Terminology codes. Above-knee amputation conversion was identified using Current Procedural Terminology codes in combination with natural language processing to match procedure laterality. After internally validating our patient identification method, risk factors were collected. Competing risk analysis estimated the cumulative incidence rate of AKA conversion and associated risk factors with death as a competing risk.Results:Our query yielded 19,875 patients (19,640 men, 98.8%) who underwent BKA with a median age of 66 years (interquartile range, 60 to 73). The median follow-up was 951 days (interquartile range, 275 to 2,026). The crude cumulative probabilities of AKA conversion and death at 5 years were 15.4% (95% confidence interval [CI], 14.9% to 16.0%) and 47.7% (95% CI, 46.9% to 48.4%), respectively. In the Fine and Gray subdistribution hazard model, peripheral vascular disease had the highest AKA conversion risk (hazard ratio [HR] 2.66; 95% CI, 2.22 to 3.20; P < 0.001). Other factors independently associated with AKA conversion included urgent operation (HR 1.32; 95% CI, 1.23 to 1.42), cerebrovascular disease (HR 1.19; 95% CI, 1.11 to 1.28), chronic obstructive pulmonary disease (HR 1.15; 95% CI, 1.07 to 1.24), and previous myocardial infarction (HR 1.10; 95% CI, 1.02 to 1.19) (All P < 0.02).Discussion:Within this predominantly male, VA population, BKA carries a high risk of conversion to AKA within 5 years, without reaching a steady risk of AKA conversion within 5 years. Peripheral vascular disease, chronic obstructive pulmonary disease, cerebrovascular disease, previous myocardial infarction, and urgent BKA increase the risk of AKA conversion.Level of Evidence:Level III

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Section: Discussionmentioning

confidence: 71%

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confidence: 99%

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confidence: 99%

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Mortality and Conversion to Transfemoral Amputation After Transtibial Amputation in the Veterans Affairs Health System

Wong

Woelber

Madison

et al. 2022

J Am Acad Orthop Surg

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Is Reoperation Higher Than Expected after Below-the-knee Amputation? A Single-center Evaluation of Factors Associated with Reoperation at 1 Year

Wong¹,

Woelber

Wyland

et al. 2020

Clin Orthop Relat Res

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Background Below-the-knee amputation (BKA) is relatively common among patients with vascular disease, infection, trauma, or neoplastic disease. Many BKAs are performed in patients with incompletely treated medical comorbidities, and some are performed in patients with acute high-energy trauma or crush injuries, malignant neoplasm undergoing time-sensitive limb removal, and diabetes with active infection or sepsis. Consequently, revision is common. Prior studies of outcomes after BKA, including several based on the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database, have follow-up periods that do not cover the entire at-risk period. Questions/purposes (1) What is the survivorship free from unplanned reoperation within 1 year of BKA? (2) What patient characteristics are associated with reoperation within 1 year of BKA? Methods We retrospectively studied all BKAs performed by the orthopaedic surgery service at a Level 1 trauma center from 2008 to 2018, as identified by Current Procedural Terminology (CPT) codes. Twenty-eight percent (38 of 138) underwent amputation as treatment for traumatic injury, 57% (79 of 138) for infection, and 15% (21 of 138) for malignancy. A total of 17% (23 of 138) had a final follow-up encounter before the 1-year study minimum, without differential loss to follow-up by surgical indication (p = 0.43) or hemoglobin A1c (p = 0.71). Median (range) follow-up was 570 days (6 to 3375). The primary outcome was survivorship from unplanned reoperation within 1 year of BKA index surgery or last planned reoperation, as determined by Kaplan-Meier estimation. Secondarily, we identified patient characteristics independently associated with reoperation within 1 year of BKA. Collected data included age, indication, BMI, diabetes, hemoglobin A1c level, closure method, and substance use. Unplanned reoperation was defined as irrigation and débridement, stump revision, or revision to a higher-level amputation; this did not include planned reoperations for BKAs closed in a staged manner. Factors associated with reoperation were determined using multivariate logistic regression analyses. All endpoints and variables related to patients and their surgical procedures were extracted from electronic medical records by someone other than the operating surgeon. Results Using Kaplan-Meier estimation, 38% of patients (95% confidence interval 29 to 46) who underwent BKA had an unplanned reoperation within 1 year of their index surgery. Twelve percent of patients (95% CI 7 to 17) who underwent BKA did not reach 30 days with the limb survivorship free from unplanned reoperation. The median (range) time between the initial surgery and reoperation was 54 days (6 to 315). After controlling for potential confounding variables like age, gender, platelet count, albumin, and the reason for undergoing amputation, a hemoglobin A1c level greater than 8.1% (relative to A1c ≤ 8.1%) was the only variable independently associated with increased odds of reoperation (odds ratio 4.6 [95% CI 1.3 to 18.1]; p = 0.02). Conclusion BKA carries a higher risk for reoperation than currently reported in studies that use 30-day postoperative follow-up periods. Clinicians should critically assess whether BKA is necessary, especially in patients with uncontrolled diabetes assessed by hyperglycemia. Before planned BKA, patients should have documented glycemic control to minimize the odds of reoperation. Because many of this study’s limitations were due to its retrospective single center design, we recommend that future work cover a clinically appropriate surveillance period using a larger cohort such as a national database and/or employ a prospective design. Level of Evidence Level III, therapeutic study.

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PC060 Reoperation Following Lower Extremity Amputation

Cited by 2 publications

References 0 publications

Mortality and Conversion to Transfemoral Amputation After Transtibial Amputation in the Veterans Affairs Health System

Mortality and Conversion to Transfemoral Amputation After Transtibial Amputation in the Veterans Affairs Health System

Is Reoperation Higher Than Expected after Below-the-knee Amputation? A Single-center Evaluation of Factors Associated with Reoperation at 1 Year

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