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Title: Fate of the contralateral limb in lower extremity amputation
Objective: Lower extremity (LE) amputation is often performed in patients where both limbs are at risk due to vascular disease, yet the proportion of patients who progress to amputation on their contralateral limb is not well defined. We sought to determine the rate of subsequent amputation on both the ipsilateral and contralateral limbs following initial amputation.
Methods: We conducted a retrospective review of all patients undergoing LE amputation for vascular disease at an academic tertiary care center from 1998-2010. ICD-9 codes identified patients and procedures, as well as comorbidities. Outcomes included the proportion of patients undergoing contralateral and/or ipsilateral amputation stratified by major or minor amputation at 1 and 5 years. Multivariable analysis was performed to determine predictors of major contralateral amputation.
Results: We identified 1751 patients (2534 procedures).  Mean age was 67 years; 63% were male. A majority (52%) of procedures were performed on diabetics. Many of the procedures (64%) were minor amputations (toe or ray). After minor amputation 11% and 19% had an ipsilateral major amputation at 1 and 5 years while 3% and 9% had a contralateral major amputation at 1 and 5 years.  After major amputation 5% and 11% have a contralateral major amputation at 1 and 5 years.  Multivariate analysis indicated that female gender (OR1.5 [1.1-2.2] p=0.02), diabetes (OR2.2 [1.5-3.2] p<0.001), end stage renal disease (OR1.9 [1.0-3.5] p=0.04), and initial major amputation (OR1.5 [1.1-2.2] p=0.02) were all independent predictors of subsequent major contralateral amputation.
Conclusion: Rates of contralateral limb amputation vary by the level of the initial procedure. The majority of subsequent LE amputations occur within the first year. A high risk group of patients may be identified for improved surveillance and counseling.

	Percent of Vascular Patients Undergoing Subsequent Amputation at 1 and 5 years, %(n)
Initial Amputation	Ipsilateral, Minor		Ipsilateral, Major		Contralateral, Minor		Contralateral, Major
	1 year	5 years	1 year	5 years	1 year	5 years	1 year	5 years
Minor	13.8 (150)	23.6 (181)	10.9(118)	19.0 (146)	6.4 (69)	15.9 (122)	2.8 (30)	9.0 (69)
Major	N/A	N/A	8.7 (48)	13.0 (51)	3.1 (17)	7.9 (31)	4.6 (25)	10.7 (42)