Ambulatory Patients Undergoing Above-Knee Amputation have Significantly Higher Post-Operative Mortality Compared to Non-Ambulatory Patients
Patricia O. Yau, M.D.1, Charles DeCarlo, MD2, Katherine Maccallum, MD1, Patricia Friedmann, MS3, John Phair, MD1, Saadat Shariff, MD1, Larry Scher, MD1, Evan Lipsitz, MD1, Karan Garg, MD1.
1Montefiore Medical Center, Bronx, NY, USA, 2Massachusetts General Hospital, Boston, MA, USA, 3Albert Einstein College of Medicine, Bronx, NY, USA.
Objective: Above-Knee Amputation (AKA) is associated with higher mortality than Below-Knee Amputation (BKA), however, factors contributing to this difference have not been well elucidated. Given the reported difference in pre- and post-operative ambulatory rates in patients undergoing an AKA or BKA, we sought to determine the effect of pre-operative ambulatory status on mortality.
Methods: Institutional data for patients undergoing AKA and BKA between 2009 and 2014 was queried. Outcomes were 30-day, 90-day, and one-year post-operative mortality. Predictors of outcomes were determined with multivariable logistic regression and Cox proportional hazards modeling.
Results: 811 patients underwent AKA (40.2%) or BKA (59.8%). Mean age was 68.8+/-14.9 years, 53.8% were male, and 33.4% were non-ambulatory (AKA 54.6%, BKA 19.2%). Thirty- and 90-day mortality was 8.4% (AKA 13.5%, BKA 4.9%) and 15.1% (AKA 23.6%, BKA 9.5%), respectively. Ambulatory BKA patients had lower 30-day, 90-day, and one-year mortality (4.3%, 7.1%, and 16.3%, respectively) than non-ambulatory BKA patients (7.5%, 19.4%, and 32.3%). Ambulatory AKA patients had significantly higher 30- and 90- day mortality (18.9% and 25.7%, respectively) than non-ambulatory AKA patients (8.5% and 21.0%). Predictors of 30-day mortality for AKA patients were ambulatory status, COPD, ESRD on hemodialysis, and emergency surgery. One-year mortality was 37.4% for AKA patients (ambulatory 36.5%, non-ambulatory 38.2%, p=0.75). Predictors of one-year mortality for AKA patients were age greater than 70, white race, ESRD on dialysis, emergency surgery, and COPD.
Conclusions: While ambulatory status is an independent predictor of early post-operative mortality after AKA, it is not associated with one-year mortality, suggesting that ambulatory patients requiring an AKA are more severely ill on presentation. Further focus on this high-risk group of patients may help to improve survival following major amputation. 
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