Predictors of major adverse limb events after open forefoot amputation in patients with critical limb ischemia
Nallely Saldana-Ruiz, MD, MPH, Ramsey S. Elsayed, MD, Louis Z. Zhang, MD, David G. Armstrong, MD PhD DPM, Gregory A. Magee, MD Msc, Aria C. Woods, BS, Vincent L. Rowe, MD.
University of Southern California, Los Angeles, CA, USA.
Objective: Management of patients with critical limb ischemia (CLI) and extensive foot necrosis presents a challenge for limb salvage. Our study evaluates preoperative risk factors that contribute to major adverse limb events (MALE) after open transmetatarsal amputation (TMA) in the management of patients with critical limb ischemia.
Methods: Consecutive patents who underwent open TMA at a single institution between 2009-2018 were analyzed. Patient demographics, comorbidities, indications, limb revascularizaiton history, postoperative complications, re-interventions and functionals status were collected. Descriptive statistics were used for analysis of the entire cohort. Univariate and multivariate analyses were performed to determine predictors MALE. MALE was defined as patients who underwent a subsequent major amputations or required revascularization procedures.
Results: Forty-three complete forefoot amputations were performed in 39 patents, with 9 females. The man age of our cohort was 65+/-12 years. Indication for TMA was dry gangrene (56%) and infection (44%). Ninety percent were diabetic, 95% had hypertension, 54% had end-stage renal disease (ESRD), and 80% had prior toe amputations. Time-to-healing was available for 20/43 limbs with a mean of 8.7+/-11.4 months. Ipsilateral revascularization was performed on 34 limbs, 21 via open and 13 via endovascular approach. Major amputation in the form of below-knee amputation (BKA) was required in 4 limbs (9%), all in ESRD patients. MALE were noted in 13 (30%) of patients, 12 men and 1 woman. Demographics of age, sex, race, diabetes, hypertension, smoking, ESRD and mortality did not differ by MALE status (P>0.05). Stepwise multivariate logistic regression showed that indication of gangrene (vs. infection) (OR 9.61 %CI [1.43, 64.53] P=0.0198) and ESRD (OR 6.39 95%CI [1.04, 39.10] P=0.044) were predictors of MALE.
Conclusions: Open TMA provide acceptable rates of limb salvage. Despite low transition to BKA for CLI patients undergoing open TMA, ESRD patients undergoing open TMA for an indication of gangrene have a significantly higher risk of MALE. In ESRD patients with critical limb ischemia secondary to gangrene, consideration for primary below knee amputation should be entertained.
| Effect | Point Estimate (OR) | 95% CI lower | 95% CI upper | P-Value |
| Age | 0.974 | 0.91 | 1.042 | 0.4471 |
| Sex | 0.145 | 0.011 | 1.875 | 0.1394 |
| ESRD | 6.399 | 1.047 | 39.107 | 0.0444 |
| Indication Gangrene | 9.614 | 1.432 | 64.531 | 0.0198 |
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