Excessive Procedures Before Lower Extremity Amputation Lead To Worse Patient Outcomes
Maxwell Grant, BA, Samuel Steerman, MD, Andrew McChesney, MD, Fanny Alie-Cusson, MD, Justin Milligan, MD, Animesh Rathore, MD, Jean Panneton, MD.
Eastern Virginia Medical School, Norfolk, VA, USA.
Objectives: This study sought to investigate whether outcomes after major lower extremity amputation (MLEA) were affected by the number and timing of limb salvage attempts (LSA) received prior to MLEA.
Methods: Retrospective chart review was performed to identify patients who underwent MLEA between 2014 and 2016. Data on patient demographics, pre-operative comorbidities, LSA, and outcomes after MLEA were collected for each amputee. LSA were defined as an endovascular revascularization, open surgical revascularization, wound debridement requiring intravenous sedation or general anesthesia, and amputation at or below the level of TMA.
Results: This study identified 293 patients within a single health system (58.7% male, mean age 66.4±11.6 years) who underwent 364 MLEA (50.5% BKA, 49.5% AKA) during the study period. All amputations were performed in the setting of chronic limb ischemia or infection. Median follow-up was 516 days post-amputation. Patients undergoing two or more lifetime revascularization attempts prior to amputation had an increased risk of wound complications (infection or non-healing wound) ≤60 days after amputation (31.1% vs 20.7%, p=0.024). Patients undergoing an open or endovascular revascularization ≤30 days prior to MLEA showed a higher incidence of wound complications than those who did not (36.2% vs 22.0%, p=0.005). Any patient who experienced a post-operative wound complication had a higher chance of needing operative revision or a more proximal amputation (27.4% vs. 4.5%, p<0.001). Increased LSA in patients initially undergoing BKA was associated with the need for revision to AKA (LSA=3.500 vs. 1.988, p=0.026). Patients undergoing any LSA while non-ambulatory had a greater chance of developing wound complications after amputation than non-ambulatory patients without prior LSA (33.3% vs 11.1%, p=0.010). Those who experienced a wound complication and eventually became ambulatory with a prosthesis took >7 months longer to reach ambulation (461.13 days (n=25) vs 238.52 (n=63) days, p<0.001).
Conclusions: Pre-operative non-ambulatory status, revascularization within 30 days of amputation, and multiple (≥2) prior lifetime revascularizations were associated with increased wound complications in patients undergoing major lower extremity amputation. Wound complications doubled overall time to ambulation, and patients undergoing more limb salvage attempts had a higher rate of revision from BKA to AKA. For patients ultimately undergoing major amputations, multiple overzealous attempts at limb salvage are associated with worse outcomes.
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