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Patients Experience Significant Long-term Social And Health Challenges After Major Lower Extremity Amputation
Elina H. Farber, Max Zhu, BS, Thomas McNamara, BS, Thomas W. Cheng, MD, Elizabeth King, MD, Jeffrey Kalish, MD, Andrea Alonso, MD, Jeffrey J. Siracuse, MD, MBA;
Boston University, Boston, MA, USA

OBJECTIVES: Major lower extremity amputation is a significant life-changing event that can have long-term implications. Our goal was to assess long-term medical and social determinants of health (SDH) challenges in this population.
METHODS: A retrospective review of major lower extremity (above ankle) amputations (2018-2022) was performed at a safety-net tertiary center. At least 6 months were needed for long-term follow-up. Patients who participated in a SDH survey between 6-months to 1.5 years postoperatively, were included. Patient demographics, comorbidities, perioperative and long-term outcomes were analyzed.
RESULTS: There were 100 patients who underwent major lower extremity amputations. Mean age was 61.5 years and 23% were of female gender. The majority (57%) were Black race, 20% White race, and 21% Hispanic ethnicity. Comorbidities included diabetes (78%), chronic kidney disease (51%), coronary artery disease (31%), congestive heart failure (23%), previous cerebrovascular events (19%), and 37% used opioids pre-admission. Before admission, the majority (62%) lived at home. Guillotine amputation was performed in 35%; definitive amputation was below and above knee in 67% and 33%, respectively. Median length of stay was 7 days. Readmission at 30, 90 days, and 1-year was 13%, 30%, and 43%, respectively. The majority (93%) had 6 month follow-up; mean follow-up was 839 days. At long-term follow-up, 55% of patients lived at home, 25% used opioids, and only 25% were independently ambulatory. In the survey at follow-up, 32% had a SDH challenge with younger patients more affected (58 vs. 63 years, P=.031). These findings consisted of food insecurity (17%), housing insecurity (13%), transportation challenges (13%), seeking employment (8%), difficulty paying for utilities (5%) and medications (4%), seeking further education (5%), and difficulty caring for family/friends (4%). On multivariable analysis having a SDH challenge was independently associated with 1-year readmission (OR 6.7, 95% CI 1.3-35.8, P<.001). Older age was associated with lower long-term independent ambulation (OR 0.92, 95% CI 0.85-0.99, P=.025).
CONCLUSIONS: After major lower extremity amputation, patients have significant medical and social challenges with fewer living at home, the majority not independently ambulatory, and one third having a SDH challenge. Improvements in long-term support including medical, social, and rehabilitation services are required for this vulnerable population.
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