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Published on: September 22, 2020
Major lower extremity amputation: outcome of a modern series
Bernadette Aulivola1, Chantel N Hile, Allen D Hamdan
1Division of Vascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass. 02215, USA. baulivo@caregroup.harvard.edu
Insights
Major lower extremity amputation carries high risks, with above-knee amputations (AKAs) showing worse outcomes than below-knee amputations (BKAs). Long-term survival is poor for patients with diabetes or renal disease undergoing amputation.
Area of Science:
- Surgical Outcomes
- Vascular Surgery
- Limb Amputation
Background:
- Major lower extremity amputation is associated with substantial morbidity and mortality.
- Understanding outcomes is crucial for patient management and prognosis.
Purpose of the Study:
- To evaluate patient survival, cardiac morbidity, infectious complications, and subsequent operations following major lower extremity amputations.
- To compare outcomes between below-knee amputations (BKAs) and above-knee amputations (AKAs).
Main Methods:
- Retrospective review of 959 major lower extremity amputations in 788 patients from 1990-2001.
- Data included patient survival, complications, and need for subsequent operations.
- Mean follow-up was 33.6 months.
Main Results:
- Overall 30-day mortality was 8.6%, significantly higher for AKAs (16.5%) than BKAs (5.7%).
- Complications included cardiac issues (10.2%), wound infections (5.5%), and pneumonia (4.5%).
- Five-year survival was 34.7% overall, with significantly worse survival for AKAs, patients with diabetes mellitus, and those with end-stage renal disease.
Conclusions:
- Major lower extremity amputation remains a high-risk procedure with significant mortality.
- Below-knee amputations generally have better outcomes than above-knee amputations.
- Long-term survival is particularly poor for patients with comorbidities like diabetes and end-stage renal disease.
Hypothesis:
Major lower extremity amputation results in significant morbidity and mortality.
Design:
Retrospective database query and medical record review for January 1, 1990, to December 31, 2001. Mean follow-up was 33.6 months.
Setting:
Academic tertiary care center.
Patients:
Nine hundred fifty-nine consecutive major lower extremity amputations in 788 patients, including 704 below-knee amputations (BKAs) (73.4%) and 255 above-knee amputations (AKAs) (26.6%).
Main Outcome Measures:
Patient survival, cardiac morbidity, infectious complications, and subsequent operation.
Results:
Overall 30-day mortality was 8.6%, worse for AKA (16.5%) than BKA (5.7%) patients (P<.001). Thirty-day mortality for guillotine amputation for sepsis control was 14.3% compared with 7.8% for closed amputation (P =.03). Complications included cardiac (10.2%), wound infection (5.5%), and pneumonia (4.5%). Twelve AKA (4.7%) and 129 BKA (18.4%) limbs required subsequent operation. Only 66 BKAs (9.4%) required conversion to AKA (average, 77.1 days postoperatively). Overall survival was 69.7% and 34.7% at 1 and 5 years, respectively. Survival was significantly worse for AKAs (50.6% and 22.5%) than BKAs (74.5% and 37.8%) (P<.001). Survival in patients with diabetes mellitus (DM) was 69.4% and 30.9% vs 70.8% and 51.0% in patients without DM at 1 and 5 years, respectively (P =.002). Survival in end-stage renal disease patients was 51.9% and 14.4% vs 75.4% and 42.2% in patients without renal failure at 1 and 5 years, respectively (P<.001).
Conclusions:
Major amputation continues to result in significant morbidity and mortality. Survivors with BKA require revision or conversion to AKA infrequently. Long-term survival is dismal for patients with DM and end-stage renal disease and those undergoing AKA.
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