Benefits of an Enhanced Recovery Pathway for Lower Extremity Amputation Patients

Enhanced recovery programs (ERPs) may improve lower extremity amputation (LEA) care through interdisciplinary collaboration, patient education, multimodal pain control, and early mobilization. We sought to determine the ERP impact on outcomes for patients undergoing major LEA.

Patients receiving ERP care (02/01/2022-07/31/2023) were compared to a historic pre-ERP cohort (01/01/2020-01/31/2022). Outcomes analyzed included length of stay (LOS), perioperative complications, time to prosthetic receipt, and achieved K-level.

220 and 152 patients were in the pre-ERP and ERP groups, respectively. In the pre-ERP group, the most common indication was infection (45.0% vs. 25.2%), while in the ERP group, rest pain was most common (37.1% vs. 10.5%), P < 0.001. Staged (i.e., initial amputation followed by closure at a subsequent operation) ERP patients had lower rates of 30-day readmissions (11.9% vs. 29.3%, P = 0.01) and 90-day complications (49.3% vs. 68.0%, P = 0.02) than staged non-ERP patients. ERP below-knee amputation (BKA) patients had lower 90-day mortality than pre-ERP patients (2.5% vs. 12.2%, P = 0.02). ERP above-knee amputation (AKA) patients had a shorter LOS than pre-ERP patients (6 vs. 7 days, P = 0.04). The ERP cohort had shorter prosthetic receipt times (176 vs. 226 days, log-rank P = 0.02). Patients who achieved at least a K1 level of ambulation had greater 18-month survival compared to patients who never ambulated (log-rank P < 0.001).

ERP implementation was associated with fewer complications and readmissions, most pronounced in ERP-staged patients. ERP patients tended to receive a prosthesis more quickly, which is important given the association of ambulation with survival. Significant comorbidities in this patient population highlight the importance of optimization efforts promoted by the ERP.