Modification of Ertl Operation for Short Stump.

Background: Despite a sufficient number of papers on the technique of transtibial amputations, the technique of Ertl-type reamputation in short tibial stump remains unreported. Aim: To propose a modification of the Ertl operation in the proximal tibia. Case Presentation: The technique of bone bridge creation in a patient with a malformed stump in the upper third of the tibia at the expense of the regenerate formed after corticotomy of the tibial remnant and dosed distraction of the graft by the Ilizarov apparatus is described. Radiological, ultrasound and MRI methods were used to control the regenerate. The follow-up period was 36 months. At 3.5 months, a synostosis was formed, which allowed primary and then permanent prosthesis with a full-contact prosthesis. At 36 months, the organotypic remodelling of the regenerate was completed. The patient works, uses the prosthesis for 15-16 hours a day, and walks on average 8-10 km. Conclusion: The use of the proposed method makes it possible to obtain tibial synostosis without their shortening with elimination of valgus deviation of the fibula stump and the possibility of early functional loading. Synostosis formation occurs within 3.5 months after surgery. Organotypic bone remodelling occurs during primary and then permanent prosthetics. The formed bone bridge has a large support area, which is maintained during the whole follow-up period of 36 months and allows to perform full-contact prosthetics with maximum load on the residual limb end.

Analysis of systemic risk factors between diabetic/vascular patients having primary lower limb amputations and re-amputations.

Background: Patients with diabetes mellitus (DM) are known to be predisposed to many complications in the lower extremities such as neuropathy, peripheral artery disease (PAD) and infection. Diabetic foot ulcers are complications of diabetes that can lead to lower extremity amputations, re-amputations and high mortality rates.Purpose: The aim of this study is to evaluate the risk factors associated with higher re-amputation rates in diabetic foot disease.Research Design: This is a mono-centric retrospective comparative study.Study Sample: the study included 136 patients, with a total of 193 procedures (111 primary amputations and 82 re-amputations) between 2011 and 2021.Data Analysis: The t-student test and Spearman correlation were used to look for mean differences and any relevant association, respectively. Multivariate logistic regression analysis was computed to look for independent variables.Results: Twenty-two (27%) and 60 (50%) of those who had major and minor amputations, respectively, had a re-amputation (p = 0.006). Besides diabetes (89%), the commonest risk factor associated with amputation was hypertension (86.7%), be it for primary amputation or re-amputation, followed by peripheral (PAD) and coronary artery diseases. Only three risk factors showed independent correlation with re-amputation; chronic kidney disease (r = 15%, p = 0.03), smoking (r = 15%, p = 0.03), and simultaneous presence of DM + PAD (r = 13.7%, p = 0.05).Conclusions: Factors that were significantly correlated with increased re-amputation rates have a clear pathologic pathway that affects vascularity and wound healing. Further studies should be aimed at developing a clear scoring system that can be used to stratify patient for re-amputation risk, and to better predict the results according to the severity of diabetes.

Risk Factors for Failure After Surgery in Patients With Diabetic Foot Syndrome.

Background: In the present study, we aimed to identify risk factors for failure (defined as reoperation within 60 days) after debridement or amputation at the lower extremity in patients with diabetic foot syndrome and to develop a model using the significant risk factors to predict the success rate at different levels of amputation. Methods: Between September 2012 and November 2016, we performed a prospective observational cohort study of 174 surgeries in 105 patients with diabetic foot syndrome. In all patients, debridement or the level of amputation, need for reoperation, time to reoperation, and potential risk factors were assessed. A cox regression analysis, dependent on the level of amputation, with the endpoint reoperation within 60 days defined as failure and a predictive model for the significant risk factors were conducted. Results: We identified the following 5 independent risk factors: More than 1 ulcer (hazard ratio [HR] 3.8), peripheral artery disease (PAD, HR 3.1), C-reactive protein >100 mg/L (HR 2.9), diabetic peripheral neuropathy (HR 2.9), and nonpalpable foot pulses (HR 2.7) are the 5 independent risk factors for failure, which were identified. Patients with no or 1 risk factor have a high success rate independent of the level of amputation. A patient with up to 2 risk factors undergoing debridement will achieve a success rate of <60%. However, a patient with 3 risk factors undergoing debridement will need further surgery in >80%. In patients with 4 risk factors a transmetatarsal amputation and in patients with 5 risk factors a lower leg amputation is needed for a success rate >50%. Conclusion: Reoperation for diabetic foot syndrome occurs in 1 of 4 patients. Risk factors include presence of more than 1 ulcer, PAD, CRP > 100, peripheral neuropathy, and nonpalpable foot pulses. The more risk factors are present, the lower the success rate at a certain level of amputation. Level of Evidence: Level II, prospective observational cohort study.

Risk factors for reamputation in patients with diabetic foot: A case-control study.

BACKGROUND: Reamputation as a complication of diabetic foot ulcers presents a high economic burden and represents a therapeutic failure. It is paramount to identify as early as possible patients in whom a minor amputation may not be the best option. The purpose of this investigation was to do a case-controlled study to determine risk factors associated with re-amputation in patients with DFU (diabetic foot ulcers) at two University Hospitals. METHODS: Multicentric, observational, retrospective, case-control study from clinical records of 2 university hospitals. Our study included 420 patients, with 171 cases (re-amputations), and 249 controls. We performed a multivariate logistic regression analysis and time-to-event survival analysis to identify re-amputation risk factors. RESULTS: Statistically significant risk factors were artery history of tobacco use (p = 0.001); male sex (p = 0.048); arterial occlusion in Doppler ultrasound (p = 0.001); percentage of stenosis in arterial ultrasound >50 % (p = 0.053); requirement of vascular intervention (p = 0.01); and microvascular involvement in photoplethysmography (p = 0.033). The most parsimonious regression model suggests that history of tobacco use, male sex, arterial occlusion in ultrasound, and percentage of stenosis in arterial ultrasound >50 % remained statistically significant. The survival analysis identified earlier amputations in patients with larger occlusion in arterial ultrasound, high leukocyte count, and elevated ESR. CONCLUSION: Direct and surrogate outcomes in patients with diabetic foot ulcers identify vascular involvement as an important risk factor for reamputation. LEVEL OF EVIDENCE: III.

Impact of time in range during hospitalization on clinical outcomes in diabetic patients with toe amputation: a propensity score matching analysis.

PURPOSE: In recent years, time in range (TIR), defined as a percentage within a target time range, has attracted much attention. This study was aimed to investigate the short-term effects of Time in Rang on diabetic patients undergoing toe amputation in a more specific and complete manner. METHODS: A retrospective analysis on patients with diabetic foot ulcer (DFU) treated by toe amputation or foot amputation at the First Affiliated Hospital of Wenzhou Medical University between January 2015 and December 2019 were evaluated. A 1:1 match was conducted between the TIR < 70% group and the TIR ≥ 70% group using the nearest neighbor matching algorithm. Data were analyzed using Chi-squared, Fisher's exact, and Mann-Whitney U tests. RESULTS: Compared with patients in the TIR ≥ 70% group, patients in the TIR < 70% had a higher rate of re-amputation, and a higher rate of postoperative infection. Multivariate analysis revealed that smoking, lower extremity arterial disease and TIR < 70% were risk factors for surgery of re-amputation. The results of subgroup analysis found that the TIR < 70% was associated with a greater risk of re-amputation in patients with HbA1c < 7.5%, lower extremity arterial disease, and non-smokers. CONCLUSIONS: TIR can be used as a short-term glycemic control indicator in patients with DFUs and should be widely accepted in clinical practice. However, a future multicenter prospective study is needed to determine the relationship between TIR and toe re-amputation in diabetic foot patients.

Analysis of repeated lesions after diabetic forefoot amputation.

AIM: This study was performed to analyze the clinical characteristics, related factors, and prognosis of repeated lesions after diabetic forefoot amputation. METHODS: The medical records of 998 patients who underwent forefoot amputation because of their diabetic feet from March 2002 to February 2021 were retrospectively analyzed. Of the 508 selected patients with a follow-up period of at least 6 months, 288 had repeated lesions in the forefoot, and 220 did not have repeated lesions. The related factors of repeated lesions were compared and analyzed. Of the patients with repeated lesions, 142 and 104 on the ipsilateral and contralateral sides, respectively were also compared and examined. RESULTS: Repeated lesions were statistically significant in diabetic polyneuropathy, vascular calcification, and dialysis. However, the anatomical positions of diabetic foot lesions, causes of lesions, anatomical amputation levels, number of surgeries, and management duration had no significant differences. Contralateral lesions occurred 8 months later than ipsilateral lesions, but reamputation above the Lisfranc joint was more frequent and prognosis was poorer. CONCLUSIONS: Repeated lesions were affected by general conditions, and the contralateral side must be carefully examined after diabetic forefoot amputation.

Re-amputation and survival following toe amputation: outcome data from a tertiary referral centre.

PURPOSE: Toe amputation is a commonly performed procedure for irreversible foot sepsis. However, outcome and predictors of outcome are poorly understood. Our aim was to determine survival and rate of progression to further amputation following index toe amputation. METHODS: Consecutive patients between 2010 and 2015 were included. Progression to further minor amputation, major amputation or death was recorded. Multivariable Cox regression analyses were undertaken to determine independent predictors of outcome and survival. RESULTS: One hundred forty-six patients were included, with mean age of 65 years. Fifty-five (37.7%) patients underwent hallux amputation, while 91 (62.3%) underwent amputation of non-hallux digit(s). Following index toe amputation, 63 (43.2%) patients progressed to further minor or major ipsilateral amputation, median time to which was 36 months. Twenty-one patients (14.4%) progressed to major ipsilateral amputation. Patients undergoing index non-hallux amputation were significantly more likely to require further minor amputation (P = 0.050); however, the rate of major amputation between hallux (14.5%) and non-hallux (14.3%) groups was similar. Overall, 5-year ipsilateral amputation-free (iAFS) was 39.6 ± 4.1%, ipsilateral major amputation-free (iMAFS) was 55.9 ± 4.1% and overall survival (OS) was 64.3 ± 4.0% and did not differ between index amputation sites. CONCLUSION: Almost half of patients undergoing toe amputation required further digital amputation. However, limb preservation rates are high, and a majority of patients are alive at 5-year follow-up. There was no significant difference in outcome between patients undergoing hallux and non-hallux primary procedures. Overall, increasing age remains the only independent predictor of iMAFS and OS.

Anxiety and/or depression: which symptoms contribute to adverse clinical outcomes after amputation?

BACKGROUND: One of the most serious complications of diabetes mellitus (DM) is a diabetic foot ulcer (DFU), with lower extremity amputation (LEA). AIMS: This study aims to explore the role of anxiety and depression on mortality, reamputation and healing, after a LEA due to DFU. METHODS: A sample of 149 patients with DFU who underwent LEA answered the Hospital Anxiety and Depression Scale and a sociodemographic and clinical questionnaire. This is a longitudinal and multicenter study with four assessment moments that used Cox proportional hazards models adjusted for demographic and clinical variables. RESULTS: Rate of mortality, reamputation and healing, 10 months after LEA were 9.4%, 27.5% and 61.7%, respectively. Anxiety, at baseline, was negatively associated with healing. However, depression was not an independent predictor of mortality. None of the psychological factors was associated with reamputation. CONCLUSION: Results highlight the significant contribution of anxiety symptoms at pre-surgery, to healing after a LEA. Suggestions for psychological interventions are made.

Predictive Factors and Amputation Level for Reamputation in Patients With Diabetic Foot: A Retrospective Case-Control Study.

The aim of this study was to assess the rate and level of reamputation in patients who had a previous amputation from diabetic foot. We retrospectively analyzed patients who underwent amputation and reamputation due to diabetic foot in our clinic between 2011 and 2019. Fifty-nine were evaluated as the healed group after the first amputation and 55 were evaluated as the reamputation group. Given 55 patients who needed reamputation: there were 13 finger or ray, 23 transmetatarsal or syme, 18 transtibial, and 1 transfemoral in the first operation. We found the reamputation rate was 65.4% in distal amputations. When serum parameters were examined before the first amputation in each group, there was no statistically significant difference in white blood cells, neutrophils, lymphocytes, platelets, sedimentation, C-reactive protein, total protein, hematocrit, urea, creatinine, and HgA1c values. There was, however, a significant difference between groups in albumin levels. When comorbidities were assessed for smoking, hypertension, duration of diabetes, and number of debridements after the first surgery, a significant difference between groups was found. When peripheral artery disease and chronic renal failure were examined, no significant difference was observed. In our study, it was observed that the rate of reamputation was higher in distal level amputations for diabetic foot patients. Accordingly, albumin values, smoking, hypertension, duration of diabetes, number of debridements after surgery, were seen as risk factors for reamputation patients.

Geographical socioeconomic disadvantage is associated with adverse outcomes following major amputation in diabetic patients.

OBJECTIVE: Socioeconomic disadvantage is a known predictor of adverse outcomes and amputation in patients with diabetes. However, its association with outcomes after major amputation has not been described. Here, we aimed to determine the association of geographic socioeconomic disadvantage with 30-day readmission and 1-year reamputation rates among patients with diabetes undergoing major amputation. METHODS: Patients from the Maryland Health Services Cost Review Commission Database who underwent major lower extremity amputation with a concurrent diagnosis of diabetes mellitus between 2015 and 2017 were stratified by socioeconomic disadvantage as determined by the area deprivation index (ADI) (ADI1 [least deprived] to ADI4 [most deprived]). The primary outcomes were rates of 30-day readmission and 1-year reamputation, evaluated using multivariable logistic regression models and Kaplan-Meier survival analyses. RESULTS: A total of 910 patients were evaluated (66.0% male, 49.2% Black), including 30.9% ADI1 (least deprived), 28.6% ADI2, 19.1% ADI3, and 21.2% ADI4 (most deprived). After adjusting for differences in baseline demographic and clinical factors, the odds of 30-day readmission was similar among ADI groups (P > .05 for all). Independent predictors of 30-day readmission included female sex (odds ratio [OR], 1.45), Medicare insurance (vs private insurance; OR, 1.76), and peripheral artery disease (OR, 1.49) (P < .05 for all). The odds of 1-year reamputation was significantly greater among ADI4 (vs ADI1; OR, 1.74), those with a readmission for stump complication or infection/sepsis (OR, 2.65), and those with CHF (OR, 1.53) or PAD (OR, 1.59) (P < .05 for all). CONCLUSIONS: Geographic socioeconomic disadvantage is independently associated with 1-year reamputation, but not 30-day readmission, among Maryland patients undergoing a major amputation for diabetes. A directed approach at improving postoperative management of chronic disease progression in socioeconomically deprived patients may be beneficial to reducing long-term morbidity in this high-risk group.

Re-amputation in patients with diabetes-related minor amputations who underwent physical therapy during their hospitalization.

BACKGROUND: Diabetes-related foot lesions are a major cause of non-traumatic lower limb amputations and are associated with a high re-amputation rate. Lesions can cause hindrance in activities of daily living, reduce physical function, and lower a patient's quality of life. Physical therapy is necessary to prevent these limitations. Thus far, there has been limited investigation into the re-amputation rate in patients who have undergone physical therapy. This study aimed to elucidate modifiable risk factors for re-amputation in patients with minor amputations who were treated with physical therapy during their hospitalization. METHODS: This was a retrospective cohort study of 245 consecutive hospitalized patients who presented to our Wound Care Center between January 2015 and February 2018 and received physical therapy after a minor amputation. Participants were identified from admission records to surgical and physical therapy units stored in the electronic medical records. We examined re-amputations that occurred in the ipsilateral lower extremity during the 1-year post-discharge outpatient period. The maximum follow-up period was set at 1 year. We used Cox proportional hazards analysis to examine factors affecting the risk of re-amputation. RESULTS: Of the 129 patients enrolled, 42 patients (32.5%) underwent re-amputations during an average observation period of 6.2 months (range, 2.1 to 10.9 months). The factors associated with re-amputation were a requirement for hemodialysis, ankle dorsiflexion angle, and the Functional Independence Measure (FIM) ambulation score. CONCLUSIONS: In diabetes patients with minor amputations, a requirement for hemodialysis, ankle dorsiflexion angle, and the FIM ambulation score were shown to be modifiable risk factors for re-amputation. This emphasizes that maintaining vascular endothelial function through lower limb muscle exercises for hemodialysis, improving ankle mobility, and relieving plantar pressure during walking are necessary to reduce the risk of re-amputation. Patients with these risk factors should be encouraged to participate in physical therapy.

Susceptibility Factors for Early Reamputation in Diabetic Great Toe Gangrene.

INTRODUCTION: The effectiveness of the treatment has long been significant in diabetes and its complications, especially in developing countries. Prolonged hospitalization and repeated surgery should be avoided due to clinical and economic reasons. Wound breakdowns or necrosis can occur after amputation procedures, and subsequently will require reamputation. This study analyzed susceptibility factors in diabetic foot patients undergoing prior high toe amputation that are thought to be related to early reamputation. METHODS: We performed a retrospective analysis in 107 patients that have undergone amputation for great toe gangrene, during May 2014-April 2019. Demographic data, clinical features, laboratory results and treatment modality, were documented and statistically analyzed by simple and multiple logistic regression methods. RESULTS: Of all 107 patients, 17 patients had to undergo early reamputation. Limited dorsiflexion, level of amputation, and sepsis condition is shown to be significantly associated with first amputation. Multiple logistic regression analysis confirmed a significant association of early reamputation with amputation or disarticulation at the level of the metatarsophalangeal joint. CONCLUSION: While limited ankle dorsiflexion and sepsis conditions need to be addressed comprehensively, from the surgical options point of view, we suggest ray amputation to be preferred over metatarsophalangeal joint disarticulation to prevent early reamputation.

Risk factors for reamputations in patients amputated after revascularization for critical limb-threatening ischemia.

OBJECTIVE: Despite vascular intervention, patients with critical limb-threatening ischemia (CLTI) have a high risk of amputation. Furthermore, this group has a high risk for stump complications and reamputation. The primary aim of this study was to identify risk factors predicting reamputation after a major lower limb amputation in patients revascularized because of CLTI. The secondary aim was to investigate mortality after major lower limb amputation. METHODS: There were 288 patients who underwent a major ipsilateral amputation after revascularization because of CLTI in Stockholm, Sweden, during 2007 to 2013. The main outcome was ipsilateral reamputation. RESULTS: Of 288 patients, 50 patients had a reamputation and 222 died during the 11-year follow-up. Patients with ischemic pain as an indication for primary amputation had nearly four times higher risk for a reamputation compared with those with a nonhealing ulcer (subdistribution hazard ratio, 3.55; confidence interval, 1.55-8.17). Higher age was associated with an increased risk for death in the multivariable analysis (hazard ratio, 1.03; confidence interval, 1.02-1.04). CONCLUSIONS: Patients with ischemic pain as an indication for amputation have an elevated risk of reamputation. Ischemic pain may be indicative of a more extensive and proximal ischemia compared with patients with foot tissue loss. An extended evaluation of the preoperative circulation before amputation may facilitate the choice of amputation level and could lead to a reduction of reamputations.

Impact of Geographic Socioeconomic Disadvantage on Minor Amputation Outcomes in Patients With Diabetes.

BACKGROUND: Socioeconomic disadvantage is a known contributor to adverse events and higher admission rates in the diabetic population. However, its impact on outcomes after lower extremity amputation is unclear. We aimed to assess the association of geographic socioeconomic disadvantage with short- and long-term outcomes after minor amputation in patients with diabetes. MATERIALS AND METHODS: Geographic socioeconomic disadvantage was determined using the area deprivation index (ADI). All patients from the Maryland Health Services Cost Review Commission database (2012-2019) who underwent minor amputation with a concurrent diagnosis of diabetes were included and stratified by the ADI quartile. Associations of the ADI quartile with 30-day readmission and 1-year reamputation were evaluated using Kaplan-Meier survival analyses and multivariable logistic regression models adjusting for baseline differences. RESULTS: A total of 7415 patients with diabetes underwent minor amputation (70.1% male, 38.7% black race), including 28.1% ADI1 (least deprived), 42.8% ADI2, 22.9% ADI3, and 6.2% ADI4 (most deprived). After adjusting for demographic and clinical factors, the odds of 30-day readmission were greater in the intermediate ADI groups than those in the ADI1 group, but not among the most deprived. Adjusted odds of 1-year reamputation were greater among ADI4 than those among ADI1. Kaplan-Meier analysis confirmed a greater likelihood of reamputation with an increasing ADI quartile over a 1-year period (P < 0.001). CONCLUSIONS: Geographic socioeconomic disadvantage is independently associated with both short- and long-term outcomes after minor diabetic amputations in Maryland. A targeted approach addressing the health care needs of deprived regions may be beneficial in optimizing postoperative care in this vulnerable population.

Two-phase amputation among critically ill patients with ischemic gangrene of lower limbs as a way to improve treatment outcome. Cohort study.

BACKGROUND: The results of lower limb amputation, especially in critically ill patients with severe endogenous intoxication, sepsis, multi-organ failure and severe concomitant diseases are still unsatisfactory. Guillotine amputation is a method routinely used to reduce wound complications associated with wet gangrene and severe cases of diabetic foot, however, it is unclear how well it could help to decrease mortality and improve functional outcome when dealing with critically ill patients. THE OBJECTIVE: of the study was to estimate the effectiveness of two-phase method of urgent low limb amputation among critically ill patients with high risk of complications. The effectiveness was evaluated in terms of perioperative mortality, frequency of early complications and ultimate level of limb loss. MATERIALS AND METHODS: Two cohort groups of patients with acute lower limb gangrene were retrospectively matched. Approximately 25.8% of patients from the comparison (control) group (N = 240) died without surgery due to severity of their condition and ineffective pre-operative treatment. The remaining patients underwent one-phase high-level amputation after 48-72 h of pre-operative intensive care. The experimental group consisted of 153 patients who underwent guillotine amputation at the lower part of tibia (34.6%), knee disarticulation (32.0%), or open thigh amputation (33.3%), depending on the level of irreversible soft tissue necrosis. The reamputation with the stump shaping was performed later when their health status improved. RESULTS: The assessment of treatment outcomes showed that the two-phase amputation in critically ill patients (i) decreased the mortality from 48.7 to 37.9%, (ii) reduced the risk of wound complications from 20.9 to 11.1%, and (iii) improved functional results by saving the knee joint in 34.6 versus 4.5% in comparison/control group. CONCLUSION: The method of two-phase amputation is recommended for critically ill patients.

Analysis of routine blood markers for predicting amputation/re-amputation risk in diabetic foot.

Diabetic foot is challenging progressive disease which requires multisystemic control. Neuropathy, arteriopathy, and cellular responses should treated collaboratively. Despite all medical advances, diabetic foot can highly resulted with amputation and also re-amputation can be required because of failed wound healing. In this study, we aimed to investigate the relation between blood parameters and amputation events. Diabetic 323 patients include to the study who referred to orthopaedic clinic for amputation. Amputation levels (amputation levels phalanx, metatarsal, lisfranc, syme, below knee, knee-disarticulation, above-knee amputation) and re-amputations recorded and compared with routine blood parameters. Re-amputation was observed at 69 patients. The significant difference detected between lower albumin, higher HbA1c, higher CRP levels (P < 0.05) in regards to gross amputation levels, and increased wound depth. Furthermore, lower albumin levels and higher levels of WBC, HbA1c, CRP, and Creatinine were detected in re-amputation levels. Especially, HbA1c, CRP, and Creatinine levels were found as upper bound of reference line for re-amputation. The statistically optimal HbA1c cutoff point for diabetes was ≥7.05%, with a sensitivity of 86% and a specificity of 59%. In according to our results, simple blood parameters can be useful for observing the progress of amputation in diabetic foot. Particularly, lower albumin, and higher HbA1c, CRP, and Creatinine levels detected as related with poor prognosis. Besides, screening of HbA1c level seems to be highly sensitive for detecting of re-amputation possibility.

Lower extremity amputations and long-term outcomes in diabetic foot ulcers: A systematic review.

BACKGROUND: Diabetes mellitus causes a large majority of non-traumatic major and minor amputations globally. Patients with diabetes are clinically complex with a multifactorial association between diabetic foot ulcers (DFU) and subsequent lower extremity amputations (LEA). Few studies show the long-term outcomes within the cohort of DFU-associated LEA. AIM: To highlight the long-term outcomes of LEA as a result of DFU. METHODS: PubMed/MEDLINE and Google Scholar were searched for key terms, "diabetes", "foot ulcers", "amputations" and "outcomes". Outcomes such as mortality, re-amputation, re-ulceration and functional impact were recorded. Peer-reviewed studies with adult patients who had DFU, subsequent amputation and follow up of at least 1 year were included. Non-English language articles or studies involving children were excluded. RESULTS: A total of 22 publications with a total of 2334 patients were selected against the inclusion criteria for review. The weighted mean of re-amputation was 20.14%, 29.63% and 45.72% at 1, 3 and 5 years respectively. The weighted mean of mortality at 1, 3 and 5 years were 13.62%, 30.25% and 50.55% respectively with significantly higher rates associated with major amputation, re-amputation and ischemic cardiomyopathy. CONCLUSION: Previous LEA, level of the LEA and patient comorbidities were significant risk factors contributing to re-ulceration, re-amputation, mortality and depreciated functional status.

Risks and Risk Factors for Ipsilateral Re-Amputation in the First Year Following First Major Unilateral Dysvascular Amputation.

OBJECTIVE: To identify timing, incidence, and risk factors for ipsilateral re-amputation within 12 months of first dysvascular amputation and to determine specific subgroups of patients at each amputation level that are at increased risk. METHODS: A retrospective cohort study evaluating 7187 patients with first unilateral transmetatarsal (TM), transtibial (TT), or transfemoral (TF) amputation secondary to diabetes and/or peripheral artery disease (PAD) were identified in the VA Surgical Quality Improvement Program database between 2004 and 2014. Re-amputation was defined as any subsequent ipsilateral soft tissue/bony revision or amputation to a higher level. Twenty-three potential pre-operative risk factors (and nine potential interactions) were identified. A backward stepwise Cox regression was used to identify risk factors. Incidence rates and hazard ratios (HR) with 95% confidence intervals (CI) were computed. RESULTS: The median time to highest level of re-amputation in the first year was 33 (interquartile range, 13-73) days. Risk of requiring at least one re-amputation was 41% (TM), 25% (TT), and 9% (TF). Risk factors associated with requiring re-amputation included chronic obstructive pulmonary disease, elevated white blood cell count, abnormal ankle brachial index (ABI), history of revascularisation, and alcohol misuse. TM patients who had diabetes only (HR 1.9; 95% CI 1.4-2.5), diabetes with an abnormal ankle brachial index (ABI) score (HR 2.4; 95% CI 1.8-3.2), and kidney failure (HR 1.7; 95% CI 1.3-2.1) were at the greatest risk of re-amputation. TT amputees who were smokers were also at an increased risk (HR 1.4; 95% CI 1.2-1.6). CONCLUSION: This research identified important risk factors for failure of primary healing and need for re-amputation at the TM and TT level. If considering a TM amputation, caution should be exercised in patients with diabetes, in particular those with an abnormal ABI and/or renal failure. At the TT level, caution should be exercised in those who smoke.

Amputation rates of the lower limb by amputation level - observational study using German national hospital discharge data from 2005 to 2015.

BACKGROUND: In international comparisons, rates of amputations of the lower limb are relatively high in Germany. This study aims to analyze trends in lower limb amputations over time, as well as outcomes of care concerning in-hospital mortality and reamputation rates during the same hospital stay which might indicate the quality of surgical and perioperative health care processes. METHODS: This work is an observational population-based study using complete national hospital discharge data (Diagnosis-Related Group Statistics (DRG Statistics)) from 2005 to 2015. All inpatient cases with lower limb amputation were identified and stratified by eight amputation levels. Time trends of case numbers and in-hospital mortality were studied age-sex standardized. For inpatient cases with reamputation during the same hospital stay, first and last amputation levels were cross tabulated. RESULTS: A total of 55,595 amputations of the lower limb in 2015 (52,096 in 2005) were identified. After age-sex standardization to the demographic structure of 2005, a relative decrease of - 11.1% was revealed (men - 2.6%, women - 25.0%). The stratified analysis by amputation levels showed that the decreases were induced by higher amputation levels, whereas the amputation levels of toe/foot ray after standardization still showed a relative increase of + 12.8%. In-hospital mortality of all cases with lower limb amputation fell from 11.2% in 2005 to 7.7% in 2015 (SMR 0.89 [95% CI 0.86; 0.92]). The percentage of reamputations during the same hospital stay declined from 13.2 to 10.2%. CONCLUSIONS: The number of lower limb amputations declined in Germany, however distinctly stronger in women than in men. The observed decreases of in-hospital mortality as well as of reamputation rates point to improvements in perioperative health care. Despite these indications of improvements, the distinct increase in case numbers at the level of toe/foot ray calls for additional targeted prevention efforts, especially for patients with diabetes.

Outcomes of minor amputations in patients with peripheral vascular disease over a 10-year period at a tertiary care institution.

OBJECTIVES: Choosing an optimal amputation level requires balance between maximizing limb salvage while minimizing chances of non-healing wounds and re-amputation. Our aim was to assess the long-term outcome for minor amputations in patients with peripheral vascular disease. METHODS: A retrospective study of minor amputations between January 1, 2005 and December 31, 2015 was performed. Electronic medical records of eligible patients were examined to extract demographics, co morbidities and clinical data. RESULTS: Within the study period, 220 patients underwent 296 primary minor amputations in 244 lower extremities. Wound healing was achieved in 18.2% (54 of 296 amputations) and 43.6% (129 of 296 amputations) at 90 days and 365 days, respectively. Rates of progression to major amputation were 16.4% (40 or 244 limbs) and 21.7% (53 of 244 limbs) at 90 days and 365 days, respectively. In the final multivariate model, lower ipsilateral posterior tibial waveforms predicted poor 90-day healing (OR = 2.22, p = 0.01) as well as limb loss (OR = 3.02, p = 0.02) in a dose-response manner. In the final logistic regression model, emergency department admission (OR = 0.20, p < 0.01), ipsilateral posterior tibial waveform (OR = 2.63, p < 0.01), and post-operative infection (OR = 0.30, p < 0.01) were predictors of poor healing status at study endpoint. CONCLUSION: This study shows that a majority of foot amputees require ongoing care for non-healing wounds and a proportion necessitate conversion to major amputation. Adequate vascularization is essential to promote and maintain healing.