Mortality and Conversion Rates to Below-Knee or Above-Knee Amputation After Transmetatarsal Amputation.

INTRODUCTION: The purpose of this study was to identify associated risk factors for complications, need for a higher level of amputation such as below-knee amputation (BKA) or above-knee amputation (AKA), and mortality after transmetatarsal amputation (TMA). METHODS: We identified 265 patients who underwent 286 TMA procedures between June 2002 and July 2016. Medical records were reviewed for revision surgery and amputation. Mortality was verified using the National Death Index. We identified and documented potential risk factors including diabetes, hemoglobin A1c level, end-stage renal disease, cardiovascular disease, peripheral vascular disease, history of revascularization, contralateral amputation, and neuropathy. Sixty-eight percent were male, the mean age was 56.9 years (SD 12.8; range 24.1 to 92.1), and the median body mass index was 28.6 (interquartile range, 24.5 to 33.1). RESULTS: Twenty-seven percent of the patients required a subsequent BKA or AKA after the index TMA surgery. The results of a multivariable model indicated that women (odds ratio [OR], 3.63; 95% confidence interval [CI], 1.716 to 7.672), patients aged 57 to 64 years (OR, 0.17; 95% CI, 0.06 to 0.51), and patients with a history of revascularization (OR, 7.06, 95% CI, 2.86 to 17.44) had markedly higher odds than the relevant comparison groups. Forty percent of the patients died after the index TMA at a median of 27 months. After adjusting for all patient factors, history of end-stage renal disease (OR, 2.2; 95% CI, 1.206 to 4.014) and cardiovascular disease (OR, 2.879; 95% CI, 1.615 to 5.131) remained markedly associated with mortality after TMA. DISCUSSION: There are high rates of additional amputation after nontraumatic TMA and a high mortality rate. Surgeons should set realistic expectations with patients considered for TMA and identify risk factors, which may guide treatment. Treatment is multidisciplinary, requiring attention to surgical details, correction of vascular deficiency or contracture when present, and perioperative medical optimization. LEVEL OF EVIDENCE: IV.

Ethics and economic appraisals in health care.

Although the author recognizes that the ethical point of view could be an aid to a group of professionals, he examines the ethical value of economic appraisal in health care. First of all he considers the issue of the experimental nature of appraisals and demonstrates that certain studies using human subjects do not respect the most elementary ethical rules: conformity of the experiment to the present state of scientific knowledge, consideration for the risks which the experiment could involve for the subject, consent of the person concerned. Without aiming at an exhaustive list he then looks at the different value conflicts which could be picked out, a characteristic of ethical research. He states first of all that economic appraisals in health care try to bring together very different value systems in using common criteria in decisions, but this cannot completely eliminate these systems and the conflicts which stem from them. In particular he underlines the phenomenon of occultation which could result from the use of mathematical formulae. After the contradictions between medicine and economics he then goes on to point out the contradictions between the levels of understanding reality, between fields of economic or social considerations. Finally, he insists on the mobility of ethical thought and on the vigilance which it is always necessary to observe.

KIE: Medicine has been faced with the problem of proving its efficiency, not only in clinical results but also in terms of cost effectiveness. Economic appraisal in health care which requires human experimentation must conform to ethical rules, including consideration of existing scientific knowledge, risk analysis, and informed consent. Value conflicts may occur when the best treatment is not the most economical or, on a larger scale, when the therapeutic strategy which is most efficient, on the average, for a group of patients is not the most efficient for an individual in that group. A medical strategy considered only in terms of costs and benefits may be in opposition to social needs, so there must be consideration of the medical consequences of economic studies.