Assessing the Long-Term Outcomes of Minor Lower Limb Amputations: A 5-Year Study

Abstract

Our aim was to assess the long-term outcome for minor forefoot amputations. A retrospective study of 126 patients who had such amputations between 1999 and 2004 was performed. Patients were divided into 2 groups, diabetic (group A: 79 patients) and nondiabetic (group B: 47 patients). Angiograms were requested in 45 patients in group A compared with 31 patients in group B (P = ·77). In group A, 11 patients underwent further ipsilateral amputations compared with 30 patients in group B (P = ·02.). The 2 groups were equally likely to have vascular reconstruction (35% vs 37%). The overall 5-year mortality was 27%, with 58% of deaths occurring within the first year. This study shows that foot amputees have high mortality and reintervention rates. Adequate utilization of vascular services, extra vigilance in the prevention of complications, and risk factor modifications are required to improve postoperative outcomes.

Keywords

toe transmetatarsal amputation minor amputation outcome north London

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References

de Godoy JM , de Godoy MF , Batigalia F. , Trávolo AR , Monteiro EH Lower-extremity amputation: a 6-year follow-up study in Brazil. J Orthop Surg (Hong Kong). 2005;13(2):164-166.

Kerstein MD , Welter V. , Gahtan V. , Roberts AB Toe amputation in the diabetic patient. Surgery. 1997;122(3):546-547.

Schofield CJ , Libby G. , Brennan GM , MacAlpine RR , Morris AD , Leese GP Mortality and hospitalization in patients after amputation: a comparison between patients with and without diabetes. DARTS/MEMO Collaboration. Diabetes Care. 2006;29(10): 2252-2256.

Nehler MR , Whitehill TA , Bowers SP , et al. Intermediate-term outcome of primary digit amputations in patients with diabetes mellitus who have forefoot sepsis requiring hospitalization and presumed adequate circulatory status. J Vasc Surg. 1999;30(3): 509-517.

Izumi Y. , Satterfield K. , Lee S. , Harkless LB Risk of reamputation in diabetic patients stratified by limb and level of amputation: a 10-year observation. Diabetes Care. 2006;29(3):566-570.

Bardwell J. , Olczak S. The relationship between diabetic amputees and vascular reviews. J Tissue Viability. 1999;9(1):5-8.

Jones RN , Marshall WP

Does the proximity of an amputation, length of time between foot ulcer development and amputation, or glycemic control at the time of amputation affect the mortality rate of people with diabetes who undergo an amputation?

Adv Skin Wound Care. 2008;21(3):118-123.

Marshall C. , Stansby G. Amputation. Surgery. 2008;26(1): 21-24.

Sheahan MG , Hamdan AD , Veraldi JR , et al. Lower extremity minor amputations: the roles of diabetes mellitus and timing of revascularization. J Vasc Surg. 2005;42(3):476-480.

10.

Tseng CH , Chong CK , Tseng CP , Cheng JC , Wong MK , Tai TY Mortality, causes of death and associated risk factors in a cohort of diabetic patients after lower-extremity amputation: a 6.5-year follow-up study in Taiwan . Atherosclerosis. 2008;197(1): 111-117.

11.

Margolis DJ , Allen-Taylor L. , Hoffstad O. , Berlin JA Diabetic neuropathic foot ulcers and amputation . Wound Repair Regen. 2005;13(3):230-236.

12.

Miyajima S. , Shirai A. , Yamamoto S. , Okada N. , Matsushita T. Risk factors for major limb amputations in diabetic foot gangrene patients. Diabetes Res Clin Pract. 2006;71(3):272-279.

13.

Stone PA , Back MR , Armstrong PA , et al. Midfoot amputations expand limb salvage rates for diabetic foot infections. Ann Vasc Surg. 2005;19(6):805-811.

14.

Cruz CP , Eidt JF , Capps C. , Kirtley L. , Moursi MM Major lower extremity amputations at a Veterans Affairs hospital. Am J Surg. 2003;186(5):449-454.

15.

Yeager RA , Moneta GL , Edwards JM , et al. Predictors of outcome of forefoot surgery for ulceration and gangrene. Am J Surg. 1998;175(5):388-390.

16.

Glass H. , Rowe VL , Hood DB , Yellin AE , Weaver FA Influence of transmetatarsal amputation in patients requiring lower extremity distal revascularization. Am Surg. 2004;70(10): 845-849.

17.

Chen HF , Ho CA , Li CY Age and sex may significantly interact with diabetes on the risks of lower-extremity amputation and peripheral revascularization procedures: evidence from a cohort of a half-million diabetic patients. Diabetes Care. 2006;29(11):2409-2414.

18.

Apelqvist J. , Ragnarson-Tennvall G. , Persson U. , Larsson J. Diabetic foot ulcers in a multidisciplinary setting. An economic analysis of primary healing and healing with amputation. J Intern Med. 1994;235(5):463-471.

19.

Edmonds M. , Boulton A. , Buckenham T. , et al. Report of the Diabetic Foot and Amputation Group. Diabet Med. 1996;13(9suppl4):S27-S42.

20.

Lepäntalo M. , Biancari F. , Tukiainen E. Never amputate without consultation of a vascular surgeon. Diabetes Metab Res Rev. 2000;16(suppl 1):S27-S32.

21.

Toursarkissian B. , Hagino RT , Khan K. , Schoolfield J. , Shireman PK , Harkless L. Healing of transmetatarsal amputation in the diabetic patient: is angiography predictive? Ann Vasc Surg . 2005;19(6):769-773.

22.

Jude EB , Oyibo SO , Chalmers N. , Boulton AJ Peripheral arterial disease in diabetic and nondiabetic patients: a comparison of severity and outcome. Diabetes Care. 2001 ;24(8):1433-1437.

23.

Marso SP , Hiatt WR Peripheral arterial disease in patients with diabetes. J Am Coll Cardiol. 2006;47(5):921-929.

24.

Wakabayashi I. , Masuda H. Relationships between vascular indexes and atherosclerotic risk factors in patients with type 2 diabetes mellitus. Angiology. 2008;59(5):567-573.

25.

Silvestro A. , Diehm N. , Savolainen H. , et al. Falsely high ankle-brachial index predicts major amputation in critical limb ischemia. Vasc Med. 2006;11(2):69-74.

26.

Gu YQ Determination of amputation level in ischaemic lower limbs. ANZ J Surg. 2004;74(1-2):31-33.

27.

Guzman RJ , Brinkley DM , Schumacher PM , Donahue RM , Beavers H. , Qin X. Tibial artery calcification as a marker of amputation risk in patients with peripheral arterial disease. J Am Coll Cardiol. 2008;51(20):1967-1974.

28.

Ohsawa S. , Inamori Y. , Fukuda K. , Hirotuji M. Lower limb amputation for diabetic foot. Arch Orthop Trauma Surg. 2001; 121(4):186-190.

29.

Oishi CS , Fronek A. , Golbranson FL The role of non-invasive vascular studies in determining levels of amputation . J Bone Joint Surg Am. 1988;70(10):1520-1530.

30.

Davis BL , Kuznicki J. , Praveen SS , Sferra JJ Lower-extremity amputations in patients with diabetes: pre- and post-surgical decisions related to successful rehabilitation. Diabetes Metab Res Rev. 2004;20(suppl 1):S45-S50.

31.

Van Damme H. , Rorive M. , Martens De Noorthout BM , Quaniers J. , Scheen A. , Limet R. Amputations in diabetic patients: a plea for footsparing surgery. Acta Chir Belg. 2001;101(3):123-129.

32.

Daskalopoulou SS , Pathmarajah M. , Kakkos SK , et al. Association between ankle-brachial index and risk factor profile in patients newly diagnosed with intermittent claudication. Circ J. 2008; 72(3):441-448.

33.

Peters EJ , Childs MR , Wunderlich RP , Harkless LB , Armstrong DG , Lavery LA Functional status of persons with diabetes-related lower-extremity amputations . Diabetes Care. 2001;24(10):1799-1804.