SLR - October 2021 - Vincent A. Lefler
Reference: Maguire SC, Mohan HM, Fenelon C, Stow J, Nicholson P, Huang A, Ryall N, Sheehan S, Mehigan D, Dowdall J, Barry MC. Trends and Outcomes of Non-Traumatic Major Lower Extremity Amputations in an Irish Tertiary Referral Hospital. Ir J Med Sci. 2020 Nov;189(4):1351-1358.Level of Evidence: Level IV
Scientific Literature Review
Reviewed By: Vincent A. Lefler, DPM
Residency Program: McLaren Oakland Hospital – Pontiac, MI
Podiatric Relevance: This article explores the post-surgical outcomes for patients undergoing non-traumatic lower extremity amputation. Despite attempts at limb salvage in the vascularly compromised, definitive amputation is a reality for many of our podiatric patients. This article provides a good examination of the morbidity and mortality of this patient demographic following these amputations when they would no longer be under our care and supervision. The authors attempt to determine trends and outcomes of lower extremity amputation in an Irish setting (tertiary vascular center).
Methods: Authors described characteristics and up to five-year survival outcomes in Irish dysvascular patients undergoing lower extremity amputation: either transfemoral amputation (TFA) or transtibial amputation (TTA). One hundred seventy-two patients undergoing non-traumatic lower extremity amputation were enrolled. Data compiled level of amputation, timed mortality, medical comorbidities and patient mobility post-operatively.
Results: Forty-nine TTA performed were compared to 143 TFA. The TTA group had significantly higher prevalence of diabetes. Twenty-three patients (13.2 percent) died during the hospital stay of their amputation. Median survival for the group of 172 was 14.6-months post-amputation with no significant difference between the two amputation types. The five-year survival for TFA and TTA were 19 percent and 28 percent respectively. Median length of stay for those with amputation was 41-days for TTA and 25-days for TFA. 60.8 percent of amputation patients had undergone previous revascularization attempts. Twenty patients had distal amputations during same hospital stay which progressed to TTA or TFA.
Conclusions: The authors concluded that diabetes and other comorbidities such as peripheral vascular disease greatly increase the risk of lower extremity amputation and loss of limb. The five-year survival rate; as low as 19 percent in this study, is worse than 17 of the 21 most commonly diagnosed cancers in the UK. Only esophageal, lung, brain, and pancreatic cancer had worse five-year survival rate. The authors did find that mobility prior to amputation was a prognostic indicator to mobility post-amputation. Specifically, patients living at home pre-operatively were more likely to be ambulatory post-amputation. They also found that 76 percent of the amputees discharged from rehabilitation facility following amputation achieved some level of ambulation on discharge. With five-year life expectancies worse than other cancers, involving vascular specialists for revascularization when possible will likely aid in decreasing amputation rates. Additionally, aggressive wound care management and preventative measures including diabetic education should be a mainstay of practice protocols to reduce amputation risk and morbidity associated with it. Even after lower extremity amputation, the rehabilitation potential is vital to optimizing patient outcomes.