Reamputation after Minor Foot Amputation in Diabetic Patients: Risk Factors Leading to Limb Loss

doi:10.1053/j.jfas.2012.11.015

The Journal of Foot and Ankle Surgery

Volume 52, Issue 2, March–April 2013, Pages 184-187

https://doi.org/10.1053/j.jfas.2012.11.015 Get rights and content

Abstract

The prevalence of lower extremity reamputation in diabetic patients has been well-documented. We sought to determine the risk factors for major lower extremity amputation (LEA) after minor foot amputation in diabetic patients. We studied 163 diabetic patients who had undergone an initial minor foot amputation and then had undergone at least 1 subsequent major or minor LEA. The patients were separated into a minor LEA group (initial minor LEA followed by at least 1 subsequent minor LEA) and a major LEA group (initial minor LEA followed by at least 1 subsequent major LEA). We then studied the possible risk factors for both groups. The possible risk factors analyzed were age, glycemic control, kidney function, previous kidney or kidney–pancreas transplantation, smoking history, and presence and severity of peripheral arterial disease (PAD). No statistical significance was found between the 2 groups for hemoglobin A1c, smoking status, chronic kidney disease, end-stage renal disease requiring dialysis, kidney or kidney-pancreas transplantation, or vascular intervention (peripheral arterial bypass). In the minor group, 22.23% had severe PAD. In the major group, 71.15% had severe PAD. This was statistically significant (p < .001). The average interval to major amputation in those without PAD, mild to moderate PAD, and severe PAD was 1,180.9, 591.0, and 559.6 days, respectively. This demonstrates the importance of assessing the peripheral vascular status in all diabetic patients with minor LEA. Early referral to a vascular surgeon might delay (or prevent) major LEA.

Section snippets

Patients and Methods

In the present retrospective study, we identified 172 patients at our institution who had undergone a minor foot amputation (“International Classification of Disease, 9th revision” [ICD-9], codes 84.11 and 84.12) and had diabetes mellitus (ICD-9 code 250.XX) and at least 1 subsequent lower extremity amputation (ICD-9 codes 84.14, 84.15, and 84.17) from January 1, 2000 to January 1, 2011. Amputations were performed by the vascular surgery, orthopedic surgery, and podiatric surgery services. The

Demographic Data

The findings are summarized in the Table. There were 298 amputations (111 patients) in the minor amputation group, and 211 amputations (52 patients) in the major amputation group. The average patient age was 53.18 ± 11.11 and 56.23 ± 10.76 for the minor and major LEA groups, respectively. The percentage of male patients in the minor and major LEA group was 58.56% (n = 65) and 65.39% (n = 34), respectively. The percentage of patients who were white was 58.56% (n = 65) in the minor LEA group and

Discussion

The present retrospective study examined the differences in a diabetic population that had undergone an initial minor foot amputation and then subsequently underwent either a minor LEA or major LEA. The hypothesis was that the patients in the major LEA group would have a greater incidence of our tested risk factors than those patients in the minor LEA group. The results of the present study partially refuted our hypothesis and showed that the only significant risk factor for diabetic patients

Acknowledgment

The authors wish to thank Mahmoud Abdel-Rasoul, MS, MPH, of the Ohio State University Center for Biostatistics for his statistical analysis.

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Cited by (27)

Risk factors for reamputation in patients with diabetic foot: A case-control study
2023, Foot and Ankle Surgery
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.
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.
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.
Direct and surrogate outcomes in patients with diabetic foot ulcers identify vascular involvement as an important risk factor for reamputation.
III
Analysis of repeated lesions after diabetic forefoot amputation
2022, Diabetes Research and Clinical Practice
Citation Excerpt :
With challenges in adjusting for variables, previous clinical studies on diabetic foot evaluated the risk factors for recurrence and reamputation [6–8]. Despite controversies, the well-known risk factors for diabetic foot recurrence and reamputation are type 1 diabetes, diabetic polyneuropathy, infection, gangrene, smoking, peripheral arterial disease, chronic renal failure, and dialysis [9–15]. Patients that underwent a previous amputation have a higher risk of recurrence of diabetic foot diseases, such as ulcer, gangrene, and infection.
This study was performed to analyze the clinical characteristics, related factors, and prognosis of repeated lesions after diabetic forefoot amputation.
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.
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.
Repeated lesions were affected by general conditions, and the contralateral side must be carefully examined after diabetic forefoot amputation.
Geographical socioeconomic disadvantage is associated with adverse outcomes following major amputation in diabetic patients
2021, Journal of Vascular Surgery
Citation Excerpt :
Aside from ADI, we found that PAD was associated with higher odds of reamputation. This finding was expected, given that PAD has been associated with higher risks of lower extremity amputation and reamputation in the past.34-36 Importantly, we did not find a significant difference in odds of reamputation between patients who underwent BKA vs AKA.
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.
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.
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).
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.
Rates and timing of subsequent amputation after initial minor amputation
2020, Journal of Vascular Surgery
Citation Excerpt :
In this higher risk group, the finding that revascularization before repeat minor amputation is protective against major amputation is compelling and corroborates the point that earlier recognition of vascular disease can improve outcomes. The mechanism of this finding cannot be elucidated with the present dataset, but the hypothesis is that it could possibly be due to closer follow-up and disease specific care; other authors have suggested that early referral and involvement of vascular specialists may delay or prevent amputation.16,18 The selection criteria used in this study includes a large number of patients with critical limb ischemia and these patients often have significant comorbidities.
Studies evaluating major amputation after initial minor amputation are few with rates of subsequent major amputation ranging from 14% to 35% with limited understanding of associated comorbidities and time to limb loss. The aim of this study is to determine the major amputation rates for patients who had already undergone an initial minor amputation and determine which factors are associated with the need for subsequent major amputation.
Using statewide data between 2005 and 2013, patients with peripheral artery disease (PAD), diabetes mellitus (DM), and combined PAD/DM who had a lower extremity ulcer and who had also undergone a minor amputation were identified. These patients were evaluated for the rate of subsequent major amputation and competing risk Cox proportional hazards modeling was used to study which factors were associated with the risk of subsequent limb loss.
The cohort consisted of 11,597 patients (DM, n = 4254; PAD, n = 2142; PAD/DM, n = 5201) with lower extremity ulcers who underwent an initial minor amputation. The rate of any subsequent amputation was highest in patients with PAD/DM (23% vs DM = 17%, PAD = 17%; P = not statistically significant). The rate of subsequent minor amputation was 16% in the PAD/DM versus 15.2% in PAD and 12.2% in patients with DM (P < .001). Patients with PAD/DM had the highest rate of subsequent major amputation (6.3% vs DM = 5.2%, PAD = 2.1%; P < .001). There was no statistically significant difference in the median time to major amputation among the three groups (PAD/DM, 13 months; DM, 14 months; PAD, 8.6 months; P = NS). Patients who were revascularized before a repeat minor amputation had a decreased risk of a major amputation compared with those who were intervened on after a repeat minor amputation (hazard ratio, 0.002; 95% confidence interval, 0-0.22). Patients treated completely in the outpatient setting were also less likely to undergo subsequent major amputation (hazard ratio, 0.7; 95% confidence interval, 0.5-0.98) compared with those who required hospitalization or presented to the emergency room.
Patients with ulcers and combined PAD and DM have a higher risk for secondary major and minor amputation than patients with either disease alone with half of the limb loss occurring at approximately 1 year after the initial minor amputation. Additionally, early diagnosis and appropriate referral may result in decreased limb loss for these patients.
Outcome of trans-metatarsal amputations in patients with diabetes mellitus
2019, Foot
This retrospective case series reports the reoperation rate, survival rate and mobility status in patients with diabetes mellitus who had undergone a trans-metatarsal amputation (TMA) managed within a diabetic foot care service.
Forty-one consecutive patients (37 men, 4 women) underwent a TMA with primary wound closure between January 2008 and December 2017. Eighty-eight per cent (36/41) of the patients were followed-up for a mean of 2.3 years. The outcomes were retrospectively reviewed.
Four (11%) of the 36 patients required reoperation, including three (8%) major amputations. All of the patients requiring a reoperation had peripheral vascular disease. Eleven patients died giving a four-year survival rate of 69% (25/36). Of the surviving patients who had not required revision to a major amputation 96% (21/22) were fully mobile in bespoke orthoses. A third used a walking cane.
This study shows that a TMA with primary wound closure in patients with diabetes mellitus, is effective for limb salvage with low reoperation and major amputation rates. A well healed TMA stump provides independent mobility in the majority of patients. The failures occurred in patients with peripheral vascular disease who, even after percutaneous trans-luminal angioplasty, had a 19% major amputation rate.
Level IV, retrospective case series.
Salami-Tactics: when is it time for a major cut after multiple minor amputations?
2023, Archives of Orthopaedic and Trauma Surgery

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Original ResearchReamputation after Minor Foot Amputation in Diabetic Patients: Risk Factors Leading to Limb Loss

Abstract

Section snippets

Patients and Methods

Demographic Data

Discussion

Acknowledgment

Am J Surg

J Foot Ankle Surg

J Diabetes Complications

Transplant Proc

Eur J Vasc Endovasc Surg

J Vasc Surg

J Am Coll Cardiol

Risk of reamputation in diabetic patients stratified by limb and level of amputation: a 10-year observation

Diabetes Care

Major lower extremity amputation: outcome of a modern series

Arch Surg

Energy cost of walking of amputees: the influence of level of amputation

J Bone Joint Surg Am

Foot infections in diabetic patients: decision and cost-effectiveness analyses

JAMA

Risk factors for lower extremity amputation in persons with diabetes

Diabetes Care

Risk factors for amputation in patients with diabetes mellitus: a case-control study

Ann Intern Med

Original Research
Reamputation after Minor Foot Amputation in Diabetic Patients: Risk Factors Leading to Limb Loss