Advertisement

The Timing of Limb Amputation in Nontraumatic Patients: Impact on Mortality and Postoperative Complication Rates

  • Shani Shamir
    Affiliations
    Resident, Infectious Disease Unit, Shaare Zedek Medical Center, Affiliated with the Hebrew University-Hadassah Medical School, Jerusalem, Israel
    Search for articles by this author
  • Yuval Schwartz
    Affiliations
    Fellow, Infectious Disease Unit, Shaare Zedek Medical Center, Affiliated with the Hebrew University-Hadassah Medical School, Jerusalem, Israel
    Search for articles by this author
  • Daniel Cohen
    Affiliations
    Orthopedic Surgeon, Department of Orthopedics, Shaare Zedek Medical Center, Affiliated with the Hebrew University-Hadassah Medical School, Jerusalem, Israel
    Search for articles by this author
  • Tali Bdolah-Abram
    Affiliations
    Statistician, Shaare Zedek Medical Center, Affiliated With the Hebrew University-Hadassah Medical School, Jerusalem, Israel
    Search for articles by this author
  • Amos M. Yinnon
    Affiliations
    Professor, Infectious Disease Unit, Shaare Zedek Medical Center, Affiliated with the Hebrew University-Hadassah Medical School, Jerusalem, Israel

    Professor, Division of Internal Medicine, Shaare Zedek Medical Center, Affiliated with the Hebrew University-Hadassah Medical School, Jerusalem, Israel
    Search for articles by this author
  • Yonit Wiener-Well
    Correspondence
    Address correspondence to: Yonit Wiener-Well, MD, Infectious Disease Unit, Shaare Zedek Medical Center, P.O. Box 3235, Jerusalem 91031, Israel
    Affiliations
    Consultant, Infectious Disease Unit, Shaare Zedek Medical Center, Affiliated with the Hebrew University-Hadassah Medical School, Jerusalem, Israel
    Search for articles by this author
Published:August 11, 2021DOI:https://doi.org/10.1053/j.jfas.2021.08.002

      Abstract

      Diabetes and peripheral vascular diseases are accompanied frequently by lower limb ischemia and in minority, need for amputation, as a treatment of last resort. Even after a decision has been made regarding amputation, the procedures are often repeatedly postponed due to more urgent surgeries and lack of operating room availability. This study assessed the possible relationship between the duration of time inpatients wait for semiurgent amputations and the incidence of postamputation complications. A retrospective cohort, including all 360 adult patients who underwent nontraumatic limb amputation due to an ischemic/gangrenous/infected foot in a single center during an 11-year period (2007-2017). Most (96%) of the procedures were major amputations. The mean waiting time until amputation was 3 ± 5 days. Mortality during hospitalization occurred in 101 (28%) patients and re-amputation in 38 (11%). The duration of antibiotic treatment was 11 ± 14 days. The rate of sepsis was 30% (107/360). There was no significant difference between the duration of time until amputation and mortality during hospitalization: among those who waited ≤48 hours, the mortality rate was 27% (60/224) and among those who waited >48 hours 30% (41/136) (p = .5). Patients waiting ≤48 hours had higher re-amputation rates than those waiting >48 (31/223 (14%) vs 7/136 (5%), p = .009). Mortality was associated significantly to patients' age and renal function. Correlation was found between the waiting time until amputation (≤48 or >48 hours) and the rates of in-hospital mortality, sepsis, duration of antibiotic treatment and overall duration of hospitalization. Re-amputation rate was higher in group with the shorter waiting time. This correlation may be explained by the fact that patients who needed urgent amputation had a more extensive and severe disease, and thus tended to require more re-amputation operations.

      Level of Clinical Evidence

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to The Journal of Foot and Ankle Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

      1. International Diabetes Federation. IDF Diabetes Atlas—7th edition. Available at: http://www.idf.org/diabetesatlas. Accessed August 30, 2021.

        • Fowkes FGR
        • Rudan D
        • Rudan I
        • Aboyans V
        • Denenberg JO
        • McDermott MM
        • Norman PE
        • Sampsom UKA
        • Williams LJ
        • Mensah GA
        • Criqui MH.
        Comparison of global estimates of prevalence and risk factors for peripheral artery disease in 2000 and 2010: a systematic review and analysis.
        Lancet. 2013; 382: 1329-1340
        • Weledji EP
        • Fokam P.
        Treatment of the diabetic foot – to amputate or not?.
        BMC Surgery. 2014; 14: 83
        • Wu SC
        • Driver VR
        • Wrobel JS
        • Armstrong DG.
        Foot ulcers in the diabetic patient, prevention and treatment.
        Vasc Health Risk Manag. 2007; 3: 65-76
      2. National Amputee Statistical Database (NASDAB) National Amputee Statistical Database Annual Report 2004/2005, UK: NASDAB, 2005

        • Peter-Riesch B.
        The diabetic foot: the never-ending challenge.
        Endocr Dev. 2016; 31: 108-134
        • Font-Jiménez I
        • Llaurado-Serra M
        • Roig-Garcia M
        • De Los Mozos-Perez B
        • Acebedo-Urdiales S.
        Retrospective study of the evolution of the incidence of non-traumatic lower-extremity amputations (2007-2013) and risk factors for re-amputation.
        Prim Care Diabetes. 2016; 6: 434-441
        • Czerniecki J
        • Thompson M
        • Littman A
        • Boyko E
        • Landry G
        • Henderson W
        • Turner A
        • Maynard C
        • Moore K
        • Norvell D.
        Predicting re-amputation risk in patients undergoing lower extremity amputation due to the complications of peripheral artery disease and/or diabetes.
        Br J Surg. 2019; 106: 1026-1034
        • Moxey PW
        • Hofman D
        • Hinchliffe RJ
        • Jones K
        • Thompson MM
        • Holt PJ.
        Epidemiological study of lower limb amputation in England between 2003 and 2008.
        Br J Surg. 2010; 97: 1348-1353
        • Narres M
        • Kvitkina T
        • Claessen H
        • Droste S
        • Schuster B
        • Morbach S
        • Rümenapf G
        • Van Acker K
        • Icks A.
        Incidence of lower extremity amputations in the diabetic compared with the non-diabetic population: a systematic review.
        PLoS One. 2017; 12e0182081
        • van Netten JJ
        • Fortington LV
        • Hinchliffe RJ
        • Hijmans JM.
        Early post-operative mortality after major lower limb amputation: a systematic review of population and regional based studies.
        Eur J Vasc Endovasc Surg. 2016; 51: 248-257
        • Davenport DL
        • Ritchie JD
        • Xenos ES.
        Incidence and risk factors for 30-day postdischarge mortality in patients with vascular disease undergoing major lower extremity amputation.
        Ann Vasc Surg. 2012; 26: 219-224
        • Thorud JC
        • Plemmons B
        • Buckley CJ
        • Shibuya N
        • Jupiter DC.
        Mortality after nontraumatic major amputation among patients with diabetes and peripheral vascular disease: a systematic review.
        J Foot Ankle Surg. 2016; 55: 591-599
        • Bickell NA
        • Federman AD
        • Aufses Jr., AH.
        Influence of time on risk of bowel resection in complete small bowel obstruction.
        J Am Coll Surg. 2005; 201: 847-885
        • Bjorkelund KB
        • Hommel A
        • Thorngren KG
        • Lundberg D
        • Larsson S.
        The influence of perioperative care and treatment on the 4-month outcome in elderly patients with hip fracture.
        AANA J. 2011; 79: 51-61
        • Leung F
        • Lau TW
        • Kwan K
        • Chow SP
        • Kung AW.
        Does timing of surgery matter in fragility hip fractures?.
        Osteoporos Int. 2010; 21: S529-SS34
        • Moxey PW
        • Hofman D
        • Hinchliffe RJ
        • Poloniecki J
        • Loftus IM
        • Thompson MM
        • Holt PJ.
        Delay influences outcome after lower limb major amputation.
        Eur J Vasc Endovasc Surg. 2012; 44: 485-490
        • Zonderland ME
        • Boucherie RJ
        • Litvak N
        • Vleggeert-Lankamp CLAM.
        Planning and scheduling of semi-urgent surgeries.
        Health Care Manag Sci. 2010; 13: 256-267
      3. The National Quality Indicators Program in General Hospitals, 2013-2017 indicators, Ministry of Health, Israel (from Hebrew). Available at: https://www.health.gov.il/PublicationsFiles/Quality_National_Prog.pdf. Accessed August 30, 2021.

        • Holt RIJ.
        Putting feet first: rising to the challenge.
        Diabet Med. 2016; 33: 1463
        • Lowe JA
        • Crist BD
        • Bhandari M
        • Ferguson TA.
        Optimal treatment of femoral neck factures according to patient's physiologic age: an evidence-based review.
        Orthop Clin North Am. 2010; 41: 157-166
        • Muhsen K
        • Green MS
        • Soskolne V
        • Neumark Y.
        Inequalities in non-communicable diseases between the major population groups in Israel: achievements and challenges.
        Lancet. 2017; 389: 2531-2541
        • Tirosh A
        • Calderon-Margalit R
        • Mazar M
        • Stern Z.
        Differences in quality of diabetes care between Jews and Arabs in Jerusalem.
        Am J Med Qual. 2008; 23: 60-65