Predisposal factors leading to early re-amputation among diabetic patients who underwent minor amputation

Underlying factors for early subsequent amputations

Authors

Keywords:

minor amputation, re-amputation, diabetic foot

Abstract

Background/Aim: Prolonged wound complications and the possibility of reoperations are significant outcomes following minor amputations. As time progresses after the initial surgery, re-amputations become more prevalent. Contrary to prevailing beliefs, the incidence of early amputations remains consistent. Additionally, it is widely acknowledged that the first 6 months following the initial surgery pose the highest risk period for reoperation. This retrospective clinical study aims to investigate the risk factors contributing to ipsilateral re-amputation procedures within 6 months of the initial minor amputation.

Methods: A retrospective cohort study was conducted involving amputee patients from 2008 to 2020. Patients with traumatic events, musculoskeletal tumors, prior major amputations, and those who underwent soft tissue procedures such as debridement, incision, drainage, or secondary closure were excluded. Patients who had undergone preoperative lower limb arterial Doppler ultrasound and whose initial preoperative laboratory records were accessible were included. The total cohort comprised 168 patients, comprising 57 women and 109 men. The mean follow-up duration was 1.5 years (range: 1.1–3.2 years). Patients who underwent ipsilateral re-amputation were categorized into two groups based on the timing of the subsequent surgery. The first group comprised 110 (65.5%) patients who underwent ipsilateral re-amputation 6 months after the initial amputation, while the second group encompassed 58 (34.5%) patients who underwent ipsilateral re-amputation within 6 months of the initial amputation.

Results: Among the 168 patients, 58 (34.5%) experienced ipsilateral re-amputation within 6 months of their initial minor amputations, while 64.5% underwent re-amputation surgery after the initial 6 months. The absence of peripheral arterial disease was not linked to early re-amputations (P=0.001). Although the mean C-reactive protein values (80.30 mg/dL and 84.26 mg/dL for groups 1 and 2, respectively) did not display significance between the groups (P=0.40), the group undergoing amputation within 6 months demonstrated significance with elevated serum white blood cell mean levels (10.44 mcL and 11.96 mcL for groups 1 and 2, respectively; [P=0.004]). Moreover, lower hemoglobin levels (11.41 g/dL and 10.77 g/dL for groups 1 and 2, respectively) were associated with re-amputation within the initial 6 months following the initial surgery (P=0.024).

Conclusion: The study underscores that the incidence of re-amputation after minor amputations in diabetic patients is comparably high, as has been reported in recent literature. While the selection of the initial amputation level remains pivotal, and not all patient-specific factors were examined in this study, the research brings attention to specific laboratory values and the vascular status of the diabetic limb as crucial considerations for surgeons prior to the initial surgery.

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References

Malay DS, Margolis DJ, Hoffstad OJ, Bellamy S. The incidence and risks of failure to heal after lower extremity amputation for the treatment of diabetic neuropathic foot ulcer. J Foot Ankle Surg. 2006 Nov-Dec;45(6):366-74. DOI: https://doi.org/10.1053/j.jfas.2006.08.002

Thorud JC, Jupiter DC, Lorenzana J, Nguyen TT, Shibuya N. Reoperation and reamputation after transmetatarsal amputation: a systematic review and meta-analysis. J Foot Ankle Surg. 2016;55:1007–12 DOI: https://doi.org/10.1053/j.jfas.2016.05.011

Van Damme H, Limet R. Amputation in diabetic patients. Clin Podiatr Med Surg. 2007;24:569-82. DOI: https://doi.org/10.1016/j.cpm.2007.03.007

Harding JL, Pavkov ME, Gregg EW, Burrows NR. Trends of nontraumatic lower extremity amputation in end-stage renal disease and diabetes: United States, 2000–2015. Diabetes Care. 2019;42:1430-5. DOI: https://doi.org/10.2337/dc19-0296

Nerone VS, Springer KD, Woodruff DM, Atway SA. Reamputation after minor foot amputation in diabetic patients: risk factors leading to limb loss. J Foot Ankle Surg. 2013 Mar-Apr;52(2):184-7. DOI: https://doi.org/10.1053/j.jfas.2012.11.015

Snyder DC, Salameh JR, Clericuzio CP. Retrospective review of forefoot amputations at a Veterans Affairs hospital and evaluation of post-amputation follow-up. Am J Surg. 2006 Nov;192(5):e51-4. DOI: https://doi.org/10.1016/j.amjsurg.2006.08.015

Beaulieu RJ, Grimm JC, Lyu H, Abularrage CJ, Perler BA. Rates and predictors of readmission after minor lower extremity amputations. J Vasc Surg. 2015 Jul;62(1):101-5. DOI: https://doi.org/10.1016/j.jvs.2015.02.021

Izumi Y, Lee S, Satterfield Y, Harkless L. Risk of reamputation in diabetic patients stratified by limb and level of amputation. Diabetes Care. 2006;29:566e70. DOI: https://doi.org/10.2337/diacare.29.03.06.dc05-1992

Skoutas D, Papanas N, Georgiadis GS, Zervas V, Manes C, Maltezos E, et al. Risk factors for ipsilateral reamputation in patients with diabetic foot lesions. Int J Low Extrem Wounds. 2009 Jun;8(2):69-74. DOI: https://doi.org/10.1177/1534734609334808

Stone PA, Back MR, Armstrong PA, Flaherty SK, Keeling WB, Johnson BL, et al. Midfoot amputations expand limb salvage rates for diabetic foot infections. Ann Vasc Surg. 2005 Nov;19(6):805-11. DOI: https://doi.org/10.1007/s10016-005-7973-3

Newhall KA, Bekelis K, Suckow BD, Gottlieb DJ, Farber AE, Goodney PP, et al. The relationship of regional hemoglobin A1c testing and amputation rate among patients with diabetes. Vascular. 2017 Apr;25(2):142-8. DOI: https://doi.org/10.1177/1708538116650099

Nather A, Bee CS, Huak CY, Chew JL, Lin CB, Neo S, et al. Epidemiology of diabetic foot problems and predictive factors for limb loss. J Diabetes Complications. 2008;22:77–82. DOI: https://doi.org/10.1016/j.jdiacomp.2007.04.004

Nasri H, Rafieian-Kopaei M. Diabetes mellitus and renal failure: Prevention and management. J Res Med Sci. 2015 Nov;20(11):1112-20. DOI: https://doi.org/10.4103/1735-1995.172845

Faglia E, Clerici G, Clerissi J, Gabrielli L, Losa S, Mantero M, et al. Early and five-year amputation and survival rate of diabetic patients with critical limb ischemia: data of a cohort study of 564 patients. Eur J Vasc Endovasc Surg. 2006;32:484–90. DOI: https://doi.org/10.1016/j.ejvs.2006.03.006

Ratliff HT, Shibuya N, Jupiter DC. Minor vs. major leg amputation in adults with diabetes: Six-month readmissions, reamputations, and complications. J Diabetes Complications. 2021 May;35(5):107886. DOI: https://doi.org/10.1016/j.jdiacomp.2021.107886

Birmpili P, Li Q, Johal AS, Atkins E, Waton S, Chetter I, et al. Outcomes after minor lower limb amputation for peripheral arterial disease and diabetes: population-based cohort study. Br J Surg. 2023 Jul 17;110(8):958-65. DOI: https://doi.org/10.1093/bjs/znad134

Murdoch DP, Armstrong DG, Dacus JB, Laughlin TJ, Morgan CB, Lavery LA. The natural history of great toe amputations. J Foot Ankle Surg. 1997 May-Jun;36(3):204-8; discussion 256. DOI: https://doi.org/10.1016/S1067-2516(97)80116-0

Joyce A, Yates B, Cichero M. Transmetatarsal amputation: a 12-year retrospective case review of outcomes. Foot 2020;42(July):101637. DOI: https://doi.org/10.1016/j.foot.2019.08.008

Lin JH, Jeon SY, Romano PS, Humphries MD. Rates and timing of subsequent amputation after initial minor amputation. J Vasc Surg. 2020 Jul;72(1):268-75. DOI: https://doi.org/10.1016/j.jvs.2019.10.063

Liu R, Petersen BJ, Rothenberg GM, Armstrong DG. Lower extremity reamputation in people with diabetes: a systematic review and meta-analysis. BMJ Open Diabetes Res Care. 2021 Jun;9(1):e002325. DOI: https://doi.org/10.1136/bmjdrc-2021-002325

Gülcü A, Etli M, Karahan O, Aslan A. Analysis of routine blood markers for predicting amputation/re-amputation risk in diabetic foot. Int Wound J. 2020 Dec;17(6):1996-2004. DOI: https://doi.org/10.1111/iwj.13491

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Published

2023-08-30

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Research Article

How to Cite

1.
Gürsan O, Çeltik M, Türemiş C. Predisposal factors leading to early re-amputation among diabetic patients who underwent minor amputation: Underlying factors for early subsequent amputations. J Surg Med [Internet]. 2023 Aug. 30 [cited 2023 Sep. 26];7(8):514-7. Available from: https://jsurgmed.com/article/view/7933