Can Early Post-Operative Scoring of Non-Traumatic Amputees Decrease Rates of Revision Surgery?
Abstract
:1. Introduction
2. Materials and Methods
2.1. Study Design
2.2. Retrospective Data Analysis
- -
- Sociodemographic data (age at amputation, sex, height, weight);
- -
- Amputation-related data (date of admission, amputation, and discharge; total duration of hospital stay; level and side of amputation, caring postoperative ward);
- -
- ICD-coded comorbidities;
- -
- Revision-related data (revision date, number of revisions, time (days) between revisions, reason for revision, performed surgical procedure);
- -
- Other (documented wound healing disorders, infection, ulceration, bleeding, nicotine use, alcohol consumption).
2.3. Analysis of ICD-Coded Comorbidities
2.4. Processing of the ICD-Coded Comorbidities and Hypothesized Risk Factors
3. Results
3.1. Demographics and Amputation Level Non Traumatic Amputees
3.2. Demographics and Amputation Level of Revised Non Traumatic Amputees
3.3. Prevalence of ICD-Coded Comorbidities in Non-Traumatic Amputees
3.4. Prevalence of ICD-Coded Comorbidities of Not Revised Non-Traumatic Amputees
3.5. Prevalence of ICD-Coded Comorbidities of Revised Non-Traumatic Amputees
3.6. Duration of Hospital Stay of Not-Revised Non-Traumatic Amputees
3.7. Duration of Hospital Stay of Revised Non-Traumatic Amputees
3.8. Results of the Correlation Analyses of Revision Surgery vs. Risk Factors
3.9. Non-Traumatic Amputation Score
3.10. Non-Traumatic Revision Score
3.11. Identification of the Cut Off-Values for the Designed Scoring Systems
4. Discussion
5. Conclusions
Supplementary Materials
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
References
- Kröger, K.; Berg, C.; Santosa, F.; Malyar, N.; Reinecke, H. Lower Limb Amputation in Germany—An Analysis of Data from the German Federal Statistical Office between 2005 and 2014. Dtsch. Arztebl. Int. 2017, 114, 130–136. [Google Scholar] [CrossRef] [PubMed]
- Spoden, M. Amputationen Der Unteren Extremität in Deutschland—Regionale Analyse Mit Krankenhausabrechnungsdaten von 2011 Bis 2015. Das Gesundheitswesen 2019, 81, 422–430. [Google Scholar] [CrossRef] [PubMed]
- Rowe, V.L.; Lee, W.; Weaver, F.A.; Etzioni, D. Patterns of Treatment for Peripheral Arterial Disease in the United States: 1996–2005. J. Vasc. Surg. 2009, 49, 910–917. [Google Scholar] [CrossRef] [PubMed]
- Goodney, P.P.; Beck, A.W.; Nagle, J.; Welch, H.G.; Zwolak, R.M. National Trends in Lower Extremity Bypass Surgery, Endovascular Interventions, and Major Amputations. J. Vasc. Surg. 2009, 50, 54–60. [Google Scholar] [CrossRef]
- Winell, K.; Venermo, M.; Ikonen, T.; Sund, R. Indicators for Comparing the Incidence of Diabetic Amputations: A Nationwide Population-Based Register Study. Eur. J. Vasc. Endovasc. Surg. 2013, 46, 569–574. [Google Scholar] [CrossRef] [PubMed]
- Pütter, C.; Stausberg, J.; von Beckerath, O.; Reinecke, H.; Schäfer, E.; Kröger, K. Determinants of Decreasing Major Amputation Rates in Germany. Vasa-Eur. J. Vasc. Med. 2016, 45, 311–315. [Google Scholar] [CrossRef]
- Nelson, M.T.; Greenblatt, D.Y.; Soma, G. Preoperative Factors Predict Mortality After Major Lower-Extremity Amputation. J. Vasc. Surg. 2013, 57, 1173. [Google Scholar] [CrossRef]
- Leaper, D.; Whitaker, I. OSH Post-Operative Complications; Leaper, D., Whitaker, I., Eds.; Oxford University Press: Oxford, UK, 2010; ISBN 9780199546268. [Google Scholar]
- Wanivenhaus, F.; Mauler, F.; Stelzer, T.; Tschopp, A.; Böni, T.; Berli, M.C. Revision Rate and Risk Factors after Lower Extremity Amputation in Diabetic or Dysvascular Patients. Orthopedics 2016, 39, e149–e154. [Google Scholar] [CrossRef] [PubMed]
- Kılıç, B.; Yücel, A.S.; Yaman, Ç.; Hergüner, G.; Korkmaz, M. Methods of Determining the Amputation Level of Lower Extremity. Eur. J. Exp. Biol. 2014, 4, 55–60. [Google Scholar]
- Wozniak, G.; Baumgartner, R. Prinzipien Der Amputation. In Operative und Interventionelle Gefäßmedizin; Debus, E.S., Gross-Fengels, W., Eds.; Springer: Berlin/Heidelberg, Germany, 2012; pp. 967–982. ISBN 978-3-642-01709-4. [Google Scholar]
- Vogel, T.R.; Petroski, G.F.; Kruse, R.L. Impact of Amputation Level and Comorbidities on Functional Status of Nursing Home Residents after Lower Extremity Amputation. J. Vasc. Surg. 2014, 59, 1323–1330.e1. [Google Scholar] [CrossRef]
- Davie-Smith, F.; Paul, L.; Nicholls, N.; Stuart, W.P.; Kennon, B. The Impact of Gender, Level of Amputation and Diabetes on Prosthetic Fit Rates Following Major Lower Extremity Amputation. Prosthet. Orthot. Int. 2017, 41, 19–25. [Google Scholar] [CrossRef] [PubMed]
- Czerniecki, J.M.; Turner, A.P.; Williams, R.M.; Thompson, M.L.; Landry, G.; Hakimi, K.; Speckman, R.; Norvell, D.C. The Development and Validation of the AMPREDICT Model for Predicting Mobility Outcome after Dysvascular Lower Extremity Amputation. J. Vasc. Surg. 2017, 65, 162–171.e3. [Google Scholar] [CrossRef] [PubMed]
- Wood, M.R.; Hunter, G.A.; Millstein, S.G. The Value of Revision Surgery after Initial Amputation of an Upper or Lower Limb. Prosthet. Orthot. Int. 1987, 11, 17–20. [Google Scholar] [CrossRef] [PubMed]
- Bourke, H.E.; Yelden, K.C.; Robinson, K.P.; Sooriakumaran, S.; Ward, D.A. Is Revision Surgery Following Lower-Limb Amputation a Worthwhile Procedure? A Retrospective Review of 71 Cases. Injury 2011, 42, 660–666. [Google Scholar] [CrossRef] [PubMed]
- Zidane, Z.B.; Salim, M.E.; Eidin, S.; Mahadi, I. Revision Surgery of Major Limb Amputations, Indication, Surgical Management and Outcome. Glob. J. Med. Res. 2016, 14, 2–8. [Google Scholar]
- Forbes, M.K.E.; Cobb, M.W.; Jeevaratnam, M.J.; King, M.I.; Cubison, L.C.T. Amputation Revision Surgery—Refining the Surgical Approach. Ten Years of Experience and 250 Cases, Impressions, Outcomes, and Thoughts for the Future. Injury 2021, 52, 3293–3298. [Google Scholar] [CrossRef] [PubMed]
- Liu, K.; Tang, T.; Wang, A.; Cui, S. Surgical Revision for Stump Problems after Traumatic Above-Ankle Amputations of the Lower Extremity. BMC Musculoskelet. Disord. 2015, 16, 1–7. [Google Scholar] [CrossRef] [PubMed]
- O’Brien, P.J.; Cox, M.W.; Shortell, C.K.; Scarborough, J.E. Risk Factors for Early Failure of Surgical Amputations: An Analysis of 8,878 Isolated Lower Extremity Amputation Procedures. J. Am. Coll. Surg. 2013, 216, 836–842. [Google Scholar] [CrossRef] [PubMed]
- Bondurant, F.J.; Cotler, H.B.; Buckle, R.; Miller-Crotchett, P.; BROWNER, B.D. The Medical and Economic Impact of Severely Injured Lower Extremities. J. Trauma Inj. Infect. Crit. Care 1988, 28, 1270–1273. [Google Scholar] [CrossRef]
- Stinus, H.; Schüling, S.; Geerken, J. Epidemiologische Daten Zu Amputationen an Der Unteren Extremität. Z. Orthop. Ihre Grenzgeb. 2008, 132, 239–243. [Google Scholar] [CrossRef]
- Guo, S.; DiPietro, L.A. Critical Review in Oral Biology & Medicine: Factors Affecting Wound Healing. J. Dent. Res. 2010, 89, 219–229. [Google Scholar] [CrossRef] [PubMed]
- Liu, M.; Zhang, W.; Yan, Z.; Yuan, X. Smoking Increases the Risk of Diabetic Foot Amputation: A Meta-Analysis. Exp. Ther. Med. 2018, 15, 1680–1685. [Google Scholar] [CrossRef] [PubMed]
- Singh, R.K.; Prasad, G. Long-Term Mortality after Lower-Limb Amputation. Prosthet. Orthot. Int. 2016, 40, 545–551. [Google Scholar] [CrossRef] [PubMed]
- Brownrigg, J.R.W.; Hinchliffe, R.J.; Apelqvist, J.; Boyko, E.J.; Fitridge, R.; Mills, J.L.; Reekers, J.; Shearman, C.P.; Zierler, R.E.; Schaper, N.C. Performance of Prognostic Markers in the Prediction of Wound Healing or Amputation among Patients with Foot Ulcers in Diabetes: A Systematic Review. Diabetes Metab. Res. Rev. 2016, 32, 128–135. [Google Scholar] [CrossRef] [PubMed]
- Robinson, W.P.; Loretz, L.; Hanesian, C.; Flahive, J.; Bostrom, J.; Lunig, N.; Schanzer, A.; Messina, L. Society for Vascular Surgery Wound, Ischemia, Foot Infection (WIfI) Score Correlates with the Intensity of Multimodal Limb Treatment and Patient-Centered Outcomes in Patients with Threatened Limbs Managed in a Limb Preservation Center. J. Vasc. Surg. 2017, 66, 488–498.e2. [Google Scholar] [CrossRef] [PubMed]
- Hwang, J.M. Time Is Tissue. Want to Save Millions in Wound Care? Start Early: A QI Project to Expedite Referral of High-Risk Wound Care Patients to Specialised Care. BMJ Open Qual. 2023, 12, e002206. [Google Scholar] [CrossRef] [PubMed]
- Conte, M.S.; Bradbury, A.W.; Kolh, P.; White, J.V.; Dick, F.; Fitridge, R.; Mills, J.L.; Ricco, J.B.; Suresh, K.R.; Murad, M.H.; et al. Global Vascular Guidelines on the Management of Chronic Limb-Threatening Ischemia. Eur. J. Vasc. Endovasc. Surg. 2019, 58, S1–S109.e33. [Google Scholar] [CrossRef] [PubMed]
- Norvell, D.C.; Czerniecki, J.M. Risks and Risk Factors for Ipsilateral Re-Amputation in the First Year Following First Major Unilateral Dysvascular Amputation. Eur. J. Vasc. Endovasc. Surg. 2020, 60, 614–621. [Google Scholar] [CrossRef] [PubMed]
- 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 of Reamputation. Prim. Care Diabetes 2016, 10, 434–441. [Google Scholar] [CrossRef]
- Gurney, J.K.; Stanley, J.; York, S.; Rosenbaum, D.; Sarfati, D. Risk of Lower Limb Amputation in a National Prevalent Cohort of Patients with Diabetes. Diabetologia 2018, 61, 626–635. [Google Scholar] [CrossRef]
- Mayfield, J.A.; Reiber, G.E.; Nelson, R.G.; Greene, T. A Foot Risk Classification System to Predict Diabetic Amputation in Pima Indians. Diabetes Care 1996, 19, 704–709. [Google Scholar] [CrossRef] [PubMed]
- Berli, M.C.; Wanivenhaus, F.; Kabelitz, M.; Götschi, T.; Böni, T.; Rancic, Z.; Waibel, F.W.A. Predictors for Reoperation after Lower Limb Amputation in Patients with Peripheral Arterial Disease. Vasa-Eur. J. Vasc. Med. 2019, 48, 419–424. [Google Scholar] [CrossRef] [PubMed]
- Thorud, J.C.; Plemmons, B.; Buckley, C.J.; Shibuya, N.; Jupiter, D.C. Mortality After Nontraumatic Major Amputation Among Patients with Diabetes and Peripheral Vascular Disease: A Systematic Review. J. Foot Ankle Surg. 2016, 55, 591–599. [Google Scholar] [CrossRef] [PubMed]
- Moxey, P.W.; Hofman, D.; Hinchliffe, R.J.; Poloniecki, J.; Loftus, I.M.; Thompson, M.M.; Holt, P.J. Delay Influences Outcome after Lower Limb Major Amputation. Eur. J. Vasc. Endovasc. Surg. 2012, 44, 485–490. [Google Scholar] [CrossRef]
- Condie, N.V.; Ambler, G.K. Re-Amputation: Time for Major Revision of Current Practice? Eur. J. Vasc. Endovasc. Surg. 2020, 60, 622. [Google Scholar] [CrossRef]
OPS-Code | Procedure |
---|---|
5-864 | Amputation and disarticulation of the lower limb |
5-864.0 | Hemipelvectomy |
5-864.1 | Incomplete hemipelvectomy |
5-864.2 | Hip disarticulation |
5-864.3 | Above the knee amputation, not specified |
5-864.4 | Amputation of the proximal femur |
5-864.5 | Amputation of the shaft or distal femur |
5-864.6 | Amputation on knee-level |
5-864.7 | Knee disarticulation |
5-864.8 | Below the knee amputation, not specified |
5-864.9 | Below the knee amputation, proximal |
5-864.a | Below the knee amputation, mid |
5-865 | Amputation and Disarticulation of the foot |
5-865.0 | Syme-Amputation |
5-865.1 | Amputation of the foot, not specified |
5-865.2 | Spitzy-Amputation |
5-865.3 | Pirogoff-Amputation |
5-865.4 | Chopart-Amputation |
5-865.5 | Lisfranc-Amputation |
Total N = 39 (100%) | |
---|---|
Male | 26 (66.7%) |
Female | 19 (33.3%) |
Age at amputation (mean, range in years) | 68.2 (39–94) |
Revision amputation level | |
Foot | 14 (36%) |
BKA | 15 (38%) |
Knee | 7 (18%) |
AKA | 3 (8%) |
Reason for Revision | Total of Revisions N = 63 |
Pain | 1 (0.02%) |
Would Healing Disorder | 42 (0.67%) |
Infection | 11 (17.5%) |
Hematoma | 2 (0.04%) |
Necrosis | 5 (0.08%) |
Type of Revision | |
Debridement | 23 (37%) |
Re-Amputation | 37 (59%) |
Neuroma Resection | 1 (0.02%) |
Risik Factor | Revision Yes (N = 39) | Revision No (N = 105) | Total (N = 144) |
---|---|---|---|
Lifestyle | |||
BMI | 28.55 % (26.3; 30.8) | 26.79 (25.4; 28.2) | 27.28 (26.1; 28.5) |
Nicotine consumption | 15.38% (5.86%; 30.53%) | 17.14% (10.49%; 25.73%) | 16.67% (10.98%; 23.78%) |
Diabetes | 46.15% (30.09%; 62.82%) | 40% (30.56%; 50.02%) | 41.67% (33.52%; 50.17%) |
Hyperlipidaemia | 12.82% (4.3%; 27.43%) | 10.48% (5.35%; 17.97%) | 11.11% (6.49%; 17.42%) |
Neuropathic Foot | |||
Polyneuropathy | 10.26% (2.87%; 24.22%) | 11.43% (6.05%; 19.11%) | 11.11% (6.49%; 17.42%) |
Vascular disease | |||
PAD | 76.92% (60.67%; 88.87%) | 69.52% (59.78%; 78.13%) | 71.53% (63.42%; 78.73%) |
Atherosclerosis | 71.79% (55.13%; 85%) | 67.62% (57.79%; 76.43%) | 68.75% (60.5%; 76.21%) |
Hypertonus | 35.9% (21.2%; 52.82%) | 39.05% (29.67%; 49.06%) | 38.19% (30.23%; 46.65%) |
Documented thrombosis/embolism | 28.21% (15%; 44.87%) | 23.81% (16.04%; 33.11%) | 25% (18.16%; 32.89%) |
Heart attack | 17.95% (7.54%; 33.53%) | 19.05% (12.04%; 27.87%) | 18.75% (12.73%; 26.1%) |
Infection | |||
Sepsis/SIRS | 17.95% (7.54%; 33.53%) | 20% (12.83%; 28.93%) | 19.44% (13.33%; 26.86%) |
Wound healing disorder | 64.1% (47.18%; 78.8%) | 11.43% (6.05%; 19.11%) | 25.69% (18.78%; 33.64%) |
Infection | 20.51% (9.3%; 36.46%) | 9.52% (4.66%; 16.82%) | 12.5% (7.58%; 19.03%) |
Ulceration | 33.33% (19.09%; 50.22%) | 31.43% (22.72%; 41.22%) | 31.94% (24.43%; 40.22%) |
Gangrene | 28.21% (15%; 44.87%) | 54.29% (44.28%; 64.04%) | 47.22% (38.85%; 55.71%) |
Osteomyelitis | 0% (0%; 9.03%) | 12.38% (6.76%; 20.24%) | 9.03% (4.89%; 14.94%) |
Fasciitis | 2.56% (0.06%; 13.48%) | 2.86% (0.59%; 8.12%) | 2.78% (0.76%; 6.96%) |
Amputation Score | ||||
---|---|---|---|---|
Value: | ||||
1. | PAD | I–III: | +1 | |
IV: | +2 | |||
Closure: | +3 | |||
2. | Hypertension | Yes | +1 | |
No | +0 | |||
3. | Diabetes | Yes | +2 | |
No | +0 | |||
4. | BMI | 25.0–29.9 | +1 | |
30.0–34.9 | +2 | |||
35.0–39.9 | +3 | |||
>40 | +4 | |||
5. | Smokers | Yes | +1 | |
No | +0 | |||
6. | Gangrene/necrosis of the foot | +1 | ||
Sepsis | +2 | |||
7. | Age | <55 | +0 | |
56–75 | +1 | |||
>75 | +2 | |||
Maximum score value: | 15 | |||
Revision risk score | ||||
8. | Postoperative wound healing disorders | Yes | +3 | |
(3 weeks post-op not healed) | Neo | +0 | ||
10. | Time between admission and amputation | >30 Days | +3 | |
<30 Days | +0 | |||
11. | Amputation distal to the knee | Yes | +1 | |
No | +0 | |||
Maximum score value: | 7 | |||
Combined non-traumatic amputation-revision score | ||||
Maximum score value | 22 |
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Brauckmann, V.; Block, O.M.; Pardo, L.A., Jr.; Lehmann, W.; Braatz, F.; Felmerer, G.; Mönnighoff, S.; Ernst, J. Can Early Post-Operative Scoring of Non-Traumatic Amputees Decrease Rates of Revision Surgery? Medicina 2024, 60, 565. https://doi.org/10.3390/medicina60040565
Brauckmann V, Block OM, Pardo LA Jr., Lehmann W, Braatz F, Felmerer G, Mönnighoff S, Ernst J. Can Early Post-Operative Scoring of Non-Traumatic Amputees Decrease Rates of Revision Surgery? Medicina. 2024; 60(4):565. https://doi.org/10.3390/medicina60040565
Chicago/Turabian StyleBrauckmann, Vesta, Ole Moritz Block, Luis A. Pardo, Jr., Wolfgang Lehmann, Frank Braatz, Gunther Felmerer, Sebastian Mönnighoff, and Jennifer Ernst. 2024. "Can Early Post-Operative Scoring of Non-Traumatic Amputees Decrease Rates of Revision Surgery?" Medicina 60, no. 4: 565. https://doi.org/10.3390/medicina60040565