Retrospective cohort study of long-term outcomes and prognostic factors for survival after lower extremity amputation in patients with diabetes

Diabetes and its complications are an increasing global problem.1 Moreover, diabetic foot is prone to recurrent ulceration and infection, that can eventually lead to lower extremity amputation (LEA).2 Infection and ischemia in the diabetic foot are considered the two most significant threats to limb retention.3 LEA is a severe complication that causes physical impairment and seems to negatively affect life expectancy.4 Even after below ankle amputation (BAA), five year mortality is higher than in many cancers.5 Suprisingly, health related quality of life is not always negatively impacted by minor amputation.6 However, among patients with diabetic foot disease, LEA is a complication feared more than death.7

The level of amputation is a crucial choice that impacts the physical health status of the patient.4 Insufficient or delayed primary debridement has been associated with more proximal amputation.8 In an earlier study among patients with diabetic foot infection, major amputation was associated with a six-fold risk for mortality over time.9 After BAA, it is usually possible for the patient to use the lower limb for walking or at least for transitioning from bed to chair, and thus the patient retains some level of independent capability. More proximal amputations below the knee (BKA) or above the knee (AKA) require rehabilitation with a prosthesis to ambulate and could therefore pose a risk that the patient will end up dependent or in wheelchair.10

In Finland, majority of amputations is performed by plastic surgeons, vascular surgeons and orthopaedic surgeons. Since 2012, the evaluation of these patients in our hospital has been carried out by a multidisciplinary team including a podiatrist and wound care nurse alongside dermatologist, internist, infectious disease specialist and earlier mentioned surgical specialists. Such structured diabetic foot service has been associated with reduction in a frequency of LEA.11., 12. Finland has a national guideline of treating diabetic foot problems, which mainly aligns with the guideline of international working group of diabetic foot.13

Incidence of diabetes has increased globally during the last decades and simultaneously an international interest in limb salvage has grown.1 This interest has resulted in the initiation of multidisciplinary centers that have reduced the number of major amputations.14., 15., 16., 17. In Finland, the rate of all LEAs has increased, whereas major amputations (especially BKA) have decreased.18., 19., 20. Moreover, an exponential increase in revascularizations (especially in the infrapopliteal region) has been associated with this favorable change from major amputation to limb salvage among patients with diabetes.18., 19. The increasing number of patients with diabetes (especially type 2) has led to an increasing demand for knowledge of outcomes after amputation and those factors affecting such outcomes to be updated.1 Earlier review has summarized low 5-year overall survival (OS) rates (between 0 % and 47 %) after non-traumatic LEA.21 However, patients with and without diabetes are different and for example the location of peripheral artery disease (PAD) in lower extremity differs between these groups.22 At present, there is a lack of studies with sufficient sized population comprised entirely of patients with diabetes and providing long term follow-up. In addition, major amputation-free survival (MAFS) is a significant endpoint that is seldom reported.

In this study, we observed OS and MAFS after LEA in a population comprised entirely of patients with diabetes. Secondarily, we evaluated the effect of amputation level and other significant factors to OS and MAFS.

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