Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 8  |  Issue : 2  |  Page : 144-147

Factors affecting contralateral extremity following lower-extremity major amputation


Peripheral Vascular and Endovascular Surgery, Jain Institute of Vascular Sciences, A Unit of Bhagwan Mahaveer Jain Hospital, Bengaluru, Karnataka, India

Date of Submission11-May-2020
Date of Decision03-Aug-2020
Date of Acceptance18-Sep-2020
Date of Web Publication13-Apr-2021

Correspondence Address:
B Nishan
Peripheral Vascular and Endovascular Surgery, Jain Institute of Vascular Sciences, A Unit of Bhagwan Mahaveer Jain Hospital, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_58_20

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  Abstract 


Objective: Lower-extremity amputation is performed in patients who are at risk due to acute limb ischemia (ALI), chronic limb-threatening ischemia (CLTI), and diabetic foot infections, yet the proportion of patients who progress to amputation of their contralateral extremity following major amputation is not well defined. This study determines the rate of subsequent minor or major amputation of a contralateral extremity. Methods: We conducted a retrospective review of patients undergoing lower-extremity major amputation at JIVAS from 2011 to 2015. Outcomes included the proportion of patients who underwent minor or major amputation of contralateral extremity for a follow-up of 3 years. Results: From 2011 to 2015 period, 113 patients underwent major lower-extremity amputation. The mean age of patients was 59.5 years. Seventy-five percent were male, 88% were diabetic, 69% were hypertensive, 19% had renal insufficiency, 35% had coronary artery disease, 15% were smokers, 31% presented with diabetic foot infections, 20% presented with ALI (four patients underwent contralateral major amputation within the same admission), and 48% presented with CLTI who underwent an initial major amputation. After ipsilateral major amputation, 54% had normal contralateral extremity (four patients had ALI and six patients had CLTI and underwent revascularization), 14% underwent contralateral minor amputation (toe/transmetatarsal), 4% underwent contralateral major amputation (below/above the knee), 6% lost to follow-up, and 19% were dead at follow-up for 3 years. In this study, there is no significant difference between factors (gender and comorbidities) affecting contralateral limb amputation in patients who underwent major amputation. Conclusions: Preexisting comorbidities and gender might not affect contralateral limb amputations in patients with major amputation. Good control of comorbidities in the follow-up and diligent foot care probably play a role in predicting contralateral limb amputations. Vascular surgeons should be alert, and close surveillance and counseling of patients should be followed to prevent subsequent amputation in their contralateral lower extremity.

Keywords: Acute limb ischemia, chronic limb-threatening ischemia, diabetic foot infections, lower-extremity amputation


How to cite this article:
Nishan B, Sivakrishna K, Hudgi V V, Ahsan V P, Vivekanand. Factors affecting contralateral extremity following lower-extremity major amputation. Indian J Vasc Endovasc Surg 2021;8:144-7

How to cite this URL:
Nishan B, Sivakrishna K, Hudgi V V, Ahsan V P, Vivekanand. Factors affecting contralateral extremity following lower-extremity major amputation. Indian J Vasc Endovasc Surg [serial online] 2021 [cited 2021 Jun 24];8:144-7. Available from: https://www.indjvascsurg.org/text.asp?2021/8/2/144/313558




  Introduction Top


Lower-extremity amputations are performed due to consequences of peripheral arterial disease and diabetic foot infections.[1] Risk factors such as increased age, smoking, male gender, diabetes, hypertension (HTN), coronary artery disease, and renal insufficiency have been well documented.[2],[3],[4],[5],[6],[7],[8] Lower-extremity amputations affect not just the extremity undergoing the amputation but also the patient systemically.[9],[10],[11] The factors affecting contralateral extremity following major amputation have been documented in this study. In this study, rates of amputation in contralateral extremity (minor – 14% and major – 4%) were followed up for 3 years. Amputations have an impact on both mobility and functionality; this study further investigates factors that may lead to contralateral amputations.[12]


  Methods Top


Overview – we performed a retrospective review of all patients who underwent lower-extremity major amputation at JIVAS from 2011 to 2015 and studied the factors affecting the contralateral extremity for follow-up of 3 years. Demographics (age and sex) and comorbidities (diabetes mellitus [DM]/HTN, renal insufficiency, coronary artery disease, and smoking) are noted. Patients with diabetic foot infections, acute limb ischemia (ALI), and chronic limb-threatening ischemia (CLTI) who underwent major amputation are included. Patients who had trauma, tumor, or orthopedic complications were excluded. Toe or transmetatarsal amputations were considered minor, and amputations above transmetatarsal were considered major. Our primary outcome was to identify the factors contributing to subsequent amputations in the contralateral extremity.

Statistical analysis

The data were summarized by frequency and percentages for categorical parameters and mean with standard deviation for quantitatively measured parameters. The association of the risk factor with desired outcome was assessed by the Chi-square test of independence. P < 0.05 was considered as the statistical significance. The statistical software R version 3.6.2 (R Core Team, 2019) was used for statistical analysis.


  Results Top


We retrospectively analyzed 113 patients presented to JIVAS who underwent lower-extremity major (A/K or B/K) amputation during 2011–2015 and followed up for 3 years to identify factors affecting contralateral extremity.

The mean age was 59.5 years. Eighty-five (75%) were male and 28 (25%) were female. Seventy-eight (69%) were hypertensive, 99 (88%) were diabetic, 22 (19%) had renal insufficiency, 40 (35%) had coronary artery disease, and 18 (15%) were smokers [Table 1].
Table 1: Demographic data of 113 patients

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Of 113 patients who underwent major amputation, 35 (31%) were diagnosed with diabetic foot infections; 23 (20%) were diagnosed with ALI, of which four patients presented underwent contralateral major amputation with in the same admission (right –B/K and left –A/K); and 55 (48%) were diagnosed with CLTI [Table 2].
Table 2: Diagnosis

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Above- and below-knee amputations were done in 25 (22%) and 84 (74%) patients, respectively [Table 3]. All amputee stumps healed by primary intention with no infection. Four patients who underwent bilateral major amputation at initial admission expired during follow-up.
Table 3: Amputation during first admission

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In follow-up for 3 years, factors predisposing to minor or major amputation of contralateral extremity were evaluated. Sixty-two (54%) patients had normal contralateral limb with no minor or major amputation (four patients presented with ALI and six patients presented with CLTI and underwent revascularization). Seventeen (14%) patients underwent minor amputation, of which 13 (11%) were toe amputation (eight patients presented with diabetic foot infection and 5 presented with CLTI who underwent revascularization) and 4 (3%) were TMA (one patient presented with diabetic foot infection and three patients presented with CLTI and underwent revascularization). Five (4%) underwent major amputation, of which 4 (3%) were below the knee and 1 (≈1%) was above the knee who presented with nonsalvageable extremity. Seven (6%) patients were lost to follow-up and 22 (19%) were dead [Table 4]. All amputee stumps healed by primary intention with no infection in follow-up.
Table 4: Contralateral limb status at the end of three year follow up

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Of 17 (14%) patients who underwent minor amputation, 14 were male, 15 were diabetic, 12 were hypertensive, 3 had renal insufficiency, 6 had coronary artery disease, and 3 were smokers [Table 5].
Table 5: Factors affecting patients who underwent major and minor amputation vs no amputation of contralateral extremity during follow up of 3 years

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Of 5 patients who underwent major amputation, 3 were male, 3 were diabetic, 2 were hypertensive, 2 had renal insufficiency, 2 had coronary artery disease, and 1 was a smoker [Table 5].

In this study, there is no significant difference between factors (gender and comorbidities) affecting contralateral limb amputation in patients who underwent major amputation.


  Discussion Top


Our analysis shows that patients who underwent major amputation of the lower extremity would undergo a contralateral minor amputation in 14% and major amputation in 4% within 3 years. Age, sex, and comorbidities including DM, HTN, coronary artery disease, renal insufficiency, and smoking are included. Patients diagnosed with diabetic foot infections and peripheral vascular disease (acute/chronic) are evaluated. Patients who underwent major amputations are followed up for 3 years, and statuses of contralateral extremity and factors contributing to contralateral extremity amputations were noted. Pezzin et al. have evaluated subpopulations of patients with diabetes and vascular patients.[13],[14],[15] Lim et al., a single-institution series, reviewed rates of subsequent amputations in 87–277 patients undergoing major lower-extremity amputation.[16],[17],[18] Dormandy et al., reported 15%–53.3% of patients undergoing amputations needing a contralateral major amputation within 2–5 years. [19,20] Diabetics are known to be at higher risk of lower-extremity amputation[17] and are more likely to undergo contralateral amputation. [21,22] Sheahan et al., an institutional study of 258 patients, also documented that they are at greater risk of a second amputation on the same or contralateral limb.[23] Those with end-stage renal disease are also at higher risk of lower-extremity amputation.[17],[23] Lefebvre and Chevan showed that more men than women undergo lower-extremity amputation, but that women are more likely than men to undergo above-knee as compared with below-knee amputation.[24] Shore et al., using Medicare data, found survival rates at 1 year of 71%–77% for those undergoing minor amputations and 47%–64% for those undergoing major amputations.[9] In the present study, of 113 patients who underwent major amputation, 62 patients had normal contralateral limb, 17 patients underwent contralateral minor amputation, 5 patients underwent contralateral major amputation, 7 patients lost to follow-up, and 22 patients were dead in follow-up for 3 years.

In this study, there is no significant difference between factors (gender and comorbidities) affecting contralateral limb amputation in patients who underwent major amputation. Due to a numerically higher number of contralateral amputations following index limb major amputation, although statistically not significant, we recommend that good control of comorbidities and risk factors and diligent care of contralateral limb would prevent amputation.


  Conclusions Top


Preexisting comorbidities and gender might not affect contralateral limb amputations in patients with major amputation. Good control of comorbidities and risk factors and diligent foot care probably play a role in predicting contralateral limb amputations. More studies are required to assess other factors that might contribute to contralateral limb amputations. Vascular surgeons should be alert, and close surveillance and counseling of patients should be followed to prevent subsequent amputation in their contralateral lower extremity.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Selvin E, Erlinger TP. Prevalence of and risk factors for peripheral arterial disease in the United States: Results from the National Health and Nutrition Examination Survey, 1999-2000. Circulation 2004;110:738-43.  Back to cited text no. 1
    
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Nowygrod R, Egorova N, Greco G, Anderson P, Gelijns A, Moskowitz A, et al. Trends, complications, and mortality in peripheral vascular surgery. J Vasc Surg 2006;43:205-16.  Back to cited text no. 2
    
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Norgren L, Hiatt W, Dormandy J, Nehler M, Harris K, Fowkes F, et al. Inter-society consensus for the management of peripheral arterial disease (TASC II). J Vasc Surg 2006;45:67.  Back to cited text no. 3
    
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Global Lower Extremity Amputation Study Group. Epidemiology of lower extremity amputation in centres in Europe, North America and East Asia. The Global Lower Extremity Amputation Study Group. Br J Surg 2000;87:328-65.  Back to cited text no. 4
    
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Papazafiropoulou A, Tentolouris N, Soldatos RP, Liapis CD, Dounis E, Kostakis AG, et al. Mortality in diabetic and nondiabetic patients after amputations performed from 1996 to 2005 in a tertiary hospital population: A 3-year follow-up study. J Diabetes Complications 2009;23:7-11.  Back to cited text no. 5
    
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Dillingham TR, Pezzin LE, Mackenzie EJ. Racial differences in the incidence of limb loss secondary to peripheral vascular disease: A population-based study. Arch Phys Med Rehabil 2002;83:1252-7.  Back to cited text no. 6
    
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Henry AJ, Hevelone ND, Belkin M, Nguyen LL. Socioeconomic and hospital-related predictors of amputation for critical limb ischemia. J Vasc Surg 2011;53:330-90.  Back to cited text no. 7
    
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Callaghan BC, Feldiabetesan E, Liu J, Kerber K, Pop-Busui R, Moffet H, et al. Triglycerides and amputation risk in patients with diabetes: Ten year follow-up in the distance study. Diabetes Care 2011;34: 635-40.  Back to cited text no. 8
    
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Dillingham TR, Pezzin LE, Shore AD. Reamputation, mortality, and health care costs among persons with dysvascular lower-limb amputations. Arch Phys Med Rehabil 2005;86:480-6.  Back to cited text no. 9
    
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Aulivola B, Hile CN, Hamdan AD, Sheahan MG, Veraldi JR, Skillman JJ, et al. Major lower extremity amputation: Outcome of a modern series. Arch Surg 2004;139:395-9.  Back to cited text no. 10
    
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Faglia E, Clerici G, Mantero M, Caminiti M, Quarantiello A, Curci V, et al. Incidence of critical limb ischemia and amputation outcome in contralateral limb in diabetic patients hospitalized for unilateral critical limb ischemia during 1999-2003 and followed-up until 2005. Diabetes Res Clin Pract 2007;77:445-50.  Back to cited text no. 11
    
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Nehler MR, Coll JR, Hiatt WR, Regensteiner JG, Schnickel GT, Klenke WA, et al. Functional outcome in a contemporary series of major lower extremity amputations. J Vasc Surg 2003;38:7-14.  Back to cited text no. 12
    
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Izumi Y, Satterfield K, Lee S, Harkless LB. Risk of reamputation in diabetic patients stratified by limb and level of amputation: A 10-year observation. Diabetes Care 2006;29:566-70.  Back to cited text no. 13
    
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Faglia E, Favales F, Morabito A. New ulceration, new major amputation, and survival rates in diabetic subjects hospitalized for foot ulceration from 1990 to 1993: A 6.5-year follow-up. Diabetes Care 2001;24:78-83.  Back to cited text no. 14
    
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Dillingham TR, Pezzin LE, MacKenzie EJ. Limb amputation and limb deficiency: Epidemiology and recent trends in the United States. South Med J 2002;95:875-83.  Back to cited text no. 15
    
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Lim TS, Finlayson A, Thorpe JM, Sieunarine K, Mwipatayi BP, Brady A, et al. Outcomes of a contemporary amputation series. ANZ J Surg 2006;76:300-5.  Back to cited text no. 16
    
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Abou-Zamzam AM Jr., Teruya TH, Killeen JD, Ballard JL. Major lower extremity amputation in an academic vascular center. Ann Vasc Surg 2003;17:86-90.  Back to cited text no. 17
    
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Cruz CP, Eidt JF, Capps C, Kirtley L, Moursi MM. Major lower extremity amputations at a Veterans Affairs Hospital. Am J Surg 2003;186:449-54.  Back to cited text no. 18
    
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Dormandy J, Heeck L, Vig S. Major amputations: Clinical patterns and predictors. Semin Vasc Surg 1999;12:154-61.  Back to cited text no. 19
    
20.
Ebskov B, Josephsen P. Incidence of reamputation and death after gangrene of the lower extremity. Prosthet Orthot Int 1980;4:77-80.  Back to cited text no. 20
    
21.
Goodney PP, Beck AW, Nagle J, Welch HG, Zwolak RM. National trends in lower extremity bypass surgery, endovascular interventions, and major amputations. J Vasc Surg 2009;50:54-60.  Back to cited text no. 21
    
22.
Tarry WC, Walsh DB, Birkmeyer NJ, Fillinger MF, Zwolak RM, Cronenwett JL. Fate of the contralateral leg after infrainguinal bypass. J Vasc Surg 1998;27:1039-47.  Back to cited text no. 22
    
23.
Sheahan MG, Hamdan AD, Veraldi JR, McArthur CS, Skillman JJ, Campbell DR, et al. Lower extremity minor amputations: The roles of diabetes mellitus and timing of revascularization. J Vasc Surg 2005;42:476-80.  Back to cited text no. 23
    
24.
Lefebvre KM, Chevan J. Sex disparities in level of amputation. Arch Phys Med Rehabil 2011;92:118-24.  Back to cited text no. 24
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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