Fate of the Contralateral Limb After Lower Extremity Amputation

SLR- March 2014- Angela Riznyk

Reference: Glaser JD, Bensley RP, Hurks R, et al. Fate of the Contralateral Limb After Lower Extremity Amputation. J VascSurg.  2013; 6(58): 1571-1577.

 

Scientific Literature Review

Reviewed By: Angela Riznyk, DPM 
Residency Program: Inova Fairfax Hospital
 

Podiatric Relevance: Unfortunately, even with all attempts at limb salvage, certain podiatric patients will undergo amputations, whether minor or major. This article gives a quantitative measure that demonstrates the importance of post-operative surveillance of not only the operative limb but the contralateral limb as well.

Methods: This article provides a retrospective review of all patients undergoing a first time lower extremity amputation at Beth Israel Deaconess Medical Center from 1998 to 2010. Patients were identified using ICD-9 procedure codes for lower extremity amputations. Toe or transmetatarsal amputations were considered minor and amputations through the ankle or above were considered major. Patients were included if their amputations were related to non-healing wounds with or without PAD or ischemic rest pain. Patients were excluded if their amputations were due to trauma, tumor, or orthopaedic complications. Laterality of the amputation was also documented after a chart review was performed. Co-morbidities were also elucidated using admission ICD-9 codes. Primary outcome was the rate of subsequent major amputations in the contralateral limb. Secondary outcomes included the rate of other subsequent amputations, including contralateral minor, ipsilateral minor, and ipsilateral major amputations.
 

Results: One thousand, seven hundred and fifteen patients underwent a lower extremity amputation at their institution between 1998-2010 – 575 major amputations and 1140 minor amputations. Seventy-seventy percent of amputees were diabetic. Patients who initially underwent major amputations tended to be older, female, and were more likely to be diabetic than those who initially underwent minor amputations. Following initial amputation, 559 patients went on to have 729 subsequent amputations; 1,156 patients did not undergo subsequent amputations. Four-hundred and fifteen patients had amputations on the ipsilateral limb (184 major) and 314 had amputations on the contralateral limb (134 major). Patients who underwent subsequent major amputation on the contralateral limb were more likely to be female, of nonwhite race, diabetic, and have renal disease. During follow up, 11.5 percent of patients who underwent an initial major amputation had a contralateral major amputation within five years compared with 8.4 percent of those that underwent an initial minor amputation. 8.4 percent of patients who underwent an initial major amputation had an ipsilateral revision amputation or more proximal major amputation within five years while 14.2 percent of those undergoing an initial minor amputation had an ipsilateral major amputation. 15 percent of patients who underwent an initial minor amputation underwent a contralateral minor amputation while 19.9 percent had a subsequent ipsilateral minor amputation. Significant predictors of contralateral major amputation were end stage renal disease, chronic renal insufficiency, atherosclerosis with and without diabetic neuropathy, and initial major amputation. Estimates of mortality were 17 percent, 29.1 percent, and 49 percent at one, three, and five years after initial minor amputations and 19.2 percent, 48.7 percent, and 61.3 percent at one, three, and five years after initial major amputations.

Conclusions: The authors’ main conclusions were as follows – 8.4 percent of those undergoing a minor amputation and 11.5 percent of those undergoing an initial major amputation will undergo a contralateral major amputation within five years and 14 percent of those undergoing an initial minor amputation will need an ipsilateral major amputation within five years. Their work also shows that those with diabetes and especially those with concomitant renal disease are particularly at risk for limb loss. They described that women who require amputation are more likely to undergo a major amputation than a minor amputation. The reason for this is not well understood. Possible theories include that they are more likely to present with occlusions and multilevel disease than men. The overall results of this work are not necessarily surprising, however they could be presented to patients in an effort to discuss with them the seriousness of subsequent amputations especially when it relates to their contralateral limb. They also point to the importance of close surveillance by providers of not only the operative limb but also the contralateral limb. Limb salvage is a multi-disciplinary field which necessitates close follow-up of the patient as a whole by all providers involved (podiatrists, vascular surgeons, primary careproviders, nephrologists etc.).