Amputation for vascular disease. Prognostic factors for healing, long-term outcome and costs

Abstract: General characteristics and outcome was evaluated in 177 consecutive patients who underwent a major amputation in a defined population. Smoking and diabetes lowered the mean amputation age. Healing failure at six months was seen in 24% of transtibial and in 11% of transfemoral amputees. Preoperative absence of gangrene and hemoglobin >120 g/L increased the risk of healing failure. Six months after amputation, about 1/3 used a prosthesis, 1/3 were confined to bed or a wheelchair and 1/3 had died. We analyzed all surgical procedures, total hospital stay and hospital costs in 321 consecutive patients having surgery for critical leg ischemia until at least 6-years postoperatively or until death. The first recorded operation during the inclusion year was a vascular procedure in 2/3 of all patients and a major amputation in 1/3. One third of those undergoing a reconstructive vascular procedure and half of those having a restorative vascular procedure eventually underwent an ipsilateral major amputation. The mean total long-term hospital costs were high (47,000 USD/patient), because of the need for repeated surgery (mean=3 procedures) and long hospital stay (mean=117 days). Thirty-two consecutive patients who underwent a transtibial amputation were subjected to nutritional assessment and given supplementary nutrition for 11 days. Twenty-eight patients were classified as malnourished (88%). Supplementary nutrition improved wound healing in patients with transtibial amputation, compared to a matched control group. All diabetic patients with a deep foot infection (n=223) were included consecutively during 10 years, and prospectively followed until healing for at least six months or until death. Multi-disciplinary treatment resulted in a low major amputation rate, but almost all patients needed local surgery. Duration of diabetes <14 years, a palpable popliteal pulse, a toe blood pressure >45 and an ankle blood pressure >80 mmHg, absence of exposed bone and a white blood cell count <12x10⁹/L were all related to healing without amputation.