Lower Limb Amputation Rates in Germany

Background and Objectives: The current epidemiology of lower limb amputations is unknown. Therefore, the purpose of this study was to determine (1) lower extremity amputation rates as a function of age, gender, and amputation level between 2015 and 2019, (2) main diagnoses indicating amputation, (3) revision rates after lower extremity amputation. Materials and Methods: Lower extremity amputation rates were quantified based on annual Operation and Procedure Classification System (OPS) and International Classifications of Disease (ICD)-10 codes from all German medical institutions between 2015 through 2019, provided by the Federal Statistical Office of Germany (Destatis). Results: In 2019, 62,016 performed amputations were registered in Germany. Out of these 16,452 procedures (26.5%) were major amputations and 45,564 patients (73.5%) underwent minor amputations. Compared to 2015, the incidence of major amputations decreased by 7.3% to 24.2/100,000 inhabitants, whereas the incidence of minor amputation increased by 11.8% to 67.1/100,000 inhabitants. Highest incidence was found for male patients aged 80–89 years. Patients were mainly diagnosed with peripheral arterial disease (50.7% for major and 35.7% for minor amputations) and diabetes mellitus (18.5% for major and 44.2% for minor amputations). Conclusions: Lower limb amputations remain a serious problem. Further efforts in terms of multidisciplinary team approaches and patient optimization strategies are required to reduce lower limb amputation rates.

Diabetes and other vascular risk factors in association with the risk of lower extremity amputation in chronic limb-threatening ischemia: a prospective cohort study

Background Patients with diabetes are at increased risk of developing chronic limb-threatening ischemia (CLTI) due to peripheral arterial disease, and this often results in lower extremity amputation (LEA). Little is known of the interaction between diabetes and other vascular risk factors in affecting the risk of CLTI. Methods We investigated the association of diabetes, and its interaction with hypertension, body mass index (BMI) and smoking, with the risk of LEA due to CLTI in the population-based Singapore Chinese Health Study. Participants were interviewed at recruitment (1993–1998) and 656 incident LEA cases were identified via linkage with nationwide hospital database through 2017. Multivariate-adjusted Cox proportional hazards models were used to compute hazard ratios (HRs) and 95% CIs for the associations. Results The HR (95% CI) for LEA risk was 13.41 (11.38–15.79) in participants with diabetes compared to their counterparts without diabetes, and the risk increased in a stepwise manner with duration of diabetes (P for trend < 0.0001). Hypertension and increased BMI independently increased LEA risk in those without diabetes but did not increase the risk in those with diabetes (P for interaction with diabetes ≤ 0.0006). Conversely, current smoking conferred a risk increment of about 40% regardless of diabetes status. Conclusions Although diabetes conferred more than tenfold increase in risk of LEA, hypertension and increased BMI did not further increase LEA risk among those with diabetes, suggesting a common mechanistic pathway for these risk factors. In contrast, smoking may act via an alternative pathway and thus confer additional risk regardless of diabetes status.

Quality of Life and Wellbeing in Peripheral Arterial Disease: A Qualitative Study

Peripheral arterial disease (PAD) is a vascular condition disproportionately affecting adults &gt; 60 and the leading cause of disability for adults &gt; 50. Because PAD is marked by severe leg pain and sometimes lower extremity amputation, quality of life (QOL) and wellbeing may be compromised however, we understand little about these constructs in this population. Furthermore, surgical care providers lack a comprehensive understanding of how individuals think about wellbeing and what is important to individuals during surgical care. We conducted a qualitative photographic elicitation study (n = 60) in one academic multidisciplinary PAD clinic to understand specific aspects of QOL of older individuals with PAD. Guided by interpretive description, a methodology pioneered in nursing, we analyzed data within and across five clinical symptom severity categories to examine for QOL constructs, impact on everyday life, understanding of disease, and desired treatment. Results demonstrate that individuals do not fully understand PAD diagnosis or its implications (e.g., “[I] have never heard of it. Do I have that?”). Disease-specific knowledge was prevalent among patients experiencing lower extremity amputation but those suffering from wounds or gangrene had limited understanding. Furthermore, patients’ descriptions of QOL conflicted with the conceptualization of QOL in clinical practice and research. That is, many participants describe QOL based on activities they are capable of performing despite limitations. Results demonstrate the need for integrating gerontological knowledge into clinical care to improve quality of care for older adults.

Effects of Anesthetic Techniques on the Risk of Postoperative Complications Following Lower Extremity Amputation in Diabetes Patients with Coagulation Abnormalities: A Retrospective Cohort Study Using Propensity Score Analysis

Diabetic foot amputation is associated with high morbidity and mortality rates. To prevent cardiovascular complications along with vasculopathy in the course of diabetes mellitus, a high number of patients receive anticoagulant therapy. However, anticoagulants are contraindicated in neuraxial anesthesia limiting available anesthetic modalities. Therefore, in this retrospective study, we aimed to compare between general anesthesia and peripheral nerve block (PNB) with respect to postoperative complications following lower extremity amputation (LEA) in patients with coagulation abnormalities. In total, 320 adult patients who underwent LEA for diabetic foot were divided into two groups according to the anesthetic type (general anesthesia vs. PNB). The inverse probability of treatment weighting was performed to balance the baseline patient characteristics and surgical risk between the two groups. The adjusted analysis showed that compared with the general anesthesia group, the PNB group had lower risks of pneumonia (odds ratio: 0.091, 95% confidence interval [CI]: 0.010–0.850, p = 0.0355), acute kidney injury (odds ratio: 0.078, 95% CI: 0.007–0.871, p = 0.0382), and total major complications (odds ratio: 0.603, 95% CI: 0.400–0.910, p = 0.0161). Additionally, general anesthesia was associated with a higher amount of intraoperative crystalloid administration and a requirement for more frequent vasopressors. In conclusion, PNB appears to be protective against complications following LEA in diabetes patients with coagulopathy.

Predictive risk factors for lower limb amputations in patients with diabetic foot ulcer in correlation with Wagner’s grading

Background: Lower extremity amputation in diabetic patients results in high morbidity causing poor quality of life despite high medical expenses. A correlate of risk factors with Wagner‘s grading of foot ulcers and their improvement with multidisciplinary team approach would form a basis for preventive diabetic foot care guidelines in health care policy. Objectives of current study were to assess the risk factors and role of multidisciplinary team approach in patients undergoing lower extremity amputations with diabetic footulcer with different Wagner‘s grading.Methods: Prospective data of diabetic patients above eighteen years with foot ulcers admitted in departments of general surgery/general medicine at Vydehi Institute of medical sciences and research centre, between October 2017 to October 2019 were included. Multi-disciplinary treatment approach was adopted and treated accordingly. Patients were followed up for three months to reassess the risk factors for lower extremity amputation and correlated with Wagner‘s grading system and analyzed using descriptive statistical analysis, SPSS-21.Results: fifty patients with Wagner’s grade 1-4 of which forty four (88%) males and six (12%) females. Four (8%) of the patients underwent major limb amputation. 18% underwent minor amputation and 16% SSG. 54% were grade 3,4 on day 1 and 24% patients were grade 3, 4 and 5 after 3 months of follow up (p=0.034).Conclusions: Clinical assessment of diabetic foot ulcer and identification of risk factors for the nonhealing predicts the favourable outcome in the management of diabetic foot combined with multi-disciplinary team approach strategy.