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Lower Extremity Amputations Among Veterans: Have Ambulatory Outcomes and Survival Improved?

  • Gabrielle Daso
    Affiliations
    David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
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  • Alina J. Chen
    Affiliations
    David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
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  • Savannah Yeh
    Affiliations
    David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
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  • Jessica B. O'Connell
    Affiliations
    Division of Vascular & Endovascular Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA

    Division of Vascular Surgery, Surgical & Perioperative Careline, Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, CA
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  • David A. Rigberg
    Affiliations
    Division of Vascular & Endovascular Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA

    Division of Vascular Surgery, Surgical & Perioperative Careline, Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, CA
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  • Christian de Virgilio
    Affiliations
    Division of Vascular & Endovascular Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA

    Division of Vascular Surgery, Surgical & Perioperative Careline, Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, CA
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  • Hugh A. Gelabert
    Affiliations
    Division of Vascular & Endovascular Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA

    Division of Vascular Surgery, Surgical & Perioperative Careline, Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, CA
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  • Jesus G. Ulloa
    Correspondence
    Correspondence to: Jesus G. Ulloa, MD, 11301 Wilshire Blvd, Surgical & Perioperative Care, Mail Code 10H2, Los Angeles, CA 90073, USA
    Affiliations
    Division of Vascular & Endovascular Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA

    Division of Vascular Surgery, Surgical & Perioperative Careline, Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, CA
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      Highlights

      • Postoperative multidisciplinary teams increase odds of reaching ambulation.
      • Postamputation ambulation significantly improved odds of survival.
      • Postamputation ambulation may reduce postoperative mortality.
      • On average, more patients achieve ambulation yearly.

      Background

      We hypothesize among patients undergoing lower extremity amputation, access to pre-, and post operative rehabilitation services; as well as improved medical care, have led to higher rates of postoperative ambulation, and improved survival.

      Methods

      Retrospective single center review of all major lower extremity amputations performed at the Greater Los Angeles Veterans Affairs Healthcare System from 2000–2020 stratified into multiyear cohorts. We abstracted demographics, operative indication, comorbidities, preoperative medical management, perioperative complications, discharge location, and pre and postoperative ambulatory status. Odds of ambulation after amputation were analyzed using multivariate logistic regression. Survival was analyzed using multivariate logistic regression and Kaplan-Meier survival analysis. Multivariate logistic predictors were selected based on prior literature and clinical experience.

      Results

      We identified 654 operations in our study, noting fewer amputations performed in the latest 3 cohort years as compared to the initial cohort (2000–2004). Patients undergoing below-knee amputations (BKA) had 2.7 times (P < 0.05) greater odds of postoperative ambulation and 86% (P < 0.05) increased odds of survival compared to above-knee amputations (AKA). The odds of ambulation increased by 8.8% (P < 0.05) for each consecutive study year. Ambulation post-amputation conferred 13.2 times (P < 0.05) greater odds of survival. The odds of survival in “emergent” operations decreased by 48% (P < 0.05) compared to an “elective” operation. For each additional comorbidity, the odds of survival decreased by 18% (P < 0.05). Patients with any perioperative complication had a 48% (P < 0.05) lower odds of survival. Kaplan-Meier survival estimates demonstrated significant survival difference between patients by amputation level and postoperative ambulatory status (P < 0.05).

      Conclusions

      Ambulatory status following distal amputation has improved over time and is significantly associated with increased survival post-amputation. Patients undergoing a BKA or discharged home were most likely to ambulate postoperatively. Amputation level, preoperative comorbidities, and perioperative complications remain strong predictors of survival.
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