K. Sebekos1, G. Stamelos1, K. Guiab1, T. A. Evans1, F. Bokhari1 1John H. Stroger, Jr. Hospital of Cook County, Trauma & Burn Surgery, Chicago, IL, USA
Introduction:
Below-knee amputation (BKA) operations can be performed by General Surgeons (GS), Orthopedic Surgeons (OS) and Vascular Surgeons (VS). This retrospective study looks at post-operative complication rate, mortality and prolonged length of stay after a BKA and compares the outcomes among the three specialties.
Methods:
Adult patients who underwent a BKA were identified from the 2016 – 2018 National Surgical Quality Improvement Project (NSQIP) database. Patient characteristics including age, gender, race, ethnicity, BMI, comorbidities, frailty index, anesthesia type, emergency cases, wound class and postoperative diagnosis were collected for the three surgical specialties. Statistical data for orthopedic and vascular BKA cases were then compared with GS cases using logistic regression analysis. Outcomes included complication rate, mortality and length of hospital stay.
Results:
There were 6,744 BKA cases identified for this study. VS had the highest volume of BKA with 60.2% of the cases, compared to GS at 21.8% and OS at 18.1%. Majority of amputations were male (69.9%) and white (62.6%) among all three specialties. Patients requiring BKA were likely to be diabetic (71.2%), have hypertension requiring medication (78.2%), current smokers (28.4%), and be overweight with a median BMI of 28.16. At the conclusion of the cases, 55.3% were clean wounds, 37.2% contaminated/infected and 7.5% clean/contaminated. Overall mortality rate was 2.4%, and 39.2% had complications.
The three groups were similar in terms of age, gender, race, BMI. 5.0% of GS patients had severe frailty compared to OS (3.9%) and in VS (3.7%, p<0.001). OS had significantly higher rates of emergency cases (17.1% vs. 10% for GS and 7.3% for VS, p<0.001), and worse wound classification (46.4% vs. 41.4% for GS and 33.0% for VS, p<0.001). PVD was notably higher in VS (44.9% vs. 32.4% for GS and 17.0% for OS, p<0.001). Of all the complications, bleeding requiring transfusions accounted for the highest amount with 20.5% and was highest in the VS group (22.6% vs. 19.1% for GS vs.15.3% for OS, p<0.001). Deep incisional SSI accounted for 2.4% of complications with the highest occurring in the GS group (3.2%) and lowest found in the OS group (1.7%, p=0.031). Amputations performed by OS had lower rates of overall complications at 32.9%, compared to VS (41.1%) and GS (39.3%, <0.001).
Compared to GS, VS was more likely to have a prolonged length of stay (OR 1.467, 95% CI 1.288-1.670) while OS was less likely (OR 0.681, 95% CI 0.571-0.811). OS had a lower risk of complications (OR 0.815, 95% CI 0.682-0.975). Mortality was not significantly different among the three specialties.
Conclusion:
There are less complications when orthopedic surgery performs an amputation. There are opportunities for operative result improvement by collaboration among surgical subspecialties.