Major lower extremity amputations : outcomes, complications, and patient perspectives

An amputation is considered to be one of the oldest surgical procedures; yet, despite advancements in medical care, it continues to be associated with high rates of complications and postoperative mortality. This thesis aims to shed light on the complications, outcomes, and patient perspectives surrounding major lower extremity amputations (LEA).

Study I investigated mortality rates following the first-ever transfemoral amputation (TFA) at 1 week and 1 year, focusing on the potential influence of diabetes. A total of 162 individuals who underwent their first-ever TFA between 1996 and 2012 were included. Diabetes was present in 30 patients (19%). Mortality rates were notably higher for patients with diabetes compared to those without at both 1 week (30% versus 8%, p = 0.001) and 1 year (80% versus 57%, p = 0.02). This difference remained significant after conducting a multivariable analysis.

Study II examined and compared outcomes after two different reamputation levels following a failed transtibial amputation (TTA) – TFA and knee disarticulation (KD). The primary outcomes were further reoperation and reamputation. A total of 152 patients were included, with 66 cases of KD and 86 cases of TFA. Following KD, the reamputation rate was 36% compared to 15% after TFA (p = 0.004). In the multivariable analysis, TFA was associated with a decreased risk of reamputation, with an odds ratio of 0.31 (95% CI 0.14 – 0.69). The reoperation rate was 22% after TFA, compared to 38% after KD (p = 0.03). Prosthetic fitting was achieved in 30% of KD cases and 19% of TFA cases (p = 0.1), however, this was not statistically significant. Mortality did not significantly differ between the two reamputation levels.

Study III analyzed the impact on days to prosthesis after the implementation of a new guideline for transtibial amputations. We included 263 TTA patients after the new guideline was implemented and compared them against 169 patients undergoing TTA before the new guideline. Following the implementation of the new guideline, there was a significant reduction of time to prosthesis compared to before (76 versus 103 days, p < 0.001). The rates of prosthetic fitting were similar in the two cohorts, but female gender was significantly associated with lower prosthetic fitting rates also after adjusting for potential confounders. Mortality rates did not differ between the two cohorts.

Using a qualitative method, Study IV explored patients’ experiences of their care trajectory, the given information, and involvement in care following the implementation of a new guideline. In total, 15 participants were selected and interviewed, all with experience of a TTA within the care under the new guideline. The interviews were analyzed using content analysis, and three themes emerged: (1) The mixed experience of becoming an amputee; (2) The need to be seen during the amputation process; and (3) The importance of being involved in the care. The main discovery is the participants’ desire for increased involvement in the decision-making process, with our interdisciplinary team follow-up serving as an exceptional demonstration of shared decision-making. While participants appreciated the printed information, oral communication was deemed most significant presenting the gravity of the subject. Participants also noted a lack of continuity throughout their care trajectory.

In conclusion, the prevalence of postoperative complications following major LEA underscores the need for improved optimization and careful consideration of surgical approaches and treatment for each patient. Nevertheless, there are ways to enhance care for transtibial amputees, as demonstrated by the implementation of a new guideline, which has the potential to reduce the transition time from surgery to prosthetic fitting in a clinical setting. Gender disparities in prosthetic fitting persist as a significant concern, warranting further investigations. Another important enhancement in clinical practice would involve bolstering shared decision-making processes, facilitating greater involvement and information exchange with patients and their families. In this regard, introducing an interdisciplinary pre-amputation meeting and assigning a contact nurse for improved continuity could represent meaningful improvements. Shared decision-making holds particular significance in surgical interventions like amputations, given the elevated risk of complications.

List of scientific papers

I. Increased mortality among patients with diabetes following first-ever transfemoral amputation. Sjödin L, Enocson A, Rotzius P, Lapidus LJ. Diabetes Res Clin Pract. 2018 Sep;143:225-231.
https://doi.org/10.1016/j.diabres.2018.07.016

II. Knee disarticulation vs. transfemoral amputation after failed transtibial amputation: Surgical outcome and prosthetic fitting in patients with peripheral vascular disease. Sjödin L, Ottoson C, Lapidus LJ. Prosthtet Orthot Int. 2024 Jan 1;48(1):25-29.
https://doi.org/10.1097/PXR.0000000000000304

III. Shorter time to prosthesis after implementation of a new guideline for transtibial amputees. Sjödin L, Enocson A, Lapidus LJ. [Submitted]

IV. Transtibial amputees’ perspectives on information and shared decision-making. Sjödin L, Lapidus LJ, Torbjörnsson E. [Submitted]