Surgical wound complications after major lower limb amputations for chronic limb-threatening ischemia.

Abstract

Objective: To investigate rates, risk factors and the impact of surgical wound complications (SWCs) on healthcare resources after below-the-knee (BKA) and above-the-knee amputation (AKA) for chronic limb-threatening ischemia (CLTI).

Methods: This single-center retrospective study included consecutive patients undergoing major amputation for CLTI between 2011-2020. Primary endpoint was surgical wound complication (SWC) defined as surgical revision, higher amputation or non-healing wound at one year. Risk factors for SWCs were studied in multivariable analyses and expressed as odds ratios (ORs) with 95% confidence intervals. Secondary aim was to estimate hospital resources consumed by SWCs.

Results: One-hundred-twenty patients (27%) with CLTI underwent 132 BKAs and 322 patients (73%) underwent 362 AKAs. One-year mortality was 32% in BKA and 52% in AKA group (p<.001). SWC rates were 47% and 11%, respectively (p<.001). AKA patients were older, more often female and memory disorders were more common compared to BKA patients. BKA patients had more often diabetes, chronic kidney disease and dialysis. None of these factors were associated with SWCs. Nineteen patients (14%) in the BKA group had no continuous arterial line to the amputation level; this did not increase the risk of SWC. Nineteen (14%) BKA patients had undergone guillotine ankle amputation before BKA, which was independently protective of SWC (OR 0.16 [0.04-0.60], p=.006). Long-term corticosteroid use increased the risk of SWC after BKA (OR 2.93 [1.19-7.23], p=.020) and AKA (OR 2.25 [1.07-4.73], p=.032). BKA was a major independent risk factor for SWC with more than four times higher risk compared to AKA (OR 4.13 [2.32-7.35], p<0.001). BKAs required more hospital resources than AKAs. SWCs more than doubled median hospital and healthcare center stay and multiplied mean number of readmissions and outpatient clinic visits.

Conclusion: Nearly half of patients with CLTI developed SWC after BKA. Corticosteroid use increases the risk whereas guillotine amputation was associated with lower SWC rate after BKA. SWCs increase the need for healthcare resources significantly. SWCs are difficult to predict and the decision between BKA versus AKA remains a challenge for the vascular surgeon.