Mortality After Amputation: Putting Evidence Into Practice

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Click here to read Dr. Thorud's April cover story.

Hi, I'm Jacob Thorud. I'm a podiatrist, as mentioned out in Mercy McHenry.
 
What are the most important things DPMs should know about amputation and mortality?
 
So I think overall, that the mortality is extremely high after a major amputation. I mean, we're talking about a 40% survival rate after about 5 years, years after below-knee amputation and above-knee amputations, which is pretty, pretty striking. And even those that have not even gone through a major amputation, those with minor amputations, ulcerations, critical limb ischemia—all those also have a very high level of mortality. I mean, those are usually in the 40 to 50% mortality rate at 5 years, also pretty striking, but it kind of underlines the severity of the disease burden that's in our patients.
 
I think also that the ambulation from the research seems to be one of the key factors influencing mortality and quality of life. It's not the only factor though. There's certainly age, there's health, of course, those that are older are going to have higher mortality, those that are less healthy, previous amputations confounds that, and so it's really difficult to really tease apart the only factor, and there's probably more than just ambulation, but it just seems to make sense to us. Exercise and physical activity is good for us, not just those with the ones with the previous amputations or those that are at risk for high mortality, but just us in general.
 
And then finally, that now more patients really can walk after minor amputations than major amputations, which kind of lends into that same idea. I mean, we're talking like 67% or so are able to walk after a below-knee amputation versus roughly like 80% are able to walk after a minor amputation. But minor amputations have higher failure rates. They also have more reamputations, so they can't just be decided upon for minor amputations for everyone.
 
How you can use the evidence in your practice
 
One, this really reinforces the functional limb salvage efforts that we are already undertaking, so it really encourages us to continue doing our efforts on that, but also I think it discourages the nonfunctional limb salvage. So ones that we know are never going to walk again, are never going to do any activities, and why are we taking that extra risk? There are extenuating circumstances where that's, of course, important, or that we don't want to go under a major amputation. But it really helps us differentiate those, or at least try to differentiate those that we want functional limb salvage, so we do more minor amputations. And those that we know are not going to, and so we're trying to reduce the risks for them postoperatively.
 
I also now really encourage a lot of my patients to increase their activity level. This is somewhat controversial after ulcerations, as well as amputations, but I feel like this improvement that we can have in not only a mortality quality of life is a much higher priority than just merely existing.

Final insights on amputation and ambulation
 
I think really kind of the benefit of physical and activity levels and exercise in those patients that are very ill. I think that's pretty surprising. I mean the numbers are pretty striking. You're talking about people that are basically on the last few years of life.
 
We can get 30% or more reduction of mortality after 5 years, after about 2 hours of walking a week. I think that's pretty stunning. Also, not just walking, there's cycling, there's all these other things that we can do that are consistently shown improvements in mortality rates in these populations, as well as other populations too.
 
And then I think the other thing that is striking to me is the similarity between minor amputations and those that are population-based that are kind of what we thought of as baseline, like those with ulcerations and those with critical limb ischemia are all in about that 40–50% mortality rate at five years, which just strikes you as very similar.
 
Now is that for sure that that's going to be in every population? No, but I think that helps us give us the idea that if we are bringing them down to somewhere with a level of amputation that they're able to continue walking and being able to do activities that they're likely to have that baseline mortality rate.