IJLXXX10.1177/1534734613502046The International Journal of Lower Extremity WoundsJindeel and Narahara

Letter to the Editor

Lower Extremity Amputation: A Complete Series From a Tertiary Hospital

The International Journal of Lower Extremity Wounds 12(4) 322­–323 © The Author(s) 2013 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1534734613502046 ijl.sagepub.com

Ayad Jindeel, MD1, and Kenneth A. Narahara, MD1 Sir, Although the majority of traumatic and nontraumatic lower extremity amputations (LEAs) are preventable, both remain common and are associated with a significant health care cost.1-8 As with nontraumatic amputations,7 the incidence of traumatic amputations has significantly declined.5 Despite this decline in the incidence of amputation, an estimated 1.6 million Americans live with limb loss: 53% secondary to nontraumatic LEA, 45% to trauma, and 2% to cancer.4 The medical cost associated with caring for Medicare patients with nontraumatic amputation for 1 year exceeded $4.3 billion. LEA, whether traumatic or nontraumatic, has a significant negative impact on the health and life of those affected, and hospital admissions for LEA are among the most expensive.2,3 Most patients with an amputation need subsequent rehabilitation, prosthesis, and other expensive services.5 Patients with traumatic LEA require services for a longer duration, as they are typically younger than those with nontraumatic LEA. Despite the high number of amputations and the high associated medical cost, few contemporary studies on amputations, particularly traumatic amputations, exist.6 The principal goal of this study is to improve our understanding of LEA, especially among minorities and those of lower socioeconomic status typically treated at public nonfederal hospitals like HarborUCLA Medical Center (HUMC),8 and to focus attention on opportunities to implement proven effective measures like diabetic foot care and improved industrial safety. Previously, we reported that 847 patients underwent nontraumatic LEAs over a 7-year period at an approximate cost of $47 million with a 1-year reamputation rate of 26.7% and a 5-year mortality rate of 25.6%.1 Here, we report results related to traumatic and cancer-related LEA. This retrospective study was approved by the HUMC Institutional Review Board. The HUMC electronic database was searched by procedure codes (84.10-84.19) to identify all patients with LEA performed at HUMC from January 2000 through December 2006. The NDI database was searched to identify death data in the study subjects to calculate the 1-year and 5-year mortality rates. Children were excluded, as were adults with upper extremity amputations. LEA distal to the ankle joint was considered “minor,” whereas LEA through or proximal to the ankle joint was considered “major.” Results are summarized in Table 1. The length of

hospital stay after traumatic amputation was 12.2 days (significantly longer than the 5.3-day average of all other hospital discharges during the same time period).1 The 1-year mortality rate of those with nontraumatic and traumatic amputations was identical (9.1%); however, the 5-year mortality rate was significantly higher for those with nontraumatic amputations (24.6% vs 12%). The reamputation rate at 1 year was significantly higher for patients with nontraumatic amputation than for those with traumatic amputation (26.7% vs7.8%, P = .0004). There were 16 (1.7%) patients with cancer-related LEA with a 5-year mortality rate of 40%. The causes of trauma are known in 32 cases (48.48%). Of these 32 cases, there were 9 (28.1%) secondary to motor vehicle accidents, 9 (28.1%) to gunshot wounds, and 14 (43.8%) to machinery and tools. As far as we know, this is the first study that included all LEAs from one institution with 1- and 5-year mortality rates. HUMC is an urban trauma level 1 academic county hospital serving a large portion of those without health insurance in Los Angeles County. The percentage of traumatic LEA at HUMC is not significantly different from that previously reported (7.3% vs 6.02, P = .164); however, the proportion of traumatic minor LEA is significantly lower than previously reported (31.8% vs 51.48%, P = .0014). This could be due to improved survival after severe trauma leading to more survival but with more major LEA. In addition, improvement in reconstructive surgery and industrial safety prevents and reduces more minor than major LEA. Also, consistent with previous studies,4,6 the majority of patients with traumatic amputations (80.3%) were males and significantly younger than patients with nontraumatic amputations (37 vs 55 years, P < .0001). The 5-year mortality rate after nontraumatic amputations is significantly higher than that after traumatic amputation (24.6% vs12%, P = .018).4 Patients of lower socioeconomic status and minorities are disproportionally affected by amputation.8 This high number of LEA from a single hospital that does not treat war casualties and


Harbor-UCLA Medical Center, Torrance, CA, USA

Corresponding Author: Ayad Jindeel, Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center, 1000 W Carson St, Torrance, CA 90502, USA. Email: [email protected]

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Jindeel and Narahara Table 1.  LEA at HUMC, January 1, 2000, to January 1, 2007.

Patients, n (%) Traumatic

66 (7.1%)

Nontraumatic 847 (91.2%) Cancer related

16 (1.7%)

Admissions, n (%)

Minor/Major, n (%)

74 (5.9%)

21 (31.8%)/ 45 (68.2%) 594 (70.1%)/ 253 (29.9%) 9 (56.25%)/ 7 (43.75%)

1169 (92.7%) 18 (1.4%)

Average Age (Years) 36.9 55.0 43.7

Males/Females, n (%)

One-Year Mortality, n (%)

Five-Year Mortalitya, n (%)

Average Days in Hospital

53 (80.3%)/ 13 (19.7%) 617 (72.8%)/ 230 (27.2%) 10 (62.5%)/ 6 (37.5%)

6/66 (9.1%) 77/847 (9.1%) 1/16 (6.3%)

8/66 (12.1%) 162/633 (25.6%) 6/15 (40.0%)

12.2 12.7 12

Whites (W), Hispanics (H) Blacks (B), and Others (O), n (%) W = 9 (13.6%), H = 38, (57.6%), B = 16 (24.2%), O = 3 (4.6%) W = 141 (16.6%), H = 504 (59.5%), B = 153 (18.1%), O = 49 (5.785%) W = 2 (12.5%), H = 12 (75.0%), B = 2 (12.5%)

Abbreviation: LEA, lower extremity amputation; HUMC, Harbor-UCLA Medical Center. Five-year mortality data were not available for 2005 and 2006.


is in a country that has the highest per capita medical expenditure is alarming and deserves further investigation. Acknowledgments The authors acknowledge the staff of Los Angeles Biomedical Research Institute for their assistance with this project and the staff of A. F. Parlow Library for their assistance with literature search; Drs John Tayek and Rajesh Mehrorta for their valuable input regarding the project methods; and Dr Ravi Dixit for his assistance in preliminary data in the early stages of this project.

Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.

References 1. Jindeel A, Narahara KA. Nontraumatic amputation: incidence and cost analysis. Int J Low Extrem Wounds. 2012;11: 177-179.

2.  Dillingham TR, Pezzin LE, Shore AD. Reamputation, mortality, and health care costs among persons with dysvascular lower-limb amputations. Arch Phys Med Rehabil. 2005;86:480-486. 3. Gerdtham UG, Clarke P, Hayes A, Gudbjornsdottir S. Estimating the cost of diabetes mellitus-related events from inpatient admissions in Sweden using administrative hospitalization data. Pharmacoeconomics. 2009;27:81-90. 4. Ziegler-Graham K, MacKenzie EJ, Ephraim PL, Travison TG, Brookmeyer R. Estimating the prevalence of limb loss in the United States: 2005 to 2050. Arch Phys Med Rehabil. 2008;89:422-429. 5.  Dillingham T, Pezzin L, MacKenzie E. Incidence, acute care length of stay, and discharge to rehabilitation of traumatic amputee patients: an epidemiologic study. Arch Phys Med Rehabil. 1998;79:279-287. 6.  Dillingham TR, Pezzin LE, MacKenzie EJ. Limb amputation and limb deficiency: epidemiology and recent trends in the United States. South Med J. 2002;95:875-883. 7.  Centers for Disease Control and Prevention. Crude and ageadjusted hospital discharge rates for nontraumatic lower extremity amputation per 1,000 diabetic population, United States, 1988-2006. http://www.cdc.gov/diabetes/statistics/lea/ fig3.htm. Accessed March 24, 2013. 8.  Eslami MH, Zayaruzny M, Fitzgerald GA. The adverse effects of race, insurance status, and low income on the rate of amputation in patients presenting with lower extremity ischemia. J Vasc Surg. 2007;45:55-59.

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Lower extremity amputation: a complete series from a tertiary hospital.

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