Injury, Int. J.

Care Injured 48 (2017) 364370

Contents lists available at ScienceDirect

Injury
journal homepage: www.elsevier.com/locate/injury

Full length article

Complications and revision amputation following trauma-related

lower limb loss
Eric Edison Lowa , Elizabeth Inkellisb , Saam Morshedb,c,*
a
University of California, San Francisco School of Medicine, United States
b
University of California, San Francisco Department of Orthopaedic Surgery, United States
c
Orthopaedic Trauma Institute, Zuckerberg San Francisco General Hospital, United States

A R T I C L E I N F O A B S T R A C T

Introduction: Trauma-related amputations are a common cause of limb loss in the United States. Despite
Keywords: the military and public health impact of trauma-related amputations, distributions of various lower limb
Trauma
amputations and the relative frequency of complications and revision amputations have not been well
Lower extremity amputation
National trauma data bank
described. We used the National Trauma Data Bank (NTDB) in order to investigate the epidemiology of
Revision amputation trauma-related lower extremity amputations among civilians in U.S. trauma centers.
Compartment syndrome Materials and methods: We conducted a secondary data analysis of the 20112012 NTDB research data
sets, using means and frequencies to characterize the patient population and describe the distribution of
major lower extremity amputations. Multivariable regression models were t to identify predictors of
major post-surgical complications, revision amputation, length of hospitalization, and in-hospital
mortality.
Results: A total of 2879 patients underwent a major lower extremity amputation secondary to a trauma-
related lower limb injury, representing 0.18% of all NTDB trauma admissions from 2011 to 2012. 80.4%
were male and 67.6% were white. The three most frequent denitive amputations preformed included
trans-tibial (46%), trans-femoral (37.5%), and through foot (7.6%). The average length of hospitalization for
all amputees was 22.7 days. Patients with at least one revision amputation stayed in the hospital
approximately 5.5 days longer than patients not needing a revision amputation. 1204 patients (41.8%)
required at least one revision amputation. 27.5% of amputees experienced at least one major post-surgical
complication. African Americans experienced a 49% higher major post-surgical complication incidence
and stayed, on average, 2.5 days longer in the hospital compared to whites. Injury severity score, age,
hospital teaching status, presence of a crush injury, fracture location, presence of compartment
syndrome, and experiencing a major post-surgical complication were all signicant predictors of revision
amputation.
Conclusion: We report a high rate of complications and revision amputations among trauma-related
lower limb amputees, and identify predictors of surgical outcomes that have not been described in the
literature including African American race. Compartment syndrome is a signicant predictor of major
post-surgical complications, revision amputation, and length of hospitalization.
2016 Elsevier Ltd. All rights reserved.

Introduction increasingly common challenges to military and civilian orthopae-

Trauma-related amputations are the second most common
cause of limb loss in the United States, second to dysvascular
conditions such as diabetes, and are a prominent source of
permanent impairment and functional limitations [15]. Although
major lower extremity injuries requiring amputation are becoming
* Corresponding author at: Orthopaedic Trauma Institute, Address: 2550 23rd
Street, Building 9, 2nd Floor, San Francisco, CA 94110, United States.
E-mail address: Saam.Morshed@ucsf.edu (S. Morshed).
dic trauma surgeons, little is known about the epidemiology,
including predictors for post-surgical complications and revision
amputation [1,311].
Our current understanding of the epidemiology of lower
extremity amputations is limited. Research suggests an overall
decline in the rate of civilian trauma-related amputations over the
past several decades [1,3]; however, this rate is rising among
wounded warriors given increased counterinsurgency operations
in Syria, Iraq and Afghanistan and higher survival rates in theatre
[7,11]. Only a handful of research has been published on rates of

http://dx.doi.org/10.1016/j.injury.2016.11.019
0020-1383/ 2016 Elsevier Ltd. All rights reserved.
 E.E. Low et al. / Injury, Int. J. Care Injured 48 (2017) 364370
revision amputation following lower extremity amputations
[1219], none of which are specic for trauma-related injuries.
Data from the Lower Extremity Assessment Project (LEAP), a
multicenter prospective study of lower limb-threatening injuries,
suggests that socioeconomic and psychosocial factors are more
important predictors of civilian, trauma-related amputation
outcomes than treatment factors [8,20]. Still, data form the
Military Extremity Trauma Amputation/Limb Salvage Study
(METALS) challenges these nding in reporting improved out-
comes for patients undergoing trans-tibial amputation over those
undergoing limb salvage[6]. These differences and controversies
highlight how different study target populations can inuence
outcomes, and emphasize how important it is to better study the
epidemiology of trauma-related amputations and associated
complications.
Use of the National Trauma Data Bank (NTDB) Research Data Set
(RDS) presents a unique opportunity to analyze thousands of
trauma-related lower extremity amputation cases and conduct a
robust analysis of data from a census of U.S. trauma centers,
making the convenience sample of the NTDB resemble a
population-based study. The purpose of this study is to use the
20112012 NTDB to investigate the epidemiology of lower
extremity amputations secondary to traumatic injury, and to
assess predictors of post-surgical complications, revision
amputation, length of hospitalization, and in-hospital mortality.
Materials and methods
Subjects
We conducted a secondary data analysis of the 20112012
NTDB RDS. The NTDB draws from over 900 trauma centers from
around the U.S. Of the 1,617,999 incident admissions included in
the 20112012 RDS, 4343 subjects 0.27% of the total cohort
underwent any lower extremity amputation (Fig. 1). The ICD-9
procedure codes used to identify these subjects include: 84 (lower
extremity amputation, not otherwise specied), 84.11 (toe
amputation), 84.12 (foot amputation), 84.13 (ankle disarticulation),
84.14 (ankle amputation through the malleoli of the tibia and
bula), 84.15 (trans-tibial amputation), 84.16 (knee disarticula-
tion), 84.17 (trans-femoral amputation), 84.18 (hip disarticulation),
and 84.19 (abdominopelvic amputation).
Subjects were then assessed for lower extremity injuries. Of the
4343 subjects who underwent a lower extremity amputation, 4142
subjects (95.4%) were documented as having an associated, lower
extremity injury. The following ICD-9 diagnostic codes were used
to dene a lower extremity injury: 820828.9, 835838.19,
1,617,999 subjects in the
2011-2012 NTDB RDS
4,343 Lower extremity
Amputees
4,142 Amputees with a 50 Subjects with
Lower extremity Injury Unclassifiable Amputations
1,213 Subjects with only
Minor Amputations
2,879 Subjects with a
Major Amputation
Fig. 1. Cohort Calculation.
365
843845.19, 887.5887.7, 890897.7, 903904.8, 927927.9,
943945.59, 955956.9, and 959.2959.7. Of the 4142 subjects
with a lower extremity injury, 45 subjects underwent an
unspecied lower extremity amputation and 5 subjects had
missing amputation data. These 50 subjects were excluded from
the study cohort as unclassiable amputations (Fig. 1). The
remaining subjects were ltered by minor or major amputations.
Minor amputations included toe amputations. Major amputations
included any level from the foot to the most proximal amputation,
an abdominopelvic amputation. 1213 subjects only underwent a
minor amputation and were removed from the study cohort
(Fig. 1). Our nal study cohort includes 2879 subjects who
underwent a major lower extremity amputation, following a
traumatic lower extremity injury (Fig. 1).
Statistical analysis
Means and frequencies were calculated in order to characterize
the patient population and describe the distribution of lower limb
amputations. Multivariable regression models were t to identify
which variables with bivariable associations to each dependent
variable signicantly correlate with major post-surgical
complications, revision amputation, length of hospitalization,
and in-hospital mortality. Incidences of various major post-
surgical complications were considered individually and as a
composite outcome variable for regression analyses. A logistic
regression model was t to identify risk factors for major post-
surgical complications. The following complications were identi-
ed as major post-surgical complications: graft/prosthetic/ap
failure, deep surgical site infection, decubitus ulcer, osteomyelitis,
deep vein thrombosis (DVT)/thrombophlebitis, pulmonary embo-
lism (PE), pneumonia, acute kidney injury, acute lung injury/acute
respiratory distress syndrome (ARDS), and severe sepsis. A logistic
regression model was t to identify predictors for revision
amputation as well as in-hospital mortality. A subject was
identied as needing a revision amputation if he/she had either
(1) an irrigation, debridement, or closure of a residual limb stump
or (2) a more proximal amputation. A linear regression model was
t to identify predictors for length of hospitalization after a
subjects initial amputation procedure. In all regression analyses
performed, predictors were selected using a stepwise approach.
Predictors were initially included in the model if they had an
association with the outcome in a bivariable logistic model, at a P-
value threshold of 0.2 or less, and were retained in the model if
their respective P-value did not exceed 0.25 with the addition of
other variables. Model t was assessed using the Hosmer-
Lemeshow test, and found to be acceptable in all nal regression
models used in these analyses. All statistical analyses were
preformed using Statistical Analysis System (SAS Institute Inc.,
Cary, NC) for Windows (Microsoft Corporation, Redmond, WA),
version 9.4.
Results
A total of 2879 patients underwent a major lower extremity
amputation secondary to a traumatic lower limb injury, represent-
ing 0.18% of all NTDB trauma admissions during 20112012. 80.4%
were male and 19.6% were female (Table 1). The average age for
males was 42.3 years and for females was 47.5 years. 67.6% of the
subjects were White. Table 1 provides a more detailed description
of the cohort demographics.
The three most frequent denitive amputations preformed
included trans-tibial (46%), trans-femoral (37.5%), and through foot
(7.6%) (Table 2). Subjects with a denitive trans-tibial amputation
had an average Injury Severity Score (ISS) of 14.6. The average time
to denitive trans-tibial amputation was 7.4 days, and subjects
366 E.E. Low et al. / Injury, Int. J. Care Injured 48 (2017) 364370

Table 1
Cohort Demographics, Mechanism of Injury and Hospital Characteristics.

Number, N Frequency (%)

Gender
Male 2314 80.38
Female 565 19.62

Ethnicity
Not Hispanic or Latino 2044 71
Hispanic or Latino 329 11.43
Not Known/Recorded 506 17.57
Race
White 1946 67.59
African or African American 444 15.42
Other 292 10.14
Asian 36 1.25
American Indian 22 0.76
Native Hawaiian or Other Pacic Islander 6 0.21
Not Known/Recorded 133 4.62

Mechanism of Injury
Motor Vehicle Trafc Injury 1775 61.65
Fall Injury 231 8.02
Firearm Injury 217 7.54
Machinery Injury 184 6.39
Other Transport Injury 130 4.52
Struck by, against Injury 120 4.17
Cut/pierce injury 62 2.15
Fire/ame injury 46 1.6
Other 108 3.75
Not Known/Recorded 6 0.21

Teaching Status
University 1838 63.84
Community 777 26.99
Non-Teaching 264 9.17

State Trauma Level

I 1945 67.56
II 517 17.96
III 56 1.95
IV 7 0.24
Not Known/Recorded 354 12.3

Discharge Information
Discharged home with no home services 894 31.05
Discharged/Transferred to another type of rehabilitation or long-term care facility 890 30.91
Discharged/Transferred to Skilled Nursing Facility 358 12.43
Discharge/Transferred to home under care of organized home health service 226 7.85
Discharged/Transferred to an Intermediate Care Facility 218 7.57
Expired 179 6.22
Discharged/Transferred to a short-term general hospital for inpatient care 100 3.47
Left against medical advice or discontinued care 7 0.24
Discharged/Transferred to hospice care 7 0.24

stayed, on average, 14.4 days following the procedure for a total
length of stay of 20.8 days. Table 2 includes mean ISS and
procedure time-course characteristics for each denitive
amputation level.
The most frequent diagnostic codes for all lower limb
amputations included unilateral traumatic amputations below
the knee (7.3%), open tibia and bula shaft fractures (5.4%), and
injuries to the popliteal artery (4.9%). The most common causes of
injury were motor vehicle/trafc accidents (61.7%), fall accidents
(8%), and rearm accidents (7.5%) (Table 1). A majority of subjects
were treated at a Level I trauma center (67.6%), and were eventually
discharged home without services (31.1%) or to a rehabilitation or
long-term care facility (30.9%). Table 1 provides further details of
the mechanism of injury and several hospital characteristics.
Of all 2879 amputees, 21.8% experienced a neurovascular injury.
Other injuries of interest, which were included in all regression
analyses, included compartment syndrome (7.2%) and crush
injuries (11.4%). 27.5% of amputees experienced at least one major
post-surgical complication; the most frequent included pneumo-
nia (21.1%), acute kidney injury (15.1%), and DVT/thrombophlebitis
(14.8%). Other major complications included acute lung injury/
ARDS (12.6%), deep surgical site infection (8.4%), decubitus ulcer
(7.9%), severe sepsis (6.4%), PE (5.9%), graft/prosthesis/ap failure
(4.8%), and osteomyelitis (3.1%).
Signicant predictors of major post-surgical complications
(Table 3) included ISS, time to procedure, age, presence of
compartment syndrome, race (African American vs. White),
presence of neurovascular injury, and hospital teaching status.
Patients with compartment syndrome had approximately three
times higher odds of experiencing a major post-surgical compli-
cation than patients without compartment syndrome. Patients
who experienced a neurovascular injury had 35% higher odds of
experiencing a major post-surgical complication compared to
patients without a neurovascular injury. African Americans had
49% higher odds of experiencing a major post-surgical complica-
tion compared to Whites (Table 3).
 E.E. Low et al. / Injury, Int. J. Care Injured 48 (2017) 364370 367

Table 2
Amputation Frequencies and Injury and Procedure Characteristics.

Denitive Injury Days to Post Length of Initial Subjects with a Revision Subjects with a Proximal
Amputation Severity Procedureb Operative Stay Amputation of an Amputation Extension Procedure, Nd
Frequency, N (%)a Score (ISS)b Daysb (days)b Frequency, N Stump, Nc
(%)a
Trans-tibial amputation 1325 (46.02) 14.57 7.42 14.42 20.84 1455 (50.54) 496 199
Trans-femoral 1080 (37.51) 17.87 7 19.51 23.89 866 (30.08) 311 20
amputation
Amputation through foot 220 (7.64) 9.58 7 12.77 18.78 274 (9.52) 58 56
Knee disarticulation 139 (4.83) 20.75 6.99 19.62 23.45 164 (6) 59 56
Amputation of ankle 49 (1.7) 13.19 5.31 15.25 19.25 65 (2.26) 20 21
through malleoli of
tibia and bula
Hip disarticulation 37 (1.29) 26.74 12.17 40.29 43.14 17 (0.59) 6 2
Ankle disarticulation 20 (0.69) 12.79 2.68 13.58 15.05 32 (1.11) 8 14
Abdomino-pelvic 9 (0.31) 28 7.88 37.13 38.38 6 (0.21) 0 0
amputation
a
Percentages reect the proportion of the total cohort (N = 2879).
b
Values represent the mean and correspond with the denitive amputation.
c
Reect the number of subjects who underwent a stump revision amputation at the corresponding initial amputation level.
d
Reect the number of subjects who underwent a more proximal amputation at the corresponding initial amputation level.

Table 3
Predictors of Major Post-surgical Complications.

Variable Odds Ratio (95% CI) P-value

Injury Severity Score 1.058 (1.05, 1.066) <0.0001
Time to initial procedure 1.043 (1.033, 1.052) <0.0001
Age 1.017 (1.011, 1.022) <0.0001
Neurovascular Injury (yes vs. no) 1.353 (1.088, 1.683) 0.0065
Compartment Syndrome (yes vs. no) 2.976 (2.165, 4.092) <0.0001
Hospital teaching status (non-teaching vs. University) 0.654 (0.455, 0.939) 0.0213
Race (African American vs. White) 1.493 (1.17, 1.905) 0.0013

Three other variables were included in the model but were not statistically signicant at p = 0.05: presence of a crush injury (yes vs. no), Hospital Teaching Status (nonteaching
vs. University), and Race (Asian vs. White).

41.8% of patients required at least one revision amputation
procedure. 1455 (50.5%) subjects underwent a trans-tibial
amputation as their initial procedure during hospitalization
(Table 2). 496 patients required a revision of their trans-tibial
amputation stump and 199 patients required a more proximal
amputation. Table 2 provides initial amputation levels for the total
cohort and the frequency of stump revisions and proximal
extension procedures for each amputation level. ISS, age, hospital
teaching status, presence of a crush injury, fracture location,
presence of compartment syndrome, and experiencing a major
post-surgical complication were signicant predictors of revision
amputation (Table 4). Patients who experienced a major post-
surgical complication had 22% higher odds of undergoing a
revision amputation compared to those patients who did not
experience a major complication. Patients with compartment
syndrome had 44% higher odds of needing a revision amputation
compared to those without compartment syndrome. There was a
37%higher odds of requiring a revision amputation for patients
with a crush injury compared to those without a crush injury
(Table 4).
A majority of the amputations occurred at University hospitals
(63.8%) compared to community (27%) and non-teaching hospitals
(9.2%) (Table 5). 46% of amputees at a University hospital required a
revision amputation, whereas 35.5% and 31.1% of amputees
required a revision amputation at community and non-teaching
hospitals, respectively. Patients treated at University hospitals had
a greater mean ISS than patients treated at non-University
hospitals and were more likely to present with a compartment
syndrome (Table 5).
The average length of hospitalization for all amputees was
22.7 days. Patients with at least one revision amputation stayed in
the hospital approximately 5.5 days longer on average than
patients who did not require a revision amputation. Signicant
predictors for length of hospitalization (Table 6) included ISS, time

Table 4
Predictors of Revision amputation Procedures.

Variable Odds Ratio (95% CI) P-value

Injury Severity Score 1.015 (1.008, 1.022) <0.0001
Age 0.99 (0.986, 0.995) <0.0001
Crush fracture (yes vs. no) 1.365 (1.077, 1.73) 0.0101
Compartment Syndrome (yes vs. no) 1.435 (1.062, 1.939) 0.0187
Major Post-surgical Complication (yes vs. no) 1.219 (1.012, 1.467) 0.0369
Shaft vs. Proximal Fracture 1.489 (1.084, 2.047) 0.0141
Distal vs. Proximal Fracture 1.411 (1.019, 1.954) 0.0382
Hospital teaching status (non-teaching vs. University) 0.571 (0.431, 0.756) <0.0001
Hospital teaching status (community vs. University) 0.674 (0.565, 0.805) <0.0001

Presence of a neurovascular injury (yes vs. no) and time to procedure were included in the model but were not statistically signicant at p = 0.05.
368 E.E. Low et al. / Injury, Int. J. Care Injured 48 (2017) 364370

Table 5
Injury Characteristics by Hospital Teaching Status.

Non-Teaching Hospital Community Hospital University Hospital P-value

N = 264 N = 777 N = 1838
Subjects needing re-amputation, N (%) 82 (31.06) 276 (35.52) 846 (46.03) <0.0001
Injury Severity Score (mean) 13.72 15.73 16.25 0.0009
Days to Procedure (mean) 5.72 7.41 7.32 0.0618
Subjects with Major Post-Surgical Complications, N (%) 44 (16.67) 226 (29.09) 521 (28.35) 0.0002
Subjects with Compartment Syndrome, N (%) 10 (3.79) 47 (6.05) 150 (8.16) 0.0129
Subjects with a Crush Injury, N (%) 29 (10.98) 101 (13) 199 (10.83) 0.2726

Table 6
Predictors of Length of Hospitalization.

Variable Parameter Estimate (95% CI) P-value

Injury Severity Score 0.4796 (0.4255, 0.5338) <0.0001
Time to Procedure 0.3022 (0.2458, 0.3587) <0.0001
Age 0.0399 ( 0.074, 0.0063) 0.0201
Compartment Syndrome (yes vs. no) 5.4562 (3.1258, 7.7865) <0.0001
Hospital teaching status (community vs. University) 1.7898 ( 3.1117, 0.4679) 0.008
Hospital teaching status (non-teaching vs. University) 3.5862 ( 5.6195, 1.553) 0.0006
Race (African American vs. White) 2.5003 (0.8848, 4.1159) 0.0024
Gender (female vs. male) 1.8585 (0.384, 3.3329) 0.0135

Presence of a neurovascular injury (yes vs. no) and hospital American College of Surgeons (ACS) level I and II vs. III were included in the model but were not statistically
signicant at p = 0.05.

to procedure, presence of compartment syndrome, hospital
teaching status, race (African American vs. White), gender, and
age. For every one-unit increase in ISS, a patient stayed
approximately 12 h longer in the hospital. The time to procedure
signicantly affected the patients length of time spent in the
hospital following the initial procedure. For every additional day
leading up to the procedure, the patient stayed approximately 7 h
longer following their initial procedure. Patients with compart-
ment syndrome, compared to those without compartment
syndrome, stayed approximately 5.5 days longer. African American
patients stayed approximately 2.5 days longer in the hospital
compared to White patients.
Out of all 2879 subjects, 6.2% died during hospitalization. ISS,
age, and presence of major post-surgical complication were
signicant predictors of in-hospital mortality. For every additional
ISS point or year of age, the odds of mortality increased by 1.063
(95% CI [1.052, 1.076]; p < 0.0001) and 1.028 (95% CI [1.019, 1.038];
p = < 0.0001), respectively. Amputation patients who experienced
a major post-surgical complication had an almost 2-fold higher
odds of in-hospital mortality (OR = 1.993, 95% CI [1.406, 2.825];
p = 0.0001) compared to patients who did not experience a
complication.
Discussion
We performed an analysis of civilian trauma-related lower
extremity amputations using the 20112012 NTDB RDS and
identied predictors of major post-surgical complications and
revision amputations areas that are currently lacking from the
literature for this patient population. To our knowledge this is the
rst study examining rates and predictors of revision amputation
in subjects undergoing trauma-related lower limb amputations. Of
the 2879 incident cases of trauma-related lower limb amputations,
we report a high prevalence of post-surgical complications (27.5%)
the most frequent including pneumonia, acute kidney injury, and
DVT/thrombophlebitis and revision amputations (41.8%).
This high rate of revision amputations is consistent with
previous studies, although none of these studies are specic to
trauma-related lower limb amputees. Izumi et al. [12] reported
cumulative revision amputation rates of 26.7% at 1 year, 48.3% at 3
years, and 60.7% at 5 years for diabetic patients with a rst lower
extremity amputation. Other studies have reported that initial
amputations fail to heal 2030% of the time; 1020% of patients
with an initial trans-tibial amputation require a more proximal
extension to the trans-femoral level [1318]. In our study we
reported a similar proportion 199 (13.7%) of the 1455 subjects
who underwent an initial trans-tibial amputation required a more
proximal extension amputation. Given that the NTDB only collects
data through discharge from index hospitalization, it is not
possible to infer or compare long term rates of revision amputation
or advancement to a more proximal level over the intermediate to
long term to those reported in these prior studies.
Revision amputations performed in the acute setting are often
required to better understand the evolving zone of injury in order
to enhance decision making on safe wound closure and soft tissue
coverage. Still, there is a need for research to identify those revision
amputations that positively affect outcomes as well as modiable
risk factors for revision amputation. Reducing rates of revision
amputation can signicantly impact healthcare cost burden.
MacKenzie et al. [10] reported that the average two-year and
lifetime costs for an individual undergoing a lower extremity
amputation, not including cost of revision amputations, are
$91,106 and $509,275, respectively; the high lifetime cost is
ascribed largely to costs associated with purchasing and main-
taining new prosthetic devices. Another study by Franklin et al.
[21] determined that the average cost for a lower extremity
amputation in the 2010 scal year was $60,647, with inpatient
surgery accounting for greater than 88% of the total cost. Patients
with multiple amputations had markedly increased healthcare
costs due to greater inpatient surgery costs [21]. The potential to
reduce revision amputations that do not add value could therefore
decrease costs by eliminating additional inpatient surgeries and
shortening hospital stay.
Diabetes has been one of the few predictors of revision
amputation described in nontrauma-related amputees [12,19]. In
our study, ISS, sustaining a crush fracture, presence of compart-
ment syndrome, presence of a major post-surgical complication,
fracture location, and hospital status were all signicant
predictors of revision amputation. Although none of these factors
are evidently modiable, early detection of compartment
 E.E. Low et al. / Injury, Int. J. Care Injured 48 (2017) 364370
syndrome and early fasciotomies may help mitigate the
downstream morbidity associated with this condition. Notably,
we found that presence of compartment syndrome is signicantly
correlated with higher odds of revision amputation as well as
greater odds of post-surgical complications and longer hospital
length of stay.
It is also notable that fracture location predicts odds of revision
amputation. Distal and shaft fractures increased the odds of
revision amputation by 41.1 and 48.9%, respectively, compared to
proximal fractures. This may be due to an initial, more conservative
approach by surgeons to spare as much of the lower extremity
length as possible, knowing that further debridement may still be
allowed while preserving the amputation level. Revision ampu-
tation frequency is also disproportionately higher at University
hospitals compared to non-University centers, which may be a
result of treating a higher volume of more complex cases cases in
which the ISS is higher and presence of compartment syndrome is
more prevalent. Additionally, surgeons at teaching hospitals may
be more likely to initially try and salvage the limb or a more distal
level, thus making revision amputation more likely.
Through our analysis we also report a high prevalence of major
post-surgical complications (27.5%) and in-hospital mortality
(6.2%), which is consistent with the literature [1318]. Belmont
et al. [22] examined 2911 patients included in the 20052008
National Surgical Quality Improvement Program who underwent a
trans-tibial amputation, and reported a 7% mortality rate and 34.4%
complication rate thirty-days following surgery. The most com-
mon complications included wound infection and sepsis [22].
Cardiac issues and pneumonia are also prevalent post-surgical
complications reported in the literature [13]. In our study, higher
ISS and age were both associated with increased burden of major
post-surgical complications and greater odds of in-hospital
mortality, which is consisted with prior reports [7,9].
Two variables affecting both odds of post-surgical complica-
tions and length of hospitalization are time to procedure and
African American race. Rates of complications and length of
hospital stay may be reduced by minimizing the time to index
procedure. Bondurant et al. [23] examined subjects with trauma-
related open tibia fractures and determined that patients with
delayed amputations, on average, stayed in the hospital 31.1 days
longer, underwent 5.3 more surgical procedures, and accumulated
$24,498 more in hospital costs. Additionally, patients with delayed
amputations had a signicant increase in sepsis, disability, and
death [23].
It is notable that there are disparities in rates of complications
and hospital stay between African Americans and Whites. To our
knowledge this is the rst study showing health disparities among
subjects undergoing trauma-related lower limb amputations.
Other studies have shown that the risk of nontrauma-related
lower limb amputations among African Americans ranges from 1.5
to 3.5 times greater than non-Hispanic Whites [2429]. This
discrepancy may be due to higher prevalence of diabetes among
African Americans [30], differences in access to care, or socio-
demographic status [31]. In our study, where trauma patients were
presumably triaged and treated based on need rather than
socioeconomic status, African Americans compared to Whites
experienced a 49% increase in major post-surgical complications
and stayed, on average, 2.5 days longer in the hospital. If race
doubles as a proxy for socioeconomic status, then our ndings
compliment the functional outcomes data reported in the LEAP
trial which determined that nonwhites (vs. Whites) and subjects of
lower socioeconomic status (having less than a high-school
education or having a household income below the federal poverty
level) had a lower Sickness Impact Prole [32]. These discrepancies
between racial groups warrant further investigation of health
disparities affecting health outcomesin trauma care delivery.
369
This database study has limitations inherent to the study
design. While the NTDB provides detailed data about a large
population of trauma patients across the United States, missing
data and reporting discrepancies are to be expected. Causal
relationships cannot be inferred given that statistical adjustments
can only be made for known and/or measured confounders. In
addition, the data is limited to the patients index hospital stay and
does not provide any information on long-term complications or
need for revision amputation following discharge. Functional
outcomes, including rate of employment, prosthesis use, or
residual limb pain, were also not available in the datasets. Such
long-term outcomes data would be useful for the study of lower
extremity amputees. Future prospective studies should focus on
providing longitudinal information as well as data on modiable
risk factors for complications, revision amputation, and quality of
life outcomes.
Conclusion
We report a high rate of major post-surgical complications and
revision amputations among trauma-related lower limb amputees.
We identied predictors for revision amputation that have not
been described in the literature. Future therapeutic studies should
focus on modiable risk factors for revision amputation and
surgical outcomes, which may have the potential to inform difcult
therapeutic decision-making and minimize healthcare cost
burden.
Conict of interest statement
The authors listed above have no conicts of interest.
Disclosure of funding
No funding was received for this research study.
Consent
All authors give consent for publication.
Appendix A. Supplementary data
Supplementary data associated with this article can be found, in
the online version, at http://dx.doi.org/10.1016/j.
injury.2016.11.019.
References
[1] Dillingham TR, Pezzin LE, MacKenzie EJ. Limb amputation and limb deciency:
epidemiology and recent trends in the United States. South Med J 2002;95
(8):87583.
[2] Johannesson A, Larson G-U, Ramstrand N, Turkiewicz A, Wirehn A-B, Atroshi I.
Incidence of lower-limb amputation in the diabetic and nondiabetic general
population a 10-year population-based cohort study of initial unilateral and
contralateral amputations and reamputations. Diabetes Care 2009;32(2):275
80.
[3] Dillingham TR, Pezzin LE, MacKenzie EJ. Incidence, acute care length of stay,
and discharge to rehabilitation of traumatic amputee patients: an
epidemiologic study. Arch Phys Med Rehabil 1998;79(3):27987.
[4] Ephraim PL, Dillingham TR, Sector M, Pezzin LE, MacKenzie EJ. Epidemiology of
limb loss and congenital limb deciency: a review of the literature. Arch Phys
Med Rehabil 2003;84(5):74761.
[5] Ebskov LB. Trauma-related major lower limb amputations: an epidemiologic
study. J Trauma 1994;36(6):77883.
[6] Doukas WC, Hayda RA, Frisch M, Andersen RC, Mazurek MT, Ficke JR, et al. The
military extremity trauma amputation/limb salvage (METALS) study
outcomes of amputation versus limb salvage following major lower extremity
trauma. J Bone Joint Surg Am 2013;95(2):13845.
[7] Morrison JJ, Hunt N, Midwinter M, Jansen J. Associated injuries in casualties
with traumatic lower extremity amputations caused by improvised explosive
devices. Br J Surg 2012;99(3):3626.
370 E.E. Low et al. / Injury, Int. J. Care Injured 48 (2017) 364370
[8] MacKenzie EJ, Bosse MJ, Kellam JF, Burgess AR, Webb LX, Swiontkowski MF,
et al. Characterization of patients with high-energy lower extremity trauma. J
Orthop Trauma 2000;14(7):45566.
[9] Matityahu A, Elson J, Morshed S, Marmor M. Survivorship and severe
complications are worse for octogenarians and elderly patients with pelvis
fractures as compared to adults: data from the national trauma data bank. J
Osteoporos 2012;475739.
[10] MacKenzie EJ, Jones AS, Bosse MJ, Castillo RC, Pollak AN, Webb LX, et al. Health-
care costs associated with amputation or reconstruction of a limb-threatening
injury. J Bone Joint Surg Am 2007;89(8):168592.
[11] Rispoli DM, MacKenzie EJ. Extremity war injuries VII outcomes panel.
Orthopaedic outcomes: combat and civilian trauma care. J Am Acad Orthop
Surg 2012;20(Suppl. 1):S847.
[12] Izumi Y, Sattereld K, Lee S, Harkless LB. Risk of reamputation in diabetic
patients stratied by limb and level of amputation: a 10-year observation.
Diabetes Care 2006;29(3):56670.
[13] Aulivola B, Hile CN, Hamdan AD, Sheahan MG, Veraldi JR, Skillman JJ, et al.
Major lower extremity amputation: outcome of a modern series. Arch Surg
2004;139(4):3959.
[14] Cruz CP, Eidt JF, Capps C, Kirtley L, Moursi MM. Major lower extremity
amputations at a Veterans Affairs hospital. Am J Surg 2003;186(5):44954.
[15] Ploeg AJ, Lardenoye JW, Vrancken Peeters MP, Breslau PJ. Contemporary series
of morbidity and mortality after lower limb amputation. Eur J Vasc Endovasc
Surg 2005;29(6):6337.
[16] Nehler MR, Coll JR, Hiatt WR, Regensteiner JG, Schnickel GT, Klenke WA, et al.
Functional outcome in a contemporary series of major lower extremity
amputations. J Vasc Surg 2003;38(1):714.
[17] Stone PA, Flaherty SK, Hayes JD, AbuRahma AF. Lower extremity amputation: a
contemporary series. W V Med J 2007;103(5):148.
[18] Abou-Zamzam Jr. AM, Teruya TH, Killeen JD, Ballard JL. Major lower extremity
amputation in an academic vascular center. Ann Vasc Surg 2003;17(1):8690.
[19] Schoeld CJ, Libby G, Brennan GM, MacAlpine RR, Morris AD, Leese GP.
Mortality and hospitalization in patients after amputation: a comparison
between patients with and without diabetes. Diabetes Care 2006;29(March
(10)):22526.
[20] Pezzin LE, Dillingham TR, MacKenzie EJ. Rehabilitation and the long-term
outcomes of persons with trauma-related amputations. Arch Phys Med
Rehabil 2000;81(3):292300.
[21] Franklin H, Rajan M, Tseng CL, Pogach L, Sinha AM. Cost of lower-limb
amputation in U.S. veterans with diabetes using health services data in scal
years 2004 and 2010. J Rehabil Res Dev 2014;51(8):132530.
[22] Belmont Jr. PJ, Davey S, Orr JD, Ochoa LM, Bader JO, Schoenfeld AJ. Risk factors
for 30-day postoperative complications and mortality after below-knee
amputation: a study of 2,911 patients from the national surgical quality
improvement program. J Am Coll Surg 2011;213(3):3708.
[23] Bondurant FJ, Cotler HB, Buckle R, Miller-Crotchett P, Browner BD. The medical
and economic impact of severely injured lower extremities. J Trauma 1988;28
(8):12703.
[24] Wetterhall SF, Olson DR, DeStefano F, Stevenson JM, Ford ES, German RR, et al.
Trends in diabetes and diabetic complications, 19801987. Diabetes Care
1992;15(8):9607.
[25] Lavery LA, van Houtum WH, Ashry HR, Armstrong DG, Pugh JA. Diabetes-
related lower-extremity amputations disproportionately affect Blacks and
Mexican Americans. South Med J 1999;92(6):5939.
[26] Lavery LA, Ashry HR, van Houtum W, Pugh JA, Harkless LB, Basu S. Variation in
the incidence and proportion of diabetes-related amputations in minorities.
Diabetes Care 1996;19(1):4852.
[27] van Houtum WH, Lavery LA. Methodological issues affect variability in
reported incidence of lower extremity amputations due to diabetes. Diabetes
Res Clin Pract 1997;38(3):17783.
[28] Huber TS, Wang JG, Wheeler KG, Cuddeback JK, Dame DA, Ozaki CK, et al.
Impact of race on the treatment for peripheral arterial occlusive disease. J Vasc
Surg 1999;30(3):41725.
[29] Tunis SR, Bass EB, Klag MJ, Steinberg EP. Variation in utilization of procedures
for treatment of peripheral arterial disease. A look at patient characteristics.
Arch Intern Med 1993;153(8):9918.
[30] Harris MI, Flegal KM, Cowie CC, Eberhardt MS, Goldstein DE, Little RR, et al.
Prevalence of diabetes, impaired fasting glucose, and impaired glucose
tolerance in U.S. adults. The Third National Health and Nutrition Examination
Survey, 19881994. Diabetes Care 1998;21(4):51824.
[31] Feinglass J, Kaushik S, Handel D, Kosifas A, Martin GJ, Pearce WH. Peripheral
bypass surgery and amputation: northern Illinois demographics, 1993 to 1997.
Arch Surg 2000;135(1):7580.
[32] Bosse MJ, MacKenzie EJ, Kellam JF, Burgess AR, Webb LX, Swiontkowski MF,
et al. An analysis of outcomes of reconstruction or amputation after leg-
threatening injuries. N Engl J Med 2002;347(24):192431.