A multidisciplinary limb preservation service under the leadership of vascular surgery in a level one trauma center was associated with an immediate and rapid decline in the number of amputations performed for all indications, including trauma, acute limb ischemia (ALI), chronic limb-threatening ischemia (CLTI) and revision—supporting their implementation in spite of the resources they might demand.
Those were the main findings of a research team from the division of vascular surgery at University of Washington (UW) in Seattle after a retrospective review of all amputations performed at UW Medicine’s Harborview Medical Center over a 10-year period. The results were recently published in the Annals of Vascular Surgery.
The investigators aimed to characterize trends of major amputations performed for all indications at a level one trauma center. Multidisciplinary services have been shown by multiple groups to be a cost-effective approach to improving limb salvage and wound healing rates in patients with CLTI and diabetic foot ulcers but their impact on amputations performed for non-vascular causes remains unknown, noted first-named author Jake Hemingway, a vascular surgery resident at UW, et al. The Harborview multidisciplinary service, which also involves orthopedic surgery, plastic surgery, rehabilitation medicine, podiatry, prosthetics, wound care and infectious disease, was opened in 2014.
Amputations from between January 2009 and December 2018 were studied. Patients were divided into two cohorts: the pre- (2009–2013) and post-service eras (2014– 2018). The results demonstrated that of the 609 major amputations performed, 490 took place prior to the multidisciplinary limb preservation service’s creation, with just 119 coming afterward—representing a 76% reduction. An increasing number was observed each year prior to the service.
Below-the-knee amputation was the most common in both cohorts, but a much higher proportion pre-service were at the through-knee level compared with the post-service era (27% vs. 7%). Practice patterns showed a single surgeon performed more than 50% of all amputations during the study period but when this practitioner— an orthopedic surgeon—was excluded the data showed the maintenance of a 63.5% reduction in the number of major amputations following the coming of the multidisciplinary limb preservation service. Similarly, most amputations were performed by orthopedic surgery during the study period (68% pre- vs. 71% post-service), largely owing to the single surgeon, the researchers point out. Upon this individual’s elimination, vascular surgery emerges as the specialty most commonly performing amputations.
Previous research has shown an association between a multidisciplinary service and improved limb salvage and wound healing, but their impact on amputations for indications like trauma or ALI is unknown, they write. Hemingway et al say their study is the first review to probe the affect on amputations within a level one trauma center setting, and showed steep falls for all indications. Notably, there was a drastic reduction in the number carried out for trauma (95%) after the service went into operation.
“The utilization of aggressive endovascular and open revascularization techniques, along with podiatric surgery involvement, has led to a decrease in major amputations,” they write. “In addition, vascular surgeons in our institution are more likely to perform definitive major amputations when appropriate…”
The investigators conclude that a multidisciplinary limb preservation service’s value extends beyond vascular disease alone.
Commenting on the significance of the findings, Hemingway told Vascular Specialist that the significant reduction in amputations across all indications “strongly supports the institution of these programs.”
He continued: “These efforts should be led by vascular surgery, as opposed to the previous iteration led by orthopedic surgery and physical medicine. While we anticipated seeing a decline in vascular related amputations following institution of our limb preservation service, similar to results published at other institutions, we did not expect to see such a drastic reduction in the number of amputations performed for other indications, such as trauma.
“We continue to actively investigate these findings in order to understand how the multidisciplinary limb preservation service has changed practice patterns within our institution, so that we may continue improving the care of patients with threatened limbs, regardless of the etiology.”