Correlation of orthopaedic surgery applications and radiological examinations and cardiovascular surgery consultations in non-traumatic amputations of the lower extremity

Purpose Amputation is not only a limb salvage surgery, but also causes major problems in the psychology of patients besides a financial burden on the healthcare system, as it may require long-term and repetitive hospitalizations. In order to avoid these problems, it is very important to determine an optimal approach and develop appropriate protocols. Choosing the apropriate level the amputation is still a matter of debate. The number of the revision surgeries following non-traumatic extremity amputations are still very high. The purpose of this study is to investigate the reason for revision of patients who underwent a non-traumatic lower extremity re-amputations and the correlation of these revisions with radiological examination (Doppler USG, CT angiography) and Cardio Vascular Surgery (CVS) consultation. Furthermore we eventually aimed to compare the re-amputation patients with a group that has not undergone revision surgery. In this study, we eventually aimed to find an answer to the question of ''if a surgeon's decision for level of the amputation play a role in the need for revision or reamputation following for non-traumatic lower limb amputations?". Material method 598 (607 with the others who undergone revision twice) amputations performed to 476 (320 male, 156 female) patients who were operated in department of orthopaedics and traumatology surgery were analysed retrospectively in the last 10 years between January 2011 and May 2020. 92 patients (100 amputations) with revision amputation were named as group A. As a control group (group B), 100 cases among amputation patients that did not require revision were randomly chosen. Patients with insufficient data were excluded from the groups. Gender, etiology, amputation levels, the time between two operations, follow-up periods, radiological examinations (Doppler USG, CTA) and CVS consultations were evaluated using statistical methods. Also whether the orthopedist's compliance with the radiologicalexamination reports and CVS recommendations changed the reamputation rates were evaluated using statistical methods. NCSS (Number Cruncher Statistical System) Statistical Software (Utah, USA) program was used for statistical analysis. While evaluating the data of the study, additionally, descriptive statistical methods (mean, standard deviation, median, frequency, ratio), Shapiro Wilk test and box plot graphics were used for the compliance of the variables to the normal distribution. Spearman's correlation test was used to compare the agreement between Doppler USG, BTA, CVS and the orthopaedist. As a non-parametric analysis, Mann-Whitney U Test was used for comparisonof group A and B their correlation with investigations and CVS consultations. Significance was determined at the p <0.05 level. Results 476 patients data who have underwent surgery our department of orthopaedics and traumatology surgery were obtained. For these patients, 598 amputations were performed in total. 16.72% of 598 amputations were revision surgeries. In 476 patients, revision rates were found 21.48% for diabetics and 19.53% for PAD patients. In the groups of revision amputations 76.1% (70) with Diabetes and 23.9% (22) with PAD were determined. In this study, a total of 188 patients and 196 amputations in groups A and B were evaluated. The average age in the groups A and B were 69.3 and 71.9 respectively. 59 (64.1%) patients of group A and 56 (58.3%) of group B were male. 8 patients(%8.7) needed bilateral reamputation, while 9 patients (9%) had ipsilateral reamputation twice. The average follow-up period was 27.85 (8-97) months in group A and 28.4 (8-98) months in group B. In addition, in the group A the average length of staying in hospital were 12.9 and 12.7 days for the first and the second operation respectively, while the average hospital stay was 14.3 days in group B. Moreover, the interval between two operations in group A is 80 days on average. In revision patients (group A), the correlation between the level of amputation at the first surgery and radiological examination and CVS consultation was weak (rs = 0.37, p = 0.00015), While in the control group (group B) this ratio was moderate (rs= 0.51, p = 0.0001). Furthermore, there was a significant difference between the groups with and without revision (groups A and B) in the rate of surgeons' compliance with the results of radiological examination and CVS consultations (p = 0.03) in favour of the control group. In addition, it was found that, amputation level was increased to the level of AKA after BKA by 33.02% (36 cases). In the second frequency (25 cases), 22.93% of the cases were found to be applied BKA reamputation after finger amputation. Conclusion: These results show us how important is careful evaluation of the results of examination findings and interpretation of consultations to obtain better results from amputation while make a decision the amputation level as a surgeon. Although the emotional status of the patients sometimes affects this decision, in the long term shows if if selection of the amputation level does nor correlate with radiological investigations and CVS consultation, longer hospital stays, a higher burden on the national health system in terms of both finance and bed occupancy might be inevitable. We believe that this study might gives an important hint on how to choose the amputation level to the surgeons who deal with extrimity amputation surgery. Keywords: diabetic foot, peripheral artery disease, non-traumatic amputations, revision amputation, reamputations