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Cross-Sectional Analysis of 180,595 Lower Limb Amputations in the State of Sao Paulo Over 12 Years

  • Surgery in Low and Middle Income Countries
  • Published:
World Journal of Surgery Aims and scope Submit manuscript

Abstract

Background

Lower limb amputations represent a high social, economic and health burden. Most of them are preventable and reflect areas for improvement in health care, making it essential to know their epidemiology.

Materials and Methods

This is a retrospective population-based cross-sectional analysis on all lower limb amputations performed in public hospitals in Sao Paulo between 2009 and 2020, the most populous Brazilian state, with 46 million inhabitants. Using a public database, we evaluated types, rates and trends of the amputations performed, main etiologies leading to the indication for amputation, hospital length of stay and in-hospital mortality rates, demographics of the amputees and procedure costs.

Results

In total, 180,595 lower limb amputations and surgical revision of amputations were performed, with toe amputations (45%) and major amputations (33%) being the most frequent types of surgeries, with a recent significant increase in the rates for both these procedures. Peripheral artery disease was the most frequent etiology, followed by diabetes mellitus, with both showing an upward trend over the years. Most patients were male (69.3%), Caucasians (55.6%) and elderly. August was the month with the highest number of amputations in all years. Overall in-hospital mortality after lower limb amputations was 6.6%. Total reimbursed by the government was US$ 67,675,875.55.

Conclusions

Peripheral artery disease is the most frequent underlying diagnosis for lower limb amputations, followed by diabetes mellitus, with both showing an upward trend over the years. We observed seasonality in procedure rates, with peaks in August in all years.

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Abbreviations

LEA:

Lower extremity amputation

HIC:

High-income countries

LMIC:

Low- and middle-income countries

PAD:

Peripheral artery disease

DM:

Diabetes mellitus

ICD-10:

International classification of diseases-tenth revision

References

  1. Hoffmann M, Kujath P, Flemming A et al (2015) Survival of diabetes patients with major amputation is comparable to malignant disease. Diab Vasc Dis Res 12:265–271. https://doi.org/10.1177/1479164115579005

    Article  PubMed  Google Scholar 

  2. dos Santos KPB, da Luz SCT, Mochizuki L, d’Orsi E (2018) Carga da doença para as amputações de membros inferiores atribuíveis ao diabetes mellitus no Estado de Santa Catarina, Brasil, 2008–2013. Cad Saúde Pública. https://doi.org/10.1590/0102-311x00013116

    Article  PubMed  Google Scholar 

  3. Sampson UKA, Fowkes FGR, McDermott MM et al (2014) Global and regional burden of death and disability from peripheral artery disease: 21 world regions, 1990 to 2010. Glob Heart 9:145. https://doi.org/10.1016/j.gheart.2013.12.008

    Article  PubMed  Google Scholar 

  4. Ogurtsova K, da Rocha Fernandes JD, Huang Y et al (2017) IDF diabetes atlas: global estimates for the prevalence of diabetes for 2015 and 2040. Diabet Res Clin Pract 128:40–50. https://doi.org/10.1016/j.diabres.2017.03.024

    Article  CAS  Google Scholar 

  5. Wang C, Mai L, Yang C et al (2016) Reducing major lower extremity amputations after the introduction of a multidisciplinary team in patient with diabetes foot ulcer. BMC Endocr Disord 16:38. https://doi.org/10.1186/s12902-016-0111-0

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  6. Musuuza J, Sutherland BL, Kurter S et al (2020) A systematic review of multidisciplinary teams to reduce major amputations for patients with diabetic foot ulcers. J Vasc Surg 71:1433-1446.e3. https://doi.org/10.1016/j.jvs.2019.08.244

    Article  PubMed  Google Scholar 

  7. Saver BG, Martin SA, Adler RN et al (2015) Care that matters: quality measurement and health care. PLOS Med 12:e1001902. https://doi.org/10.1371/journal.pmed.1001902

    Article  PubMed  PubMed Central  Google Scholar 

  8. Carinci F, Massi Benedetti M, Klazinga NS, Uccioli L (2016) Lower extremity amputation rates in people with diabetes as an indicator of health systems performance. A critical appraisal of the data collection 2000–2011 by the organization for economic cooperation and development (OECD). Acta Diabetol 53:825–832. https://doi.org/10.1007/s00592-016-0879-4

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  9. Barmparas G, Inaba K, Teixeira PGR et al (2010) Epidemiology of post-traumatic limb amputation: a national trauma databank analysis. Am Surg 76:1214–1222. https://doi.org/10.1177/000313481007601120

    Article  PubMed  Google Scholar 

  10. Jeffcoate WJ, van Houtum WH (2004) Amputation as a marker of the quality of foot care in diabetes. Diabetologia 47:2051–2058. https://doi.org/10.1007/s00125-004-1584-3

    Article  CAS  PubMed  Google Scholar 

  11. Behrendt C-A, Sigvant B, Szeberin Z et al (2018) International variations in amputation practice: a VASCUNET report. Eur J Vasc Endovasc Surg 56:391–399. https://doi.org/10.1016/j.ejvs.2018.04.017

    Article  PubMed  Google Scholar 

  12. Hughes W, Goodall R, Salciccioli JD et al (2020) Editor’s choice—trends in lower extremity amputation incidence in European Union 15+ countries 1990–2017. Eur J Vasc Endovasc Surg 60:602–612. https://doi.org/10.1016/j.ejvs.2020.05.037

    Article  PubMed  Google Scholar 

  13. Imam B, Miller WC, Finlayson HC et al (2017) Incidence of lower limb amputation in Canada. Can J Public Health 108:374–380. https://doi.org/10.17269/CJPH.108.6093

    Article  PubMed Central  Google Scholar 

  14. Karam J, Shepard A, Rubinfeld I (2013) Predictors of operative mortality following major lower extremity amputations using the national surgical quality improvement program public use data. J Vasc Surg 58:1276–1282. https://doi.org/10.1016/j.jvs.2013.05.026

    Article  PubMed  Google Scholar 

  15. Instituto Brasileiro de Geografia e Estatística Painel de Indicadores | IBGE. https://www.ibge.gov.br/indicadores.html. Accessed 16 Jul 2021

  16. Ministry of Health of Brazil DATASUS. http://www2.datasus.gov.br/DATASUS/index.php?area=02. Accessed 15 Jul 2021

  17. Ministério da Saúde do Brasil Agência Nacional de Saúde Suplementar. https://www.gov.br/ans/pt-br. Accessed 30 Aug 2021

  18. Dillon MP, Fortington LV, Akram M et al (2017) Geographic variation of the incidence rate of lower limb amputation in Australia from 2007–12. PLoS ONE 12:e0170705. https://doi.org/10.1371/journal.pone.0170705

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  19. Moxey PW, Hofman D, Hinchliffe RJ et al (2010) Epidemiological study of lower limb amputation in England between 2003 and 2008. Br J Surg 97:1348–1353. https://doi.org/10.1002/bjs.7092

    Article  CAS  PubMed  Google Scholar 

  20. Heyer K, Debus ES, Mayerhoff L, Augustin M (2015) Prevalence and regional distribution of lower limb amputations from 2006 to 2012 in Germany: a population based study. Eur J Vasc Endovasc Surg 50:761–766. https://doi.org/10.1016/j.ejvs.2015.07.033

    Article  CAS  PubMed  Google Scholar 

  21. Spoden M, Nimptsch U, Mansky T (2019) Amputation rates of the lower limb by amputation level—observational study using German national hospital discharge data from 2005 to 2015. BMC Health Serv Res 19:8. https://doi.org/10.1186/s12913-018-3759-5

    Article  PubMed  PubMed Central  Google Scholar 

  22. Yaghi K, Yaghi Y, McDonald AA et al (2012) Diabetes or war? Incidence of and indications for limb amputation in Lebanon, 2007. East Mediterr Health J 18:9

    Article  Google Scholar 

  23. Moxey PW, Gogalniceanu P, Hinchliffe RJ et al (2011) Lower extremity amputations—a review of global variability in incidence: lower extremity amputations—a global review. Diabet Med 28:1144–1153. https://doi.org/10.1111/j.1464-5491.2011.03279.x

    Article  CAS  PubMed  Google Scholar 

  24. Endoh S, Yamana H, Nakahara Y, et al (2017) Risk factors for in-hospital mortality and reamputation following lower limb amputation. Prog Rehabil Med 2:n/a. https://doi.org/10.2490/prm.20170015

  25. Vigitel_brasil_2019_vigilancia_fatores_risco.pdf. https://bvsms.saude.gov.br/bvs/publicacoes/vigitel_brasil_2019_vigilancia_fatores_risco.pdf. Accessed 15 Jul 2021

  26. Malta DC, Soares Filho AM, Pinto IV et al (2020) Association between firearms and mortality in Brazil, 1990 to 2017: a global burden of disease Brazil study. Popul Health Metr 18:19. https://doi.org/10.1186/s12963-020-00222-3

    Article  PubMed  PubMed Central  Google Scholar 

  27. Goodney PP, Tarulli M, Faerber AE et al (2015) Fifteen-year trends in lower limb amputation, revascularization, and preventive measures among medicare patients. JAMA Surg 150:84. https://doi.org/10.1001/jamasurg.2014.1007

    Article  PubMed  PubMed Central  Google Scholar 

  28. Wolosker N, da Silva MFA, Leiderman DBD et al (2021) lower limb revascularization for peripheral arterial disease in 10,951 procedures over 11 years in a public health system: a descriptive analysis of the largest Brazilian city. Ann Vasc Surg 70:223–229. https://doi.org/10.1016/j.avsg.2020.07.026

    Article  PubMed  Google Scholar 

  29. Kamrad I, Söderberg B, Örneholm H, Hagberg K (2020) SwedeAmp—the Swedish amputation and prosthetics registry: 8-year data on 5762 patients with lower limb amputation show sex differences in amputation level and in patient-reported outcome. Acta Orthop 91:464–470. https://doi.org/10.1080/17453674.2020.1756101

    Article  PubMed  PubMed Central  Google Scholar 

  30. Conte MS, Bradbury AW, Kolh P, et al (2019) Global vascular guidelines on the management of chronic limb-threatening Ischemia. Eur J Vasc Endovasc Surg 58:S1-S109.e33. https://doi.org/10.1016/j.ejvs.2019.05.006

  31. Leung HB, Ho YC, Wong WC, Guerin J (2007) Seasonal variations in non-traumatic major lower limb amputation in Hong Kong Chinese diabetic patients. Hong Kong Med J Xianggang Yi Xue Za Zhi 13:379–381

    CAS  PubMed  Google Scholar 

  32. Klode J, Stoffels I, Körber A et al (2011) Relationship between the seasonal onset of chronic venous leg ulcers and climatic factors: seasonal onset of chronic venous leg ulcers and climatic factors. J Eur Acad Dermatol Venereol 25:1415–1419. https://doi.org/10.1111/j.1468-3083.2011.03988.x

    Article  CAS  PubMed  Google Scholar 

  33. van Netten JJ, Price PE, Lavery LA et al (2016) Prevention of foot ulcers in the at-risk patient with diabetes: a systematic review. Diabet Metab Res Rev 32(Suppl 1):84–98. https://doi.org/10.1002/dmrr.2701

    Article  Google Scholar 

  34. Scott SWM, Bowrey S, Clarke D et al (2014) Factors influencing short- and long-term mortality after lower limb amputation. Anaesthesia 69:249–258. https://doi.org/10.1111/anae.12532

    Article  CAS  PubMed  Google Scholar 

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Acknowledgements

We thank Rogerio Ruscitto do Prado, PhD, for his statistical consultation.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.

Author information

Authors and Affiliations

  1. Hospital do Servidor Público Estadual de São Paulo, Rua Pedro de Toledo, 1800, Vila Clementino, São Paulo - SP, 04039-000, Brazil

    Rodrigo Bruno Biagioni & Marcelo Fiorelli Alexandrino da Silva

  2. Vascular and Endovascular Surgery, Hospital Israelita Albert Einstein, Av. Albert Einstein, 627, Bloco A1, sala 423, Morumbi, São Paulo - SP, 05652-900, Brazil

    Andressa Cristina Sposato Louzada, Marcelo Passos Teivelis & Nelson Wolosker

  3. Hospital Santa Marcelina, R. Santa Marcelina, 177, Vila Carmosina, São Paulo - SP, 08270-070, Brazil

    Luiza Ciucci Biagioni

  4. Hospital A.C. Camargo Cancer Center, Rua Tamandaré, 753, Liberdade, São Paulo - SP, 01525-001, Brazil

    Luiza Ciucci Biagioni

  5. Faculdade Israelita de Ciências da Saúde Albert Einstein, Av. Prof. Francisco Morato, 4293, Butantã, São Paulo - SP, 05521-200, Brazil

    Marcelo Passos Teivelis & Nelson Wolosker

  6. São Paulo University Medical School, Av. Dr. Arnaldo, 455, Cerqueira César, São Paulo - SP, 01246903, Brazil

    Nelson Wolosker

Authors
  1. Rodrigo Bruno Biagioni
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  2. Andressa Cristina Sposato Louzada
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  3. Luiza Ciucci Biagioni
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  4. Marcelo Fiorelli Alexandrino da Silva
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  6. Nelson Wolosker
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Corresponding author

Correspondence to Andressa Cristina Sposato Louzada.

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Ethical approval

The Ethics Committee of the Hospital Israelita Albert Einstein approved this study. Since we used a publicly available database with de-identified entries, a waiver of informed consent forms was requested and granted by the Institutional Review Board.

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Institution where the study was performed: Hospital Israelita Albert Einstein, Department of Vascular and Endovascular Surgery.

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Biagioni, R.B., Louzada, A.C.S., Biagioni, L.C. et al. Cross-Sectional Analysis of 180,595 Lower Limb Amputations in the State of Sao Paulo Over 12 Years. World J Surg 46, 2498–2506 (2022). https://doi.org/10.1007/s00268-022-06631-9

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  • DOI: https://doi.org/10.1007/s00268-022-06631-9

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