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Effect of Prosthesis Fitting on Mortality after Major Lower Extremity Amputation
Nathaniel Forrester1, Maja Wichhart Donzo1, Chengcheng Hu2, Brandi Mize3, Yazan Duwayri3, Luke Brewster4, Olamide Alabi4
1Emory University School of Medicine, Atlanta, GA;2Department of Surgery, Emory University School of Medicine, Atlanta, GA;3Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Emory University School of Medicine, Atlanta, GA;4Surgical and Perioperative Care, Atlanta VA Healthcare System, Atlanta, GA

Prior studies suggest that ambulation after major lower extremity amputation (LEA) is low and mortality after LEA is high. Successful prosthetic fitting after LEA has been shown to provide a significant quality of life benefit, however, it is unclear if there is any benefit to post-LEA mortality. The purpose of this study was to examine a contemporary cohort of patients who underwent LEA and determine if there is an association between fitting for a prosthetic and mortality.
We reviewed all patients who underwent LEA between 2015 and 2022 at two academic healthcare systems in a large metropolitan city. The exposure of interest was prosthetic fitting after LEA. The primary outcomes were mortality within 1- and 3-years of follow-up. Ambulation after LEA was defined as being ambulatory with or without an assistive device. Patients with prior LEA were excluded. Extended Cox models with time-dependent exposure were used to evaluate the association between prosthetic fitting and mortality at 1- and 3-years of follow up.
Among 702 patients who underwent LEA, the mean (SD) age was 64.3 (12.6) years and 329 (46.6%) were fitted for prosthesis. The study population was mostly male (n=488, 69.5%), predominantly Non-Hispanic Black (n=410, 58.4%), and nearly one-fifth were non-ambulatory prior to LEA (n=139, 19.8%). Of note, 14.3% of all subjects who were non-ambulatory preoperatively were fitted for prosthetic at some point after LEA, and 28.5% of patients not ambulatory preoperatively were eventually ambulatory after LEA [Table 2]. The rate of death among those fitted for a prosthetic was 12.0/100 person-years at 1 year and 15.8/100 person-years at 3 years of follow up and among those not fitted for a prosthetic, the rate of death was 55.7/100 person-years and 50.7/100 person-years at 1- and 3-years of follow up, respectively. After adjusting for several sociodemographic data, comorbidities, pre- or post-COVID pandemic timeframe, and procedural factors, prosthesis fitting is associated with decreased likelihood of mortality within 1 year of follow-up (adjusted hazard ratio [aHR] 0.24; 95% CI, 0.14 - 0.40) as well as within 3 years (aHR 0.40; 95% CI, 0.29 - 0.55) [Table 1].
Our data suggests that prosthesis fitting is associated with improved survival. There is also a suggestion that preoperative functional status does not always predict postoperative functional status. Characterization of the patient, surgical, and rehabilitation factors associated with achieving fitting for a prosthesis towards improved function among patients that were non-ambulatory preoperatively may improve long-term survival in these patients. Process measures employed by the VA, such as prosthetic department evaluation of all amputees, may represent a ‘best practice’. Further evaluation into optimizing receipt of prosthetic after LEA in reasonable candidates is necessary.

Table 1. Association between Prosthesis Fitting and Mortality During 1 year and 3 years of Follow up
1 year Mortality3 year Mortality
Prosthesis FittingUnadjusted HR (95% CI)Adjusted HR (95% CI)Unadjusted HR (95% CI)Adjusted HR (95% CI)
0.25 (0.15-0.41)0.24 (0.14-0.40)0.36 (0.27-0.48)0.40 (0.29-0.55)
*adjusted for age, sex, ADI, ethnoracial background, obesity, PAD, CKD status, preoperative ambulatory status, mFI5 score, surgical team, procedural site, level of amputation, pre or post-COVID pandemic timeframe

Table 2. Postoperative Ambulatory status presented by preoperative ambulatory status and site of amp
Preoperative Ambulatory StatusPostoperative Ambulatory Status
Ambulatory246AHC= 184 (74.8)280AHC = 196 (70.0)380
VA= 62 (25.2)VA= 84 (30.0)146
Non-ambulatory37AHC= 9 (24.3)93AHC= 88 (94.6)97
VA= 28 (75.7)VA= 5 (5.4)33
Abbreviations: AHC, academic health center; VA, Department of Veterans Affairs*46 patients had missing data for ambulatory status

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