January 2021

Disparities Persist in Amputations for Critical Limb Ischemia

Critical limb ischemia (or chronic limb threatening ischemia, CLI) is a state of arterial insufficiency manifested by chronic inadequate tissue perfusion at rest, reducing patients’ quality of life and increasing the risk for amputation and death. Prevalence for PAD ranges from 3% – 10% but increases to 15% – 20% in persons age ≥70 years and is increasing worldwide. Common risk factors include age, smoking, diabetes, body mass, sedentary lifestyle, high cholesterol, high blood pressure and family history. But previous studies have identified disparities in amputation rates, namely demonstrating that blacks were 2 times more likely to undergo amputation than whites.

In a new study published in the Journal of the American Academy of Orthopaedic Surgeons, researchers used data from the National Surgical Quality Improvement Program’s database for the years 2011 – 2017. They sought to isolate the effect of race and ethnicity on the likelihood of a below-knee or above-knee amputation (BKA and AKA, respectively) for CLI secondary to type 2 diabetes mellitus, atherosclerosis, peripheral vascular disease, chronic osteomyelitis, and deep soft-tissue infections.

For all diagnoses, blacks were 93.3%, and Hispanics were 61.9% more likely to undergo a BKA than white patients (P < 0.001). In addition, black patients had a 133.0% higher risk of an AKA than white patients (P < 0.001). Disparities were greatest with blacks undergoing surgery for CLI secondary to atherosclerosis (BKA odds ratio 2.093; AKA: odds ratio 2.625). Black patients also had an elevated risk of amputation secondary to diabetes, peripheral vascular disease, and deep soft-tissue infections
(P < 0.001).

The researchers concluded that their findings from this nationally representative, cohort-based study demonstrate that notable racial and ethnic disparities for lower extremity amputations persist, with a higher proportion of black and Hispanic patients undergoing amputation compared with limb salvage procedures for atraumatic CLI and infection. Data from other studies advocate for an endovascular-first approach to revascularization in treating patients with CLI.

Source: Traven SA, Synovec JD, Walton ZJ, et al. Notable Racial and Ethnic Disparities Persist in Lower Extremity Amputations for Critical Limb Ischemia and Infection. J Am Acad Orthop Surg. 2020 Nov 1;28(21):885-892.

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