The Journal of Foot & Ankle Surgery 59 (2020) 484−490

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The Journal of Foot & Ankle Surgery

journal homepage: www.jfas.org

Transmetatarsal and Minor Amputation Versus Major Leg Amputation:

30-Day Readmissions, Reamputations, and Complications
Daniel C. Jupiter, PhD1,2, Marc El Beaino, MD, MSc2, Javier LaFontaine, DPM3,
Neal Barshes, MD, MPH4, Dane K. Wukich, MD5, Naohiro Shibuya, DPM, MS, FACFAS6,7,8
1
Associate Professor, Department of Preventive Medicine and Population Health, The University of Texas Medical Branch, Galveston, TX
2
Research Associate, Department of Orthopaedic Surgery and Rehabilitation, The University of Texas Medical Branch, Galveston, TX
3
Professor, Department of Plastic Surgery, The University of Texas Southwestern Medical Center, Dallas, TX
4
Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
5
Professor and Chairman, Department of Orthopaedic Surgery, The University of Texas Southwestern Medical Center, Dallas, TX
6
Professor, Texas A&M University, College of Medicine, Temple, TX
7
Section of Podiatry, Department of Surgery, Central Texas Veterans Affairs Health Care System, Temple, TX
8
Department of Surgery, Baylor Scott & White Health, Temple, TX

A R T I C L E I N F O A B S T R A C T

Level of Clinical Evidence: 2 Aims: The optimal level of lower-extremity amputation, particularly in diabetic patients with ulceration, is
Keywords: debated. Proximal amputations more greatly decrease function versus distal amputations, but healing and compli-
below knee amputation cation rates may differ between the 2 types. This study compares early postoperative outcomes after transmeta-
complications tarsal and other partial foot amputations and major leg amputations.
diabetes mellitus Methods: Data were derived from National Surgical Quality Improvement Program datasets covering 2012 to 2014.
reoperation Outcomes studied include 30-day rates of readmission to hospital for wound complications. We matched the 2
transmetatarsal amputation
types of amputation patients by propensity score to fairly compare between levels of amputation when either
type of amputation might be indicated. The same analysis was then performed with emphasis on diabetic patients.
Results: Major amputation patients were more likely to have dependent functional status, although their surgeries
tended to be more complicated. Minor amputation patients had 2.5 times the odds of irrigation and debridement
compared with major amputation patients, but only 0.49 and 0.47 times the odds of urinary tract infection or
transfusion, respectively.
Conclusions: Although short-term complications, readmissions, and reoperations were more common in distal
amputation, UTI and the need for transfusion were higher in major amputation.
© 2019 by the American College of Foot and Ankle Surgeons. All rights reserved.

Preservation of a lower extremity is a major goal of limb-salvage
teams. Amputation, in many cases, can result in loss of function, decline
in quality of life, and even death (1,2). On the other hand, there are
many situations where amputation can provide equal or better overall
outcomes compared with limb salvage. Despite some potential advan-
tages of amputation, patients with severe foot pathology often fear
major amputation more than death (3). Specifically, it has been shown
in both healthy and high-risk individuals that energy costs for higher-
level amputations are not necessarily greater than those for lower-level
Financial Disclosure: This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Conflict of Interest: Dr. Wukich is a consultant for Orthofix and receives royalties
from Arthrex. The other authors have no conflicts of interest to declare.
Address correspondence to: Daniel C. Jupiter, PhD, Department of Preventive Medi-
cine and Population Health, The University of Texas Medical Branch, 301 University Blvd,
Galveston, Texas 77555-1148.
E-mail address: dajupite@utmb.edu (D.C. Jupiter).
amputations (4−6). If patients are capable of full rehabilitation, they
may be able to functionally adapt to the amputation (7−10).
Quality of life is also not necessarily poorer in patients who have had
successful minor or major amputation than in those who are actively being
treated for problems such as ulceration or severe deformity (11−15).
Although 5-year mortality may be worse in those who have proximal
amputations, the patients tend to be much older, have a higher burden of
comorbidities than those with more distal amputation, and have decreased
cardiovascular capacity due to lack of mobility (16,17). Therefore, it can be
suggested that proximal amputation may be a proxy for frailty rather than
a causative factor for death.
There are consequences to well-meaning attempts at limb preserva-
tion in patients with unsalvageable extremities: prolonged treatment,
non-weightbearing status, multiple surgeries, and readmissions can
result in significant deconditioning of a patient, decline in health and
mental status, and development of functional dependence (18−21). It is
also known that reamputation rates after minor amputations are high

1067-2516/$ - see front matter © 2019 by the American College of Foot and Ankle Surgeons. All rights reserved.
https://doi.org/10.1053/j.jfas.2019.09.019
 D.C. Jupiter et al. / The Journal of Foot & Ankle Surgery 59 (2020) 484−490
(22,23). Izumi et al (24) showed a significantly higher reamputation
rate of distal amputation in the ipsilateral extremity in a diabetic popu-
lation compared with more proximal amputation. This suggests that
some high-risk patients may benefit from more definitive, proximal
amputation that allows them to rehabilitate quickly, with relatively less
deconditioning and without recurrence of a similar problem.
The concern remains that proximal amputation is associated with
more short-term complications, such as wound dehiscence, need for
further operation, and transfusion. This perception perhaps comes from
the general observation of more frequent complications after major
versus minor amputations. It is conceivable, however, that those who
have major amputations are at higher medical risk than those who
have minor amputations, and that it is this burden, rather than the
amputation, that leads to the complications. Curran et al (25) showed
significant differences in patient characteristics between those who
underwent a below-knee amputation (BKA) and those who underwent
transmetatarsal amputation (TMA).
The independent complication risks of proximal, compared to distal,
amputations are not entirely understood. Belmont et al (26) identified risk
factors for complications and mortality after BKA, including renal disease
and cardiac issues, which are more frequently encountered in patients
undergoing BKA than those having minor amputations. The relationship
between these factors and postoperative complications in those undergo-
ing more distal amputations is unclear. In this study, we attempted to
compare the risk of short-term complications associated with minor
amputation (TMA, Chopart, Lisfranc) versus major amputation (BKA) after
adjusting for these, and other, clinically relevant covariates.
Methods
Cohort Selection
Patients were selected from the National Surgical Quality Improvement Program
(NSQIP) data from 2012 to 2014. This database was developed by the American College of
Surgeons as a tool for helping hospitals improve and to benchmark quality of care
(27,28). More than 700,000 cases were recorded in 2014 from the hospitals that voluntar-
ily participate in the program. Patients were included if the primary Current Procedural
Terminology (CPT) code for their surgery indicated that they had undergone an minor
amputation (TMA, Chopart, Lisfranc) or a major amputation (BKA) (Appendix, Table A1).
This table was also used to classify patients into the 2 study groups: minor amputation
and major amputation. The demographic variables collected were age (those with age
>90 years were coded as being 90), gender, race, ethnicity, and body mass index (BMI)
(computed from weight and height). Comorbidities recorded were presence of bleeding
disorder, preoperative steroid use, presence of open wound at the time of surgery, dialy-
sis, functional status (coded as dependent, partially dependent, or independent), smok-
ing, and diabetes mellitus. Several perioperative variables were also included: American
Society of Anesthesiologists (ASA) class (1/2, 3, or 4/5), wound class (clean, an uninfected
surgical wound in which no inflammation is encountered; clean/contaminated, a surgical
wound in which the alimentary (or respiratory, etc.) canal is entered; contaminated, a
surgical wound with leakage from the gastrointestinal tract, or breaks in sterile tech-
nique; and dirty/infected, a surgical wound in which the infectious agents were present
before surgery), whether the surgery was emergent, length of stay (LOS), operative time,
and time from operation until discharge. Discharge destination and patient transfer status
were both coded as either home or not home. Primary outcomes were reamputation and
occurrence of wound complication or irrigation and debridement within 30 days of sur-
gery (Appendix, Table A2). Secondary outcomes were the occurrence of urinary tract
infection (UTI), deep venous thrombosis/pulmonary embolism, wound complications
(surgical site infection or wound disruption), or blood transfusion, within the same time
frame. There were no exclusions for any comorbidities or age. In preparation for propen-
sity score matching based on gender, location from which patients arrived, emergency/
nonemergency, discharge location, intraoperative variables, LOS, all the comorbidities
listed above, age, and BMI, any patients missing data on any of these variables were
removed.
All variables were described in the amputation patients using univariate statistics
(means and standard deviations [SDs] for continuous variables, frequencies and percen-
tages for discrete variables). The 2 types of amputation were compared in terms of demo-
graphics and comorbidities, as well as outcomes, using bivariate tests. Student’s t tests
and Fisher’s exact/chi-squared tests compared continuous and discrete variables, respec-
tively. Associations between demographic and comorbid factors and the outcomes of
interest were assessed using bivariate analyses. For each outcome, a logistic regression
model was built, including amputation type and any other factor whose p value in the
485
test for association with the outcome was <0.2. Wound class, ASA score, discharge desti-
nation, functional status, and operative time were included in all models.
To account for underlying differences in indication for the 2 amputation types, the 2
amputation samples were matched by propensity score on the variables mentioned
above in describing cohort selection. A conditional logistic regression model for each of
our outcomes assessed the impact of amputation type. The propensity score matching
and subsequent conditional logistic regression were repeated after restricting to patients
with diabetes. All analyses were executed in the R statistical package (https://www.R-
project.org) (29).
Results
A total of 6936 patients in the NSQIP data sets from 2012 to 2014
had an appropriate primary CPT code (Appendix, Table A1). Of these,
956 were missing data for ASA (9), discharge destination (37), func-
tional status (87), race (579), ethnicity (537), transfer status (18), BMI
(198), LOS (30), operative time (1), or time for operation to discharge
(17). In comparing the patients who were excluded to those who
remained, there were several notable differences. The LOS was roughly
6 days longer in the former group, in part because the time from opera-
tion to discharge was 5 days greater, although the operative time was
the same. Of the excluded patients, 24% were emergent, perhaps
explaining why some data was not properly recorded. There were
roughly 7%, 4%, and 9% fewer bleeding disorders, smokers, or African
American patients among those excluded, respectively. Most difficult to
explain were the 21% more Hispanics in the excluded sample. In terms
of outcomes, there were some notable differences between those
excluded and those included: 30% more of those excluded were dis-
charged home, and 4% fewer were readmitted (Appendix, Table A3).
Patients who underwent amputation were 63.4 § 13.3 years old
(mean § SD) and overweight (mean BMI 29.1 § 7.8) (Table 1). They
remained in hospital 11.8 § 10.7 days, with an operative time of 66.6 § 43
minutes. The majority of wounds were clean (56.4%), and most cases were
ASA 3 (57.6%). Discharge destination was most often not home (68.4%). A
quarter of patients had bleeding disorders, 69.8% had wound infections,
20.4% were on dialysis, and 71.4% had diabetes. The other comorbidities
also indicate a relatively heavy burden of disease. Rates of UTI, irrigation
and debridement, deep venous thrombosis/pulmonary embolism, and
reamputation were all <3%. However, 23.5% of patients had transfusions,
15.3% were readmitted, and 7.7% had wound complications.
The 2 types of amputation differed in terms of comorbidities and
perioperative factors (Table 2). Major amputation patients were more
often dependent (26.5% versus 16.6%). Their surgeries were longer
(69.9 versus 52.2 minutes) but were less frequently dirty/infected
(21.9% versus 48.3%). However, they had higher ASA scores (40.5% ver-
sus 28.7% with score 4 or 5) and were discharged home less frequently
(25.8% versus 56.6%). There were several notable differences in terms of
complications (Table 3). Although the rate of readmission was higher in
the minor versus major amputation group (17% versus 14.9%), this dif-
ference did not reach statistical significance. Significantly more patients
who underwent minor amputation (4.1%) required postoperative inci-
sion and drainage than patients who underwent major amputation
(2.2%). Postoperative UTI and transfusion were more frequent after
major amputation (3.3% and 26%), as opposed to minor amputation
(1.5% and 12.5%), and these differences were significant.
In multivariate analysis, after accounting for potential confounders
as identified in bivariate analysis (data not shown), the above differen-
ces remained significant (Table 4). Those undergoing minor amputation
had 2.5 times (95% confidence interval [CI] 1.68 to 3.71) the odds of
requiring irrigation and debridement compared with major amputation
patients, but only 0.49 (0.29 to 0.85) and 0.47 (0.39 to 0.58) times the
odds of UTI or transfusion need.
Propensity score matching achieved balance in most variables, as
evidenced by standardized mean differences <0.2. However, many of
those differences were already small, and the matching was unable to
486 D.C. Jupiter et al. / The Journal of Foot & Ankle Surgery 59 (2020) 484−490

Table 1 Table 2
Univariate analysis of amputation patients Bivariate comparison of demographics and comorbidities in BKA and TMA patients

Age (yr) 63.4 § 13.3 BKA (n = 4852) TMA (n = 1128) p Value

Body mass index (703 lb/inches2) 29.1 § 7.8
Length of stay (d) 11.8 § 10.7 Age (yr) 63.8 § 13.2 62.1 § 13.5 <.01
Operative time (min) 66.6 § 43 Body mass index (703 lb/inches2) 29.1 § 7.9 29.1 § 7.7 .98
Time from operation to discharge (d) 8§8 Length of stay (d) 12 § 10.4 11.4 § 11.6 .12
Wound Operative time (min) 69.9 § 44.9 52.2 § 29.6 <.01
Clean 3372 (56.4) Time from operation to discharge (d) 8 § 7.6 8.1 § 9.3 .67
Clean/contaminated 425 (7.1) Wound class
Contaminated 573 (9.6) Clean 3055 (63) 317 (28.1)
Dirty/infected 1610 (26.9) Clean/contaminated 335 (6.9) 90 (8) <.01
American Society of Anesthesiologists score Contaminated 397 (8.2) 176 (15.6)
1/2 242 (4.1) Dirty/infected 1065 (21.9) 545 (48.3)
3 3447 (57.6) American Society of Anesthesiologists score
4/5 2291 (38.3) 1/2 176 (3.6) 66 (5.9) <.01
Sex 3 2709 (55.8) 738 (65.4)
Male 4048 (67.7) 4/5 1967 (40.5) 324 (28.7)
Female 1932 (32.3)
Sex
Discharge
Male 3247 (66.9) 801 (71) <.01
Home 1890 (31.6)
Female 1605 (33.1) 327 (29)
Not home 4090 (68.4)
Discharge
Emergency
Home 1252 (25.8) 638 (56.6) <.01
Yes 776 (13)
No 5204 (87) Not home 3600 (74.2) 490 (43.4)
Bleeding disorders Emergency
Yes 1405 (23.5) Yes 625 (12.9) 151 (13.4) .65
No 4575 (76.5) No 4227 (87.1) 977 (86.6)
Steroid Bleeding disorder
Yes 379 (6.3) Yes 1149 (23.7) 256 (22.7) .48
No 5601 (93.7) No 3703 (76.3) 872 (77.3)
Wound infection Steroid
Yes 4172 (69.8) Yes 285 (5.9) 94 (8.3) <.01
No 1808 (30.2) No 4567 (94.1) 1034 (91.7)
Dialysis Wound infection
Yes 1222 (20.4) Yes 3370 (69.5) 802 (71.1) .28
No 4758 (79.6) No 1482 (30.5) 326 (28.9)
Functional status Dialysis
Dependent 1474 (24.6) Yes 1002 (20.7) 220 (19.5) .39
Independent 4506 (75.4) No 3850 (79.3) 908 (80.5)
Smoker
Functional status
Yes 1618 (27.1)
Dependent 1287 (26.5) 187 (16.6) <.01
No 4362 (72.9)
Independent 3565 (73.5) 941 (83.4)
Diabetes mellitus
Smoker
Yes 4271 (71.4)
Yes 1317 (27.1) 301 (26.7) .75
No 1709 (28.6)
Race No 3535 (72.9) 827 (73.3)
White 4108 (68.7) Diabetes mellitus
Black 1650 (27.6) Yes 3438 (70.9) 833 (73.9) .04
American Indian or Alaska native 44 (0.7) No 1414 (29.1) 295 (26.1)
Native Hawaiian or Pacific Islander 65 (1.1) Race
Asian 113 (1.9) White 3361 (69.3) 747 (66.2)
Ethnicity Hispanic Black 1323 (27.3) 327 (29) .02
Yes 566 (9.5) American Indian or Alaska native 33 (0.7) 11 (1)
No 5414 (90.5) Native Hawaiian or Pacific Islander 55 (1.1) 10 (0.9)
Transfer Asian 80 (1.6) 33 (2.9)
Home 4704 (78.7) Ethnicity Hispanic
Not home 1276 (21.3) No 4394 (90.6) 1020 (90.4) .89
Wound complication Yes 458 (9.4) 108 (9.6)
Yes 460 (7.7) Transfer
No 5520 (92.3) Home 3762 (77.5) 942 (83.5) <.01
Readmission Not home 1090 (22.5) 186 (16.5)
Yes 913 (15.3)
No 5048 (84.7) Data are mean § standard deviation or n (%).
Reamputation Abbreviations: BKA, below-knee amputation; TMA, trans-metatarsal amputation.
Yes 81 (1.3)
No 5899 (98.7)
Irrigation and debridement achieve balance in functional status, race, ASA score, operative time,
Yes 154 (2.6) transfer status, discharge disposition, or wound class. Conditional logis-
No 5826 (97.4) tic regression results mimic what was seen in multivariate analysis,
Urinary tract infection
Yes 179 (3)
with roughly the same magnitudes of effect, but for 2 exceptions: read-
No 5801 (97) mission was significantly more likely in minor amputation compared
Deep vein thrombosis or pulmonary embolism with major amputation, with an odds ratio of 1.36 (95% CI 1.08 to 1.71).
Yes 59 (1) UTI was no longer significantly different between the groups, with an
No 5921 (99)
Transfusion odds ratio of 0.68 (95% CI 0.35 to 1.31). Both changes are small in terms
Yes 1403 (23.5) of magnitude of the odds ratios. Repeating the analysis restricted to dia-
No 4577 (76.5) betic patients did not change either the quality of matching, the effect
Data are mean § standard deviation or n (%). sizes, or significance in conditional logistic regression, except for
 D.C. Jupiter et al. / The Journal of Foot & Ankle Surgery 59 (2020) 484−490 487

Table 3 contribute to blood loss owing to bleeding from the intramedullary

Bivariate comparison of complications in BKA and TMA patients compartment. Therefore, hemodynamic stability of a patient and tech-
BKA (n = 4852) TMA (n = 1128) p value nical consideration of major amputation should be assessed carefully as
a part of the decision-making process before carrying out an amputa-
Wound complication
tion at this level. Many patients who require major amputation also
No 4484 (92.4) 1036 (91.8) .52
Yes 368 (7.6) 92 (8.2) have decreased cardiac function, and the burden of transfusion can
Readmission result in volume overload. Although the use of tourniquets is surgeon
No 4115 (85.1) 933 (83) .08 dependent, these devices have been shown to reduce the risk of trans-
Yes 167 (14.9) 191 (17)
fusion in major amputations (30).
Reamputation
No 4789 (98.7) 1110 (98.4) .44
Although we were unable to achieve balance in some variables to
Yes 63 (1.3) 18 (1.6) account for all differences between the 2 amputation populations, the
Irrigation and debridement lack of differences in wound complication and reoperation between
No 4744 (97.8) 1082 (95.9) <.01 these 2 groups before propensity score matching suggests that minor
Yes 108 (2.2) 46 (4.1)
amputations may be more prone to these short-term complications if all
Urinary tract infection
No 4690 (96.7) 1111 (98.5) .01 the other variables are equal (i.e., while higher ASA scores were found in
Yes 162 (3.3) 17 (1.5) the major amputation group, the minor amputation group had a similar
Deep vein thrombosis or pulmonary embolism proportion of short-term complications). We speculate that distal perfu-
No 4800 (98.9) 1121 (99.4) .17 sion is less ideal for healing than proximal perfusion, predisposing minor
Yes 52 (1.1) 7 (0.5)
Transfusion
amputation patients to increased wound-healing complications. It is well
No 3590 (74) 987 (87.5) <.01 known that patients with diabetes classically have infrapopliteal disease,
Yes 1262 (26) 141 (12.5) and this would be much more likely to impact healing for minor amputa-
Data are n (%). tions compared with major amputations. When performing a major
Abbreviations: BKA, below-knee amputation; TMA, transmetatarsal amputation. amputation, the tissue margins are much more likely to be free of edema,
infection, and inflammation as opposed to the margins achieved with
readmission once again not being significantly different between the 2 foot amputations. Consequently, the local metabolic demand for oxygen
groups, and UTI returning to being significant. and nutrition may be accentuated in distal amputations. Eradication of
Given that we were missing race and ethnicity data for a large num- infection and achieving uninfected tissue margins are paramount to
ber of patients, we performed a sensitivity analysis and repeated all of achieving optimal wound healing (31,32).
our analyses, excluding the propensity score analysis, coding race and In emergency or sepsis situations, staged open amputation (i.e., circu-
ethnicity as “missing.” Although the impact of other covariates in multi- lar or guillotine) or more proximal amputation have been shown to yield
variate models for our outcomes changed, the impact of amputation better results (33). Therefore, proximity to inflammation, infection, and
type remained the same, in both significance and magnitude of effect. edema may be important factors to consider when deciding level of
The exception to this was readmission, for which the magnitude amputation. Often, patients undergoing minor amputation have infection
remained the same in the sensitivity analysis, but the amputation type in the digit or even at the distal metatarsal level. Although it may appear
was now a significant factor. grossly that all the necrotic tissue has been resected, surrounding
inflammation, edema, and microscopic contamination may result in
wound-healing complications that can be mitigated with more proximal
Discussion amputation.
We found that patients undergoing minor amputation were 2.66 times
Wound complications and reoperations are the most common rea- more likely to return to the operating room for irrigation and debride-
sons for readmission after lower-extremity amputations (25). Minimiz- ment than patients undergoing major amputation. This may be because
ing such complications would tremendously impact the health care patients and providers alike, in nonemergent cases, may opt for
system in terms of costs and effectiveness of delivery. In general, attempted limb salvage. Alternately, providers may be trying to resolve
patients would strongly prefer to preserve their foot, even if it does the aftermath of an acute problem with multiple debridements. Partial
require a higher number of operations, more hospital time, or no bene- foot amputations, such as TMA, Lisfranc, Chopart, and Syme, are per-
fits and function. However, aggressive attempts at limb salvage, or at formed to avoid major amputation. Because of problems with tendon
minimizing the level of amputation, may also result in unnecessary imbalance, it is generally accepted that TMA is more functional than
reoperation and readmission. Therefore, selecting an appropriate more proximal limb-sparing foot amputation. When performing a TMA, it
amputation level in high-risk patients is critical in terms of effective- is critical to maintain the metatarsal bases to avoid an equinovarus defor-
ness of health care delivery. mity. However, studies suggest that the functional difference between
We have shown that more proximal amputation (major amputation) these foot amputation levels may be minimal, and if patients are able to
did not yield higher rates of wound-healing complications, reamputation, rehabilitate with a functional prosthesis, they do well, even with more
or readmission compared with more distal amputations. Although major proximal amputation (7,9,34). Postrecovery demands for oxygen are not
amputations were more likely to be associated with UTI, this condition is significantly different between foot and BKA levels, with the exception of
possibly due to underlying comorbidities that were not fully adjusted for above-knee amputation (AKA). Every effort should be made to avoid an
in this study. Another plausible explanation is that patients who under- AKA, because increased energy requirements to ambulate are »60% to
went major amputation were more likely to have placement of a Foley 70% higher than baseline (4,5,9,35).
catheter to monitor hemodynamic parameters. There are several limitations to this current study. The NSQIP database
The increased risk of transfusion after major amputation is impor- is limited to the first 30 days of follow-up, and additional complications
tant to acknowledge because of several factors. More proximal amputa- can occur beyond this time period. NSQIP may have multiple visits per
tions involve larger vessels and naturally predispose to higher risk for patient. However, unless a subsequent amputation was coded as a new
blood loss. Most major amputations are performed distal to the popli- amputation, multiple visits within the 30-day follow-up period are
teal trifurcation, requiring identification and ligation of 3 distinct arter- unlikely in the context of amputation. NSQIP data is generally well main-
ies and multiple veins. Transection of the tibia and fibula also tained with minimal error rates; however, participation in NSQIP is
 488
Table 4
Multivariate Logistic Regression for Complications

Wound Complication Readmission Reamputation Irrigation and Debridement Urinary Tract Infection DVT/PE Transfusion

OR p OR p OR p OR p OR p OR p OR p

TMA versus BKA 1.14 (0.88 to 1.49) .31 1.2 (0.98 to 1.46) .07 0.99 (0.55 to 1.77) .97 2.5 (1.68 to 3.71) <.01 0.49 (0.29 to 0.85) .01 0.56 (0.24 to 1.31) .18 0.47 (0.39 to 0.58) <.01

D.C. Jupiter et al. / The Journal of Foot & Ankle Surgery 59 (2020) 484−490
Clean/contaminated versus clean 1.14 (0.79 to 1.65) .48 0.98 (0.73 to 1.32) .90 1 (0.39 to 2.58) 1 0.93 (0.48 to 1.79) .83 0.69 (0.33 to 1.44) .33 0.85 (0.25 to 2.89) .8 0.83 (0.64 to 1.08) .16
Contaminated versus clean 0.94 (0.66 to 1.33) .72 1.19 (0.94 to 1.52) .16 1.25 (0.59 to 2.63) .56 0.89 (0.51 to 1.55) .67 1.65 (1.04 to 2.6) .03 1.4 (0.6 to 3.3) .44 0.89 (0.71 to 1.12) .31
Dirty/infected versus clean 1.03 (0.82 to 1.31) .78 1.10 (0.92 to 1.31) .31 1.15 (0.68 to 1.96) .6 0.72 (0.48 to 1.09) .12 0.91 (0.61 to 1.34) .62 1.44 (0.78 to 2.68) .25 1.07 (0.92 to 1.25) .38
ASA score 3 versus 1/2 1.11 (0.66 to 1.87) .7 1.95 (1.18 to 3.22) .01 0.76 (0.27 to 2.16) .6 1.29 (0.51 to 3.30) .59 2.24 (0.54 to 9.28) .27 1.91 (0.25 to 14.35) .53 1.89 (1.18 to 3.03) .01
ASA score 4/5 versus 1/2 1.23 (0.72 to 2.11) .45 2.92 (1.37 to 3.83) <.01 0.87 (0.29 to 2.55) .79 1.24 (0.47 to 3.26) .67 2.45 (0.58 to 10.29) .22 1.7 (0.22 to 13.1) .61 2.48 (1.53 to 4) <.01
Male versus female 0.61 (0.39 to 0.95) .03 0.6 (0.44 to 0.81) <.01 0.38 (0.22 to 0.65) <.01 0.9 (0.78 to 1.02) .11
Discharge home versus discharge not home 1 (0.8 to 1.24) .98 0.94 (0.8 to 1.11) .49 1.29 (0.79 to 2.1) .31 0.59 (0.39 to 0.87) <.001 0.63 (0.42 to 0.95) .03 0.45 (0.21 to 0.97) .04 0.82 (0.71 to 0.95) .01
Emergency 0.87 (0.69 to 1.11) .26 1.52 (0.86 to 2.68) .15 1.48 (0.75 to 2.92) .26 1.22 (1.01 to 1.47) .03
Bleeding disorder 1.22 (0.98 to 1.52) .07 1.20 (1.02 to 1.41) .03 1.73 (1.22 to 2.45) .002 1.21 (0.86 to 1.7) .27 1.4 (1.21 to 1.61) <.01
Steroid 1.46 (1.03 to 2.07) .03 1.15 (0.87 to 1.52) .32 0.4 (0.1 to 1.64) .2 1.51 (0.92 to 2.47) .1 1.95 (0.89 to 4.28) .09 0.82 (0.62 to 1.07) .14
Wound infection 1.38 (1.1 to 1.73) <.01 1.41 (1.21 to 1.62) <.01
Dialysis 1.48 (1.24 to 1.77) <.01 1.32 (0.88 to 1.97) .18 0.42 (0.26 to 0.70) <.01 0.89 (0.76 to 1.04) .15
Independent status versus dependent 1.12 (0.89 to 1.4) .35 0.94 (0.79 to 1.12) .48 1.49 (0.82 to 2.69) .19 0.87 (0.59 to 1.29) .48 0.85 (0.6 to 1.19) .33 0.98 (0.55 to 1.76) .95 0.86 (0.75 to 1.00) .05
Smoker 1.22 (0.99 to 1.51) .07 1.32 (0.83 to 2.11) .25 1.45 (1.01 to 2.06) .04 0.61 (0.31 to 1.2) .15 0.84 (0.72 to 0.98) .02
Diabetes mellitus 0.87 (0.7 to 1.07) .19 0.87 (0.74 to 1.03) .10 0.49 (0.28 to 0.84) .01 1.4 (1.2 to 1.64) <.01
Asian versus American Indian 1.31 (0.25 to 6.78) .75 0.33 (0.06 to 1.81) .29 2.23 (0.82 to 6.1) .11
Black versus American Indian 1.49 (0.36 to 6.27) .58 0.26 (0.07 to 0.92) .04 2.55 (1.04 to 6.25) .04
Native Asian versus American Indian 3.49 (0.71 to 17.15) .12 0.38 (0.06 to 2.6) .33 2.60 (0.91 to 7.41) .07
White versus American Indian 1.95 (0.47 to 8.11) .36 0.43 (0.12 to 1.47) .18 1.83 (0.75 to 4.47) .19
Hispanic versus Not Hispanic 0.37 (0.12 to 1.2) .1
Transfer home versus not home 1.19 (1.00 to 1.41) .05 1.39 (0.95 to 2.04) .09 1.18 (0.83 to 1.67) .35 1.27 (1.09 to 1.47) <.01
Age (yr) 1 (1 to 10.1) .05 0.98 (0.97 to 1) .02 1.03 (1.01 to 1.04) <.01
Body mass index (703 lb/inches) 0.99 (0.98 to 1.00) .13 0.97 (0.94 to 1.01) .13 1.01 (1 to 1.02) .03
Length of stay (d) 1.01 (1 to 1.02) .08 0.98 (0.93 to 1.03) .37 0.95 (0.91 to 0.99) <.01 1.01 (0.99 to 1.03) .27 1.02 (0.98 to 1.05) .33 1.02 (1.01 to 1.03) <.01
Operative time (min) 1 (1 to 1) <.01 1 (1 to 1) .25 0.99 (0.99 to 1) .1 1 (1 to 1.01) .01 1 (0.99 to 1) .37 1 (1 to 1.01) .83 1 (1 to 1.01) <.01
Time from operation to discharge (d) 1.01 (1 to 1.01) .05 0.94 (0.93 to 0.96) <.01 1.05 (1 to 1.11) .07 1.09 (1.04 to 1.14) <.01 1.03 (1 to 1.05) .05 1.03 (0.99 to 1.07) .13 1 (0.99 to 1.01) .98
All models were adjusted for wound class, ASA score, discharge destination, functional status, operative time, and any other factor whose p value in the bivariate test for association with the outcome was <0.2.
Abbreviations: ASA, American Society of Anesthesiologists; BKA, below-knee amputation; DVT, deep vein thrombosis; OR, odds ratio; PE, pulmonary embolism; TMA, transmetatarsal amputation.
 D.C. Jupiter et al. / The Journal of Foot & Ankle Surgery 59 (2020) 484−490
voluntary. It is thus not exhaustive and may also suffer from some self-
selection bias. Further, the decision regarding the level of amputation is
surgeon dependent and based on multiple factors, not all of which were
considered in the study. This could result in selection bias. Although
NSQIP records »150 variables, several important factors are lacking,
including ability to rehabilitate, risk of short-term mortality, socioeco-
nomic status, vascular status, religion, and mental health. We did not con-
trol for surgeon specialty, although NSQIP does code, for example,
orthopaedic, general, vascular, and plastic surgical specialties. It may also
have been possible to examine postoperative diagnosis to better under-
stand why amputations were done. As it stands, we examined all amputa-
tions available, rather than those for any specific indication. This means
that we also included amputations that happened in emergency situa-
tions, which may differ from those secondary to complications of diabe-
tes. However, this factor was balanced in our propensity score−matched
sample, so its impact should be the same in our 2 amputation groups.
The use of propensity scores is a strength of our study, and adds a
useful dimension. Propensity score matching is a tool that allows us to
achieve balance in our study populations, remove some indication bias,
and mimic randomized controlled trials (36). Although the decision to
choose between minor amputation and major amputation may be obvi-
ous in certain situations, most cases fall into a gray zone, and the choice
of the procedure depends on the specialty and expertise of the surgeon,
geography, hospital volume, and socioeconomic factors. Using propen-
sity scores helps us elucidate the amputation level associated with bet-
ter results in situations where either could be used. Our propensity
matching in this study was relatively successful, although we did not
achieve perfectly balanced matching.
Much research remains to be done to answer the question of which
level of amputation should be used in different situations. In many
cases, the decision is made based on the vascular status of the lower
extremity and its potential to heal after the amputation is performed.
When vascular supply is adequate, based on a noninvasive or invasive
study, amputation is often performed just proximal to the infection or
other relevant pathology. However, long-term function, overall health
condition, comorbidities, socioeconomic state, and perhaps cost effec-
tiveness in a health care system should also be considered in decision
making. Research in these areas is scarce, and future investigations
could greatly impact the health care system. Not yet mentioned are
patient preferences and the role that they play in surgeon choices.
These preferences are informed by emotional states, education, and a
multitude of other social factors (37). A further area of research is inves-
tigating how to facilitate the interactions between providers and
patients in these difficult clinical settings.
Supplementary Materials
Supplementary material associated with this article can be found in
the online version at https://doi.org/10.1053/j.jfas.2019.09.019.
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