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Risk Factors for Below-the-Knee Amputation in Diabetic Foot Osteomyelitis After Minor Amputation

Whitney Miller Division of Infectious Diseases, Denver Health Medical Center and University of Colorado, Denver, CO.

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Chrystal Berg Department of Orthopedics, Denver Health Medical Center and University of Colorado, Denver, CO.

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Michael L. Wilson Department of Pathology and Laboratory Services, Denver Health Medical Center and University of Colorado, Denver, CO.

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Susan Heard Research and Consulting Services, Rocky Mountain Poison and Drug Center, Denver, CO.

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Bryan Knepper Department of Patient Safety and Quality, Denver Health Medical Center, Denver, CO.

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Heather Young Division of Infectious Diseases, Denver Health Medical Center and University of Colorado, Denver, CO.

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Background:

Below-the-knee amputation (BKA) can be a detrimental outcome of diabetic foot osteomyelitis (DFO). Ideal treatment of DFO is controversial, but studies suggest minor amputation reduces the risk of BKA. We evaluated risk factors for BKA after minor amputation for DFO.

Methods:

This is a retrospective cohort of patients discharged from Denver Health Medical Center from February 1, 2012, through December 31, 2014. Patients who underwent minor amputation for diagnosis of DFO were eligible for inclusion. The outcome evaluated was BKA in the 6 months after minor amputation.

Results:

Of 153 episodes with DFO that met the study criteria, 11 (7%) had BKA. Failure to heal surgical incision at 3 months (P < .001) and transmetatarsal amputation (P = .009) were associated with BKA in the 6 months after minor amputation. Peripheral vascular disease was associated with failure to heal but not with BKA (P = .009). Severe infection, bacteremia, hemoglobin A1c, and positive histopathologic margins of bone and soft tissue were not associated with BKA. The median antibiotic duration was 42 days for positive histopathologic bone resection margin (interquartile range, 32–47 days) and 16 days for negative margin (interquartile range, 8–29 days). Longer duration of antibiotics was not associated with lower risk of BKA.

Conclusions:

Patients who fail to heal amputation sites in 3 months or who have transmetatarsal amputation are at increased risk for BKA. Future studies should evaluate the impact of aggressive wound care or whether failure to heal is a marker of another variable.

Corresponding author: Whitney Miller, FNP, Division of Infectious Diseases, Denver Health Medical Center and University of Colorado, NP-C, 777 Bannock St, MC 4002, Denver, CO 80204. (E-mail: Whitney.miller@dhha.org)