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The Journal of Foot & Ankle Surgery 000 (2023) 1−5
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery
journal homepage: www.jfas.org
Original Research
Amputation Acceptance: A Survey of Factors Influencing the Decision to
Undergo Lower Extremity Amputation
Gina Cach, BA1, Ashley E. Rogers, MD2, Daisy L. Spoer, MS1, Adaah A. Sayyed, BS1,
Romina Deldar, MD2, Christopher E. Attinger, MD2, Karen K. Evans, MD2
1
2
Georgetown University School of Medicine, Washington, DC
Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC
A R T I C L E
I N F O
Level of Clinical Evidence: 3
Keywords:
decision-making process
multidisciplinary team
patient education
postoperative satisfaction
shared decision making
A B S T R A C T
Accepting to undergo amputation is an arduous process often fraught with confusion, fear, and uncertainty. To
assess how to best facilitate discussions with at-risk patients, we surveyed lower extremity amputees about their
experiences surrounding this decision-making process. Patients who underwent lower extremity amputation at
our institution from October 2020 to October 2021 were asked to complete a 5-item telephone survey assessing
their decision to undergo amputation and postoperative satisfaction. Retrospective chart review of respondent
demographics, comorbidities, operative details, and complications was conducted. Of 89 lower extremity amputees identified, 41 (46.07%) responded to the survey, with the majority undergoing below-knee amputations
(n = 34, 82.93%). At a mean follow-up of 5.90 § 3.45 months, 20 patients (48.78%) were ambulatory. Surveys were
completed at a mean of 7.74 § 4.03 months since amputation. Factors that helped patients decide to undergo
amputation included discussions with doctors (n = 32, 78.05%) and concern for worsening health (n = 19, 46.34%).
Deteriorating ability to walk (n = 18, 45.00%) was the most common concern prior to surgery. Recommendations
by survey respondents to ease the decision-making process included speaking with amputees (n = 9. 22.50%),
more discussions with doctors (n = 8, 20.00%), and access to mental health and social services (n = 2, 5.00%); however, many had no recommendations (n = 19, 47.50%), and most were pleased with their decision to undergo
amputation (n = 38, 92.68%). Despite most patients primarily citing satisfaction with their decision to undergo
lower extremity amputation, it is critical to consider factors that affect patient decisions and recommendations to
improve this decision-making process.
© 2023 by the American College of Foot and Ankle Surgeons. All rights reserved.
Approximately 100,000 traumatic and atraumatic lower extremity (LE) amputations are performed in the United States each year,
with more than half occurring in populations with comorbidities
such as diabetes mellitus (DM) and peripheral vascular disease
(PVD) (1,2). National trends suggest that the overall rate of LE
amputation in the United States has decreased over recent years;
however, DM and PVD continue to pose a significant disease burden
given increasing rates of these comorbidities (1). Despite the rising
prevalence of these chronic diseases, there has also been an
increase in integrative team-based care as well as utility of procedures such as surgical revascularization, which can decrease the
Financial Disclosure: None reported.
Conflict of Interest: None reported.
MedStar Georgetown University Hospital IRB approved on 11/11/2021 via expedited
review: STUDY00004369.
Address correspondence to: Karen K. Evans, MD, Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, 3800 Reservoir Road NW,
First Floor PHC Building, Washington, DC 20007.
E-mail address: karen.k.evans@medstar.net (K.K. Evans).
risk of amputation (3). Unfortunately, amputation may need to be
considered when other treatment options are lengthy, costly, or
offer a poor prognosis (4).
Our institution’s wound care center includes plastic, podiatric, and
vascular surgeons, hospitalists, infectious disease specialists, endocrinologists, nephrologists, rheumatologists, nurses, prosthetists, and
physical therapists. We treat approximately 1200 new patients and
over 20,000 total patients yearly. As a result of this high at-risk patient
volume, our team is routinely tasked with initiating discussions regarding LE amputation with our patients.
LE amputation is complicated not only by the aforementioned medical comorbidities, but also by numerous psychosocial factors. Patients
are faced with the significant morbidity and mortality of these procedures, along with the task of redefining their identity and functionality
postoperatively. Over the last year, 89 patients received LE amputations
at our institution. To assess the most effective methods to facilitate
amputation discussions and best support at-risk patients, we surveyed
recent LE amputees regarding their experiences surrounding this decision-making process.
1067-2516/$ - see front matter © 2023 by the American College of Foot and Ankle Surgeons. All rights reserved.
https://doi.org/10.1053/j.jfas.2022.12.012
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Patients and Methods
Following institutional review board approval, patients who underwent LE amputation at our institution from October 2020 to October 2021 were asked to complete a 5item telephone survey designed to assess their decision to undergo amputation and their
overall satisfaction following the procedure. The full survey text is available (Supplemental Digital Content 1). The survey period began on December 1, 2021 and ended on January 27, 2022.
Following the survey collection period, a retrospective chart review was conducted to
collect patient demographics, comorbidities, operative details, and complications for
those who completed the survey. Patient demographics included age, sex, smoking history, and body mass index (BMI). Comorbidity data was collected to assess comorbidity
status using the Charlson comorbidity index (CCI) scoring system. Operative details
included the indication for amputation, level of amputation, and whether peripheral
nerve procedures such as targeted muscle reinnervation (TMR) or regenerative peripheral
nerve interface (RPNI) were performed at time of amputation. Recorded complications
were postoperative infection, dehiscence, hematoma, seroma, and return to the operating
room (OR). Outcomes such as ambulatory status and the need for an assistive device were
also recorded.
Descriptive statistics were used to characterize study subjects. Continuous variables
were described using mean and standard deviation (SD) or median and interquartile
range (IQR) as determined by the Shapiro-Wilk test of normality. Categorical variables
were described using frequencies and percentages. Statistical analysis was performed
using STATA v.17 (StataCorp, College Station, Texas) with statistical significance set at values of p ≤ .05.
Results
Patient Demographics
A total of 89 LE amputees were identified, of which 41 (46.07%)
responded to the survey. Thirty respondents were male (73.17%) and
11 were female (26.83%). Mean age and BMI were 59.71 § 15.52 years
and 31.70 § 7.02 kg/m2, respectively. Mean CCI score was 5.07 § 2.64,
with the most frequent comorbidities being DM (n = 27, 65.85%) and
PVD (n = 25, 60.98%). Other comorbidities included chronic kidney disease (CKD; n = 14, 34.15%), end-stage renal disease (ESRD; n = 8,
19.51%), congestive heart failure (CHF; n = 7, 17.07%), history of venous
thromboembolism (VTE; n = 5, 12.20%), and history of stroke or transient ischemic attack (n = 5, 12.20%). Patients most commonly had no
prior smoking history (n = 26, 63.41%). Table 1 details survey respondent demographics.
Table 1
Respondent demographics
Variable
n (%)
Total responses
Complete responses
Partial responses
Age (years)
Sex
Male
Female
Smoking history
None
Prior history
Current smoker
BMI (kg/m2)
CCI
Comorbidities
DM
PVD
CKD
ESRD
VTE
Stroke or TIA
Months from date of surgery to survey date
41/89 (46.07%)
40/41 (97.56%)
1/41 (2.44%)
Mean § SD
59.71 § 15.55
30 (73.17%)
11 (26.83%)
26 (63.41%)
8 (19.51%)
7 (17.07%)
31.71 § 7.02
5.07 § 2.64
27 (65.85%)
25 (60.98%)
14 (34.15)
8 (19.51%)
5 (12.20%)
5 (12.20%)
7.74 § 4.03
Abbreviations: BMI, body mass index; CCI, Charlson comorbidity index; CKD, chronic kidney disease; DM, diabetes mellitus; ESRD, end-stage renal disease; PVD, peripheral vascular disease; SD, standard deviation; TIA, transient ischemic attack; VTE, venous
thromboembolism.
There were no significant differences between survey respondents
and nonrespondents with regards to age and sex. Reasons for not completing the survey included being unable to contact the patient after 3
attempts (n = 27, 56.25%), contact information being incorrect (n = 8,
16.67%), the patient being deceased (n = 7, 14.58%), or the patient
declining to participate (n = 6, 12.50%).
Operative Details and Follow-Up
At time of surgery, mean albumin and prealbumin levels were
4.11 g/dL and 15.82 mg/dL, respectively. Average hemoglobin A1c
(HbA1c) was 6.62%. The most common indications for LE amputation
were infection (n = 22, 53.66%) and ischemia (n = 9, 21.95%), and less
commonly Charcot foot (n = 4, 9.76%), chronic pain (n = 4, 9.76%), and
chronic wounds (n = 2, 4.88%). The majority of patients underwent
below-knee amputations (BKA; n = 34, 82.93%) and received TMR
(n = 30, 73.17%) or RPNI (n = 7, 17.07%) at time of amputation. There
was no significant difference in type of amputation performed between
survey respondents and nonrespondents.
Postoperatively, 6 patients (14.63%) experienced complications
which required return to the OR. Complications most commonly
included dehiscence (n = 5, 12.20%) or infection (n = 3, 7.32%). The
mean follow-up was 5.90 § 3.45 months. Based on most recent followup clinic visit data, 20 patients (48.78%) were ambulatory, either independently (n = 11, 26.83%) or with an assistive device (n = 9, 21.95%)
such as a walker, crutch, or walking stick. Among ambulatory patients,
the mean time to ambulation was 4.07 § 2.65 months postoperatively.
Table 2 outlines operative details and postoperative outcomes.
Survey Responses
There were 41 survey respondents (41/89 amputees, 46.07%
response rate), of which 40 (97.56%) completed the entire survey.
Table 2
Respondent operative details and follow-up
Variable
Indication for amputation
Infection
Ischemia
Charcot
Chronic pain
Chronic wounds
Type of amputation
BKA
AKA
Peripheral nerve surgery
Total
TMR
RPNI
Preoperative Labs
Albumin (g/dL)
Prealbumin (mg/dL)
HbA1c (%)
Complications
Infection
Dehiscence
Return to operating room
Follow-up (months)
Ambulatory status
Yes, independent
Yes, with assistive device
No
Time to ambulation (months)
n (%)
Mean § SD
22 (53.66%)
9 (21.95%)
4 (9.76%)
4 (9.76%)
2 (4.88%)
34 (82.93%)
7 (17.07%)
37 (90.24%)
30 (73.17%)
7 (17.07%)
4.11 § 3.07
15.82 § 6.77
6.62 § 1.45
3 (7.32%)
5 (12.20%)
6 (14.63%)
5.90 § 3.45
11 (26.83%)
9 (21.95%)
20 (48.78%)
4.07 § 2.65
Abbreviations: AKA, above-knee amputation; BKA, below-knee amputation; HbA1C,
hemoglobin A1C; RPNI, regenerative peripheral nerve interface; TMR, targeted muscle
reinnervation.
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Table 3
Survey responses
Question
Response
n (%)
What were reasons that HELPED you decide to
undergo the amputation? (n = 41)
Discussions I had with my doctors
Educational materials, pamphlets, brochures
Speaking with amputees or reading amputee testimonials
I thought it would improve my pain
I thought it would improve my ability to walk
I listened to my friends and family
I was worried my health would worsen without the amputation
Speaking with prosthetists
I thought it would improve my chronic wounds and infections
Discussions I had with my doctors
Educational material, pamphlets, brochures
Speaking with amputees or reading amputee testimonials
I thought it would worsen my pain
I thought it would worsen my ability to walk
I was worried I would lose my job
I was worried my health would worsen with the amputation
I was worried about how it would change my body image
I was worried I would get depressed
Uncertainty of the future
Remaining independent
Undergoing surgery and postoperative recovery
Making the decision quickly due to life-threatening circumstances
No worries about amputation
More educational materials and information
More discussions with my doctors
Speaking with amputees
Access to videos of amputees walking
Access to resources for mental health and social services
No additional recommendations
Yes
No
32 (78.05%)
9 (21.95%)
7 (17.07%)
9 (21.95%)
10 (24.39%)
14 (34.15%)
19 (46.34%)
2 (4.88%)
9 (21.95%)
0 (0%)
0 (0%)
1 (2.50%)
6 (15.00%)
18 (45.00%)
3 (7.50%)
7 (17.50%)
4 (10.00%)
5 (12.50%)
4 (10.00%)
4 (10.00%)
7 (17.50%)
7 (17.50%)
11 (27.50%)
6 (15.00%)
8 (20.00%)
9 (22.50%)
2 (5.00%)
2 (5.00%)
19 (47.50%)
38 (92.68%)
3 (7.32%)
What were reasons you were WORRIED about
getting the amputation? (n = 40)
How could your surgery team have helped make
this an easier decision for you to make? (n = 40)
Are you pleased with your decision to undergo
amputation? (n = 41)
Surveys were completed at a mean of 7.74 § 4.03 months since amputation. The most cited reasons that helped patients decide to undergo
LE amputation included discussions with their doctors (n = 32, 78.05%),
concern for worsening health if they did not undergo amputation
(n = 19, 46.34%), and advice from friends and family (n = 14, 34.15%).
Other helpful factors included printed educational materials (n = 9,
21.95%) and hope that undergoing amputation would improve chronic
wounds and infections (n = 9, 21.95%), pain (n = 9, 21.95%), and the ability to walk (n = 10, 24.39%; Table 3).
Regarding concerns about undergoing amputation, a deteriorating
ability to walk (n = 18, 45.00%) was cited as the most common concern
among patients. Other concerns included worsening health (n = 7,
17.50%), undergoing surgery itself and postoperative recovery (n = 7,
17.50%), and having to make the decision quickly due to life-threatening circumstances (n = 7, 17.50%). Five patients (12.50%) also reported
concerns about depression postoperatively. However, 11 patients
(27.50%) reported no concerns with undergoing amputation.
Samples of the free responses provided by patients are noted in
Table 4. Regarding the usefulness of communication with doctors and
staff, one patient stated: “it was helpful that my doctors were upfront,
straight-forward, and honest about the possibility of amputation, discussing advantages and disadvantages.” The importance of communication with family and friends was also highlighted through patient
responses such as: “it was helpful to bring family to visits prior to the
amputation,” and “I had many discussions with family prior to surgery.”
As for worries prior to undergoing amputation, some patients voiced
concerns regarding their health with comments such as: “my doctor
explained that the problem would lead to deterioration of the leg. . .
[my decision] was more driven by my health.” Many patients also
highlighted both hopes and worries regarding mobility postoperatively: “I felt like I would be able to walk better after surgery,” or “my
biggest worry was wearing shoes and walking again.” The uncertainty
about life after surgery impacted many patients, with one patient
describing “I was worried I would be a burden and not be able to do my
daily activities alone.”
When asked about ways the surgical team could have eased the
decision-making process, many had no additional recommendations
Table 4
Themes among survey responses
Communication with doctors and
staff
Communication with family and
friends
Worries about health
Hopes and worries about mobility
Uncertainty about life after surgery
"It was helpful to speak with various members of
the care team across specialties."
"It was helpful that my doctors were upfront,
straight-forward, and honest about the possibility of amputation, discussing advantages and
disadvantages."
"I trusted my doctors and care team."
"It was helpful to bring family to visits prior to
the amputation."
"I had many discussions with family prior to
surgery."
"I was septic and felt I had no other choice."
"The infection in my leg was worsening, and my
health was deteriorating."
"My doctor explained that the problem would
lead to deterioration of the leg, that was the
most important. It was more driven by my
health."
"I felt like I would be able to walk better after surgery."
"I wanted to get back to walking."
"I live on a farm, and I was fearful I would not be
able to get back to that."
"My biggest worry was wearing shoes and walking again."
"I was worried I would be a burden and not be
able to do my daily activities alone."
"I was worried about the uncertainty of the
future."
"I had fears of the unknown."
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(n = 19, 47.50%), and most patients were pleased with their decision to
undergo amputation (n = 38, 92.68%). In comparison, 22.50% (n = 9)
stated that speaking with other amputees would have aided in their
decision, and 20.00% (n = 8) reported that more discussions with doctors would be helpful. Two (5.00%) patients reported that access to
resources for mental health and social services could have made their
decision easier.
Discussion
We present the first study assessing personal and clinical factors
impacting a patient’s decision to undergo amputation as well as patient
recommendations to improve this process. Patients highlighted the
importance of discussions with their physicians along with hopes and
fears regarding the impact amputation would have on their ability to
walk. Most patients had no recommendations for changes the clinical
team could make to improve the process, with most of those surveyed
stating that they were pleased with their decision to undergo amputation. The overall satisfaction of our patients with the decision-making
process and their amputation emphasizes the importance of the multidisciplinary team (MDT) approach to patient care that we utilize at our
wound care center.
The MDT approach to the diabetic foot has been widely recognized
to improve patient care and to reduce ulcer recurrence, the rate of
major limb amputations, and healthcare costs (5,6). These benefits of a
MDT are well known and were further substantiated by this study, as
most patients (78%) cited discussions with doctors as the most prevalent factor in aiding their decision to undergo LE amputation. Furthermore, 5% of our patients reported that speaking with prosthetists aided
their decision. Given the overall satisfaction of our patients with their
experience, we highlight the protocol used by our wound care center
when approaching patients at-risk for amputation in the Fig.
Despite the vast nature of the MDT approach, the inclusion of psychiatry is a potentially overlooked facet of this team. A psychiatrist can
not only assist during the amputation decision-making period, but also
provide close follow-up in the postoperative period as patients become
accustomed to their new life after amputation. Akin to the loss of a
loved one, amputees have been said to face the 5 stages of grief (7).
Physical disability, such as the loss of a limb, can result in despair,
depression, anxiety, nervousness, loss of self-esteem, isolation, stigma,
and the recognition of weakness (8). This loss may necessitate assistance as patients transition into a new phase of life without their limb,
and the importance of psychiatry as part of the MDT during this transition period has been touted (7).
As part of this study, 12.5% of our patients cited concerns about
depression postoperatively, and 5% reported access to mental health
and support services as a component that could have eased their decision to undergo amputation. An 18-month longitudinal study by the
World Health Organization found that 14.1% of amputees reported
depression (9). McKechnie et al found levels of anxiety and depression
to be significantly higher in amputees compared to the general population, with another study by Horgan et al estimating depression and
anxiety to be moderately elevated for up to 2 years following amputation (10,11). While psychiatry has yet to be added to our MDT, it is certainly a consideration to further improve care.
Social support represents another critical component of wellness
following major amputation. A patient’s perceived social support can
not only aid in the decision-making process, but also in the recovery
period. Support from family and friends was cited by 34.1% of respondents as a factor that helped them make the decision to undergo amputation. As stated above, many amputees experience depression
postoperatively, and studies done among amputees have observed that
social support is a protective factor against depression and adjusting to
life after amputation (12-14). However, we are conscious that not every
patient has close social relationships. At our institution, we host a
monthly amputee support group and connect patients with former
amputee patients. Seven patients (17.1%) felt that this connection
helped them to make the decision. However, results of this study suggest inconsistency with awareness and/or availability, as 22.5% of
patients felt they could have benefited from such a resource. Our team
recognizes the importance of inquiring about support early on, and ideally preoperatively if possible. Previously, we would initiate discussions
based on need, but we now see the value in standardizing this process
by inquiring about support at each clinic visit and providing information regarding upcoming amputee meetings or support availability.
If a patient is at-risk for amputation, it is also integral to initiate discussions regarding the possibility of amputation as early in the patient’s
course as possible. Seven respondents (17.5%) reported that making the
decision to amputate quickly due to being in a life-threatening situation
was a concern. Deciding to undergo LE amputation is difficult and
Fig. Protocol for approaching patients at-risk of amputation. This figure outlines our protocol for approaching patients at-risk of amputation. Our study highlights the relative success of
our current protocol given that the majority of patients were pleased with the decision-making process.
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G. Cach et al. / The Journal of Foot & Ankle Surgery 00 (2023) 1−5
fraught with uncertainty, and for these patients, it was compounded by
the pressures of deteriorating health. It is evident that conversations
regarding amputation should be initiated early so that patients can be
prepared and understand treatment options available to them prior to
these critical moments. While this is an option for our established
patients, unfortunately these discussions cannot always be planned,
such as in trauma patients. Our limb salvage and wound care center
also receives many tertiary referral patients, who often travel long distances to our practice. As such, these patients do not have the means to
establish care and have discussions regarding amputation in advance.
Initiating early discussions regarding amputation also allows for
adequate and substantial patient education. While 22% of patients
found printed educational materials helpful in making the decision to
undergo LE amputation, 15% of our patients reported wanting additional educational materials. Furthermore, 20% of our patients may
have benefited from further discussions with our care team. The results
of this study have encouraged us to streamline our educational process
and consider additional means of providing patients with information
regarding amputation, such as a folder to consolidate educational materials or an interactive website that can include testimonies from previous patients, videos of prior amputee patients taking part in physical
activities, resources for diseases associated with amputation such as
DM, care tips when living with a prosthetic, and details for amputee
support groups and online forums.
Our study has several limitations, including a small sample size
along with the retrospective nature of data collection, which is influenced by the quality of data captured in the electronic medical record.
Furthermore, there is a possibility of recall bias given that surveys were
completed at a mean of 7.7 months postoperatively. Survey responses
could also have been biased by the quick decision-making timeline, as
several patients’ decisions to undergo LE amputation were influenced
by life-threatening circumstances.
Despite the difficulty of making the decision to undergo LE amputation, 92.7% of respondents reported satisfaction with their decision.
These positive postoperative satisfaction results could be influenced by
the functional-based amputation and pain reduction techniques, such
as prophylactic TMR or RPNI, that were performed in 90.2% of patients
at the time of amputation. Thus, it is difficult to extrapolate postoperative satisfaction results to other centers that may not utilize these prophylactic techniques. Other limitations include variations in who is
initiating the conversation about LE amputation with patients who
present to our hospital for limb salvage or amputation. At our institution, these discussions may be started by attendings to chief residents
to interns. It may be advantageous to have psychiatry be a central and
integral member present for initiation of these discussions to facilitate
concerns and provide continuity of care.
5
In conclusion, the majority of patients cited satisfaction with their
decision to undergo LE amputation, and many did not recommend
changes to their surgical decision-making process. However, it is crucial
to recognize the various factors that can affect a patient’s decision, as
incorporating patient feedback into our multidisciplinary care team
allows us to provide the best care for this vulnerable patient population.
Future studies will be necessary to assess the utility and helpfulness of
new protocols implemented to our clinic’s approach to patients at-risk
for amputation (e.g., updated and accessible educational materials,
team psychiatrist).
Supplementary Materials
Supplementary material associated with this article can be found in
the online version at https://doi.org/10.1053/j.jfas.2022.12.012.
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