ST. LOUIS — Incidence rates of lower extremity amputation increased at the VA between 2008 and 2018, and burgeoning rates of diabetes played a role in the trend.

That’s according to a study in JAMA Network Open which determined that incidence rates of LEA among veterans using VA services increased in the 10-year period. Noting that amputation of lower extremities leads to significant morbidity and mortality, researchers from the St. Louis VA Healthcare System and colleagues also pointed out that national temporal trends of LEA incidence rates among U.S. veterans and associated factors have not been well characterized.1

To remedy that, the study team sought to describe the temporal trends of LEA, characterize associated risk factors and analyze the associations of risk factors with changes in temporal trends of LEA among VA patients. Data were analyzed from Oct. 1, 2007, to Sept. 30, 2018.

Defined as the primary outcomes were toe, transmetatarsal, below-knee or above-knee LEA.

Included in the research were about 6.5 million veterans with a median age of 64 and 93.4% male. The veterans were studied for a median (interquartile range) of 10.9 (5.6-11.0) years.

Results indicated that, between 2008 and 2018, rates of LEA increased from 12.89 (95% CI, 12.53-13.25) LEA per 10,000 persons to 18.12 (95% CI, 17.70-18.54) LEA per 10,000 persons, representing a net increase of 5.23 (95% CI, 4.68-5.78) LEA per 10,000 persons.

More specifically, study authors report that, during the time period, toe amputation rates increased by 3.24 (2.89-3.59) amputations per 10,000 persons, accounting for 62.0% of the total increase in LEA rates.

Also increasing by 1.54 (95% CI, 1.27-1.81) per 10,000 persons were transmetatarsal amputations and below-knee amputation rates, by 0.81 (95% CI, 0.56-1.05) amputations per 10,000 persons. At the same time, above-knee amputation rates decreased by 0.37 (95% CI, 0.14-0.59) amputations per 10,000 persons.

Compared with men, women had decreased risk of any LEA (hazard ratio [HR], 0.34 [95% CI, 0.31-0.37]), researchers noted. Factors associated with increased risk of any LEA, however, included:

  • Black race (HR, 1.25 [95% CI, 1.21-1.28]) or another non-White race (i.e., Asian, Latino, or other); HR, 2.36 [95% CI, 2.30-2.42]),
  • Obesity (HR, 1.59 [95% CI, 1.55-1.63]),
  • Diabetes (HR, 6.38 [95% CI, 6.22-6.54]),
  • Chronic kidney disease (CKD; e.g., CKD Stage 5: HR, 3.94 [95% CI, 3.22-4.83]), and smoking status (e.g., current smoking: HR, 1.97 [95% CI, 1.92-2.03]).

In their analysis, the authors noted that an increased proportion of women veterans, was associated with a decrease of 0.18 (95% CI, 0.14-0.22) LEA per 10 000 persons, while drops in smoking rates, was associated with a decrease of 0.88 (95% CI, 0.79-0.97) LEA per 10,000 persons.

“However, these were overwhelmed by increased rates of diabetes, associated with an increase of 1.86 (95% CI, 1.72-1.99) LEA per 10,000 persons; peripheral arterial disease, associated with an increase of 1.53 (95% CI, 1.41-1.65) LEA per 10,000 persons; CKD, associated with an increase of 1.45 (95% CI, 1.33-1.57) LEA per 10,000 persons; and other clinical factors, including body mass index, cancer, cardiovascular disease, cerebrovascular disease, chronic lung disease, dementia, and hypertension, associated with an increase of 1.45 (95% CI, 1.33-1.57) LEA per 10,000 persons,” the researchers wrote.

The authors recommended that efforts seeking to reduce the burden of LEA should target the reduction of diabetes, peripheral arterial disease and CKD at the individual and population levels.

  1. Cai M, Xie Y, Bowe B, Gibson AK, Zayed MA, Li T, Al-Aly Z. Temporal Trends in Incidence Rates of Lower Extremity Amputation and Associated Risk Factors Among Patients Using Veterans Health Administration Services From 2008 to 2018. JAMA Netw Open. 2021 Jan 4;4(1):e2033953. doi: 10.1001/jamanetworkopen.2020.33953. PMID: 33481033; PMCID: PMC7823225.