Abstract
Study design
This is a retrospective case–control study.
Objectives
To identify predictors of lower extremity (LE) long bone fracture-related amputation in persons with traumatic spinal cord injury (tSCI).
Setting
US Veterans Health Administration facilities (2005–2015).
Methods
Fracture-amputation sets in Veterans with tSCI were considered for inclusion if medical coding indicated a LE amputation within 365 days following an incident LE fracture. The authors adjudicated each fracture-amputation set by electronic health record review. Controls with incident LE fracture and no subsequent amputation were matched 1:1 with fracture-amputation sets on site and date of fracture (±30 days). Multivariable conditional logistic regression determined odds ratios (OR) and 95% confidence intervals (CI) for potential predictors (motor-complete injury; diabetes mellitus (DM); peripheral vascular disease (PVD); smoking; primary (within 30 days) nonsurgical fracture management; pressure injury and/or infection), controlling for age and race.
Results
Forty fracture-amputation sets from 37 Veterans with LE amputations and 40 unique controls were identified. DM (OR = 26; 95% CI, 1.7–382), PVD (OR = 30; 95% CI, 2.5–371), and primary nonsurgical management (OR = 40; 95% CI, 1.5–1,116) were independent predictors of LE fracture-related amputation.
Conclusions
Early and aggressive strategies to prevent DM and PVD in tSCI are needed, as these comorbidities are associated with increased odds of LE fracture-related amputation. Nonsurgical fracture management increased the odds of LE amputation by at least 50%. Further large, prospective studies of fracture management in tSCI are needed to confirm our findings. Physicians and patients should consider the potential increased risk of amputation associated with non-operative management of LE fractures in shared decision making.
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Data availability
The data that support the findings of this study are the property of the United States Government’s Department of Veterans Affairs (VA) and are only available as part of VA-approved research activities pursuant to Veterans Health Administration (VHA) Directives 1200.05(2), VHA 1200.01, and/or VHA 1080.01.
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Funding
This material is based upon work supported by the Department of Veterans Affairs (VA), Veterans Health Administration (VHA), Office of Research and Development and Health Services Research and Development, VA IIR 15-294: Best Practices for Management of Fractures in Spinal Cord Injuries and Disorders. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.
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REE was responsible for conceiving and designing the work, extracting and analyzing data, interpreting results, drafting the manuscript, and approval of the final version. CER was responsible for extracting and analyzing the data, revising the manuscript, and approval of the final version. SM was responsible for extracting and analyzing the data and approval of the final version. FMW was responsible for conceiving and designing the work, interpreting results, revising the manuscript, and approval of the final version. BG was responsible for extracting and analyzing the data and approval of the final version. WO was responsible for conceiving and designing the work, interpreting results, revising the manuscript, and approval of the final version. LDC was responsible for conceiving and designing the work interpreting results, revising the manuscript, and approval of the final version.
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The Veterans Affairs (VA) Institutional Review Boards at the Charlie Norwood VA Hospital, Augusta, Georgia [reference number 975087] and the Hines VA Hospital, Hines, Illinois [reference number 1000753] approved this study.
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Elam, R.E., Ray, C.E., Miskevics, S. et al. Predictors of lower extremity fracture-related amputation in persons with traumatic spinal cord injury: a case–control study. Spinal Cord 61, 260–268 (2023). https://doi.org/10.1038/s41393-023-00879-1
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DOI: https://doi.org/10.1038/s41393-023-00879-1
