title: Early Post-operative Mortality After Major Lower Limb Amputation: A Systematic Review of Population and Regional Based Studies.
abstract: OBJECTIVE
  Lower limb amputation is often associated with a high risk of early post-operative mortality. Mortality rates are also increasingly being put forward as a possible benchmark for surgical performance. The primary aim of this systematic review is to investigate early post-operative mortality following a major lower limb amputation in population/regional based studies, and reported factors that might influence these mortality outcomes.
  
  
  METHODS
  Embase, PubMed, Cinahl and Psycinfo were searched for publications in any language on 30 day or in hospital mortality after major lower limb amputation in population/regional based studies. PRISMA guidelines were followed. A self developed checklist was used to assess quality and susceptibility to bias. Summary data were extracted for the percentage of the population who died; pooling of quantitative results was not possible because of methodological differences between studies.
  
  
  RESULTS
  Of the 9,082 publications identified, results were included from 21. The percentage of the population undergoing amputation who died within 30 days ranged from 7% to 22%, the in hospital equivalent was 4-20%. Transfemoral amputation and older age were found to have a higher proportion of early post-operative mortality, compared with transtibial and younger age, respectively. Other patient factors or surgical treatment choices related to increased early post-operative mortality varied between studies.
  
  
  CONCLUSIONS
  Early post-operative mortality rates vary from 4% to 22%. There are very limited data presented for patient related factors (age, comorbidities) that influence mortality. Even less is known about factors related to surgical treatment choices, being limited to amputation level. More information is needed to allow comparison across studies or for any benchmarking of acceptable mortality rates. Agreement is needed on key factors to be reported.
authors.affiliation: Department of Surgery, Ziekenhuisgroep Twente, Almelo and Hengelo, The Netherlands. Electronic address: jaapvannetten@gmail.com.
authors.forename: J J
authors.initials: JJ
authors.lastname: van Netten
authors.affiliation: Australian Centre for Research into Injury in Sport and its Prevention (ACRISP), Federation University Australia, Ballarat, Australia.
authors.forename: L V
authors.initials: LV
authors.lastname: Fortington
authors.affiliation: St. George's Vascular Institute, St. George's Healthcare NHS Trust, London, UK.
authors.forename: R J
authors.initials: RJ
authors.lastname: Hinchliffe
authors.affiliation: University of Groningen, University Medical Center, Department of Rehabilitation Medicine, Groningen, The Netherlands.
authors.forename: J M
authors.initials: JM
authors.lastname: Hijmans
mesh_terms: D000367:Age Factors; D000671:Amputation, Surgical / Q000009:adverse effects / Q000379:methods / Q000401:mortality*; D015897:Comorbidity; D017052:Hospital Mortality; D006801:Humans; D035002:Lower Extremity / Q000601:surgery*; D016017:Odds Ratio; D011183:Postoperative Complications / Q000401:mortality*; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome
keywords: Amputation; Benchmarking; Mortality; Operative surgical procedure; Post-operative complications; Systematic review