CORR - 2026-03-03 - Journal Article
What Are the Patient-reported Outcomes After Elective Transtibial Amputation? A Comparison of CRPS, Neuropathic Pain, and Other Conditions That Lead to Late Amputation After Limb Salvage.
Lansford JL, Cantor AG, Oplinger SL, Hoyt BW, Bozzay AB, Potter BK
Topics
Key Takeaway
Elective transtibial amputation for CRPS/neuropathic pain produced greater VAS pain reduction (median ΔVAS -5) than nonneurogenic late amputation (median ΔVAS -3, p=0.02), with no difference in PROMIS pain interference scores (57 vs. 56, p=0.81) and 0% revision to higher amputation level at median 9-year follow-up.
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Summary
This retrospective comparative study asked whether elective transtibial amputation for CRPS or neuropathic pain yields inferior outcomes versus late amputation for nonneurogenic indications in a predominantly combat-injured male cohort (94% male, 74% combat-related). Fifty patients (CRPS n=10, neuropathic pain n=10, nonneurogenic controls n=30) were evaluated at median 9-year follow-up using PROMIS domains, VAS pain, opioid use, prosthetic use, revision rate, and decision regret. Neurogenic pain patients achieved greater VAS reduction (ΔVAS -5 vs. -3, p=0.02), equivalent PROMIS pain interference (57 vs. 56, p=0.81), 100% median reduction in opioid frequency in both groups, 0% revision to higher level, and zero patients expressed definitive decision regret.
Key Limitation
The cohort is 94% male active-duty service members with combat-related trauma, severely limiting generalizability to civilian patients, women, and non-traumatic etiologies of CRPS or neuropathic pain.
Original Abstract
BACKGROUND
In the United States, approximately 2.3 million people live with limb loss, of whom about 91% have undergone lower extremity amputation. Despite these numbers, relatively few studies have evaluated outcomes after elective transtibial amputation. In particular, we do not know whether the outcomes after amputation for intractable neurogenic pain such as complex regional pain syndrome (CRPS) are comparable to outcomes after late amputations (6 weeks or more after limb salvage) performed for other reasons such as recurrent infection, soft tissue problems, recalcitrant nonunion, poor function, and chronic nonneurogenic pain.
QUESTIONS/PURPOSES
(1) Did patients who underwent late amputation for CRPS or neuropathic pain have inferior Patient-Reported Outcomes Measurement Information System (PROMIS) scores at follow-up compared with patients who had nonneurogenic elective amputation? (2) Did patients who underwent late amputation for CRPS or neuropathic pain have more pain, use more pain medication, or wear prosthetics less often than patients who have undergone nonneurogenic elective amputation? (3) Were patients who underwent late amputation for CRPS or neuropathic pain more likely to be revised to a higher level of amputation or express decision regret than patients undergoing nonneurogenic elective amputation?
METHODS
This retrospective comparative study examined 70% (50 of 71) of patients who underwent elective (that is, scheduled, nonurgent) transtibial amputation between July 2006 and September 2019 at least 6 weeks after lower extremity trauma (median [range] 2 years [6 weeks to 15 years]). Most patients were men (94% [47 of 50]) and active duty service members who sustained combat-related trauma (74% [37 of 50]). Patients with CRPS (defined using the Budapest criteria diagnostic guidelines, which requires ongoing disproportionate pain plus signs in four categories: sensory, vasomotor, sudomotor/edema, and motor/trophic changes, n = 10) and other forms of neuropathic pain (n = 10) were compared with a control group of patients who had nonneurogenic elective amputation (n = 30). Demographic characteristics among cohorts were not different given the numbers available. The median (range) follow-up was 9 years (3 to 16) after amputation. The primary outcome was the PROMIS pain interference score. Secondary outcomes included other PROMIS metrics, VAS pain, and patient-reported medication and prosthetic use as well as revision to a higher level of amputation and decision regret.
RESULTS
With the numbers available, we found no difference in PROMIS pain interference scores for patients with transtibial amputations performed for neurogenic pain compared with other causes of late amputation (median [range] 57 [45 to 64] versus 56 [39 to 72]; p = 0.81). There were likewise no differences with the numbers available in PROMIS physical function, mobility, life satisfaction, and severity of substance use. Amputations performed for neurogenic pain resulted in more pain reduction than late amputations for other causes (median ΔVAS -5 [-9 to -1] versus median Δ VAS -3 [-8 to 7]; p = 0.02). Both groups reported a reduction in opioid use (100% reduction in median frequency of opioid administrations for both groups; p < 0.001). Prosthetic use was not different with the numbers available among all cohorts. No patients in the CRPS plus neuropathic pain cohort were revised to a higher level of amputation compared with 2 patients in the nonneurogenic elective amputation cohort. No patients expressed definitive decision regret.
CONCLUSION
Patients undergoing elective transtibial amputations for intractable neurogenic pain experienced clinically meaningful improvement in pain. Our findings support the use of transtibial amputation for treatment-resistant neurogenic pain, and they provide reasonable, but generally favorable, expectations for patients considering this irreversible procedure that are generally comparable to outcomes from patients undergoing late amputations for other indications.
LEVEL OF EVIDENCE
Level III, therapeutic study.