{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,25]],"date-time":"2026-08-25T15:28:06Z","timestamp":1787671686143,"version":"build-2736575974"},"reference-count":38,"publisher":"Ovid Technologies (Wolters Kluwer Health)","issue":"16","content-domain":{"domain":["lww.com","ovid.com"],"crossmark-restriction":true},"short-container-title":["J Am Acad Orthop Surg","JAAOS"],"published-print":{"date-parts":[[2022,8,15]]},"abstract":"<jats:sec>\n                    <jats:title>Introduction:<\/jats:title>\n                    <jats:p>Transtibial below-knee amputation (BKA) is associated with considerable morbidity, particularly in the vasculopathic population. The purpose of this study was to determine the cumulative probability of undergoing transfemoral above-knee amputation (AKA) conversion within 5 years of BKA and associated risk factors while accounting for the competing risk of death.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods:<\/jats:title>\n                    <jats:p>This is a retrospective, national database study with structured query of the Veterans Affairs (VA) database for patients who underwent BKA from 1999 to 2020, identified by Current Procedural Terminology codes. Above-knee amputation conversion was identified using Current Procedural Terminology codes in combination with natural language processing to match procedure laterality. After internally validating our patient identification method, risk factors were collected. Competing risk analysis estimated the cumulative incidence rate of AKA conversion and associated risk factors with death as a competing risk.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results:<\/jats:title>\n                    <jats:p>\n                      Our query yielded 19,875 patients (19,640 men, 98.8%) who underwent BKA with a median age of 66 years (interquartile range, 60 to 73). The median follow-up was 951 days (interquartile range, 275 to 2,026). The crude cumulative probabilities of AKA conversion and death at 5 years were 15.4% (95% confidence interval [CI], 14.9% to 16.0%) and 47.7% (95% CI, 46.9% to 48.4%), respectively. In the Fine and Gray subdistribution hazard model, peripheral vascular disease had the highest AKA conversion risk (hazard ratio [HR] 2.66; 95% CI, 2.22 to 3.20;\n                      <jats:italic toggle=\"yes\">P<\/jats:italic>\n                      &lt; 0.001). Other factors independently associated with AKA conversion included urgent operation (HR 1.32; 95% CI, 1.23 to 1.42), cerebrovascular disease (HR 1.19; 95% CI, 1.11 to 1.28), chronic obstructive pulmonary disease (HR 1.15; 95% CI, 1.07 to 1.24), and previous myocardial infarction (HR 1.10; 95% CI, 1.02 to 1.19) (All\n                      <jats:italic toggle=\"yes\">P<\/jats:italic>\n                      &lt; 0.02).\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Discussion:<\/jats:title>\n                    <jats:p>Within this predominantly male, VA population, BKA carries a high risk of conversion to AKA within 5 years, without reaching a steady risk of AKA conversion within 5 years. Peripheral vascular disease, chronic obstructive pulmonary disease, cerebrovascular disease, previous myocardial infarction, and urgent BKA increase the risk of AKA conversion.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Level of Evidence:<\/jats:title>\n                    <jats:p>Level III<\/jats:p>\n                  <\/jats:sec>","DOI":"10.5435\/jaaos-d-22-00262","type":"journal-article","created":{"date-parts":[[2022,7,20]],"date-time":"2022-07-20T18:00:10Z","timestamp":1658340010000},"page":"798-807","update-policy":"https:\/\/doi.org\/10.1097\/lww.0000000000001000","source":"Crossref","is-referenced-by-count":4,"title":["Mortality and Conversion to Transfemoral Amputation After Transtibial Amputation in the Veterans Affairs Health System"],"prefix":"10.5435","volume":"30","author":[{"given":"Liam H.","family":"Wong","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Erik","family":"Woelber","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Cecelia J.","family":"Madison","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Khanh P.","family":"Nguyen","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bruce J.","family":"Sangeorzan","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"James E.","family":"Meeker","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0451-0561","authenticated-orcid":false,"given":"Kenneth R.","family":"Gundle","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"276","reference":[{"key":"R1-20250503","doi-asserted-by":"crossref","first-page":"e2033953","DOI":"10.1001\/jamanetworkopen.2020.33953","article-title":"Temporal trends in incidence rates of lower extremity amputation and associated risk factors among patients using veterans health administration services from 2008 to 2018","volume":"4","author":"Cai","year":"2021","journal-title":"JAMA Netw Open"},{"key":"R2-20250503","doi-asserted-by":"crossref","first-page":"422","DOI":"10.1016\/j.apmr.2007.11.005","article-title":"Estimating the prevalence of limb loss in the United States: 2005 to 2050","volume":"89","author":"Ziegler-Graham","year":"2008","journal-title":"Arch Phys Med Rehabil"},{"key":"R3-20250503","doi-asserted-by":"crossref","first-page":"395","DOI":"10.1001\/archsurg.139.4.395","article-title":"Major lower extremity amputation: Outcome of a modern series","volume":"139","author":"Aulivola","year":"2004","journal-title":"Arch Surg"},{"key":"R4-20250503","doi-asserted-by":"crossref","first-page":"324","DOI":"10.1097\/CORR.0000000000001455","article-title":"Is reoperation higher than expected after below-the-knee amputation? 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