Lower extremity amputations in adults less than forty years of age: An underestimated risk from premature atherosclerosis

Between 1987 and 1992, 57 patients aged twenty-five to forty (average, 34.0 +/- 4.5 years) underwent major lower extremity amputations in five community hospitals, including a Level II Trauma Center. Only 19 (33%) patients had traumatic amputations, 3 (5%) had malignant tumors, and 4 (7%) had juvenile-onset diabetes mellitus without atherosclerotic involvement of the large arteries. Thirty (53%) patients had premature atherosclerosis (PAS) of the lower extremities with end-stage renal disease (ESRD) present in half and related to diabetes in 12. All patients with ESRD required continuous dialysis therapy. Overall 19 (33%) patients in this study had diabetes. Of 32 patients greater than or equal to thirty-five years of age, 47% had traumatic amputations, and PAS was diagnosed in 28%. However, PAS was diagnosed in 84% of 25 patients greater than or equal to thirty-six years of age (OR=14.3; P < 0.001). In total, 67 amputations were done. Twenty-one (68%) of 31 above-knee amputations (AKA) were performed in patients with PAS, and 26% of AKA were related to trauma. Of 10 bilateral amputations, 9 (90%) were done in patients with PAS. Patients with PAS had a high prevalence of risk factors for cardiovascular disease including smoking (87%), diabetes (50%), hypertension (50%), and hyperlipidemia (30%). Nine (30%) of the patients with PAS had hypercoagulable states. PAS was identified as the leading cause for major amputations among young adults in this community and was frequently associated with heavy smoking, diabetes, end-stage renal disease, and hypercoagulability.