Background Despite advances in revascularization strategies, lower extremity amputations remain a mainstay of treatment for chronic limb threatening ischemia (CLTI). Peripheral arterial occlusive disease results in approximately 185,000 major amputations in the United States per year. The Society for Vascular Surgery guidelines on the management of CLTI emphasize the importance of engaging patients in physical rehabilitation and obtaining prosthetics to optimize functional status after major amputation. Amputees who ambulate with a prosthetic are more well equipped to perform activities of daily living and have a survival advantage versus non-ambulatory amputees. We hypothesize that sociodemographic variables, particularly disadvantaged financial environments, have the potential to impact both rate of prosthetic utilization and the achievement of ambulation post major amputation.

Methods All cases in the Vascular Quality Initiative amputation module were queried. Inclusion was limited to below-, through-, and above-knee amputations. Two outcomes were investigated: Non-ambulatory status after amputation (min 120 days F/U) and not having obtained a prosthetic (min 90 days F/U). The ambulation status and prosthetic status analyses had 6984 and 6793 patients meet inclusion. Multivariable binary logistic regression was performed for the outcomes using significant (P<0.05) factors on univariable analysis.

Results Factors with significant multivariable association for the outcome of no prosthetic utilization in follow up included: advancing age (aOR 1.011/year (1.006-1.016), P<.001); female sex (aOR 1.43 (1.28-1.61), P<.001); top 20% area of deprivation index representing most deprived areas (aOR 1.24 (1.09-1.41) P=.001); race (P=.002) with incidence of no prosthetic use at 61% for Native American, 46% for Asians; 52% for Black, 62% for Hawaiian/Pacific Islanders, 43% for White, 53% for multiracial, and 50% for unidentified race; Insurance status (P=.028) with protective status for commercial insurance (39% rate of no prosthetic) and non US insurance (33%) versus Medicare (51%), Medicaid (48%), VA insurance (49%), Self Pay (42%) and Medicare Advantage (51%).

Conclusions Living within the most financially disadvantaged areas and race both have a significant independent association with lack of prosthetic use following major amputation. Black, Native American and Pacific Islander demographic patients experience lack of prosthetic use at a higher rate than White and Asian patients independent of co-morbidities and socioeconomic co-variables. Female patients utilize a prosthetic and ambulate less frequently than males after major amputation, largely due to a higher rate of above knee amputation. Co-morbidities, and not socioeconomic variables are the leading drivers of non-ambulation.