Salami-Tactics: when is it time for a major cut after multiple minor amputations?
INTRODUCTION
Repetitive minor amputations carry the concomitant risks of multiple surgical procedures, major amputations have physical and economical major drawbacks. The aim of this study was to evaluate whether there is a distinct number of minor amputations predicting a major amputation in the same leg and to determine risk factors for major amputation in multiple minor amputations.


MATERIALS AND METHODS
A retrospective chart review including 429 patients with 534 index minor amputations between 07/1984 and 06/2019 was conducted. Patient demographics and clinical data including number and level of re-amputations were extracted from medical records and statistically analyzed.


RESULTS
290 legs (54.3%) had one or multiple re-amputations after index minor amputation. 89 (16.7%) legs needed major amputation during follow up. Major amputation was performed at a mean of 32.5 (range 0 - 275.2) months after index minor amputation. No particular re-amputation demonstrated statistically significant elevated odds ratio (a.) to be a major amputation compared to the preceding amputation and (b.) to lead to a major amputation at any point during follow up. Stepwise multivariate Cox regression analysis revealed minor re-amputation within 90 days (HR 3.8, 95% CI 2.0-7.3, p <0.001) as the only risk factor for major amputation if at least one re-amputation had to be performed.


CONCLUSIONS
There is no distinct number of prior minor amputations in one leg that would justify a major amputation on its own. If a re-amputation has to be done, the timepoint needs to be considered as re-amputations within 90 days carry a fourfold risk for major amputation.


LEVEL OF EVIDENCE
Retrospective comparative study (Level III).
['Berli|Martin C|MC|', 'Rancic|Zoran|Z|', 'Schöni|Madlaina|M|', 'Götschi|Tobias|T|', 'Schenk|Pascal|P|', 'Kabelitz|Method|M|', 'Böni|Thomas|T|', 'Waibel|Felix W A|FWA|http://orcid.org/0000-0003-3991-8743']
Minor Amputation Major Amputation Diabetes Osteomyelitis PAD Ulcer