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Shen Q, Li B, Chen H, Gao S, Hu Y, Sun Y, Li G. Podiatrist intervention could reduce the incidence of foot ulcers in patients with diabetes: a hospital survey in China. J Wound Care 2024; 33:S25-S32. [PMID: 38573950 DOI: 10.12968/jowc.2024.33.sup4.s25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
OBJECTIVE This study aimed to evaluate the effectiveness of podiatrists in preventing diabetic foot ulcers (DFUs) in China. METHOD The study was a prospective investigation. A total of 300 patients were enrolled from May 2016 to May 2018 in Handan Central Hospital, China. All patients who participated in this study had been diagnosed with type 2 diabetes, according to the International Classification of Diseases (ICD-10). All participants underwent our survey, which included basic patient data and information about DFUs. The patients were followed for one year, during which time they received appropriate intervention from podiatrists, including lifestyle guidance, callus resection, tinea grinding and ingrown nail correction. At the end of the year all the patients were surveyed again. The data before and after the year were statistically compared. RESULTS The results showed that the incidence of DFUs in patients with diabetes was significantly decreased after one year of intervention from podiatrists (20.7% versus 6.7%, p<0.001). Additionally, there was a negative correlation between the number of intervention visits and the number of DFU occurrences (Spearman correlation coefficient: -0.496, p<0.001). Furthermore, we found that 68 patients with a history of DFUs or amputation had an obviously reduced incidence of DFUs after intervention by a podiatrist (89.7% versus 27.9%, p<0.001). We also investigated other foot risk factors in all participants, such as limb neuropathy (76.3%), lower extremity vascular disease (65.7%) and foot paralysis (43.7%). CONCLUSION The results of this study help in understanding the situation of patients with diabetes in China and to prove that standardised podiatrist intervention has an important role in inhibiting the occurrence and development of DFUs.
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Affiliation(s)
- Qian Shen
- School of Foreign Studies of Zhongnan University of Economics and Law; Wuhan, China
| | - Binghui Li
- Department of Wound Repair Surgery, Liyuan Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Huating Chen
- Department of Wound Repair Surgery, Liyuan Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Suwen Gao
- Department of Endocrinology, Handan Central Hospital, Handan, China
| | - Yingyue Hu
- Department of Wound Repair Surgery, Liyuan Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yi Sun
- School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Gongchi Li
- Department of Hand Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Abstract
Diabetic foot ulcer represents the primary cause of hospital admissions, amputations, and mortality in diabetic patients. The development of diabetic foot ulcers is influenced by peripheral neuropathy, infection, and ischemia, with diabetes contributing to peripheral artery disease. Free tissue transfer combined with revascularisation of the lower extremity provides the potential opportunity for limb salvage in individuals with lower extremity defects due to critical limb ischemia and diabetic foot.
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Affiliation(s)
- Daniel J Kedar
- Department of Plastic and Reconstructive Surgery, Tel-Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Hyun Suk Suh
- Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Republic of Korea
| | - Changsik John Park
- Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Republic of Korea
| | - Joon Pio Hong
- Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Republic of Korea
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The impact of diabetic nephropathy and severe diabetic retinopathy on chronic limb threatening ischemia risk in individuals with type 1 diabetes: a nationwide, population study. Lancet Reg Health Eur 2023; 28:100594. [PMID: 37180744 PMCID: PMC10173269 DOI: 10.1016/j.lanepe.2023.100594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 01/13/2023] [Accepted: 01/25/2023] [Indexed: 02/17/2023] Open
Abstract
Background The prevalence, incidence and risk factors and especially the effect of diabetic nephropathy (DN) and diabetic retinopathy on the risk of chronic limb threatening ischemia (CLTI) have been sparsely studied in individuals with type 1 diabetes (T1D). Methods The prospective cohort study consisted of 4697 individuals with T1D from the nationwide Finnish Diabetic Nephropathy (FinnDiane) Study. Medical records were thoroughly reviewed in order to ascertain all CLTI events. The key risk factors were DN and severe diabetic retinopathy (SDR). Findings There were 319 events of confirmed CLTI, 102 prevalent events at baseline and 217 incident events during the follow-up of 11.9 (IQR 9.3-13.8) years. The 12-year cumulative incidence of CLTI was 4.6% (95% CI 4.0-5.3). Risk factors included presence of DN, SDR, age, duration of diabetes, HbA1c, systolic blood pressure, triglycerides and current smoking. Sub-hazard ratios (SHRs) according to combinations of DN status and presence (+) or absence (-) of SDR were 4.8 (2.0-11.7) for normoalbuminuria/SDR+, 3.2 (1.1-9.4) for microalbuminuria/SDR-, 11.9 (5.4-26.5) for microalbuminuria/SDR+, 8.7 (3.2-23.2) for macroalbuminuria/SDR-, 15.6 (7.4-33.0) for macroalbuminuria/SDR+ and 37.9 (17.2-78.9) for kidney failure compared with individuals with normal albumin excretion rate and without SDR. Interpretation Diabetic nephropathy, especially kidney failure, is associated with high risk of limb threatening ischemia in individuals with T1D. The risk of CLTI increases gradually according to the severity of diabetic nephropathy. Also, diabetic retinopathy is independently and additively associated with high risk of CLTI. Funding This research was funded by grants from Folkhälsan Research Foundation, Academy of Finland (316664), Wilhelm and Else Stockmann Foundation, Liv och Hälsa Society, Novo Nordisk Foundation (NNF OC0013659), Finnish Foundation for Cardiovascular Research, Finnish Diabetes Research Foundation, Medical Society of Finland, Sigrid Jusélius Foundation and Helsinki University Hospital Research Funds.
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Vasilchenko E, Zoloev G, Karapetian K, Puzin S. Trends in the incidence rates of lower limb amputation due to nondiabetic peripheral artery disease in a large industrial city in Western Siberia, Russia: A review from 1996 to 2019. Prosthet Orthot Int 2022; 46:619-624. [PMID: 36515907 DOI: 10.1097/pxr.0000000000000151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 03/14/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND lower limb amputation (LLA) is a growing problem in the population with and without diabetes mellitus. Monitoring the incidence rates of LLA is important for health care planning and has implications for the future problems of medical and social care. OBJECTIVE This study aimed to determine the trends in incidence rates of LLA due to nondiabetic peripheral artery disease in Novokuznetsk, Western Siberia, Russia. STUDY DESIGN An observational study. METHODS Data on all transtibial and transfemoral amputations performed in inpatient facilities in Novokuznetsk from 1996 to 2019 were derived from the regional Register of patients with limb amputations. The rates were calculated per 100,000 population. RESULTS A total of 2448 persons with amputations due to nondiabetic peripheral artery disease were included in this study (3191 amputations). The overall incidence rate of LLA in Novokuznetsk increased from 14.6 in 1996 to 30.4 in 2019. The proportion of persons older than 60 years increased from 15.5% in 1996 to 20.3% in 2019. CONCLUSION The expected aging of the population and increasing incidence of LLA are relevant issues in Russia. These findings can contribute to improving healthcare services and the development of prevention programs to reverse the alarming trend.
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Affiliation(s)
- Elena Vasilchenko
- Federal State Budgetary Institution "Novokuznetsk Scientific and Practical Centre for Medical and Social Expertise and Rehabilitation of Disabled Persons," Ministry of Labour and Social Protection of the Russian Federation Novokuznetsk, Russian Federation
| | | | - Karine Karapetian
- Federal State Budgetary Institution "Novokuznetsk Scientific and Practical Centre for Medical and Social Expertise and Rehabilitation of Disabled Persons," Ministry of Labour and Social Protection of the Russian Federation Novokuznetsk, Russian Federation
| | - Sergey Puzin
- Federal State Budgetary Scientific Institution "Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology" Moscow, Russian Federation
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Koivunen V, Dabravolskaite V, Nikulainen V, Juonala M, Helmiö P, Hakovirta H. Major Lower Limb Amputations and Amputees in an Aging Population in Southwest Finland 2007-2017. Clin Interv Aging 2022; 17:925-936. [PMID: 35707730 PMCID: PMC9189152 DOI: 10.2147/cia.s361547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 05/19/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose The aim of the present study was to describe and analyze changes in the incidences of lower extremity amputations (LEAs), patient characteristics, vascular history of amputees and survival in Southwest Finland. Patients and Methods This is a retrospective patient study in the Hospital District of Southwest Finland. All consecutive patients with atherosclerosis and diabetes-caused LEA, between 1st January 2007 and 31st December 2017, were included. The annual incidences of major LEA patients were statistically standardized. Patients' diagnoses, functional status, previous revascularizations and minor amputations were recorded, and survival was analyzed. Results During the 11-year-period major LEAs were performed on 891 patients, 118 (13.2%) were urgent operations. The overall incidence of major LEA was 17.2/100 000 and was age-dependent (3.1 for ≤64 years, 34.3 for 65-74 years, 81.5 for 75-84 years, 216 for ≥85 years). A decrease in incidence was detected in the <65 year-age-group (incidence 4.98 in 2007 and 1.88 in 2017; p = 0.0018). Among older age groups, there was no significant change. Half (50.6%) of all amputees were diabetics. Altogether, 472 patients (53.0%) had a history of revascularization before LEA. 80.1% of index amputations were transfemoral and 19.9% transtibial. Re-surgery was performed on 94 (10.5%) patients. The 1-, 3- and 5-year overall survival were 56%, 30%, and 18%, respectively. Conclusion Our results suggest that in an aging population, despite good availability of vascular services, a significant number of patients are not fit for active revascularization, and LEA is the only feasible treatment for critical limb ischemia.
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Affiliation(s)
| | - Vaiva Dabravolskaite
- University of Turku, Faculty of Medicine, Turku, 20521, Finland.,Department of Vascular Surgery, Turku University Hospital, Turku, 20521, Finland
| | - Veikko Nikulainen
- University of Turku, Faculty of Medicine, Turku, 20521, Finland.,Department of Vascular Surgery, Turku University Hospital, Turku, 20521, Finland
| | - Markus Juonala
- University of Turku, Faculty of Medicine, Turku, 20521, Finland.,Department of Internal Medicine, Division of Medicine, Turku University Hospital, Turku, 20521, Finland
| | - Päivi Helmiö
- University of Turku, Faculty of Medicine, Turku, 20521, Finland.,Department of Vascular Surgery, Turku University Hospital, Turku, 20521, Finland
| | - Harri Hakovirta
- University of Turku, Faculty of Medicine, Turku, 20521, Finland.,Department of Vascular Surgery, Turku University Hospital, Turku, 20521, Finland.,Department of Surgery, Satasairaala, Pori, 28500, Finland
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Ponkilainen VT, Vuorlaakso M, Kaartinen I, Kiiski J, Saarinen E, Huttunen TT, Paloneva J, Mattila VM. The Development of Lower Limb Amputations in Finland from 1997 to 2018: A Nationwide Retrospective Registry Study. Eur J Vasc Endovasc Surg 2021; 63:138-146. [PMID: 34774371 DOI: 10.1016/j.ejvs.2021.09.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 08/25/2021] [Accepted: 09/19/2021] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To investigate the rates of transfemoral, transtibial foot and toe amputations, and lower limb revascularisations in Finland between 1997 and 2018. METHODS Retrospective observational cohort study. Data from the Finnish National Hospital Discharge Register for the period 1997 - 2018 were used. The study population covered all patients 20 years and older who underwent lower limb revascularisations or amputations in private and public hospitals during the study period. All (outpatient and inpatient) amputations and revascularisations were included. The age adjusted incidence rates were based on the annual mid populations, which were obtained from the Official Statistics of Finland. Continuous variables were presented as median with interquartile range (IQR) or as mean with standard deviation. The 95% confidence intervals (CI) for the incidence rates were calculated using the Poisson exact method. All changes in incidence were calculated as relative change (%). RESULTS A total of 75 230 patients underwent 149 492 lower limb revascularisations and amputations between 1997 and 2018 in Finland. The median (IQR) age of the patients was 73 (65, 80) and 60% of the patients were men. The incidence of all endovascular lower limb revascularisations increased by 159% while the incidence of lower limb amputations increased by 25%. The most notable increase occurred in toe (84%) and foot (107%) amputations, while the incidence of transfemoral amputations remained steady and transtibial amputations decreased by 53%. The first minor-major amputation ratio (CI) increased from 1.13 (1.03 - 1.24) to 1.49 (1.36 to 1.62) during the study period. CONCLUSION The findings of this nationwide cohort study suggest that the incidence of both lower limb revascularisations and amputations is increasing. More specifically, revascularisations are more often performed endovascularly, and the incidence of transtibial amputations is declining, whereas the incidence of toe and foot amputations is increasing.
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Affiliation(s)
| | - Miska Vuorlaakso
- Faculty of Medicine and Life Sciences, Tampere University, Tampere, Finland; Department of Surgery, Kanta-Häme Central Hospital, Hämeenlinna, Finland
| | - Ilkka Kaartinen
- Faculty of Medicine and Life Sciences, Tampere University, Tampere, Finland; Department of Plastic Surgery, Tampere University Hospital, Tampere, Finland
| | - Juha Kiiski
- Department of Plastic Surgery, Tampere University Hospital, Tampere, Finland
| | - Eva Saarinen
- Faculty of Medicine and Life Sciences, Tampere University, Tampere, Finland; Centre for Vascular Surgery and Interventional Radiology, Tampere University Hospital, Tampere, Finland
| | - Tuomas T Huttunen
- Faculty of Medicine and Life Sciences, Tampere University, Tampere, Finland; Tampere Heart Hospital, Tampere University Hospital, Tampere, Finland; The Division of Orthopaedics and Biotechnology, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Juha Paloneva
- Faculty of Medicine and Life Sciences, Tampere University, Tampere, Finland; Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Ville M Mattila
- Faculty of Medicine and Life Sciences, Tampere University, Tampere, Finland; Department of Orthopaedics and Traumatology, Tampere University Hospital, Tampere, Finland; COXA Hospital for Joint Replacement, Tampere, Finland
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Long CA, Mulder H, Fowkes FGR, Baumgartner I, Berger JS, Katona BG, Mahaffey KW, Norgren L, Blomster JI, Rockhold FW, Hiatt WR, Patel MR, Jones WS, Nehler MR. Incidence and Factors Associated With Major Amputation in Patients With Peripheral Artery Disease. Circ Cardiovasc Qual Outcomes 2020; 13:e006399. [DOI: 10.1161/circoutcomes.119.006399] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Peripheral artery disease (PAD) is associated with increased risk of mortality, cardiovascular morbidity, and major amputation. Data on major amputation from a large randomized trial that included a substantial cohort of patients without critical limb ischemia (CLI) have not been described. The objective was to describe the incidence and types of amputations in the EUCLID trial (Examining Use of Ticagrelor in Peripheral Artery Disease) population, subcategorize amputations in the CLI versus no CLI cohorts, and describe the events surrounding major amputation.
Methods and Results:
Postrandomization major amputation was analyzed in the EUCLID trial. Patients were stratified by baseline CLI status. The occurrence of major amputation was ascertained and defined as the highest level. Perioperative events surrounding major amputation were obtained including acute limb ischemia, revascularization, and all-cause mortality. All variables were assessed for significance in univariable and multivariable models. The rate of major amputation during the course of the trial was 1.6% overall, 8.4% in the CLI at baseline group, and 1.2% in the no CLI at baseline group. The annualized rate of major amputation was 0.6% in PAD overall, 3.9% in the CLI at baseline group, and 0.5% in the no CLI at baseline group. Several factors were associated with increased risk of major amputation, including history of amputation, the presence of diabetes mellitus, baseline Rutherford category 4 to 6, and an ankle-brachial index <0.8. Factors associated with a lower risk for major amputation included prior statin use. The 30-day mortality rate after major amputation was 6.5% overall, 5.6% in the CLI at baseline group, and 6.8% in the no CLI at baseline group. The annual mortality rate following major amputation was 22.8% in the CLI at baseline group and 16.0% in the no CLI at baseline group.
Conclusions:
The risk factors for major amputation in EUCLID patients are similar to previous large registries’ reports except for diabetes mellitus in patients with CLI. The mortality following major amputation is lower in the EUCLID trial compared with registry data.
Registration:
URL:
https://www.clinicaltrials.gov
; Unique identifier: NCT01732822.
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Affiliation(s)
- Chandler A. Long
- Department of Surgery, Division of Vascular Surgery and Endovascular Surgery (C.A.L.), Duke University Health System, Durham, NC
| | - Hillary Mulder
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (H.M., F.W.R., M.R.P., W.S.J.)
| | - F. Gerry R. Fowkes
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, United Kingdom (F.G.R.F.)
| | - Iris Baumgartner
- Division of Angiology, Swiss Cardiovascular Centre, Inselspital, Bern University Hospital, University of Bern, Switzerland (I.B.)
| | - Jeffrey S. Berger
- Departments of Medicine (J.S.B.), New York University School of Medicine
- Surgery (J.S.B.), New York University School of Medicine
| | | | - Kenneth W. Mahaffey
- Stanford Center for Clinical Research, Stanford University School of Medicine, CA (K.W.M.)
| | - Lars Norgren
- Faculty of Medicine and Health, Örebro University, Sweden (L.N.)
| | - Juuso I. Blomster
- Heart Centre, Turku University Hospital, University of Turku, Finland (J.I.B.)
| | - Frank W. Rockhold
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (H.M., F.W.R., M.R.P., W.S.J.)
| | - William R. Hiatt
- Department of Medicine, Division of Cardiology (W.R.H.), University of Colorado School of Medicine and CPC Clinical Research, Aurora
| | - Manesh R. Patel
- Department of Medicine, Division of Cardiology (M.R.P., W.S.J.), Duke University Health System, Durham, NC
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (H.M., F.W.R., M.R.P., W.S.J.)
- Department of Surgery, Division of Vascular Surgery and Endovascular Surgery (M.R.N.), University of Colorado School of Medicine and CPC Clinical Research, Aurora
| | - W. Schuyler Jones
- Department of Medicine, Division of Cardiology (M.R.P., W.S.J.), Duke University Health System, Durham, NC
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (H.M., F.W.R., M.R.P., W.S.J.)
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Atherectomy-assisted versus percutaneous angioplasty interventions for treatment of symptomatic infra-inguinal peripheral arterial disease. ACTA ACUST UNITED AC 2019; 4:e231-e242. [PMID: 31824991 PMCID: PMC6900743 DOI: 10.5114/amsad.2019.89900] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Accepted: 08/06/2019] [Indexed: 11/21/2022]
Abstract
Introduction The role of atherectomy (ATHERO) for the treatment of symptomatic infra-inguinal arterial lesions remains controversial. We evaluated the effectiveness and safety of atherectomy-assisted endovascular interventions in comparison with percutaneous angioplasty (PTA). Material and methods A systematic search utilizing MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials was conducted for studies comparing ATHERO with PTA from February 1995 to May 2018. Only studies comparing ATHERO to PTA for symptomatic infra-inguinal disease were included. Random-effects meta-analysis was used to pool the data and endpoints across studies. Study endpoints included vessel dissection, distal embolization, residual stenosis (> 30%), vessel patency at 6 months, target lesion revascularization (TLR) at 12 months and major amputation rates at 1, 6, and 12 months. Results A total of 2923 patients were included from 8 studies. PTA was associated with higher vessel dissection (OR = 4.00, 95% CI: 1.15–13.86) and lower 12-month major amputation rates (OR = 0.73, 95% CI: 0.59–0.90). There was no significant difference between ATHERO and PTA groups in terms of distal embolization (OR = 0.45, 95% CI: 0.04–4.63), residual stenosis (OR = 1.28, 95% CI: 0.58–2.80), vessel patency at 6 months (OR = 1.27, 95% CI: 0.50–3.22), TLR at 12 months (OR = 1.07, 95% CI: 0.46–2.51), or limb amputation at 1 month (OR = 0.69, 95% CI: 0.44–1.07) or 6 months (OR = 1.54, 95% CI: 0.38–6.15). Conclusions In patients undergoing infra-inguinal endovascular interventions, PTA was associated with higher peri-procedural vessel dissection and lower 12-month major amputation rates. Both modalities were associated with similar distal embolization, residual stenosis, and 6-month vessel patency and amputation rates.
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Nikulainen V, Helmiö P, Hakovirta H. Changes in rates of vascular procedure types and lower extremity amputations in Finland for 2007-2017 inclusive, a population cohort study of 69,523 revascularizations. Int J Surg 2019; 72:118-125. [PMID: 31704419 DOI: 10.1016/j.ijsu.2019.10.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 10/27/2019] [Accepted: 10/30/2019] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Since 2000 the numbers of both open and endovascular revascularization procedures have increased. Despite these increases, the number of major lower extremity amputations (LEAs) has remained relatively constant. The aim of the present study was to assess the number of vascular procedures in relation to the frequency of major LEAs in Finland. METHODS The Finnish National Institute for Health and Welfare (THL) administers a national registry of all procedures conducted by official healthcare providers in Finland. Data regarding all revascularization procedures and major LEAs between 2007 and 2017 inclusive, were collected from the THL registry. The rates of both open and endovascular procedures were analyzed. RESULTS A total of 69,523 revascularization procedures were registered over the 11-year period. Of all revascularizations, 22.6% were endovascular in 2007, which rose to 60.5% in 2017. The annual rates of vascular procedures per 100,000 inhabitants increased from 66 in 2007 to 172 in 2017 (increase 10 procedures per year, 95% CI 8.6-12.3, P < 0.01) There was a significant increase (by 141 per year, 95% CI 110-174, P < 0.01) for open revascularizations (2705 operations in 2007, 3992 operations in 2017) and (by 491 per year, 95% CI 433-550, P < 0.01) for endovascular revascularizations (791 in 2007-5514 in 2017). Open aorto-iliac segment revascularization decreased, whereas the numbers of procedures increased for all other arterial segments. The overall frequency of amputations was 18-20 per 100,000. The frequency of amputations in the subpopulation over 65 years old decreased from 93 in 2007 to 72 in 2017 (P < 0.01). CONCLUSION The present study demonstrated increases in vascular surgery procedures over the 11-year study-period. The increase was greatest for endovascular procedures. During the same period, there was a significant decrease in the frequency of major LEAs in the >65-year-old subpopulation.
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Affiliation(s)
- Veikko Nikulainen
- Department of Vascular Surgery, Turku University Hospital, Hämeentie 11, 20521, Turku, Finland; University of Turku, Kiinanmyllynkatu 4-8, 20521, Turku, Finland.
| | - Päivi Helmiö
- Department of Vascular Surgery, Turku University Hospital, Hämeentie 11, 20521, Turku, Finland; University of Turku, Kiinanmyllynkatu 4-8, 20521, Turku, Finland
| | - Harri Hakovirta
- Department of Vascular Surgery, Turku University Hospital, Hämeentie 11, 20521, Turku, Finland; University of Turku, Kiinanmyllynkatu 4-8, 20521, Turku, Finland
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von Plato H, Kontinen V, Hamunen K. Efficacy and safety of epidural, continuous perineural infusion and adjuvant analgesics for acute postoperative pain after major limb amputation - a systematic review. Scand J Pain 2019; 18:3-17. [PMID: 29794290 DOI: 10.1515/sjpain-2017-0170] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Accepted: 01/11/2018] [Indexed: 11/15/2022]
Abstract
BACKGROUND AND AIMS Treatment of pain following major limb amputations is often a clinical challenge in a patient population consisting mainly of elderly with underlying diseases. Literature on management of acute post-amputation pain is scarce. We performed a systematic review on this topic to evaluate the efficacy and safety of analgesic interventions for acute pain following major limb amputation. METHODS A literature search was performed in PubMed, Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews using the following key words: [(amputation) AND (pain OR analgesi* OR pain relief)] AND (acute OR postoperative). Randomized controlled studies (RCTs) and observational studies investigating treatment of acute pain following major amputations for any indication (peripheral vascular disease, malignant disease, trauma) were included. The review was performed according to the standards described in the PRISMA statement. The Cochrane quality assessment tool was used to evaluate the risk of bias in the RCTs. RESULTS Nineteen studies with total of 949 patients were included. The studies were generally small and heterogeneous on outcomes, study designs and quality. There were 16 studies on epidural or continuous perineural analgesia (CPI). Based on five RCTs (n=268) and two observational studies (n=49), epidural analgesia decreased the intensity of acute stump pain as compared to systemic analgesics, during the first 24 h after the operation. Based on one study epidural analgesia caused more adverse effects like sedation, nausea and motor block than continuous perineural local anesthetic infusion. Based on one RCT (n=21) and eight observational studies (n=501) CPI seemed to decrease opioid consumption as compared to systemic analgesics only, on the first three postoperative days, and was well tolerated. Only three trials investigated systemic analgesics (oral memantine, oral gabapentine, iv ketamine). Ketamine did not decrease acute pain or opioid consumption after amputation as compared to other systemic analgesics. Gabapentin did not decrease acute pain when combined to epidural analgesia as compared to epidural analgesia and opioid treatment, and caused adverse effects. CONCLUSIONS The main finding of this systematic review is that evidence regarding pain management after major limb amputation is very limited. Epidural analgesia may be effective, but firm evidence is lacking. Epidural causes more adverse effects than CPI. The results on efficacy of CPI are indecisive. The data on adjuvant medications combined to epidural analgesia or CPI is limited. Studies on efficacy and adverse effects of systemic analgesics for amputation pain, especially concentrating on elderly patients, are needed.
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Affiliation(s)
- Hanna von Plato
- Division of Perioperative Care, Jorvi Hospital, Department of Anesthesiology and Intensive Care Medicine, University of Helsinki and Helsinki University Hospital, P. O. Box 800, 00029 HUS, Helsinki, Finland, Phone: +350504284471
| | - Vesa Kontinen
- Division of Perioperative Care, Jorvi Hospital, Department of Anesthesiology and Intensive Care Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Katri Hamunen
- Division of Pain Medicine, Department of Anesthesiology and Intensive Care Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Bosiers M, Deloose K, Callaert J. Anterograde or retrograde arterial access for diabetic limb revascularization. Semin Vasc Surg 2018; 31:76-80. [DOI: 10.1053/j.semvascsurg.2018.12.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Evaluation of Use of Prosthesis, Mobility, and Quality of Life in Young and Adult Persons with Unilateral Above-Knee Amputation 7 Years after the 2008 Sichuan Earthquake. ACTA ACUST UNITED AC 2018. [DOI: 10.1097/jpo.0000000000000173] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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13
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Beyaz S, Güler ÜÖ, Bağır GŞ. Factors affecting lifespan following below-knee amputation in diabetic patients. ACTA ORTHOPAEDICA ET TRAUMATOLOGICA TURCICA 2017; 51:393-397. [PMID: 28865844 PMCID: PMC6197166 DOI: 10.1016/j.aott.2017.07.001] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Revised: 04/20/2017] [Accepted: 07/09/2017] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Untreatable foot problems in diabetics may require lower extremity amputation, which has a high level of patient mortality. This high mortality rate is worse than most malignancies. The present study aimed to identify parameters that can be used to estimate survival in DM patients undergoing below-knee amputations for diabetic foot problems. MATERIALS AND METHODS A total of 470 patients (299 males, 171 females) with a mean age of 64.32 years who underwent below-knee amputation for diabetic foot problems between 2004 and 2014 were enrolled in the study. The length of time from the operation to time of death was recorded in days. Patient details were obtained, including age during surgery, BMI, oral antidiabetic and insulin usage, dialysis therapy history, lower extremity endovascular intervention, previous amputation at the same extremity, the need for stump revision surgery during follow-up, and above-knee amputation at the same site. Biochemical test results of pre-operative HbA1c, ESR, and levels of CRP, BUN, and creatinine were also obtained. RESULTS A total of 333 patients (70.9%) died and 137 (29.1%) survived post-surgery. Survival rates were 90% in the first 7 days, 84% in the first 30 days, and 64% after the first year. Patient median life expectancy post-surgery was 930 ± 106 days. Hemodialysis treatment (p = 0.001), endovascular intervention (p = 0.04), sex (p = 0.004), age (p = 0.001), BUN level (p = 0.001), and duration of insulin use (p = 0.003) were shown to be effective predictors of mortality. CONCLUSIONS Life expectancy is low (<3 years) in DM patients requiring below-knee amputations for untreatable foot problems. Survival could be predicted by duration of insulin use, age, sex, and renal insufficiency. LEVEL OF EVIDENCE Level IV, Therapeutic study.
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Major Lower Limb Amputation: Outcomes are Improving. Ann Vasc Surg 2017; 45:29-34. [PMID: 28602903 DOI: 10.1016/j.avsg.2017.05.039] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2017] [Revised: 05/26/2017] [Accepted: 05/30/2017] [Indexed: 11/21/2022]
Abstract
BACKGROUND Outcomes following major lower limb amputation (MLLA) between 2000 and 2002 from the Department of Vascular Surgery at Royal Perth Hospital have been published; mean postoperative length of stay 20 days, inpatient complication rate 54%, and 30-day mortality 10%. The last decade has seen increasing endovascular revascularization techniques, increased focus on MLLA patients, and general improvements in the model of care. The aim of this study is to compare outcomes between 2000-2002 and 2010-2012. METHODS Data on all patients undergoing MLLA, transtibial or proximal, in the 2 time periods were extracted from the department of vascular surgery database. Medical records, government registries, and phone calls to primary care providers were used to clarify mortality. RESULTS Limb ischemia remains the most common indication for MLLA with smoking, hypertension, and diabetes being the main comorbid diseases. The rates of wound infections have fallen from 26.4% to 12.4% (P = 0.023), rate of admission to ICU has fallen from 48.3% to 17.5% (P = 0.001), and revision amputation to a higher level has fallen from 11.5% to 7.2% (P = 0.043). Acute hospital, postoperative length of stay has trended down from 15.74 to 20.29 days (P = 0.075). Mortality overall has fallen from 60.92% to 46.39% (P = 0.049). Thirty-day mortality fallen from 10.34% to 5.15% (P = 0.185), 6-month 28.76% to 16.5% (P = 0.046), and 1-year 40.22% to 21.65% (P = 0.006). CONCLUSIONS Patients undergoing MLLA still carry a high burden of comorbid disease. With changes in revascularization technique, consultant supervision, and multidisciplinary model of care, we have seen the rate of complications fall, length of stay trend down, and overall mortality reduce. Despite improvements, outcomes remain sobering and more can be done.
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Repo JP, Piitulainen K, Häkkinen A, Roine RP, Kautiainen H, Becker P, Tukiainen EJ. Reliability and validity of the Finnish version of the prosthesis evaluation questionnaire. Disabil Rehabil 2017; 40:2081-2087. [PMID: 28486856 DOI: 10.1080/09638288.2017.1323032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Thus far there have been no specific patient-reported outcome instrument in Finnish for health-related quality of life (HRQoL) assessment after major lower extremity amputation and successful prosthesis fitting. METHODS The prosthesis evaluation questionnaire (PEQ) was translated and cross-culturally adapted into Finnish. Participants completed a questionnaire package including the Finnish version of the PEQ and the 15 D HRQoL instrument. Scales (n = 10) were tested for internal consistency, floor-ceiling effect, and reproducibility for which participants completed the PEQ twice within a 2-week interval. Validity was tested by estimating the correlation between the 15 D index and the scales. The authors included 122 participants who had completed the questionnaire on two separate occasions in the final analysis. RESULTS Mean scale scores of the 10 scales varied from 52 to 83. Cronbach's alphas ranged from 0.67 to 0.96. The total score showed no floor-ceiling effect. Reproducibility of the scales was good (intraclass correlation coefficient, 0.78-0.87; coefficient of repeatability, 19-36). Significant correlations were observed between the 15 D index and the scales for ambulation, social burden, usefulness, and well-being. CONCLUSIONS This study provided evidence of the reliability and validity of the Finnish version of the PEQ in assessing the HRQoL among major lower extremity amputated patients who have been fitted with prosthesis. Implications for rehabilitation Measurement of quality of life during rehabilitation can provide important information on patients' well-being. The prosthesis evaluation questionnaire (PEQ) is a valid instrument for assessing health-related quality of life (HRQoL) after major lower extremity amputation. This study provided evidence of the reliability and validity of the Finnish version of the PEQ for assessing HRQoL among patient who have undergone major lower extremity amputation.
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Affiliation(s)
- Jussi Petteri Repo
- a Department of Plastic Surgery , Helsinki University Hospital, University of Helsinki , Helsinki , Finland
| | - Kirsi Piitulainen
- b Department of Health Sciences , University of Jyväskylä , Jyväskylä , Finland.,c Department of Physical Medicine , Central Finland Health Care District , Jyväskylä , Finland
| | - Arja Häkkinen
- b Department of Health Sciences , University of Jyväskylä , Jyväskylä , Finland.,c Department of Physical Medicine , Central Finland Health Care District , Jyväskylä , Finland
| | - Risto Paavo Roine
- d Group Administration , Helsinki University Hospital, University of Helsinki , Helsinki , Finland.,e Department of Health and Social Management, Research Centre for Comparative Effectiveness and Patient Safety , University of Eastern Finland , Kuopio , Finland
| | - Hannu Kautiainen
- f Department of General Practice , Helsinki University Hospital, University of Helsinki , Helsinki , Finland
| | - Paju Becker
- b Department of Health Sciences , University of Jyväskylä , Jyväskylä , Finland
| | - Erkki Juhani Tukiainen
- a Department of Plastic Surgery , Helsinki University Hospital, University of Helsinki , Helsinki , Finland
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Davies RSM. Commentary on "Analysis of the Elective Treatment Process for Critical Limb Ischemia with Tissue Loss: Diabetic Patients Require Rapid Revascularisation". Eur J Vasc Endovasc Surg 2016; 53:214. [PMID: 27956090 DOI: 10.1016/j.ejvs.2016.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 11/08/2016] [Indexed: 11/29/2022]
Affiliation(s)
- R S M Davies
- The Department of Vascular Surgery, Leicester Royal Infirmary, Leicester, UK.
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Eskelinen E, Eskelinen A, Albäck A, Lepäntalo M. Major Amputation Incidence Decreases Both in Non-Diabetic and in Diabetic Patients in Helsinki. Scand J Surg 2016; 95:185-9. [PMID: 17066615 DOI: 10.1177/145749690609500311] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background and Aims: The aim of the study was to assess the changes in diabetes-related lower extremity amputations and to compare it with the development of amputations for critical leg ischaemia in patients without diabetes. Material and Methods: Clinical records of 1094 patients undergoing major lower limb amputations for vascular disease in the town of Helsinki during 13 years from 1990 to 2002 were analyzed retrospectively. Data concerning patient factors, diagnosis, existence of diabetes and amputation level were recorded. The study period was divided into three parts (1990–1994, 1995–1998 and 1999–2002) and results were compared between diabetic and nondiabetic vascular amputees during these time periods. Results: From 1990 through 2002, 561 of patients undergoing major lower limb amputation had diabetes mellitus. The overall incidence of major amputations of diabetics reduced from the first time period to the last period by 23%. At the same time, the incidence of amputations in non-diabetic patient group decreased 40%. If the incidence rate for amputations is expressed per million individuals with diabetes, 33% decrease was observed during the study period. Conclusions: The decrease in major amputation rates among diabetic as well as non-diabetic patients can be attributed to the increased interest in amputation prevention, with a contribution by vascular surgeons being made in both groups.
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Affiliation(s)
- E Eskelinen
- Department of Vascular Surgery, Helsinki University Central Hospital, Helsinki, Finland.
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Eskelinen E, Lepäntalo M. Role of Infrainguinal Angioplasty in the Treatment of Critical Limb Ischaemia. Scand J Surg 2016; 96:11-6. [PMID: 17461306 DOI: 10.1177/145749690709600103] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Objective: To review the published papers reporting on the use of infrainguinal angioplasty in the treatment of critical limb ischaemia (CLI). Methods: A MEDLINE (1966–2005) and Cochrane library search for articles relating to the use of infrainguinal angioplasty in the treatment of CLI. Results: Recent papers reporting on the results of infrainguinal angioplasty as treatment for CLI patients show excellent limb salvage rates regardless of the patency rates. The Cochrane Database of systematic reviews has accepted two prospective randomised trials comparing bypass operations and angioplasty among CLI patients. Pooling both trials showed no overall significant difference in amputation rates between the surgery and PTA groups. A multicentre, randomised controlled trial, the BASIL (bypass versus Angioplasty in Severe Ischaemia of the Leg) trial showed that in the medium term (after six months), the outcomes after angioplasty or surgery among CLI patients did not differ significantly with respect to amputation-free survival, all-cause mortality and quality of life. Conclusions: Infrainguinal PTA is feasible in CLI patients. Data from the BASIL trial show the similar ability of bypass surgery and balloon angioplasty in preserving both life and limb in short term. These results are, however, not applicable for the majority of CLI patients as only 15% (70/456) of the patients with severe limb ischaemia were considered candidates for the trial.
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Affiliation(s)
- E Eskelinen
- Department of Vascular Surgery, Helsinki University Central Hospital, Helsinki, Finland.
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Masiero FS, Thyssen PJ. Evaluation of conventional therapeutic methods versus maggot therapy in the evolution of healing of tegumental injuries in Wistar rats with and without diabetes mellitus. Parasitol Res 2016; 115:2403-7. [PMID: 26976407 DOI: 10.1007/s00436-016-4991-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 03/09/2016] [Indexed: 11/25/2022]
Abstract
Larval therapy consists on the application of sterilized carrion flies larvae, reared in laboratory, on acute, chronic, and/or infected wounds in order to promote healing. Conventional methods for treating injuries include mechanical debridement or silver-based dressings; however, they are not always effective for wound healing. Larval therapy is a feasible and safe treatment for therapeutic application and, in many cases, the only and the most recommended alternative for difficult healing injuries. Thus, this study aimed to evaluate the competence of Cochliomyia macellaria F. (Diptera: Calliphoridae) as a suitable species for therapeutic application and evaluate time and effectiveness of the types of treatments most commonly used to treat integumental injuries. C. macellaria eggs were obtained from colonies established in laboratory and sterilized prior to application. Twenty-five larvae were applied for each centimeter squared of lesion. Lesions were induced in 24 Wistar rats; type 1 diabetes mellitus was induced in 12 of them. Animals were divided in four groups with three individuals each, being denominated: larval therapy, larval therapy associated with foam dressing with silver release, mechanical debridement with foam dressing silver and control group, without treatment. All treatments were applied once and held for 24 h. Medical application of larvae was found to be safe, as only dead tissue was removed, and efficient to accelerate healing process when compared to other treatments.
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Affiliation(s)
- Franciéle Souza Masiero
- Department of Microbiology and Parasitology, Federal University of Pelotas-UFPel, POB 354, PC 96010-900, Capão do Leão, Rio Grande do Sul, Brazil
| | - Patricia Jacqueline Thyssen
- Department of Animal Biology, State University of Campinas-UNICAMP, POB 6109, PC 13083-970, Campinas, São Paulo, Brazil.
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Describe the outcomes of dysvascular partial foot amputation and how these compare to transtibial amputation: a systematic review protocol for the development of shared decision-making resources. Syst Rev 2015; 4:173. [PMID: 26637465 PMCID: PMC4670495 DOI: 10.1186/s13643-015-0161-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Accepted: 11/25/2015] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Helping people make well-informed decisions about dysvascular partial foot amputation is becoming increasingly important as improvements in diabetes care and vascular surgery make more distal amputations increasingly possible. The high rates of complications and reamputations associated with partial foot amputation are of concern, particularly given that transtibial amputation seems to result in similar outcomes (e.g., mobility and quality of life) with comparatively few complications and reamputations. The aim of this review is to describe the outcomes of dysvascular partial foot amputation and compare these to transtibial amputation. Results from the review are intended for use in the development of shared decision-making resources. METHODS/DESIGN A comprehensive range of databases-MEDLINE, EMBASE, PsycINFO, AMED, Cumulative Index of Nursing and Allied Health Literature (CINAHL), ProQuest Nursing and Allied Health, and Web of Science-will be searched using National Library of Medicine, Medical Subject Headings (MeSH) terms as well as title, abstract, and keywords relating to different amputation levels and outcomes of interest; specifically: incidence, prevalence, and rate of amputation; rate of mortality, wound failure, dehiscence, and time between index and ipsilateral reamputations; and mobility, functional ability, activity and participation, quality of life, pain, and psychosocial outcomes including depression and anxiety. Articles that meet the inclusion criteria will be hand-searched for relevant citations. A forward citation search using Google Scholar will be used to identify articles not yet indexed. Original research published in the English language after 1 January 2000 will be included. The McMaster Critical Review Forms will be used to assess methodological quality and identify sources of bias. Included articles will be independently appraised by two reviewers. Data will be extracted using a spreadsheet based on the Cochrane Consumers and Communication Review Group's data extraction template by a primary reviewer and checked for accuracy and clarity by a second reviewer. Findings from the review will be reported as a narrative without meta-analysis given the anticipated heterogeneity of the literature. DISCUSSION Results from the review can be used in the design of shared decision-making resources to help inform difficult decisions about partial foot amputation. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42015029186.
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Howard DPJ, Banerjee A, Fairhead JF, Hands L, Silver LE, Rothwell PM. Population-Based Study of Incidence, Risk Factors, Outcome, and Prognosis of Ischemic Peripheral Arterial Events: Implications for Prevention. Circulation 2015; 132:1805-15. [PMID: 26350058 PMCID: PMC4633967 DOI: 10.1161/circulationaha.115.016424] [Citation(s) in RCA: 114] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Accepted: 08/24/2015] [Indexed: 01/04/2023]
Abstract
BACKGROUND There are few published data on the incidence and long-term outcomes of critical limb ischemia, acute limb ischemia, or acute visceral ischemia with which to inform health service planning, to monitor prevention, and to enable risk prediction. METHODS AND RESULTS In a prospective population-based study (Oxfordshire, UK; 2002-2012), we determined the incidence and outcome of all acute peripheral arterial events in a population of 92,728. Risk factors were assessed by comparison with the underlying population. A total of 510 acute events occurred in 386 patients requiring 803 interventions. Two hundred twenty-one patients (59.3%) were ≥75 years of age, and 98 (26.3%) were ≥85 years old. Two hundred thirty patients (62.3%) were independent before the event, but 270 (73.4%) were dead or dependent at the 6-month follow-up, and 328 (88.9%) were dead or dependent at 5 years. The 30-day survival was lowest for patients with acute visceral ischemia (28.2%) compared with acute limb ischemia (75.3%) and critical limb ischemia (92.6%; P<0.001). Risk factors (all P<0.001) were hypertension (age- and sex-adjusted risk ratio, 2.75; 95% confidence interval, 1.95-3.90), smoking (adjusted risk ratio, 2.14; 95% confidence interval, 1.37-3.34), and diabetes mellitus (adjusted risk ratio, 3.01; 95% confidence interval, 1.69-5.35), particularly for critical limb ischemia (adjusted risk ratio, 5.96; 95% confidence interval, 3.15-11.26). Two hundred eighty-eight patients (77.2%) had known previous cardiovascular disease, and 361 (96.8%) had vascular risk factors, but only 203 (54.4%) were on an antiplatelet and only 166 (44.5%) were on a statin. Although 260 patients (69.7%) were taking antihypertensives, 42.9% of all blood pressures recorded during the 5 years before the event were >140/90 mm Hg. Of 88 patients (23.6%) with incident cardioembolic events, 62 had known atrial fibrillation (diagnosed before the event), of whom only 14.5% were anticoagulated despite 82.3% having a CHA2DS2VASC score ≥2 without contraindications. CONCLUSIONS The clinical burden of peripheral arterial events is substantial. Although the vast majority of patients have known vascular disease in other territories and multiple treatable risk factors, premorbid control is poor.
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Affiliation(s)
- Dominic P J Howard
- From Stroke Prevention Research Unit, Nuffield Department of Clinical Neurosciences, University of Oxford, UK (D.P.J.H., A.B., J.F.F., L.E.S., P.M.R.); Department of Vascular Surgery, Oxford University Hospitals NHS Trust, UK (D.P.J.H., L.H.); and Centre for Cardiovascular Sciences, University of Birmingham, UK (A.B.)
| | - Amitava Banerjee
- From Stroke Prevention Research Unit, Nuffield Department of Clinical Neurosciences, University of Oxford, UK (D.P.J.H., A.B., J.F.F., L.E.S., P.M.R.); Department of Vascular Surgery, Oxford University Hospitals NHS Trust, UK (D.P.J.H., L.H.); and Centre for Cardiovascular Sciences, University of Birmingham, UK (A.B.)
| | - Jack F Fairhead
- From Stroke Prevention Research Unit, Nuffield Department of Clinical Neurosciences, University of Oxford, UK (D.P.J.H., A.B., J.F.F., L.E.S., P.M.R.); Department of Vascular Surgery, Oxford University Hospitals NHS Trust, UK (D.P.J.H., L.H.); and Centre for Cardiovascular Sciences, University of Birmingham, UK (A.B.)
| | - Linda Hands
- From Stroke Prevention Research Unit, Nuffield Department of Clinical Neurosciences, University of Oxford, UK (D.P.J.H., A.B., J.F.F., L.E.S., P.M.R.); Department of Vascular Surgery, Oxford University Hospitals NHS Trust, UK (D.P.J.H., L.H.); and Centre for Cardiovascular Sciences, University of Birmingham, UK (A.B.)
| | - Louise E Silver
- From Stroke Prevention Research Unit, Nuffield Department of Clinical Neurosciences, University of Oxford, UK (D.P.J.H., A.B., J.F.F., L.E.S., P.M.R.); Department of Vascular Surgery, Oxford University Hospitals NHS Trust, UK (D.P.J.H., L.H.); and Centre for Cardiovascular Sciences, University of Birmingham, UK (A.B.)
| | - Peter M Rothwell
- From Stroke Prevention Research Unit, Nuffield Department of Clinical Neurosciences, University of Oxford, UK (D.P.J.H., A.B., J.F.F., L.E.S., P.M.R.); Department of Vascular Surgery, Oxford University Hospitals NHS Trust, UK (D.P.J.H., L.H.); and Centre for Cardiovascular Sciences, University of Birmingham, UK (A.B.)
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A Novel and Alternative Treatment Method for Diabetic Heel Ulceration Exposing the Calcaneus Which Is Not Suitable for Flap Surgery: Vacuum Assisted Sandwich Dermal Matrix. BIOMED RESEARCH INTERNATIONAL 2015; 2015:785819. [PMID: 26516626 PMCID: PMC4592884 DOI: 10.1155/2015/785819] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Accepted: 09/03/2015] [Indexed: 11/18/2022]
Abstract
Background. Currently, free flaps and pedicled flaps are the first treatment choices for large heel ulcer reconstruction. However, flap reconstruction of heel ulcerations cannot be performed in all diabetics especially with concurrent severe peripheral vascular disease because of higher flap failure rate. In recent years, the use of acellular dermal matrix (ADM) has emerged as an alternative treatment option for extremity ulcers. Methods. We present 13 diabetic patients with a large heel ulceration exposing the calcaneus, who were not eligible for flap surgery due to the presence of only one patent artery of trifurcation. These cases were treated with the vacuum assisted sandwich dermal matrix (VASDEM) method. Results. None of the patients required amputation. Skin grafting was successful in ten patients. Although partial losses were observed in three patients, they were healed spontaneously without surgical interventions. During the follow-up period none of the patients developed ulceration on the treatment area. All patients maintained their preoperative ambulatory ability. Conclusion. VASDEM is a novel method offering opportunity for treatment before proceeding to amputation in diabetic heel ulceration exposing the calcaneus which is not suitable for flap surgery. It also has the potential to close wounds of all sizes independent of the vessel status and wound size in selected diabetic patients.
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Rolim D, Sampaio S, Gonçalves‐Dias P, Almeida P, Almeida‐Lopes J, Teixeira JF. Mortalidade depois da amputação. ANGIOLOGIA E CIRURGIA VASCULAR 2015. [DOI: 10.1016/j.ancv.2015.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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von Allmen RS, Anjum A, Powell JT, Earnshaw JJ. Hospital trends of admissions and procedures for acute leg ischaemia in England, 2000-2011. Ann R Coll Surg Engl 2015; 97:59-62. [PMID: 25519269 DOI: 10.1308/003588414x14055925059354] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Acute leg ischaemia (ALI) is a common vascular emergency for which new minimally invasive treatment options were introduced in the 1990s. The aim of this study was to determine recent hospital trends for ALI in England and to assess whether the introduction of the new treatment modalities had affected management. METHODS Routine hospital data covering ALI were provided by Hospital Episode Statistics for the years 2000 to 2011 and mortality data were obtained from the Office for National Statistics. All data were age standardised, reported per 100,000 of the population, and stratified by age band (60-74 years and ≥75 years) and sex. RESULTS Hospital admissions have risen significantly from 60.3 to 94.3 per 100,000 of the population, with an average annual increase of 6.2% since 2003 (p<0.001). The rise was greater in the older age group (from 79.9 to 134.4 vs 49.3 to 73.0) and yet procedures for ALI have shown a significant decrease since 2000 from 14.3 to 12.4 per 100,000 (p=0.013), independent of age and sex. Open embolectomy of the femoral artery remains the most common procedure and the proportion of endovascular interventions showed only a small increase. Only a few deaths were attributed to ALI (range: 95-150 deaths per year). CONCLUSIONS Hospital workload for ALI has increased, particularly since 2003, but this trend does not appear to have translated into increased endovascular or surgical activity.
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Affiliation(s)
- Hyun-Suk Suh
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Joon Pio Hong
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Eskelinen E, Kaartinen I, Kääriäinen M, Kuokkanen H. Successful foot salvage with microvascular flaps in diabetic patients. Scand J Surg 2014; 104:103-7. [PMID: 24694779 DOI: 10.1177/1457496914524389] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Accepted: 01/24/2014] [Indexed: 12/30/2022]
Abstract
BACKGROUND AND AIMS Complex nontraumatic foot lesions often lead to major lower-limb amputation in diabetic patients. We aimed to evaluate outcome of free flap transfer in such cases. MATERIALS AND METHODS A total of 11 consecutive diabetic patients, hospitalized between 2007 and 2012 at a university central hospital for a free flap transfer, were followed until September 2013. Amputation-free survival, patient survival, and complete wound healing were defined as primary endpoints. Healing time of tissue lesions was analyzed. All pre- and postoperative data were retrospectively collected from hospital charts. RESULTS Complete tissue healing at 6 and 12 months after free flap transfer were 55% (6/11) and 82% (9/11), respectively. The median time to complete tissue healing was 123 days (range, 45-207 days). Overall limb salvage, survival, and amputation-free survival rates at 12 months were 90%, 91%, and 82%, respectively. The clinically important endpoint, namely, amputation-free survival with completely healed wounds, was attained in 9 of 11 patients at 1 year. CONCLUSION Free tissue transfer enables successful wound healing and limb salvage rather than amputation in selected diabetic patients with difficult-to-heal wounds. Complete healing of tissue lesions is slow even after successful surgery. Preoperative assessment of the condition of patients is the key to success.
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Affiliation(s)
- E Eskelinen
- Department of Plastic Surgery, Tampere University Hospital, Tampere, Finland
| | - I Kaartinen
- Department of Plastic Surgery, Tampere University Hospital, Tampere, Finland
| | - M Kääriäinen
- Department of Plastic Surgery, Tampere University Hospital, Tampere, Finland
| | - H Kuokkanen
- Department of Plastic Surgery, Tampere University Hospital, Tampere, Finland
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Dillon MP, Kohler F, Peeva V. Incidence of lower limb amputation in Australian hospitals from 2000 to 2010. Prosthet Orthot Int 2014; 38:122-32. [PMID: 23798042 DOI: 10.1177/0309364613490441] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Contemporary literature reports that the incidence of lower limb amputation has declined in many countries. This impression may be misleading given that many publications only describe the incidence of lower limb amputations above the ankle and fail to include lower limb amputations below the ankle. OBJECTIVES To describe trends in the incidence of different levels of lower limb amputation in Australian hospitals over a 10-year period. STUDY DESIGN Descriptive. METHOD Data describing the age-standardised incidence of lower limb amputation were calculated from the Australian National Hospital Morbidity database and analysed for trends over a 10-year period. RESULTS The age-standardised incidence of lower limb amputation remained unchanged over time (p = 0.786). A significant increase in the incidence of partial foot amputations (p = 0.001) and a decline in the incidence of transfemoral (p = 0.00) and transtibial amputations (p = 0.00) were observed. There are now three lower limb amputations below the ankle for every lower limb amputation above the ankle. CONCLUSION While the age-standardised incidence of all lower limb amputation has not changed, a shift in the proportion of lower limb amputations above the ankle and lower limb amputations below the ankle may be the result of improved management of precursor disease that makes partial foot amputation a more commonly utilised alternative to lower limb amputations above the ankle. Clinical relevance This article highlights that although the incidence of lower limb amputation has remained steady, the proportion of amputations above the ankle and below the ankle has changed dramatically over the last decade. This has implications for how we judge the success of efforts to reduce the incidence of lower limb amputation and the services required to meet the increasing proportion of persons with amputation below the ankle.
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Affiliation(s)
- Michael P Dillon
- 1National Centre for Prosthetics and Orthotics, La Trobe University, Victoria, Australia
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Alavi A, Sibbald RG, Mayer D, Goodman L, Botros M, Armstrong DG, Woo K, Boeni T, Ayello EA, Kirsner RS. Diabetic foot ulcers: Part I. Pathophysiology and prevention. J Am Acad Dermatol 2014; 70:1.e1-18; quiz 19-20. [PMID: 24355275 DOI: 10.1016/j.jaad.2013.06.055] [Citation(s) in RCA: 170] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2012] [Revised: 06/17/2013] [Accepted: 06/23/2013] [Indexed: 12/24/2022]
Abstract
Diabetes mellitus is a serious, life-long condition that is the sixth leading cause of death in North America. Dermatologists frequently encounter patients with diabetes mellitus. Up to 25% of patients with diabetes mellitus will develop diabetic foot ulcers. Foot ulcer patients have an increased risk of amputation and increased mortality rate. The high-risk diabetic foot can be identified with a simplified screening, and subsequent foot ulcers can be prevented. Early recognition of the high-risk foot and timely treatment will save legs and improve patients' quality of life. Peripheral arterial disease, neuropathy, deformity, previous amputation, and infection are the main factors contributing to the development of diabetic foot ulcers. Early recognition of the high-risk foot is imperative to decrease the rates of mortality and morbidity. An interprofessional approach (ie, physicians, nurses, and foot care specialists) is often needed to support patients' needs.
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Affiliation(s)
- Afsaneh Alavi
- Department of Medicine (Dermatology), University of Toronto, Toronto, Ontario, Canada; Wound Care Centre, Women's College Hospital, Toronto, Ontario, Canada.
| | - R Gary Sibbald
- Department of Medicine (Dermatology), University of Toronto, Toronto, Ontario, Canada; Department of Medicine (Dermatology) and Public Health, University of Toronto, Toronto, Ontario, Canada; Wound Care Centre, Women's College Hospital, Toronto, Ontario, Canada
| | - Dieter Mayer
- Clinic for Cardiovascular Surgery, University Hospital of Zurich, Zurich, Switzerland
| | | | - Mariam Botros
- Wound Care Centre, Women's College Hospital, Toronto, Ontario, Canada
| | - David G Armstrong
- Department of Surgery, the University of Arizona College of Medicine/SALSA, Tucson, Arizona
| | - Kevin Woo
- Faculty of Nursing, Queen's University, Kingston, Ontario, Canada
| | - Thomas Boeni
- Department of Prosthetics and Orthotics, University of Zurich, Zurich, Switzerland
| | | | - Robert S Kirsner
- Department of Dermatology and Cutaneous Surgery, University of Miami, Miami, Florida
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Diabetic foot ulcers: Part II. Management. J Am Acad Dermatol 2014; 70:21.e1-24; quiz 45-6. [PMID: 24355276 DOI: 10.1016/j.jaad.2013.07.048] [Citation(s) in RCA: 128] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2012] [Revised: 06/26/2013] [Accepted: 07/01/2013] [Indexed: 12/12/2022]
Abstract
The management of diabetic foot ulcers can be optimized by using an interdisciplinary team approach addressing the correctable risk factors (ie, poor vascular supply, infection control and treatment, and plantar pressure redistribution) along with optimizing local wound care. Dermatologists can initiate diabetic foot care. The first step is recognizing that a loss of skin integrity (ie, a callus, blister, or ulcer) considerably increases the risk of preventable amputations. A holistic approach to wound assessment is required. Early detection and effective management of these ulcers can reduce complications, including preventable amputations and possible mortality.
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Keo HH, Duval S, Baumgartner I, Oldenburg NC, Jaff MR, Goldman J, Peacock JM, Tretinyak AS, Henry TD, Luepker RV, Hirsch AT. The FReedom from Ischemic Events-New Dimensions for Survival (FRIENDS) registry: design of a prospective cohort study of patients with advanced peripheral artery disease. BMC Cardiovasc Disord 2013; 13:120. [PMID: 24354507 PMCID: PMC3878262 DOI: 10.1186/1471-2261-13-120] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2013] [Accepted: 12/02/2013] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Advanced lower extremity peripheral artery disease (PAD), whether presenting as acute limb ischemia (ALI) or chronic critical limb ischemia (CLI), is associated with high rates of cardiovascular ischemic events, amputation, and death. Past research has focused on strategies of revascularization, but few data are available that prospectively evaluate the impact of key process of care factors (spanning pre-admission, acute hospitalization, and post-discharge) that might contribute to improving short and long-term health outcomes. METHODS/DESIGN The FRIENDS registry is designed to prospectively evaluate a range of patient and health system care delivery factors that might serve as future targets for efforts to improve limb and systemic outcomes for patients with ALI or CLI. This hypothesis-driven registry was designed to evaluate the contributions of: (i) pre-hospital limb ischemia symptom duration, (ii) use of leg revascularization strategies, and (iii) use of risk-reduction pharmacotherapies, as pre-specified factors that may affect amputation-free survival. Sequential patients would be included at an index "vascular specialist-defined" ALI or CLI episode, and patients excluded only for non-vascular etiologies of limb threat. Data including baseline demographics, functional status, co-morbidities, pre-hospital time segments, and use of medical therapies; hospital-based use of revascularization strategies, time segments, and pharmacotherapies; and rates of systemic ischemic events (e.g., myocardial infarction, stroke, hospitalization, and death) and limb ischemic events (e.g., hospitalization for revascularization or amputation) will be recorded during a minimum of one year follow-up. DISCUSSION The FRIENDS registry is designed to evaluate the potential impact of key factors that may contribute to adverse outcomes for patients with ALI or CLI. Definition of new "health system-based" therapeutic targets could then become the focus of future interventional clinical trials for individuals with advanced PAD.
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Affiliation(s)
- Hong H Keo
- Division of Angiology, Kantonsspital Aarau AG, Aarau, Switzerland
| | - Sue Duval
- Vascular Medicine Program, Lillehei Heart Institute and Cardiovascular Division, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Iris Baumgartner
- Swiss Cardiovascular Center, Division of Angiology, University Hospital Bern, Bern, Switzerland
| | - Niki C Oldenburg
- Vascular Medicine Program, Lillehei Heart Institute and Cardiovascular Division, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Michael R Jaff
- Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - JoAnne Goldman
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - James M Peacock
- Minnesota Department of Health, Heart Disease and Stroke Prevention Unit, Saint Paul, MN, USA
| | - Alexander S Tretinyak
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Timothy D Henry
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Russell V Luepker
- Division of Epidemiology and Community Health, University of Minnesota School of Public Health, Minneapolis, MN, USA
| | - Alan T Hirsch
- Vascular Medicine Program, Lillehei Heart Institute and Cardiovascular Division, University of Minnesota Medical School, Minneapolis, MN, USA
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Deliberations About the Functional Benefits and Complications of Partial Foot Amputation: Do We Pay Heed to the Purported Benefits at the Expense of Minimizing Complications? Arch Phys Med Rehabil 2013; 94:1429-35. [DOI: 10.1016/j.apmr.2013.03.023] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2013] [Revised: 03/19/2013] [Accepted: 03/23/2013] [Indexed: 12/26/2022]
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Fortington L, Geertzen J, van Netten J, Postema K, Rommers G, Dijkstra P. Short and Long Term Mortality Rates after a Lower Limb Amputation. Eur J Vasc Endovasc Surg 2013; 46:124-31. [DOI: 10.1016/j.ejvs.2013.03.024] [Citation(s) in RCA: 124] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2012] [Accepted: 03/25/2013] [Indexed: 10/26/2022]
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Moxey P, Hofman D, Hinchliffe R, Poloniecki J, Loftus I, Thompson M, Holt P. Delay Influences Outcome after Lower Limb Major Amputation. Eur J Vasc Endovasc Surg 2012; 44:485-90. [DOI: 10.1016/j.ejvs.2012.08.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2011] [Accepted: 08/09/2012] [Indexed: 11/28/2022]
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Jörneskog G. Why critical limb ischemia criteria are not applicable to diabetic foot and what the consequences are. Scand J Surg 2012; 101:114-8. [PMID: 22623444 DOI: 10.1177/145749691210100207] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Neuropathy, peripheral arterial occlusive disease and microvascular disturbances are important factors contributing to foot problems in diabetic patients. In the diabetic foot with ischemia, the alterations in skin microvascular function are pronounced including severely reduced capillary circulation and abolished hyperaemic responses. These microvascular disturbances, which are superimposed on the already existing structural diabetic microangiopathy, are compatible with a state of "chronic capillary ischemia" and an increased shunting of blood through arteriovenous channels. This maldistribution of blood in skin microcirculation is not detected by measurement of peripheral blood pressure (systolic ankle blood pressure, systolic toe blood pressure). As indicated in several studies toe blood pressure is a poor predictor of local tissue perfusion, tissue survival and healing of chronic foot ulcers. Consequently, the disturbances in peripheral tissue perfusion of the diabetic foot may be underestimated leading to delayed vascular interventions and/or medical treatment. Thus, measurements of peripheral blood pressure, e.g. toe blood pressure, should be combined with investigations of local tissue perfusion in order to get an adequate estimation of peripheral tissue perfusion in diabetic patients. For this purpose local skin microcirculation can be investigated by transcutaneous oxygen tension of the forefoot. Also, due to these reasons, the threshold for revascularization should be lower in diabetic patients with foot ulcer.
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Affiliation(s)
- G Jörneskog
- Karolinska Institutet, Department of Clinical Sciences, Danderyd Hospital, Stockholm, Sweden.
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Ohmine S, Kimura Y, Saeki S, Hachisuka K. Community-based survey of amputation derived from the physically disabled person's certification in Kitakyushu City, Japan. Prosthet Orthot Int 2012; 36:196-202. [PMID: 22314214 DOI: 10.1177/0309364611433443] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND There were no recent reports of community-based surveys on the incidence, level and causes of amputation in Japan. OBJECTIVES To identify any changes in the incidence, level, causes of amputation and gender distribution. STUDY DESIGN A community-based survey. METHODS The subjects were Kitakyushu-citizens amputated between 2001 and 2005 and selected based on medical certificates for the physically disabled person's certificate. RESULTS The incidence of amputation (/100,000 population per year) was 6.9 overall, 1.4 for upper limbs and 5.8 for lower limbs. The average age at amputation was 63.5 ± 20.1 years and the male:female ratio was 1.9:1. The most frequent levels of amputations were partial hand amputation (84.4%) for upper limbs, and transtibial amputation (42.3%) and transfemoral amputation (36.8%) for lower limbs. The major causes were injuries (54.3%) for upper limbs, and peripheral vascular disorder (49.0%) and diabetes mellitus with peripheral circulatory complications (28.6%) for lower limbs. CONCLUSIONS The incidence of amputation was 6.9 overall, 1.4 for upper limbs and 5.8 for lower limbs, and the male:female ratio was 1.9:1. In comparison to a previous survey the percentages of amputation due to peripheral circulatory disorders and injuries increased and decreased, respectively, and the rate of female amputations increased. CLINICAL RELEVANCE This study provides useful data about change of the recent epidemiology of amputation in Kitakyushu, Japan. These data are essential to perform clinical practices in amputation rehabilitation, including prescription of prosthesis, general fatigue for aged amputees, and complication of peripheral circulatory disorders.
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Affiliation(s)
- Saburo Ohmine
- Kyushu Rehabilitation College, 1-5-1, Kuzuhara-Takamatsu, Kitakyushu, Japan
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Lepäntalo M, Apelqvist J, Setacci C, Ricco JB, de Donato G, Becker F, Robert-Ebadi H, Cao P, Eckstein HH, De Rango P, Diehm N, Schmidli J, Teraa M, Moll FL, Dick F, Davies AH. Chapter V: Diabetic foot. Eur J Vasc Endovasc Surg 2012; 42 Suppl 2:S60-74. [PMID: 22172474 DOI: 10.1016/s1078-5884(11)60012-9] [Citation(s) in RCA: 118] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Ulcerated diabetic foot is a complex problem. Ischaemia, neuropathy and infection are the three pathological components that lead to diabetic foot complications, and they frequently occur together as an aetiologic triad. Neuropathy and ischaemia are the initiating factors, most often together as neuroischaemia, whereas infection is mostly a consequence. The role of peripheral arterial disease in diabetic foot has long been underestimated as typical ischaemic symptoms are less frequent in diabetics with ischaemia than in non-diabetics. Furthermore, the healing of a neuroischaemic ulcer is hampered by microvascular dysfunction. Therefore, the threshold for revascularising neuroischaemic ulcers should be lower than that for purely ischaemic ulcers. Previous guidelines have largely ignored these specific demands related to ulcerated neuroischaemic diabetic feet. Any diabetic foot ulcer should always be considered to have vascular impairment unless otherwise proven. Early referral, non-invasive vascular testing, imaging and intervention are crucial to improve diabetic foot ulcer healing and to prevent amputation. Timing is essential, as the window of opportunity to heal the ulcer and save the leg is easily missed. This chapter underlines the paucity of data on the best way to diagnose and treat these diabetic patients. Most of the studies dealing with neuroischaemic diabetic feet are not comparable in terms of patient populations, interventions or outcome. Therefore, there is an urgent need for a paradigm shift in diabetic foot care; that is, a new approach and classification of diabetics with vascular impairment in regard to clinical practice and research. A multidisciplinary approach needs to implemented systematically with a vascular surgeon as an integrated member. New strategies must be developed and implemented for diabetic foot patients with vascular impairment, to improve healing, to speed up healing rate and to avoid amputation, irrespective of the intervention technology chosen. Focused studies on the value of predictive tests, new treatment modalities as well as selective and targeted strategies are needed. As specific data on ulcerated neuroischaemic diabetic feet are scarce, recommendations are often of low grade.
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Affiliation(s)
- M Lepäntalo
- Department of Vascular Surgery, Helsinki University Central Hospital, Helsinki, Finland.
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Abstract
BACKGROUND AND PURPOSE In the city of Trondheim, Norway, diabetic lower-limb amputations accounted for one-third of all lower-limb amputations (LLAs). In an attempt to reduce this rate, a diabetic foot team was established in 1996. We present the incidence of LLA in Trondheim as measured 10 years later. PATIENTS AND METHODS In 2004-07, we registered all LLAs performed in Trondheim and then compared the data with previously published data from 1994-1997. From 1996 through 2006, we registered the activity of the diabetic foot team and we also registered the number of vascular procedures performed on citizens of Trondheim from 1998 through 2006. RESULTS Comparing the two 3-year periods 1994-97 and 2004-07, we observed a decrease in all non-traumatic LLAs. The incidence of diabetic major LLAs per 10³ diabetics per year decreased from 4.0 to 2.4, and in patients with peripheral vascular disease we observed a decrease in LLAs from 18 to 12 per 10⁵ inhabitants per year. 5,915 consultations on diabetic subjects were conducted by the diabetic foot team during the period 1996-2006. From 1998 to 2006, the rate of vascular procedures decreased in the non-diabetic population, and was unchanged in diabetic subjects. INTERPRETATION In the population of Trondheim city there appears to have been a reduction in the rate of vascular obstructive lower-limb disease between the two 3-year periods 1994-97 and 2004-07. In our judgment, the decline in diabetic LLA also reflects better care of the diabetic foot.
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Affiliation(s)
| | - Arne Lium
- Department of Orthopaedic Surgery, St. Olav's University Hospital
| | - Stian Lydersen
- Norwegian University of Science and Technology, Trondheim, Norway
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Ikonen TS, Sund R, Venermo M, Winell K. Fewer major amputations among individuals with diabetes in Finland in 1997-2007: a population-based study. Diabetes Care 2010; 33:2598-603. [PMID: 20807872 PMCID: PMC2992197 DOI: 10.2337/dc10-0462] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Complications occur in diabetes despite rigorous efforts to control risk factors. Since 2000, the National Development Programme for the Prevention and Care of Diabetes has worked to halve the incidence of amputations in 10 years. Here we evaluate the impact of the efforts undertaken by analyzing the major amputations done in 1997-2007. RESEARCH DESIGN AND METHODS All individuals with diabetes (n = 396,317) were identified from comprehensive national databases. Data on the first major amputations (n = 9,481) performed for diabetic and nondiabetic individuals were obtained from the National Hospital Discharge Register. RESULTS The relative risk for the first major amputation was 7.4 (95% CI 7.2-7.7) among the diabetic versus the nondiabetic population. The standardized incidence of the first major amputation decreased among the diabetic and nondiabetic populations (48.8 and 25.2% relative risk reduction, respectively) over 11 years, and the time from the registration of diabetes to the first major amputation was significantly longer, on average 1.2 years more. The cumulative five-year postamputation mortality among diabetic individuals was 78.7%. CONCLUSIONS In our nationwide diabetes database, the duration from the registration of diabetes to the first major amputation increased, and the incidence of major amputations decreased almost 50% in 11 years. Approximately half of this change was due to the increasing size of the diabetic population. The risk for major amputation is more than sevenfold that among the nondiabetic population. These results pose a continuous challenge to improve diabetes care.
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Affiliation(s)
- Tuija S Ikonen
- THL (National Institute for Health and Welfare), Helsinki, Finland.
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Finnvasc score and modified Prevent III score predict long-term outcome after infrainguinal surgical and endovascular revascularization for critical limb ischemia. J Vasc Surg 2010; 52:1218-25. [DOI: 10.1016/j.jvs.2010.06.101] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2010] [Revised: 06/05/2010] [Accepted: 06/07/2010] [Indexed: 11/15/2022]
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Vincent C, Demers É, Moffet H, Corriveau H, Nadeau S, Mercier C. Use of an innovative model to evaluate mobility in seniors with lower-limb amputations of vascular origin: a pilot study. BMC Geriatr 2010; 10:68. [PMID: 20854684 PMCID: PMC2955596 DOI: 10.1186/1471-2318-10-68] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2009] [Accepted: 09/20/2010] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND The mobility of older individuals has often been only partially assessed, without considering all important aspects such as potential (available) versus effective (used) mobilities and the physical and psychosocial factors that modulate them. This study proposes a new model for evaluating mobility that considers all important aspects, applied here to lower-limb amputees with vascular origin. This model integrates the concepts of potential mobility (e.g. balance, speed of movement), effective mobility (e.g. life habits, movements in living areas) and factors that modulate these two types of mobility (e.g. strength, sensitivity, social support, depression). The main objective was to characterize potential and effective mobility as well as mobility modulators in a small sample of people with lower-limb amputations of vascular origin with different characteristics. The second objective of this pilot study was to assess the feasibility of measuring all variables in the model in a residential context. METHODS An observational and transversal design was used with a heterogeneous sample of 10 participants with a lower-limb amputation of vascular origin, aged 51 to 83, assessed between eight and 18 months after discharge from an acute care hospital. A questionnaire of participant characteristics and 16 reliable and valid measurements were used. RESULTS The results show that the potential mobility indicators do not accurately predict effective mobility, i.e., participants who perform well on traditional measures done in the laboratory or clinic are not always those who perform well in the real world. The model generated 4 different profiles (categories) of participants ranging from reduced to excellent potential mobility and low to excellent effective mobility, and characterized the modulating factors. The evaluations were acceptable in terms of the time taken (three hours) and the overall measurements, with a few exceptions, which were modified to optimize the data collected and the classification of the participants. For the population assessed, the results showed that some of the negative modulators (particularly living alone, no rehabilitation, pain, limited social support, poor muscle strength) played an important role in reducing effective mobility. CONCLUSION The first use of the model revealed interesting data that add to our understanding of important aspects linked to potential and effective mobility as well as modulators. The feasibility of measuring all variables in the model in a residential context was demonstrated. A study with a large number of participants is now warranted to rigorously characterize mobility levels of lower-limb amputees with vascular origin.
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Affiliation(s)
- Claude Vincent
- Centre for Interdisciplinary Research in Rehabilitation and Social Integration (CIRRIS), Institut de réadaptation en déficience physique de Québec, 525, Wilfrid-Hamel Blvd East, Québec (Québec), G1M 2S8, Canada
- Département de réadaptation, Laval University, Pavillon Ferdinand-Vandry, Quebec City, Quebec, G1K 7P4, Canada
| | - Émilie Demers
- Centre for Interdisciplinary Research in Rehabilitation and Social Integration (CIRRIS), Institut de réadaptation en déficience physique de Québec, 525, Wilfrid-Hamel Blvd East, Québec (Québec), G1M 2S8, Canada
| | - Hélène Moffet
- Centre for Interdisciplinary Research in Rehabilitation and Social Integration (CIRRIS), Institut de réadaptation en déficience physique de Québec, 525, Wilfrid-Hamel Blvd East, Québec (Québec), G1M 2S8, Canada
- Département de réadaptation, Laval University, Pavillon Ferdinand-Vandry, Quebec City, Quebec, G1K 7P4, Canada
| | - Hélène Corriveau
- Research Centre on Aging, University Institute of Geriatrics of Sherbrooke, 1036 Belvédère South, Sherbrooke, Quebec J1H 4C4, Canada
- Department of Rehabilitation, Faculty of Medicine and Health Sciences, Université de Sherbrooke, 3001, 12th Avenue, Sherbrooke, Quebec, Canada
| | - Sylvie Nadeau
- Department of Rehabilitation, Faculty of Medicine and Health Sciences, Université de Sherbrooke, 3001, 12th Avenue, Sherbrooke, Quebec, Canada
- École de réadaptation, Université de Montréal, c.p. 6128, succursale Centre-ville, Montréal (Québec), H3C 3J7, Canada
- Centre de recherche interdisciplinaire de réadaptation, Institut de réadaptation Gingras-Lindsay de Montréal, Canada
| | - Catherine Mercier
- Centre for Interdisciplinary Research in Rehabilitation and Social Integration (CIRRIS), Institut de réadaptation en déficience physique de Québec, 525, Wilfrid-Hamel Blvd East, Québec (Québec), G1M 2S8, Canada
- Département de réadaptation, Laval University, Pavillon Ferdinand-Vandry, Quebec City, Quebec, G1K 7P4, Canada
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Moxey PW, Hofman D, Hinchliffe RJ, Jones K, Thompson MM, Holt PJE. Epidemiological study of lower limb amputation in England between 2003 and 2008. Br J Surg 2010; 97:1348-53. [PMID: 20632310 DOI: 10.1002/bjs.7092] [Citation(s) in RCA: 115] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The purpose of this study was to investigate the prevalence of lower extremity amputation in England, to establish the associated mortality, and to determine the relationship with diabetes mellitus and previous revascularization. METHODS Data on all patients who had a lower extremity amputation between 2003 and 2008 were extracted from the Hospital Episode Statistics database. Risk adjustment and linear regression were used to compare the data. RESULTS The major amputation rate was 5.1 per 100,000 population and did not change over the 5 years. The mortality rate for major leg amputation was 16.8 per cent (21.4 per cent for above-knee and 11.6 per cent for below-knee amputation); this decreased significantly over time (P < 0.001). There was a significant difference in amputation rate, mortality rate and the below-knee : above-knee amputation ratio between different areas of England (P < 0.001). Some 39.4 per cent of patients who underwent major amputation had diabetes mellitus. The odds of revascularization before amputation increased significantly over time (P = 0.035). CONCLUSION Major and minor amputation rates were stable across England between 2003 and 2008, accompanied by a significant reduction in perioperative mortality. There were significant geographical variations in amputation rates, mortality rates and the below-knee : above-knee amputation ratio.
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Affiliation(s)
- P W Moxey
- Department of Outcomes Research, St George's Vascular Institute, St George's Healthcare NHS Trust, London, UK.
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Egorova NN, Guillerme S, Gelijns A, Morrissey N, Dayal R, McKinsey JF, Nowygrod R. An analysis of the outcomes of a decade of experience with lower extremity revascularization including limb salvage, lengths of stay, and safety. J Vasc Surg 2010; 51:878-85, 885.e1. [DOI: 10.1016/j.jvs.2009.10.102] [Citation(s) in RCA: 125] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2009] [Revised: 10/06/2009] [Accepted: 10/06/2009] [Indexed: 11/27/2022]
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Khandanpour N, Meyer FJ, Choy L, Skinner J, Armon MP. Are femorodistal bypass grafts for acute limb ischemia worthwhile? J Vasc Bras 2009. [DOI: 10.1590/s1677-54492009000400003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background: It has been shown that autogenous veins are associated with the best limb salvage rates for femorodistal bypass surgery. However, in emergency settings, when an autogenous vein is unavailable, use of synthetic graft material or amputation is a critical decision to make. Objective: To assess the appropriateness of femorodistal bypass grafts for acute limb ischemia in emergency settings. Methods: Patients who underwent emergent bypass and elective femorodistal bypass surgery between 1996 and 2006 were reviewed retrospectively in a single center. Results: There were 147 patients of which 84 had elective and 63 had emergent bypass. The graft patency rates for elective admissions were 44 and 25% vs. 25 and 23% for admissions for acute femorodistal graft surgery at 2 and 4 years, respectively (p < 0.004). Admissions for acute ischemia who were treated with prosthetic grafts had a primary patency of 24 vs. 27% for vein grafts at 2 years and 24 vs. 23% at 4 years (p = 0.33). In the acute femorodistal grafts group, primary patency at 2 years for vein and prosthetic grafts was 27 and 24% as compared to 42 and 32% for electives. These values for cumulative limb salvage rates for elective bypasses were 73 and 63% as compared to 52% at both time points in the acute femorodistal graft group (p < 0.004). In emergency settings, the limb salvage rate for acute femorodistal bypass with prosthetic grafts was 38%, and for vein grafts it was 62% at both time points (p = 0.08). Conclusion: The long term limb salvage rate of 38% suggests that emergent femorodistal revascularization is worthwhile.
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Affiliation(s)
| | | | - Lily Choy
- Norfolk and Norwich University Hospital, United Kingdom
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Remes L, Isoaho R, Vahlberg T, Viitanen M, Rautava P. Predictors for institutionalization and prosthetic ambulation after major lower extremity amputation during an eight-year follow-up. Aging Clin Exp Res 2009; 21:129-35. [PMID: 19448384 DOI: 10.1007/bf03325220] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND AND AIMS Major lower extremity amputation (LEA) leads to great loss in mobility, exposing old people to the risk of losing their independent living status. This study applies predictors for institutionalization and considers prosthesis use by major lower leg amputees with peripheral arterial disease (PAD). METHODS 119 PAD patients admitted from home (mean age 73.6, SD 11.5 years, 48% men) underwent their first major LEA, 1998- 2002, and survived at least one month after the operation. Logistic regression analysis was run to clarify institutionalization predictors. Prosthesis use and ambulatory capacity were recorded during the follow-up. RESULTS Older age, living alone, and unilateral above-knee amputation (AKA) or bilateral amputation predicted institutionalization. Of prosthesis users, 69% (27/39) were younger than 75 and 44% (17/39) were able to walk both in- and outdoors. Reasons for not receiving a prosthesis after amputation were: 1) short expected survival; 2) old age, combined with unilateral AKA or bilateral amputation; 3) unilateral AKA or bilateral amputation and a comorbid condition such as hemiparesis, paraplegia, uremia, dementia, or alcohol misuse. After one year, 72% (36/50) of amputees who were able to return home and 9% (3/32) of amputees in institutional care used a prosthesis. CONCLUSION The majority of amputated patients cannot return home after their first LEA. Comorbid conditions particularly influencing functional capacity also hinder ambulation with a prosthesis.
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Tang TY, Prytherch DR, Walsh SR, Athanassoglou V, Seppi V, Sadat U, Lees TA, Varty K, Boyle JR. The development of a VBHOM-based outcome model for lower limb amputation performed for critical ischaemia. Eur J Vasc Endovasc Surg 2008; 37:62-6. [PMID: 18993092 DOI: 10.1016/j.ejvs.2008.09.019] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2007] [Accepted: 09/23/2008] [Indexed: 11/17/2022]
Abstract
BACKGROUND VBHOM (Vascular Biochemistry and Haematology Outcome Models) adopts the approach of using a minimum data set to model outcome and has been previously shown to be feasible after index arterial operations. This study attempts to model mortality following lower limb amputation for critical limb ischaemia using the VBHOM concept. METHODS A binary logistic regression model of risk of mortality was built using National Vascular Database items that contained the complete data required by the model from 269 admissions for lower limb amputation. The subset of NVD data items used were urea, creatinine, sodium, potassium, haemoglobin, white cell count, age on and mode of admission. This model was applied prospectively to a test set of data (n=269), which were not part of the original training set to develop the predictor equation. RESULTS Outcome following lower limb amputation could be described accurately using the same model. The overall mean predicted risk of mortality was 32%, predicting 86 deaths. Actual number of deaths was 86 (chi(2)=8.05, 8 d.f., p=0.429; no evidence of lack of fit). The model demonstrated adequate discrimination (c-index=0.704). CONCLUSIONS VBHOM provides a single unified model that allows good prediction of surgical mortality in this high risk group of individuals. It uses a small, simple and objective clinical data set that may also simplify comparative audit within vascular surgery.
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Affiliation(s)
- T Y Tang
- Cambridge Vascular Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Major lower extremity amputation in elderly patients with peripheral arterial disease: incidence and survival rates. Aging Clin Exp Res 2008; 20:385-93. [PMID: 19039278 DOI: 10.1007/bf03325142] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND AND AIMS The methods of treating peripheral arterial disease (PAD) have changed and become more prophylactic. This study describes and analyzes 1) the incidence rates of major lower extremity amputation (LEA) due to PAD, 2) occurrence of re-amputation, and 3) the survival of amputees and factors predicting survival. METHODS The series consisted of 210 patients (mean age 76.6, SD 10.7 yrs, 45.2% men) who underwent their first, i.e. index, major leg amputation because of PAD, in 1998-2002, in the city of Turku, Finland, population 175,000. RESULTS The age-and gender-standardized incidence rate of combined above-knee and below-knee amputations was 24.1/100,000 person-years during 1998-2002. Thirty-four per cent of amputees underwent repetitive amputation. One-month mortality was 21% (n=45), one-year mortality 52% (n=109) and overall mortality 80% (n=168). Cardiovascular diseases predicted equally well 31-day, one-year, and overall mortality in age- and gender- adjusted analysis. Multiple co-morbidities (p=0.023) and unilateral above-knee amputations (p=0.047) were significant predictors for overall mortality in age- and gender-adjusted analysis. Cardiovascular diseases remained a significant predictor for 31-day and overall mortality in multivariate analysis (p=0.008 and p=0.015, respectively). Amputated patients' previous vascular procedures did not have any effect on mortality in the Cox model. Most revascularizations were performed less than six months before the index/first major LEA. CONCLUSION Major LEAs seem to have been done late, and mainly for pain relief in the end-stage of patients with peripheral arterial disease.
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Larsson J, Eneroth M, Apelqvist J, Stenström A. Sustained reduction in major amputations in diabetic patients: 628 amputations in 461 patients in a defined population over a 20-year period. Acta Orthop 2008; 79:665-73. [PMID: 18839374 DOI: 10.1080/17453670810016696] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND AND PURPOSE With an ageing population and an increasing incidence of diabetes, reduction of the number of diabetes-related amputations becomes increasingly difficult to achieve and maintain. There is controversy in this respect regarding the degree of success. We started a multidisciplinary treatment program for diabetic foot ulcers in 1982, and have now assessed incidence rates of amputations from 1982 through 2001. METHODS In a defined population, gradually increasing from 199,000 to 234,000, all diabetes-related amputations of the lower extremity from toe to hip were recorded from January 1, 1982 to December 31, 2001, using several sources of information. RESULTS The incidence of major amputations decreased by 0.57 from 16 (11-22) to 6.8 (6.1-7.5) per 100,000 inhabitants between the first and last 4-year period. The most substantial decrease was seen in patients aged 80 years and older. The fraction of amputations with a final level at or below the ankle (n = 240) increased from 0.23 in the first 4-year period to 0.31, 0.49, 0.47, and 0.49 in the following 4-year periods. The overall fraction of re-amputation was 0.34 in the first 4- year period and 0.27, 0.21, 0.32, and 0.21 in the following 4-year periods. The fraction of amputations in diabetic patients that were channeled through the footcare team prior to amputation increased from 0.51 in the first 4- year period to 0.83, 0.86, 0.90, and 0.90 in the following 4-year periods. INTERPRETATION Our findings indicate that a substantial decrease in the incidence of major lower extremity amputations in diabetic patients has been achieved and maintained.
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Affiliation(s)
- Jan Larsson
- Department of Orthopedics, Lund University Hospital, Lund, Sweden.
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Tartari S, Zattoni L, Rizzati R, Aliberti C, Capello K, Sacco A, Mollo F, Benea G. Subintimal Angioplasty as the First-Choice Revascularization Technique for Infrainguinal Arterial Occlusions in Patients with Critical Limb Ischemia. Ann Vasc Surg 2007; 21:819-28. [DOI: 10.1016/j.avsg.2007.07.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2006] [Revised: 05/29/2007] [Accepted: 07/16/2007] [Indexed: 10/21/2022]
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Steel MW, DeOrio JK. Forefoot amputation with limb revascularization: the effects of amputation, timing, and wound closure on the peripheral vascular bypass graft site. Foot Ankle Int 2007; 28:690-4. [PMID: 17592699 DOI: 10.3113/fai.2007.0690] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Much has been written about the effects of successful arterial bypass on forefoot surgery for ulceration and gangrene. This study examined the effects of the amputation site and timing on the arterial bypass graft site. METHODS We reviewed the records of all patients who had successful vascular bypass graft surgery and amputation at our institution, between October, 1995 and May, 2002. Thirty-eight procedures in 35 patients fit the criteria and were included in the study. RESULTS Thirty-five patients had successful vascular bypass graft surgery and forefoot amputation for gangrene or nonhealing ulceration. Three of these patients developed gangrene on the contralateral side and received similar treatment for that side. All of the wounds eventually healed. Healing time, rate of graft infection, and rate of wound dehiscence did not differ noticeably between patients with amputation immediately after arterial bypass and patients with amputation one or more days after arterial bypass. Infection at the bypass site occurred in two patients; their amputation sites were closed primarily. Wound dehiscence developed at the bypass site in one patient whose amputation site was closed by secondary intention. Although not statistically significant, the median healing time in patients treated with primary closure (37 days) was less than that in patients treated with closure by secondary intention (61 days; p = 0.09), and rates of graft infection and wound dehiscence did not differ between these two groups of patients. CONCLUSIONS Amputation site wound closure may adversely affect the bypass graft, but results were not statistically significant. Treatment requires a closely coordinated team approach between the vascular surgeon and the orthopedic surgeon.
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Clinical improvement after treatment with VEGF(165) in patients with severe chronic lower limb ischaemia. Genomic Med 2007; 1:47-55. [PMID: 18923928 PMCID: PMC2276892 DOI: 10.1007/s11568-007-9006-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2006] [Accepted: 04/30/2007] [Indexed: 01/13/2023] Open
Abstract
The present study focuses on the application of a therapeutic strategy in patients with chronic severe lower limb ischaemia using a plasmid vector encoding the vascular endothelial growth factor (phVEGF(165)). It has been shown that VEGF promotes neo-vascularization and blood vessel network formation and thus might have the ability to improve blood-flow at the level of the affected limbs. However, little information is available regarding the necessary level of expression of VEGF and its possible related adverse effects. We have subcloned VEGF ( 165 )isoform into pCMV-Script expression vector (Stratagene) under the control of the CMV promoter. Three patients with chronic ischaemia of the lower limb, considered as not suitable for surgical re-vascularization, received intramuscular injection with 0.5 ml saline solution containing 10(11) copies of VEGF ( 165 ) plasmid. The clinical evolution has been monitored by angiography and estimated by walking time on the rolling carpet (Gardner protocol). Two months after therapy, all three patients showed complete relief of rest pain, improvement of ischaemic ulcer lesions and increased walking distance on the rolling carpet most probably due to appearance of newly formed collateral vessels.
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