Ten-year survival of Finnish lower limb amputees

The application of targeted muscle reinnervation in lower extremity amputations: A systematic review

BACKGROUND

Targeted muscle reinnervation (TMR) is a promising surgical modality for reducing post-amputation pain. We sought to provide a succinct overview of TMR specific to the lower extremity (LE) amputation population.

METHODS

A systematic review was performed per PRISMA guidelines. Ovid MEDLINE, PubMed, and Web of Science were queried for records using various combinations of Medical Subject Heading (MeSH) terms such as "LE "amputation," "below-knee amputation" (BKA), "above-knee amputation" (AKA), and "TMR." Primary outcomes included (1) operative techniques, (2) changes in neuroma, phantom limb pain (PLP), or residual limb pain (RLP), and (3) postoperative complications. Studies were only included if outcomes data were discretely provided for LE patients.

RESULTS

Eleven articles examining 318 patients were identified. Average patient age was 47.5 ± 9.3 years, and most patients were male (n = 246, 77.4%). Eight manuscripts (72.7%) described TMR at the index amputation. The average number of nerve transfers performed per TMR case was 2.1 ± 0.8, and the most commonly employed nerve was the tibial (178/498; 35.7%). Nine (81.8%) articles incorporated patient-reported outcomes after TMR, with common methods including the Numerical Rating Scale (NRS) and questionnaires. Four studies (33.3%) reported functional outcomes such as ambulation ability and prosthesis tolerance. Complications were described in seven manuscripts (58.3%), with postoperative neuroma development being the most common (21/371; 7.2%).

CONCLUSIONS

The application of TMR to LE amputations is effective in reducing PLP and RLP with limited complications. Continued investigations are warranted to better understand patient outcomes specific to anatomic location using validated patient-reported outcome measures (PROM).

Life Expectancy and Mortality After Lower Extremity Amputation: Overview and Analysis of Literature

Lower limb amputation (LLA) is a major surgical procedure with a significant impact on quality of life and mortality rates as well. Previous studies have shown that mortality rates following LLA can range from 9-17% within 30 days in the UK. This study systematically evaluates and reviews the published literature on life expectancy, mortality, and survival rates following lower extremity amputation (LEA). We have conducted a comprehensive search on Medline, CINAHL, and Cochrane Central databases resulting in 87 full-text articles. After a thorough review, only 45 (52.9%) articles met the minimum inclusion criteria for the study. Our analysis indicated 30-day mortality rates following LEA ranged from 7.1% to 51.4%, with an average mortality rate of 16.45% (SD 14.35) per study. Furthermore, 30-day mortality rates following below-knee amputation (BKA) and above-knee amputation (AKA) were found to be between 6.2% to 51.4%, X= 17.16% ± 19.46 SD and 12.7 to 21.7%, X= 16.15% ± 4.17 SD, respectively. Our review provides a comprehensive insight into the life expectancy, mortality, and survival rates following LEA. These findings highlight the importance of considering various factors, including patient age, presence of comorbidities such as diabetes, heart failure, and renal failure, and lifestyle factors such as smoking, in determining prognosis following LLA. Further research is necessary to determine strategies for improving outcomes and reducing mortality in this patient population.

Preoperative Transcutaneous Oxygen Perfusion Measurements in Predicting Atraumatic Wound Healing After Major Lower Extremity Amputation

This study examined the correlation between preoperative transcutaneous oxygen perfusion (TcPO₂) measurement and the success of wound healing after major lower extremity amputation. There is no validated consensus on how to accurately determine appropriate amputation levels. A TcPO₂ greater than 30 to 40 mm Hg is widely cited as a positive predictor of postoperative wound healing, but its validity has not been well defined. A retrospective chart review was performed for patients who underwent above-knee amputation (AKA), through-knee amputation, or below-knee amputation (BKA) at a single institution from 2012 to 2018 with preoperative TcPO₂ values and a minimum 30-day postoperative clinical follow-up. This review yielded 141 total amputations: 93 BKAs, 6 through-knee amputations, and 42 AKAs. Fifty-five amputations were unsuccessful, defined by postoperative wound dehiscence or infection. Of these, 37 were BKAs, 4 were through-knee amputations, and 14 were AKAs. There was a significant difference in preoperative TcPO₂ between the successful and unsuccessful amputations, at 46.2 and 38.3 mm Hg, respectively (P=.02). A TcPO₂ of 30 to 40 mm Hg showed a 68.8% success rate, and a TcPO₂ of less than 20 mm Hg showed an 18.2% success rate. A receiver operating characteristic curve for TcPO₂ predicting amputation success had an area under the curve of 0.53 for AKAs and 0.61 for BKAs; the diagnostic ability is far from prognostic. There is no linear association between TcPO₂ and success rate. A TcPO₂ of less than 20 mm Hg has a high positive predictive value for failure, but higher levels are not 100% predictive of wound healing success after amputation, as previously reported. [Orthopedics. 2022;45(3):174-180.].

Current Predictors of Mortality in Veteran Patients Undergoing Major Lower Extremity Amputations: Risk Factors Have Not Changed and Mortality Remains High

Major lower extremity amputation (LEA-above the ankle) carries a high rate of mortality. In the present study, we performed an institutional review of all patients submitting to LEAs at a Veteran Administration Hospital (between 2009 and 2021) accompanied with a review of the literature.For the past 12 years, 1042 LEAs were performed in 603 patients at our hospital. The 30-day, 1-year, and 5-year mortalities were 8.5%, 28.9%, and 53.0%, respectively. Age, hypoalbuminemia, and Clavien-Dindo Class were independent predictors of mortality in all the time intervals in the analysis. Cardiac disease was not an independent predictor of mortality. In 39 studies reviewed, the average 30-day, 1-year, and 5-year mortality was 14%, 36%, and 56%, respectively. There was no difference in mortality in multiple studies analyzed. No significant temporal variation was identified between 1950 and 2000 vs. 2001 and 2021. Predictors of mortality were not substantially different from our institutional experience.The mortality rate for LEAs remains constant over time. Increasing age and hypoalbuminemia are strong predictors of short- and long-term mortality.

Rehabilitation outcomes after major lower limb amputation in the oldest old: a systematic review

BACKGROUND

Because the population grows older and the burden of chronic disease increases, many individuals will undergo major lower limb amputation (LLA) at advanced ages. There is a scarcity of literature focusing on the outcomes of rehabilitation for people who acquire LLA at 80 years of age and older.

OBJECTIVES

To determine the scope of empirical evidence regarding prosthetic rehabilitation for newly acquired LLA in the oldest old (≥80 years of age).

STUDY DESIGN

Systematic Review.

METHODS

The databases CINAHL, EMBASE, MEDLINE, and Scopus were searched from inception through June 6, 2020 (PROSPERO: #CRD 42020188623). Two authors independently reviewed all titles and abstracts for inclusion. Inclusion criteria, LLA of any etiology at the transtibial level or above, those who were ≥80 years of age at the time of amputation, and had rehabilitation outcomes reported.

RESULTS

Of 11,738 articles identified from databases, 117 underwent full-text review and 10 met inclusion criteria. Multiple rehabilitation outcomes were assessed by the selected studies, including general outcomes, prosthetic-related outcomes, and functional abilities. Individuals ≥80 years of age were able to successfully use a prosthesis, discharged home, and performed activities independently or with support. However, increased age was negatively associated with prosthesis fitting and rehabilitation success was not uniform in some participants.

CONCLUSIONS

The oldest old with major LLA can be successful in prosthetic rehabilitation. Age alone should not disqualify individuals from assessment or participation in an amputee rehabilitation program. More research is needed to better understand the rehabilitation outcomes in this population of people with LLA.

Long-term Mortality After Nontraumatic Major Lower Extremity Amputation: A Systematic Review and Meta-analysis

Chronic wounds that lead to major lower extremity amputation have immense consequences on quality of life, and ultimately, mortality. However, mortality rates after lower extremity amputation for a chronic wound are broad within the literature and have escaped precise definition. This systematic review aims to quantify long-term mortality rates after major lower extremity amputation in the chronic wound population available in the existing literature. Ovid MEDLINE was searched for publications which provided mortality data after major, nontraumatic, primary lower extremity amputations. Lower extremity amputations were defined as below and above the knee amputation. Data from included studies was analyzed to obtain pooled 1-, 2-, 3-, 5- and 10-year mortality rates. Sixty-one studies satisfied inclusion criteria representing 36,037 patients who underwent nontraumatic major lower extremity amputation. Pooled mortality rates were 33.7%, 51.5%, 53%, 64.4%, and 80% at 1-, 2-, 3-, 5- and 10-year follow-up, respectively. Within the 8184 diabetic patients (types 1 and 2), 1- and 5-year mortality was 27.3% and 63.2%. Sources of mortality data were varied and included electronic medical records, national health and insurance registries, and government databases. Mortality after nontraumatic major lower extremity amputation is high, both in patients with diabetes as well as those without. Methods used to measure and report mortality are inconsistent, lack reliability, and may underestimate true mortality rates. These findings illustrate the need for a paradigm shift in wound management and improved outcomes reporting. A focus on amputation prevention and care within a multidisciplinary team is critical for recalcitrant ulcers.

Popliteal artery patency is an indicator of ambulation and healing after below-knee amputation in vasculopaths

BACKGROUND

The posterior flap is a conventional technique for closing a below-knee amputation (BKA) that uses the gastrocnemius and soleus muscle and relies on the popliteal and posterior compartment arteries. If the prior mentioned arterial blood supply is compromised, this flap likely relies on collateral flow. The purpose of this study is to identify and differentiate any significant associations between preoperative popliteal and tibial arterial flow and BKA outcomes and patient-reported function.

METHODS

A retrospective review identified patients from a single tertiary wound care center who received BKAs and angiogram between 2010 and 2017 by a single surgeon. BKA complications, wound healing, and amputee ambulatory status at latest follow-up were all stratified for differences according to baseline tibial vessel run-off (VRO) status, popliteal artery patency, and popliteal angioplasty outcome. Chi-square, Fisher's exact, and Wilcoxon rank sum tests were used with significance defined as p ≤ 0.05.

RESULTS

BKAs were performed on 313 patients, of which, 167 underwent preoperative angiography. Thirty-two were excluded due to lack of adequate follow-up leaving a total of 135 patients in the studied population. Diabetes was present in 87%, and 36% had end-stage renal disease. By the study's conclusion, 92% of BKAs had fully healed, with median time-to-healing of 79 days (range 19-1314 days). 60% of patients were ambulatory at 9.5 months. Higher VRO was associated with higher healing rates and lower complications and time-to-healing. The conversion rate of BKA to above-knee amputation (AKA) was 4%. Preoperative popliteal patency was associated with higher postoperative ambulation rates when compared to patients without popliteal flow preoperatively (patent: 71/109, 65%; occluded: 10/26, 40%; p = 0.02) and independently increased the likelihood of postoperative ambulation.

CONCLUSIONS

The posterior flap design for BKA works even in the setting of popliteal occlusion. Complication rates are higher in patients with more compromised blood flow, which may ultimately lead to AKA. Given poor ambulation rates in patients who undergo AKA, the results of this study should encourage surgeons to consider a more functional BKA, even in instances when the popliteal artery is occluded.

Postoperative healing in the diabetic foot is impacted by discharge destination

The aim of this study was to evaluate the impact of discharge destination on diabetes‐related limb salvage surgery outcomes post‐hospitalisation. This was a single‐centre, observational, descriptive study of 175 subjects with diabetes who underwent limb salvage surgery of a minor foot amputation or wide incision and debridement for an acutely infected diabetic foot ulcer (DFU). Comparisons were made between subjects discharged home vs a skilled nursing facility (SNF) for 12 months postoperatively. Univariate, multivariate, and time‐to‐event analyses were performed. The SNF discharge group (n = 40) had worse outcomes with longer healing time (P = .022), more rehospitalisations requiring a podiatry consult (P = .009), increase of subsequent ipsilateral major lower‐extremity amputation (P = .028), and a higher mortality rate (P = .012) within the 12‐month postoperative period. There was no significant difference between the cohorts in surgically cleared osteomyelitis (P = .8434). The Charlson Comorbidity Index values for those discharged home and those in a short‐term nursing facility were similar (P = .3819; home x¯=5.33 ± 2.84 vs SNF x¯=5.75 ± 2.06). The planned discharge destination after limb salvage surgery among people with an acutely infected DFU should be an added risk factor for healing outcomes. Patients discharged to SNFs experience additional morbidity and mortality compared with patients discharged home post‐hospitalisation.

Trends and outcomes of non-traumatic major lower extremity amputations in an Irish tertiary referral hospital

OBJECTIVES

Data on vascular patients following amputation in Ireland is lacking, limiting capability to plan services. This paper seeks to benchmark survival and rehabilitation outcomes among vascular patients in Ireland following lower extremity amputation (LEA), and compare subgroups of those undergoing transfemoral (TFA) or transtibial amputation (TTA).

METHODS

A review was conducted of all patients who underwent non-traumatic TFA or TTA from 2000 to 2009 in a tertiary vascular surgery centre. Demographics, surgical data, perioperative outcomes, medium-term functional outcomes, and survival were assessed.

RESULTS

One hundred and seventy-two patients (2:1 male: female) underwent 192 non-traumatic LEAs. Median age for TFA was 75 years and TTA 67 (p = 0.002). A percentage of 36.5% had undergone prior attempts at surgical revascularization, 25% had undergone prior distal amputation or debridement. Thirty-three (17%) required stump revision. Twenty-three (13.2%) died in hospital. Median survival for those who died in hospital was 17 days (0-367), versus 17 months (2-106) for those who survived to discharge.

CONCLUSION

LEA for vascular pathology has significant morbidity and mortality, with long in-patient stays and short median survival; there is need to focus on improving quality of life in postoperative pathways.

Mortality after amputation in dialysis patients is high but not modified by diabetes status

Background

Survival among dialysis patients with diabetes mellitus (DM) is inferior to survival of non-diabetic dialysis patients, probably due to the higher prevalence of diabetes-related comorbid conditions. One could hypothesize that these comorbid conditions also contribute to a decreased survival after amputation in diabetic patients compared with non-diabetic patients on dialysis.

Methods

Data were collected from the Netherlands Cooperative Study on the Adequacy of Dialysis, a multicentre, prospective cohort study in which new patients with end-stage renal disease were monitored until transplantation or death. Amputation rates (incident cases) were calculated in patients with and without DM. The primary endpoint was all-cause survival after first amputation during dialysis therapy in diabetic patients compared with non-diabetic dialysis patients with an amputation. This was formally assessed using interaction analysis (Poisson regression).

Results

During follow-up (mean duration 2.9 years), 50 of the 413 diabetic patients had a new amputation (12.1%), compared with 20 of 1553 non-diabetic patients (1.2%). Amputation rates/1000 person-years were 47.9 [95% confidence interval (CI) 36.3–63.2] and 4.1 (95% CI 2.7–6.4), respectively, for diabetic patients and non-diabetic patients. Amputation increased mortality risk more than 4-fold in patients without diabetes [hazard ratio (HR) 4.6 (95% CI 2.8–7.6)] as well as in patients with diabetes [HR 4.6 (95% CI 3.3–6.4)]. No formal interaction between diabetes and amputation was found (P = 0.12).

Conclusions

Amputation in dialysis patients is associated with a 4-fold increased mortality risk; this mortality risk was similar for diabetes and non-diabetes patients. Importantly, the risk for amputation is 10-fold higher in DM compared with non-diabetic dialysis patients.

Increased mortality among patients with diabetes following first-ever transfemoral amputation

AIMS

Transfemoral amputation (TFA) is associated with a high postoperative mortality though it is unclear whether diabetes is associated with an increased mortality or not. The aim was to examine mortality at 1 week and 1 year after first-ever TFA with special reference to diabetes.

METHODS

We included 162 first-ever TFAs from 1996 to 2012. Mortality data were collected with the use of the Swedish personal identification number.

RESULTS

The median age was 85 years. Diabetes mellitus were present in 19% (n = 30) of the patients and 67% (n = 109) had cardiovascular disease. Mortality was significantly higher for patients with diabetes compared to patients without diabetes at 1 week (30% vs. 8%, p = 0.001) and at 1 year (80% vs. 57%, p = 0.02). This difference was significant in multivariable analysis.

CONCLUSIONS

We conclude that postoperative mortality was high. The high mortality rate emphasizes the need for early and adequate evaluation of every patient́s overall condition and whether amputation is beneficial or not. Although further studies are needed to analyze the specific causes of early death in amputees and we suggest close monitoring of blood-sugar in patients with diabetes and early treatment of infections and cardiac events in all patients.

Long-term mortality after lower-limb amputation

BACKGROUND

Mortality after amputation is known to be extremely high and is associated with a number of patient features. We wished to calculate this mortality after first-time lower-limb amputation and investigate whether any population or treatment factors are associated with worse mortality.

OBJECTIVE

To follow up individuals after lower limb amputation and ascertain the mortality rate as well as population or treatment features associated with mortality.

STUDY DESIGN

A prospective cohort study.

METHODS

Prospective lower-limb amputations over 1 year (N = 105) at a Regional Rehabilitation Centre were followed up for 3 years.

RESULTS

After 3 years, 35 individuals in the cohort had died, representing a mortality of 33%. On initial univariate analysis, those who died were more likely to have diabetes mellitus (χ(2) = 7.16, df = 1, p = 0.007) and less likely to have been fitted with a prosthesis (χ(2) = 5.84, df = 1, p = 0.016). There was no association with age, gender, level of amputation, social isolation, significant medical co-morbidity other than diabetes or presence of mood disorders. A multi-variable logistic regression (backward step) confirmed that diabetes (odds ratio = 3.04, confidence intervals = 1.25-7.40, p = 0.014) and absence of prosthesis-fitting (odds ratio = 2.60, confidence interval = 1.16-6.25, p = 0.028) were independent predictors of mortality.

CONCLUSION

Mortality after amputation is extremely high and is increased in individuals with diabetes or in those who are not fitted with a prosthesis after amputation.

CLINICAL RELEVANCE

The link between diabetes and mortality after amputation has been noted by others, but this is the first study to find an effect from prosthetic limb-wearing. This requires further investigation to ascertain why the wearing of a prosthetic limb, confers an independent survival benefit that is not related to the presence of medical co-morbidity.

Lower Extremity Arterial Reconstruction in Octogenarians and Older

BACKGROUND

Despite previous single-institution studies showing that lower extremity arterial reconstruction (LEAR) in octogenarians and older patients may be undertaken with acceptable postoperative morbidity and mortality, there continues to be significant reluctance, in the vascular surgical community, to undertaking these complex revascularization procedures in this very elderly population. We undertook this study in an effort to determine the outcomes of LEAR in octogenarians and older patients on a national level.

METHODS

The American College of Surgeons' National Surgical Quality Improvement Program database was queried to identify all patients who underwent LEAR between January 1, 2005 and December 31, 2009. Patient demographics and presenting comorbidities were recorded, and multivariate analyses were performed to compare outcomes in patients 80 and older to those in younger patients.

RESULTS

There were 19,028 patients who underwent open infrainguinal LEAR during this time period. Patients ≥80 comprised 18% (3,486 patients), and patients <80 years comprised 82% (15,542 patients). Multivariate analysis demonstrated that patients aged ≥80 years had an increased likelihood of mortality (odds ratio [OR] 1.79; 95% confidence interval [CI] 1.42-2.26), cardiovascular (OR, 1.46; 95% CI, 1.12-1.89), respiratory (OR, 1.37; 95% CI, 1.12-1.67), and renal (OR, 1.57; 95% CI, 1.27-1.95) complications. There was, however, no significant difference in the likelihood of graft failure (OR, 1.04; 95% CI, 0.86-1.27), wound infection (OR, 0.92; 95% CI, 0.79-1.06), or major amputation (OR, 0.59; 95% CI, 0.13-2.74) between these 2 groups.

CONCLUSIONS

LEAR in octogenarians is associated with an increased risk of postoperative morbidity and mortality but no increased risk of wound infection, amputation, or graft failure.

An enhanced treatment program with markedly reduced mortality after a transtibial or higher non-traumatic lower extremity amputation

Background and purpose - Historically, high 30-day and 1-year mortality post-amputation rates (> 30% and 50%, respectively) have been reported in patients with a transtibial or higher non-traumatic lower extremity amputation (LEA). We evaluated whether allocating experienced staff and implementing an enhanced, multidisciplinary recovery program would reduce the mortality rates. We also determined factors that influenced mortality rates. Patients and methods - 129 patients with a LEA were consecutively included over a 2-year period, and followed after admission to an acute orthopedic ward. Mortality was compared with historical and concurrent national controls in Denmark. Results - The 30-day and 1-year mortality rates were 16% and 37%, respectively, in the intervention group, as compared to 35% and 59% in the historical control group treated in the same orthopedic ward. Cox proportional harzards models adjusted for age, sex, residential and health status, the disease that caused the amputation, and the index amputation level showed that 30-day and 1-year mortality risk was reduced by 52% (HR =0.48, 95% CI: 0.25-0.91) and by 46% (HR =0.54, 95% CI: 0.35-0.86), respectively, in the intervention group. The risk of death was increased for patients living in a nursing home, for patients with a bilateral LEA, and for patients with low health status. Interpretation - With similarly frail patient groups and instituting an enhanced program for patients after LEA, the risks of death by 30 days and by 1 year after LEA were markedly reduced after allocating staff with expertise.

Mortality After Nontraumatic Major Amputation Among Patients With Diabetes and Peripheral Vascular Disease: A Systematic Review

High mortality rates have been reported after major amputations of a lower limb secondary to diabetes and peripheral vascular disease. However, the mortality rates have varied across studies. A systematic review of the 5-year mortality after nontraumatic major amputations of the lower extremity was conducted. A data search was performed of Medline using OVID, CINHAL, and Cochrane, 365 abstracts were screened, and 79 full text articles were assessed for eligibility. After review, 31 studies met the inclusion and exclusion criteria. Overall, the 5-year mortality rate was very high among patients with any amputation (major and minor combined), ranging from 53% to 100%, and in patients with major amputations, ranging from 52% to 80%. Mortality after below-the-knee amputation ranged from 40% to 82% and after above-the-knee amputation from 40% to 90%. The risk factors for increased mortality included age, renal disease, proximal amputation, and peripheral vascular disease. Although our previous systematic review of the 5-year mortality after ulceration had much lower rates of death, additional studies are warranted to determine whether amputation hastens death or is a marker for underlying disease severity.

Effects of prosthetic limb prescription on 3-year mortality among Veterans with lower-limb amputation

Our objective was to determine the relationship between receipt of a prescription for a prosthetic limb and 3 yr mortality postsurgery among Veterans with lower-limb amputation (LLA). We conducted a retrospective observational study that included 4,578 Veterans hospitalized for LLA and discharged in fiscal years 2003 and 2004. The outcome was time to all-cause mortality from the amputation surgical date up to the 3 yr anniversary of the surgical date. Of the Veterans with LLA, 1,300 (28.4%) received a prescription for a prosthetic limb within 1 yr after the surgical amputation. About 46% (n = 2,086) died within 3 yr of the surgical anniversary. Among those who received a prescription for a prosthetic limb, only 25.2% died within 3 yr of the surgical anniversary. After adjustment, Veterans who received a prescription for a prosthetic limb were less likely to die after the surgery than Veterans without a prescription, with a hazard ratio of 0.68 (95% confidence interval: 0.60-0.77). Findings demonstrated that Veterans with LLA who received a prescription for a prosthetic limb within 1 yr after the surgical amputation were less likely to die within 3 yr of the surgical amputation after controlling for patient-, treatment-, and facility-level characteristics.

Preoperative characteristics and functional outcomes of lower limb amputees treated at Southern Älvsborg Hospital, Sweden

BACKGROUND

Within the prosthetics profession, there is a lack of evidence to support many clinical practices. It is therefore important that clinicians systematically document and evaluate their daily practices.

OBJECTIVES

To record preoperative characteristics and functional outcomes for patients with a lower limb amputation and to investigate variations between prosthetic users and non-prosthetic users.

STUDY DESIGN

Prospective cohort study.

METHODS

A total of 23 patients (mean age = 80 years, standard deviation = 7.3) who underwent a major lower limb amputation were assessed within 2 weeks of admission and 6 months post-operatively. Locomotor Capabilities Index-5, the Timed-Up-and-Go Test and prosthetic use were used to evaluate functional outcomes.

RESULTS

A total of 13 participants (57%) received a prosthesis within 6 months of amputation. Mean time to prosthetic fitting was 48 days (range = 28-97). No statistically significant difference was found between prosthetic users and non-prosthetic users regarding age, time to rehabilitation and Locomotor Capabilities Index-5 (p > 0.05). Locomotor Capabilities Index-5 basic was significantly lower at 6 months than prior to amputation (p = 0.039).

CONCLUSION

The functional outcome at 6 months indicates a sizable restriction in mobility among lower limb amputees. No variation in preoperative characteristics between prosthetic users and non-prosthetic users could be confirmed in this study.

CLINICAL RELEVANCE

This study highlights the need for prosthetists to better incorporate research findings into their daily practice and presents an example of how to implement a procedure for assessment and documentation of patients' functional outcomes in a clinical setting. Results confirm difficulties in identifying amputees who will become prosthetic users based on preoperative characteristics.

Total hip replacement in an ipsilateral above-the-knee amputation: surgical technique, rehabilitation, and review of the literature

In this article, we present a case report of a 62-year-old patient who previously underwent an above-the-knee amputation for vascular disease and we performed a total hip replacement on him because of hip osteoarthritis. As the only postoperative complication, the patient developed a methicillin-resistant Staphylococcus aureus surgical site infection, which was successfully treated. The surgical technique and the postoperative rehabilitation program are described in detail in an attempt to detect and face the challenges that patients with major lower limb amputations may present. The literature is reviewed and all known cases of hip replacements in amputees are presented.

Very low survival rates after non-traumatic lower limb amputation in a consecutive series: what to do?

The aim of this retrospective study was to evaluate factors potentially influencing short- and long-term mortality in patients who had a non-traumatic lower limb amputation in a university hospital. A consecutive series of 93 amputations (16% toe/foot, 33% trans-tibial, 9% through knee and 42% trans-femoral) were studied. Their mean age was 75.8 years; 21 (23%) were admitted from a nursing home and 87 (92%) were amputated due to a vascular disease and/or diabetes. Thirty days and 1-year mortality were 30 and 54%, respectively. Cox regression analysis demonstrated that the 30-day mortality was associated with older age (P = 0.01), and the number of co-morbidities (P = 0.04), when adjusted for gender, previous amputations, cause of and amputation level, and residential status. Thus, a patient with 4 or 5 co-morbidities (n = 20) was seven times more likely to die within 30 days, compared with a patient with 1 co-morbidity (n = 16). Further, the risk of not surviving increased with 7% per each additional year the patient got older. Of concern, almost one-third of patients died within 1 month. This may be unavoidable, but a multidisciplinary, optimized, multimodal pre- and postoperative programme should be instituted, trying to improve the outcome.

Time-dependent impact of diabetes on mortality in patients after major lower extremity amputation: survival in a population-based 5-year cohort in Germany

OBJECTIVE

To estimate the impact of diabetes on mortality in patients after first major lower extremity amputation (LEA).

RESEARCH DESIGN AND METHODS

Using claims data of a nationwide statutory health insurance, we assessed all deaths in a cohort of all 444 patients with a first major LEA since 2005 (71.8% male; mean age 69.1 years; 58.3% diabetic; 43% with amputation above the knee) up to 2009. Using Cox regression, we estimated the time-dependent hazard ratios to compare patients with and without diabetes.

RESULTS

The cumulative 5-year mortality was 68% in diabetic and 59% in nondiabetic individuals. In the first course, mortality was lower in diabetic compared with nondiabetic patients. Later, the diabetes risk increased yielding crossed survival curves after 2 to 3 years (time dependency of diabetes; P = 0.003). Age- and sex-adjusted hazard ratios for diabetes were as follows: 0-30 days: 0.50 [95% CI 0.31-0.84]; 31-60 days: 0.60 [0.25-1.41]; 61 days to 6 months: 0.75 [0.38-1.48]; >6-12 months: 1.27 [0.63-2.53]; >12-24 months: 1.65 [0.88-3.08]; >24-36 months: 2.02 [0.80-5.09]; and >36-60 months: 1.91 [0.70-5.21]. The pattern was similar in both sexes. In the full model, significant risk factors for mortality were age (1.05; 1.03-1.06), amputation above the knee (1.50; 1.16-1.94), and quartile category 3 or 4 of the number of prescribed medications (1.64; 1.12-2.40 and 1.76; 1.20-2.59). Further adjustment for comorbidity did not alter the results.

CONCLUSIONS

In this population-based study, we found a time-dependent mortality risk of diabetes following first major LEA, which may be in part a result of a healthier lifestyle in diabetic patients or the access to specific treatment structures in diabetic individuals.

[A new method for prosthetisation of vascular patients with lower limb amputation: initial experiences with osseointegration technique]

INTRODUCTION/AIMS

Prostheses use for lower limb amputees is difficult, while the socket is hard, the prosthesis is heavy. Drawbacks of conventional prosthesis are mainly associated with the socket, therefore osseointegration technique is a promising solution, since it doesn't require a socket. Our aim was to introduce this technique in Hungary and extend indication for vascular patients.

METHODS

The method includes two operative and one rehabilitation phases: during first operation a titanium screw is fixed into the femoral bone marrow cavity, this connects to an abutment, which also penetrates the skin, making a direct connection between the femur and the prosthesis during the second intervention. During rehabilitation the patient makes loading exercises and learns to walk with new prosthesis.

RESULTS

This method was launched in Hungary in 2005. Two female amputees were operated on initially, their second surgery was performed in 2006 (when titanium screw was applied in the male patients, as well). Incorporation of titanium screw was exquisite, and rehabilitation was successful. One of our male patients died eight months after his first operation due to myocardial infarction.

CONCLUSION

Based on our experiences, the osseointegration technique facilitates rehabilitation of vascular patients for prostheses use. Adequate follow-up and stable vascular diseases are not contraindications, although further clinical trials are needed to determine its indication.

Medical and endovascular management of critical limb ischemia

Critical limb ischemia (CLI) is the term used to designate the condition in which peripheral artery disease has resulted in resting leg or foot pain or in a breakdown of the skin of the leg or foot, causing ulcers or tissue loss. If not revascularized, CLI patients are at risk for limb loss and for potentially fatal complications from the progression of gangrene and the development of sepsis. The management of CLI requires a multidisciplinary team of experts in different areas of vascular disease, from atherosclerotic risk factor management to imaging, from intervention to wound care and physical therapy. In the past decade, the most significant change in the treatment of CLI has been the increasing tendency to shift from bypass surgery to less invasive endovascular procedures as first-choice revascularization techniques, with bypass surgery then reserved as backup if appropriate. The goals of intervention for CLI include the restoration of pulsatile, inline flow to the foot to assist wound healing, the relief of rest pain, the avoidance of major amputation, preservation of mobility, and improvement of patient function and quality of life. The evaluating physician should be fully aware of all revascularization options in order to select the most appropriate intervention or combination of interventions, while taking into consideration the goals of therapy, risk-benefit ratios, patient comorbidities, and life expectancy. We discuss the incidence, risk factors, and prognosis of CLI and the clinical presentation, diagnosis, available imaging modalities, and medical management (including pain and ulcer care, pharmaceutical options, and molecular therapies targeting angiogenesis). The endovascular approaches that we review include percutaneous transluminal angioplasty (with or without adjunctive stenting); subintimal angioplasty; primary femoropopliteal and infrapopliteal deployment of bare nitinol, covered, drug-eluting, or bioabsorbable stents; cryoplasty; excimer laser-assisted angioplasty; excisional atherectomy; and cutting balloon angioplasty.

Amputation rehabilitation and prosthetic restoration. From surgery to community reintegration

PURPOSE

The purpose of this review is to summarize the literature related to the advances that have taken place in the management and rehabilitation care of limb amputation.

RESULTS

Prostheses for the lower and upper limb amputee have changed greatly over the past several years, with advances in components, socket fabrication and fitting techniques, suspension systems and sources of power and electronic controls. Higher levels of limb amputation can now be fitted with functional prostheses, which allow more patients to achieve independent life styles. This is of particular importance for the multi-limb amputee. The rehabilitation of more traditional lower limb levels of amputation have also greatly benefited from the technological advances including energy storing feet, electronic control hydraulic knees, ankle rotators and shock absorbers to mention a few. For the upper limb amputee, myoelectric and proportional controlled terminal devices and elbow joints are now used routinely in some rehabilitation facilities. Experimental prosthetic fitting techniques and devices such as the use of osseo-implantation for suspension of the prosthesis, tension control hands or electromagnetic fluids for knee movement control will also be briefly discussed in this paper.

CONCLUSION

It is possible to conclude from this review that many advances have occurred that have greatly impacted the functional outcomes of patients with limb amputation.

Survival analysis in amputees based on physical independence grade achievement

BACKGROUND

Survival implications of achieving different grades of physical independence after lower extremity amputation are unknown.

OBJECTIVES

To identify thresholds of physical independence achievement associated with improved 6-month survival and to identify and compare other risk factors after removing the influence of the grade achieved.

DESIGN

Data were combined from 8 administrative databases. Grade was measured on the basis of 13 individual self-care and mobility activities measured at inpatient rehabilitation discharge.

SETTING

Ninety-nine US Department of Veterans Affairs Medical Centers.

PATIENTS

Retrospective longitudinal cohort study of 2616 veterans who underwent lower extremity amputation and subsequent inpatient rehabilitation between October 1, 2002, and September 30, 2004.

MAIN OUTCOME MEASURE

Cumulative 6-month survival after rehabilitation discharge.

RESULTS

The 6-month survival rate (95% confidence interval [CI]) for those at grade 1 (total assistance) was 73.5% (70.5%-76.2%). The achievement of grade 2 (maximal assistance) led to the largest incremental improvement in prognosis with survival increasing to 91.1% (95% CI, 85.6%-94.5%). In amputees who remained at grade 1, the 30-day hazards ratio for survival compared with grade 6 (independent) was 43.9 (95% CI, 10.8-278.2), sharply decreasing with time. Whereas metastatic cancer and hemodialysis remained significantly associated with reduced survival (both P < or = .001), anatomical amputation level was not significant when rehabilitation discharge grade and other diagnostic conditions were considered.

CONCLUSIONS

Even a small improvement to grade 2 in the most severely impaired amputees resulted in better 6-month survival. Health care systems must plan appropriate interdisciplinary treatment strategies for both medical and functional issues after amputation.

Mortality in diabetic and nondiabetic patients after amputations performed from 1996 to 2005 in a tertiary hospital population: a 3-year follow-up study

AIMS

Diabetes is the leading cause of lower-extremity amputations worldwide. The objective of this study was to look at the survival after first amputation between subjects with and without diabetes in a sample of Greek population.

METHOD

We performed a retrospective study of all nontrauma, nonneoplasm-related amputations performed in a tertiary centre during the years 1996-2005 in diabetic (n=183) and nondiabetic patients (n=75). Survival status was assessed from the first amputation until December 31, 2005.

RESULTS

A total of 54.6% of amputees with diabetes and 51.6% of those without diabetes died in a mean [95% confidence interval (CI)] time of 4.3 (3.5-5.1) and 6.6 (4.6-8.6) years after the first amputation, respectively (P=.65). Diabetic patients underwent a second amputation (P=.003) and contralateral amputations (P=.02) more often in comparison with nondiabetic subjects. Predictors of all-cause mortality in the diabetic group, after adjustment for sex, were age [hazard ratio (HR) (95% CI), 1.04 (1.02-1.06); P<.001] and the level of amputation (major vs. minor) [HR, 1.55 (1.00-2.40), P=.05]. The respective values in the nondiabetic patients were HR of 1.06 (1.03-1.08; P<.001) and HR of 3.12 (1.27-7.64; P=.01). Median length of hospital stay was comparable between the two groups.

CONCLUSION

Mortality rates after amputation were high in both patients with and without diabetes. Older age and a higher level of amputation were associated with poorer survival. Diabetic patients more often underwent a second amputation to the same and the contralateral limb. Additionally, mortality rates, length of hospital stay, and perioperative mortality were not different between patients with and without diabetes.

Predictors of quality of life among individuals who have a lower limb amputation

OBJECTIVE

The purpose of this study was to identify factors that predict an individual's subjective quality of life (QoL) after having a lower limb amputation.

DESIGN

Cross-sectional descriptive study design.

SUBJECTS

A total of 415 unilateral, above knee (27.0%) and below knee (73.0%) amputees with an average age of 61.9 years (SD = 15.7) who had lost their limb related to vascular (53.0%) or non-vascular (47.0%) etiology.

METHODS

Medical chart review, questionnaires (Frenchay Activities Index, Interpersonal Support Evaluation List, the Center for Epidemiology Studies - Depression scale, Prosthetic Evaluation Questionnaire mobility subscale, and the Activities-specific Balance Confidence Scale) and a QoL Visual Analogue Scale were assessed using multiple linear regression analysis.

RESULTS

The analysis revealed seven significant factors (depression, perceived prosthetic mobility, social support, comorbidity, prosthesis problems, age and social activity participation) as predictors of subjects' perceived QoL. Depression explained 30% of the variation, while the full model explained 42% of the variation.

CONCLUSION

Several modifiable characteristics influence QoL after lower limb amputation including depression and participation in daily living. This finding suggests the importance of addressing individuals' affective status to regain or maintain QoL.

Ipsilateral total hip arthroplasty in a dysvascular below-knee amputee for advanced hip osteoarthritis: A case report and review of the literature

This retrospective file review outlines a case study of an 84 year-old man with a transtibial amputation for vascular disease who underwent an ipsilateral total hip replacement (THR). The question being addressed was how surgical techniques, rehabilitation processes and outcomes of joint arthroplasty would need to vary in a case of an ipsilateral dysvascular amputees. The surgery and associated rehabilitation was undertaken for groin pain, falls and reduced mobility due to mechanical osteoarthritis of the hip. The surgical technique and post-operative multidisciplinary rehabilitation is described in detail. Information on exercise regimes, length of stay and follow-up data on function, driving and pain management is presented. The literature is reviewed and all known cases of THR in amputees as well as data on survival of dysvascular amputees is presented. In light of advances in secondary prevention of vascular disease and cardiovascular surgical techniques, amputees with vascular disease may be living longer than they were 20 years ago. They may be beginning to experience the issues associated with aging such as osteoarthritis of the large joints. This case review and others in the literature may suggest that survival rates for vascular amputees be reviewed.

Risk factors associated with mortality in veteran population following transtibial or transfemoral amputation

This study explored medical conditions associated with mortality among veterans following transfemoral amputation, transtibial amputation, or hip disarticulation. We applied logistic regression models to identify clinical factors associated with mortality postoperatively. The participants included patients with lower-limb amputations (n = 2,375) who were discharged from Veterans Health Administration hospitals between October 1, 2002, and September 30, 2003. Most (98.9%) were male. We measured cumulative in-hospital, 3-month, and 1-year mortality. The results were 180 in-hospital deaths, 368 by 3 months, and 634 by the 1-year postsurgical amputation date. Those who had perioperative systemic sepsis (odds ratio = 4.28, 95% confidence interval = 2.87-6.39) had more than a fourfold increased likelihood of in-hospital mortality. Congestive heart failure, renal failure, and liver disease were significantly associated with mortality at all time periods. Metastatic cancer was associated only at 3 months and 1 year. We concluded that high medical complexity and mortality rates attest to the need for careful medical oversight during the postacute rehabilitation period.

Osseointegrated trans-femoral amputation prostheses: prospective results of general and condition-specific quality of life in 18 patients at 2-year follow-up

This is the first report on prospective outcome for individuals treated with bone-anchored trans-femoral amputation prostheses (OI-prostheses) using the method of osseointegration. The aim was to analyze general and condition-specific health related quality of life (HRQL) at 2-year follow-up as compared to the preoperative situation. The study population consists of the first 18 consecutively treated patients (8 male/10 female, mean age 45 years) in a clinical investigation with amputations mainly caused by trauma and tumour. At inclusion the mean time since the amputation was 15 years (10 months - 33 years). Two self-report questionnaires were answered preoperatively and at follow-up: the SF-36 Health Survey (SF-36) and the Questionnaire for persons with a Transfemoral Amputation (Q-TFA). At follow-up 17/18 patients used the OI-prosthesis; one did not due to pain and loosening of the implant. Four of the scales of the SF-36 (Physical Functioning, Role Functioning Physical, Bodily Pain and Physical Component Score) and all four scores of Q-TFA (Prosthetic Use, Prosthetic Mobility, Problems and Global Health) were statistically significantly improved at follow-up showing superior general physical HRQL, increased prosthetic use, better prosthetic mobility, fewer problems and a better global amputation situation. Thus, osseointegrated prostheses represent a promising development in the rehabilitation of individuals with transfemoral amputation and increase their quality of life.

Effect of hyperbaric oxygen on cardiac neural regulation in diabetic individuals with foot complications

AIMS

There are relatively few effective methods to treat autonomic neuropathy in patients with diabetes mellitus. Our aim was to test the hypothesis that hyperbaric oxygen therapy may restore cardiac neural regulation dysfunction in diabetic individuals with foot complications.

METHODS

We conducted a prospective randomized controlled study in patients with diabetic foot problems. Daily heart-rate variability analysis from 5-min electrocardiography was used to evaluate the temporal change of cardiac neural regulation. The experimental group consisted of 23 subjects exposed to hyperbaric oxygen therapy of 202.65 kPa for 90 min every Monday to Friday for 4 weeks (20 treatments). The control group consisted of 15 age-, sex- and disease-matched subjects who were not exposed to hyperbaric therapy. Patients with medical complications and failure of wound healing were excluded to eliminate possible confounding effects.

RESULTS

There was no significant difference in baseline R-R interval (RR), variance, high-frequency power (HF), low-frequency power (LF), and LF/HF ratio between the two groups. In the hyperbaric oxygen group there were significant increases in changes of RR (82.7 +/- 16.02 ms); variance 0.88 +/- 0.12 ln(ms2); HF 1.06 +/- 0.18 ln(ms2); and LF 0.87 +/- 0.15 ln(ms2) after the treatment. Measurements of tissue oxygen demonstrated significant increases in local tissue oxygenation in the hyperbaric oxygen group (53.0 +/- 2.6 mmHg) compared with the control group (27.5 +/- 3.1 mmHg), P < 0.05.

CONCLUSION

Hyperbaric oxygen therapy has a significant vagotonic effect, which is beneficial in improving cardiac neural regulation in patients with diabetic autonomic dysfunction.

Survival rates in dysvascular lower limb amputees

BACKGROUND

To assess the 5-year and 10-year survival rates of major (above ankle disarticulation level) dysvascular lower limb amputees attending a sub-regional Disablement Services Centre (DSC) specialising in amputee rehabilitation. Also to investigate the association between survival rates, cause of dysvascularity, level of amputation, smoking status and occupational status.

SETTING

The study was undertaken in sub-regional DSC for amputee rehabilitation covering a base population of about 3.5million people. Over 80% of lower limb amputations were done for dysvascularity (peripheral vascular disease, diabetic or combination). All these patients were followed up in the DSC for their prosthetic/amputee rehabilitation. Modular case records of 201 consecutive patients from 1994 to 1995 who had diagnosis of dysvascularity as the cause of major lower limb amputations, were scrutinised regarding their 10-year survival; demographic details, level of lower limb amputations, Above Knee (AK=Transfemoral), Below Knee (BK=Transtibial), smoking status, occupational status, healing of the stump at first assessment, cause of amputation and association of these factors with survival rates.

RESULTS

Of 201 individuals with either AK or BK amputations, 60% (121) had AK amputations and 67% (134) were males, the mean age was 69years of age. Sixty-seven percent (97) had history of smoking, either current 43% (62) or prior 24% (35) smoking, and 59% (68) were skilled or non-skilled manual workers. Fifty-one percent (99) had diagnosis of peripheral vascular disease, whilst 34% (65) had combination of peripheral vascular disease and diabetes, diabetes on its own in 4% (7). In 12% (23) other causes were noted such as embolism, acute ischaemia, venous ulcers, etc. Regarding stumps healing at first assessment, healing was noted in 54% (109) whilst stump was unhealed in 46% (92). The median survival was 48months. Using Cox proportional hazards regression to identify association with survival, the hazard ratio (HR) was significant regarding level of amputation: HR 2.34; 95% confidence interval (CI) (1.58, 3.47), P<0.001 (a recent BK amputation increases the risk by 2.3 compared to a recent AK amputation in diabetic cohort and also in the peripheral vascular disease/diabetes cohort). Hazard ratio was less than 1.0 in bilateral amputees: HR 0.35, 95% CI (0.21, 0.60), P<0.001 (bilateral amputation decreases risk by 0.35).

CONCLUSION

Our study indicates that the median survival remains at 4years, which is similar to the previously published evidence in the Finish study of 1998 and the earlier study from Scotland in 1992. Unlike the previous data, our study indicates that patients with BK amputations have a higher hazard ratio than the AK amputees, and an association with diabetes has poorer prognosis regarding survival.

Care of elderly lower limb amputees, as described in medical and nursing records

The aim of this study was to characterize elderly lower limb amputees and explore problems/requirements inherent in their care. A retrospective study of medical and nursing records of patients who had undergone lower limb amputation (LLA) at Uddevalla General Hospital in 1997 was conducted. Demographic data were compared with those from a comparable regional health care district. Hospitalization, rehabilitation and nursing-related data related to subjects alive after 6 months were compared with data concerning those deceased during hospital stay and within 6 months after amputation. During the defined period, the study population consisted of 45 patients aged 60 and above. Fifty-six percent were men, with a mean age of 81.6. Eight patients died in the hospital post-amputation and five died within 6 months of surgery. The aetiology of the diagnosis leading to the LLA was cardiovascular disease in the majority of cases. The most common amputation level was below the knee. LLA patients were reported to have major problems maintaining physical and mental functions, markedly deteriorated general health status and severe pain problems. LLA patients require well functioning and qualified care and rehabilitation. The patients surviving after 6 months had permanent problems in the area of nutrition, elimination, skin ulceration, sleep, pain and pain alleviation. The patients who died during the hospital stay had problems in all these areas. With increasing shorter stays in hospital and decreasing resources in primary and municipal care, there is a risk that these patients' needs and requirements for professional care might be underestimated and thus remain unfulfilled.

Perioperative and long-term morbidity and mortality after above-knee and below-knee amputations in diabetics and nondiabetics

We performed a retrospective review of a vascular surgery quality assurance database to evaluate the perioperative and long-term morbidity and mortality of above-knee amputations (AKA, n = 234) and below-knee amputations (BKA, n = 720) and to examine the effect of diabetes mellitus (DM) (181 of AKA and 606 of BKA patients). All patients in the database who had AKA or BKA from 1990 to May 2001 were included in the study. Perioperative 30-day cardiac morbidity and mortality and 3-yr and 10-yr mortality after AKA or BKA were assessed. The effect of DM on 30-day cardiac outcome was assessed by multivariate logistic regression and the effect on long-term survival was assessed by Cox regression analysis. The perioperative cardiac event rate (cardiac death or nonfatal myocardial infarction) was at least 6.8% after AKA and at most 3.6% after BKA. Median survival was significantly less after AKA (20 mo) than BKA (52 mo) (P < 0.001). DM was not a significant predictor of perioperative 30-day mortality (odds ratio, 0.76 [0.39-1.49]; P = 0.43) or 3-yr survival (Hazard ratio, 1.03 [0.86-1.24]; P = 0.72) but predicted 10-yr mortality (Hazard ratio, 1.34 [1.04-1.73]; P = 0.026). Significant predictors of the 30-day perioperative mortality were the site of amputation (odds ratio, 4.35 [2.56-7.14]; P < 0.001) and history of renal insufficiency (odds ratio, 2.15 [1.13-4.08]; P = 0.019). AKA should be triaged as a high-risk surgery while BKA is an intermediate-risk surgery. Long-term survival after AKA or BKA is poor, regardless of the presence of DM.

Appareillage précoce par manchon silicone avec attache terminale après amputation vasculaire sous le genou : évaluation par score de marche du devenir fonctionnel

PURPOSE

To assess by a specific questionnaire the functional outcome of patients with below-the-knee amputation after early prosthetic fitting by the ICEROSS silicone liner, which had demonstrated improvement of stump healing and length of hospital stay.

PATIENTS AND METHODS

In this retrospective study, walking ability was assessed by a specific score resulting from answers on a questionnaire. The outcome variables were walking inside and outside, transfer from sitting, climbing stairs, and use of walking aids. Following amputation, the ICEROSS system was used for compression therapy, then for temporary prosthesis. The questionnaire was administered at the fitting stabilized state.

RESULTS

Twenty-nine of 51 patients who underwent trans-tibial amputation were included: 5 women (mean age 72.8+/-4.1 years) and 24 men (mean age: 69+/-7.4 years). The mean total score was 14.5/20 (good functional outcome) for the 22 unilateral amputees and 7.2/20 (intermediate result) for the seven bilateral amputees. Previous studies concerning functional outcome with other contact casts (without a silicon liner with a bolt) had shown similar results.

CONCLUSION

Despite its beneficial initial effect, early fitting by the ICEROSS system did not improve walking ability at the steady functional state, which is more linked to advanced age and comorbidities.

The geriatric amputee

There are special aspects of aging with an amputation and with being elderly at the time of an amputation. Older adults who have undergone amputation have many issues to contend with, including comorbidities that affect postoperative care and rehabilitation, general deconditioning and loss of mobility (especially if the onset of rehabilitation is delayed), and lack of social support upon returning to the community. These problems are compounded by a lack of knowledge about caring for the residual limb and prosthesis, maintenance of general health, and management of comorbid conditions. People who have sustained an amputation at an early age and who are ambulatory may find increasing difficulties as they age. Acquired chronic disease occurs more frequently as people age. These conditions can adversely affect function after amputation. Prosthetic designs may need modification because certain components may become more difficult to use. The prevention of a (second) amputation results in saving a limb and preserving self-image and independent function. Considering the emotional and economic cost of amputation and lifelong management of a prosthesis, it is worth the time and effort to practice preventive measures. Should amputation become necessary, careful patient assessment, compassionate management, and communication among the team members results in a more favorable outcome. Including the physiatrist early in the clinical course makes this process easier.

Balloon angioplasty of popliteal and crural arteries in elderly with critical chronic limb ischemia

OBJECTIVE

Elderly patients with extensive infrainguinal peripheral vascular disease and critical chronic limb ischemia (CCLI) are poor surgical candidates. Our purpose was to evaluate angiographic and clinical results of popliteal, infrapopliteal, and multi-level disease percutaneous transluminal angioplasty (PTA) in such patients.

DESIGN

Retrospective study of angiographic and clinical files in selected group.

MATERIALS AND METHODS

Between 1996 and 2002, 38 elderly patients aged 80-94 years old (mean age 83.3) with critical leg ischemia were treated with PTA. All patients were at high surgical risk. 31/38 (81.5%) patients had chronic non-healing wounds, and 14/38 (37%) had multi-level disease of superficial femoral, popliteal and crural arteries. One hundred and two lesions were treated by angioplasty. Immediate angiographic and 1 year clinical results were retrospectively analyzed.

RESULTS

The overall procedural success rate was 32/38 (84.2%). There were three major complications (7.9%), but no deaths, and three technical failures, all were of infrapopliteal lesions. After 1 year, 27 patients could be followed, five patients died during the first year of unrelated causes. Twenty-three patients (85.2%), were clinically re-occluded within 1 year, but complete and partial wound healing was achieved in 80% (16/20) and rest pain improvement in 57% (4/7), so that overall limb salvage was 74% (20/27).

CONCLUSIONS

Elderly patients with multi-level CCLI have a short patency term following angioplasty of 14.8% after 1 year. Nevertheless, this temporary vascular patency enables wound healing or improvement in 74% of these patients, thus such endovascular interventions are recommended in this age group.

From major amputation to prosthetic outcome: a prospective study of 190 patients in a defined population

In this prospective study, the overall treatment and outcome of patients that underwent major lower limb amputation in a defined population is described. The study was performed over a five year period in the Health Care District of North-East Skåne, Sweden. Some 190 patients, permanent inhabitants of the Health Care District, underwent major lower limb amputation. Sixteen (16) of these patients had amputations before the study started and went through late second leg amputation during the period. One hundred and seventy four (174) patients had primary major amputation. Seventy nine (79) were men and 95 were women, with a median age of 81. The re-amputation rate was 17% although the primary knee preservation ratio was as high as 3.0:1. Rigid dressing was the standard method following trans-tibial amputation and was used for 5-7 days. ICEROSS silicone liner was used for compression therapy in 90% of all cases that resulted in delivery of a prosthesis. Prostheses were delivered to 43% of all patients with primary amputations. These patients spent a median of 13 days at the orthopaedic clinic. 55 days at the rehabilitation unit. Pressure casting was used as a standard method in the production of the prosthetic socket. ICEX carbon-fibre socket was used in 52%. New procedures, treatments and techniques were introduced, standardised and evaluated whilst the routines in the hospital were reorganised. In this way, a system has been implemented that better guarantees the outcome of the whole procedure and the service received by this category of patients.

Mobility outcome following unilateral lower limb amputation

This study investigated mobility outcome following unilateral trans-tibial or trans-femoral amputation. It was an observational study at the sub-regional amputee rehabilitation centre in Sheffield, UK. All unilateral trans-tibial or transfemoral amputees referred during the study period were included. The Harold Wood Stanmore mobility grade was recorded approximately one year following initial assessment at the centre. Of the 357 amputees referred, complete outcome data was available for 281 (78.7%). The mean age was 68 years (range 16-95), 70.1% were male, and the aetiology of the amputation was vascular or diabetic in 87.5% of cases. Trans-tibial amputations accounted for 50.5% and trans-femoral 49.5%. Almost all trans-tibial and trans-femoral amputees aged 50 and under achieved functional household and community mobility. Approximately 50% of the trans-tibial amputees aged over 50 years gained independent community mobility and around 60% household mobility. There was a significant worsening of community mobility rates with increasing age but for household mobility the differences did not reach statistical significance. Fewer than 25% of trans-femoral amputees aged over 50 achieved community mobility and around 50% achieved household mobility. There was a statistically significant deterioration in both community and household mobility levels with increasing age. This study concludes that mobility rates one year after prosthetic provision for unilateral trans-tibial and trans-femoral amputees worsen with increasing age at amputation and a higher level of amputation.

Functional outcome in a contemporary series of major lower extremity amputations

PURPOSE

We undertook this study to document the functional natural history of patients undergoing major amputation in an academic vascular surgery and rehabilitation medicine practice.

METHODS

A retrospective review was conducted of consecutive patients undergoing major lower extremity amputation and rehabilitation in a university and Department of Veterans Affairs hospital. Main outcome variables included operative mortality, follow-up, survival, median time to incision healing, secondary operative procedures for wound management, and conversion from below-knee amputation (BKA) to above-knee amputation (AKA). For surviving patients, quality of life was determined by degree of ambulation, eg, outdoors, indoors only, or no ambulation; use of a prosthesis; and independence, eg, community housing or nursing facility.

RESULTS

From August 1997 through March 2002, 154 patients (130 men; median age, 62 years) underwent 172 major amputations, 78 AKA and 94 BKA, because of either critical limb ischemia (87%) or diabetic neuropathy (13%). Thirty-day operative mortality was 10%. Mean follow-up was 14 months. Healing at 100 and 200 days, as determined with the Kaplan-Meier method, was 55% and 83%, respectively, for BKA, and 76% and 85%, respectively, for AKA. Twenty-three BKA and 16 AKA required additional operative revision, and 18 BKA ultimately were converted to AKA. Survival was 78% at 1 year and 55% at 3 years. Function in surviving patients at 10 and 17 months, respectively, was as follows: 21% and 29% of patients ambulated outdoors, 28% and 25% ambulated indoors only, and 51% and 46% of patients were nonambulatory; 32% and 42% of patients used prosthetic limbs; and 17% and 8% of patients who lived in the community before amputation required care in a nursing facility.

CONCLUSIONS

We were surprised to find that vascular patients in a contemporary setting who require major lower extremity amputation and rehabilitation often remain independent despite infrequent prosthesis use and outdoor ambulation. Although any hope for postoperative ambulation in this population requires salvaging the knee joint, because of the morbidity incurred in both wound healing and rehabilitation efforts, aggressive effort should be reserved for selected patients at good risk. Ability to predict ambulation after BKA in the vascular population is poor.

Phantom pain and health-related quality of life in lower limb amputees

Amputation of a limb may affect quality of life. However, little is known concerning health-related quality of life in amputees. The purposes of this study were to describe health-related quality of life in a population of lower limb amputees and to investigate potential determinants, including phantom pain. Data from 437 patients with a lower limb amputation were analyzed in this cross-sectional study. Amputation-related problems were investigated using a questionnaire. Health-related quality of life was investigated using the RAND-36 DLV. Amputees with phantom pain had a poorer health-related quality of life than amputees without phantom pain. In general, the most important amputation-specific determinants of health-related quality of life were "walking distance" and "stump pain."

Maximizing health in menopausal women with disabilities

There are nearly 30 million women with disabilities in the United States. Of these, more than 16 million are over the age of 50. Years ago, women with disabilities did not commonly live to the age of menopause, and, if they did, they reached this stage of life in a very debilitated condition. Now, women with disabilities are entering their mature years as active members of society who can look forward to productive futures. Because the health needs of women with disabilities might differ from those of other women, special attention should be focused on how physiological changes of perimenopausal and menopausal states affect this population. In addition to functional changes that might affect menopausal women with disabilities, basic health maintenance issues may be adversely affected by environmental factors. Physical barriers can influence compliance with preventive health screening that is essential in aging populations. Treatment options might need to be tailored to the individual. The disabling condition itself may progress, resulting in secondary conditions requiring creative interventions. A comprehensive evaluation and the development of a suitable management plan, which takes into account the multifactorial nature of aging as a disabled woman, are essential in delivering optimal care to this population.