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Bazikian S, Pyun AJ, Zheng H, Padula W, Khan T, Ziegler K, Shin L, Magee GA, Rowe VL, Armstrong DG. Evaluating the impact of an interdisciplinary integrated limb preservation service operating concurrently with a single-specialty service. J Foot Ankle Res 2024; 17:e12013. [PMID: 38613833 DOI: 10.1002/jfa2.12013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 04/02/2024] [Indexed: 04/15/2024] Open
Abstract
BACKGROUND This study examined the efficacy of an interdisciplinary limb preservation service (LPS) in improving surgical outcomes for diabetic foot ulcer (DFU) patients compared to traditional care. METHODS Data from January 1, 2017 to September 30, 2020 were retrospectively reviewed. An interdisciplinary LPS clinic began on August 1, 2018, coexisting with a preexisting single specialty service. Primary outcomes were major/minor amputation rates and ratios and hospital length of stay. Surgical endpoints pre- and post-LPS launch were compared. RESULTS Among 976 procedures for 731 unique DFU patients, most were male (80.4%) and Hispanic (89.3%). Patient demographics were consistent before and after LPS initiation. Major amputation rates decreased by 45.5% (15.4%-8.4%, p = 0.001), with outpatient procedures increasing over 5-fold (3.3% pre-LPS to 18.7% post-LPS, p < 0.001). Hospital stay reduced from 10.1 to 8.5 days post-LPS (p < 0.001). The major to minor amputation ratio declined from 22.4% to 12.7%. CONCLUSIONS The interdisciplinary LPS improved patient outcomes, marked by fewer major amputations and reduced hospital stays, suggesting the model's potential for broader application.
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Affiliation(s)
- Sebouh Bazikian
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Alyssa J Pyun
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Hanke Zheng
- Department of Pharmaceutical and Health Economics, Alfred E. Mann School of Pharmacy and Pharmaceutical Sciences, University of Southern California, Los Angeles, California, USA
- Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, California, USA
| | - William Padula
- Department of Pharmaceutical and Health Economics, Alfred E. Mann School of Pharmacy and Pharmaceutical Sciences, University of Southern California, Los Angeles, California, USA
- Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, California, USA
| | - Tanzim Khan
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Kenneth Ziegler
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Laura Shin
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Gregory A Magee
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Vincent L Rowe
- Division of Vascular Surgery and Endovascular Therapy, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - David G Armstrong
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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Norvell DC, Turner AP, Morgenroth DC, Henderson AW, Halsne EG, Hurwitz M, Czerniecki JM. The effect of depression on prosthesis prescription in men and women who have undergone a lower limb amputation. Disabil Rehabil 2024; 46:1204-1211. [PMID: 37035925 DOI: 10.1080/09638288.2023.2192976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 03/15/2023] [Indexed: 04/11/2023]
Abstract
PURPOSE To determine gender disparities and potential factors that modify prosthesis prescription practices in veteran patients who have undergone their first major unilateral amputation due to diabetes or peripheral arterial disease. MATERIALS AND METHODS A retrospective cohort study using the VA Corporate Data Warehouse to compare prosthesis prescription rates and time to prescription between men and women veterans. The primary exposure was gender. The primary outcome was a qualifying prosthesis prescription within 12 months of the incident amputation. The secondary outcome was time to prosthesis prescription. Multiple logistic and linear regression was used to control for potential confounders and identify potential effect modification. RESULTS 2,862 individuals met study criteria, with 1690 (60%) prescribed a qualifying prosthesis. Men were more likely to receive a prosthesis prescription than women (59% versus 45%, respectively; p = 0.03). This difference was observed primarily among those with a diagnosis of major depressive disorder. In this subgroup, the odds of men receiving a prosthesis over women was over 3 times (adjusted odds ratio = 3.3; 95% Confidence Interval, 1.5, 7.4). Men had a mean shorter time to prescription compared to women (112 ± 72 versus 136 ± 79 days, respectively, p = 0.08). Depression in women negatively impacts their prosthesis prescription rates and time to prescription compared to men. This disparity may have significant impacts on future function and quality of life.Implications for RehabilitationThis study found that men more commonly received a prosthesis prescription and received it earlier than women.This disparity was most extreme among women who had been diagnosed with major depressive disorder.Providers should identify at risk patients early and consider targeted interventions to address depression during the preoperative and immediate postoperative phases.Future research should continue to work to identify gender-specific needs that exacerbate disparity.
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Affiliation(s)
- Daniel C Norvell
- VA Puget Sound Health Care System, WA, Seattle
- Department of Rehabilitation Medicine, University of Washington, WA, Seattle
- Center for Limb Loss and Mobility (CLiMB), Seattle, WA
| | - Aaron P Turner
- VA Puget Sound Health Care System, WA, Seattle
- Department of Rehabilitation Medicine, University of Washington, WA, Seattle
- Center for Limb Loss and Mobility (CLiMB), Seattle, WA
| | - David C Morgenroth
- VA Puget Sound Health Care System, WA, Seattle
- Department of Rehabilitation Medicine, University of Washington, WA, Seattle
- Center for Limb Loss and Mobility (CLiMB), Seattle, WA
| | - Alison W Henderson
- VA Puget Sound Health Care System, WA, Seattle
- Center for Limb Loss and Mobility (CLiMB), Seattle, WA
| | - Elizabeth G Halsne
- VA Puget Sound Health Care System, WA, Seattle
- Department of Rehabilitation Medicine, University of Washington, WA, Seattle
- Center for Limb Loss and Mobility (CLiMB), Seattle, WA
| | - Max Hurwitz
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, PA, Pittsburgh
| | - Joseph M Czerniecki
- VA Puget Sound Health Care System, WA, Seattle
- Department of Rehabilitation Medicine, University of Washington, WA, Seattle
- Center for Limb Loss and Mobility (CLiMB), Seattle, WA
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Villarreal JV, Hussien DG, Panchbhavi VK, Jupiter DC. Predisposing Factors for 30-Day Complications Following Leg Amputation. Foot Ankle Spec 2024; 17:49-57. [PMID: 33771044 DOI: 10.1177/19386400211001980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Although amputation rates, morbidity, and mortality have been established for select populations, the impact of general demographic factors on postoperative surgical complications remains little studied. METHODS The American College of Surgeons' National Surgical Quality Improvement Program database was searched for leg amputations from 2012 to 2017 using CPT codes 27881, 27882, 27884, and 27886, identifying 4162 patients. A total of 29 demographic variables with 4 complications (surgical infection, additional service, and deep-vein thrombosis [DVT], and sepsis) were analyzed. RESULTS Preoperative open, contaminated, or dirty/infected wounds; longer intraoperative times; development of sepsis prior to surgery; and admission of patients from home or another hospital influenced postoperative infection rates. Preoperative open, infected, or dirty/infected wounds; height; weight; total length of hospital stay; and ethnicity affected postoperative additional service incidence. Preoperative congestive heart failure, large decreases in body weight, and total length of hospital stay influenced postoperative DVT rates. Preoperative functional heath status, total length of hospital stay, amputations conducted as emergency cases, preoperative acute renal failure, open or infected wounds, sepsis, and contaminated or dirty/infected wounds affected postoperative sepsis rates. BACKGROUND Conclusion. Understanding these risk factors may allow providers to anticipate and address higher rates of complications in certain patient populations. LEVEL OF EVIDENCE Level III: Prognostic.
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Affiliation(s)
- Joseph V Villarreal
- the School of Medicine, The University of Texas Medical Branch, Galveston, Texas
| | - Doha G Hussien
- the School of Medicine, The University of Texas Medical Branch, Galveston, Texas
| | - Vinod K Panchbhavi
- the Department of Orthopaedic Surgery and Rehabilitation, The University of Texas Medical Branch, Galveston, Texas
| | - Daniel C Jupiter
- the Department of Orthopaedic Surgery and Rehabilitation, The University of Texas Medical Branch, Galveston, Texas
- the Department of Preventive Medicine and Population Health, The University of Texas Medical Branch, Galveston, Texas
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Lauwers P, Wouters K, Vanoverloop J, Avalosse H, Hendriks JMH, Nobels F, Dirinck E. The impact of diabetes on mortality rates after lower extremity amputation. Diabet Med 2024; 41:e15152. [PMID: 37227722 DOI: 10.1111/dme.15152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 05/16/2023] [Accepted: 05/23/2023] [Indexed: 05/26/2023]
Abstract
OBJECTIVE To assess the impact of diabetes, amputation level, sex and age on mortality rates after lower extremity amputation (LEA) in Belgium, and to assess temporal trends in one-year survival rates from 2009 to 2018. METHODS Nationwide data on individuals who underwent minor and major LEA from 2009 to 2018 were collected. Kaplan-Meier survival curves were constructed. A Cox regression model with time-varying coefficients was used to estimate the likelihood of mortality after LEA in individuals with or without diabetes. Matched amputation-free individuals with or without diabetes were used for comparison. Time trends were analysed. RESULTS Amputations 41,304 were performed: 13,247 major and 28,057 minor. Five-year mortality rates in individuals with diabetes were 52% and 69% after minor and major LEA, respectively (individuals without diabetes: 45% and 63%, respectively). In the first six postoperative months, no differences in mortality rates were found between individuals with or without diabetes. Later, hazard ratios (HRs) for mortality in individuals with diabetes (compared with no diabetes) after minor LEA ranged from 1.38 to 1.52, and after major LEA from 1.35 to 1.46 (all p ≤ 0.005). Among individuals without LEA, HRs for mortality in diabetes (versus no diabetes) were systematically higher compared to the HRs for mortality in diabetes (versus no diabetes) after minor and major LEA. One-year survival rates did not change for individuals with diabetes. CONCLUSIONS In the first six postoperative months, mortality rates after LEA were not different between individuals with or without diabetes; later, diabetes was significantly associated with increased mortality. However, as HRs for mortality were higher in amputation-free individuals, diabetes impacts mortality less in the minor and major amputation groups relative to the comparison group of individuals without LEA.
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Affiliation(s)
- Patrick Lauwers
- Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Edegem, Belgium
| | - Kristien Wouters
- Antwerp University Hospital, Clinical Trial Center (CTC), CRC Antwerp, Edegem, Belgium
| | - Johan Vanoverloop
- IMA/AIM (Intermutualistisch Agentschap/Agence Intermutualiste), Brussels, Belgium
| | - Hervé Avalosse
- IMA/AIM (Intermutualistisch Agentschap/Agence Intermutualiste), Brussels, Belgium
- Landsbond der Christelijke Mutualiteiten/Alliance Nationale des Mutualités Chrétiennes, Brussels, Belgium
| | - Jeroen M H Hendriks
- Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Edegem, Belgium
| | - Frank Nobels
- Department of Endocrinology, Onze Lieve Vrouw Ziekenhuis Aalst, Aalst, Belgium
| | - Eveline Dirinck
- Department of Endocrinology, Diabetology and Metabolism, Antwerp University Hospital, Edegem, Belgium
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Beckman JA, Sullivan AE. Lipoprotein(a), Peripheral Artery Disease, and Abdominal Aortic Aneurysm: The Next Frontier or Another Risk Enhancer? J Am Coll Cardiol 2023; 82:2277-2279. [PMID: 38057069 DOI: 10.1016/j.jacc.2023.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 10/16/2023] [Indexed: 12/08/2023]
Affiliation(s)
- Joshua A Beckman
- Division of Vascular Medicine, University of Texas Southwestern, Dallas, Texas, USA.
| | - Alexander E Sullivan
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA. https://twitter.com/AlexSullivan_MD
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Zhu Y, Xu H, Wang Y, Feng X, Liang X, Xu L, Liang Z, Xu Z, Li Y, Le Y, Zhao M, Yang J, Li J, Cao Y. Risk factor analysis for diabetic foot ulcer-related amputation including Controlling Nutritional Status score and neutrophil-to-lymphocyte ratio. Int Wound J 2023; 20:4050-4060. [PMID: 37403337 PMCID: PMC10681407 DOI: 10.1111/iwj.14296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 06/08/2023] [Accepted: 06/16/2023] [Indexed: 07/06/2023] Open
Abstract
Diabetic foot ulcer often leads to amputation, and both nutritional status and immune function have been associated with this process. We aimed to investigate the risk factors of diabetic ulcer-related amputation including the Controlling Nutritional Status score and neutrophil-to-lymphocyte ratio biomarker. We evaluated data from hospital in patients with diabetic foot ulcer, performing univariate and multivariate analyses to screen for high-risk factors and Kaplan-Meier analysis to correlate high-risk factors with amputation-free survival. Overall, 389 patients underwent 247 amputations over the follow-up period. After correction to relevant variables, we identified five independent risk factors for diabetic ulcer-related amputation: ulcer severity, ulcer site, peripheral arterial disease, neutrophil-to-lymphocyte ratio and nutritional status. Amputation-free survival was lower for the moderate-to-severe versus mild cases, for the plantar forefoot versus hindfoot location, for the concomitant peripheral artery disease versus without and in the high versus low neutrophil-to-lymphocyte ratio (all p < 0.01). The results showed that ulcer severity (p < 0.01), ulcer site (p < 0.01), peripheral artery disease (p < 0.01), neutrophil-to-lymphocyte ratio (p < 0.01) and Controlling Nutritional Status score (p < 0.05) were independent risk factors for amputation in diabetic foot ulcer patients and have predictive values for diabetic foot ulcer progression to amputation.
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Affiliation(s)
- Yandan Zhu
- Shanghai University of Traditional Chinese MedicineShanghaiChina
| | - Hongtao Xu
- Shanghai Traditional Chinese Medicine Integrated HospitalShanghai University of Traditional Chinese MedicineShanghaiChina
| | - Yuzhen Wang
- Shanghai Traditional Chinese Medicine Integrated HospitalShanghai University of Traditional Chinese MedicineShanghaiChina
| | - Xia Feng
- Shanghai University of Traditional Chinese MedicineShanghaiChina
| | - Xinyu Liang
- Shanghai University of Traditional Chinese MedicineShanghaiChina
| | - Liying Xu
- Shanghai Traditional Chinese Medicine Integrated HospitalShanghai University of Traditional Chinese MedicineShanghaiChina
| | - Zhiqiang Liang
- Shanghai Traditional Chinese Medicine Integrated HospitalShanghai University of Traditional Chinese MedicineShanghaiChina
| | - Zhongjia Xu
- Shanghai Traditional Chinese Medicine Integrated HospitalShanghai University of Traditional Chinese MedicineShanghaiChina
| | - Yawen Li
- Shanghai Traditional Chinese Medicine Integrated HospitalShanghai University of Traditional Chinese MedicineShanghaiChina
| | - Yi Le
- Shanghai Traditional Chinese Medicine Integrated HospitalShanghai University of Traditional Chinese MedicineShanghaiChina
| | - Manchen Zhao
- Shanghai Traditional Chinese Medicine Integrated HospitalShanghai University of Traditional Chinese MedicineShanghaiChina
| | - Jianfei Yang
- Shanghai Traditional Chinese Medicine Integrated HospitalShanghai University of Traditional Chinese MedicineShanghaiChina
| | - Ji Li
- Shanghai Traditional Chinese Medicine Integrated HospitalShanghai University of Traditional Chinese MedicineShanghaiChina
| | - Yemin Cao
- Shanghai Traditional Chinese Medicine Integrated HospitalShanghai University of Traditional Chinese MedicineShanghaiChina
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Khatoon MA, Karim SMK, Khan L, Karimi S, Abro UF. Exploring the Indications, Levels, and Outcomes of Lower Extremity Amputation at a Tertiary Care Hospital in Pakistan. Cureus 2023; 15:e48856. [PMID: 38024078 PMCID: PMC10656106 DOI: 10.7759/cureus.48856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2023] [Indexed: 12/01/2023] Open
Abstract
BACKGROUND Lower extremity amputation (LEA) is a surgical procedure performed to remove either a part or the entire lower limb due to medical conditions such as trauma, infection, peripheral vascular disease, or malignancy. The procedure is becoming increasingly common in Pakistan, with a bulk of patients presenting from rural areas in tertiary care centers. Understanding the indications, levels, and outcomes of LEA is essential for improving patient care and adopting preventive strategies, especially in developing countries. METHODOLOGY This study was conducted at Dow University Hospital in Karachi, Pakistan. Retrospective data of 384 patients who underwent non-traumatic lower extremity amputations between January 2016 and December 2020 was collected to include relevant history and characteristics, amputation indication and level, type of anesthesia used, and outcome within hospital stay. The data was analyzed using descriptive statistics. RESULTS The data is composed of a wide age range (18 to 91 years) of patients, including a male majority (76.3%, n = 293). The employment status of the patients was taken into consideration, with a reported high number of unemployed individuals (60.4%, n = 232). Diabetes mellitus (84.4%, n = 324) was a commonly reported past medical condition, followed by hypertension (4.4%, n = 17). Indications for amputation exceedingly recorded were diabetic foot ulcers (84.4%, n = 324), followed by infections (9.4%, n = 36) and peripheral arterial disease (3.6%, n = 14). The anesthetic approach that was observed most in these patients was regional anesthesia (74.7%, n = 287). Right-sided amputations (52.9%, n = 203) were dominant, with below-knee amputations leading by the level of amputation performed (42.5%, n = 163). Many patients delayed seeking treatment (71.6%, n = 275) and indicated denial of severity (18%, n = 69) as a reason for the delay. Regarding outcome, many patients were successfully discharged following treatment (85.9%, n = 330). CONCLUSION Overall, LEAs are being frequently performed in developing countries, such as Pakistan, especially with a large population living with diabetes mellitus. The implications of this disease are reflected in this study population, with the majority of patients reporting delays in treatment due to reasons such as the unknown severity of the disease or financial burdens. The challenges faced by these individuals, especially in this country, can be tackled with widespread affordability and availability of care and education on early management.
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Affiliation(s)
- Malik Amna Khatoon
- Orthopedic Surgery, Dow University of Health Sciences, Dow International Medical College, Karachi, PAK
| | - Syed Muhammad Khalid Karim
- Orthopedics and Trauma, Dow University of Health Sciences, Dow International Medical College, Karachi, PAK
| | - Laraib Khan
- Medical Education, Dow University of Health Sciences, Dow International Medical College, Karachi, PAK
| | - Sundas Karimi
- Orthopedic Surgery, Dow University of Health Sciences, Dow International Medical College, Karachi, PAK
| | - Umar Farooq Abro
- Orthopedics, Liaquat National Hospital and Medical College, Karachi, PAK
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Zhang H, Huang C, Bai J, Wang J. Effect of diabetic foot ulcers and other risk factors on the prevalence of lower extremity amputation: A meta-analysis. Int Wound J 2023; 20:3035-3047. [PMID: 37095728 PMCID: PMC10502264 DOI: 10.1111/iwj.14179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 03/21/2023] [Accepted: 03/27/2023] [Indexed: 04/26/2023] Open
Abstract
A meta-analysis study was conducted to measure the consequence of diabetic foot ulcers (DFUs) and other risk factors (RFs) on the prevalence of lower extremity amputation (LEA). A comprehensive literature inspection till February 2023 was applied and 2765 interrelated studies were reviewed. Of the 32 chosen studies enclosed, 9934 subjects were in the chosen studies' starting point, and 2906 of them were with LEA. Odds ratio (OR) in addition to 95% confidence intervals (CIs) were used to compute the value of the effect of DFUs and other RFs on the prevalence of LEA by the continuous and dichotomous approaches and a fixed or random effect model. Male gender (OR, 1.30; 95% CI, 1.17-1.44, P < .001), smoking (OR, 1.24; 95% CI, 1.01-1.53, P = .04), previous foot ulcer (OR, 2.69; 95% CI, 1.93-3.74, P < .001), osteomyelitis (OR, 3.87; 95% CI, 2.28-6.57, P < .001), gangrene (OR, 14.45; 95% CI, 7.03-29.72, P < .001), hypertension (OR, 1.17; 95% CI, 1.03-1.33, P = .01), and white blood cells count (WBCC) (MD, 2.05; 95% CI, 1.37-2.74, P < .001) were significantly shown to be an RF in LEA in subjects with DFUs. Age (MD, 0.81; 95% CI, -0.75 to 2.37, P = .31), body mass index (MD, -0.55; 95% CI, -1.15 to 0.05, P = .07), diabetes mellitus type (OR, 0.99; 95% CI, 0.63-1.56, P = .96), and glycated haemoglobin (MD, 0.33; 95% CI, -0.15 to 0.81, P = .17) were not shown to be an RF in LEA in subjects with DFUs. Male gender, smoking, previous foot ulcer, osteomyelitis, gangrene, hypertension, and WBCC were significantly shown to be an RF in LEA in subjects with DFUs. However, age and diabetes mellitus type were not shown to be RF in LEA in subjects with DFUs. However, caused of the small sample sizes of several chosen studies for this meta-analysis, care must be exercised when dealing with its values.
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Affiliation(s)
- Huiling Zhang
- Department of Endocrinology and MetabologyLiaocheng People's HospitalShandongChina
| | - Chuanwang Huang
- Department of Orthopedic SurgeryLiaocheng People's HospitalShandongChina
| | - Jie Bai
- Department of Endocrinology and MetabologyLiaocheng People's HospitalShandongChina
| | - Jing Wang
- Department of Endocrinology and MetabologyLiaocheng People's HospitalShandongChina
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Aragón-Sánchez J, Víquez-Molina G, López-Valverde ME, Rojas-Bonilla JM, Segura-Retana E. Residual osteomyelitis at the resection margin after conservative surgery is not associated with the recurrence of diabetic foot infection and may successfully be treated without postoperative antibiotic therapy. Diabet Med 2023; 40:e15162. [PMID: 37306219 DOI: 10.1111/dme.15162] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 05/23/2023] [Accepted: 06/03/2023] [Indexed: 06/13/2023]
Abstract
AIMS We hypothesize that microbiology- and pathology-confirmed positive bone margins after the resection of diabetes-related foot osteomyelitis are associated with worse outcomes. METHODS We conducted a prospective study consisting of a cohort of 93 patients with diabetes-related foot osteomyelitis (histopathology confirmed) who underwent bone resection and where an additional bone biopsy was taken at the resection margin. The primary outcome was the recurrence of the infection. RESULTS Pathology-confirmed positive margins were detected in 62 cases (66.7%), microbiology-confirmed positive margins were detected in 75 cases (80.6%) and recurrence was detected in 19 patients (20.4%). Chi-squared test failed to show the presence of an association between the recurrence of the infection with pathology-confirmed positive margins (p = 0.82), with microbiology-confirmed positive margins, (p = 0.34) and with the use of postoperative antibiotics (p = 0.70). Healing in patients with pathology-confirmed positive margins was achieved in a median of 12 weeks (95% CI 9.2-18) and those with pathology-confirmed negative margins in 14.9 weeks (95% CI 10.2-21.9), Log-rank test, p = 0.74. Thirty-four patients out of 61 available for follow-up (55.7%) with pathology-confirmed positive margins were treated without postoperative antibiotics. In that group, Chi-squared test failed to show the presence of an association between the recurrence of the infection with the use of postoperative antibiotics (p = 0.47). CONCLUSIONS A positive margin was neither associated with the recurrence of the infection nor with the time to healing. More than half of patients with pathology-confirmed positive margins were treated without postoperative antibiotics and this approach was not associated with the recurrence of the infection.
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Affiliation(s)
- Javier Aragón-Sánchez
- Department of Surgery, Diabetic Foot Unit, La Paloma Hospital, Las Palmas de Gran Canaria, Spain
| | | | | | | | - Elvira Segura-Retana
- Microbiology department, San Juan de Dios Hospital, San José de Costa Rica, Costa Rica
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Blanchette V, Patry J, Brousseau-Foley M, Todkar S, Libier S, Leclerc AM, Armstrong DG, Tremblay MC. Diabetic foot complications among Indigenous peoples in Canada: a scoping review through the PROGRESS-PLUS equity lens. Front Endocrinol (Lausanne) 2023; 14:1177020. [PMID: 37645408 PMCID: PMC10461566 DOI: 10.3389/fendo.2023.1177020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 07/18/2023] [Indexed: 08/31/2023] Open
Abstract
Introduction Indigenous peoples in Canada face a disproportionate burden of diabetes-related foot complications (DRFC), such as foot ulcers, lower extremity amputations (LEA), and peripheral arterial disease. This scoping review aimed to provide a comprehensive understanding of DRFC among First Nations, Métis, and Inuit peoples in Canada, incorporating an equity lens. Methods A scoping review was conducted based on Arksey and O'Malley refined by the Joanna Briggs Institute. The PROGRESS-Plus framework was utilized to extract data and incorporate an equity lens. A critical appraisal was performed, and Indigenous stakeholders were consulted for feedback. We identified the incorporation of patient-oriented/centered research (POR). Results Of 5,323 records identified, 40 studies were included in the review. The majority of studies focused on First Nations (92%), while representation of the Inuit population was very limited populations (< 3% of studies). LEA was the most studied outcome (76%). Age, gender, ethnicity, and place of residence were the most commonly included variables. Patient-oriented/centered research was mainly included in recent studies (16%). The overall quality of the studies was average. Data synthesis showed a high burden of DRFC among Indigenous populations compared to non-Indigenous populations. Indigenous identity and rural/remote communities were associated with the worse outcomes, particularly major LEA. Discussion This study provides a comprehensive understanding of DRFC in Indigenous peoples in Canada of published studies in database. It not only incorporates an equity lens and patient-oriented/centered research but also demonstrates that we need to change our approach. More data is needed to fully understand the burden of DRFC among Indigenous peoples, particularly in the Northern region in Canada where no data are previously available. Western research methods are insufficient to understand the unique situation of Indigenous peoples and it is essential to promote culturally safe and quality healthcare. Conclusion Efforts have been made to manage DRFC, but continued attention and support are necessary to address this population's needs and ensure equitable prevention, access and care that embraces their ways of knowing, being and acting. Systematic review registration Open Science Framework https://osf.io/j9pu7, identifier j9pu7.
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Affiliation(s)
- Virginie Blanchette
- Department of Human Kinetics and Podiatric Medicine, Université du Québec à Trois-Rivières, Trois-Rivières, QC, Canada
- VITAM-Centre de Recherche en Santé Durable, Québec, QC, Canada
- Centre de Recherche du Centre Intégré de Santé et Services Sociaux de Chaudière-Appalaches, Lévis, QC, Canada
| | - Jérôme Patry
- Centre de Recherche du Centre Intégré de Santé et Services Sociaux de Chaudière-Appalaches, Lévis, QC, Canada
- Faculty of Medicine, Family and Emergency Medicine Department, Université Laval, Québec, QC, Canada
| | - Magali Brousseau-Foley
- Department of Human Kinetics and Podiatric Medicine, Université du Québec à Trois-Rivières, Trois-Rivières, QC, Canada
- Faculty of Medicine, Centre Intégré Universitaire de Santé et de Services Sociaux de la Mauricie et du Centre-du-Québec Affiliated with Université de Montréal, Trois-Rivières Family Medicine University Clinic, Trois-Rivières, QC, Canada
| | - Shweta Todkar
- Department of Nursing, Université du Québec à Trois-Rivières, Trois-Rivières, QC, Canada
| | - Solène Libier
- Department of Human Kinetics and Podiatric Medicine, Université du Québec à Trois-Rivières, Trois-Rivières, QC, Canada
| | - Anne-Marie Leclerc
- Department of Nursing, Université du Québec à Trois-Rivières, Trois-Rivières, QC, Canada
| | - David G. Armstrong
- Southwestern Academic Limb Salvage Alliance (SALSA), Department of Surgery, Keck School of Medicine of University of Southern California, Los Angeles, CA, United States
| | - Marie-Claude Tremblay
- VITAM-Centre de Recherche en Santé Durable, Québec, QC, Canada
- Faculty of Medicine, Family and Emergency Medicine Department, Université Laval, Québec, QC, Canada
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11
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Lew E, Collins NP, Marek J, Schenck RC, Richter D, Gallegos R, Dunlap L, Murdock R. The Impact of Implementing a Diabetic Limb-Preservation Program on Amputation Outcomes at an Academic Institution in a Majority-Minority State. INT J LOW EXTR WOUND 2023:15347346231169879. [PMID: 37157806 DOI: 10.1177/15347346231169879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
Background. Diabetic foot osteomyelitis may precede major limb amputations and lengthy hospital admission. These complications impact patients' morbidity and mortality. Healthcare institutions with dedicated limb-preservation teams realize reduced amputation rates and improved quality of care. This study evaluates the outcomes following the implementation of a rigorous diabetic limb-preservation program at an academic institution. Methods. Patients with diabetes admitted for osteomyelitis occurring below the knee were identified by ICD-10 codes and included for retrospective review. The number and type of amputations, bone biopsies, revascularizations, and hospital length of stay (LOS) were evaluated. Outcomes were compared using the high-low (Hi-Lo) amputation ratio for the 24 months preceding and the 24 months after the integration of a diabetic limb-preservation service. Results. The authors identified and included 337 patients admitted for diabetic foot osteomyelitis. In the 24-month period prior to program implementation, 140 patients were evaluated. In the 24-month period after program implementation, 197 patients were evaluated. The overall amputation rate decreased from 67.1% (n = 94) to 59.9% (n = 118) (P = .214). Major limb amputation rates significantly decreased from 32.9% (n = 46) to 12.7% (n = 25) (P = .001). Minor amputation rates significantly increased from 34.2% (n = 48) to 47.2% (n = 93) (P = .024). The Hi-Lo amputation ratio decreased from 0.96 to 0.27 (P < .001). The rate of obtaining bone biopsies increased from 32.1% (n = 45) to 72.1% (P < .001). The rate of revascularization increased from 10.7% (n = 15) to 15.2% (n = 30) (P = .299). Average hospital LOS decreased significantly from 11.6 days to 9.8 days (P = .044). Conclusion. After the implementation of a limb-preservation team, there was a precipitous drop in major limb amputations in favor of minor amputations. The average hospital LOS decreased. These findings demonstrated improved clinical care and outcomes in patients with lower extremity osteomyelitis and reinforce the importance of a diabetic foot-preservation service within healthcare institutions.
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Affiliation(s)
- Eric Lew
- Department of Orthopaedics and Rehabilitation, Center for Healing in the Lower Extremity, The University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Nathaniel Perryman Collins
- Department of Internal Medicine, The University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - John Marek
- Department of Surgery, The University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Robert C Schenck
- Department of Orthopaedics and Rehabilitation, The University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Dustin Richter
- Department of Orthopaedics and Rehabilitation, The University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Regina Gallegos
- Rehabilitation Services Center for Healing in the Lower Extremity, The University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Leslie Dunlap
- Department of Orthopaedics and Rehabilitation, Center for Healing in the Lower Extremity, The University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Richard Murdock
- Rehabilitation Services Center for Healing in the Lower Extremity, The University of New Mexico Health Sciences Center, Albuquerque, NM, USA
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12
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Littman AJ, Peterson AC, Korpak A, Czerniecki JM, Turner A, Norvell DC, Williams RM, Lehavot K. Differences in prosthetic prescription between men and women Veterans following transtibial or transfemoral lower extremity amputation: a longitudinal cohort study (2005-2018). Arch Phys Med Rehabil 2023:S0003-9993(23)00146-6. [PMID: 36906098 DOI: 10.1016/j.apmr.2023.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 01/26/2023] [Accepted: 02/20/2023] [Indexed: 03/11/2023]
Abstract
OBJECTIVE To evaluate whether prosthetic prescription differed by gender and the extent to which differences were mediated by measured factors. DESIGN Retrospective longitudinal cohort study using data from Veterans Health Administration (VHA) administrative databases. SETTING VHA patients throughout the United States. PARTICIPANTS The sample included 20,889 men and 324 women who had an incident transtibial or transfemoral amputation between 2005 and 2018. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Time to prosthetic prescription (up to one year). We used parametric survival analysis (an accelerated failure time [AFT] model) to assess gender differences. We estimated mediation effects of amputation level, pain comorbidity burden, medical comorbidities, depression, and marital status on time to prescription. RESULTS In the 1 year after amputation, the proportion of women (54.3%) and men (55.7%) prescribed a prosthesis was similar. However, after controlling for age, race, ethnicity, enrollment priority, VHA region, and service-connected disability, the time to prosthetic prescription was significantly faster among men compared to women (Acceleration factor= 0.71, 95% CI 0.60-0.86). The difference in time to prosthetic prescription between men and women was significantly mediated by amputation level (19%), pain comorbidity burden (-13%), and marital status (5%), but not medical comorbidities or depression. CONCLUSION Though the proportion of patients with prosthetic prescription at 1-year post-amputation was similar between men and women, women received prosthetic prescriptions more slowly than men, suggesting that more work is needed to understand barriers to timely prosthetic prescriptions among women, and how to intervene to reduce those barriers.
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Affiliation(s)
- Alyson J Littman
- Seattle Epidemiologic Research Information Center, VA Puget Sound Health Care System, Seattle, Washington; Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, US Department of Veterans Affairs, Seattle, Washington; Department of Epidemiology, University of Washington, Seattle, Washington.
| | - Alexander C Peterson
- Seattle Epidemiologic Research Information Center, VA Puget Sound Health Care System, Seattle, Washington
| | - Anna Korpak
- Seattle Epidemiologic Research Information Center, VA Puget Sound Health Care System, Seattle, Washington
| | - Joseph M Czerniecki
- VA Center for Limb Loss and Mobility (CLiMB), VA Puget Sound, Seattle, Washington; Department of Rehabilitation Medicine, University of Washington, Seattle, Washington
| | - Aaron Turner
- VA Center for Limb Loss and Mobility (CLiMB), VA Puget Sound, Seattle, Washington; Department of Rehabilitation Medicine, University of Washington, Seattle, Washington; Rehabilitation Care Service, VA Puget Sound Health Care System, Seattle, Washington
| | - Daniel C Norvell
- VA Center for Limb Loss and Mobility (CLiMB), VA Puget Sound, Seattle, Washington; Department of Rehabilitation Medicine, University of Washington, Seattle, Washington
| | - Rhonda M Williams
- VA Center for Limb Loss and Mobility (CLiMB), VA Puget Sound, Seattle, Washington; Department of Rehabilitation Medicine, University of Washington, Seattle, Washington; Rehabilitation Care Service, VA Puget Sound Health Care System, Seattle, Washington
| | - Keren Lehavot
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, US Department of Veterans Affairs, Seattle, Washington; Department of Psychiatry & Behavioral Sciences, University of Washington, Seattle, Washington; Department of Health Services, University of Washington, Seattle, Washington
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13
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López-Valverde ME, Aragón-Sánchez J, Víquez-Molina G. Handgrip Strength But Not Malnutrition According to Global Leadership Initiative on Malnutrition Criteria Is a Risk Factor for Mortality in Hospitalized Patients with Ischemic Diabetic Foot Ulcers. Adv Wound Care (New Rochelle) 2023; 12:127-134. [PMID: 34465187 DOI: 10.1089/wound.2021.0109] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Objective: This study aimed to test the hypothesis that patients with malnutrition and impaired muscle function determined by hand grip strength (HGS) will have adverse outcomes. Approach: We conducted a prospective observational study of 77 patients admitted for ischemic diabetic foot ulcers (IDFU). Global Leadership Initiative on Malnutrition (GLIM) criteria were used to diagnose malnutrition. Values obtained with a dynamometer were dichotomized into values < and ≥ mean according to the values obtained in both sexes. The Cox proportional hazards model and the Kaplan-Meier method were applied. STROBE guidelines for cohorts were met in the present study. Results: In total, 55 patients (71.4%) were malnourished. Malnutrition according to GLIM criteria was not associated with adverse outcomes. HGS < mean was associated with patient age, duration of diabetes mellitus, body mass index, brachial circumference, plasma albumin, prealbumin, hemoglobin, transferrin, and HbA1c levels. Predictive variables of mortality after applying multivariate Cox model were age >69years (hazard ratio [HR] 4.0, 95% confidence interval [CI] 1.3-12.0, p = 0.01), and HGS < mean (HR 3.7, 95% CI 1.2-11.3, p = 0.01). Survival time in patients with HGS < mean was shorter than in those with HGS ≥ mean, p < 0.01. Innovation: HGS is an easy and useful tool associated with nutritional parameters and with prognosis in patients admitted for IDFU. Conclusions: Neither malnutrition nor muscle function impairment were associated with limb loss or a need for readmission. Patients with HGS < mean presented shorter survival times. As HGS is a simple and cost-effective tool, it should be implemented as part of the nutritional admission evaluation.
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Affiliation(s)
| | - Javier Aragón-Sánchez
- Diabetic Foot Unit, Department of Surgery, La Paloma Hospital, Las Palmas de Gran Canaria, Spain
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14
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Aragón-Sánchez J, Víquez-Molina G, López-Valverde ME, Rojas-Bonilla JM, Murillo-Vargas C. Does Metabolic Control Have Any Influence on the Clinical Presentation and Short-Term Outcomes of Diabetic Foot Infections? Adv Wound Care (New Rochelle) 2023; 12:135-144. [PMID: 34078116 DOI: 10.1089/wound.2021.0072] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Objective: We hypothesized that patients with poor glycemic control undergoing treatment for diabetic foot infections (DFIs) would have a poorer prognosis than those with better metabolic control assessed by glycated hemoglobin (HbA1c). Approach: We analyzed a retrospective cohort of 245 patients with moderate and severe DFIs. HbA1c values were dichotomized (<7% or ≥7% and ≤75th percentile (P75) and >P75) to analyze patient outcomes regarding metabolic control. The present study adhered to the STROBE guidelines for cohort studies. Results: One hundred sixty-nine patients (69%) were men. Their mean age was 60.7 years (10.8). HbA1c ≥7% was detected in 203 patients (82.9%). P75 HbA1c was 10.9%. After performing univariate analysis, we found an association of HbA1c <7% with major amputations and mortality. However, after applying the logistic regression model, we did not find HbA1c <7% to be a predictive factor of major amputation. The risk factors for mortality following application of Cox's proportional hazards model were osteomyelitis (HR: 0.2, 95% CI: 0.07-0.62, p < 0.01), eGFR <60 mL/min/1.73 m2 (HR: 2.7, 95% CI: 1.0-7.5, p = 0.04), and HbA1c <7% (HR: 4.9, 95% CI: 1.8-13.2, p < 0.01). Innovation: The group with optimal glycemic control (HbA1c <7%) had a shorter survival time than those with worse metabolic control. Conclusions: We did not find a longer duration of hospitalization, a higher rate of amputations, or longer healing times in the groups with worse metabolic control. HbA1c <7% was a risk factor for mid-term mortality.
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Affiliation(s)
- Javier Aragón-Sánchez
- Department of Surgery, Diabetic Foot Unit, La Paloma Hospital, Las Palmas de Gran Canaria, Spain
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15
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Madsen UR, Biesbjerg CB, Mikkelsen TB, Marsaa K, Olsen Zwisler AD, Vedste Aagaard T. Considerable gaps and differences in rehabilitation after major lower extremity amputations across regions and municipalities in Denmark - A national survey. Scand J Caring Sci 2023; 37:595-607. [PMID: 36727432 DOI: 10.1111/scs.13144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 11/14/2022] [Accepted: 01/05/2023] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Equal access to healthcare is a fundamental principle in the fully tax-financed Danish healthcare system. This study reveals whether this system lives up to the principle of equal access when it comes to the rehabilitation of patients who have major lower extremity amputations. METHODS With the aim of exploring possible inequality in rehabilitation for patients having major lower extremity amputation in Denmark, a nationwide electronic survey was conducted in the autumn of 2020, which included all hospitals and municipalities in Denmark. RESULTS Eighty six percent of hospitals (n = 19) and 97% (n = 95) of municipalities responded. Of the 32% (n = 6) of hospitals and 78% (n = 74) of municipalities that provided prosthesis rehabilitation, the majority (hospitals 50% /municipalities 91%) provided prostheses for <10 patients in 2019, and 36% reported having competencies at only a general level among physiotherapists performing prosthetic training. Psychosocial rehabilitation modalities were lacking overall. CONCLUSIONS This national study documents pronounced geographic inequality in access to qualified rehabilitation services for the relatively few patients undergoing lower extremity amputations in Denmark. The decentralised organisation of amputation rehabilitation makes it difficult to build and maintain specialist competencies among healthcare professionals. Inconsistent availability of psychosocial rehabilitation modalities of all kinds found in this study points to a need for action particularly among patients not in prosthetic rehabilitation where palliative needs should also be considered.
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Affiliation(s)
- Ulla Riis Madsen
- Department of Orthopedic Surgery, Holbaek Hospital, Holbaek, Denmark.,REHPA, Danish Knowledge Centre for Rehabilitation and Palliative Care, University of Southern Denmark, Holbaek, Denmark
| | | | - Tina Broby Mikkelsen
- REHPA, The Danish Knowledge Centre for Rehabilitation and Palliative Care, Odense University Hospital, Nyborg, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | | | - Ann-Dorthe Olsen Zwisler
- REHPA, The Danish Knowledge Centre for Rehabilitation and Palliative Care, Odense University Hospital, Nyborg, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Thomas Vedste Aagaard
- Department of Orthopedic Surgery, Holbaek Hospital, Holbaek, Denmark.,Department of Physiotherapy and Occupational Therapy, Holbaek Hospital, Holbaek, Denmark.,Department of Orthopaedic Surgery, Zealand University Hospital, Koege, Denmark
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16
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Eidmann A, Kamawal Y, Luedemann M, Raab P, Rudert M, Stratos I. Demographics and Etiology for Lower Extremity Amputations-Experiences of an University Orthopaedic Center in Germany. Medicina (Kaunas) 2023; 59:medicina59020200. [PMID: 36837401 PMCID: PMC9965459 DOI: 10.3390/medicina59020200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 01/09/2023] [Accepted: 01/18/2023] [Indexed: 01/20/2023]
Abstract
Background and Objectives: Currently, the worldwide incidence of major amputations in the general population is decreasing whereas the incidence of minor amputations is increasing. The purpose of our study was to analyze whether this trend is reflected among orthopaedic patients treated with lower extremity amputation in our orthopaedic university institution. Materials and Methods: We conducted a single-center retrospective study and included patients referred to our orthopaedic department for lower extremity amputation (LEA) between January 2007 and December 2019. Acquired data were the year of amputation, age, sex, level of amputation and cause of amputation. T test and Chi² test were performed to compare age and amputation rates between males and females; significance was defined as p < 0.05. Linear regression and multivariate logistic regression models were used to test time trends and to calculate probabilities for LEA. Results: A total of 114 amputations of the lower extremity were performed, of which 60.5% were major amputations. The number of major amputations increased over time with a rate of 0.6 amputation/year. Men were significantly more often affected by LEA than women. Age of LEA for men was significantly below the age of LEA for women (men: 54.8 ± 2.8 years, women: 64.9 ± 3.2 years, p = 0.021). Main causes leading to LEA were tumors (28.9%) and implant-associated complications (25.4%). Implant-associated complications and age raised the probability for major amputation, whereas malformation, angiopathies and infections were more likely to cause a minor amputation. Conclusions: Among patients in our orthopaedic institution, etiology of amputations of the lower extremity is multifactorial and differs from other surgical specialties. The number of major amputations has increased continuously over the past years. Age and sex, as well as diagnosis, influence the type and level of amputation.
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17
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Gong H, Ren Y, Li Z, Zha P, Bista R, Li Y, Chen D, Gao Y, Chen L, Ran X, Wang C. Clinical characteristics and risk factors of lower extremity amputation in the diabetic inpatients with foot ulcers. Front Endocrinol (Lausanne) 2023; 14:1144806. [PMID: 37065766 PMCID: PMC10102466 DOI: 10.3389/fendo.2023.1144806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Accepted: 03/16/2023] [Indexed: 04/03/2023] Open
Abstract
OBJECTIVES To analyze clinical characteristics of the diabetic inpatients with foot ulcers and explore the risk factors of lower extremity amputation (LEA) in West China Hospital of Sichuan University. METHODS A retrospective analysis was performed based on the clinical data of the patients with diabetic foot ulcer (DFU) hospitalized in West China Hospital of Sichuan University from January 1, 2012 to December 31, 2020. The DFU patients were divided into three groups: non-amputation, minor amputation, and major amputation groups. The ordinal logistic regression analysis was used to identify the risk factors for LEA. RESULTS 992 diabetic patients (622 males and 370 females) with DFU were hospitalized in the Diabetic Foot Care Center of Sichuan University. Among them, 72 (7.3%) (55 minor amputations and 17 major amputations) cases experienced amputation, and 21(2.1%) refused amputation. Excluding the patients who refused amputation, the mean age and duration of diabetes of and HbA1c the 971 patients with DFU, were 65.1 ± 12.3 years old, 11.1 ± 7.6 years, and 8.6 ± 2.3% respectively. The patients in the major amputation group were older and had longer course of diabetes for a longer period of time than those in the non-amputation and minor amputation groups. Compared with the non-amputation patients (55.1%), more patients with amputation (minor amputation (63.5%) and major amputation (88.2%)) suffered from peripheral arterial disease (P=0.019). The amputated patients had statistically lower hemoglobin, serum albumin and ankle brachial index (ABI), but higher white blood cell, platelet counts, fibrinogen and C-reactive protein levels. The patients with amputation had a higher incidence of osteomyelitis (P = 0.006), foot gangrene (P < 0.001), and a history of prior amputations (P < 0.001) than those without amputation. Furthermore, a history of prior amputation (odds ratio 10.194; 95% CI, 2.646-39.279; P=0.001), foot gangrene (odds ratio 6.466; 95% CI, 1.576-26.539; P=0.010) and ABI (odds ratio 0.791; 95% CI, 0.639-0.980; P = 0.032) were significantly associated with LEAs. CONCLUSIONS The DFU inpatients with amputation were older with long duration of diabetes, poorly glycemic control, malnutrition, PAD, severe foot ulcers with infection. A history of prior amputation, foot gangrene and a low ABI level were the independent predictors of LEA. Multidisciplinary intervention for DFU is essential to avoid amputation of the diabetic patients with foot ulcer.
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Affiliation(s)
- Hongping Gong
- Department of Endocrinology and Metabolism, Diabetic Foot Care Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- International Medical Center Ward, Department of General Practice, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yan Ren
- Department of Endocrinology and Metabolism, Diabetic Foot Care Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Zhenyi Li
- Department of Endocrinology and Metabolism, Diabetic Foot Care Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Panpan Zha
- Department of Endocrinology and Metabolism, Diabetic Foot Care Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Raju Bista
- Department of Endocrinology and Metabolism, Diabetic Foot Care Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yan Li
- Department of Clinical Research Management, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Dawei Chen
- Department of Endocrinology and Metabolism, Diabetic Foot Care Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yun Gao
- Department of Endocrinology and Metabolism, Diabetic Foot Care Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Lihong Chen
- Department of Endocrinology and Metabolism, Diabetic Foot Care Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xingwu Ran
- Department of Endocrinology and Metabolism, Diabetic Foot Care Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Chun Wang
- Department of Endocrinology and Metabolism, Diabetic Foot Care Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- *Correspondence: Chun Wang, ,
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18
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Coman H, Stancu B, Gâvan NA, Bowling FL, Podariu L, Bondor CI, Radulian G. Diabetes-Related Lower Extremity Amputations in Romania: Patterns and Changes between 2015 and 2019. Int J Environ Res Public Health 2022; 20:557. [PMID: 36612876 PMCID: PMC9819762 DOI: 10.3390/ijerph20010557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 12/24/2022] [Accepted: 12/26/2022] [Indexed: 06/17/2023]
Abstract
Lower extremity amputations (LEAs) are a feared complication of diabetes mellitus (DM). Here we evaluated the recent trends in DM-related LEAs in Romania. We collected data from a national database regarding minor and major LEAs performed between 2015 and 2019 in patients with DM admitted to a public hospital. Absolute numbers of LEAs were presented by year, diabetes type, sex and age; incidence rates of LEAs in the general population were also calculated. Over the study period, 40,499 LEAs were recorded nationwide (83.16% in persons with type 2 DM [T2DM]); on average, the number of LEAs increased by 5.7%/year. This trend was driven by an increased number of LEAs in patients with T2DM; in patients with type 1 DM (T1DM), LEAs decreased over the study period. In patients with T2DM, the increase in minor LEAs was more pronounced than that in major LEAs. The overall number of LEAs showed an increasing trend with age (r = 0.72), which was most pronounced in patients aged ≥70 years. Men had a higher frequency of LEAs than women, regardless of DM type. These data support renewed efforts to prevent and decrease the burden of amputations among patients with DM.
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Affiliation(s)
- Horaţiu Coman
- Vascular Surgery Clinic, Cluj County Emergency Hospital, 400347 Cluj-Napoca, Romania
| | - Bogdan Stancu
- Second Department of Surgery, “Iuliu Haţieganu” University of Medicine and Pharmacy, 400006 Cluj-Napoca, Romania
| | | | - Frank L. Bowling
- Developmental Biomedicine Research Group, The University of Manchester, Manchester M13 9PL, UK
- Department of Vascular Surgery and Reconstructive Microsurgery, “Victor Babeş” University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | - Laura Podariu
- Vascular Surgery Clinic, Cluj County Emergency Hospital, 400347 Cluj-Napoca, Romania
- “Nicolae Stăncioiu” Heart Institute, 400001 Cluj-Napoca, Romania
| | - Cosmina I. Bondor
- Department of Medical Informatics and Biostatistics, “Iuliu Haţieganu” University of Medicine and Pharmacy, 400349 Cluj-Napoca, Romania
| | - Gabriela Radulian
- Department of Internal Medicine, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucureşti, Romania
- “Prof. Dr. Nicolae Paulescu” National Institute for Diabetes, Nutrition and Metabolic Diseases, 030167 Bucuresti, Romania
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Poehler D, Czerniecki J, Norvell D, Henderson A, Dolan J, Devine B. The Development and Pilot Study of a Multiple Criteria Decision Analysis (MCDA) to Compare Patient and Provider Priorities around Amputation-Level Outcomes. MDM Policy Pract 2022; 7:23814683221143765. [PMID: 36545397 PMCID: PMC9761219 DOI: 10.1177/23814683221143765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 11/11/2022] [Indexed: 12/23/2022] Open
Abstract
Background. Patients with chronic limb-threatening ischemia who are facing a lower-limb amputation often require a transmetatarsal amputation (TMA) or a transtibial amputation (TTA). A TMA preserves more of the patient's limb and may provide better mobility but has a lower probability of primary wound healing relative to a TTA and may result in additional amputation surgeries. Understanding the differences in how patients and providers prioritize key outcomes may enhance the amputation decisional process. Purpose. To develop and pilot test a multiple criteria decision analysis (MCDA) tool to elicit patient values around amputation-level selection and compare those with provider perceptions of patient values. Methods. We conducted literature reviews to identify and measure the performance of criteria important to patients. Because the quantitative literature was sparse, we developed a Sheffield elicitation framework exercise to elicit criteria performance from subject matter experts. We piloted our MCDA among patients and providers to understand tool acceptability and preliminarily assess differences in patient and provider priorities. Results. Five criteria of importance were identified: ability to walk, healing after amputation surgery, rehabilitation intensity, limb length, and prosthetic/orthotic device ease. Patients and providers successfully completed the MCDA and identified challenges in doing so. We propose potential solutions to these challenges. The results of the pilot test suggest differences in patient and provider outcome priorities. Limitations. The pilot test study enrolled a small sample of providers and patients. Conclusions. We successfully implemented the pilot study to patients and providers, received helpful feedback, and identified solutions to improve the tool. Implications. Once modified, our MCDA tool will be suitable for wider rollout. Highlights Patients and providers have successfully completed our MCDA, and patients feel the MCDA may be useful in clinical practice.We encountered several methodologic challenges and identified approaches to ease participant burden.When data are sparse, using the Sheffield elicitation framework is helpful in creating a performance matrix, although patients relied largely on their amputation experiences to complete the exercise. Blinding the alternatives may help patients better understand the process.
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Affiliation(s)
- Diana Poehler
- Diana Poehler, Department of Health
Services, Magnuson Health Sciences Center, University of Washington (UW), 1959
NE Pacific St, Seattle, WA 98195-0005, USA;
()
| | - Joseph Czerniecki
- Department of Rehabilitation Medicine,
University of Washington, Seattle, WA, USA
| | - Daniel Norvell
- VA Puget Sound Health Care System, Veterans
Affairs Center for Limb Loss and Mobility (CLiMB), Seattle, WA, USA,Department of Rehabilitation Medicine,
University of Washington, Seattle, WA, USA
| | - Alison Henderson
- VA Puget Sound Health Care System, Veterans
Affairs Center for Limb Loss and Mobility (CLiMB), Seattle, WA, USA
| | - James Dolan
- Department of Public Health Sciences (Retired),
University of Rochester, Rochester, NY, USA
| | - Beth Devine
- The Comparative Health Outcomes, Policy, and
Economics Institute, University of Washington, Seattle, WA, USA,Department of Health Services, University of
Washington, Seattle, WA, USA
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20
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Yammine K, Akiki S, Assi C, Hayek Md F. Amputation as a First Treatment is Highly Associated With Late Presentation: An Underestimated Modifiable Major Risk Factor for Diabetic Foot Ulcer. Foot Ankle Spec 2021:19386400211067625. [PMID: 34967230 DOI: 10.1177/19386400211067625] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE Several risk factors for lower extremity amputation in diabetic patients have been identified; however, late presentation has been poorly investigated. Very few studies looked at the impact of such risk factor. As none has investigated the link between admission to amputation and late presentation in this population, we investigated such association. METHODS The study is a retrospective comparative cohort of continuous series of patients admitted for amputation related to diabetic foot ulcer (DFU) as a first treatment. A late presentation was defined as a period of 3 weeks or more from the onset of the ulcer. RESULTS Forty-six patients admitted for amputation and all wounds were infected and located on the plantar forefoot in 32 cases (69.5%), on the toes in 10 cases (21.7%), and in the heel area in 4 cases (8.8%). The mean duration to admission was 5.2 ±1.8 weeks (range 4-10 weeks). Late presentation was recorded in 42 (91.3%) patients. CONCLUSION This study demonstrates that amputation due to DFU is highly associated with late presentation. Educational campaigns targeting patient and first-line health care providers and highlighting the urgency of diabetic ulcers are needed to impact this major modifiable risk factor.Levels of Evidence: Therapeutic, Level III: Retrospective Comparative.
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Affiliation(s)
- Kaissar Yammine
- Department of Orthopedic Surgery, LAU Medical Center-Rizk Hospital, School of Medicine, Lebanese American University, Beirut, Lebanon (KY, CA)
- Diabetic Foot Clinic, LAU Medical Center-Rizk Hospital, Lebanese American University, Beirut, Lebanon (KY)
- Center for Evidence-Based Anatomy, Sport & Orthopedics Research (KY, CA)
- Department of Clinical Nutrition, LAU Medical Center-Rizk Hospital, School of Medicine, Lebanese American University, Beirut, Lebanon (SA)
- Division of Vascular Surgery, Department of Surgery, LAU Medical Center-Rizk Hospital, School of Medicine, Lebanese American University, Beirut, Lebanon (FH)
| | - Sandra Akiki
- Department of Orthopedic Surgery, LAU Medical Center-Rizk Hospital, School of Medicine, Lebanese American University, Beirut, Lebanon (KY, CA)
- Diabetic Foot Clinic, LAU Medical Center-Rizk Hospital, Lebanese American University, Beirut, Lebanon (KY)
- Center for Evidence-Based Anatomy, Sport & Orthopedics Research (KY, CA)
- Department of Clinical Nutrition, LAU Medical Center-Rizk Hospital, School of Medicine, Lebanese American University, Beirut, Lebanon (SA)
- Division of Vascular Surgery, Department of Surgery, LAU Medical Center-Rizk Hospital, School of Medicine, Lebanese American University, Beirut, Lebanon (FH)
| | - Chahine Assi
- Department of Orthopedic Surgery, LAU Medical Center-Rizk Hospital, School of Medicine, Lebanese American University, Beirut, Lebanon (KY, CA)
- Diabetic Foot Clinic, LAU Medical Center-Rizk Hospital, Lebanese American University, Beirut, Lebanon (KY)
- Center for Evidence-Based Anatomy, Sport & Orthopedics Research (KY, CA)
- Department of Clinical Nutrition, LAU Medical Center-Rizk Hospital, School of Medicine, Lebanese American University, Beirut, Lebanon (SA)
- Division of Vascular Surgery, Department of Surgery, LAU Medical Center-Rizk Hospital, School of Medicine, Lebanese American University, Beirut, Lebanon (FH)
| | - Fady Hayek Md
- Department of Orthopedic Surgery, LAU Medical Center-Rizk Hospital, School of Medicine, Lebanese American University, Beirut, Lebanon (KY, CA)
- Diabetic Foot Clinic, LAU Medical Center-Rizk Hospital, Lebanese American University, Beirut, Lebanon (KY)
- Center for Evidence-Based Anatomy, Sport & Orthopedics Research (KY, CA)
- Department of Clinical Nutrition, LAU Medical Center-Rizk Hospital, School of Medicine, Lebanese American University, Beirut, Lebanon (SA)
- Division of Vascular Surgery, Department of Surgery, LAU Medical Center-Rizk Hospital, School of Medicine, Lebanese American University, Beirut, Lebanon (FH)
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21
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Ohnuma T, Horres CR, Raghunathan K, Bartz RR, Krishnamoorthy V, Brookhart MA, Kent ML. Trends in multimodal analgesics among end-stage renal disease patients undergoing lower extremity amputation in the US from 2009 to 2018. Br J Anaesth 2021; 128:e43-e45. [PMID: 34852927 DOI: 10.1016/j.bja.2021.10.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 10/13/2021] [Accepted: 10/19/2021] [Indexed: 11/20/2022] Open
Affiliation(s)
- Tetsu Ohnuma
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA.
| | - C Russell Horres
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Karthik Raghunathan
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA; Patient Safety Center of Inquiry, Durham VA Medical Center, Durham, NC, USA
| | - Raquel R Bartz
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | | | - M Alan Brookhart
- Department of Population Health Sciences, Duke University, Durham, NC, USA
| | - Michael L Kent
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
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22
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Tehan PE, Hawes MB, Hurst J, Sebastian M, Peterson BJ, Chuter VH. Factors influencing lower extremity amputation outcomes in people with active foot ulceration in regional Australia: A retrospective cohort study. Wound Repair Regen 2021; 30:24-33. [PMID: 34698428 DOI: 10.1111/wrr.12978] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 08/19/2021] [Accepted: 10/05/2021] [Indexed: 11/29/2022]
Abstract
Australia has the second highest rate of non-traumatic lower extremity amputation (LEA) globally. Australia's large geographical size is one of the biggest challenges facing limb preservation services and may be contributing to LEA. The aim of this study was to determine what factors contribute to the likelihood of LEA in people with active foot ulceration in regional Australia. This retrospective cohort study audited patients with active foot ulceration in a multidisciplinary high risk foot service (HRFS) in regional Australia. Neurological, vascular and wound characteristics were systematically extracted, along with demographic information. Participants were followed for at least 12 months until healing or LEA occurred. Correlations between LEA and clinical and demographic characteristics were assessed using the Pearson's product moment correlation coefficient and chi squared test for independence. Significant variables (p < 0.05) were included in the model. Direct logistic regression assessed the independent contribution of significantly correlated variables on the likelihood of LEA. Of note, 1876 records were hand screened with 476 participants (25%) meeting the inclusion criteria. Geographical distance from the HRFS, toe systolic pressure (TSP), diabetes and infection were all significantly correlated with LEA and included in the logistic regression model. TSP decrease of 1 mmHg (OR 1.02, 95% CI 1.01-1.03), increased geographical distance (1 km) from HRFS (OR 1.006, 95% CI 1.001-1.01) infection (OR 2.08, 95% CI 1.06-4.07) and presence of diabetes (OR 3.77, 95% CI 1.12-12.65) were all significantly associated with increased likelihood of LEA. HRFS should account for the disparity in outcomes between patients living in close proximity to their service, compared to those in rural areas. Optimal management of diabetes, vascular perfusion and control of infection may also contribute to preventing LEA in people with active foot ulceration.
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Affiliation(s)
- Peta Ellen Tehan
- School of Health Sciences, Faculty of Health and Medicine, University of Newcastle, New South Wales, Australia
| | - Morgan Brian Hawes
- School of Health Sciences, Faculty of Health and Medicine, University of Newcastle, New South Wales, Australia
| | - Joanne Hurst
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, Scotland, UK
| | - Mathew Sebastian
- Department of Surgery, John Hunter Hospital, New Lambton Heights, New South Wales, Australia
| | - Benjamin John Peterson
- School of Health Sciences, Faculty of Health and Medicine, University of Newcastle, New South Wales, Australia
| | - Vivienne Helaine Chuter
- School of Health Sciences, Faculty of Health and Medicine, University of Newcastle, New South Wales, Australia
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23
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Lo ZJ, Chandrasekar S, Yong E, Hong Q, Zhang L, Chong LRC, Tan G, Chan YM, Koo HY, Chew T, Sani NF, Cheong KY, Cheng LRQ, Tan AHM, Muthuveerappa S, Lai TP, Goh CC, Ang GY, Zhu Z, Hoi WH, Lin JHX, Chew DEK, Lim B, Yeo PS, Liew H. Clinical and economic outcomes of a multidisciplinary team approach in a lower extremity amputation prevention programme for diabetic foot ulcer care in an Asian population: A case-control study. Int Wound J 2021; 19:765-773. [PMID: 34363329 PMCID: PMC9013583 DOI: 10.1111/iwj.13672] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 07/28/2021] [Accepted: 07/28/2021] [Indexed: 12/28/2022] Open
Abstract
Present guidelines recommend a multidisciplinary team (MDT) approach to diabetic foot ulcer (DFU) care, but relevant data from Asia are lacking. We aim to evaluate the clinical and economic outcomes of an MDT approach in a lower extremity amputation prevention programme (LEAPP) for DFU care in an Asian population. We performed a case‐control study of 84 patients with DFU between January 2017 and October 2017 (retrospective control) vs 117 patients with DFU between December 2017 and July 2018 (prospective LEAPP cohort). Comparing the clinical outcomes between the retrospective cohort and the LEAPP cohort, there was a significant decrease in mean time from referral to index clinic visit (38.6 vs 9.5 days, P < .001), increase in outpatient podiatry follow‐up (33% vs 76%, P < .001), decrease in 1‐year minor amputation rate (14% vs 3%, P = .007), and decrease in 1‐year major amputation rate (9% vs 3%, P = .05). Simulation of cost avoidance demonstrated an annualised cost avoidance of USD $1.86m (SGD $2.5m) for patients within the LEAPP cohort. In conclusion, similar to the data from Western societies, an MDT approach in an Asian population, via a LEAPP for patients with DFU, demonstrated a significant reduction in minor and major amputation rates, with annualised cost avoidance of USD $1.86m.
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Affiliation(s)
- Zhiwen Joseph Lo
- Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore.,Lee Kong Chian School of Medicine Centre for Population Health Sciences, Nayang Technological University, Singapore.,Skin Research Institute of Singapore, Agency for Science, Technology and Research, Singapore
| | - Sadhana Chandrasekar
- Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | - Enming Yong
- Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | - Qiantai Hong
- Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | - Li Zhang
- Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | | | - Glenn Tan
- Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | - Yam Meng Chan
- Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | - Hui Yan Koo
- Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | - Tiffany Chew
- Department of Podiatry, Tan Tock Seng Hospital, Singapore
| | | | | | | | - Audrey Hui Min Tan
- Wound and Stoma Care, Nursing Specialty, Tan Tock Seng Hospital, Singapore
| | | | - Tina Peiting Lai
- Wound and Stoma Care, Nursing Specialty, Tan Tock Seng Hospital, Singapore
| | - Cheng Cheng Goh
- Wound and Stoma Care, Nursing Specialty, Tan Tock Seng Hospital, Singapore
| | - Gary Y Ang
- Health Services and Outcomes Research, National Healthcare Group, Singapore
| | - Zhecheng Zhu
- Health Services and Outcomes Research, National Healthcare Group, Singapore
| | - Wai Han Hoi
- Department of Endocrinology, Woodlands Health Campus, Singapore
| | - Jaime H X Lin
- Department of Endocrinology, Woodlands Health Campus, Singapore
| | - Daniel E K Chew
- Department of Endocrinology, Tan Tock Seng Hospital, Singapore
| | - Brenda Lim
- Department of Endocrinology, Tan Tock Seng Hospital, Singapore
| | - Pei Shan Yeo
- Department of Endocrinology, Tan Tock Seng Hospital, Singapore
| | - Huiling Liew
- Department of Endocrinology, Tan Tock Seng Hospital, Singapore
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24
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Pran L, Harnanan D, Baijoo S, Short A, Cave C, Maharaj R, Cawich SO, Naraynsingh V. Major Lower Limb Amputations: Recognizing Pitfalls. Cureus 2021; 13:e16972. [PMID: 34540383 PMCID: PMC8423325 DOI: 10.7759/cureus.16972] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/06/2021] [Indexed: 11/21/2022] Open
Abstract
Major lower extremity amputations have been an area of much concern in the Caribbean population. Hence, the purpose of this research was to investigate the current trends in major lower-extremity amputations. Data regarding all major lower-extremity amputations performed at a tertiary care institution in Trinidad and Tobago, from January 2010 to December 2016 were reviewed. The variation of yearly trends, gender, type of amputation and reason for amputation were analysed. The yearly amputation rate demonstrated a progressive increase from 2010 to 2016, the average for the seven years was 28 per 105/year. Males accounted for 59% of cases, and 60% of amputations were done above the level of the knee joint. The most common reason for amputation was control of sepsis in 71.5% of cases. A strong association between major amputations and prior intervention for a foot-related problem was observed, as 52% of the sample had a pre-existing wound or a prior minor amputation (32%). Overall, 14.5% of all amputees were able to acquire a prosthesis. Diabetes mellitus was the most consistently associated co-morbidity occurring in 91% of the study population. Major limb amputations continue to affect our population significantly, with a rise in the amputation rate despite the introduction of a Vascular Surgical Unit. Diabetes and its foot-related complications are one of the leading causes of major lower extremity amputations. Prosthetic limb acquisition for our amputee population continues to be lacking, reflected by the low prosthetic acquisition rate observed.
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Affiliation(s)
- Lemuel Pran
- Vascular Surgery, Eric Williams Medical Sciences Complex, Mount Hope, TTO
| | - Dave Harnanan
- Clinical Surgical Sciences, The University of the West Indies, St. Augustine, TTO
| | - Shanta Baijoo
- Surgery, Eric Williams Medical Sciences Complex, Mount Hope, TTO
| | - Andy Short
- Statistics, Eric Williams Medical Sciences Complex, Mount Hope, TTO
| | - Cristo Cave
- Surgery, Eric Williams Medical Sciences Complex, Mount Hope, TTO
| | - Ravi Maharaj
- Clinical Surgical Sciences, The University of the West Indies, St. Augustine, TTO
| | - Shamir O Cawich
- Clinical Surgical Sciences, The University of the West Indies, St. Augustine, TTO
| | - Vijay Naraynsingh
- Clinical Surgical Sciences, The University of the West Indies, St. Augustine, TTO
- Surgery, Medical Associates Hospital, St. Joseph, TTO
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25
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Aragón-Sánchez J, Víquez-Molina G, López-Valverde ME, Aragón-Hernández J, Rojas-Bonilla JM, Murillo-Vargas C. Long-term Mortality of a Cohort of Patients Undergoing Surgical Treatment for Diabetic Foot Infections. An 8-year Follow-up Study. INT J LOW EXTR WOUND 2021; 22:314-320. [PMID: 33909492 DOI: 10.1177/15347346211009425] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
We analyzed a retrospective cohort of 150 patients with diabetic foot infections (DFIs) who underwent surgical treatment to determine long-term outcomes. The median follow-up of the series was 7.6 years. Cox's proportional hazards model for survival time was performed and hazard ratios (HRs) were estimated. Survival times were plotted using the Kaplan-Meier method. Fifteen patients (10%) required readmission after discharge from the hospital for a recurrence of the infection. Ninety patients (60%) had re-ulcerations. Forty-nine (54.4% of those re-ulcerated) required new admission and 24 of them (26.6% of those re-ulcerated) finally required a new amputation. Overall cumulative survival rates at 1, 5, and 8 years were 95%, 78%, and 64%, respectively. Predictive variables of long-term mortality were insulin treatment (HR: 2.0, 95% CI: 1.1-3.6, P = .01), female sex (HR: 3.1, 95% CI: 1.7-5.3, P<.01) and estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m2 (HR: 2.2, 95% CI: 1.1-4.2, P = .01). In conclusion, patients undergoing surgical treatment for DFIs had a high rate of recurrences and mortality. Women, patients who underwent treatment with insulin, and those with eGFR <60 ml/min/1.73 m2 had a higher risk of long-term mortality.
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26
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Yang L, Gabriel N, Hernandez I, Winterstein AG, Guo J. Using machine learning to identify diabetes patients with canagliflozin prescriptions at high-risk of lower extremity amputation using real-world data. Pharmacoepidemiol Drug Saf 2021; 30:644-651. [PMID: 33606340 DOI: 10.1002/pds.5206] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 02/16/2021] [Indexed: 02/06/2023]
Abstract
AIMS Canagliflozin, a sodium-glucose cotransporter 2 inhibitor indicated for lowering glucose, has been increasingly used in diabetes patients because of its beneficial effects on cardiovascular and renal outcomes. However, clinical trials have documented an increased risk of lower extremity amputations (LEA) associated with canagliflozin. We applied machine learning methods to predict LEA among diabetes patients treated with canagliflozin. METHODS Using claims data from a 5% random sample of Medicare beneficiaries, we identified 13 904 diabetes individuals initiating canagliflozin between April 2013 and December 2016. The samples were randomly and equally split into training and testing sets. We identified 41 predictor candidates using information from the year prior to canagliflozin initiation, and applied four machine learning approaches (elastic net, least absolute shrinkage and selection operator [LASSO], gradient boosting machine and random forests) to predict LEA risk after canagliflozin initiation. RESULTS The incidence rate of LEA was 0.57% over a median 1.5 years follow-up. LASSO produced the best prediction, yielding a C-statistic of 0.81 (95% CI: 0.76, 0.86). Among individuals categorized in the top 5% of the risk score, the actual incidence rate of LEA was 3.74%. Among the 16 factors selected by LASSO, history of LEA [adjusted odds ratio (aOR): 33.6 (13.8, 81.9)] and loop diuretic use [aOR: 3.6 (1.8,7.3)] had the strongest associations with LEA incidence. CONCLUSIONS Our machine learning model efficiently predicted the risk of LEA among diabetes patients undergoing canagliflozin treatment. The risk score may support optimized treatment decisions and thus improve health outcomes of diabetes patients.
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Affiliation(s)
- Lanting Yang
- Department of Pharmacy and Therapeutics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Nico Gabriel
- Department of Pharmacy and Therapeutics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Inmaculada Hernandez
- Department of Pharmacy and Therapeutics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Center for Pharmaceutical Policy and Prescribing, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Almut G Winterstein
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida, USA
| | - Jingchuan Guo
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida, USA
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27
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Rossboth S, Lechleitner M, Oberaigner W. Risk factors for diabetic foot complications in type 2 diabetes-A systematic review. Endocrinol Diabetes Metab 2021; 4:e00175. [PMID: 33532615 PMCID: PMC7831214 DOI: 10.1002/edm2.175] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 07/15/2020] [Accepted: 07/18/2020] [Indexed: 12/14/2022] Open
Abstract
Aims With increasing numbers of patients with type 2 diabetes mellitus (T2DM) worldwide, the number of associated diabetic foot complications might also increase. This systematic review was performed to summarize published data about risk factors for the diabetic foot (DF) syndrome in order to improve the identification of high-risk patients. Materials and methods Six electronic databases were searched for publications up to August 2019 using predefined stringent inclusion and exclusion criteria. Results Of 9,476 identified articles, 31 articles from 28 different study populations fulfilled the criteria for our evaluation. The overall quality of the studies was good, and the risk of bias was low. There was large heterogeneity among the studies concerning study protocols and patient populations analysed. A total of 79 risk factors were analysed within this review. The majority of studies described a consistently positive association with different outcomes of interest related to DF for gender, peripheral neuropathy, retinopathy, nephropathy, poor glycaemic control, insulin use, duration of diabetes, smoking and height. For age, hypertension, dyslipidaemia and body mass index, the results remain inconsistent. Conclusion A most up-to-date literature review resulted in glycaemic control and smoking as the only amenable risk factors with a consistently positive association for DF. Due to the high personal and financial burden associated with DF and the large heterogeneity among included studies, additional longitudinal studies in large patient populations are necessary to identify more modifiable risk factors that can be used in the prediction and prevention of DF complications.
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Affiliation(s)
- Sophia Rossboth
- Medical Informatics and TechnologyPublic Health, Health Services Research and Health Technology AssessmentUMIT ‐ University for Health SciencesHall in TrollAustria
| | | | - Willi Oberaigner
- Medical Informatics and TechnologyPublic Health, Health Services Research and Health Technology AssessmentUMIT ‐ University for Health SciencesHall in TrollAustria
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28
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Lee CY, Wu TC, Lin SJ. Effects of Postoperative Percutaneous Coronary Intervention, Pharmacologic Treatment, and Predisposing Factors on Clinical Outcomes in Patients With and Without Type 2 Diabetes Along With Critical Limb Ischemia. Clin Ther 2020; 43:195-210.e2. [PMID: 33358255 DOI: 10.1016/j.clinthera.2020.11.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 10/29/2020] [Accepted: 11/22/2020] [Indexed: 12/16/2022]
Abstract
PURPOSE Critical limb ischemia (CLI) has been identified as being connected to rates of cardiovascular mortality and lower extremity amputation (LEA). This prospective study investigated the effects of percutaneous coronary intervention (PCI), pharmacologic treatment, and predisposing factors on clinical outcomes in patients with and without type 2 diabetes mellitus (DM) along with CLI after endovascular intervention. METHODS 249 consecutive patients with CLI (Fontaine stages III-IV) received pharmacologic treatment after successful endovascular intervention. Their primary patency rates of infrapopliteal lesions and cardiovascular and amputation events during a 36-month follow-up period were assessed. FINDINGS Patients with DM were more likely to be younger (P = 0.026); 50% (n = 63), 42.9% (n = 54), 52.4% (n = 66), and 77% (n = 97) of DM patients had arterial calcification, end-stage renal disease, diabetic neuropathy, and Fontaine stage IV (P < 0.001, P < 0.001, P < 0.001, and P = 0.019, respectively). The primary patency rates were 61%, 48.8%, and 42.3% at 12, 24, and 36 months, in the patients without DM (P = 0.034, P = 0.013, and P = 0.005). Patients with DM had higher risks of 36-month coronary artery disease, cerebrovascular accident, mortality, and LEA (P = 0.005, P = 0.042, P = 0.042, and P < 0.001). Patients with CLI receiving long-term cilostazol treatment had a better primary patency and amputation-free survival, and a lower risk of mortality at 36 months (P < 0.001, P < 0.001, and P = 0.001). Statin use was associated with 36-month amputation-free survival but not with primary patency (P = 0.032 and P = 0.088). Subgroup multivariate Cox analyses showed that primary patency was independently associated with long-term cilostazol treatment, PCI in the first postoperative year, and direct revascularization in the DM group, whereas in the control group, long-term cilostazol treatment was the main independent factor. The risk of amputation was independently associated with a high high-sensitivity chronic reactive protein level, diabetic neuropathy, sole use of an oral hypoglycemic agent, and lack of supervised exercise. IMPLICATIONS Long-term cilostazol treatment, aggressive management of dyslipidemia, and meticulous assessment and prevention of postoperative unstable coronary artery disease should be considered in CLI patients with and without DM to maximize clinical outcomes. PCI in the first postoperative year may be a predisposing factor for patency failure in patients with CLI, especially those with DM. A large-scale prospective randomized trial should be conducted to confirm these findings (TVGH IRB No. 2013-08-020B).
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Affiliation(s)
- Chiu-Yang Lee
- Division of Cardiovascular Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei City, Taiwan; Institute of Clinical Medicine, School of Medicine, National Yang Ming University, Taipei, Taiwan.
| | - Tao-Cheng Wu
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Shing-Jong Lin
- Institute of Clinical Medicine, School of Medicine, National Yang Ming University, Taipei, Taiwan; Taipei Heart Institute, Taipei Medical University, Taipei, Taiwan; Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan.
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29
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Zhu X, Goh LJ, Chew E, Lee M, Bartlam B, Dong L. Struggling for normality: experiences of patients with diabetic lower extremity amputations and post-amputation wounds in primary care. Prim Health Care Res Dev 2020; 21:e63. [PMID: 33323161 DOI: 10.1017/S146342362000064X] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Aim: To explore the experiences of patients living with diabetic lower extremity amputation (DLEA) and its post-amputation wound in primary care. Background: DLEA, including both minor and major amputation, is a life-altering condition that brings numerous challenges to an individual’s life. Post-amputation physical wound healing is complicated and challenging because of wound dehiscence and prolonged healing times. Understanding patients’ experiences after DLEA with a post-amputation wound will enable healthcare professionals to develop interventions to assist patients in physical healing and psychosocial recovery. Methods: This study employs a qualitative design using interpretative phenomenological analysis (IPA). A purposive maximum variation sample of nine patients who had had lower extremity amputations and post-amputation wound attributed to diabetes in the previous 12 months was recruited from a primary care setting in Singapore. Semi-structured audio recorded one-to-one interviews with a duration of 45–60 min each were conducted between September 2018 and January 2019. The interviews were transcribed verbatim and analysed using IPA. Findings: The essential meaning of the phenomenon ‘the lived experiences for patients with DLEA and post-amputated wound’ can be interpreted as ‘struggling for “normality”’ which encompasses four domains of sense making: physical loss disrupted normality, emotional impact aggravated the disrupted normality, social challenges further provoked the disrupted normality, and attempt to regain normality. The study highlights the complex physical and psychosocial transition facing patients after DLEA before post-amputation wound closure. In primary care, an amputation, whether minor or major, is a life-altering experience that requires physical healing, emotional recovery, and social adaptation to regain normality. Patients living with DLEA and a post-amputation wound may benefit from an interdisciplinary team care model to assist them with physical and psychosocial adjustment and resume normality.
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Arakelian VS. [Ways of decreasing incidence of complications in patients after endured reconstructive and endovascular operations on lower limb arteries]. Angiol Sosud Khir 2020; 26:165-173. [PMID: 32240153 DOI: 10.33529/angio2020106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Peripheral artery disease represented predominantly by atherosclerosis obliterans is a common social burden all over the world. The main method of treatment for peripheral artery disease (PAD) is considered to be open surgical or endovascular revascularization. Unfortunately, despite a steadily growing number of operations and implementation of new types of interventions, including endovascular ones, the prognosis in patients with peripheral artery diseases still remains unfavourable. Moreover, patients having endured revascularization are susceptible to especially high risk of subsequent ischaemic complications from the side of both the cardiovascular system as a whole (strokes, infarctions, cardiovascular death) and the limb in the form of progressing ischaemia, development of critical and/or acute ischaemia. All the above mentioned determines the necessity of carrying out intensive accompanying medicamentous therapy. At the same time, the contemporary literature contains contradictory results of using different drugs in order to decrease the risk for progression of lower limb ischaemia, as well as the incidence of adverse cardiovascular events in the form of strokes, infarctions, and cardiovascular death. Disputable remains the question of whether monotherapy with acetylsalicylic acid still remains the only well evidence-based method of treatment in randomized multiple-centre studies. There are various opinions on the place of dual anticoagulant and antiplatelet therapy in treatment of PAD. The findings of the multi-centre randomized COMPASS trial published in 2018 significantly altered the approaches to medicamentous therapy of this patient cohort. The purpose of our study was to carry out a systematic review of literature, making it possible to assess the risks and prognosis in patients presenting with peripheral artery disease after a vascular intervention, as well as to determine therapy capable of improving the outcomes of surgical treatment.
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Affiliation(s)
- V S Arakelian
- National Medical Research Centre of Cardiovascular Surgery named after A.N. Bakulev under the RF Ministry of Public Health, Moscow, Russia
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Çamur S, Batıbay SG, Bayram S. Effect of lower extremity amputation on caregiving burden in caregivers of patients with diabetic foot: Prospective cohort study. Int Wound J 2020; 17:890-896. [PMID: 32219992 DOI: 10.1111/iwj.13342] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 03/02/2020] [Accepted: 03/09/2020] [Indexed: 01/14/2023] Open
Abstract
Lower extremity amputation as a treatment of diabetic foot ulcer is probably a major burden for the patient's family and friends, who typically act as caregivers and support the patient in coping with the physical disabilities and emotional distress. In the present prospective study, we investigated the effects of different lower extremity amputation levels for diabetic foot ulcer treatment on caregivers of patients with diabetes using the Zarit Burden Interview (ZBI-12) scale. Patients with diabetic foot ulcers who underwent unilateral major amputation (above-below knee) and minor amputation of foot (heel sparing) and their caregivers were requested to volunteer to participate in this study from June 2016 to December 2018. The ZBI-12 form was completed immediately preoperatively and 3 and 6 months after postoperatively. In the minor amputation group, the mean age of the 51 patients was 72.1 years. In the major amputation group, the mean age of the 88 patients was 73.7 years. Both groups of caregivers of patients with minor amputation and major amputations showed a significant improvement in ZBI-12 score when compared preoperatively and at 3- and 6-month follow-up visits. The mean ZBI-12 score was significantly higher in the major than in the minor amputation group in preoperative and all postoperative visits. The absence of the ankle joint in the below- or above-knee amputation renders it more difficult for the amputee to quickly learn the use of prosthesis, thereby increasing the burden of the patient and caregivers. We found that lower extremity amputation for the treatment of chronic diabetic foot ulcers has significantly favourable effect on the caregiver burden, and thereby heel sparing was considerably more effective for the caregiver burden.
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Affiliation(s)
- Savaş Çamur
- Department of Orthopedics and Traumatology, Umraniye Education and Research Hospital, Istanbul, Turkey
| | - Sefa G Batıbay
- Department of Orthopedics and Traumatology, Ankara Occupational and Environmental Diseases Hospital, Ankara, Turkey
| | - Serkan Bayram
- Department of Orthopedics and Traumatology, Istanbul University Faculty of Medicine, Istanbul, Turkey
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Kim SJ, Kim N, Kim EH, Roh YH, Song J, Park KH, Choi YS. Use Of Regional Anesthesia For Lower Extremity Amputation May Reduce The Need For Perioperative Vasopressors: A Propensity Score-Matched Observational Study. Ther Clin Risk Manag 2019; 15:1163-1171. [PMID: 31632043 PMCID: PMC6778747 DOI: 10.2147/tcrm.s213443] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 09/14/2019] [Indexed: 11/23/2022] Open
Abstract
Purpose Lower extremity amputation (LEA) is associated with a high risk of postoperative mortality. The effect of type of anesthesia on postoperative mortality has been studied in various surgeries. However, data for guiding the selection of optimal anesthesia for LEA are limited. This study aimed to determine the effect of anesthesia type on perioperative outcomes in patients with diabetes and/or peripheral vascular disease undergoing LEA. Patients and methods We reviewed the medical records of patients who underwent LEA at our center between September 2007 and August 2017, who were grouped according to use of general anesthesia (GA) or regional anesthesia (RA). Primary outcomes were 30-day and 90-day mortality. Secondary outcomes were postoperative morbidity, intraoperative events, postoperative intensive care unit admission, and postoperative length of stay. Propensity score-matched cohort design was used to control for potentially confounding factors, including patient demographics, comorbidities, medications, and type of surgery. Results Five hundred and nineteen patients (75% male, mean age 65 years) were identified to have received GA (n=227) or RA (n=292) for above-knee amputation (1.5%), below-knee amputation (16%), or more minor amputation (82.5%). Before propensity score matching, there was an association of GA with coronary artery disease (44% [GA] vs 34.5% [RA], p=0.028), peripheral arterial disease (73.1% vs 60.2%, p=0.002), and preoperative treatment with aspirin and clopidogrel (68.7% vs 55.1%, p=0.001; 63% vs 41.8%, p<0.001, respectively). Propensity score matching produced a cohort of 342 patients equally divided between GA and RA. There was no significant between-group difference in 30-day (3.5% vs 2.9%, p=0.737) or 90-day (6.4% vs 4.6%, p=0.474) mortality or postoperative morbidity. However, postoperative ICU admission (14.6% vs 7%, p=0.032), intraoperative hypotension (61.4% vs 14.6%, p<0.001), and vasopressor use (52% vs 14%, p<0.001) were more common with GA than with RA. Conclusion Type of anesthesia did not significantly affect mortality or morbidity after LEA. However, intraoperative hypotension, vasopressor use, and postoperative ICU admission rates were lower with RA.
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Affiliation(s)
- Seon Ju Kim
- Department of Anesthesiology and Pain Medicine, National Health Insurance Service Ilsan Hospital, Goyang 10444, Korea
| | - Namo Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul 03722, Korea.,Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Eun Hwa Kim
- Biostatistics Collaboration Unit, Department of Biomedical Systems Informatics, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Yun Ho Roh
- Biostatistics Collaboration Unit, Department of Biomedical Systems Informatics, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Jeehyun Song
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Kwang Hwan Park
- Department of Orthopaedic Surgery, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Yong Seon Choi
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul 03722, Korea.,Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul 03722, Korea
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Yang JY, Wang T, Pate V, Gower EW, Crowley MJ, Buse JB, Stürmer T. Sodium-glucose co-transporter-2 inhibitor use and risk of lower-extremity amputation: Evolving questions, evolving answers. Diabetes Obes Metab 2019; 21:1223-1236. [PMID: 30697897 PMCID: PMC6459697 DOI: 10.1111/dom.13647] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Revised: 01/11/2019] [Accepted: 01/24/2019] [Indexed: 02/06/2023]
Abstract
AIM To examine whether sodium-glucose co-transporter-2 (SGLT2) inhibitors are associated with a higher risk of lower-extremity amputation than dipeptidyl-peptidase-4 (DPP-4) inhibitors and sulphonylureas. METHODS We conducted a retrospective cohort study, using the MarketScan Commercial Claims and Encounters Database (2013-2015), to compare the incidence of lower-extremity amputation (LEA) between initiators of SGLT2 inhibitors and initiators of two second-line drugs, DPP-4 inhibitors and sulphonylureas (SUs). We estimated crude incidence rates (IRs) and adjusted hazard ratios (aHR), with 95% confidence intervals (CIs), before and after propensity-score weighting. We additionally conducted sensitivity analyses using a comparator group of all non-metformin, non-SGLT2 inhibitor glucose-lowering drugs, as previous studies used this approach. RESULTS In a cohort of 328 150 individuals aged 18 to 64 years, the IR of LEA ranged from 1.5 to 2.4 per 1000 person-years. In as-treated analysis, the estimated hazard of LEA was increased among SGLT2 inhibitor initiators compared to DPP-4 inhibitor initiators (aHR 1.69, 95% CI 1.20-2.38), but not compared to SU initiators (aHR 1.02, 95% CI 0.67-1.55) or non-metformin, non-SGLT2 inhibitor initiators (aHR 1.02, 95% CI 0.54-1.93). Results were consistent in intention-to-treat analysis and across a number of sensitivity analyses. CONCLUSIONS Among commercially insured patients in the United States, our results suggest that initiation of SGLT2 inhibitors may increase the risk of LEA compared to initiation of DPP-4 inhibitors. Contrasting results when comparing SGLT2 inhibitor initiators to DPP-4 inhibitor and SU initiators highlight the importance of choosing appropriate comparator drugs when addressing comparative effectiveness and safety questions that can inform clinical decision-making.
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Affiliation(s)
- Jeff Y. Yang
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
| | - Tiansheng Wang
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
| | - Virginia Pate
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
| | - Emily W. Gower
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
| | | | - John B. Buse
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Til Stürmer
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
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Hu WS, Lin CL. A nationwide cohort study of the role of CHADS 2 score in predicting lower extremity amputation and death among patients with peripheral arterial occlusive disease. Aging Male 2019; 22:39-44. [PMID: 29580119 DOI: 10.1080/13685538.2018.1454420] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Abstract
OBJECTIVES The current study aimed to explore whether the CHADS2 score was predictive of lower extremity amputation (LEA) and death in people with peripheral arterial occlusive disease (PAOD). METHODS This nationwide cohort came from Taiwan, with 16,888 PAOD patients, from 2000 through 2011, extracted from the Longitudinal Health Insurance Database 2000. Cox proportional hazard regression models were employed to identify the LEA and mortality risk according to CHADS2 score. The discriminatory properties of the score in predicting the outcomes were quantified by the area under the receiver operating characteristic curve (AUROC) and the Cox C-index. RESULTS The AUROC of the CHADS2 score in predicting LEA and death were 0.75 (95% CI = 0.73-0.77) and 0.70 (95% CI = 0.69-0.71), respectively. The CHADS2 score had an acceptable stratification capacity for LEA (C-index = 0.79) and death (C-index = 0.76) based on Cox-regression analysis. CONCLUSIONS This study correlates the CHADS2 score with risk of developing LEA and death in patients with PAOD. The acceptable discriminative power of the score diversifies its predictive role in this population.
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Affiliation(s)
- Wei-Syun Hu
- a School of Medicine, College of Medicine , China Medical University , Taichung , Taiwan
- b Division of Cardiovascular Medicine, Department of Medicine , China Medical University Hospital , Taichung , Taiwan
| | - Cheng-Li Lin
- c Management Office for Health Data , China Medical University Hospital , Taichung , Taiwan
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Adams BE, Edlinger JP, Ritterman Weintraub ML, Pollard JD. Three-Year Morbidity and Mortality Rates After Nontraumatic Transmetatarsal Amputation. J Foot Ankle Surg 2019; 57:967-971. [PMID: 30005966 DOI: 10.1053/j.jfas.2018.03.047] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Indexed: 02/03/2023]
Abstract
Patients requiring a nontraumatic transmetatarsal amputation (TMA) typically have multiple comorbidities that place them at high risk of postoperative complications and additional surgery. The present study identified the demographic, clinical, and surgical risk factors that predict complications after a nontraumatic TMA, including the incidence of 3-year mortality, proximal limb amputation, and lack of healing. The electronic medical records of patients who had undergone TMA within a Kaiser Permanente Northern California facility from March 2007 to January 2012 (n = 375) were reviewed. We used bivariate and multivariate analyses to examine the variations in the rates of TMA complications according to sex, age, race, and comorbid conditions, including nonpalpable pedal pulses, end-stage renal disease, coronary artery disease, hypertension, smoking status, and preoperative albumin <3.5 mg/dL. After a nontraumatic TMA, 136 (36.3%) patients had died within 3 years, 138 (36.8%) had required a more proximal limb amputation, and 83 (22.1%) had healed without complications. The patients with nonpalpable pedal pulses had 3 times the odds of requiring a proximal limb amputation (adjusted odds ratio [aOR] 3.07; 95% confidence interval [CI] 1.84 to 5.11), almost twice the odds of dying within 3 years (aOR 1.70; 95% CI 0.98 to 2.93), and >2 times the odds of not healing after the TMA (aOR 2.45; 95% CI 1.40 to 4.31). The patients with end-stage renal disease had 3 times the odds of dying within 3 years (aOR 3.10; 95% CI 1.69 to 5.70). The present findings can help us identify patients with an increased risk of postoperative complications after nontraumatic TMA, including patients with nonpalpable pedal pulses or end-stage renal disease, and suggest the vulnerability of this patient population.
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Affiliation(s)
- Barbara E Adams
- Chief Resident, Kaiser San Francisco Bay Area Foot & Ankle Residency, Department of Podiatric Surgery, Kaiser Permanente Oakland Medical Center, Oakland, CA
| | - Joshua P Edlinger
- Surgeon, Department of Podiatric Surgery, Kaiser Permanente Diablo Service Area, Walnut Creek, CA
| | - Miranda L Ritterman Weintraub
- Senior Research Project Manager, Department of Graduate Medical Education, Kaiser Permanente Oakland Medical Center, Oakland, CA
| | - Jason D Pollard
- Research Director and Surgeon, Department of Podiatric Surgery, Kaiser Permanente Oakland Medical Center, Oakland, CA.
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36
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Wright MA, Steffens D, Huilgol RL. Vascular surgery trends in Australia: 2001-2015: less open surgery, less limb loss and more endovascular intervention. ANZ J Surg 2018; 89:309-313. [PMID: 30321911 DOI: 10.1111/ans.14878] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Revised: 08/04/2018] [Accepted: 08/18/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND The prevalence of peripheral arterial disease (PAD) in Australia is currently poorly characterized. The risk factor profile for PAD is changing with the population ageing, diabetes increasing and smoking rates declining. The management of PAD is also evolving, with advances in medical management and endovascular technique. The trends in PAD prevalence and surgical management have implications for preventative medicine, the Australian health system and vascular surgery. We report and analyse trends in PAD surgical intervention performed between 2001 and 2015. METHODS Data was extracted from the National Hospital Morbidity Database procedural item code records. Procedural numbers of endovascular lower extremity revascularization (LER); open LER; minor and major lower extremity amputations (LEA) between 2001 and 2015 in adults ≥45 years were included. Results were population-adjusted and age-stratified using census information from the Australian Bureau of Statistics to analyse changes in intervention rates. Linear regression analyses were performed to calculate the average annual change in procedures per capita (100 000). RESULTS From 2001 and 2015, per capita (100 000 population) volume of endovascular LER increased 89%, open LER decreased 70%, major LEA decreased 65% and minor LEA increased 14%. The most remarkable changes were in the ≥85-year-old cohort, with endovascular procedures per capita increasing 188%; coinciding with both open LER and major LEA decreasing by 73% between 2001 and 2015. CONCLUSIONS Australian hospital data between 2001 and 2015 shows that endovascular LER interventions and minor LEA have significantly increased per capita in Australians ≥45 years. In contrast, both open LER and major LEA rates have significantly decreased in the same cohort.
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Affiliation(s)
- Melissa Anne Wright
- Liverpool Hospital, South Western Sydney Local Health District, Sydney, New South Wales, Australia.,The University of Notre Dame Australia, Sydney, New South Wales, Australia
| | - Daniel Steffens
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Ravi Lee Huilgol
- The University of Notre Dame Australia, Sydney, New South Wales, Australia.,Department of Vascular Surgery, St Vincent's Hospital, Sydney, New South Wales, Australia
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Kerfeld C, Jirikowic T, Allyn KJ, Maitland ME. Participation in active play of children who use lower extremity prostheses: An exploratory questionnaire. Prosthet Orthot Int 2018; 42:437-445. [PMID: 29623809 DOI: 10.1177/0309364618767139] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Through play, children develop motor, cognitive, social, and other life skills. Play barriers can impede physical and psychosocial benefits. OBJECTIVES We describe participation in active play, fundamental movement skills, play environment characteristics, and potential play barriers for school-aged children (6-12 years) who use lower extremity prostheses. STUDY DESIGN Cross-sectional questionnaire study. METHODS A questionnaire was developed and administered online to parents of children 6-12 years who use lower extremity prostheses. Questions focused on children's valued play activities, participation in active play, fundamental movement skills, body positions for play, and characteristics of play environments. RESULTS Parents (n = 26) reported their children who use lower extremity prostheses participated in a range of activities including active play (e.g. playgrounds, swimming). Fundamental movement skill limitations were identified (e.g. walking long distances, running fast, hopping on one foot, and skipping). Mobility limitations with floor positions, movement transitions, and uneven or sloped surfaces were reported. Active play with equipment such as roller skating, climbing structures, and bicycling presented challenges. CONCLUSION Parents of children who use lower extremity prostheses reported participation restrictions associated with mobility limitations, activity type, and built environment characteristics (e.g. surfaces and equipment). Challenges made it difficult for children who use lower extremity prostheses to keep up with peers in schools and communities. Clinical relevance Understanding potential barriers to participation in active play of children who use lower extremity prostheses may contribute to enhanced prosthetic design, rehabilitation strategies, universal design of play and built environments, and improved outcome measures ultimately enabling these children to participate fully in active play in diverse contexts.
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Howell RS, Criscitelli T, Woods JS, Gillette BM, Brem H, Gorenstein S. A Perioperative Approach to Increase Limb Salvage When Treating Foot Ulcers in Patients With Diabetes. AORN J 2018; 107:431-440. [PMID: 29595900 DOI: 10.1002/aorn.12099] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Foot ulceration in patients with diabetes increases the risk of lower extremity amputation. Major amputations produce substantial adverse consequences, increase length of hospital stay, diminish quality of life, and increase mortality. In this article, we describe approaches that decrease amputations and improve the quality of life for patients with diabetes and foot ulcers. We highlight the role of the perioperative nurse, who is essential to providing optimal patient care in the perioperative period. Perioperative care of patients with diabetes involves providing optimal surveillance for a break in the skin of the foot, screening for neuropathy, following guidelines for foot ulcer infections, preparing for pathophysiology-based debridement, using adjuvant therapies, and offloading the patient's affected foot. Nurses should understand the disease process and pathophysiology and how to use these approaches in the perioperative setting to assist in curtailing the morbidity and mortality associated with foot ulcers in patients with diabetes.
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Jensen PS, Petersen J, Kirketerp-Møller K, Poulsen I, Andersen O. Progression of disease preceding lower extremity amputation in Denmark: a longitudinal registry study of diagnoses, use of medication and healthcare services 14 years prior to amputation. BMJ Open 2017; 7:e016030. [PMID: 29101132 PMCID: PMC5695421 DOI: 10.1136/bmjopen-2017-016030] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVES Patients with non-traumatic lower extremity amputation are characterised by high age, multi-morbidity and polypharmacy and long-term complications of atherosclerosis and diabetes. To ensure early identification of patients at risk of amputation, we need to gain knowledge about the progression of diseases related to lower extremity amputations during the years preceding the amputation. DESIGN A retrospective population-based national registry study. SETTING The study includes data on demographics, diagnoses, surgery, medications and healthcare services from five national registries. Data were retrieved from 14 years before until 1 year after the amputation. Descriptive statistics were used to describe the progression of diseases and use of medication and healthcare services. PARTICIPANTS An unselected cohort of patients (≥50 years; n=2883) subjected to a primary non-traumatic lower extremity amputation in 2010 or 2011 in Denmark. RESULTS The prevalence of atherosclerosis, hypertension and diabetes was 70%, 53% and 49%, respectively. Among patients with atherosclerosis, 42% had not received cholesterol-lowering treatment even though 87% had visited their general practitioner within the last year prior to amputation. Further, 16% were diagnosed with diabetes at the time of the amputation. The prevalence of cardiovascular diseases increased from 22% to 70%, atherosclerosis from 5% to 53% and diabetes from 17% to 35% over the 14 years preceding major amputation. Of all patients, 64% had been in contact with the hospital or outpatient clinics within the last 3 years, and 29% received a prescription of opioids 3 years prior to the amputation. CONCLUSION Among patients with non-traumatic lower extremity amputation, one-third live with undiagnosed and untreated atherosclerosis and one-sixth suffer from undiagnosed diabetes despite continuous contacts to general practitioner and the hospital. This study emphasises a need for enhanced focus, among both hospital clinicians and general practitioners, on the early identification of atherosclerosis and diabetes.
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Affiliation(s)
- Pia Søe Jensen
- Clinical Research Centre Copenhagen University Hospital, Hvidovre, Denmark
- Department of Orthopaedic Surgery, Copenhagen University Hospital, Hvidovre, Denmark
| | - Janne Petersen
- Clinical Research Centre Copenhagen University Hospital, Hvidovre, Denmark
- Department of Public Health Section of Biostatistics, University of Copenhagen, Copenhagen, Denmark
| | | | - Ingrid Poulsen
- Traumatic Brain Injury Unit, Rigshospitalet, Clinic of Neurorehabilitation, Copenhagen, Denmark
| | - Ove Andersen
- Clinical Research Centre Copenhagen University Hospital, Hvidovre, Denmark
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Wied C, Tengberg PT, Kristensen MT, Holm G, Kallemose T, Troelsen A, Foss NB. Total Blood Loss After Transfemoral Amputations Is Twice the Intraoperative Loss: An Observational Cohort Study of 81 Nontraumatic Amputations. Geriatr Orthop Surg Rehabil 2017; 8:123-127. [PMID: 28835867 PMCID: PMC5557193 DOI: 10.1177/2151458517706595] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 02/15/2017] [Accepted: 02/16/2017] [Indexed: 12/14/2022] Open
Abstract
Introduction: Underestimation of the actual blood loss in patients undergoing nontraumatic transfemoral amputation (TFA) can impact negatively on outcome in these often frail patients, with very limited physiological reserves. The primary aim of this study is to estimate the total blood loss (TBL) after TFA, and second, to evaluate the impact of blood loss on 30-day mortality and medical complications. Methods: A single-center retrospective cohort study conducted from 2013 to 2015. The TBL was calculated on the fourth postoperative day. It was based on the hemoglobin levels, transfusions, and the estimated blood volume. Results: Eighty-one patients undergoing TFA were included for final analysis. The median TBL was 964 mL (interquartile range [IQR]: 443-1558). The intraoperative blood loss (OBL) was 400 mL (IQR: 200-500). The median difference between TBL and OBL was 688 mL (IQR: 124-1075). The patient received red blood cell (RBC) transfusion of a median amount of 2 units. Higher number of transfusions (>2) did not impact the outcome. From multivariable analysis, it was evident that the TBL increased significantly in patients with renal disease prior to surgery, (P = .034). The TBL itself was not independently associated with increased 30-day mortality or medical complications. Conclusion: The TBL after TFAs is significantly greater than the volume estimated intraoperatively and increases significantly in the presence of renal disease prior to surgery. An increased TBL and requirement for RBC transfusion is not directly associated with 30-day mortality or medical complications. A high vigilance for anemia seems advisable when planning for TFA surgery. Research on optimum blood conservation and transfusion strategies during TFA is warranted.
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Affiliation(s)
- Christian Wied
- Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Peter T Tengberg
- Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Morten T Kristensen
- Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark.,Physical Medicine and Rehabilitation Research-Copenhagen (PMR-C), Department of Physiotherapy, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Gitte Holm
- Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Thomas Kallemose
- Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark.,Clinical Research Centre, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Anders Troelsen
- Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Nicolai B Foss
- Department of Anesthesiology and Intensive Care, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
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Leijendekkers RA, van Hinte G, Frölke JP, van de Meent H, Nijhuis-van der Sanden MWG, Staal JB. Comparison of bone-anchored prostheses and socket prostheses for patients with a lower extremity amputation: a systematic review. Disabil Rehabil 2016; 39:1045-1058. [PMID: 27494092 DOI: 10.1080/09638288.2016.1186752] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
PURPOSE This study aimed to provide an overview of a) the used measurement instruments in studies evaluating effects on quality of life (QoL), function, activity and participation level in patients with a lower extremity amputation using bone-anchored prostheses compared to socket prostheses and b) the effects themselves. METHOD A systematic literature search was conducted in MEDLINE, Cochrane, EMBASE, CINAHL and Web of Science. Included studies compared QoL, function, activity and/or participation level in patients with bone-anchored or socket prostheses. A best-evidence synthesis was performed. RESULTS Out of 226 studies, five cohort and two cross-sectional studies were eligible for inclusion, all had methodological shortcomings. These studies used 10 different measurement instruments and two separate questions to assess outcome. Bone-anchored prostheses were associated with better condition-specific QoL and better outcomes on several of the physical QoL subscales, outcomes on the physical bodily pain subscale were inconclusive. Outcomes on function and activity level increased, no change was found at participation level. The level of evidence was limited. CONCLUSIONS There is a need for a standard set of instruments. There was limited evidence that bone-anchored prostheses resulted in higher QoL, function and activity levels than socket prostheses, in patients with socket-related problems. Implications for Rehabilitation Use of bone-anchored prostheses in combination with intensive outpatient rehabilitation may improve QoL, function and activity level compared with socket prosthesis use in patients with a transfemoral amputation and socket-related problems. All clinicians and researchers involved with bone-anchored prostheses should use and publish data on QoL, function, activity and participation level. There needs to be an agreement on a standard set of instruments so that interventions for patients with a lower extremity amputation are assessed consistently.
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Affiliation(s)
- Ruud A Leijendekkers
- a Department of Orthopaedics , Physical Therapy, Radboud University Medical Centre , Nijmegen , The Netherlands.,b Master Clinical Health Sciences, Program in Physical Therapy Science , University Utrecht and University Medical Centre Utrecht , Utrecht , The Netherlands
| | - Gerben van Hinte
- a Department of Orthopaedics , Physical Therapy, Radboud University Medical Centre , Nijmegen , The Netherlands
| | - Jan Paul Frölke
- c Department of Surgery , Radboud University Medical Centre , Nijmegen , The Netherlands
| | - Hendrik van de Meent
- d Department of Rehabilitation , Radboud University Medical Centre , Nijmegen , The Netherlands
| | - Maria W G Nijhuis-van der Sanden
- a Department of Orthopaedics , Physical Therapy, Radboud University Medical Centre , Nijmegen , The Netherlands.,e Scientific Centre for Quality of Care, Radboud University Medical Centre , Nijmegen , The Netherlands
| | - J Bart Staal
- e Scientific Centre for Quality of Care, Radboud University Medical Centre , Nijmegen , The Netherlands.,f Research Group Musculoskeletal Rehabilitation, HAN University of Applied Sciences , Nijmegen , The Netherlands
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Ramanujam CL, Han D, Zgonis T. Lower Extremity Amputation and Mortality Rates in the Reconstructed Diabetic Charcot Foot and Ankle With External Fixation: Data Analysis of 116 Patients. Foot Ankle Spec 2016; 9:113-26. [PMID: 26276212 DOI: 10.1177/1938640015599036] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
UNLABELLED The aim of this study was to determine the lower extremity amputation and mortality rates of a group of patients who underwent reconstructive surgery using circular external fixation for treatment of diabetic Charcot neuroarthropathy (CN) of the foot and/or ankle. Existing studies regarding lower extremity amputation or mortality rates for diabetic CN of the foot and/or ankle have been performed on mostly conservatively treated patients. The objective of the statistical analysis in this studied population was to understand the difference in overall amputation and mortality rates between the 2 main groups: one with foot and/or ankle ulceration (group 1), and the other without ulceration or osteomyelitis (group 2, control group). Within group 1, 2 subgroups were established: one with osteomyelitis (group 1A) and the other without osteomyelitis (group 1B). Initially, a retrospective analysis of 150 consecutive surgically reconstructed diabetic foot and ankle cases using circular external fixation from January 2005 through December 2012 was conducted. Those which were not supported with the diagnosis of diabetic CN were excluded and the 2 other charts without proper follow-up duration (6 months) for analysis were removed, resulting in the final sample size of N = 116. There were a total of n = 7 (6.0%) below the knee amputations (group 1A = 1, group 1B = 4, and group 2 = 2) with a total of n = 5 mortalities (4.3%) (group 1A = 2, group 1B = 2, and group 2 = 1). The total amount of time for a lower extremity amputation event (n = 7) since the time of surgical reconstruction was 729.43 ± 519.73 days (range 230-1777 days) while for a mortality event (n = 5), it was 1302.00 ± 765.48 days (range 633-2499 days). LEVELS OF EVIDENCE Prognostic, Level III: Retrospective study.
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Affiliation(s)
- Crystal L Ramanujam
- Division of Podiatric Medicine and Surgery, Department of Orthopaedic Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas (CLR)Department of Management Science & Statistics, College of Business, The University of Texas at San Antonio, San Antonio, Texas (DH)Externship and Reconstructive Foot and Ankle Fellowship Programs, Division of Podiatric Medicine and Surgery, Department of Orthopaedic Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas (TZ)
| | - David Han
- Division of Podiatric Medicine and Surgery, Department of Orthopaedic Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas (CLR)Department of Management Science & Statistics, College of Business, The University of Texas at San Antonio, San Antonio, Texas (DH)Externship and Reconstructive Foot and Ankle Fellowship Programs, Division of Podiatric Medicine and Surgery, Department of Orthopaedic Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas (TZ)
| | - Thomas Zgonis
- Division of Podiatric Medicine and Surgery, Department of Orthopaedic Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas (CLR)Department of Management Science & Statistics, College of Business, The University of Texas at San Antonio, San Antonio, Texas (DH)Externship and Reconstructive Foot and Ankle Fellowship Programs, Division of Podiatric Medicine and Surgery, Department of Orthopaedic Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas (TZ)
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Bekelis K, Gottlieb D, Newhall K, Faerber A, Goodney P. Does Rapid Diffusion of HbA1c Testing Affect Amputation Rates? Vasc Endovascular Surg 2016; 50:1538574416637436. [PMID: 26961487 PMCID: PMC5016205 DOI: 10.1177/1538574416637436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The association of speed of diffusion of Hemoglobin A1C (hbA1c) testing with temporal changes in outcomes of primary importance to patients with diabetes, such as amputation, remains an issue of debate. We investigated these correlations. METHODS We performed a retrospective cohort study of diabetics, based on Medicare fee-for-service claims data from 2002 to 2012. We examined the association of the rate of diffusion of HbA1c testing with changes in amputation rates. Our unit of analysis was the hospital referral region (HRR), a definition of tertiary care markets defined in the Dartmouth Atlas of Health Care. RESULTS From the 11 096 270 diabetics followed in our study for a mean follow-up of 4.1 years, 106 340 (0.96%) underwent lower extremity amputations. The speed of diffusion of HbA1c testing had a moderate association with the speed of diffusion of lower extremity amputations, after adjusting for multiple factors including baseline regional amputation and testing rates (adjusted difference, -0.7%; 95% confidence interval, -1.0% to -0.3%). The risk-adjusted HRR-level speed of diffusion of testing demonstrated significant correlation with the risk-adjusted HRR-level diffusion of amputations (r = .250, P < .001). CONCLUSIONS We observed a moderate association of the speed of diffusion of HbA1c testing with the speed of diffusion of lower extremity amputations among Medicare patients with diabetes. Improvements in performance on quality metrics such as HbA1c testing may not immediately translate into tangible patient outcomes.
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Affiliation(s)
- Kimon Bekelis
- Department of Surgery, The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA
| | - Daniel Gottlieb
- Department of Surgery, The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA
| | - Karina Newhall
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Adrienne Faerber
- Department of Surgery, The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA
| | - Phillip Goodney
- Department of Surgery, The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
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Faglia E, Clerici G, Frykberg R, Caminiti M, Curci V, Cetta F, Prisco V, Greco R, Prisco M, Morabito A. Outcomes of Chopart Amputation in a Tertiary Referral Diabetic Foot Clinic: Data From a Consecutive Series of 83 Hospitalized Patients. J Foot Ankle Surg 2015; 55:230-4. [PMID: 26620421 DOI: 10.1053/j.jfas.2015.09.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2013] [Indexed: 02/03/2023]
Abstract
The purpose of the present retrospective study was to evaluate the outcomes (ie, ulcer recurrence, major amputation, death) in diabetic patients undergoing Chopart amputation because of deep infection or gangrene extending to the midfoot. From 2009 to 2011, 83 patients, aged 71.4 ± 9.3 years, underwent a midtarsal amputation and were followed up until December 31, 2012 (mean follow-up 2.8 ± 0.8 years). Of the 83 patients, 26 were female, 61 required insulin, 47 had renal insufficiency, 19 underwent hemodialysis, 65 had hypertension, 34 had a history of cardiac disease, and 4 had a history of stroke. Chopart amputation was performed in 38 patients (45.8%) with gangrene, 31 (37.4%) with abscess, and 14 (16.9%) with osteomyelitis. Urgent surgery was performed in 56 patients (67.5%). Effective revascularization was performed in 64 patients (77.1%) patients. Of the 83 patients, 47 had healed at a mean period of 164.7 (range 11 to 698) days. Ulcer recurrence developed in 15 patients (31.9%). A major amputation was necessary in 23 patients (27.7%), with an annual incidence of 13.0%. None of the included variables on logistic regression analysis was significantly associated with proximal amputation. Of the 83 patients, 38 (45.8%) died, with an annual incidence of 25.8%. On logistic regression analysis, age (odds ratio [OR] 1.11, 95% confidence interval [CI] 1.01 to 1.16), history of stroke (OR 9.94, 95% CI 3.16 to 31.24), and urgent surgery (OR 2.60, 95% CI 1.14 to 5.93) were associated with mortality. Chopart amputation represents the last chance to avoid major amputation for diabetic patients with serious foot complications. Our success rate was great enough to consider Chopart amputation a viable option for limb salvage in this high-risk population.
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Affiliation(s)
- Ezio Faglia
- Scientific Director, Diabetic Foot Centre, IRCCS Multimedica, Sesto San Giovanni, Milan, Italy
| | - Giacomo Clerici
- Chief, Diabetic Foot Centre, IRCCS Multimedica, Sesto San Giovanni, Milan, Italy.
| | - Robert Frykberg
- Director, Podiatry Service, Carl T. Hayden Veteran Affairs Medical Center, Phoenix, AZ
| | - Maurizio Caminiti
- Associate Physician, Diabetic Foot Centre, IRCCS Multimedica, Sesto San Giovanni, Milan, Italy
| | - Vincenzo Curci
- Associate Physician, Diabetic Foot Centre, IRCCS Multimedica, Sesto San Giovanni, Milan, Italy
| | - Francesco Cetta
- Consultant, Diabetic Foot Centre, IRCCS Multimedica, Sesto San Giovanni, Milan, Italy
| | - Vincenzo Prisco
- Consultant, Fondazione Onlus DeaMedica, Pagani, Salerno, Italy
| | - Rosaria Greco
- Consultant, Fondazione Onlus DeaMedica, Pagani, Salerno, Italy
| | - Marco Prisco
- Consultant, Fondazione Onlus DeaMedica, Pagani, Salerno, Italy
| | - Alberto Morabito
- Director, Medical Statistics Unit, Milan University, Milan, Italy
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Rubio JA, Aragón-Sánchez J, Jiménez S, Guadalix G, Albarracín A, Salido C, Sanz-Moreno J, Ruiz-Grande F, Gil-Fournier N, Álvarez J. Reducing major lower extremity amputations after the introduction of a multidisciplinary team for the diabetic foot. INT J LOW EXTR WOUND 2014; 13:22-6. [PMID: 24659624 DOI: 10.1177/1534734614521234] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
We analyzed the incidence of lower extremity amputations (LEAs) in the 3rd Health Care Area of Madrid before and after the March 2008 introduction of a multidisciplinary team for managing diabetic foot disease. We compared the amputation rates in people with and without diabetes during 2 periods: before (2001-2007) and after (2008-2011) the introduction of a Multidisciplinary Diabetic Foot Unit (MDFU). We also analyzed the trend of the amputation rates by joinpoint regression analysis and measured the annual percentage change (APC). During the study period, 514 nontraumatic LEAs were performed, 374 (73%) in people with diabetes and 140 (27%) in people without the disease. The incidence of LEAs showed a significant reduction in major amputations in people with diabetes, from 6.1 per 100 000 per year (95% confidence interval [CI] = 4.9 to 7.2), in the 2001 to 2007 period, to 4.0 per 100 000 per year (95% CI = 2.6 to 5.5) in the 2008 to 2011 period (P = .020). There were no changes in incidence of minor or total amputations in the diabetic population or in amputations in the nondiabetic population during the study period. Joinpoint regression analysis showed a significant reduction in the incidence of major LEAs in diabetic population with an APC of -6.6% (95% CI = -10.2 to -2.8; P = .003), but there were no other significant changes. This study demonstrates that the introduction of a multidisciplinary team, coordinated by an endocrinologist and a podiatrist, for managing diabetic foot disease is associated with a reduction in the incidence of major amputations in patients with diabetes.
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Affiliation(s)
- José Antonio Rubio
- 1Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, Spain
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Amanatullah DF, Trousdale RT, Sierra RJ. Total knee arthroplasty after lower extremity amputation: a review of 13 cases. J Arthroplasty 2014; 29:1590-3. [PMID: 24836176 DOI: 10.1016/j.arth.2014.03.041] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Revised: 03/31/2014] [Accepted: 03/31/2014] [Indexed: 02/01/2023] Open
Abstract
Below knee amputation protects the ipsilateral knee from osteoarthritis and overloads the contralateral knee predisposing it to symptomatic osteoarthritis. We retrospectively reviewed 13 primary total knee arthroplasty (TKAs) in 12 patients with a prior lower extremity amputation. Twelve TKAs were performed on the contralateral side of the amputated limb while only one TKA was performed on the ipsilateral side. The average clinical follow-up was 6.8 ± 4.8 years. Knee Society Scores improved from 30.4 ± 11.8 to 88.5 ± 4.2 after TKA with a prior contralateral amputation. Three (23.1%) patients with TKA after contralateral amputation had aseptic loosening of the tibial component. Patients experience clinically significant improvement with TKA after lower extremity amputation. Augmentation of tibial fixation with a stem may be advisable during TKA after contralateral amputation.
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Affiliation(s)
| | | | - Rafael J Sierra
- Department of Orthopedic Surgery, Mayo Clinic, Rochester Minnesota
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47
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Abstract
Peripheral artery disease affects over eight million Americans and is associated with an increased risk of mortality, cardiovascular disease, functional limitation, and limb loss. In its most severe form, critical limb ischemia, patients are often treated with lower extremity (LE) amputation (LEA), although the overall incidence of LEA is declining. In the US, there is significant geographic variation in the performing of major LEA. The rate of death after major LEA in the US is approximately 48% at 1 year and 71% at 3 years. Despite this significant morbidity and mortality, the use of diagnostic testing (both noninvasive and invasive testing) in the year prior to LEA is low and varies based on patient, provider, and regional factors. In this review we discuss the significance of LEA and methods to reduce its occurrence. These methods include improved recognition of the risk factors for LEA by clinicians and patients, strong advocacy for noninvasive and/or invasive imaging prior to LEA, improved endovascular revascularization techniques, and novel therapies.
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Affiliation(s)
| | - Sreekanth Vemulapalli
- Department of Medicine, Duke University Medical Center, Durham, NC, USA ; Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA
| | - Manesh R Patel
- Department of Medicine, Duke University Medical Center, Durham, NC, USA ; Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA
| | - W Schuyler Jones
- Department of Medicine, Duke University Medical Center, Durham, NC, USA ; Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA
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Blumberg SN, Warren SM. Disparities in initial presentation and treatment outcomes of diabetic foot ulcers in a public, private, and Veterans Administration hospital. J Diabetes 2014; 6:68-75. [PMID: 23551696 DOI: 10.1111/1753-0407.12050] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2012] [Revised: 02/04/2013] [Accepted: 03/20/2013] [Indexed: 10/27/2022] Open
Abstract
BACKGROUND Disparities in diabetic foot ulcer (DFU) treatment outcomes are well described, although few studies identify risk factors contributing to disparate healing and amputation rates. In a unique academic center serving urban public, private, and veteran patients, we investigated amputation and healing rates and specific risk factors for disparate treatment outcomes. METHODS A retrospective chart review of diabetic patients with a new diagnosis of a foot ulcer at geographically adjacent, but independent public, private, and Veterans Administration (VA) hospitals was conducted. Healing and lower extremity amputation outcomes were assessed. RESULTS Across the three hospitals, 234 patients met the inclusion criteria. Patients at the VA hospital were older (mean 72.5 years; P < 0.001) and had gangrenous ulcers (mean 14.1%; P < 0.001) compared with patients in the private and public hospitals. Public hospital patients were mostly Hispanic (mean 54%; P < 0.001) with a shorter duration of diabetes (mean 12.8 years; P = 0.02), but were more poorly controlled than VA and private hospital patients (P ≤ 0.001). Prior amputation (odds ratio [OR] 1.97; P = 0.016) and non-Caucasian race (OR 2.42; P = 0.004) increased the risk of amputation on multivariate analysis. Osteomyelitis (P = 0.0371) and gangrene (P < 0.001) are independent risk factors for amputation. Across all three hospitals, 42.3% of patients were treated by amputation (6.8% private, 12% public and 23.5% VA; P < 0.001). CONCLUSION In a single triumvirate health care system where the patient population is stratified primarily by insurance, VA patients have significantly higher amputation rates compared with patients at adjacent private and public hospitals. The VA patients are largely racial minorities with advanced DFU progression to gangrenous ulcers.
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Affiliation(s)
- Sheila N Blumberg
- Department of Surgery, New York University School of Medicine, New York, New York, USA
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Abstract
The Syme amputation (ankle disarticulation level amputation) can be a valuable procedure for properly selected patients but might be underused owing to the problem of postoperative migration of the heel pad cushion. The present report presents a modification of the Syme amputation technique to prevent postoperative heel pad migration. The technique was performed in 12 patients, most of whom were male patients with diabetic foot infections. At an average follow-up of 7 years, the soft tissue cushion remained in a stable position, without ulceration. Also, patient satisfaction was high with the Syme level of amputation using the modified technique.
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Darter BJ, Nielsen DH, Yack HJ, Janz KF. Home-based treadmill training to improve gait performance in persons with a chronic transfemoral amputation. Arch Phys Med Rehabil 2013; 94:2440-7. [PMID: 23954560 DOI: 10.1016/j.apmr.2013.08.001] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2013] [Revised: 07/30/2013] [Accepted: 08/04/2013] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To investigate the effectiveness of a home-based multiple-speed treadmill training program to improve gait performance in persons with a transfemoral amputation (TFA). DESIGN Repeated measures. SETTING Research laboratory. PARTICIPANTS Individuals with a TFA (N=8) who had undergone a unilateral amputation at least 3 years prior as a result of limb trauma or cancer. INTERVENTION Home-based treadmill walking for a total of 30 minutes a day, 3 days per week for 8 weeks. Each 30-minute training session involved 5 cycles of walking for 2 minutes at 3 speeds. MAIN OUTCOME MEASURES Participants were tested pretraining and after 4 and 8 weeks of training. The primary measures were temporal-spatial gait performance (symmetry ratios for stance phase duration and step length), physiological gait performance (energy expenditure and energy cost), and functional gait performance (self-selected walking speed [SSWS], maximum walking speed [MWS], and 2-minute walk test [2MWT]). RESULTS Eight weeks of home-based training improved temporal-spatial gait symmetry at SSWS but not at MWS. A relative interlimb increase in stance duration for the prosthetic limb and proportionally greater increases in step length for the limb taking shorter steps produced the improved symmetry. The training effect was significant for the step length symmetry ratio within the first 4 weeks of the program. Energy expenditure decreased progressively during the training with nearly 10% improvement observed across the range of walking speeds. SSWS, MWS, and 2MWT all increased by 16% to 20%. CONCLUSIONS Home-based treadmill walking is an effective method to improve gait performance in persons with TFA. The results support the application of training interventions beyond the initial rehabilitation phase, even in individuals considered highly functional.
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