Amputation and cardiac comorbidity: analysis of severity of cardiac risk

The Use of "Spare Parts" En Bloc Anterior Compartment Myocutaneous Free Flap to Reconstruct the Transmetatarsal Amputation Stump After Contralateral Below Knee Amputation: Report of Two Cases

The aim of reconstruction after lower extremity amputation is to provide adequate soft tissue coverage that is compatible with prosthetics to optimize functional status. We present two cases where the anterior compartment myocutaneous free flap used in a "spare parts" fashion was valuable in preserving the length of residual limbs for patients needing simultaneous below-knee amputation (BKA) and contralateral transmetatarsal amputation (TMA). The first case involved a 48-year-old woman undergoing TMA and BKA to address bilateral lower extremity necrosis secondary to septic shock. The anterior compartment muscles were taken en bloc as a myocutaneous free flap measuring ~4 × 12 cm based on the anterior tibial artery. A standard BKA was completed with a posterior flap, and the flap was used to cover exposed metatarsals on the opposite limb. After 4 years, she had no complications or additional surgeries and was able to ambulate independently. The second case involved a 55-year-old woman undergoing BKA and TMA for bilateral lower extremity gangrene. Again, the anterior compartment muscles were taken as a myocutaneous free flap measuring ~5 × 15 cm to cover the resulting TMA defect. This patient underwent debulking at 2 and 10 weeks postoperatively, after which she had no complications at 1 year of follow-up and returned to independent ambulation. This technique provided effective soft tissue coverage and successfully preserved limb length without additional donor site morbidity. As a myocutaneous free flap, the anterior compartment muscles may effectively preserve the length of residual limbs in patients undergoing BKA and TMA, allowing for improved functional outcomes and quality of life.

Trends and Outcomes of Lower Limb Amputation in Patients With Coronary Artery Disease

Background and aim Coronary artery disease (CAD) is a leading cause of morbidity and mortality in the United States, with peripheral arterial disease (PAD) and lower limb (LL) amputation contributing to poor cardiovascular outcomes. While previous studies have identified the link between CAD and PAD-related amputations, data on short-term in-hospital outcomes remain limited. This study aimed to compare in-hospital mortality and complications between CAD patients undergoing LL amputation and those without it. Methods We conducted a retrospective cohort study using the Nationwide Inpatient Sample (NIS) from 2016 to 2021, identifying CAD patients with and without LL amputation via International Classification of Diseases, 10th Revision (ICD-10) codes. Propensity score matching (PSM) was performed using a 1:1 nearest-neighbor algorithm to minimize selection bias, adjusting for demographics, comorbidities, and hospital characteristics. The primary outcome was in-hospital all-cause mortality, while secondary outcomes included acute heart failure, cardiogenic shock, acute kidney injury (AKI), major adverse cardiac and cerebrovascular events (MACCE), and healthcare resource utilization. Results A total of 31,379,939 CAD patients were identified, with 119,320 (0.4%) undergoing LL amputation. After propensity score matching (PSM), 23,261 patients were included in each group. The LL amputation cohort exhibited significantly higher in-hospital mortality (5.5% vs. 3.3%, p<0.001), cardiac arrest (2.3% vs. 1.4%, p<0.001), acute kidney injury (AKI) (29.3% vs. 26.8%, p<0.001), and acute limb ischemia (5.2% vs. 0.4%, p<0.001). Conversely, CAD patients without amputation had higher rates of acute heart failure (18.3% vs. 10.7%, p<0.001), major adverse cardiac and cerebrovascular events (MACCE) (22.5% vs. 12.2%, p<0.001), and percutaneous coronary intervention (6.7% vs. 0.9%, p<0.001). The length of stay and total hospital charges were significantly higher in the amputation group (10 days vs. four days; $26,590 vs. $11,686, p<0.001). Conclusion Lower limb amputation in CAD patients is associated with increased in-hospital mortality, cardiac complications, and healthcare resource utilization. These findings underscore the need for early intervention strategies targeting PAD progression and comprehensive perioperative cardiovascular risk management in amputees. Future research should focus on optimizing revascularization approaches, rehabilitation programs, and tailored preventive measures to improve outcomes in this high-risk population.

Risk of Heart Disease in Patients With Amputation: A Nationwide Cohort Study in South Korea

BACKGROUND

Amputation confers disabilities upon patients and is linked to substantial morbidity and death attributed to heart disease. While some studies have focused on traumatic amputees in veterans, few studies have focused on traumatic amputees within the general population. Therefore, the present study aimed to assess the risk of heart disease in patients with traumatic amputation with disability within the general population using a large-scale nationwide population-based cohort.

METHODS AND RESULTS

We used data from the Korean National Health Insurance System. A total of 22 950 participants with amputation were selected with 1:3 age, sex-matched controls between 2010 and 2018. We used Cox proportional hazard models to calculate the risk of myocardial infarction, heart failure, and atrial fibrillation among amputees. Participants with amputation had a higher risk of myocardial infarction (adjusted hazard ratio [aHR], 1.30 [95% CI, 1.14-1.47]), heart failure (aHR, 1.27 [95% CI, 1.17-1.38]), and atrial fibrillation (aHR, 1.17 [95% CI, 1.03-1.33]). The risks of myocardial infarction and heart failure were further increased by the presence of disability (aHR, 1.43 [95% CI, 1.04-1.95]; and aHR, 1.38 [95% CI, 1.13-1.67], respectively).

CONCLUSIONS

We demonstrate an increased risk of myocardial infarction, heart failure, and atrial fibrillation among individuals with amputation, and the risk further increased in those with disabilities. Clinicians should pay attention to the increased risk for heart disease in patients with amputation.

Barriers and Facilitators to Cardiovascular Rehabilitation Programmes for People with Lower Limb Amputation: A Survey of Clinical Practice in Canada

Purpose

This study determines barriers and facilitators to including people with lower limb amputation (LLA) in cardiovascular rehabilitation programmes (CRPs).

Method

Canadian CRP managers and exercise therapists were invited to complete a questionnaire.

Results

There were 87 respondents. Of the 32 CRP managers, 65.6% reported that people with LLA were eligible for referral, but of these, 61.9% only accepted people with LLA and cardiac disease, and 38.1% only accepted them with ≥ 1 cardiovascular risk factor. CRP eligibility progressively decreased as mobility severity increased, with 94% of programmes accepting those with mild mobility deficits but only 48% accepting those with severe deficits. Among therapists in CRPs that accepted LLAs, 54.3% reported not having an LLA participant within the past three years. Among all responding therapists and managers who were also therapists (n = 58), 43% lacked confidence in managing safety concerns, and 45%, 16%, and 7% lacked confidence in prescribing aerobic exercise to LLA with severe, moderate, and no mobility deficits respectively. There was a similar finding with prescribing resistance training. LLA-specific education had not been provided to any respondent within the past three years. The top barriers were lack of referrals (52.6%; 30) and lack of knowledge of the contraindications to exercise specific for LLA (43.1%; 31). Facilitators included the provision of a resistance-training tool kit (63.4%; 45), education on exercise safety (63.4%; 45), and indications for physician intervention/inspection (63.6%; 42).

Conclusion

Most of the CRPs surveyed only accept people with LLA if they have co-existing cardiac disease or cardiovascular risk factors. Few people with LLA participate. Education on CRP delivery for LLAs is needed to improve therapists' confidence and exercise safety.

Are physically disabled people at high risk of coronary heart disease among disabled population - Evidence from 7.5-year retrospective cohort study

OBJECTIVES

Previous cross-sectional studies suggested that people with physical disabilities (one of the subgroups of disabled people) are associated with an increased risk of cardiovascular diseases (CVD) than healthy peers. However, a longitudinal cohort of disabled people exhibited a different trend, in which the study populations were similar in health inequalities. We aimed to examine whether physical disability was associated with an increased risk of coronary heart disease (CHD) among disabled people.

STUDY DESIGN AND SETTING

This retrospective cohort study from the Shanghai Health Examination Program included a total of 6419 disabled adults (50.77 [9.88] age) with complete electronic health records and were free of CHD at baseline (2012) were followed-up for a 7.5-year period until 2019. The physical disability and non-physical disability subgroups were characterized based on the Disability Classification and Grading Standard (GB/T 26341-2010). Multivariable Cox regression analyses were used to evaluate adjusted hazard ratios (HR) for subsequent CHD, while Kaplan-Meier curves was used to assess the proportional hazards assumption. We conducted subgroup analyses based on gender, levels of disability, and baseline blood pressure.

RESULTS

Kaplan-Meier analysis revealed a higher incidence of CHD in the physical disability group compared to the non-physical disability group during the 7.5-year follow-up period (P < 0.05). Subjects with physical disabilities exhibited an increased risk for subsequent CHD occurrence (HR: 1.12; 95% CI: 1.03-1.31), compared to the non-physical subgroup after adjustments for confounders. The sensitivity analysis conducted on subgroups according to gender and disability severity indicated that moderate physical disability and female physical disability were associated with a higher prevalence of CHD, which was confirmed by multi-adjusted regression analysis. The spline curves of BP and CHD indicated that the physical disability group displayed lower SBP and DBP thresholds of 120 mmHg and SBP, respectively.

CONCLUSION

Within the disabled population, individuals with physical disability are at higher risk of developing CHD, and it is plausible that their optimal BP threshold for CHD prevention may need to be set at a lower level. Further research is essential to investigate BP management among individuals with physical disabilities and its influence on cardiovascular-related adverse events.

Dietary intakes and prevalence of overweight/obesity in male non-dysvascular lower limb amputees

BACKGROUND

Lower limb amputees are at higher risk of cardiovascular disease compared to non-amputees. Dietary intake, a major determinant of cardiovascular disease risk, has not previously been studied in this group.

OBJECTIVE

The aim of this study was to investigate dietary intakes and prevalence of overweight/obesity in adult lower limb amputees.

STUDY DESIGN

A cross-sectional survey was used to investigate the dietary intake and prevalence of overweight/obesity in adults with lower limb amputations living in the United Kingdom.

METHOD

Dietary intakes of male adult lower limb amputees ( n = 46, non-dysvascular) were assessed using food frequency questionnaires and results were compared to dietary reference values in the United Kingdom. Prevalence of overweight/obesity was assessed through body mass index and waist-to-hip ratio and compared to the general population according to the Health Survey for England 2011.

RESULTS

Dietary intake risk factors for cardiovascular disease such as sugars (22.01%), total fat (34.87%), saturated fat (12.72%) and sodium (2660.10 mg/day) were significantly higher ( p < 0.001, p < 0.001, p = 0.043, p < 0.001; p < 0.001; respectively) than the dietary reference values. A high prevalence (82.8%) of overweight/obesity was found with a significantly higher body mass index and waist-to-hip ratio ( p = 0.027; p = 0.001; respectively) compared to the Health Survey for England 2011.

CONCLUSION

High intakes of sugars, dietary fats, sugars and salts, combined with high prevalence of overweight/obesity observed in lower limb amputees are concerning. These findings suggest that greater emphasis on dietary intakes should be considered for rehabilitation programmes.

CLINICAL RELEVANCE

Findings highlight poor dietary habits in lower limb amputees with respect to fat, sugar and salt intake, also high levels of overweight/obesity. Considering greater emphasis on dietary intake and including lifestyle changing interventions in rehabilitation programmes for lower limb amputees may lower the risk of obesity and CVD.

Predictors of Receiving a Prosthesis for Adults With Above-Knee Amputations in a Well-Defined Population

BACKGROUND

Prior studies have identified age as a factor in determining an individual's likelihood of receiving a prosthesis following a lower limb amputation. These studies are limited to specific subsets of the general population and are unable to account for preamputation characteristics within their study populations. Our study seeks to determine the effect of preamputation characteristics on the probability of receiving a prosthesis for the general population in the United States.

OBJECTIVE

To identify preamputation characteristics that predict of the likelihood of receiving a prosthesis following an above-knee amputation.

DESIGN

A retrospective, population-based cohort study.

SETTING

Olmsted County, Minnesota (2010 population: 144,248).

PARTICIPANTS

Individuals (n = 93) over the age of 18 years who underwent an above-knee amputation, that is, knee disarticulation or transfemoral amputation, while residing in Olmsted County, MN, between 1987 and 2013.

METHODS

Characteristics affecting the receipt of a prosthesis were analyzed using a logistic regression and a random forest algorithm for classification trees. Preamputation characteristics included age, gender, amputation etiology, year of amputation, mobility, cognitive ability, comorbidities, and time between surgery and the prosthesis decision.

MAIN OUTCOME MEASURES

The association of preamputation characteristics with the receipt of a prosthesis following an above-knee amputation.

RESULTS

Twenty-four of the participants received a prosthesis. The odds of receiving a prosthesis were almost 30 times higher in those able to walk independently prior to an amputation relative to those who could not walk independently. A 10-year increase in age was associated with a 53.8% decrease in the likelihood of being fit for a prosthesis (odds ratio = 0.462, P =.030). Time elapsed between surgery and the prosthesis decision was associated with a rise in probability of receiving a prosthesis for the first 3 months in the random forest algorithm. No other observed characteristics were associated with receipt of a prosthesis.

CONCLUSIONS

The association of preamputation mobility and age with the likelihood of being fit for a prosthesis is well understood. The effect of age, after controlling for confounders, still persists and is associated with the likelihood of being fit for a prosthesis.