1
|
McGinnis A, Weber Z, Zuhaili B, Garrett HE. Mobility Rates After Lower-Limb Amputation for Patients Treated with Physician-Led Collaborative Care Model. Ann Vasc Surg 2024; 105:99-105. [PMID: 38599488 DOI: 10.1016/j.avsg.2024.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 02/09/2024] [Accepted: 02/20/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND Clinical outcomes after major lower-limb amputation have been historically poor. The current care provided to most amputees is often disorganized and without physician supervision. The primary purpose of this study is to examine rates of postamputation mobility achieved with a prosthesis by patients with chronic limb-threatening ischemia and/or diabetes who required major lower-limb amputation and were treated under an established physician-led collaborative care pathway. The secondary purpose is to describe the structure and utilization of the care pathway by multiple independent vascular surgery practices in the United States to enable future exploration of its impact on key clinical outcomes within this patient population. METHODS Clinical records of 2,475 patients from 6 vascular practices that adopted this collaborative care pathway between 2017 and 2020 were retrospectively reviewed. Only records with sufficient documented histories of amputation surgeries, prosthetic services, and mobility status were included. RESULTS Of 2,475 patient records reviewed, 1,787 patients (2,157 major amputations) were eligible for analysis. Sixty-two-point 2 percent (n = 1,111) of patients achieved mobility with the collaborative care pathway. Mobility rate varied by amputation level in the study. Prosthetic mobility was achieved in 73.5% of transtibial amputations, 40.4% of transfemoral amputations, and 35.7% of through-knee amputations, regardless of patient laterality, which is superior or equivalent to the best published rates of mobility. CONCLUSIONS The study describes the structure and utilization of a physician-led collaborative care pathway for treating patients who require lower-limb amputation that meets 5 of the 7 recommendations from the 2019 Global Vascular Guidelines on the Management of Chronic Limb Threatening Ischemia. Internal data analysis results suggest that patients treated via this care pathway can potentially achieve improved mobility rates with a prosthesis following amputation. This collaborative care pathway should be further evaluated for its ability to directly improve mobility and other clinically relevant amputation outcomes.
Collapse
Affiliation(s)
| | | | - Bara Zuhaili
- Michigan Vascular Center, Michigan State University, Flint, MI
| | - H Edward Garrett
- Division of Vascular Surgery, University of Tennessee-Memphis, Memphis, TN.
| |
Collapse
|
2
|
Yağız BK, Göktuğ UU, Sapmaz A, Dinç T, Budak AB, Terzioğlu SG. The impact of comorbidities on mortality in patients with non-traumatic major lower extremity amputation. J Wound Care 2023; 32:805-810. [PMID: 38060412 DOI: 10.12968/jowc.2023.32.12.805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
OBJECTIVE Major lower limb amputation is generally associated with a high risk of early and late-term mortality. In this study, 30-day, one-year and three-year mortality of non-traumatic major lower extremity amputations and comorbidities affecting the mortality rate were investigated. METHOD Patients who underwent a major lower limb amputation secondary to diabetes or peripheral artery disease between the years 2010-2015 were retrospectively evaluated. Additional to patient demographic data and comorbidities, amputation level, survival and mortality time were extracted. Mortality rates after 30 days, one year and three years were analysed. The associations of the survival to different parameters were evaluated with Kaplan-Meier analysis and log rank test, while the impact of the risk factors on mortality was evaluated with the Cox regression test. RESULTS A total of 193 patients were enrolled in the study. Approximately 60% of patients were aged ≥65 years, and 65.8% were male. Below-knee amputation was performed in 64.8% of patients and above-knee amputation in 35.2% of patients. The mean follow-up of patients was 29.48 months (range: 0-101 months). After non-traumatic major lower extremity amputation, 30-day, one-year and three-year mortality were 16.6%, 38.3% and 60.1%, respectively. On Cox regression analysis, age ≥65 years was the only variable that had significant impact on the 30-day mortality (hazard ratio (HR): 3.4; p=0.012), while age ≥65 years (HR: 2.5, p=0.000), diabetes (HR: 2, p=0.006) and renal failure (HR: 2, p=0.001) were found to have significant impacts on three-year mortality. CONCLUSION The findings of this study showed that >50% of patients with non-traumatic major lower limb amputations died within three years. Advanced age, diabetes and renal failure were the risk factors that increased the mortality. The high mortality rates revealed the importance of employing all hard-to-heal wound treatment options before making an amputation decision. Further, prospective studies are needed to determine the effects of primary disease status and timing of amputation on mortality.
Collapse
Affiliation(s)
- Betül Keskinkılıç Yağız
- Ministry of Health Samsun Gazi State Hospital, Department of General Surgery, Samsun, Turkey
| | - Ufuk Utku Göktuğ
- Yeditepe University Faculty of Medicine, Department of General Surgery, Istanbul, Turkey
| | - Ali Sapmaz
- Ministry of Health Ankara City Hospital, Department of General Surgery, Ankara, Turkey
| | - Tolga Dinç
- Ministry of Health Ankara City Hospital, Department of General Surgery, Ankara, Turkey
| | - Ali Baran Budak
- Başkent University Faculty of Medicine Alanya Practice and Research Center, Department of Cardiovascular Surgery, Antalya, Turkey
| | | |
Collapse
|
3
|
B Aledi L, Flumignan CD, Trevisani VF, Miranda F. Interventions for motor rehabilitation in people with transtibial amputation due to peripheral arterial disease or diabetes. Cochrane Database Syst Rev 2023; 6:CD013711. [PMID: 37276273 PMCID: PMC10240563 DOI: 10.1002/14651858.cd013711.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
BACKGROUND Amputation is described as the removal of an external part of the body by trauma, medical illness or surgery. Amputations caused by vascular diseases (dysvascular amputations) are increasingly frequent, commonly due to peripheral arterial disease (PAD), associated with an ageing population, and increased incidence of diabetes and atherosclerotic disease. Interventions for motor rehabilitation might work as a precursor to enhance the rehabilitation process and prosthetic use. Effective rehabilitation can improve mobility, allow people to take up activities again with minimum functional loss and may enhance the quality of life (QoL). Strength training is a commonly used technique for motor rehabilitation following transtibial (below-knee) amputation, aiming to increase muscular strength. Other interventions such as motor imaging (MI), virtual environments (VEs) and proprioceptive neuromuscular facilitation (PNF) may improve the rehabilitation process and, if these interventions can be performed at home, the overall expense of the rehabilitation process may decrease. Due to the increased prevalence, economic impact and long-term rehabilitation process in people with dysvascular amputations, a review investigating the effectiveness of motor rehabilitation interventions in people with dysvascular transtibial amputations is warranted. OBJECTIVES To evaluate the benefits and harms of interventions for motor rehabilitation in people with transtibial (below-knee) amputations resulting from peripheral arterial disease or diabetes (dysvascular causes). SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search date was 9 January 2023. SELECTION CRITERIA We included randomised controlled trials (RCT) in people with transtibial amputations resulting from PAD or diabetes (dysvascular causes) comparing interventions for motor rehabilitation such as strength training (including gait training), MI, VEs and PNF against each other. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcomes were 1. prosthesis use, and 2. ADVERSE EVENTS Our secondary outcomes were 3. mortality, 4. QoL, 5. mobility assessment and 6. phantom limb pain. We use GRADE to assess certainty of evidence for each outcome. MAIN RESULTS We included two RCTs with a combined total of 30 participants. One study evaluated MI combined with physical practice of walking versus physical practice of walking alone. One study compared two different gait training protocols. The two studies recruited people who already used prosthesis; therefore, we could not assess prosthesis use. The studies did not report mortality, QoL or phantom limb pain. There was a lack of blinding of participants and imprecision as a result of the small number of participants, which downgraded the certainty of the evidence. We identified no studies that compared VE or PNF with usual care or with each other. MI combined with physical practice of walking versus physical practice of walking (one RCT, eight participants) showed very low-certainty evidence of no difference in mobility assessment assessed using walking speed, step length, asymmetry of step length, asymmetry of the mean amount of support on the prosthetic side and on the non-amputee side and Timed Up-and-Go test. The study did not assess adverse events. One study compared two different gait training protocols (one RCT, 22 participants). The study used change scores to evaluate if the different gait training strategies led to a difference in improvement between baseline (day three) and post-intervention (day 10). There were no clear differences using velocity, Berg Balance Scale (BBS) or Amputee Mobility Predictor with PROsthesis (AMPPRO) in training approaches in functional outcome (very low-certainty evidence). There was very low-certainty evidence of little or no difference in adverse events comparing the two different gait training protocols. AUTHORS' CONCLUSIONS Overall, there is a paucity of research in the field of motor rehabilitation in dysvascular amputation. We identified very low-certainty evidence that gait training protocols showed little or no difference between the groups in mobility assessments and adverse events. MI combined with physical practice of walking versus physical practice of walking alone showed no clear difference in mobility assessment (very low-certainty evidence). The included studies did not report mortality, QoL, and phantom limb pain, and evaluated participants already using prosthesis, precluding the evaluation of prosthesis use. Due to the very low-certainty evidence available based on only two small trials, it remains unclear whether these interventions have an effect on the prosthesis use, adverse events, mobility assessment, mortality, QoL and phantom limb pain. Further well-designed studies that address interventions for motor rehabilitation in dysvascular transtibial amputation may be important to clarify this uncertainty.
Collapse
Affiliation(s)
- Luciane B Aledi
- Department of Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Carolina Dq Flumignan
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Virginia Fm Trevisani
- Medicina de Urgência and Rheumatology, Escola Paulista de Medicina, Universidade Federal de São Paulo and Universidade de Santo Amaro, São Paulo, Brazil
| | - Fausto Miranda
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
| |
Collapse
|
4
|
Qaarie MY. Life Expectancy and Mortality After Lower Extremity Amputation: Overview and Analysis of Literature. Cureus 2023; 15:e38944. [PMID: 37309338 PMCID: PMC10257952 DOI: 10.7759/cureus.38944] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2023] [Indexed: 06/14/2023] Open
Abstract
Lower limb amputation (LLA) is a major surgical procedure with a significant impact on quality of life and mortality rates as well. Previous studies have shown that mortality rates following LLA can range from 9-17% within 30 days in the UK. This study systematically evaluates and reviews the published literature on life expectancy, mortality, and survival rates following lower extremity amputation (LEA). We have conducted a comprehensive search on Medline, CINAHL, and Cochrane Central databases resulting in 87 full-text articles. After a thorough review, only 45 (52.9%) articles met the minimum inclusion criteria for the study. Our analysis indicated 30-day mortality rates following LEA ranged from 7.1% to 51.4%, with an average mortality rate of 16.45% (SD 14.35) per study. Furthermore, 30-day mortality rates following below-knee amputation (BKA) and above-knee amputation (AKA) were found to be between 6.2% to 51.4%, X= 17.16% ± 19.46 SD and 12.7 to 21.7%, X= 16.15% ± 4.17 SD, respectively. Our review provides a comprehensive insight into the life expectancy, mortality, and survival rates following LEA. These findings highlight the importance of considering various factors, including patient age, presence of comorbidities such as diabetes, heart failure, and renal failure, and lifestyle factors such as smoking, in determining prognosis following LLA. Further research is necessary to determine strategies for improving outcomes and reducing mortality in this patient population.
Collapse
|
5
|
Aizu N, Oouchida Y, Yamada K, Nishii K, Shin-Ichi I. Use-dependent increase in attention to the prosthetic foot in patients with lower limb amputation. Sci Rep 2022; 12:12624. [PMID: 35871204 PMCID: PMC9308804 DOI: 10.1038/s41598-022-16732-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 07/14/2022] [Indexed: 11/09/2022] Open
Abstract
AbstractPatients with lower limb amputation experience “embodiment” while using a prosthesis, perceiving it as part of their body. Humans control their biological body parts and receive appropriate information by directing attention toward them, which is called body-specific attention. This study investigated whether patients with lower limb amputation similarly direct attention to prosthetic limbs. The participants were 11 patients with lower limb amputation who started training to walk with a prosthesis. Attention to the prosthetic foot was measured longitudinally by a visual detection task. In the initial stage of walking rehabilitation, the index of attention to the prosthetic foot was lower than that to the healthy foot. In the final stage, however, there was no significant difference between the two indexes of attention. Correlation analysis revealed that the longer the duration of prosthetic foot use, the greater the attention directed toward it. These findings indicate that using a prosthesis focuses attention akin to that of an individual’s biological limb. Moreover, they expressed that the prosthesis felt like a part of their body when they could walk independently. These findings suggest that the use of prostheses causes integration of visual information and movement about the prosthesis, resulting in its subjective embodiment.
Collapse
|
6
|
Liu R, Petersen BJ, Rothenberg GM, Armstrong DG. Lower extremity reamputation in people with diabetes: a systematic review and meta-analysis. BMJ Open Diabetes Res Care 2021; 9:9/1/e002325. [PMID: 34112651 PMCID: PMC8194332 DOI: 10.1136/bmjdrc-2021-002325] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 05/09/2021] [Indexed: 12/03/2022] Open
Abstract
In this study, we determined the reamputation-free survival to both limbs and to the contralateral limb only following an index amputation of any-level and assessed whether reamputation rates have changed over time. We completed a systematic search using PubMed and screened a total of 205 articles for data on reamputation rates. We reported qualitative characteristics of 56 studies that included data on reamputation rates and completed a meta-analysis on 22 of the studies which enrolled exclusively participants with diabetes. The random-effects meta-analysis fit a parametric survival distribution to the data for reamputations to both limbs and to the contralateral limb only. We assessed whether there was a temporal trend in the reamputation rate using the Mann-Kendall test. Incidence rates were high for reamputation to both limbs and to the contralateral limb only. At 1 year, the reamputation rate for all contralateral and ipsilateral reamputations was found to be 19% (IQR=5.1%-31.6%), and at 5 years, it was found to be 37.1% (IQR=27.0%-47.2%). The contralateral reamputation rate at 5 years was found to be 20.5% (IQR=13.3%-27.2%). We found no evidence of a trend in the reamputation rates over more than two decades of literature analyzed. The incidence of lower extremity reamputation is high among patients with diabetes who have undergone initial amputations secondary to diabetes, and rates of reamputation have not changed over at least two decades.
Collapse
Affiliation(s)
- Rongqi Liu
- Podimetrics Inc, Somerville, Massachusetts, USA
- Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
| | | | - Gary M Rothenberg
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - David G Armstrong
- Department of Surgery, USC Keck School of Medicine, Los Angeles, California, USA
| |
Collapse
|
7
|
Shutze W, Gable D, Ogola G, Yasin T, Madhukar N, Kamma B, Alniemi Y, Eidt J. Sex, age, and other barriers for prosthetic referral following amputation and the impact on survival. J Vasc Surg 2021; 74:1659-1667. [PMID: 34082007 DOI: 10.1016/j.jvs.2021.05.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 05/01/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Despite advances in peripheral vascular disease treatment, lower extremity amputation continues to be necessary in a significant number of patients. Up to 80% of amputees are not referred for prosthetic fitting. The factors contributing to referral decisions have not been adequately investigated, nor has the impact of prosthetic referral on survival. We characterized differences between patients who were successfully referred to our in-house prosthetists and those who were not, and identified factors associated with prosthetic referral and predictive of survival. METHODS This was a retrospective analysis of all patients who underwent lower extremity amputation by surgeons in our practice from January 1, 2010, to June 30, 2017. Data regarding age, sex, race, body mass index (BMI), diabetes, hypertension, hyperlipidemia, end-stage renal disease, prior coronary artery bypass graft surgery, congestive heart failure, tobacco use, American Society of Anesthesiologists (ASA) score, previous arterial procedure, chronic obstructive pulmonary disease, statin use, postoperative ambulatory status, level of amputation, stump revision, and referral for prosthesis were collected. Survival was determined from a combination of sources, including the Social Security Death Master Index, multiple genealogic registries, and internet searches. Multivariable logistic regression was used to determine risk factors associated with prosthesis referral. Multivariable Cox proportional hazard regression with time-dependent covariates was performed to assess risk factors associated with 5-year mortality. RESULTS There were 293 patients included in this study. Mean age was 66 years, and mean BMI 27 kg/m2. The majority of patients were male (69%), white (53%), with diabetes (65.4%) and hypertension (77.5%), and underwent below-the-knee amputation (BKA) (73%). Prosthetic referral occurred in 123 (42.0%). Overall 5-year survival was 61.7% (95% confidence interval [CI], 55.9%-68.1%) (BKA 64.7% [95% CI, 57.9%-72.3%]; above-the-knee amputation 53.8% [95% CI, 43.4%-66.6%]). On multivariate analysis, age >70 years, female sex, diabetes, ASA score 4 or 5, and current tobacco use were associated with no referral for prosthetic fitting. Patients with BMI 25 to 30, a previous arterial procedure, BKA, and history of stump revision were more likely to be referred. Factors associated with decreased survival were increasing age, higher ASA class, black race, and BMI; prosthetic referral was seen to be protective. CONCLUSIONS We identified multiple patient factors associated with prosthetic referral, as well as several characteristics predictive of reduced survival after amputation. Being referred for prosthetic fitting was associated with improved survival not explained by patient characteristics and comorbidities. Further research is needed to determine whether the factors identified as associated with nonreferral are markers for patient characteristics that make them clinically unsuitable for prosthetic fitting or if they are symptoms of unconscious bias or of the patient's access to care.
Collapse
Affiliation(s)
- William Shutze
- Heart Hospital Baylor Plano, Plano, Tex; Texas Vascular Associates, Plano, Tex.
| | - Dennis Gable
- Heart Hospital Baylor Plano, Plano, Tex; Texas Vascular Associates, Plano, Tex
| | - Gerald Ogola
- Baylor Scott and White Research Institute, Dallas, Tex
| | | | | | | | | | - John Eidt
- Texas Vascular Associates, Plano, Tex; Baylor University Medical Center, Dallas, Tex
| |
Collapse
|
8
|
Hebenton J, Scott H, Seenan C, Davie-Smith F. Relationship between models of care and key rehabilitation milestones following unilateral transtibial amputation: a national cross-sectional study. Physiotherapy 2019; 105:476-482. [DOI: 10.1016/j.physio.2018.11.307] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 11/30/2018] [Indexed: 11/17/2022]
|
9
|
Abstract
BACKGROUND Dressings are part of the routine postoperative management of people after transtibial amputation. Two types of dressings are commonly used; soft dressings (e.g. elastic bandages, crepe bandages) and rigid dressings (e.g. non-removable rigid dressings, removable rigid dressings, immediate postoperative protheses). Soft dressings are the conventional dressing choice as they are cheap and easy to apply, while rigid dressings are costly, more time consuming to apply and require skilled personnel to apply the dressings. However, rigid dressings have been suggested to result in faster wound healing due to the hard exterior providing a greater degree of compression to the stump. OBJECTIVES To assess the benefits and harms of rigid dressings versus soft dressings for treating transtibial amputations. SEARCH METHODS In December 2018 we searched the Cochrane Wounds Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, Ovid Embase, EBSCO CINAHL Plus, Ovid AMED and PEDro to identify relevant trials. To identify further published, unpublished and ongoing studies, we also searched clinical trial registries, the grey literature, the reference lists of relevant studies and reviews identified in prior searches. We used the Cited Reference Search facility on ThomsonReuters Web of Science and contacted relevant individuals and organisations. There were no restrictions with respect to language, date of publication or study setting. SELECTION CRITERIA We included randomised controlled trials (RCTs) and quasi-RCTs that enrolled people with transtibial amputations. There were no restrictions on the age of participants and reasons for amputation. Trials that compared the effectiveness of rigid dressings with soft dressings were the main focus of this review. DATA COLLECTION AND ANALYSIS Two review authors independently screened titles, abstracts and full-text publications for eligible studies. Two review authors also independently extracted data on study characteristics and outcomes, and performed risk of bias and GRADE assessments. MAIN RESULTS We included nine RCTs and quasi-RCTs involving 436 participants (441 limbs). All studies recruited participants from acute and/or rehabilitation hospitals from seven different countries (the USA, Australia, Indonesia, Thailand, Canada, France and the UK). In all but one study, it was clearly stated that amputations were secondary to vascular conditions.Primary outcomes Wound healing We are uncertain whether rigid dressings decrease the time to wound healing compared with soft dressings (MD -25.60 days; 95% CI -49.08 to -2.12; one study, 56 participants); very low-certainty evidence, downgraded twice for very high risk of bias and once for serious imprecision. It is not clear whether rigid dressings increase the proportion of wounds healed compared with soft dressings (RR 1.14; 95% CI 0.74 to 1.76; one study, 51 participants); very low-certainty evidence, downgraded twice for very high risk of bias and twice for very serious imprecision.Adverse events It is not clear whether rigid dressings increase the proportion of skin-related adverse events compared with soft dressings (RR 0.65; 95% CI 0.32 to 1.32; I2 = 0%; six studies, 336 participants (340 limbs)); very low-certainty evidence, downgraded twice for very high risk of bias and once for serious imprecision.It is not clear whether rigid dressings increase the proportion of non skin-related adverse events compared with soft dressings (RR 1.09; 95% CI 0.60 to 1.99; I2 = 0%; six studies, 342 participants (346 limbs)); very low-certainty evidence, downgraded twice for very high risk of bias and once for serious imprecision. In addition, we are uncertain whether rigid dressings decrease the time to no pain compared with soft dressings (MD -0.35 weeks; 95% CI -2.11 to 1.41; one study of 23 participants); very low-certainty evidence, downgraded twice for very high risk of bias and twice for very serious imprecision.Secondary outcomesWe are uncertain whether rigid dressings decrease the time to walking compared with soft dressings (MD -3 days; 95% CI -9.96 to 3.96; one study, 56 participants); very low-certainty evidence, downgraded twice for very high risk of bias and twice for very serious imprecision. We are also uncertain whether rigid dressings decrease the length of hospital stay compared with soft dressings (MD -30.10 days; 95% CI -49.82 to -10.38; one study, 56 participants); very low-certainty evidence, downgraded twice for very high risk of bias and once for serious imprecision. It is also not clear whether rigid dressings decrease the time to readiness for prosthetic prescription and swelling compared with soft dressings, as results are based on very low-certainty evidence, downgraded twice for very high risk of bias and once/twice for serious/very serious imprecision. None of the studies reported outcomes on patient comfort, quality of life and cost. AUTHORS' CONCLUSIONS We are uncertain of the benefits and harms of rigid dressings compared with soft dressings for people undergoing transtibial amputation due to limited and very low-certainty evidence. It is not clear if rigid dressings are superior to soft dressings for improving outcomes related to wound healing, adverse events, prosthetic prescription, walking function, length of hospital stay and swelling. Clinicians should exercise clinical judgement as to which type of dressing they use, and consider the pros and cons of each for patients (e.g. patients with high risk of falling may benefit from the protection offered by a rigid dressing, and patients with poor skin integrity may have less risk of skin breakdown from a soft dressing).
Collapse
Affiliation(s)
- Li Khim Kwah
- Singapore Institute of TechnologyHealth and Social Sciences Cluster10 Dover DriveSingaporeSingapore138683
| | - Matthew T Webb
- South Eastern Sydney Local Health DistrictDirectorate of Allied HealthDistrict Executive UnitLocked Mail Bag 21Taren PointNSWAustralia2229
| | - Lina Goh
- Bankstown‐Lidcombe HospitalDepartment of PhysiotherapyEldridge RdBankstownNSWAustralia2200
| | - Lisa A Harvey
- Kolling Institute, Northern Sydney Local Health DistrictJohn Walsh Centre for Rehabilitation ResearchRoyal North Shore HospitalSt LeonardsNSWAustralia2065
| | | |
Collapse
|
10
|
Madsen UR, Baath C, Berthelsen CB, Hommel A. Age and health-related quality of life, general self-efficacy, and functional level 12 months following dysvascular major lower limb amputation: a prospective longitudinal study. Disabil Rehabil 2018; 41:2900-2909. [DOI: 10.1080/09638288.2018.1480668] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Ulla Riis Madsen
- Department of Orthopedic Surgery, Holbaek and Slagelse Hospital, Holbaek, Denmark
| | - Carina Baath
- Faculty of Health, Science and Technology, Karlstad University, Karlstad, Sweden
| | | | - Ami Hommel
- Faculty of medicine, Lund University, Lund, Sweden
| |
Collapse
|
11
|
Bowrey S, Naylor H, Russell P, Thompson J. Development of a scoring tool (BLARt score) to predict functional outcome in lower limb amputees. Disabil Rehabil 2018; 41:2324-2332. [PMID: 29754521 DOI: 10.1080/09638288.2018.1466201] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Purpose: To develop a valid preoperative scoring tool that predicts the probability of walking with a prosthetic limb after major lower limb amputation. Methods: A retrospective review of 338 patients who had undergone lower limb amputation was conducted to identify characteristics that affected the success of rehabilitation with a prosthetic limb. These data were used to devise an assessment tool (the BLARt score), which was then tested and validated in 199 patients planned to undergo lower limb amputation in two UK regional centers. Functional rehabilitation outcomes were recorded at 12 months after surgery using the SIGAM mobility grading. Results: No patient with a BLARt score ≥13 achieved good functional outcome (defined as independent mobility, SIGAM grade E or F) and only 6 patients with a BLARt score ≥17 achieved any functional outcome (defined as any ability to walk unaided, SIGAM grade C or greater). Conclusions: In the patient cohorts studied, the BLARt assessment tool was a strong predictor of whether or not patients would be able to walk with a prosthetic limb after surgery. It is simple to administer and could be useful in clinical practice to inform expectations for patients and clinicians. Implications for rehabilitation Patients undergoing lower limb amputation face major physical and psychological challenges after surgery that have a considerable impact on rehabilitation and their ability to walk independently. Many amputees are unable to walk with a prosthetic limb, but there are no validated tools to predict this before surgery. The BLARt is a potentially valuable measure that can predict the likelihood of being unable to walk after amputation. It is simple to use and could be useful to inform patients' and clinicians' expectations before surgery.
Collapse
Affiliation(s)
- Sarah Bowrey
- a Department of Cardiovascular Sciences, Anaesthesia Critical Care and Pain Management Group , University Hospitals of Leicester NHS Trust and University of Leicester , Leicester , UK
| | - Helen Naylor
- b Blatchford Clinical Services , Leicester Specialist Mobility Centre , Leicester , UK
| | - Pip Russell
- b Blatchford Clinical Services , Leicester Specialist Mobility Centre , Leicester , UK
| | - Jonathan Thompson
- a Department of Cardiovascular Sciences, Anaesthesia Critical Care and Pain Management Group , University Hospitals of Leicester NHS Trust and University of Leicester , Leicester , UK
| |
Collapse
|
12
|
Madsen UR, Bååth C, Berthelsen CB, Hommel A. A prospective study of short-term functional outcome after dysvascular major lower limb amputation. Int J Orthop Trauma Nurs 2017; 28:22-29. [PMID: 28866377 DOI: 10.1016/j.ijotn.2017.08.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Revised: 07/07/2017] [Accepted: 08/08/2017] [Indexed: 11/16/2022]
Abstract
This study investigates functional status on Day 21 after dysvascular major lower limb amputation compared with one month pre-amputation and evaluates factors potentially influencing outcome. METHODS A prospective cohort study design was used. Data were collected via in-person interviews using structured instruments and covered functional level (Barthel index 100) one month pre-amputation and on Day 21. Out of a consecutive sample of patients having major lower limb amputation (tibia, knee or femoral) (n = 105), 51 participated on Day 21 follow-up. Clinical, demographic, body function and environmental data were analysed as factors potentially influencing outcome. RESULTS From pre-amputation to Day 21, participants' functional level decreased significantly in all ten activities of daily living activities as measured by the Barthel Index. Almost 60% of participants were independent in bed-chair transfer on Day 21. Being independent in transfer on Day 21 was positively associated with younger age and attending physiotherapy after discharge. CONCLUSIONS The findings indicate that short-term functional outcome is modifiable by quality of the postoperative care provided and thus highlights the need for increased focus on postoperative care to maintain basic function as well as establish and provide everyday rehabilitation in the general population of patients who have dysvascular lower limb amputations.
Collapse
Affiliation(s)
- Ulla Riis Madsen
- Department of Orthopedic Surgery, Slagelse Hospital, Ingemannsvej 18, 4200 Slagelse, Denmark.
| | | | | | | |
Collapse
|
13
|
Davie-Smith F, Paul L, Nicholls N, Stuart WP, Kennon B. The impact of gender, level of amputation and diabetes on prosthetic fit rates following major lower extremity amputation. Prosthet Orthot Int 2017; 41:19-25. [PMID: 26850990 PMCID: PMC5302066 DOI: 10.1177/0309364616628341] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Diabetes mellitus is a leading cause of major lower extremity amputation. OBJECTIVE To examine the influence of gender, level of amputation and diabetes mellitus status on being fit with a prosthetic limb following lower extremity amputation for peripheral arterial disease. STUDY DESIGN Retrospective analysis of the Scottish Physiotherapy Amputee Research Group dataset. RESULTS Within the cohort with peripheral arterial disease ( n = 1735), 64% were men ( n = 1112) and 48% ( n = 834) had diabetes mellitus. Those with diabetes mellitus were younger than those without: mean 67.5 and 71.1 years, respectively ( p < 0.001). Trans-tibial amputation:trans-femoral amputation ratio was 2.33 in those with diabetes mellitus, and 0.93 in those without. A total of 41% of those with diabetes mellitus were successfully fit with a prosthetic limb compared to 38% of those without diabetes mellitus. Male gender positively predicted fitting with a prosthetic limb at both trans-tibial amputation ( p = 0.001) and trans-femoral amputation ( p = 0.001) levels. Bilateral amputations and increasing age were negative predictors of fitting with a prosthetic limb ( p < 0.001). Diabetes mellitus negatively predicted fitting with a prosthetic limb at trans-femoral amputation level ( p < 0.001). Mortality was 17% for the cohort, 22% when the amputation was at trans-femoral amputation level. CONCLUSION Of those with lower extremity amputation as a result of peripheral arterial disease, those with diabetes mellitus were younger, and more had trans-tibial amputation. Although both age and amputation level are good predictors of fitting with a prosthetic limb, successful limb fit rates were no better than those without diabetes mellitus. Clinical relevance This is of clinical relevance to those who are involved in the decision-making process of prosthetic fitting following major amputation for dysvascular and diabetes aetiologies.
Collapse
Affiliation(s)
- Fiona Davie-Smith
- University of Glasgow, Glasgow, UK,Fiona Davie-Smith, University of Glasgow, 61 Oakfield Ave, Glasgow G12 8LL, UK.
| | | | | | - Wesley P Stuart
- NHS GGC, Diabetes Centre, Southern General Hospital, Glasgow, UK
| | - Brian Kennon
- NHS GGC, Diabetes Centre, Southern General Hospital, Glasgow, UK
| |
Collapse
|
14
|
Kwah LK, Goh L, Harvey LA. Rigid dressings versus soft dressings for transtibial amputations. Hippokratia 2016. [DOI: 10.1002/14651858.cd012427] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Li Khim Kwah
- University of Technology Sydney; Discipline of Physiotherapy, Graduate School of Health; PO Box 123, Ultimo Sydney NSW Australia 2007
| | - Lina Goh
- St George Hospital; Department of Physiotherapy; Gray Street Kogarah NSW Australia 2217
| | - Lisa A Harvey
- Kolling Institute, Northern Sydney Local Health District; John Walsh Centre for Rehabilitation Research; Royal North Shore Hospital St Leonards NSW Australia 2065
| |
Collapse
|
15
|
Resnik L, Borgia M. Predicting prosthetic prescription after major lower-limb amputation. ACTA ACUST UNITED AC 2016; 52:641-52. [PMID: 26562228 DOI: 10.1682/jrrd.2014.09.0216] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Revised: 04/23/2015] [Indexed: 11/05/2022]
Abstract
We describe prosthetic limb prescription in the first year following lower-limb amputation and examine the relationship between amputation level, geographic region, and prosthetic prescription. We analyzed 2005 to 2010 Department of Veterans Affairs (VA) Inpatient and Medical Encounters SAS data sets, Vital Status death data, and National Prosthetic Patient Database data for 9,994 Veterans who underwent lower-limb amputation at a VA hospital. Descriptive statistics and bivariates were examined. Cox proportional hazard models identified factors associated with prosthetic prescription. Analyses showed that amputation level was associated with prosthetic prescription. The hazard ratios (HRs) were 1.41 for ankle amputation and 0.46 for transfemoral amputation compared with transtibial amputation. HRs for geographic region were Northeast = 1.49, Upper Midwest = 1.26, and West = 1.39 compared with the South (p < 0.001). African American race, longer length of hospital stay, older age, congestive heart failure, paralysis, other neurological disease, renal failure, and admission from a nursing facility were negatively associated with prosthetic prescription. Being married was positively associated. After adjusting for patient characteristics, people with ankle amputation were most likely to be prescribed a prosthesis and people with transfemoral amputation were least likely. Geographic variation in prosthetic prescription exists in the VA and further research is needed to explain why.
Collapse
Affiliation(s)
- Linda Resnik
- Providence Department of Veterans Affairs Medical Center, Providence, RI
| | | |
Collapse
|
16
|
Kristensen MT, Holm G, Krasheninnikoff M, Jensen PS, Gebuhr P. An enhanced treatment program with markedly reduced mortality after a transtibial or higher non-traumatic lower extremity amputation. Acta Orthop 2016; 87:306-11. [PMID: 27088484 PMCID: PMC4900091 DOI: 10.3109/17453674.2016.1167524] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Background and purpose - Historically, high 30-day and 1-year mortality post-amputation rates (> 30% and 50%, respectively) have been reported in patients with a transtibial or higher non-traumatic lower extremity amputation (LEA). We evaluated whether allocating experienced staff and implementing an enhanced, multidisciplinary recovery program would reduce the mortality rates. We also determined factors that influenced mortality rates. Patients and methods - 129 patients with a LEA were consecutively included over a 2-year period, and followed after admission to an acute orthopedic ward. Mortality was compared with historical and concurrent national controls in Denmark. Results - The 30-day and 1-year mortality rates were 16% and 37%, respectively, in the intervention group, as compared to 35% and 59% in the historical control group treated in the same orthopedic ward. Cox proportional harzards models adjusted for age, sex, residential and health status, the disease that caused the amputation, and the index amputation level showed that 30-day and 1-year mortality risk was reduced by 52% (HR =0.48, 95% CI: 0.25-0.91) and by 46% (HR =0.54, 95% CI: 0.35-0.86), respectively, in the intervention group. The risk of death was increased for patients living in a nursing home, for patients with a bilateral LEA, and for patients with low health status. Interpretation - With similarly frail patient groups and instituting an enhanced program for patients after LEA, the risks of death by 30 days and by 1 year after LEA were markedly reduced after allocating staff with expertise.
Collapse
Affiliation(s)
- Morten T Kristensen
- Physical Medicine and Rehabilitation Research – Copenhagen (PMR-C), Department of Physical Therapy;,Department of Orthopedic Surgery;,Correspondence:
| | | | | | - Pia S Jensen
- Department of Orthopedic Surgery;,Clinical Research Center, Copenhagen University Hospital Hvidovre, Copenhagen, Denmark
| | | |
Collapse
|
17
|
Chin T, Toda M. Results of prosthetic rehabilitation on managing transtibial vascular amputation with silicone liner after wound closure. J Int Med Res 2016; 44:957-67. [PMID: 27225860 PMCID: PMC5536617 DOI: 10.1177/0300060516647554] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 04/11/2016] [Indexed: 11/20/2022] Open
Abstract
Objective To investigate the effect of a standardized silicone liner programme on the duration of prosthetic rehabilitation in patients who underwent transtibial amputation as a result of peripheral arterial disease. Methods This retrospective study enrolled patients who underwent transtibial amputation followed by one of two stump management programmes at the same rehabilitation centre over a period of 14 years. The study compared the duration of rehabilitation following a standardized silicone liner programme compared with that following a conventional soft dressing programme. Results This study included 16 patients who underwent the silicone liner programme and 11 patients who underwent the soft dressing programme. There were no significant differences between the two groups in age, sex, interval between amputation and admission to the rehabilitation centre and stump length. The duration required for the completion of the rehabilitation programme was significantly shorter for the silicone liner programme compared with the soft dressing programme (mean ± SD: 77.3 days ± 13.4 versus 125.4 days ± 66.4 days, respectively). Conclusion A standardized silicone liner programme reduced the duration of rehabilitation and could be a valuable replacement for soft dressing-based stump management.
Collapse
Affiliation(s)
- Takaaki Chin
- Department of Physical Medicine and Rehabilitation, Hyogo Rehabilitation Centre, Kobe, Japan Department of Rehabilitation Science, Kobe University Graduate School of Medicine in Hyogo Rehabilitation Centre, Kobe, Japan
| | - Mitsunori Toda
- Department of Physical Medicine and Rehabilitation, Hyogo Rehabilitation Centre, Kobe, Japan Department of Orthopaedic Surgery, Hyogo Rehabilitation Centre, Kobe, Japan
| |
Collapse
|
18
|
Kurichi JE, Kwong P, Vogel WB, Xie D, Ripley DC, Bates BE. Effects of prosthetic limb prescription on 3-year mortality among Veterans with lower-limb amputation. JOURNAL OF REHABILITATION RESEARCH AND DEVELOPMENT 2015; 52:385-96. [PMID: 26348602 PMCID: PMC4563808 DOI: 10.1682/jrrd.2014.09.0209] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Revised: 03/04/2015] [Indexed: 11/05/2022]
Abstract
Our objective was to determine the relationship between receipt of a prescription for a prosthetic limb and 3 yr mortality postsurgery among Veterans with lower-limb amputation (LLA). We conducted a retrospective observational study that included 4,578 Veterans hospitalized for LLA and discharged in fiscal years 2003 and 2004. The outcome was time to all-cause mortality from the amputation surgical date up to the 3 yr anniversary of the surgical date. Of the Veterans with LLA, 1,300 (28.4%) received a prescription for a prosthetic limb within 1 yr after the surgical amputation. About 46% (n = 2,086) died within 3 yr of the surgical anniversary. Among those who received a prescription for a prosthetic limb, only 25.2% died within 3 yr of the surgical anniversary. After adjustment, Veterans who received a prescription for a prosthetic limb were less likely to die after the surgery than Veterans without a prescription, with a hazard ratio of 0.68 (95% confidence interval: 0.60-0.77). Findings demonstrated that Veterans with LLA who received a prescription for a prosthetic limb within 1 yr after the surgical amputation were less likely to die within 3 yr of the surgical amputation after controlling for patient-, treatment-, and facility-level characteristics.
Collapse
Affiliation(s)
- Jibby E. Kurichi
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA
| | - Pui Kwong
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA
| | - W. Bruce Vogel
- Veterans Affairs Medical Center Gainesville, FL and Department of Health Outcomes and Policy, College of Medicine, University of Florida
| | - Dawei Xie
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA
| | - Diane Cowper Ripley
- VA HSR&D/RR&D Rehabilitation Outcomes Research Center REAP North Florida/South Georgia Veterans Health System, Gainesville, FL and University of Florida, Department of Health Outcomes and Policy, College of Medicine, Gainesville, FL
| | - Barbara E. Bates
- Veterans Affairs Medical Center, Albany, NY and Physical Medicine and Rehabilitation, Albany Medical College, Albany, NY
| |
Collapse
|
19
|
Fleury AM, Salih SA, Peel NM. Rehabilitation of the older vascular amputee: A review of the literature. Geriatr Gerontol Int 2012; 13:264-73. [DOI: 10.1111/ggi.12016] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/28/2012] [Indexed: 11/27/2022]
Affiliation(s)
| | - Salih A Salih
- Centre for Research in Geriatric Medicine; The University of Queensland; Brisbane; Queensland; Australia
| | - Nancye M Peel
- Centre for Research in Geriatric Medicine; The University of Queensland; Brisbane; Queensland; Australia
| |
Collapse
|
20
|
Bates BE, Hallenbeck R, Ferrario T, Kwong PL, Kurichi JE, Stineman MG, Xie D. Patient-, treatment-, and facility-level structural characteristics associated with the receipt of preoperative lower extremity amputation rehabilitation. PM R 2012; 5:16-23. [PMID: 22939239 DOI: 10.1016/j.pmrj.2012.06.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2012] [Revised: 05/11/2012] [Accepted: 06/17/2012] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To determine patient, treatment, or facility characteristics that influence decisions to initiate a rehabilitation assessment before transtibial or transfemoral amputation within the Veterans Affairs (VA) health care system. DESIGN Retrospective database study. SETTING VA medical centers. PARTICIPANTS A total of 4226 veterans with lower extremity amputations discharged from a VA medical center between October 1, 2002, and September 30, 2004. OUTCOME Evidence of a preoperative rehabilitation assessment after the index surgical stay admission but before the surgical date. RESULTS Evidence was found that 343 of 4226 veterans (8.12%) with lower extremity amputations received preoperative rehabilitation assessments. Veterans receiving preoperative rehabilitation were more likely to be older, admitted from home, or transferred from another hospital. Patients who underwent surgical amputation at smaller-sized hospitals or in the South Central or Mountain Pacific regions were more likely to receive preoperative rehabilitation compared with patients in mid-sized hospitals or in the Northeast, Southeast, or Midwest regions. Patients with evidence of paralysis, patients treated in facilities with programs accredited by the Commission on Accreditation of Rehabilitation Facilities (P < .01), and patients in the second data wave were less likely to receive preoperative rehabilitation. After accounting for patient-, treatment-, and facility-level structural characteristics, we found that older patients were more likely to receive preoperative rehabilitation services (odds ratio [OR] 1.01, 95% confidence interval [CI] 1.01-1.02). Patients with a contributing amputation etiology of a previous amputation complication were more likely to receive preoperative consultation rehabilitation services (OR 1.50, 95% CI 1.02-2.19) compared with patients who did not have this etiology. Compared with patients treated in the Southeast region of the United States, those treated in the South Central region (OR 2.52, 95% CI 1.82-3.48) or Mountain Pacific region (OR 1.62, 95% CI 1.11-2.37) were more likely to receive preoperative consultation rehabilitation services. Patients with evidence of paralysis were less likely to receive preoperative rehabilitative services compared with patients who did not have this condition (OR 0.29, 95% CI 0.09-0.93), and patients treated in mid-sized hospitals also were less likely to receive preoperative rehabilitative services compared with patients treated in smaller-sized facilities (OR 0.38, 95% CI 0.27-0.53). Veterans in the second data year were less likely to receive services compared with patients in the first year (OR 0.74, 95% CI 0.58-0.94). CONCLUSIONS Rehabilitation assessment before lower extremity amputation surgery is a rare occurrence in the VA health care system. Practice patterns appear to be driven by location and not by patient characteristics.
Collapse
Affiliation(s)
- Barbara E Bates
- Samuel S. Stratton VAMC, 113 Holland Ave, Albany, NY 12208, USA.
| | | | | | | | | | | | | |
Collapse
|
21
|
Beggs AD, McGlone ER, Thomas PRS. Impact of centralisation on vascular surgical services. ACTA ACUST UNITED AC 2012. [DOI: 10.12968/bjhc.2012.18.9.468] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Andrew D Beggs
- Department of Surgery Epsom & St Helier Hospital NHS Trust
| | | | - Paul RS Thomas
- Department of Surgery Epsom & St Helier Hospital NHS Trust
| |
Collapse
|