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Quek MS, Oei CW, Ong PL, Chung CLH, Kong PW, Zhang X, Leo KH. Prognosticating Prosthetic Ambulation Ability in People With Lower Limb Amputation in Early Post-Operative Phase. Arch Phys Med Rehabil 2024:S0003-9993(24)00904-3. [PMID: 38570179 DOI: 10.1016/j.apmr.2024.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 02/27/2024] [Accepted: 03/27/2024] [Indexed: 04/05/2024]
Abstract
OBJECTIVE To formulate a prognostication model in the early post-operation phase of lower limb amputation to predict patient's ability to ambulate with a prosthesis post rehabilitation. DESIGN Retrospective cohort study, using data collected from electronic medical records. Predictive factors and prosthetic ambulation outcomes post rehabilitation were used to develop prognostic models via machine learning techniques. SETTING Regional hospital's ambulatory rehabilitation clinic. PARTICIPANTS Patients with major lower limb amputation (N=329). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES The outcome of prosthetic ambulation ability post rehabilitation collected was categorized in 3 groups: non-ambulant with prosthesis, homebound ambulant with prosthesis (AP), and community AP. RESULTS In a 2-class model of non-ambulant and AP (homebound and community), the model with highest accuracy of prediction included ethnicity, total Functional Comorbidity Index (FCI), level of amputation, being community ambulant prior to amputation, and age. The f1-score and area under receiver operator curve (AUROC) of the model is 0.78 and 0.82. In a 3-class model consisting of all 3 groups of outcomes, the model with highest accuracy of prediction required 10 factors. The additional factors from the 2-class model include presence of caregiver, history of congestive heart failure, diabetes, visual impairment, and stroke. The 3-class model has a moderate accuracy with a f1-score and AUROC of 0.60 and 0.79. CONCLUSION The 2-class prognostication model has a high accuracy which can be used early post-amputation to predict if patient would be ambulant with a prosthesis post rehabilitation. The 3-class prognostication model has moderate accuracy and is able to further differentiate the walking ability to either homebound or community ambulation with a prosthesis, which can assist in prosthetic prescription and setting realistic rehabilitation goals.
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Affiliation(s)
- Mei Sing Quek
- Physiotherapy Department, Tan Tock Seng Hospital, Singapore.
| | - Chien Wei Oei
- Office of Clinical Epidemiology, Analytics & kNowledge (OCEAN), Tan Tock Seng Hospital, Singapore
| | - Poo Lee Ong
- Rehabilitation Medicine, Tan Tock Seng Hospital, Singapore
| | | | - Pui Wah Kong
- National Institute of Education, Nanyang Technological University, Singapore
| | - Xiaojin Zhang
- Office of Clinical Epidemiology, Analytics & kNowledge (OCEAN), Tan Tock Seng Hospital, Singapore
| | - Kee Hao Leo
- Office of Clinical Epidemiology, Analytics & kNowledge (OCEAN), Tan Tock Seng Hospital, Singapore
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2
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Sano M, Morii H, Endo T, Kimura M, Yamamoto S, Hashimoto T, Deguchi J. Pirogoff amputation is a viable option to maintain ambulation in chronic limb-threatening ischemia with extensive midfoot tissue loss: a report of two cases. J Surg Case Rep 2024; 2024:rjae180. [PMID: 38524678 PMCID: PMC10958607 DOI: 10.1093/jscr/rjae180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Accepted: 03/01/2024] [Indexed: 03/26/2024] Open
Abstract
Eliminating necrotic and infected tissues is crucial for limb salvage in patients with chronic limb-threatening ischemia (CLTI). However, extensive lesions that involve the midfoot frequently result in transtibial amputation, restricting ambulation and independent life. The Modified Pirogoff amputation, which includes a 90° rotation of the calcaneus and fixation with the tibia, has good functional outcomes in trauma cases. Here, we report two patients with CLTI successfully managed by a combination of revascularization and modified Pirogoff amputation, resulting in preserved ambulation without a prosthesis. Modified Pirogoff amputation may be a good alternative in revascularized CLTI with extensive tissue loss of the midfoot.
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Affiliation(s)
- Masaya Sano
- Department of Vascular Surgery, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe, Saitama 350-0844, Japan
| | - Hokuto Morii
- Department of Emergency and Critical Care Medicine, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe, Saitama 350-0844, Japan
| | - Takashi Endo
- Department of Vascular Surgery, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe, Saitama 350-0844, Japan
| | - Masaru Kimura
- Department of Vascular Surgery, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe, Saitama 350-0844, Japan
| | - Satoshi Yamamoto
- Department of Vascular Surgery, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe, Saitama 350-0844, Japan
| | - Takuya Hashimoto
- Department of Vascular Surgery, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe, Saitama 350-0844, Japan
| | - Juno Deguchi
- Department of Vascular Surgery, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe, Saitama 350-0844, Japan
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3
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Meshkin DH, Zolper EG, Chang K, Bryant M, Bekeny JC, Evans KK, Attinger CE, Fan KL. Long-term Mortality After Nontraumatic Major Lower Extremity Amputation: A Systematic Review and Meta-analysis. J Foot Ankle Surg 2021; 60:567-576. [PMID: 33509714 DOI: 10.1053/j.jfas.2020.06.027] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 06/17/2020] [Accepted: 06/23/2020] [Indexed: 02/03/2023]
Abstract
Chronic wounds that lead to major lower extremity amputation have immense consequences on quality of life, and ultimately, mortality. However, mortality rates after lower extremity amputation for a chronic wound are broad within the literature and have escaped precise definition. This systematic review aims to quantify long-term mortality rates after major lower extremity amputation in the chronic wound population available in the existing literature. Ovid MEDLINE was searched for publications which provided mortality data after major, nontraumatic, primary lower extremity amputations. Lower extremity amputations were defined as below and above the knee amputation. Data from included studies was analyzed to obtain pooled 1-, 2-, 3-, 5- and 10-year mortality rates. Sixty-one studies satisfied inclusion criteria representing 36,037 patients who underwent nontraumatic major lower extremity amputation. Pooled mortality rates were 33.7%, 51.5%, 53%, 64.4%, and 80% at 1-, 2-, 3-, 5- and 10-year follow-up, respectively. Within the 8184 diabetic patients (types 1 and 2), 1- and 5-year mortality was 27.3% and 63.2%. Sources of mortality data were varied and included electronic medical records, national health and insurance registries, and government databases. Mortality after nontraumatic major lower extremity amputation is high, both in patients with diabetes as well as those without. Methods used to measure and report mortality are inconsistent, lack reliability, and may underestimate true mortality rates. These findings illustrate the need for a paradigm shift in wound management and improved outcomes reporting. A focus on amputation prevention and care within a multidisciplinary team is critical for recalcitrant ulcers.
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Affiliation(s)
- Dean H Meshkin
- Medical Student, Georgetown University School of Medicine, Washington, DC
| | - Elizabeth G Zolper
- Medical Student, Department of Plastic and Reconstructive Surgery, Center for Wound Healing, MedStar Georgetown University Hospital, Washington, DC
| | - Kevin Chang
- Medical Student, Georgetown University School of Medicine, Washington, DC
| | - Meigan Bryant
- Medical Student, Georgetown University School of Medicine, Washington, DC
| | - Jenna C Bekeny
- Medical Student, Department of Plastic and Reconstructive Surgery, Center for Wound Healing, MedStar Georgetown University Hospital, Washington, DC
| | - Karen K Evans
- Professor of Plastic Surgery, Department of Plastic and Reconstructive Surgery, Center for Wound Healing, MedStar Georgetown University Hospital, Washington
| | - Christopher E Attinger
- Professor of Plastic Surgery, Department of Plastic and Reconstructive Surgery, Center for Wound Healing, MedStar Georgetown University Hospital, Washington
| | - Kenneth L Fan
- Assistant Professor Plastic Surgery, Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC.
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4
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Andersen JC, Mannoia KA, Patel ST, Leong BV, Murga AG, Teruya TH, Kiang SC, Abou-Zamzam AM. Factors Affecting One-Year Outcomes After Major Lower Extremity Amputation in the Vascular Quality Initiative Amputation Registry. Am Surg 2021; 87:1569-1574. [PMID: 34130510 DOI: 10.1177/00031348211024639] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Major lower extremity amputation (LEA) results in significant morbidity and mortality. This study identifies factors contributing to adverse long-term outcomes after major LEA. STUDY DESIGN Amputations in the Vascular Quality Initiative (VQI) long-term follow-up database from 2012 to 2017 were included. Multivariable logistic regression determined which significant patient factors were associated with 1-year mortality, long-term functional status, and progression to higher level amputation within 1 year. RESULTS 3440 major LEAs were performed and a mortality rate of 19.9% was seen at 1 year. Logistic regression demonstrated that 1-year mortality was associated with post-op myocardial infarction (MI) (odds ratio (OR) 1.7, CI 1.02-2.97, P = .04), congestive heart failure (CHF) (OR 1.9, confidence interval (CI) 1.56-2.38, P < .001), hypertension (HTN) (OR 1.31, CI 1.00-1.72, P = .05), chronic obstructive pulmonary disease (COPD) (OR 1.36, CI 1.13-1.63, P < .001), and dependent functional status (OR 2.01, CI 1.67-2.41, P < .001). A decline in ambulatory status was associated with COPD (OR 1.36, CI 1.09-1.68, P = .006). Dependent functional status was protective against revision to higher level amputation (OR .18, CI .07-.45, P < .001). CONCLUSION In the VQI, 1-year mortality after major LEA is nearly 20% and associated with HTN, CHF, COPD, dependent functional status, and post-op MI. Decreased functional status at 1 year was associated with COPD, and progression to higher level amputation was less likely in patients with dependent functional status.
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Affiliation(s)
- James C Andersen
- Division of Vascular Surgery, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Kristyn A Mannoia
- Division of Vascular Surgery, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Sheela T Patel
- Division of Vascular Surgery, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Beatriz V Leong
- Division of Vascular Surgery, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Allen G Murga
- Division of Vascular Surgery, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Theodore H Teruya
- Division of Vascular Surgery, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Sharon C Kiang
- Division of Vascular Surgery, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Ahmed M Abou-Zamzam
- Division of Vascular Surgery, Loma Linda University Medical Center, Loma Linda, CA, USA
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5
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Williams ZF, Gilmore B, Weissler H, Long C, Southerland K, Cox MW. Retrograde Transamputation Revascularization: A Case Report. Ann Vasc Surg 2021; 74:511-514. [PMID: 33819588 DOI: 10.1016/j.avsg.2021.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Revised: 02/02/2021] [Accepted: 02/25/2021] [Indexed: 11/24/2022]
Abstract
Below-knee amputation remains the most common level of amputation in patients with lower extremity gangrene and critical limb ischemia. Failure to heal, requiring additional operative debridement or conversion to an above-knee amputation remains a significant cause of patient morbidity. There remains no definitive diagnostic test that can accurately predict healing of the amputation site. We report a case utilizing a hybrid technique of retrograde transamputation revascularization via balloon angioplasty. This proximal, retrograde approach allows for relatively easy crossing and treatment of the infrainguinal chronic total occlusions (CTOs), improving arterial inflow for optimal wound healing.
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Affiliation(s)
- Zachary F Williams
- Duke University Hospital, Department of Surgery, Durham, North Carolina.
| | - Brian Gilmore
- Duke University Hospital, Department of Surgery, Durham, North Carolina
| | - Hope Weissler
- Duke University Hospital, Department of Surgery, Durham, North Carolina
| | - Chandler Long
- Duke University Hospital, Department of Surgery, Durham, North Carolina
| | - Kevin Southerland
- Duke University Hospital, Department of Surgery, Durham, North Carolina
| | - Mitchell W Cox
- Duke University Hospital, Department of Surgery, Durham, North Carolina
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6
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Catella J, Long A, Mazzolai L. What Is Currently the Role of TcPO2 in the Choice of the Amputation Level of Lower Limbs? A Comprehensive Review. J Clin Med 2021; 10:jcm10071413. [PMID: 33915838 PMCID: PMC8037184 DOI: 10.3390/jcm10071413] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 03/15/2021] [Accepted: 03/20/2021] [Indexed: 11/18/2022] Open
Abstract
Some patients still require major amputation for lower extremity peripheral arterial disease treatment. The purpose of pre-operative amputation level selection is to determine the most distal amputation site with the highest healing probability without re-amputation. Transcutaneous oximetry (TcPO2) can detect viable tissue with the highest probability of healing. Several factors affect the accuracy of TcPO2; nevertheless, surgeons rely on TcPO2 values to determine the optimal amputation level. Background about the development of TcPO2, methods of measurement, consequences of lower limb amputation level, and the place of TcPO2 in the choice of the amputation level are reviewed herein. Most of the retrospective studies indicated that calf TcPO2 values greater than 40 mmHg were associated with a high percentage of successful wound healing after below-knee-amputation, whereas values lower than 20 mmHg indicated an increased risk of unsuccessful healing. However, a consensus on the precise cut-off value of TcPO2 necessary to assure healing is missing. Ways of improvement for TcPO2 performance applied to the optimization of the amputation-level are reported herein. Further prospective data are needed to better approach a TcPO2 value that will promise an acceptable risk of re-amputation. Standardized TcPO2 measurement is crucial to ensure quality of data.
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Affiliation(s)
- Judith Catella
- Service de Médecine Interne et Vasculaire, Hopital Edouard Herriot, Hospices Civils de Lyon, 69003 Lyon, France;
- Laboratoire d’Excellence du Globule Rouge (Labex GR-Ex), Sorbonne, 75015 Paris, France
- Laboratoire Interuniversitaire de Biologie de la Motricité (LIBM) EA7424, Université Claude Bernard Lyon 1, Université de Lyon, 69008 Lyon, France
- UMR 5305: Laboratoire de Biologie Tissulaire et Ingénierie Thérapeutique, CNRS/Université Claude Bernard Lyon 1, Institut de Biologie et Chimie des Protéines, 7 Passage du Vercors, 69367 Lyon, France
- Correspondence: ; Tel.: +33-472117791; Fax: +33-472116949
| | - Anne Long
- Service de Médecine Interne et Vasculaire, Hopital Edouard Herriot, Hospices Civils de Lyon, 69003 Lyon, France;
- Laboratoire Interuniversitaire de Biologie de la Motricité (LIBM) EA7424, Université Claude Bernard Lyon 1, Université de Lyon, 69008 Lyon, France
| | - Lucia Mazzolai
- Service d’Angiologie, Département Coeur et Vaisseaux, Centre Hospitalier Universitaire Vaudois, 1011 Lausanne, Switzerland;
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7
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Kim TI, Mena C, Sumpio BE. The Role of Lower Extremity Amputation in Chronic Limb-Threatening Ischemia. Int J Angiol 2020; 29:149-155. [PMID: 32904807 DOI: 10.1055/s-0040-1710075] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Chronic limb-threatening ischemia (CLTI) is a severe form of peripheral artery disease associated with high rates of limb loss. The primary goal of treatment in CLTI is limb salvage via revascularization. Multidisciplinary teams provide improved care for those with CLTI and lead to improved limb salvage rates. Not all patients are candidates for revascularization, and a subset will require major amputation. This article highlights the role of amputations in the management of CLTI, and describes the patients who should be offered primary amputation.
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Affiliation(s)
- Tanner I Kim
- Division of Vascular Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Carlos Mena
- Cardiology Section, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Bauer E Sumpio
- Division of Vascular Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut.,Cardiology Section, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
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8
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Andersen J, Gabel J, Mannoia K, Kiang S, Patel S, Teruya T, Bianchi C, Abou-Zamzam A. Association between Preoperative Indications and Outcomes after Major Lower Extremity Amputation. Am Surg 2019. [DOI: 10.1177/000313481908501002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Despite aggressive limb salvage techniques, lower extremity amputation (LEA) is frequently performed. Major indications for LEA include ischemia and uncontrolled infection (UI). A review of the national Vascular Quality Initiative amputation registry was performed to analyze the influence of indication on outcomes after LEA. Retrospective review of the Vascular Quality Initiative LEA registry (2012–2017) identified all above- and below-knee amputations. Outcome measures included 30-day mortality, return to operating room (OR), postoperative myocardial infarctions, and postoperative SSI. Indications for surgery included ischemic rest pain, ischemic tissue loss (TL), acute limb ischemia (ALI), UI, and neuropathic TL. A total of 6701 patients met the inclusion criteria. The indications for surgery included TL (49.0%), UI (31.7%), ALI (8.0%), rest pain (6.6%), and neuropathic TL (2.3%). Patients with ALI had the highest 30-day mortality (12.0%) compared with TL (6.6%) and UI (6.4%) [ P < 0.001]. The highest rate of return to OR occurred in the UI group (12.6%) [ P < 0.001]. Multivariate analysis demonstrated that patients with UI have significantly higher rates of return to OR, whereas those with ALI have a 30-day mortality twice as high as other indications (both P < 0.001). These data can inform expectations after LEA based on the indications for surgery.
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Affiliation(s)
| | - James Andersen
- Division of Vascular Surgery, Loma Linda University Medical Center, Loma Linda, California
| | - Joshua Gabel
- Division of Vascular Surgery, Loma Linda University Medical Center, Loma Linda, California
| | - Kristyn Mannoia
- Division of Vascular Surgery, Loma Linda University Medical Center, Loma Linda, California
| | - Sharon Kiang
- Division of Vascular Surgery, Loma Linda University Medical Center, Loma Linda, California
| | - Sheela Patel
- Division of Vascular Surgery, Loma Linda University Medical Center, Loma Linda, California
| | - Theodoreh Teruya
- Division of Vascular Surgery, Loma Linda University Medical Center, Loma Linda, California
| | - Christian Bianchi
- Division of Vascular Surgery, Loma Linda University Medical Center, Loma Linda, California
| | - Ahmedm Abou-Zamzam
- Division of Vascular Surgery, Loma Linda University Medical Center, Loma Linda, California
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9
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Peters CM, de Vries J, Veen EJ, de Groot HG, Ho GH, Lodder P, Steunenberg SL, van der Laan L. Is amputation in the elderly patient with critical limb ischemia acceptable in the long term? Clin Interv Aging 2019; 14:1177-1185. [PMID: 31308641 PMCID: PMC6612980 DOI: 10.2147/cia.s206446] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 06/05/2019] [Indexed: 12/03/2022] Open
Abstract
Purpose Despite high amputation rates, data on patient-reported outcomes is scarce in the elderly population with critical limb ischemia. The aim of this study was to provide mortality rates and long-term changes of the following patient-reported outcomes in elderly critical limb ischemia amputees: quality of life (QoL), health status (HS), and symptoms of depression. Patients and methods In this prospective observational cohort study, amputated critical limb ischemia patients ≥70 years were included. The follow-up period was two years. Within the follow-up period patients completed the following questionnaires: the World Health Organization Quality Of Life -abbreviated version of the WHOQOL 100 (WHOQOL-BREF), the 12-Item Short Form Health Survey, and the Center for Epidemiological Studies Depression Scale. Results A total of 49 elderly patients with critical limb ischemia had undergone major limb amputation within two years after inclusion. In these patients, the one-year mortality rate was 39% and the two-year mortality rate was 55%. The physical QoL was the only domain of the WHOQOL-BREF that improved significantly across time after amputation (p≤0.001). In the long-term, there was no difference in the ability to enjoy life (p=0.380) or the satisfaction in performing daily living activities (p=0.231) compared to the scores of the general elderly population. After amputation, the physical HS domain (p≤0.001) and the mental HS domain (p=0.002) improved. In the first year, amputees experienced less symptoms of depression (p=0.004). Conclusion Elderly critical limb ischemia amputees are a fragile population with high mortality rates. Their QoL and HS increased after major limb amputation as compared to the baseline situation and they experienced less symptoms of depression. Moreover, our results show that, in the long-term, major limb amputation in the elderly patients with critical limb ischemia shows an acceptable QoL, which, in some aspects, is comparable to the QoL of their peers. These results can improve the shared-decision making process that does not delay the timing of major limb amputation.
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Affiliation(s)
- Chloé Ml Peters
- Department of Surgery, Amphia Hospital, Breda, The Netherlands
| | - Jolanda de Vries
- Department of Medical and Clinical Psychology, Tilburg University, Tilburg, The Netherlands.,Department of Medical Psychology, Elisabeth-Tweesteden Hospital (ETZ), Tilburg, The Netherlands
| | - Eelco J Veen
- Department of Surgery, Amphia Hospital, Breda, The Netherlands
| | | | - Gwan H Ho
- Department of Surgery, Amphia Hospital, Breda, The Netherlands
| | - Paul Lodder
- Department of Medical and Clinical Psychology, Tilburg University, Tilburg, The Netherlands.,Department of Methodology and Statistics, Tilburg University, Tilburg, The Netherlands
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10
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Conte MS, Bradbury AW, Kolh P, White JV, Dick F, Fitridge R, Mills JL, Ricco JB, Suresh KR, Murad MH, Aboyans V, Aksoy M, Alexandrescu VA, Armstrong D, Azuma N, Belch J, Bergoeing M, Bjorck M, Chakfé N, Cheng S, Dawson J, Debus ES, Dueck A, Duval S, Eckstein HH, Ferraresi R, Gambhir R, Gargiulo M, Geraghty P, Goode S, Gray B, Guo W, Gupta PC, Hinchliffe R, Jetty P, Komori K, Lavery L, Liang W, Lookstein R, Menard M, Misra S, Miyata T, Moneta G, Munoa Prado JA, Munoz A, Paolini JE, Patel M, Pomposelli F, Powell R, Robless P, Rogers L, Schanzer A, Schneider P, Taylor S, De Ceniga MV, Veller M, Vermassen F, Wang J, Wang S. Global Vascular Guidelines on the Management of Chronic Limb-Threatening Ischemia. Eur J Vasc Endovasc Surg 2019; 58:S1-S109.e33. [PMID: 31182334 PMCID: PMC8369495 DOI: 10.1016/j.ejvs.2019.05.006] [Citation(s) in RCA: 700] [Impact Index Per Article: 140.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
GUIDELINE SUMMARY Chronic limb-threatening ischemia (CLTI) is associated with mortality, amputation, and impaired quality of life. These Global Vascular Guidelines (GVG) are focused on definition, evaluation, and management of CLTI with the goals of improving evidence-based care and highlighting critical research needs. The term CLTI is preferred over critical limb ischemia, as the latter implies threshold values of impaired perfusion rather than a continuum. CLTI is a clinical syndrome defined by the presence of peripheral artery disease (PAD) in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration. Venous, traumatic, embolic, and nonatherosclerotic etiologies are excluded. All patients with suspected CLTI should be referred urgently to a vascular specialist. Accurately staging the severity of limb threat is fundamental, and the Society for Vascular Surgery Threatened Limb Classification system, based on grading of Wounds, Ischemia, and foot Infection (WIfI) is endorsed. Objective hemodynamic testing, including toe pressures as the preferred measure, is required to assess CLTI. Evidence-based revascularization (EBR) hinges on three independent axes: Patient risk, Limb severity, and ANatomic complexity (PLAN). Average-risk and high-risk patients are defined by estimated procedural and 2-year all-cause mortality. The GVG proposes a new Global Anatomic Staging System (GLASS), which involves defining a preferred target artery path (TAP) and then estimating limb-based patency (LBP), resulting in three stages of complexity for intervention. The optimal revascularization strategy is also influenced by the availability of autogenous vein for open bypass surgery. Recommendations for EBR are based on best available data, pending level 1 evidence from ongoing trials. Vein bypass may be preferred for average-risk patients with advanced limb threat and high complexity disease, while those with less complex anatomy, intermediate severity limb threat, or high patient risk may be favored for endovascular intervention. All patients with CLTI should be afforded best medical therapy including the use of antithrombotic, lipid-lowering, antihypertensive, and glycemic control agents, as well as counseling on smoking cessation, diet, exercise, and preventive foot care. Following EBR, long-term limb surveillance is advised. The effectiveness of nonrevascularization therapies (eg, spinal stimulation, pneumatic compression, prostanoids, and hyperbaric oxygen) has not been established. Regenerative medicine approaches (eg, cell, gene therapies) for CLTI should be restricted to rigorously conducted randomizsed clinical trials. The GVG promotes standardization of study designs and end points for clinical trials in CLTI. The importance of multidisciplinary teams and centers of excellence for amputation prevention is stressed as a key health system initiative.
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Affiliation(s)
- Michael S Conte
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, CA, USA.
| | - Andrew W Bradbury
- Department of Vascular Surgery, University of Birmingham, Birmingham, United Kingdom
| | - Philippe Kolh
- Department of Biomedical and Preclinical Sciences, University Hospital of Liège, Wallonia, Belgium
| | - John V White
- Department of Surgery, Advocate Lutheran General Hospital, Niles, IL, USA
| | - Florian Dick
- Department of Vascular Surgery, Kantonsspital St. Gallen, St. Gallen, and University of Berne, Berne, Switzerland
| | - Robert Fitridge
- Department of Vascular and Endovascular Surgery, The University of Adelaide Medical School, Adelaide, South Australia, Australia
| | - Joseph L Mills
- Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, Houston, TX, USA
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University Hospitalof Poitiers, Poitiers, France
| | | | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
| | - Victor Aboyans
- Department of Cardiology, Dupuytren, University Hospital, France
| | - Murat Aksoy
- Department of Vascular Surgery American, Hospital, Turkey
| | | | | | | | - Jill Belch
- Ninewells Hospital University of Dundee, UK
| | - Michel Bergoeing
- Escuela de Medicina Pontificia Universidad, Catolica de Chile, Chile
| | - Martin Bjorck
- Department of Surgical Sciences, Vascular Surgery, Uppsala University, Sweden
| | | | | | - Joseph Dawson
- Royal Adelaide Hospital & University of Adelaide, Australia
| | - Eike S Debus
- University Heart Center Hamburg, University Hospital Hamburg-Eppendorf, Germany
| | - Andrew Dueck
- Schulich Heart Centre, Sunnybrook Health, Sciences Centre, University of Toronto, Canada
| | - Susan Duval
- Cardiovascular Division, University of, Minnesota Medical School, USA
| | | | - Roberto Ferraresi
- Interventional Cardiovascular Unit, Cardiology Department, Istituto Clinico, Città Studi, Milan, Italy
| | | | - Mauro Gargiulo
- Diagnostica e Sperimentale, University of Bologna, Italy
| | | | | | | | - Wei Guo
- 301 General Hospital of PLA, Beijing, China
| | | | | | - Prasad Jetty
- Division of Vascular and Endovascular Surgery, The Ottawa Hospital and the University of Ottawa, Ottawa, Canada
| | | | | | - Wei Liang
- Renji Hospital, School of Medicine, Shanghai Jiaotong University, China
| | - Robert Lookstein
- Division of Vascular and Interventional Radiology, Icahn School of Medicine at Mount Sinai
| | | | | | | | | | | | | | - Juan E Paolini
- Sanatorio Dr Julio Mendez, University of Buenos Aires, Argentina
| | - Manesh Patel
- Division of Cardiology, Duke University Health System, USA
| | | | | | | | - Lee Rogers
- Amputation Prevention Centers of America, USA
| | | | - Peter Schneider
- Kaiser Foundation Hospital Honolulu and Hawaii Permanente Medical Group, USA
| | - Spence Taylor
- Greenville Health Center/USC School of Medicine Greenville, USA
| | | | - Martin Veller
- University of the Witwatersrand, Johannesburg, South Africa
| | | | - Jinsong Wang
- The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Shenming Wang
- The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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11
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Conte MS, Bradbury AW, Kolh P, White JV, Dick F, Fitridge R, Mills JL, Ricco JB, Suresh KR, Murad MH. Global vascular guidelines on the management of chronic limb-threatening ischemia. J Vasc Surg 2019; 69:3S-125S.e40. [PMID: 31159978 PMCID: PMC8365864 DOI: 10.1016/j.jvs.2019.02.016] [Citation(s) in RCA: 686] [Impact Index Per Article: 137.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Chronic limb-threatening ischemia (CLTI) is associated with mortality, amputation, and impaired quality of life. These Global Vascular Guidelines (GVG) are focused on definition, evaluation, and management of CLTI with the goals of improving evidence-based care and highlighting critical research needs. The term CLTI is preferred over critical limb ischemia, as the latter implies threshold values of impaired perfusion rather than a continuum. CLTI is a clinical syndrome defined by the presence of peripheral artery disease (PAD) in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration. Venous, traumatic, embolic, and nonatherosclerotic etiologies are excluded. All patients with suspected CLTI should be referred urgently to a vascular specialist. Accurately staging the severity of limb threat is fundamental, and the Society for Vascular Surgery Threatened Limb Classification system, based on grading of Wounds, Ischemia, and foot Infection (WIfI) is endorsed. Objective hemodynamic testing, including toe pressures as the preferred measure, is required to assess CLTI. Evidence-based revascularization (EBR) hinges on three independent axes: Patient risk, Limb severity, and ANatomic complexity (PLAN). Average-risk and high-risk patients are defined by estimated procedural and 2-year all-cause mortality. The GVG proposes a new Global Anatomic Staging System (GLASS), which involves defining a preferred target artery path (TAP) and then estimating limb-based patency (LBP), resulting in three stages of complexity for intervention. The optimal revascularization strategy is also influenced by the availability of autogenous vein for open bypass surgery. Recommendations for EBR are based on best available data, pending level 1 evidence from ongoing trials. Vein bypass may be preferred for average-risk patients with advanced limb threat and high complexity disease, while those with less complex anatomy, intermediate severity limb threat, or high patient risk may be favored for endovascular intervention. All patients with CLTI should be afforded best medical therapy including the use of antithrombotic, lipid-lowering, antihypertensive, and glycemic control agents, as well as counseling on smoking cessation, diet, exercise, and preventive foot care. Following EBR, long-term limb surveillance is advised. The effectiveness of nonrevascularization therapies (eg, spinal stimulation, pneumatic compression, prostanoids, and hyperbaric oxygen) has not been established. Regenerative medicine approaches (eg, cell, gene therapies) for CLTI should be restricted to rigorously conducted randomizsed clinical trials. The GVG promotes standardization of study designs and end points for clinical trials in CLTI. The importance of multidisciplinary teams and centers of excellence for amputation prevention is stressed as a key health system initiative.
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Affiliation(s)
- Michael S Conte
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, Calif.
| | - Andrew W Bradbury
- Department of Vascular Surgery, University of Birmingham, Birmingham, United Kingdom
| | - Philippe Kolh
- Department of Biomedical and Preclinical Sciences, University Hospital of Liège, Wallonia, Belgium
| | - John V White
- Department of Surgery, Advocate Lutheran General Hospital, Niles, Ill
| | - Florian Dick
- Department of Vascular Surgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Robert Fitridge
- Department of Vascular and Endovascular Surgery, The University of Adelaide Medical School, Adelaide, South Australia
| | - Joseph L Mills
- Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, Houston, Tex
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University Hospitalof Poitiers, Poitiers, France
| | | | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Rochester, Minn
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12
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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.
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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
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Tosun B, Selek O, Gok U, Tosun O. Medial gastrocnemius muscle flap for the reconstruction of unhealed amputation stumps. J Wound Care 2017; 26:504-507. [PMID: 28795882 DOI: 10.12968/jowc.2017.26.8.504] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Unhealed amputation stumps after transtibial amputation are common and often require reamputation futher up the leg. The aim of our study is to describe our experience with medial gastrocnemius muscle flap coverage following a transtibial amputation. METHOD We retrospectively examined the records of patients who had an unhealed transtibial amputation stump who were then treated with a medial gastrocnemius muscle flap. RESULTS We identified seven patients, all had diabetes mellitus and an initial amputation by the long posterior flap technique. All of the flap reconstructions of the amputation stumps ultimately survived. A mild knee flexion contracture was seen in two amputees, whereas full range of motion in the knee was observed in the remaining five amputees. None have required further surgical intervention. CONCLUSION Medial head of gastrocnemious flap is an option for the reconstruction of the unhealed stump, particularly in the cases where stump shortening will not be feasible.
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Affiliation(s)
- B Tosun
- Associate Professor of Orthopaedics, Kocaeli University School of Medicine, Department of Orthopaedics and Traumatology, Izmit, Turkey
| | - O Selek
- Assistant Professor of Orthopaedics, Kocaeli University School of Medicine, Department of Orthopaedics and Traumatology, Izmit, Turkey
| | - U Gok
- Orthopaedic Specialist, Izmit Seka State Hospital, Clinic of Orthopaedics, Izmit, Turkey
| | - O Tosun
- Famiy Doctor, Kocaeli Directorate of Public Health, Izmit, Turkey
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Stern JR, Wong CK, Yerovinkina M, Spindler SJ, See AS, Panjaki S, Loven SL, D’Andrea RF, Nowygrod R. A Meta-analysis of Long-term Mortality and Associated Risk Factors following Lower Extremity Amputation. Ann Vasc Surg 2017; 42:322-327. [DOI: 10.1016/j.avsg.2016.12.015] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 10/15/2016] [Accepted: 12/01/2016] [Indexed: 10/19/2022]
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15
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Kaptein S, Geertzen JHB, Dijkstra PU. Association between cardiovascular diseases and mobility in persons with lower limb amputation: a systematic review. Disabil Rehabil 2017; 40:883-888. [PMID: 28129515 DOI: 10.1080/09638288.2016.1277401] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE Persons requiring a lower limb amputation often have cardiovascular diseases that reduce cardiac function, which may complicate recovery and rehabilitation after an amputation. This systematic review analysis the association between cardiovascular diseases and mobility in persons with a lower limb amputation. METHOD Four databases were searched for studies published before August 2016 using database-specific keywords and synonyms for amputation, cardiovascular diseases and mobility. Assessment of the publications was performed based on predefined criteria; first title and abstract and thereafter the full text. RESULTS Of the 1704 titles and abstracts, 51 full texts were assessed. Ten studies were included. Cardiovascular diseases were associated with cardiac complications during rehabilitation. Prosthetic training improved cardiac function. Seven studies showed that cardiovascular diseases were associated with a smaller chance of becoming a prosthetic walker, and with poorer mobility outcomes. CONCLUSION Evidence for effects of cardiovascular diseases on mobility in persons with a lower limb amputation is heterogeneous. Cardiovascular diseases reduce the chance of becoming a prosthetic walker and reduce mobility outcomes after a lower limb amputation. More research with adequate quality about cardiovascular diseases in persons requiring a lower limb amputation is needed, to enable informed choices in the pre- and post-amputation rehabilitation. Implications for rehabilitation Data about the effect of cardiovascular diseases on mobility in persons with a lower limb amputation is limited. More research about cardiovascular diseases in persons requiring a lower limb amputation is needed, to enable informed choices in the pre- and post-amputation rehabilitation.
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Affiliation(s)
- Sara Kaptein
- a Department of Rehabilitation Medicine , Center for Rehabilitation, University Medical Center Groningen, University of Groningen , Groningen , The Netherlands
| | - Jan H B Geertzen
- a Department of Rehabilitation Medicine , Center for Rehabilitation, University Medical Center Groningen, University of Groningen , Groningen , The Netherlands
| | - Pieter U Dijkstra
- a Department of Rehabilitation Medicine , Center for Rehabilitation, University Medical Center Groningen, University of Groningen , Groningen , The Netherlands.,b Department of Oral and Maxillofacial Surgery , University Medical Center Groningen, University of Groningen , Groningen , The Netherlands
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16
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Wu JT, Wong M, Lo ZJ, Wong WE, Narayanan S, Tan GWL, Chandrasekar S. A Series of 210 Peripheral Arterial Disease Below-Knee Amputations and Predictors for Subsequent Above-Knee Amputations. Ann Vasc Dis 2017; 10. [PMID: 29147164 PMCID: PMC5684163 DOI: 10.3400/avd.oa.17-00046] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Objective: To review patient characteristics and outcomes after peripheral arterial disease (PAD)-related below-knee amputation (BKA), and identify risk factors predicting subsequent above-knee amputation (AKA). Materials and Methods: A retrospective study of 210 BKAs between May 2008 and December 2015. Results: The mean age of the study population was 66 years. Most of the patients had cardiovascular comorbidities, and 33% had end-stage renal failure (ESRF); 89% were American Society of Anesthesiologists 3 or 4. Previous ipsilateral lower-limb minor amputation was present in 49% and previous contralateral lower-limb major amputation was present in 20% patients. Limb salvage revascularization via angioplasty prior to BKA was performed in 73%, while 27% had extensive tissue loss that was not suitable for limb salvage. Postoperatively, 20% had BKA wound infection, with 3% requiring further surgical debridement, and 9% (19 patients) required subsequent AKA within 1 month. Overall survival analysis at 1–5 years was 75%, 66%, 64%, 59%, and 58%, respectively. Multivariate analysis showed ESRF (Odds Ratio [OR]=3.85; p=0.01) and preoperative non-ambulatory status (OR=5.58; p=0.01) to be independent risk factors in predicting for subsequent AKA. Conclusion: Patients with underlying ESRF or preoperative non-ambulatory status may benefit from direct AKA if major amputation is required.
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Affiliation(s)
- Jing Ting Wu
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Maggie Wong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Zhiwen Joseph Lo
- Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | - Wei-En Wong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Sriram Narayanan
- Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | - Glenn Wei Leong Tan
- Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | - Sadhana Chandrasekar
- Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore
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Columbo JA, Nolan BW, Stucke RS, Rzucidlo EM, Walker KL, Powell RJ, Suckow BD, Stone DH. Below-Knee Amputation Failure and Poor Functional Outcomes Are Higher Than Predicted in Contemporary Practice. Vasc Endovascular Surg 2016; 50:554-558. [PMID: 27909207 DOI: 10.1177/1538574416682159] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The perceived functional benefit of below-knee amputation (BKA) must be carefully weighed against the need for potential reinterventions. This study sought to examine the contemporary clinical and functional outcomes of patients undergoing BKA in the endovascular era. METHODS All patients who underwent BKA from January 2008 to December 2014 at a single tertiary medical center were retrospectively reviewed. Demographics, comorbidities, ambulation status, and transcutaneous oximetry (TcPO2) values were recorded. Study end points included freedom from conversion to above-knee amputation (AKA), freedom from conversion to AKA or death, BKA healing, and ambulation. Statistical modeling was performed to determine associations with BKA failure. RESULTS Over the study interval, 130 limbs underwent BKA in 120 patients. Transcutaneous oximetry studies were obtained in 65% (n = 85). Thirty-eight percent (n = 46) of all BKA patients went on to heal and ambulate. Twenty-five percent (n = 33) required reintervention, 24 with conversion to AKA, and 9 with BKA revision. One-year freedom from conversion to AKA was 76% and was decreased among those with lower TcPO2 levels (60% TcPO2 <40 vs 81% TcPO2 ≥40; P = .04). One-year composite freedom from conversion to AKA/death was 60% and was decreased among those with lower TcPO2 readings (39% TcPO2 <40 vs 69% TcPO2 ≥40; P = .01). CONCLUSION Despite a perceived functional bias toward knee salvage at the time of major amputation, most patients failed to postoperatively ambulate. Those with decreased TcPO2 levels (<40 mm Hg) have a 2-fold higher risk of AKA conversion or death, while nearly one-fourth of all BKA patients will succumb to the same fate irrespective of TcPO2. This suggests that many BKA patients in the endovascular era fail to derive the perceived benefit of knee salvage at the time of their index amputation. These findings highlight the need for careful patient selection and for a shared decision-making model in this frail population.
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Affiliation(s)
- Jesse A Columbo
- 1 Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Brian W Nolan
- 1 Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Ryland S Stucke
- 2 Department of General Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Eva M Rzucidlo
- 1 Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Karen L Walker
- 1 Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Richard J Powell
- 1 Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Bjoern D Suckow
- 1 Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - David H Stone
- 1 Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
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Kayssi A, de Mestral C, Forbes TL, Roche-Nagle G. A Canadian population-based description of the indications for lower-extremity amputations and outcomes. Can J Surg 2016; 59:99-106. [PMID: 27007090 DOI: 10.1503/cjs.013115] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND To our knowledge, there have been no previously published reports characterizing lower-extremity amputations in Canada. The objective of this study was to describe the indications and outcomes of lower-extremity amputations in the Canadian population. METHODS We performed a retrospective cohort study of all adult patients who underwent lower-extremity amputation in Canada between 2006 and 2009. Patients were identified from the Canadian Institute for Health Information's Discharge Abstract Database, which includes all hospital admissions across Canada with the exception of the province of Quebec. Pediatric, trauma, and outpatients were excluded. RESULTS During the study period, 5342 patients underwent lower-extremity amputations in 207 Canadian hospitals. The mean age was 67 ± 13 years, and 68% were men. Amputations were most frequently indicated after admission for diabetic complications (81%), cardiovascular disease (6%), or cancer (3%). In total, 65% of patients were discharged to another inpatient or long-term care facility, and 26% were discharged home with or without extra support. Most patients were diabetic (96%) and most (65%) required a below-knee amputation. Predictors of prolonged (> 7 d) hospital stay included amputation performed by a general surgeon; cardiovascular risk factors, such as diabetes, hypertension, ischemic heart disease, congestive heart failure, or hyperlipidemia; and undergoing the amputation in the provinces of Newfoundland and Labrador, New Brunswick, or British Columbia. CONCLUSION There is variability in the delivery of lower-extremity amputations and postoperative hospital discharges among surgical specialists and regions across Canada. Future work is needed to investigate the reasons for this variability and to develop initiatives to shorten postoperative hospital stays.
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Affiliation(s)
- Ahmed Kayssi
- All authors are from the Division of Vascular Surgery, University Health Network, University of Toronto, Toronto, Ont
| | - Charles de Mestral
- All authors are from the Division of Vascular Surgery, University Health Network, University of Toronto, Toronto, Ont
| | - Thomas L Forbes
- All authors are from the Division of Vascular Surgery, University Health Network, University of Toronto, Toronto, Ont
| | - Graham Roche-Nagle
- All authors are from the Division of Vascular Surgery, University Health Network, University of Toronto, Toronto, Ont
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Venkataraman K, Fong NP, Chan KM, Tan BY, Menon E, Ee CH, Lee KK, Koh GCH. Rehabilitation Outcomes After Inpatient Rehabilitation for Lower Extremity Amputations in Patients With Diabetes. Arch Phys Med Rehabil 2016; 97:1473-1480. [PMID: 27178094 DOI: 10.1016/j.apmr.2016.04.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Revised: 04/05/2016] [Accepted: 04/14/2016] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To identify factors associated with functional gain, discharge destination, and long-term survival after inpatient rehabilitation in patients with lower extremity amputation and diabetes. DESIGN Retrospective medical records review. SETTING All community hospitals. PARTICIPANTS Patients with diabetes (N=256) admitted for inpatient rehabilitation after lower extremity amputation. INTERVENTIONS Not applicable. MAIN OUTCOMES MEASURES Absolute functional gain (AFG) using the Shah-modified Barthel Index, discharge destination, and long-term survival for each patient. RESULTS Length of stay (B=.15; 95% confidence interval [CI], .08-.21; P<.001) and admission functional status (B=-.09; 95% CI, -.18 to -.01; P=.032) were significantly associated with AFG. Availability of caregiver (foreign domestic worker: odds ratio [OR], 16.39; 95% CI, 4.65-57.78; P<.001; child: OR, 3.82; 95% CI, 1.31-11.12; P=.014; spouse: OR, 2.82; 95% CI, 1.07-7.46; P=.037 vs none), Charlson Comorbidity Index of 1 (OR, 4.32; 95% CI, 1.34-13.93; P=.014 vs ≥4), and younger age (OR, .96; 95% CI, .93-.99; P=.02) were significantly associated with being discharged home. Admission functional status (hazard ratio [HR], .98; 95% CI, .97-.99; P<.001), AFG (HR, .99; 95% CI, 0.97-1.00; P=.058), Charlson Comorbidity Index (1 vs ≥4: HR, .42; 95% CI, .24-.77; P=.004), ischemic heart disease (HR, 2.25; 95% CI, 1.27-4.00; P=.006), discharge destination (other vs home: HR, 1.82; 95% CI, 1.02-3.23; P=.041), age (HR, 1.02; 95% CI, 1.00-1.03; P=.082), and ethnicity (Malay vs Chinese: HR, .37; 95% CI, .16-.87; P=.022) predicted survival postamputation. CONCLUSIONS Admission functional status predicted both functional gain during rehabilitation and survival in these patients. We also found ethnic differences in outcomes, with Malays having better survival after amputation. Lastly, there appears to be greater reliance on foreign domestic workers as caregivers, with patients with foreign domestic workers as their primary caregiver having the highest odds of being discharged home.
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Affiliation(s)
- Kavita Venkataraman
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore
| | - Ngan Phoon Fong
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore
| | - Kin Ming Chan
- Medical Services, Ang Mo Kio Thye Hua Kwan Hospital, Singapore
| | | | - Edward Menon
- Medical Services, St Andrew's Community Hospital, Singapore
| | - Chye Hua Ee
- Elder Care and Health Consultancy, Singapore
| | | | - Gerald Choon-Huat Koh
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore.
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20
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Keeley J, Kaji A, Kim D, Plurad D, Putnam B, Neville A. Nutritional Status Does Not Correlate with Stump Complications in Two-stage Lower Extremity Amputations. Am Surg 2015. [DOI: 10.1177/000313481508101002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Unsalvageable foot infections require a two-staged amputation: an initial guillotine below-knee amputation (BKA) followed by formalization. No literature exists regarding the optimal timing to formalization, and the role of nutrition on outcomes remains unclear. This study was conducted to evaluate whether timing to formalization or nutritional markers correlate with stump complications. A retrospective review of all guillotine BKAs done at our county-funded, academic medical center between 2008 and 2013 was performed. Comorbidities, albumin, prealbumin, glycated hemoglobin, days to formalization, and postoperative complications were recorded. Primary outcome was surgical site infection or need for reoperation of the formalized stump within 30 days. One hundred and twenty-eight guillotine BKAs and subsequent formalizations were performed. Twenty-two (17.2%) patients developed surgical site infections and six (4.9%) required reoperation. Patients formalized within 14 days were as likely to develop stump complications as those formalized later (odds ratio 0.7, 0.3–1.8, P = 0.5). When comparing patients who developed stump complications to those who did not, there was no difference in preoperative albumin (2.6 ± 0.7 vs 2.4 ± 0.7, P = 0.3), prealbumin, (14.4 ± 6.2 vs 15.2 ± 5.5, P = 0.5), or glycated hemoglobin (8.8 ± 2.9 vs 9.0 ± 2.5, P = 0.7). Neither timing of formalization nor nutritional parameters predicted wound complications.
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Affiliation(s)
| | - Amy Kaji
- From Harbor-UCLA Medical Center, Torrance, California
| | - Dennis Kim
- From Harbor-UCLA Medical Center, Torrance, California
| | - David Plurad
- From Harbor-UCLA Medical Center, Torrance, California
| | - Brant Putnam
- From Harbor-UCLA Medical Center, Torrance, California
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Abstract
BACKGROUND Infections in total ankle arthroplasty are a serious complication, about which there is little information in the current literature. METHODS This is a retrospective review of infected total ankle arthroplasty at one institution from 1995 to 2012. Risk factors were compared between patients with infected total ankle arthroplasty and age- and sex-matched patients who did not have infection (control patients) within the same time period. RESULTS 966 patients with total ankle arthroplasty were reviewed, and 29 cases of infected total ankle arthroplasty (3.2%) were identified. The incidence of infection in primary ankle arthroplasty was 2.4% and in revision arthroplasty was 4%. Risk factors for infection in our cohort included diabetes, prior ankle surgery, and wound healing problems more than 14 days postoperatively. No significant difference was found between groups with respect to risk factors including smoking, body mass index, and operative time. At latest follow-up, none of the patients had signs of persistent infection. Operative intervention of infected total ankle arthroplasty resulted in limb salvage in 79% of cases (a 21% amputation rate). At final follow-up, 65.5% of cases were infection-free with retained arthroplasty. This was achieved by irrigation and debridement alone, 1-stage fusion, and most often 2-stage revision. The final outcome was fusion in 3 of 29 cases (10.3%). CONCLUSIONS Given the morbidity of infected ankle arthroplasty, careful consideration should be made about performing arthroplasty in patients with multiple prior surgeries and comorbidities that predispose to wound-healing difficulties. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Affiliation(s)
- Daniel Patton
- Department of Orthopaedic Surgery and Sports Medicine, Harborview Medical Center, Seattle, WA, USA
| | - Nathan Kiewiet
- Department of Orthopaedic Surgery and Sports Medicine, Harborview Medical Center, Seattle, WA, USA
| | - Michael Brage
- Department of Orthopaedic Surgery and Sports Medicine, Harborview Medical Center, Seattle, WA, USA
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Matthews CO, Williams IM, Lewis P, McLain AD, Twine CP. Skew flap for staged below-knee amputation in sepsis. Vascular 2015; 24:197-9. [PMID: 26002782 DOI: 10.1177/1708538115588655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Skew flap amputation was first described in the 1980s but was never as popular as the long posterior flap amputation. This report describes a staged below-knee amputation in sepsis, with pus throughout the leg and a lack of skin coverage. One benefit of skew flaps never previously published is the fact that the suture line is not directly over the tibia. Therefore, an open wound or incomplete skin coverage is not as important as in long posterior flaps where it often leads to bone exposure and revision amputation. These benefits were utilized in this case leading to stump healing.
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Affiliation(s)
| | - Ian M Williams
- South East Wales Vascular Network, Royal Gwent Hospital, Newport, Wales, UK
| | - Peter Lewis
- South East Wales Vascular Network, Royal Gwent Hospital, Newport, Wales, UK
| | - A David McLain
- South East Wales Vascular Network, Royal Gwent Hospital, Newport, Wales, UK
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Suckow BD, Goodney PP, Nolan BW, Veeraswamy RK, Gallagher P, Cronenwett JL, Kraiss LW. Domains that Determine Quality of Life in Vascular Amputees. Ann Vasc Surg 2015; 29:722-30. [PMID: 25725279 DOI: 10.1016/j.avsg.2014.12.005] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Revised: 12/08/2014] [Accepted: 12/17/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although patients with critical limb ischemia (CLI) commonly undergo major limb amputation, the quality of life (QOL) of this group remains poorly described. Therefore, we sought to describe which domains vascular amputees consider important in determining their health-related QOL. METHODS We performed 4 focus groups in patients who had major lower extremity amputations resulting from CLI. They were conducted at 4 distinct centers across the United States to ensure broad geographic, socioeconomic, and ethnic representation. RESULTS Of 26 patients (mean age, 64 years), 19 (73%) were Caucasian, 6 (23%) were African American, and 1 (4%) was Native American. Nearly, three-quarter of patients were men (n = 19, 73%) and had a high-school education or more (n = 19, 73%). Overall, 8 (31%) were double amputees and 17 (65%) had diabetes. Time since amputation varied across patients and ranged from 3 months to more than 27 years (mean, 4.3 years). Patients stated that their current QOL was determined by impaired mobility (65%), pain (60%), progression of disease in the remaining limb (55%), and depression/frustration (54%). Across 26 patients, more than half (n = 16, 62%) described multiple prior revascularization procedures. Although most felt that their physician did his/her best to salvage the affected leg (85%), a sizable minority would have preferred an amputation earlier in their CLI treatment course (27%). Furthermore, when asked how their care might have been improved, patients reported that facilitating peer support (88%), more extensive rehabilitation and prosthetist involvement (71%), earlier mention of amputation as a possible outcome (54%), and the early discontinuation of narcotics (54%) were potential areas of improvement. CONCLUSIONS Although QOL in vascular amputees seems primarily determined by mobility impairment, pain, and emotional perturbation, our focus groups identified that physician-controlled factors such as the timing of amputation, informed decision making, and postamputation support may also play an important role. The assessment of patient preferences regarding maintenance of mobility at the cost of increased pain versus relief of pain with amputation at a cost of diminished mobility is central to shared decision making in CLI treatment.
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Affiliation(s)
- Bjoern D Suckow
- Division of Vascular Surgery, University of Utah School of Medicine, Salt Lake City, UT.
| | - Philip P Goodney
- Section of Vascular Surgery, Dartmouth Medical School, Hanover, NH
| | - Brian W Nolan
- Section of Vascular Surgery, Dartmouth Medical School, Hanover, NH
| | - Ravi K Veeraswamy
- Division of Vascular Surgery, Emory University School of Medicine, Atlanta, GA
| | | | | | - Larry W Kraiss
- Division of Vascular Surgery, University of Utah School of Medicine, Salt Lake City, UT
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Unrecognized Arteriosclerosis Is Associated with Wound Complications after Below-Knee Amputation. Ann Vasc Surg 2015; 29:266-71. [DOI: 10.1016/j.avsg.2014.10.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2014] [Revised: 10/21/2014] [Accepted: 10/28/2014] [Indexed: 11/17/2022]
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Brown BJ, Attinger CE. The Below-Knee Amputation: To Amputate or Palliate? Adv Wound Care (New Rochelle) 2013; 2:30-35. [PMID: 24527321 DOI: 10.1089/wound.2011.0317] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2011] [Indexed: 11/13/2022] Open
Abstract
SIGNIFICANCE A below-knee amputation (BKA) can be the most functional option for select patients with a diseased lower extremity and may offer a better quality of life than limb salvage in some patients. RECENT ADVANCES Because of advances in prosthetic technology, some patients may have a better quality of life with a BKA than a salvaged lower extremity. Those who cannot wear a prosthesis will do better with a poorly functioning leg. Understanding which patients will not benefit from an amputation helps ensure that a maximum of patients will continue ambulating. CRITICAL ISSUES We lack a thorough understanding of which patients will be more functional with a BKA than a salvaged extremity. Some will do better with a prosthesis, whereas others will do better with a poorly functioning peg leg. This is because so many amputees never wear their prosthesis. FUTURE DIRECTIONS A better understanding of patient selection and optimal operative technique would allow us to better council patients as to how to optimize their functional outcome. Over the past 30 years, a number of useful studies have been published regarding the BKA. However, recent advances in wound care, prosthetics, and medical care in general require a re-evaluation of the BKA within the limb salvage concept.
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Affiliation(s)
- Benjamin J. Brown
- Center for Wound Healing, Georgetown University Hospital, Washington, District of Columbia
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Gaunaurd IA, Roach KE, Raya MA, Hooper R, Linberg AA, Laferrier JZ, Campbell SM, Scoville C, Gailey RS. Factors related to high-level mobility in male servicemembers with traumatic lower-limb loss. ACTA ACUST UNITED AC 2013; 50:969-84. [DOI: 10.1682/jrrd.2013.02.0035] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2013] [Revised: 06/10/2013] [Indexed: 11/05/2022]
Affiliation(s)
| | - Kathryn E. Roach
- Department of Physical Therapy, Miller School of Medicine, University of Miami, Coral Gables, FL
| | | | - Rebecca Hooper
- Center for the Intrepid, Brooke Army Medical Center, San Antonio, TX
| | | | | | | | - Charles Scoville
- Military Advanced Training Center, Walter Reed Army Medical Center, Washington, DC
| | - Robert S. Gailey
- Functional Outcomes Research and Evaluation Center, Miami Department of Veterans Affairs Healthcare System, Miami, FL
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Corey MR, St Julien J, Miller C, Fisher B, Cederstrand SL, Nylander WA, Guzman RJ, Dattilo JB. Patient education level affects functionality and long term mortality after major lower extremity amputation. Am J Surg 2012; 204:626-30. [PMID: 22906244 DOI: 10.1016/j.amjsurg.2012.07.018] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2012] [Revised: 07/10/2012] [Accepted: 07/10/2012] [Indexed: 12/30/2022]
Abstract
BACKGROUND The aim of this study was to examine the relationship between patient education level and 5-year mortality after major lower extremity amputation. METHODS The records of all patients who underwent above-knee or below-knee amputation at the Nashville Veterans Affairs Medical Center by the vascular surgery service between January 2000 and August 2006 were retrospectively reviewed. Formal levels of education of the study patients were recorded. Outcomes were compared between those patients who had completed high school and those who had not. Bivariate analysis using χ(2) and Student's t tests and multivariate logistic regression were performed. RESULTS Five-year mortality for patients who had completed high school was lower than for those who had not completed high school (62.6% vs 84.3%, P = .001), even after adjusting for important clinical factors (odds ratio for death, .377; 95% confidence interval, .164-.868; P = .022). CONCLUSION Patients with less education have increased long-term mortality after lower extremity amputation.
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Affiliation(s)
- Michael R Corey
- Department of Vascular Surgery, Nashville Veterans Affairs Medical Center and Vanderbilt University Medical Center, Nashville, TN, USA.
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van Eijk MS, van der Linde H, Buijck B, Geurts A, Zuidema S, Koopmans R. Predicting prosthetic use in elderly patients after major lower limb amputation. Prosthet Orthot Int 2012; 36:45-52. [PMID: 22252778 DOI: 10.1177/0309364611430885] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND The main determinants of prosthetic use known from literature apply to the younger patient with lower limb amputation. Studies aimed at identifying determinants of outcome of lower limb amputation in elderly patients with multimorbidity that rehabilitate in skilled nursing facilities (SNFs) are scarce. OBJECTIVES To predict prosthetic use and physical mobility in geriatric patients admitted to SNFs for rehabilitation after lower limb amputation and the impact of multimorbidity. STUDY DESIGN Prospective design. METHODS Univariate and multivariate logistic and linear regression analyses were used to identify determinants that were independently related to prosthetic use and the timed-up-and-go test (TUG test). RESULTS Of 55 eligible patients, 38 had complete assessments on admission and at discharge. Fifty per cent was provided with a prosthesis. Multimorbidity was present in 53% of the patients. Being able to ambulate independently, and having a transtibial amputation (rather than a higher level of amputation), without phantom pain determined prosthetic use (R(2)=56%), while cognitive abilities, low amputation level, and pre-operative functional abilities were independently associated with the TUG test (R(2)=82%). CONCLUSIONS Elderly patients referred to an SNF for prosthetic training have a high probability of using a prosthesis when having an independent ambulation after transtibial amputation, without phantom pain. These patients should be considered for prosthetic training.
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Affiliation(s)
- Monica Spruit- van Eijk
- Department of Primary and Community Care, Centre for Family Medicine, Geriatric Care and Public Health, Radboud University Nijmegen, Medical Centre, the Netherlands.
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Hasanadka R, McLafferty RB, Moore CJ, Hood DB, Ramsey DE, Hodgson KJ. Predictors of wound complications following major amputation for critical limb ischemia. J Vasc Surg 2011; 54:1374-82. [DOI: 10.1016/j.jvs.2011.04.048] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2011] [Revised: 03/22/2011] [Accepted: 04/19/2011] [Indexed: 11/25/2022]
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Xu J, Kohler F, Dickson H. Systematic review of concepts measured in individuals with lower limb amputation using the International Classification of Functioning, Disability and Health as a reference. Prosthet Orthot Int 2011; 35:262-8. [PMID: 21937571 DOI: 10.1177/0309364611412821] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND The International Classification of Functioning, Disability and Health (ICF) is comprehensive but difficult to use in clinical practice. ICF Core Sets are one method of increasing the use of the ICF in clinical practice. To develop a condition-specific core set requires identification of the concepts measured in current clinical practice. OBJECTIVE To identify and quantify concepts contained in functional measurements used in published clinical studies utilising the ICF as a reference, for individuals with an amputation of the lower limb. STUDY DESIGN Systematic literature review. METHODS The concepts of published clinical and outcome measures used in individuals with a lower limb amputation were extracted and linked to the categories of ICF. RESULTS The 113 outcome measures identified in the literature search contained 2210 functional concepts. Of the identified concepts, nearly 90% could be linked to ICF categories. The identified concepts linked to 44 categories in the domain of body functions and structures, 56 categories in the domain of activities and participation and 30 categories in the domain of environment. CONCLUSIONS Using the ICF as a reference, we could identify and quantify the majority of concepts in the outcome measures used in published clinical studies. The ICF categories identified will assist in the development of ICF Core Sets for persons with an amputation. CLINICAL RELEVANCE The ICF is available in over 25 languages. Improving the usefulness of the classification for clinicians will assist in standardising clinical practice and in comparison of outcomes nationally and internationally. ICF Core Sets are designed to use a manageable number of categories from the ICF to allow application in day-to-day clinical practice.
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Affiliation(s)
- Jim Xu
- Liverpool Hospital, Liverpool, Australia
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Elsharawy MA. Outcome of Midfoot Amputations in Diabetic Gangrene. Ann Vasc Surg 2011; 25:778-82. [DOI: 10.1016/j.avsg.2010.11.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2010] [Revised: 10/01/2010] [Accepted: 11/22/2010] [Indexed: 11/17/2022]
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Norvell DC, Turner AP, Williams RM, Hakimi KN, Czerniecki JM. Defining successful mobility after lower extremity amputation for complications of peripheral vascular disease and diabetes. J Vasc Surg 2011; 54:412-9. [PMID: 21531528 DOI: 10.1016/j.jvs.2011.01.046] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2010] [Revised: 01/13/2011] [Accepted: 01/17/2011] [Indexed: 10/18/2022]
Abstract
BACKGROUND Information about longer-term functional outcomes following lower extremity amputation for peripheral vascular disease and diabetes remains limited. This study examined factors associated with mobility success during the first year following amputation. METHODS Prospective cohort study of 87 amputees experiencing a first major unilateral amputation surgery. Seventy-five (86%) participants completed 12-month follow-up interview. RESULTS Twenty-eight subjects (37%) achieved mobility success, defined as returning to or exceeding a baseline level of mobility on the locomotor capability index (LCI-5). Forty-three subjects (57%) were satisfied with their mobility. Individuals who were 65 years of age and older (risk difference [RD] = -0.52; 95% confidence interval [CI]: -0.75, -0.29), reported a current alcohol use disorder (RD = -0.37; 95% CI: -0.48, -0.26), had a history of hypertension (RD = -0.23; 95% CI: -0.43, -0.03) or treatment for anxiety or depression (RD = -0.39; 95% CI: -0.50, -0.28) were less likely to achieve mobility success. Mobility success was associated with mobility satisfaction (RD = 0.36; 95% CI: 0.20, 0.53) and satisfaction with life (RD = 0.28; 95% CI: 0.06, 0.50). Although higher absolute mobility at 12 months was also associated with mobility satisfaction and overall life satisfaction, 50% of individuals who achieved success with low to moderate 12-month mobility function reported they were satisfied with their mobility. CONCLUSION Defining success after amputation in relation to an individual's specific mobility prior to the development of limb impairment which led to amputation provides a useful, patient-centered measure that takes other aspects of health, function, and impairment into account.
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