Routing through the health care system and level of functioning of lower limb amputees

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

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

The burden of amputation in patients with peripheral arterial disease in the Netherlands

INTRODUCTION

Peripheral arterial disease (PAD) can lead to severe cases of critical limb ischemia (CLI), which in turn might lead to amputation. Amputation can have substantial consequences for patients. This publication aims to give a better understanding of the amputation-related burden in patients with PAD in the Netherlands.

EVIDENCE ACQUISITION

A systematic review and grey literature searches were conducted followed by qualitative interviews with a multidisciplinary team of clinical experts in amputation. Subsequently, IQVIA's Dutch hospital claims data were analyzed.

EVIDENCE SYNTHESIS

Twenty-seven publications were identified. Dutch claims data identified claims for 2328 patients after amputation for PAD. Data for the following topics were found: incidence, mortality, complications, mobility, daily functioning, quality of life, utilities, length of stay (LoS), costs, and resource use. Annually, 90% of the 3300 amputations carried out in the Netherlands were due to vascular disease. One-year mortality in patients with an amputation ranged from 49.6% (above-the-knee amputation) to 9% (specialized care). Patients' quality of life was substantially affected and utility of post-major amputation for PAD was 0.54. LoS after amputation varied from 11.4 (general rehabilitation) to 53.4 days (amputation of the leg). Total budget incurred based on frequently claimed DBC's from Dutch claims data in patients with PAD undergoing an amputation over 2012 to 2016 was € 136,651,374. Mean cost per patient was € 17,821.

CONCLUSIONS

Amputation leads to substantial burden in patients with PAD in the Netherlands. Identified results give a better understanding of the specific Dutch burden of amputation.

Adjustment to an Artificial Limb: A Qualitative Perspective

The purpose of this study was to identify factors considered to be important in the adjustment to amputation and the wearing of a prosthetic limb from the perspective of the person who has had a lower limb amputation. Hence, focus group methodology was employed as a means of acquiring perspectives within a population of young adults who had a lower limb amputation. Preliminary thematic analysis revealed that factors such as self-image, social, physical and practical concerns, the meaning attributed to and the acceptance of the amputation and support among others were important in the adjustment process. These findings have substantial implications for directing future research.

Psychosocial adjustment to lower-limb amputation: a review

PURPOSE

To review the existing literature on the social and psychological challenges faced by people with an amputation and to provide a detailed analysis of the literature examining psychological adjustment to these challenges across time.

METHOD

Existing papers on psychological adjustment to amputation were analysed according to their results, methodology, and conclusions.

RESULTS

Although depression and anxiety are relatively high up to 2 years post-amputation, they appear to decline thereafter to general population norms. However, social discomfort and body-image anxiety have also been found among some people with amputations, and these have been associated with increased activity restriction, depression, and anxiety. Factors associated with positive adjustment to limb loss include greater time since amputation, more social support, greater satisfaction with the prosthesis, active coping attempts, an optimistic personality disposition, a lower level of amputation in the case of lower limbs, and lower levels of phantom limb pain and stump pain.

CONCLUSION

The majority of studies on adjustment to amputation are cross-sectional in design and have used noncomparable measures. Furthermore, they have neglected to study many important areas of rehabilitation, including immediate reaction to amputation, adjustment during and shortly after the rehabilitation period, and development of a changed sense of self and identity. In order to address these concerns, more longitudinal and qualitative research is called for. We end by outlining the components of a descriptive phased model of the rehabilitation process.

A study of technical changes to lower limb prostheses after initial fitting

There is little published material in recent years about the use of lower limb prostheses in an elderly amputee population. In this study the authors were interested in the technical changes to lower limb prostheses after a first limb fitting procedure in a post-rehabilitation population in The Netherlands. The process of fitting a prosthesis and the technical changes to the artificial limb in the first year afterwards are studied.