Lower limb amputation in Northern Netherlands: unchanged incidence from 1991-1992 to 2003-2004

Cardiorespiratory fitness in persons with lower limb amputation

The aim of this study is to gain insight in the cardiorespiratory fitness of persons with lower limb amputation (LLA) during rehabilitation, and in potential factors influencing their cardiorespiratory fitness. We performed a retrospective cohort study using data from cardiopulmonary exercise tests. Included participants were adults with LLA. Main outcome was cardiorespiratory fitness expressed as O 2 peak (ml/min/kg) and was directly determined using breath-by-breath gas analysis. O 2 peak was compared to reference values for able-bodied controls. Multivariate regression analysis was performed to investigate potential factors related to O 2 peak in persons with LLA. Potential factors were age, BMI adjusted, gender, level of amputation, aetiology of amputation, unilateral/bilateral, type of ergometry and use of beta blockers. Data of 74 participants with LLA are presented; 84% male (n = 62), mean age 58.9 (SD 11.6), mean BMI 26.7 (SD 5.6), 44 participants have a LLA above the knee, 30 below the knee. Overall O 2 peak was lower in persons with LLA compared to reference values for able-bodied controls, with mean O 2 peak for the total LLA group of 14.6 ± 4.1 ml/kg/min. In the multivariate regression analysis, only age was a significant predictor for lower O 2 peak (regression coefficient: -0.15, 95% CI [0.23-0.069], r 2  = 0.166). These results indicate that the cardiorespiratory fitness in persons with LLA is low, while they actually need more energy to walk and perform other daily activities. Cardiorespiratory fitness is not closely associated with the analysed demographic or clinical factors and will have to be determined on an individual basis for use in daily practice.

Epidemiology of Limb Amputations and Prosthetic Use During COVID-19 Pandemic in the Netherlands

OBJECTIVE

To evaluate the trends in the incidence of major limb amputations and the prevalence of Dutch prosthetic users at the national level in The Netherlands between 2012 and 2021 (during the COVID-19 pandemic). Local hospitals in The Netherlands reported a doubling of major lower limb amputations during COVID-19, information about a change in the incidence of major upper limb amputations was not reported. We could not confirm this remarkable increase in major lower limb amputations in our institution, nor did we observe a change in the incidence of major upper limb amputations. We hypothesize that the COVID-19 pandemic had no effect on the number of major limb amputations.

DESIGN

Observational retrospective study analyzing national open-access databases of health insurance claims.

SETTING

The Dutch national opensource database www.opendisdata.nl was used to retrieve the incidence of limb amputations in the period 2012-2021, stratified by the level of amputation and the cause of amputation. The results were verified using the www.gipdatabank.nl databank. This period included 4 intervals of nationwide COVID-19 lockdowns.

PARTICIPANTS

60,848 patients who underwent limb amputations at the upper or lower extremity in the Netherlands from 2012 to 2021 (N=60,848) were included in this study.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Upper- and lower-limb amputation and prosthetic use.

RESULTS

Data were retrieved for a total of 60,848 patients in the Netherlands, who underwent 68,180 amputations of the upper and lower extremities at any level from 2012 to 2021, including 22,095 major amputations of the lower extremities. The ongoing trend of stable numbers of major lower-limb amputations from 2012 to 2019 continued in 2020 and 2021. The verification of these data at the level of prosthetic users confirmed that the annual trends were unchanged.

CONCLUSION

The reported increased numbers of major lower-limb amputations during the COVID-19 pandemic in the Netherlands could not be confirmed using nationwide epidemiologic data.

Exploring the Indications, Levels, and Outcomes of Lower Extremity Amputation at a Tertiary Care Hospital in Pakistan

BACKGROUND

Lower extremity amputation (LEA) is a surgical procedure performed to remove either a part or the entire lower limb due to medical conditions such as trauma, infection, peripheral vascular disease, or malignancy. The procedure is becoming increasingly common in Pakistan, with a bulk of patients presenting from rural areas in tertiary care centers. Understanding the indications, levels, and outcomes of LEA is essential for improving patient care and adopting preventive strategies, especially in developing countries.

METHODOLOGY

This study was conducted at Dow University Hospital in Karachi, Pakistan. Retrospective data of 384 patients who underwent non-traumatic lower extremity amputations between January 2016 and December 2020 was collected to include relevant history and characteristics, amputation indication and level, type of anesthesia used, and outcome within hospital stay. The data was analyzed using descriptive statistics.

RESULTS

The data is composed of a wide age range (18 to 91 years) of patients, including a male majority (76.3%, n = 293). The employment status of the patients was taken into consideration, with a reported high number of unemployed individuals (60.4%, n = 232). Diabetes mellitus (84.4%, n = 324) was a commonly reported past medical condition, followed by hypertension (4.4%, n = 17). Indications for amputation exceedingly recorded were diabetic foot ulcers (84.4%, n = 324), followed by infections (9.4%, n = 36) and peripheral arterial disease (3.6%, n = 14). The anesthetic approach that was observed most in these patients was regional anesthesia (74.7%, n = 287). Right-sided amputations (52.9%, n = 203) were dominant, with below-knee amputations leading by the level of amputation performed (42.5%, n = 163). Many patients delayed seeking treatment (71.6%, n = 275) and indicated denial of severity (18%, n = 69) as a reason for the delay. Regarding outcome, many patients were successfully discharged following treatment (85.9%, n = 330).

CONCLUSION

Overall, LEAs are being frequently performed in developing countries, such as Pakistan, especially with a large population living with diabetes mellitus. The implications of this disease are reflected in this study population, with the majority of patients reporting delays in treatment due to reasons such as the unknown severity of the disease or financial burdens. The challenges faced by these individuals, especially in this country, can be tackled with widespread affordability and availability of care and education on early management.

The efficacy of flexor tenotomy to prevent recurrent diabetic foot ulcers (DIAFLEX trial): Study protocol for a randomized controlled trial

Foot ulcers are a frequent and costly problem in people with diabetes mellitus and can lead to amputations. Prevention of these ulcers is therefore of paramount importance. Claw/hammer toe deformities are commonly seen in people with diabetes. These deformities increase the risk of ulcer development specifically at the (tip of) the toe. Percutaneous needle tenotomy of the tendon of the m. flexor digitorum longus (tendon tenotomy) can be used to reduce the severity of claw/hammer toe deformity with the goal to prevent ulcer recurrence. The main objective of this randomized controlled trial is to assess the efficacy of flexor tenotomy to prevent recurrence of toe ulcers in people with diabetes and a history of toe (pre-)ulcers. Additionally, we aim to assess interphalangeal joints (IPJ) and metatarsophalangeal joint (MTPJ) angles in a weight-bearing and non-weight-bearing position, barefoot plantar pressure during walking, cost-effectiveness and quality of life before and after the intervention and compare intervention and control study groups. Sixty-six subjects with diabetes and claw/hammer toe deformity and a recent history of (pre-)ulceration on the tip of the toe will be included and randomized between flexor tenotomy of claw/hammer toes (intervention) versus standard of care including orthosis and shoe offloading (controls) in a mono-center randomized controlled trial.

Clinicaltrialsgov registration

NCT05228340.

Design and evaluation of the pneumatic leg prosthesis ERiK to assist elderly amputees with sit-down and stand-up movements

Standing up using one leg is a challenging task for those with a transfemoral amputation, particularly for elderly users with a low activity level. Active prostheses are generally not accessible to this group and available passive prostheses do not support standing up. This article presents the design and evaluation of the "Energy Restoring Intelligent Knee" (ERiK), which stores energy during sit-down in a pneumatic cylinder and returns it during stand-up. We hypothesized that the system would reduce the time needed to perform transitions and also enable higher load sharing by the prosthetic leg. However, the results of an experimental study with seven participants with transfemoral amputation contradict these hypotheses: the participants could neither move faster nor make more use of the prosthetic leg to share their body weight during transitions. We observed that a major obstacle to the useful functionality of the leg was the absence of ankle dorsiflexion - the foot tended to slip during stand-up initiation, such that only low pre-pressures and therefore support levels could be set. The rather binary action of the pneumatics also complicated movement initiation. The lessons learned from this study may be helpful to those seeking to create better designs in the future.

Lower extremity amputations (LEAs) in a tertiary hospital in Togo: a retrospective analysis of clinical, biological, radiological, and therapeutic aspects

BACKGROUND

We analysed the clinical, biological, radiological profiles, and therapeutic patterns of the patients who underwent a surgical lower extremity amputation (LEA) in Togo from 2010 to 2020.

METHODS

Retrospective analysis of clinical files of adult patients who underwent an LEA at a single centre (Sylvanus Olympio Teaching Hospital) from 1st January 2010 to 31st December 2020. Data were analysed by CDC Epi Info Version 7 and Microsoft Office Excel 2013 software.

RESULTS

We included 245 cases. The mean age was 59.62 years (15.22 SD) (range: 15-90 years). The sex ratio was 1.99. The medical history of diabetes mellitus (DM) was found in 143/222 (64.41%) files. The amputation level found in 241/245 (98.37%) files was the leg in 133/241 (55.19%) patients, the knee in 14/241 (5.81%), the thigh in 83/241 (34.44%), and the foot in 11/241 (4.56%). The 143 patients with DM who underwent LEA had infectious and vascular diseases. Patients with previous LEAs were more likely to have the same limb affected than the contralateral one. The odds of trauma as an indication for LEA were twice as high in patients younger than 65 years compared to the older (OR = 2.095, 95% CI = 1.050-4.183). The mortality rate after LEA was 17/238 (7.14%). There was no significant difference between age, sex, presence or absence of DM, and early postoperative complications (P = 0.77; 0.96; 0.97). The mean duration of hospitalization marked in 241/245 (98.37%) files was 36.30 (1-278) days (36.20 SD). Patients with LEAs due to trauma had a significantly longer hospital admission than those with non-traumatic indications, F (3,237) = 5.505, P = 0.001.

CONCLUSIONS

Compared to previous decades, from 2010 to 2020, the average incidence of LEAs for all causes at Sylvanus Olympio Teaching Hospital (Lomé, Togo) decreased while the percentage of patients with DM who underwent LEAs increased. This setting imposes a multidisciplinary approach and information campaigns to prevent DM, cardiovascular diseases, and  relative complications.

Testing and evaluation of lower limb prosthesis prototypes in people with a transfemoral amputation: a scoping review on research protocols

BACKGROUND

When developing new lower limb prostheses, prototypes are tested to obtain insights into the performance. However, large variations between research protocols may complicate establishing the potential added value of newly developed prototypes over other prostheses.

OBJECTIVE

This review aims at identifying participant characteristics, research protocols, reference values, aims, and corresponding outcome measures used during prosthesis prototype testing on people with a transfemoral amputation.

METHODS

A systematic search was done on PubMed and Scopus from 2000 to December 2020. Articles were included if testing was done on adults with transfemoral or knee disarticulation amputation; testing involved walking with a non-commercially available prototype leg prosthesis consisting of at least a knee component; and included evaluations of the participants' functioning with the prosthesis prototype.

RESULTS

From the initial search of 2027 articles, 48 articles were included in this review. 20 studies were single-subject studies and 4 studies included a cohort of 10 or more persons with a transfemoral amputation. Only 5 articles reported all the pre-defined participant characteristics that were deemed relevant. The familiarization time with the prosthesis prototype prior to testing ranged from 5 to 10 min to 3 months; in 25% of the articles did not mention the extent of the familiarization period. Mobility was most often mentioned as the development or testing aim. A total of 270 outcome measures were identified, kinetic/kinematic gait parameters were most often reported. The majority of outcome measures corresponded to the mobility aim. For 48% of the stated development aims and 4% of the testing aims, no corresponding outcome measure could be assigned. Results indicated large inconsistencies in research protocols and outcome measures used to validate pre-determined aims.

CONCLUSIONS

The large variation in prosthesis prototype testing and reporting calls for the development of a core set of reported participant characteristics, testing protocols, and specific and well-founded outcome measures, tailored to the various aims and development phases. The use of such a core set can give greater insights into progress of developments and determine which developments have additional benefits over the state-of-the-art. This review may contribute as initial input towards the development of such a core set.

Clinical usability, reliability, and repeatability of noncontact scanners in measuring residual limb volume in persons with transtibial amputation

BACKGROUND

In previous studies, noncontact 3D scanners were found to be the most reliable in measuring volume of the residual limb after a transtibial amputation (TTA). Meanwhile newly developed noncontact scanners became available to measure residual limb volume after TTA but should be tested for clinical usability and reliability.

OBJECTIVE

To determine the clinical usability, reliability, and repeatability of noncontact scanners in measuring residual limb volume in persons with a TTA.

STUDY DESIGN

Original research report; repeated measurements.

METHODS

Three noncontact scanners (Rodin4D, Omega Tracer, and Biosculptor) were used to measure the residual limb volume on two occasions by two observers in 30 persons with an unilateral or bilateral TTA. Clinical usability was assessed as scores of the Post-Study System Usability Questionnaire, participant satisfaction (0-10 scale), and time to take the measurement.

RESULTS

The usability score of the Omega Scanner 3D (123.4) and Rodin4D (121.3) was significantly better compared with the Biosculptor (117.8). Participant experience was equal for all. The residual variance was 8.4%, where participant and scanning system explained most of the error variance (80.7%). Repeatability coefficients of the systems were 16.5 cc (Omega Scanner 3D), 26.4 cc (Rodin4D), and 32.8 cc (Biosculptor). The time to perform the measurements was significantly longer (+80 seconds) for the Omega Scanner 3D.

CONCLUSIONS

For measuring residual limb volume in TT amputees, Omega software (state version 12.2) combined with the Rodin4D scanner was more usable and reliable than the Rodin 4D or Biosculptor systems, when operated by staff with limited experience and training.

The incidence and trend of geriatric amputations in Taiwan from 1996 to 2013

BACKGROUND

There has been a reported reduction in the incidence of amputation, but it is unclear whether the number of amputations has decreased in the elderly, a cohort that typically has the largest proportion of amputees.

OBJECTIVES

To investigate the incidence proportion and time trends of amputation in patients aged ≥ 65 years in Taiwan.

STUDY DESIGN

A retrospective cohort study from a large national database.

METHODS

The records of patients who underwent an amputation were collected from a nationally representative sample of 1,000,000 enrollees of Taiwan's National Health Insurance program during 1996-2013. The patients were divided into four age groups: ≤64, 65-74, 75-84, and ≥85 years. Joinpoint regression was performed with adjustment for age and sex to identify changes in incidence proportion by year.

RESULTS

During the 18 years, the incidence of upper and lower limb amputation decreased significantly in the total population, with the average annual percentage change (AAPC) of -6.1 and -1.8, respectively. However, in the elderly population over 65 years, the incidence did not decrease significantly for upper minor amputation, lower minor amputation, and major amputation with the AAPC of -1.1, -0.1, and -0.4, respectively. Although not significant, the incidence of major and minor lower limb amputation in the population over 85 years old showed an increasing trend, with the AAPC of 1.2 and 3.2, respectively.

CONCLUSION

During the study period, although the incidence of amputation of the overall population decreased in Taiwan, this trend was not simultaneously observed in the elderly and hence, it should not be ignored.

Trends of limb amputation considering type, level, sex and age in Saskatchewan, Canada 2006-2019: an in-depth assessment

BACKGROUND

Most epidemiologic reports focus on lower extremity amputation (LEA) caused specifically by diabetes mellitus. However, narrowing scope disregards the impact of other causes and types of limb amputation (LA) diminishing the true incidence and societal burden. We explored the rates of LEA and upper extremity amputation (UEA) by level of amputation, sex and age over 14 years in Saskatchewan, Canada.

METHODS

We calculated the differential impact of amputation type (LEA or UEA) and level (major or minor) of LA using retrospective linked hospital discharge data and demographic characteristics of all LA performed in Saskatchewan and resident population between 2006 and 2019. Rates were calculated from total yearly cases per yearly Saskatchewan resident population. Joinpoint regression was employed to quantify annual percentage change (APC) and average annual percent change (AAPC). Negative binomial regression was performed to determine if LA rates differed over time based on sex and age.

RESULTS

Incidence of LEA (31.86 ± 2.85 per 100,000) predominated over UEA (5.84 ± 0.49 per 100,000) over the 14-year study period. The overall LEA rate did not change over the study period (AAPC -0.5 [95% CI - 3.8 to 3.0]) but fluctuations were identified. From 2008 to 2017 LEA rates increased (APC 3.15 [95% CI 1.1 to 5.2]) countered by two statistically insignificant periods of decline (2006-2008 and 2017-2019). From 2006 to 2019 the rate of minor LEA steadily increased (AAPC 3.9 [95% CI 2.4 to 5.4]) while major LEA decreased (AAPC -0.6 [95% CI - 2.1 to 5.4]). Fluctuations in the overall LEA rate nearly corresponded with fluctuations in major LEA with one period of rising rates from 2010 to 2017 (APC 4.2 [95% CI 0.9 to 7.6]) countered by two periods of decline 2006-2010 (APC -11.14 [95% CI - 16.4 to - 5.6]) and 2017-2019 (APC -19.49 [95% CI - 33.5 to - 2.5]). Overall UEA and minor UEA rates remained stable from 2006 to 2019 with too few major UEA performed for in-depth analysis. Males were twice as likely to undergo LA than females (RR = 2.2 [95% CI 1.99-2.51]) with no change in rate over the study period. Persons aged 50-74 years and 75+ years were respectively 5.9 (RR = 5.92 [95% Cl 5.39-6.51]) and 10.6 (RR = 10.58 [95% Cl 9.26-12.08]) times more likely to undergo LA than those aged 0-49 years. LA rate increased with increasing age over the study period.

CONCLUSION

The rise in the rate of minor LEA with simultaneous decline in the rate of major LEA concomitant with the rise in age of patients experiencing LA may reflect a paradigm shift in the management of diseases that lead to LEA. Further, this shift may alter demand for orthotic versus prosthetic intervention. A more granular look into the data is warranted to determine if performing minor LA diminishes the need for major LA.

Vascular Diagnostic and Surgical Treatments Before Lower Limb Amputations in Patients with Arterial Vascular Diseases: A Population Based Study from 2013 to 2015 in Germany

OBJECTIVE

Patients with peripheral artery disease (PAD) have an increased risk of lower limb amputation. Given the international wide variance in major amputations, the high mortality rates and follow up costs as well as the significantly reduced quality of life of patients with amputations, vascular diagnostics and vascular surgery treatments are of great importance for lower limb preservation in patients with PAD. This study examines these guideline based procedures in patients before a first lower limb amputation and PAD.

METHODS

This was a retrospective longitudinal study. Data from a large German statutory health insurance scheme were examined on patients with first amputation of lower extremities and PAD between 2013 and 2015 (incidence). Pre-defined vascular diagnostic and vascular surgical procedures were considered, as specified by guidelines within inpatient and outpatient care in a defined time before lower limb amputation.

RESULTS

The overall estimated incidence of lower extremity amputations in the total population was 0.12% from 2013 to 2015. Of these, 51.7% had PAD; 81.8% of patients received at least one vascular diagnostic measure and 61.0% a vascular surgery procedure before the lower extremity amputation. There were only minor variations in the use of diagnostic or surgical treatments between patients with major and minor amputation. In total, 63.9% of patients had vascular surgery before the incident major amputation compared with 60.0% of patients with a minor amputation. Noticeable regional differences were found ranging from 91% (Berlin) to 67% (Bremen) regarding diagnostic procedures provided before amputation, and from 83% (Hamburg) to 55% (Saxony-Anhalt) regarding vascular surgery before amputations.

CONCLUSION

Of patients with PAD, 18.2% did not receive a vascular diagnostic examination before amputation as specified in the guidelines, which reflects an underuse of health services. In one third of patients who did not receive vascular surgery, major amputation probably could have been avoided.

[Correlation among tests and functional assessment scales in the follow-up of prosthetic adaptation in people with lower limb amputation]

INTRODUCTION

There is a wide variety of functional tests and scales for the assessment of different aspects in the adaptation of amputees, but there is still no consensus on which are the most appropriate.

OBJECTIVES

To describe the measures of correlation and association among three functional tests for lower-limb amputees and to define the most appropriate for this assessment. To assess general satisfaction in lower-limb prostheses users and its association with the functional tests.

METHODS

We included 83 unilateral lower-limb amputees who were users of low-cost exoskeletal prostheses. The instruments employed were the Houghton scale, the Prosthesis Evaluation Questionnaire - Mobility Scale (PEQ-MS) and the 2-minute walk test (2MWT). The statistical analysis was performed using the chi-square test and Spearman's correlation coefficient.

RESULTS

The functional tests evaluated had an acceptable correlation and association with each other, but the Spearman correlation between the Houghton scale and the 2MWT was of greater significance (whole sample: r=0.56; below-knee amputees: r=0.53). The association measures did not achieve statistically significant results for above-knee amputees or for general satisfaction.

CONCLUSIONS

The Houghton Scale and the 2MWT showed a good correlation and association with each other, becoming possible first-line instruments for the follow-up of exoskeletal lower limb prosthesis users. No significant association was identified between satisfaction and the instruments measured.

The most important activities of daily functioning: the opinion of persons with lower limb amputation and healthcare professionals differ considerably

The aim of this study is to determine the 15 most important daily activities according to persons with lower limb amputation (LLA) and healthcare professionals. Persons with LLA (n = 125) and healthcare professionals (n = 44) filled in a questionnaire. Participants had to select 10 items out of a list of 40 items on the domains activity and/or participation. Selection criterion was what they considered to be most important to perform independently and order the selected 10 items from most to least important. Mean rank scores of the 15 highest scored items according to participants with LLA were compared with the mean rank scores given by professionals, using the Mann-Whitney U test with a Hochberg adjustment for multiple testing. Participants with LLA rated five activities as significantly more important compared to professionals: 'driving a car', 'bicycling', 'ascending/descending stairs', 'heavy exercise', and 'preparing meals'. Healthcare professionals rated four activities as significantly more important compared to persons with LLA: 'going to the toilet', 'getting in and out bed', 'walking around outdoors', and 'walking around indoors'. A significant difference in rating importance was present in 9 out of 15 activities between persons with LLA and healthcare professionals. This result makes it all the more clear how complex shared decision making can be and how important it is for healthcare professionals to communicate with the person with LLA.

SwedeAmp-the Swedish Amputation and Prosthetics Registry: 8-year data on 5762 patients with lower limb amputation show sex differences in amputation level and in patient-reported outcome

Background and purpose - For want of national guidelines for lower limb amputation (LLA) the quality registry SwedeAmp was started in 2011 to increase knowledge around LLA and prosthetic rehabilitation. We now present data from the first 8 years of registration.Patients and methods - We present descriptive data from the first 8 years (2011-2018) of registration. Patient-reported outcome was collected at baseline and at follow-up 12 and 24 months after surgery for patients with prosthetic supply and included generic (EQ-5D-5L) and amputee-specific (e.g., LCI-5L and Prosthetic Use Score) measures. Sex differences were investigated.Results - As at December 31, 2018, 5,762 patients, 7,776 amputations, 2,658 prosthetic supplies, 1,848 baselines, and 2,006 follow-ups were registered. 61% of the patients were male, and mean age by the time of the first registered amputation was 74 years (SD 14). Women were older, more frequently had vascular disease without diabetes and more often underwent amputation at a higher level compared with men (p < 0.001). Time from amputation to fitting of first individual prosthesis was median 69 days (6-500) after transtibial amputation (TTA) and 97 days (19-484) after transfemoral amputation (TFA). The outcomes were lower after TFA than after TTA.Interpretation - SwedeAmp shows sex differences concerning amputation level, diagnosis, and age, leading to the conclusion that women have worse preconditions for successful prosthetic mobility after LLA. With increasing coverage, SwedeAmp can provide deeper knowledge with regard to patients undergoing LLA in Sweden.

Mortality, Reamputation, and Preoperative Comorbidities in Patients Undergoing Dysvascular Lower Limb Amputation

BACKGROUND

Historically, mortality rates after major lower limb amputations (LLAs) have been very high. However, there are inconsistencies regarding the risk factors. The reamputation rate after major LLAs is largely unknown. The aim of this study is to report the 30-day and 1-year mortality and 1-year reamputation rates after major LLA and to identify potential risk factors.

METHODS

An observational cohort study in which all patients undergoing dysvascular major LLA in 2012-2013 in 12 hospitals in the northern region of the Netherlands is included.

RESULTS

Of total 382 patients, who underwent major LLA, 65% were male and the mean age (standard deviation [SD]) was 71.9 ± 12.5 years. Peripheral arterial disease was observed in 88% and diabetes mellitus (DM), in 56% of patients. No revascularization or prior LLA on the amputated side was observed among 26%, whereas 56% had no minor or major LLA on either limb before the study period. The 30-day and 1-year mortality rates were 14% and 34%, respectively. Patients aged 75-84 and >85 years had 3-4 times higher odds of dying within 1 year. Transfemoral amputations (odds ratio [OR], 2.2), history of heart failure (OR, 2.3), myocardial infarction (OR, 1.7), hemodialysis (OR, 5.7), immunosuppressive medication (OR, 2.8), and guillotine amputations (OR, 5.1) were independently associated with 1-year mortality. Twenty-six percent underwent ipsilateral reamputation within 1 year, for which no risk factors were identified.

CONCLUSIONS

The mortality rate in the first year after major LLA is high, particularly among those undergoing transfemoral amputations, which is likely to be indicative of more severe vascular disease. Higher mortality among the most elderly patients, those with more severe cardiac disease and who underwent hemodialysis reflects the frailty of this population. Interestingly, DM, revascularization history, and prior minor or major LLA were not associated with mortality rates.

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.

Management of the sciatic nerve during transfemoral amputation: a survey of Dutch surgeons

BACKGROUND

Neuropathic pain often occurs after leg amputation. It is unclear why some patients suffer from pain and others do not. Intraoperative nerve handling might correlate with these pain syndromes. It is unknown which nerve handling techniques are currently used among surgeons and whether a specific technique is related to eliciting these pain syndromes. The aim of this study was to investigate the current surgical sciatic nerve management used among surgeons in the Netherlands.

METHODS

A survey was carried out among Dutch surgeons. Additionally, surgical sciatic nerve management data were obtained from the surgical reports of transfemoral amputations that were performed in our hospital.

RESULTS

Seventy-eight of the 102 online surveys were returned. Sharp transection without ligation was used most often (41.0%), followed by sharp transection after ligation (30.8%). There were 38 transfemoral amputations performed in our hospital. Sharp transection after ligation was most often used (55.3%), followed by transection with electrocautery (13.2%).

CONCLUSIONS

All techniques of transecting the sciatic nerve are currently performed by Dutch surgeons. These results provide a solid basis to perform future studies to investigate whether a specific surgical technique is related to postamputation pain syndromes.

Metabolic costs of activities of daily living in persons with a lower limb amputation: A systematic review and meta-analysis

Objective

To systematically review the literature on the metabolic costs of activities of daily living (ADL) in persons with a lower limb amputation (LLA).

Data sources

A literature search was undertaken in the Pubmed, Embase, CINAHL, CENTRAL, and PsycINFO databases using keywords and synonyms for LLA, metabolic costs, and ADL. The last search was performed on November 29^th, 2017.

Study selection

Studies were included if they met the following 2 criteria: participants were adults with a (unilateral or bilateral) LLA and metabolic costs were measured while participants performed a physical activity or ADL.

Data extraction and synthesis

Data of 1,912 participants from 61 studies were included in the systematic review and meta-analysis. The studies used different terms to describe metabolic costs. Participants were recruited in different settings, relatively healthy, with few comorbidities. Limited data were available on metabolic costs of other activities than walking with a prosthesis. A linear mixed model analysis was performed based on the means reported, with study as unit of analysis and test results of different groups and measurement conditions as repeated measures within the unit of analysis. Predictors entered in the analysis were e.g. level and reason of amputation, age, weight, and height. During walking, oxygen consumption (ml O₂/kg/min) and heart rate (beats/min) increased with a higher walking speed and a more proximal amputation. Additionally, oxygen consumption was determined by the interaction terms walking speed x amputation level and walking speed squared. Heart rate was determined by the interaction term walking speed squared.

Conclusion

During walking, oxygen consumption (ml O₂/kg/min) and heart rate (beats/min) increased with a higher walking speed and a more proximal amputation. Data on metabolic costs of other activities were limited. The poor quality of the studies and the relatively healthy participants limited generalizability of the results of the meta-analysis.

Test-retest reliability of the special interest group on amputation medicine/Dutch working group on amputations and prosthetics mobility scale, in persons wearing a prosthesis after a lower-limb amputation

Purpose: To assess the test-retest reliability of the Special Interest Group on Amputation Medicine Mobility Scale/Dutch Working Group on Amputations and Prosthetics, better known as SIGAM/WAP mobility scale, in persons with a lower-limb amputation.Method: Longitudinal study at the outpatient departments of a rehabilitation center and a university medical center. Persons with a lower-limb amputation, wearing a prosthesis, were assessed at the end of their multidisciplinary rehabilitation treatment twice, with a 3-week interval, by the same practitioner. Test-retest reliability was quantified using the intraclass correlation coefficient for agreement.Results: Eighty persons participated (mean age ± SD, 61 ± 15 years; 61% men; 76% vascular cause of amputation; 70% able to walk >50m). Fifty-one of them rated themselves to be stable with respect to their mobility and their intraclass correlation coefficient was 0.90 (95% confidence intervals 0.84-0.94).Conclusions: The Special Interest Group on Amputation Medicine Mobility Scale/Dutch Working Group on Amputations and Prosthetics had, at the outpatient departments of a rehabilitation center and a university medical center, excellent test-retest reliability in persons wearing a prosthesis after a lower-limb amputation.Implications for rehabilitationThe Special Interest Group on Amputation Medicine/Dutch Working Group on Amputations and Prosthetics Mobility Scale was developed to classify mobility after a lower-limb amputation and wearing a prosthesis.The Dutch translation of this mobility scale has excellent test-retest reliability.

Pre-operative rehabilitation for dysvascular lower-limb amputee patients: A focus group study involving medical professionals

Background

Major lower-limb amputation (LLA) predisposes patients post-operatively to a significant decline in daily-life functioning. The physical condition of amputee patients prior to surgery is significantly deteriorated due to chronic peripheral vascular disease (PVD) and diabetes, which accounts for the majority of LLAs in the adult population. A common strategy called pre-rehabilitation has been used in multiple patient populations to prepare the patient for undergoing a surgical event and to improve post-operative patient outcomes. Pre-rehabilitation might enhance the outcome of dysvascular LLA patients and reduce the high post-operative mortality rates. However, experience of experts with pre-rehabilitation and feasibility of a pre-rehabilitation program in this group remains unknown.

Objective

To investigate the experiences of medical professionals and researchers in the field of LLA with the use of pre-rehabilitation in general and in particular PVD patients. Additionally, the study examines their opinions regarding need for and feasibility of a pre-rehabilitation program for dysvascular patients at risk for an LLA.

Methods

Two explorative focus group discussions were organized with in total 16 experts in the field of treatment and research of LLA. Transcribed data were coded using the Atlas.ti software package. Thematic analysis with inductive approach was opted to arrange and interpret codes.

Results

The experiences of the experts with pre-rehabilitation in dysvascular patients were scarce. The experts described dysvascular patients at risk for an LLA as a difficult group for pre-rehabilitation due to short time window prior to surgery, older age, multiple co-morbidities and lack of motivation for behavioral change. The experts concluded that a pre-rehabilitation program should focus on patients who have sufficient time in advance before the amputation for pre-rehabilitation and who are motivated to participate.

Conclusion

Although in general the effects of pre-rehabilitation are promising, pre-operative rehabilitation in dysvascular patients at risk for an LLA seems not feasible. Future research could focus on a better monitoring of dysvascular patients and the development of pre-rehabilitation in subgroups of younger dysvascular LLA patients.

Taxonomy of clinical encounters during the first 90 days post-delivery of an initial lower limb prosthesis

BACKGROUND

The incidence and etiology of prosthetic services utilization is poorly understood during the first 90 days post-delivery of the initial lower limb prosthesis. This period is of critical importance, as prevailing policy dictates limits on the reimbursement for certain services provided during this time period. The first step in understanding the financial ramifications of such policy is to examine the taxonomy behind clinical encounters during this tenuous time period.

OBJECTIVES

Quantify and categorize clinical encounters by incidence and etiology.

STUDY DESIGN

Retrospective chart review.

METHODS

A central database containing data on prosthetic services was examined. Incidence and etiology were extracted through independent review of each patient chart.

RESULTS

A total of 537 unique patients were identified, with 109 meeting the inclusion criteria. Chi-square testing showed that comfort ( p < 0.05), cosmesis ( p < 0.01), and mechanical failure ( p < 0.001) yielded statistical significance in scheduled versus unscheduled visits. Stepwise regression analysis demonstrated that both sex and K-level were important predictors of unscheduled visits.

CONCLUSION

Taxonomization of clinical encounters experienced during the first 90 days provides a framework for future studies to be conducted. The data provided can serve as a basis for informing reimbursement policy, workforce planning, and advocacy. Clinical relevance Comfort is the most frequent reason for a clinical encounter during the first 90 days after delivering a lower limb prosthesis. The data on the taxonomy behind the clinical encounters can be used to guide workforce planning and advocate for just reimbursement policy that better reflect patient's needs.

Incidence rates of dysvascular lower extremity amputation changes in Northern Netherlands: A comparison of three cohorts of 1991-1992, 2003-2004 and 2012-2013

Objective

To analyze the incidence rates of dysvascular major lower extremity amputations (LEA) in Northern Netherlands in 2012–2013 compared to previous cohorts in 1991–1992 and 2003–2004.

Design

Retrospective cohort study.

Participants

Adults (N = 343) with first ever dysvascular LEA at ankle disarticulation or more proximal levels. The median age (interquartile range) was 74.2 years (64.5–81.9), 64% were male and 55% had been diagnosed with diabetes mellitus (DM).

Main outcome measures

Crude and age-standardized incidence rates of major LEA per 100.000 person-years.

Results

Crude incidence rate (IR) of first ever major LEA in 2012–2013 was 9.9 per 100.000 person-years, while the age-standardized IR was 7.7 per 100.000 person-years. A Poisson regression analysis showed that amputation rates among men were 2.3 times higher compared to women (95%CI 1.9–2.6), while in 2012–2013 the population aged >63 years had decreased amputation rates compared to 1991–1992. In the DM population the crude IR decreased from 142.6 per 100.000 person-years in 2003–2004 to 89.2 per 100.000 person-years in 2012–2013 (p<0.001).

Conclusions

In 2012–2013 a decrease in age-standardized IR for the general population and a decrease in crude IR for the DM population were observed compared to cohorts from the previous two decades, despite considerable shifts in the age distribution of the Dutch population towards more elderly people and increased prevalence of DM. These findings might suggest that improved treatment of patients at risk of dysvascular amputations is associated with reduced incidence rates of major LEA at the population level.

Are people with lower limb amputation changing? A seven-year analysis of patient characteristics at admission to inpatient rehabilitation and at discharge

Purpose: What are the characteristics of people with lower limb amputation at admission to, and discharge from, subacute rehabilitation? Have these characteristics changed over time?Methods: A total of 425 lower limb amputation inpatient rehabilitation admissions (335 individuals) from 2005 to 2011 were examined. Admission characteristics, including aetiology, gender, age, amputation level, cognition (Mini-Mental State Examination (MMSE)), indoor mobility aid, motor function (Functional Independence Measure motor subscale) and number and type of comorbidities, and discharge characteristics, including prosthetic prescription, motor function, discharge mobility aid, and destination were compared by admission date and year.Results: Proportion of people with lower limb amputation with nonvascular aetiology increased over time (2004, 15% to 2011, 24%) (ß = -181.836, p < 0.001). Admission cognition increased over time (ß = 9.296, p < 0.001). Motor function worsened over time; median admission (IQR) Functional Independence Measure motor 70 (59-77) in 2005 to 67 (51.5-73.25) in 2011 (ß = -1.937, p < 0.001) and discharge from 81 in 2005 to 79 in 2011 (ß = -1.267, p < 0.001). Prosthetic prescription rates were highest in 2005 (68%) decreasing to 47% in 2010 (ß = -200.473, p < 0.001).Conclusions: Total numbers of people with lower limb amputation did not change over the seven-year study period. Changes were observed in aetiology, cognition and motor function. Prosthetic prescription rates decreased over time.Implications for rehabilitationRehabilitation should account for the changing characteristics of people with lower limb amputation.Motor function should be addressed as part of rehabilitation to optimise the patient's ability to return home and to the community.Prescription rates for lower limb prostheses reduced across time, indicating more specific selection processes and refined clinical decision making; this decision is best informed by a multi-disciplinary approach.

Decreasing rates of major lower-extremity amputation in people with diabetes but not in those without: a nationwide study in Belgium

AIMS/HYPOTHESIS

The reduction of major lower-extremity amputations (LEAs) is one of the main goals in diabetes care. Our aim was to estimate annual LEA rates in individuals with and without diabetes in Belgium, and corresponding time trends.

METHODS

Data for 2009-2013 were provided by the Belgian national health insurance funds, covering more than 99% of the Belgian population (about 11 million people). We estimated the age-sex standardised annual amputation rate (first per year) in the populations with and without diabetes for major and minor LEAs, and the corresponding relative risks. To test for time trends, Poisson regression models were fitted.

RESULTS

A total of 5438 individuals (52.1% with diabetes) underwent a major LEA, 2884 people with above- and 3070 with below-the-knee major amputations. A significant decline in the major amputation rate was observed in people with diabetes (2009: 42.3; 2013: 29.9 per 100,000 person-years, 8% annual reduction, p < 0.001), which was particularly evident for major amputations above the knee. The annual major amputation rate remained stable in individuals without diabetes (2009: 6.1 per 100,000 person-years; 2013: 6.0 per 100,000 person-years, p = 0.324) and thus the relative risk reduced from 6.9 to 5.0 (p < 0.001). A significant but weaker decrease was observed for minor amputation in individuals with and without diabetes (5% and 3% annual reduction, respectively, p < 0.001).

CONCLUSIONS/INTERPRETATION

In this nationwide study, the risk of undergoing a major LEA in Belgium gradually declined for individuals with diabetes between 2009 and 2013. However, continued efforts should be made to further reduce the number of unnecessary amputations.

Feasibility, safety, and reliability of exercise testing using the combined arm-leg (Cruiser) ergometer in subjects with a lower limb amputation

Background

Physical fitness of patients with a lower limb amputation predicts their walking ability and may be improved by physical exercise and training. A maximal exercise test is recommended prior to training in order to determine cardiovascular risks and design exercise programs. A potentially suitable ergometer for maximal exercise testing in patients with a lower limb amputation is the combined arm-leg (Cruiser) ergometer. The aim of this study was to determine feasibility, safety, and reliability of (sub)maximal exercise testing on the Cruiser ergometer in subjects with a lower limb amputation.

Methods and findings

Subjects with a lower limb amputation performed 1 submaximal exercise test and 3 maximal exercise tests on the Cruiser ergometer. Feasibility was determined by examining whether key variables such as power output, heart rate and oxygen uptake were correctly and reliably measured, by determining whether a test was a maximal aerobic performance, by studying reasons for non-completion, and by measuring gross efficiency. Safety was analyzed by recording complications, electrocardiogram results, and blood pressure. Reliability was tested by comparing the results of the second and third maximal exercise test. Seventeen subjects (14 men and 3 women) out of 21 preselected subjects completed the study. In general, the maximal Cruiser exercise test was feasible. Almost 75% of the subjects reached a maximal aerobic performance. The test was also safe because no complications occurred, although electrocardiogram and blood pressure could only be reliably recorded in most subjects just before and after the test. Reliability was good: Intraclass correlation was 0.84 for peak oxygen uptake.

Conclusions

The Cruiser ergometer is a feasible, safe, and reliable ergometer for measuring physical fitness of subjects with a lower limb amputation.

Improved limb salvage for patients with vascular disease and tissue loss associated with new model of provision targeted at the diabetic foot

AIMS

The establishment of a vascular surgeon-led emergency diabetic foot service in 2006 has evolved to provide lower limb wound care for patients with and without diabetes. We aimed to determine whether the service was associated with sustained, improved limb salvage rates for the whole population, analyse key aspects of service provision and compare outcomes against published studies.

METHODS

The vascular unit serves a largely rural population of approximately 240,000. Data was collected prospectively on lower limb amputations, arterial and minor surgical interventions from 2006 to 2015, and retrospectively retrieved for 2004-2005, prior to service commencement. Data was also collected on referral patterns, volume of patient admissions and attendances, and delays. Lower limb amputation rates were compared against published data and analysis of admission trends and delays employed non-parametric tests.

RESULTS

Age/gender adjusted major lower limb amputations for the populations with and without diabetes were 412/100,000 in 2004 and 15/100,000 in 2005 respectively. Following service introduction, major amputations reduced and since 2012 have been sustained at between 15-44/100,000 and 1-3/100,000 for patients with and without diabetes respectively, comparing favourably with published data. Vascular interventions have remained static, but referrals of patients directly to the service and numbers of minor procedures have increased.

CONCLUSIONS

The sustained decreases in all major lower limb amputations that have coincided with the development of a core team approach to providing rapid access and comprehensive care for patients with emergency diabetic foot problems may indicate that this service design benefits patients with and without diabetes.

A systematic review describing incidence rate and prevalence of dysvascular partial foot amputation; how both have changed over time and compare to transtibial amputation

BACKGROUND

Partial foot amputation (PFA) is a common consequence of advanced peripheral vascular disease. Given the different ways incidence rate and prevalence data have been measured and reported, it is difficult to synthesize data and reconcile variation between studies. As such, there is uncertainty in whether the incidence rates and prevalence of PFA have increased over time compared to the decline in transtibial amputation (TTA). The aims of this systematic review were to describe the incidence rate and prevalence of dysvascular PFA over time, and how these compare to TTA.

METHOD

Databases (i.e., MEDLINE, EMBASE, psychINFO, AMED, CINAHL, ProQuest Nursing and Allied Health) were searched using MeSH terms and keywords related to amputation level and incidence rate or prevalence. Original research published in English from 1 January 2000 to 31 December 2015 were independently appraised, and data extracted, by two reviewers. The McMaster Critical Review Forms were used to assess methodological quality and bias. Results were reported as narrative summaries given heterogeneity of the literature and included the weighted mean annual incidence rate and 95% confidence interval.

RESULTS

Twenty two cohort studies met the inclusion criteria. Twenty one reported incidence rate data for some level of PFA; four also included a TTA cohort. One study reported prevalence data for a cohort with toe(s) amputation. Samples were typically older, male and included people with diabetes among other comorbidities. Incidence rates were reported using a myriad of denominators and strata such as diabetes type or initial/recurrent amputation.

CONCLUSION

When appropriately grouped by denominator and strata, incidence rates were more homogenous than might be expected. Variation between studies did not necessarily reduce confidence in the conclusion; for example, incidence rate of PFA were many times larger in cohorts with diabetes (94.24 per 100,000 people with diabetes; 95% CI 55.50 to 133.00) compared to those without (3.80 per 100,000 people without diabetes; 95% CI 1.43 to 6.16). It is unclear whether the incidence rates of PFA have changed over time or how they have changed relative to TTA. Further research requires datasets that include a large number of amputations each year and lengthy time periods to determine whether small annual changes in incidence rates have a cumulative and statistically significant effect over time.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015029186 .

Incidence of lower limb amputation in Canada

OBJECTIVES

To determine the Canadian age-adjusted incidence rates of lower limb amputation (LLA) by province, sex, level, and cause of amputation.

METHODS

Data on all hospital discharges associated with LLA from April 1, 2006, to March 31, 2012, were obtained from the Canadian Institute for Health Information's Discharge Abstract Database. National and provincial age-adjusted rates were calculated per 100 000 individuals by sex, level, and cause of LLA using the direct method of standardization. The relative risk of LLA in people with diabetes was calculated.

RESULTS

There were a total of 44 430 LLAs performed in Canada over the study years. The number of LLAs increased from 7331 in 2006 to 7708 in 2011. Mean (SD) age was 65.7 (16.6) years, and 68.8% were males. Sixty-five percent of the LLA cases were due to diabetes. The average age-adjusted rate of LLA in Canada was 22.9 per 100 000 individuals. The age-adjusted rates declined over the study years. The relative risk of diabetes-related LLAs was 28.9.

CONCLUSION

This study provided the first Canadian national and provincial age-adjusted incidence rates of LLA and a baseline for monitoring and evaluation in the future. Understanding the incidence of LLA is essential to managing preventive and rehabilitation services for this population. Although the age-adjusted LLA incidence rates have decreased, the number of new LLAs has increased. The increase in the number of LLAs has important implications for social and health care costs.

Outcomes of dysvascular partial foot amputation and how these compare to transtibial amputation: a systematic review for the development of shared decision-making resources

BACKGROUND

Dysvascular partial foot amputation (PFA) is a common sequel to advanced peripheral vascular disease. Helping inform difficult discussions between patients and practitioners about the level of PFA, or the decision to have a transtibial amputation (TTA) as an alternative, requires an understanding of the current research evidence on a wide range of topics including wound healing, reamputation, quality of life, mobility, functional ability, participation, pain and psychosocial outcomes, and mortality. The aim of this review was to describe a comprehensive range of outcomes of dysvascular PFA and compare these between levels of PFA and TTA.

METHODS

The review protocol was registered in PROSPERO (CRD42015029186). A systematic search of the literature was conducted using MEDLINE, EMBASE, psychINFO, AMED, CINAHL, ProQuest Nursing and Allied Health, and Web of Science. These databases were searched using MeSH terms and keywords relating to different amputation levels and outcomes of interest. Peer reviewed studies of original research-irrespective of the study design-were included if published in English between 1 January 2000, and 31 December 2015, and included discrete cohort(s) with dysvascular PFA or PFA and TTA. Outcomes of interest were rate of wound healing and complications, rate of ipsilateral reamputation, quality of life, functional ability, mobility, pain (i.e., residual limb or phantom pain), psychosocial outcomes (i.e., depression, anxiety, body image and self-esteem), participation, and mortality rate. Included studies were independently appraised by two reviewers. The McMaster Critical Review Forms were used to assess methodological quality and identify sources of bias. Data were extracted based on the Cochrane Consumers and Communication Review Group's data extraction template by a primary reviewer and checked for accuracy and clarity by a second reviewer. Findings are reported as narrative summaries given the heterogeneity of the literature, except for mortality and ipsilateral reamputation where data allowed for proportional meta-analyses.

RESULTS

Twenty-nine unique articles were included in the review, acknowledging that some studies reported multiple outcomes. Eighteen studies reported all-cause proportionate mortality. A smaller number of studies reported outcomes related to functional ability (two), mobility (four), quality of life (three), ipsilateral reamputation (six) as well as wound healing and complications (four). No studies related to pain, participation or psychosocial outcomes met the inclusion criteria. Subjects were typically older and male and had diabetes among other comorbidities. More detailed information about the cohorts such as race or sociodemographic factors were reported in an ad hoc manner. Common sources of bias included contamination, co-intervention, or lack of operational definition for some outcomes (e.g., wound healing) as illustrative examples.

CONCLUSIONS

Aside from mortality, there was limited evidence regarding outcomes of dysvascular PFA, particularly how outcomes differ between levels of PFA and TTA. Acknowledging that there is considerable uncertainty given the small body of literature on many topics where the risk of bias is high, the available evidence suggests that a large proportion of people with PFA experience delayed wound healing and ipsilateral reamputation. People with TTA have increased risk of mortality compared to those with PFA, which may reflect that those considered suitable candidates for TTA have more advanced systemic disease that also increases the risk of dying. Mobility and quality of life may be similar in people with PFA and TTA.

SYSTEMATIC REVIEW REGISTRATION

CRD42015029186.

Long-term outcomes following lower extremity press-fit bone-anchored prosthesis surgery: a 5-year longitudinal study protocol

BACKGROUND

Patients with lower extremity amputation frequently suffer from socket-related problems. This seriously limits prosthesis use, level of activity and health-related quality of life (HRQoL). An additional problem in patients with lower extremity amputation are asymmetries in gait kinematics possibly accounting for back pain. Bone-anchored prostheses (BAPs) are a possible solution for socket-related problems. Knowledge concerning the level of function, activity and HRQoL after surgery is limited. The aims of this ongoing study are to: a) describe changes in the level of function, activity, HRQoL and satisfaction over time compared to baseline before surgery; b) examine potential predictors for changes in kinematics, prosthetic use, walking ability, HRQoL, prosthesis comfort over time and level of stump pain at follow-up; c) examine potential mechanisms for change of back pain over time by identifying determinants, moderators and mediators.

METHODS/DESIGN

A prospective 5-year longitudinal study with multiple follow-ups. All adults, between May 2014 and May 2018, with lower extremity amputation receiving a press-fit BAP are enrolled consecutively. Patients with socket-related problems and trauma, tumour resection or stable vascular disease as cause of primary amputation will be included. Exclusion criteria are severe cognitive or psychiatric disorders. Follow-ups are planned at six-months, one-, two- and five-years after BAP surgery. The main study outcomes follow, in part, the ICF classification: a) level of function defined as kinematics in coronal plane, hip abductor strength, prosthetic use, back pain and stump pain; b) level of activity defined as mobility level and walking ability; c) HRQoL; d) satisfaction defined as prosthesis comfort and global perceived effect. Changes over time for the continuous outcomes and the dichotomized outcome (back pain) will be analysed using generalised estimating equations (GEE). Multivariate GEE will be used to identify potential predictors for change of coronal plane kinematics, prosthetic use, walking ability, HRQoL, prosthesis comfort and for the level of post-operative stump pain. Finally, potential mechanisms for change in back pain frequency will be explored using coronal plane kinematics as a potential determinant, stump pain as moderator and hip abductor strength as mediator.

DISCUSSION

This study may identify predictors for clinically relevant outcome measures.

TRIAL REGISTRATION

NTR5776 . Registered 11 March 2016, retrospectively registered.

Describe the outcomes of dysvascular partial foot amputation and how these compare to transtibial amputation: a systematic review protocol for the development of shared decision-making resources

BACKGROUND

Helping people make well-informed decisions about dysvascular partial foot amputation is becoming increasingly important as improvements in diabetes care and vascular surgery make more distal amputations increasingly possible. The high rates of complications and reamputations associated with partial foot amputation are of concern, particularly given that transtibial amputation seems to result in similar outcomes (e.g., mobility and quality of life) with comparatively few complications and reamputations. The aim of this review is to describe the outcomes of dysvascular partial foot amputation and compare these to transtibial amputation. Results from the review are intended for use in the development of shared decision-making resources.

METHODS/DESIGN

A comprehensive range of databases-MEDLINE, EMBASE, PsycINFO, AMED, Cumulative Index of Nursing and Allied Health Literature (CINAHL), ProQuest Nursing and Allied Health, and Web of Science-will be searched using National Library of Medicine, Medical Subject Headings (MeSH) terms as well as title, abstract, and keywords relating to different amputation levels and outcomes of interest; specifically: incidence, prevalence, and rate of amputation; rate of mortality, wound failure, dehiscence, and time between index and ipsilateral reamputations; and mobility, functional ability, activity and participation, quality of life, pain, and psychosocial outcomes including depression and anxiety. Articles that meet the inclusion criteria will be hand-searched for relevant citations. A forward citation search using Google Scholar will be used to identify articles not yet indexed. Original research published in the English language after 1 January 2000 will be included. The McMaster Critical Review Forms will be used to assess methodological quality and identify sources of bias. Included articles will be independently appraised by two reviewers. Data will be extracted using a spreadsheet based on the Cochrane Consumers and Communication Review Group's data extraction template by a primary reviewer and checked for accuracy and clarity by a second reviewer. Findings from the review will be reported as a narrative without meta-analysis given the anticipated heterogeneity of the literature.

DISCUSSION

Results from the review can be used in the design of shared decision-making resources to help inform difficult decisions about partial foot amputation.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015029186.

Use of prostheses in lower limb amputee patients due to peripheral arterial disease

OBJECTIVE

To evaluate the indication of prosthesis during rehabilitation and the maintenance of their use or abandonment rate after discharge, as well as mortality of lower limb amputees due to peripheral arterial disease.

METHODS

A retrospective and cross-sectional study carried out with lower limb amputee patients, at transfemoral and transtibial levels, due to vascular conditions. The sample was composed of 310 patients (205 men, 105 women, mean age 61.8 years), transfemoral (142) and transtibial (150) levels, unilateral or bilateral (18). A total of 217 were fitted with prosthesis and 93 did not. Nonparametric statistical tests with equality of two proportions, 95% confidence interval and p value <0,05 were used.

RESULTS

Out of 195 patients we contacted, 151 were fitted with prosthesis and 44 not. Of those that were fitted with prosthesis, 54 still use it, 80 abandoned and 17 died. In the group without prosthesis, 27 were on wheelchair and 17 died. Mortality is statistically higher among patients who were not fitted with prosthesis and 34 death occur, on average, 3.91 years after amputation. Survival time of patients who were not fitted with prosthesis was smaller than those were fitted.

CONCLUSION

The use of prosthesis in lower limb amputees, due to vascular conditions, during rehabilitation is high. However, maintenance of prosthesis is not frequent after discharge. Early and high mortality is observed mainly among diabetic patients.