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

Development of the AMPDECIDE Decision Aid to Facilitate Shared Decision Making in Patients Facing Amputation Secondary to Chronic Limb Threatening Ischemia

INTRODUCTION

We developed a patient decision aid to enhance patient participation in amputation level decision making when there is a choice between a transmetatarsal or transtibial amputation.

METHODS

In accordance with International Patient Decision Aid Standards, we developed an amputation level patient decision aid for patients who are being considered for either a transmetatarsal or transtibial amputation, incorporating qualitative literature data, quantitative literature data, qualitative provider and patient interviews, expert panel input and iterative patient feedback.

RESULTS

The rapid qualitative literature review and qualitative interviews identified five domains outcome priority domains important to patients facing amputation secondary to chronic limb threatening ischemia: 1) the ability to walk, 2) healing and risk for reamputation, 3) rehabilitation program intensity, 4) ease of prosthetic use, and 5) limb length after amputation. The rapid quantitative review identified only two domains with adequate evidence comparing differences in outcomes between the two amputation levels: mobility and reamputation. Patient, surgeon, rehabilitation and decision aid expert feedback allowed us to integrate critical facets of the decision including addressing the emotional context of loss of limb, fear and anxiety as an obstacle to decision making, shaping the decision in the context of remaining life years, and how to facilitate patient knowledge of value tradeoffs.

CONCLUSIONS

Amputation level choice is associated with significant outcome trade-offs. The AMPDECIDE patient decision aid can facilitate acknowledgment of patient fears, enhance knowledge of amputation level outcomes, assist patients in determining their personal outcome priorities, and facilitate shared amputation level decision making.

Residual limb support devices on wheelchairs for people with transtibial amputations: A scoping review and survey of rehabilitation professionals in Nova Scotia

PURPOSE

To determine what research evidence exists for the use of residual limb supports (RLSs) for people with transtibial amputations and to describe clinicians' use of such supports in Nova Scotia.

METHODS

Scoping review of published and gray literature using Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews as a guide and an anonymous online and paper-based clinician survey.

RESULTS

We identified 22 publications meeting criteria for review. Seventeen (77%) of the publications were practice guidelines or systematic reviews about care of people with lower-limb amputations, 4 (18%) involved research about the design of stump supports, and 1 (5%) researched the use of supports. Generally, the use of RLSs was recommended (e.g., to prevent contractures, control edema, and to provide comfort), but many authors acknowledged that the evidence was weak, and additional evidence in support of these treatment goals could not be found. We received 44 survey responses from health care professionals involved with the care of people with transtibial amputations in Nova Scotia. Of the 43 health care professionals who responded to the question "… what percent of patients/clients with transtibial amputations do you estimate receive stump supports …," the mean (standard deviation) was 86.1% (21.1). The most common reasons for recommending a stump support were to prevent knee contracture (38 [86.4%]), and to prevent swelling (13 [29.5%]).

CONCLUSIONS

Most clinicians who provide services to people with amputations in Nova Scotia believe that RLSs have benefits such as the prevention of contractures, the reduction of edema, and improved patient comfort. However, there is little high-quality research evidence to support their use. There is a need to perform the necessary research or to modify practice guidelines.

Trends in diabetes-related foot disease hospitalizations and amputations in Australia, 2010 to 2019

AIM

To determine trends in the incidence of hospitalizations and amputations for diabetes-related foot disease (DFD) in Australia.

METHODS

We included 70,766 people with type 1, and 1,087,706 with type 2 diabetes from the Australian diabetes registry from 2010 to 2019, linked to hospital admissions databases. Trends in age-adjusted incidence were summarized as annual percent changes (APC).

RESULTS

In people with type 1 diabetes, total DFD hospitalizations increased from 20.8 to 30.5 per 1,000 person-years between 2010 and 2019 (APC: 5.1% (95% CI: 3.5, 6.8)), including increases for ulceration (13.3% (2.9, 24.7)), osteomyelitis (5.6% (2.7, 8.7)), peripheral arterial disease (7.7% (3.7, 11.9)), and neuropathy (8.7% (5.5, 12.0)). In people with type 2 diabetes, DFD hospitalizations changed from 18.6 to 24.8 per 1,000 person-years between 2010 and 2019 (APC: 4.5% (3.6, 5.4); 2012-2019), including increases for ulceration (8.7% (4.0, 13.7)), cellulitis (5.4% (3.7, 7.0)), osteomyelitis (6.7% (5.7, 7.7)), and neuropathy (6.9% (5.2, 8.5)). Amputations were stable in type 1, whereas in type 2, above knee amputations decreased (-6.0% (-9.1, -2.7). Adjustment for diabetes duration attenuated the magnitude of most increases, but many remained significant.

CONCLUSIONS

DFD hospitalizations increased markedly in Australia, mainly driven by ulceration and neuropathy, highlighting the importance of managing DFD to prevent hospitalizations.

The Development of Lower Limb Amputations in Finland from 1997 to 2018: A Nationwide Retrospective Registry Study

OBJECTIVE

To investigate the rates of transfemoral, transtibial foot and toe amputations, and lower limb revascularisations in Finland between 1997 and 2018.

METHODS

Retrospective observational cohort study. Data from the Finnish National Hospital Discharge Register for the period 1997 - 2018 were used. The study population covered all patients 20 years and older who underwent lower limb revascularisations or amputations in private and public hospitals during the study period. All (outpatient and inpatient) amputations and revascularisations were included. The age adjusted incidence rates were based on the annual mid populations, which were obtained from the Official Statistics of Finland. Continuous variables were presented as median with interquartile range (IQR) or as mean with standard deviation. The 95% confidence intervals (CI) for the incidence rates were calculated using the Poisson exact method. All changes in incidence were calculated as relative change (%).

RESULTS

A total of 75 230 patients underwent 149 492 lower limb revascularisations and amputations between 1997 and 2018 in Finland. The median (IQR) age of the patients was 73 (65, 80) and 60% of the patients were men. The incidence of all endovascular lower limb revascularisations increased by 159% while the incidence of lower limb amputations increased by 25%. The most notable increase occurred in toe (84%) and foot (107%) amputations, while the incidence of transfemoral amputations remained steady and transtibial amputations decreased by 53%. The first minor-major amputation ratio (CI) increased from 1.13 (1.03 - 1.24) to 1.49 (1.36 to 1.62) during the study period.

CONCLUSION

The findings of this nationwide cohort study suggest that the incidence of both lower limb revascularisations and amputations is increasing. More specifically, revascularisations are more often performed endovascularly, and the incidence of transtibial amputations is declining, whereas the incidence of toe and foot amputations is increasing.

Leg dominance as a determinant in laterality of lower extremity amputation in diabetic patients: retrospective study and literature review

Background/Aims

Diabetic patients with peripheral vascular manifestations often develop foot ulcers and sometimes have to undergo lower extremity amputation. This retrospective study investigated leg dominance and laterality of lower extremity amputation in diabetic, dysvascular amputees.

Methods

All patients who met the inclusion criteria had their medical records reviewed for their dominant side and a correlation with a side of amputation was analysed. This information is routinely obtained as part of the admission history. For the literature review, PubMed, Google Scholar, ScienceDirect and Cochrane Library were searched with no date restriction until February 2018. Relevant studies were included and analysed.

Results

Of all the patients (n=27), 16 had diabetes and of these, 12 (75%) had their dominant leg amputated.

Conclusions

The data and literature analysis suggest that diabetic, dysvascular patients' dominant legs may be at higher risk for amputation than the non-dominant side. Larger studies are needed to clarify the relationship between leg dominance and laterality of lower extremity amputation.

Biobehavioral Intervention Targeting Physical Activity Behavior Change for Older Veterans after Nontraumatic Amputation: A Randomized Controlled Trial

BACKGROUND

Lower-limb amputation (LLA) due to non-traumatic vascular etiology is linked to extremely low physical activity and high disability.

OBJECTIVE

To test the feasibility of a biobehavioral intervention designed to promote physical activity.

DESIGN

A randomized, single-blind feasibility trial with a crossover design.

SETTING

Veterans Administration Medical Center.

PARTICIPANTS

Military veterans (age: 65.7 [7.8] years; mean [standard deviation]) with nontraumatic lower-limb amputation (LLA), randomized to two groups: GROUP1 (n = 16) and GROUP2 (n = 15). Both groups had similar baseline amputation characteristics (level of amputation and time since amputation).

INTERVENTIONS

Twelve weekly, 30-minute telehealth sessions of physical activity behavior-change intervention, with GROUP1 participating in weeks 1-12 and GROUP2 in weeks 13-24. GROUP1 noncontact phase in weeks 13-24 and GROUP2 attention control telehealth phase in weeks 1-12.

MAIN OUTCOME MEASURES

Feasibility (participant retention, dose goal attainment, intervention acceptability [Intrinsic Motivation Inventory [IMI] Interest and Enjoyment scale], safety) and signal of efficacy (free-living physical activity [accelerometer-based average daily step count], Late Life Function and Disability Index - Disability Scale [LLFDI-DS]).

RESULTS

Participant retention rate was high (90%), with three participants lost to follow-up during the intervention period. Dose goal attainment was low, with only 10% of participants achieving an a priori walking dose goal. Intervention was rated as acceptable, with mean IMI Interest and Enjoyment score (5.8) statistically higher than the null value of 5.0 (P = .002). There were no between-group differences in adverse event rates (falls: P = .19, lower extremity wounds: P = .60). There was no signal of efficacy for change in average daily step count (d = -0.15) or LLFDI-DS (d = -0.22 and 0.17 for frequency and limitations scales, respectively).

CONCLUSIONS

Telehealth delivered biobehavioral intervention resulted in acceptable participant retention, low dose goal attainment, high participant acceptability, and low safety risk, while having no signal of efficacy (physical activity, disability) for people with nontraumatic LLA.

Renal Function as a Predictor of Early Transmetatarsal Amputation Failure

Chronic kidney disease (CKD) is a major concern in patients with foot disease because it is associated with high rates of neuropathy, peripheral vascular disease, and poor wound healing. The purpose of this study was to evaluate renal dysfunction as a risk factor for reamputation after initial transmetatarsal amputation (TMA). Patients who underwent a TMA were retrospectively identified in the American College of Surgeons National Surgical Quality Improvement Program database. Of 2018 patients, reamputation after TMA occurred in 4.4%. End-stage renal disease (ESRD) was associated with 100% increased odds of TMA failure (adjusted odds ratio [OR] = 2.00; 95% CI = 1.10, 3.52), 128% increased odds of major amputation (adjusted OR = 2.28; 95% CI = 1.27, 3.96), and 182% increased odds of 30-day mortality (adjusted OR = 2.82; 95% CI = 1.69, 4.64). In addition, white blood cell count >10 000/mm³ and deep infection at the time of surgery were independently associated with TMA failure. In conclusion, severe renal dysfunction is associated with TMA failure in the short-term, perioperative period. There was no incremental increase in risk of TMA failure with worsening level of renal function before ESRD. A multidisciplinary approach should be implemented in patients with CKD to prevent foot-related pathologies that may necessitate lower-extremity amputation. Levels of Evidence: Level III: Retrospective cohort study.

Impact of the pay-for-performance program on lower extremity amputations in patients with diabetes in Taiwan

Patients with diabetes are at a high risk of lower extremity amputations and may have a reduced life expectancy. Taiwan has implemented a diabetes pay-for-performance (P4P) program providing team care to improve the control of disease and avoid subsequent complications. Few studies investigated the effects of adopting a nationalized policy to decrease amputation risk in diabetes previously. Our study aimed to analyze the impact of the P4P programs on the incidence of lower extremity amputations in Taiwanese patients with diabetes.This was a population-based cohort study using the Taiwan National Health Insurance Research Database (which provided coverage for 98% of the total population in Taiwan) from 1998 to 2007. Patients with diabetes were identified based on the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnostic codes. We linked procedure codes to inpatient claims to identify patients hospitalized for nontraumatic lower extremity amputations.A total of 9738 patients with diabetes with amputations were enrolled (mean age ± standard deviation: 64.4 ± 14.5 years; men: 63.9%). The incidence of nontraumatic diabetic lower extremity amputations decreased over the time period studied (3.79-2.27 per 1000 persons with diabetes). Based on the Cox proportional hazard regression model, male sex (hazard ratio: 1.83, 95% confidence interval [CI] 1.76-1.92), older age, and low socioeconomic status significantly interact with diabetes with respect to the risks of amputation. Patients who did not join the P4P program for diabetes care had a 3.46-fold higher risk of amputation compared with those who joined (95% CI 3.19-3.76).The amputation rate in Taiwanese diabetic patients decreased over the time period observed. Diabetes in patients with low socioeconomic status is associated with an increased risk of amputations. Our findings suggested that in addition to medical interventions and self-management educations, formulate and implement of medical policies, such as P4P program, might have a significant effect on decreasing the diabetes-related amputation rate.