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Forsyth A, Diamond K, Judelson D, Aiello F, Schanzer A, Simons J. Predictors of Ambulatory Status at 1 Year Following Major Lower Extremity Amputation. J Foot Ankle Surg 2023; 62:943-950. [PMID: 37399901 DOI: 10.1053/j.jfas.2023.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 06/09/2023] [Accepted: 06/23/2023] [Indexed: 07/05/2023]
Abstract
Nearly 60,000 major lower extremity amputations (AKA/BKA) are performed annually in the United States. We created a simple risk score for predicting ambulation at 1 year following AKA/BKA. We queried the Vascular Quality Initiative amputation database for patients who underwent above-knee (AKA) or below-knee (BKA) amputation (2013-2018). The primary endpoint was ambulation at 1 year either independently or with assistance. The cohort was divided into 80% derivation and 20% validation. Using the derivation set, a multivariable model identified preoperatively available independent predictors of 1 year ambulation and an integer-based risk-score was created. Scores were calculated to assign patients to risk groups-low, medium, or high chance of being ambulatory at 1 year. Internal validation was performed by applying the risk score to the validation set. Of 8725 AKA/BKA, 2055 met inclusion criteria-excluded: 2644 nonambulatory prior to amputation, 3753 missing 1-year follow-up ambulatory status. The majority-n = 1366, 66% were BKAs. The indications were CLTI; 47%, ischemic tissue loss; 9%, ischemic rest pain; 35%, infection/neuropathic; 9%, acute limb ischemia. Ambulation at 1 year was higher for BKA than AKA: 67%, versus 50%, p < .0001. In the final prediction model, contralateral BKA/AKA was the strongest predictor of nonambulation. The score provided reasonable discrimination (C-statistic = 0.65) and was well calibrated (Hosmer-Lemeshow p = .24). Sixty-two percent of patients who were ambulatory preoperatively remained ambulatory at 1 year. An integer-based risk score can stratify patients according to chance of ambulation at 1 year after major amputation and may be useful for preoperative patient counseling and selection.
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Affiliation(s)
- Alexandra Forsyth
- Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, Worcester, MA.
| | | | - Dejah Judelson
- Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, Worcester, MA
| | - Francesco Aiello
- Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, Worcester, MA
| | - Andres Schanzer
- Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, Worcester, MA
| | - Jessica Simons
- Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, Worcester, MA
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Risks and Risk Factors for Contralateral Amputation in Patients who have Undergone Amputation for Chronic Limb Threatening Ischemia. Eur J Vasc Endovasc Surg 2022; 64:111-118. [DOI: 10.1016/j.ejvs.2022.03.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 03/14/2022] [Accepted: 03/28/2022] [Indexed: 11/23/2022]
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Lu Q, Wang J, Wei X, Wang G, Xu Y. Risk Factors for Major Amputation in Diabetic Foot Ulcer Patients. Diabetes Metab Syndr Obes 2021; 14:2019-2027. [PMID: 33976562 PMCID: PMC8106455 DOI: 10.2147/dmso.s307815] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 03/25/2021] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND The purpose of our study was to identify the new and the more specific risk factors for major amputation in patients with diabetic foot ulcer (DFU). METHODS We used data from the Electronic Medical Record (EMR) database of our hospital from February 2014 to July 2020. Patients with DFU and amputation were included in the study. The logistic regression model was adjusted for demographic characteristics and related comorbidities between major and minor amputation groups. RESULTS Among 3654 patients with DFU, 363 (9.9%) were amputated. Patients with major versus minor amputation, in multivariable logistic regression models, major amputation independent factors included previous amputation history (odds ratio [OR] 2.31 [95% CI 1.17-4.53], p = 0.02), smoking (2.58 [1.31-5.07], p = 0.01), coronary artery disease (CAD) (2.67 [1.35-5.29], p = 0.03), ankle brachial index (ABI) <0.4 (15.77 [7.51-33.13], p < 0.01), Wagner 5 (5.50 [1.89-16.01], p < 0.01), activated partial thromboplastin time (APTT) (1.23 [1.03-1.48], p = 0.01), glycosylated hemoglobin A1c (HbA1c) (1.23 [1.03-1.48], p = 0.03), hemoglobin (Hb) (0.98 [0.96-1.00], p = 0.01), plasma albumin (ALB) (0.88 [0.81-0.95], p < 0.01) and white blood cell (WBC) (1.10 [1.04-1.16], p < 0.01). CONCLUSION Major amputation was associated with previous amputation history, smoking, CAD, Wagner 5, ABI <0.4, HbA1c, Hb, ALB, WBC, and APTT might be a new independent factor. In view of these factors, early prevention and guidance promptly orientated by multidisciplinary is of great significance to reduce the disability rate and economic burden.
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Affiliation(s)
- Qingwei Lu
- Department of Ulcers and Peripheral Vascular Surgery, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, 300193, People’s Republic of China
| | - Jun Wang
- Department of Ulcers and Peripheral Vascular Surgery, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, 300193, People’s Republic of China
- Correspondence: Jun Wang; Gang Wang Department of Ulcers and Peripheral Vascular Surgery, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, 300000, People’s Republic of China Email ;
| | - Xiaolu Wei
- School of Integrated Traditional Chinese and Western Medicine, Binzhou Medical University, Yantai, 264003, People’s Republic of China
| | - Gang Wang
- Department of Ulcers and Peripheral Vascular Surgery, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, 300193, People’s Republic of China
| | - Yang Xu
- Department of Ulcers and Peripheral Vascular Surgery, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, 300193, People’s Republic of China
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Schwarze M, Alimusaj M, Heitzmann DWW, Block J, Putz C, Wolf SI, Schiltenwolf M. [Expert assessment of lower extremity prosthetics]. DER ORTHOPADE 2019; 49:238-247. [PMID: 31089773 DOI: 10.1007/s00132-019-03750-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Although the number of major amputations is declining throughout Germany, more than 57,000 surgical procedures for amputation still take place. As a consequence of high prosthetic care costs, these often lead to disputes before the social court in which expert medical opinions are required. With knowledge of the legal norms, the remit of the expert opinion can be fulfilled. The expert begins with evaluation of the patient's file and a search of the contested parts. The investigation includes a medical history, in addition to a physical examination, in order to be able to comment on the disputed beneficial use of the therapeutic appliance and respond to questions of proof. Questionnaires may be helpful.
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Affiliation(s)
- M Schwarze
- Klinik für Orthopädie und Unfallchirurgie, Zentrum für Orthopädie, Unfallchirurgie und Paraplegiologie, Universitätsklinikum Heidelberg, Schlierbacher Landstraße 200a, 69118, Heidelberg, Deutschland.
| | - M Alimusaj
- Klinik für Orthopädie und Unfallchirurgie, Zentrum für Orthopädie, Unfallchirurgie und Paraplegiologie, Universitätsklinikum Heidelberg, Schlierbacher Landstraße 200a, 69118, Heidelberg, Deutschland
| | - D W W Heitzmann
- Klinik für Orthopädie und Unfallchirurgie, Zentrum für Orthopädie, Unfallchirurgie und Paraplegiologie, Universitätsklinikum Heidelberg, Schlierbacher Landstraße 200a, 69118, Heidelberg, Deutschland
| | - J Block
- Klinik für Orthopädie und Unfallchirurgie, Zentrum für Orthopädie, Unfallchirurgie und Paraplegiologie, Universitätsklinikum Heidelberg, Schlierbacher Landstraße 200a, 69118, Heidelberg, Deutschland
| | - C Putz
- Klinik für Orthopädie und Unfallchirurgie, Zentrum für Orthopädie, Unfallchirurgie und Paraplegiologie, Universitätsklinikum Heidelberg, Schlierbacher Landstraße 200a, 69118, Heidelberg, Deutschland
| | - S I Wolf
- Klinik für Orthopädie und Unfallchirurgie, Zentrum für Orthopädie, Unfallchirurgie und Paraplegiologie, Universitätsklinikum Heidelberg, Schlierbacher Landstraße 200a, 69118, Heidelberg, Deutschland
| | - M Schiltenwolf
- Klinik für Orthopädie und Unfallchirurgie, Zentrum für Orthopädie, Unfallchirurgie und Paraplegiologie, Universitätsklinikum Heidelberg, Schlierbacher Landstraße 200a, 69118, Heidelberg, Deutschland
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Hagberg K. Bone-anchored prostheses in patients with traumatic bilateral transfemoral amputations: rehabilitation description and outcome in 12 cases treated with the OPRA implant system. Disabil Rehabil Assist Technol 2018. [PMID: 29534624 DOI: 10.1080/17483107.2018.1449016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
PURPOSE To describe the rehabilitation experience and outcome of treatment with bone-anchored prostheses in individuals with bilateral transfemoral amputations (TFAs) treated in Sweden over a period of 25 years. METHOD Hospital records were reviewed for all patients with traumatic bilateral TFAs treated until 2015. The use of prostheses, walking aids and wheelchairs was noted. RESULTS The cohort comprised 12 patients (nine men and three women with a mean age 35 years at treatment) and the median follow-up time was seven years (1-20). At baseline, 9/12 used prostheses and 3/12 did not. The main means of locomotion was in a wheelchair without wearing prostheses (n = 8/12) or in a wheelchair in combination with prosthetic walking supported by walking aids (n = 4/12). All prosthetic users had problems with sitting comfort. At follow-up, 11/12 patients used prostheses, while one did not. The means of locomotion was prosthetic walking in 3/12 cases, a combination of a wheelchair and prosthetic walking in 4/12, a wheelchair while wearing prostheses but not walking in 4/12 and a wheelchair without wearing prostheses in 1/12. Three patients walked unsupported by walking aids. Seven patients had no problem with prosthetic sitting comfort (n = 3 had small problems). CONCLUSIONS Bone-anchored prostheses in patients with bilateral TFAs resulted in more prosthesis use during everyday locomotion, due hypothetically to improved comfort while wearing prostheses. The results further underline the importance of other assistive devices such as wheelchairs and walking aids used in combination with prostheses in this group of patients facing severe functional limitations. Implications for Rehabilitation This study provides an insight into the details of the rehabilitation and outcome in patients with traumatic bilateral transfemoral amputations treated with bone-anchored prostheses in Sweden. The treatment can lead to a large amount of prosthetic use, but most patients will also use a range of assistive devices including full-length prostheses, stubbies, walking aids and wheelchairs after treatment. The importance of sitting in comfort while wearing prostheses should not be underestimated in patients with bilateral transfemoral amputations.
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Affiliation(s)
- Kerstin Hagberg
- a Department of Advanced Reconstruction of Extremities , Sahlgrenska University Hospital , Gothenburg , Sweden.,b Department of Orthopaedics, Institute of Clinical Sciences , University of Gothenburg, Sahlgrenska Academy , Gothenburg , Sweden
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Leite JO, Costa LO, Fonseca WM, Souza DU, Goncalves BC, Gomes GB, Cruz LA, Nister N, Navarro TP, Bath J, Dardik A. General outcomes and risk factors for minor and major amputations in Brazil. Vascular 2017; 26:291-300. [PMID: 29041830 DOI: 10.1177/1708538117736677] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objectives Major and minor amputations are associated with significant rates of mortality. However, little is known about the impact of unplanned redo-amputation during the same hospitalization on outcomes. The objectives of this study were to identify the risk factors associated with in-hospital mortality after both major and minor amputations as well as the results of unplanned redo-amputation on outcome. Methods Retrospective study of 342 consecutive patients who were treated with lower extremity amputation in Brazil between January 2013 and October 2014. Results The in-hospital mortality rate was higher in major compared to minor amputation (25.6% vs. 4.1%; p < 0.0001). Whereas chronic kidney disease, chronic obstructive pulmonary disease, and planned staged amputation predicted in-hospital mortality after major amputation, age, and congestive heart failure predicted mortality after minor amputation. The white blood cell count predicted in-hospital mortality following both major and minor amputation. However, postoperative infection predicted in-hospital mortality only following major amputation. Conclusions In-hospital mortality was high after major amputations. Unplanned redo-amputation was not a predictor of in-hospital mortality after major or minor amputation. Planned staged amputation was associated with reduced survival after major but not minor amputation. Postoperative infection predicted mortality after major amputation. Systemic diseases and postoperative white blood cell were associated with in-hospital mortality. This study suggests a possible link between a pro-inflammatory state and increased in-hospital mortality following amputation.
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Affiliation(s)
- Jose O Leite
- 1 Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil.,2 Departamento de Cirurgia Vascular, Hospital Risoleta Tolentino Neves, Belo Horizonte, Brazil
| | - Leandro O Costa
- 1 Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil.,2 Departamento de Cirurgia Vascular, Hospital Risoleta Tolentino Neves, Belo Horizonte, Brazil
| | - Walter M Fonseca
- 1 Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil.,2 Departamento de Cirurgia Vascular, Hospital Risoleta Tolentino Neves, Belo Horizonte, Brazil
| | - Debora U Souza
- 2 Departamento de Cirurgia Vascular, Hospital Risoleta Tolentino Neves, Belo Horizonte, Brazil.,3 Faculdade de Fisioterapia, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Barbara C Goncalves
- 1 Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil.,2 Departamento de Cirurgia Vascular, Hospital Risoleta Tolentino Neves, Belo Horizonte, Brazil
| | - Gabriela B Gomes
- 1 Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil.,2 Departamento de Cirurgia Vascular, Hospital Risoleta Tolentino Neves, Belo Horizonte, Brazil
| | - Lucas A Cruz
- 1 Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil.,2 Departamento de Cirurgia Vascular, Hospital Risoleta Tolentino Neves, Belo Horizonte, Brazil
| | - Nilder Nister
- 1 Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil.,2 Departamento de Cirurgia Vascular, Hospital Risoleta Tolentino Neves, Belo Horizonte, Brazil
| | - Tulio P Navarro
- 1 Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil.,2 Departamento de Cirurgia Vascular, Hospital Risoleta Tolentino Neves, Belo Horizonte, Brazil
| | - Jonathan Bath
- 4 Department of Surgery, Division of Vascular Surgery, University of Cincinnati College of Medicine, Cincinnati, USA
| | - Alan Dardik
- 5 Department of Surgery, Division of Vascular Surgery, Yale School of Medicine, Yale University, New Haven, USA
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Shimizu Y, Mutsuzaki H, Maezawa T, Idei Y, Takao K, Takeuchi R, Onishi S, Hada Y, Yamazaki M, Wadano Y. Hip prosthesis in sitting posture for bilateral transfemoral amputee after burn injury: a case report. Prosthet Orthot Int 2017; 41:522-526. [PMID: 28293984 DOI: 10.1177/0309364616682384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND To overcome the challenges of rehabilitation of bilateral transfemoral amputees, we developed a novel "hip prosthesis in the sitting posture." Case Description and Methods: A 64-year-old male bilateral transfemoral amputee was transferred for rehabilitation 4 months following a burn injury. His wounds remained unhealed for 20 months; thus, he was unable to participate in standing training with the standard prosthetic sockets. Hip prosthesis in the sitting posture has very little friction between the sockets and residual limbs, which facilitated our patient to begin standing and walking exercises. Findings and Outcomes: The patient's refractory wounds healed 1 month after initiating exercises using hip prosthesis in the sitting posture, and he could begin rehabilitation with the standard prostheses. DISCUSSION AND CONCLUSION Hip prosthesis in the sitting posture enabled a bilateral transfemoral amputee with unhealed residual limbs to stand, walk, and begin balance training. Hip prosthesis in the sitting posture is an effective temporary prosthesis to prevent disuse until wounds are healed and to continue rehabilitation with standard prostheses. Clinical relevance Hip prosthesis in the sitting posture is useful for bilateral transfemoral amputees with unhealed residual limbs after burn injuries to prevent disuse and maintain motivation for walking.
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Affiliation(s)
- Yukiyo Shimizu
- 1 Department of Rehabilitation Medicine, University of Tsukuba Hospital, Tsukuba, Ibaraki, Japan.,2 Department of Orthopaedic Surgery, Ibaraki Prefectural University of Health Sciences, Ibaraki, Japan
| | - Hirotaka Mutsuzaki
- 2 Department of Orthopaedic Surgery, Ibaraki Prefectural University of Health Sciences, Ibaraki, Japan
| | - Takayuki Maezawa
- 3 Department of Physical Therapy, Ibaraki Prefectural University Hospital of Health Sciences, Ibaraki, Japan
| | - Yuji Idei
- 4 Kowa gishi Laboratory, Ojirahazama, Tsukuba, Ibaraki, Japan
| | - Kazuya Takao
- 5 Department of Occupational Therapy, Ibaraki Prefectural University Hospital of Health Sciences, Ibaraki, Japan
| | - Ryoko Takeuchi
- 2 Department of Orthopaedic Surgery, Ibaraki Prefectural University of Health Sciences, Ibaraki, Japan
| | - Shinzo Onishi
- 6 Department of Orthopaedics Surgery, University of Tsukuba Hospital, Ibaraki, Japan
| | - Yasushi Hada
- 1 Department of Rehabilitation Medicine, University of Tsukuba Hospital, Tsukuba, Ibaraki, Japan
| | - Masashi Yamazaki
- 7 Department of Orthopaedic Surgery, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Yasuyoshi Wadano
- 8 Department of Rehabilitation Medicine, Ibaraki Prefectural University of Health Sciences, Ibaraki, Japan
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