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Jayaraman C, Mummidisetty CK, Albert MV, Lipschutz R, Hoppe-Ludwig S, Mathur G, Jayaraman A. Using a microprocessor knee (C-Leg) with appropriate foot transitioned individuals with dysvascular transfemoral amputations to higher performance levels: a longitudinal randomized clinical trial. J Neuroeng Rehabil 2021; 18:88. [PMID: 34034753 PMCID: PMC8146219 DOI: 10.1186/s12984-021-00879-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 05/14/2021] [Indexed: 12/02/2022] Open
Abstract
Background Individuals with transfemoral amputations who are considered to be limited community ambulators are classified as Medicare functional classification (MFCL) level K2. These individuals are usually prescribed a non-microprocessor controlled knee (NMPK) with an appropriate foot for simple walking functions. However, existing research suggests that these individuals can benefit from using a microprocessor controlled knee (MPK) and appropriate foot for their ambulation, but cannot obtain one due to insurance policy restrictions. With a steady increase in older adults with amputations due to vascular conditions, it is critical to evaluate whether advanced prostheses can provide better safety and performance capabilities to maintain and improve quality of life in individuals who are predominantly designated MFCL level K2. To decipher this we conducted a 13 month longitudinal clinical trial to determine the benefits of using a C-Leg and 1M10 foot in individuals at K2 level with transfemoral amputation due to vascular disease. This longitudinal clinical trial incorporated recommendations prescribed by the lower limb prosthesis workgroup to design a study that can add evidence to improve reimbursement policy through clinical outcomes using an MPK in K2 level individuals with transfemoral amputation who were using an NMPK for everyday use. Methods Ten individuals (mean age: 63 ± 9 years) with unilateral transfemoral amputation due to vascular conditions designated as MFCL K2 participated in this longitudinal crossover randomized clinical trial. Baseline outcomes were collected with their current prosthesis. Participants were then randomized to one of two groups, either an intervention with the MPK with a standardized 1M10 foot or their predicate NMPK with a standardized 1M10 foot. On completion of the first intervention, participants crossed over to the next group to complete the study. Each intervention lasted for 6 months (3 months of acclimation and 3 months of take-home trial to monitor home use). At the end of each intervention, clinical outcomes and self-reported outcomes were collected to compare with their baseline performance. A generalized linear model ANOVA was used to compare the performance of each intervention with respect to their own baseline. Results Statistically significant and clinically meaningful improvements were observed in gait performance, safety, and participant-reported measures when using the MPK C-Leg + 1M10 foot. Most participants were able to achieve higher clinical scores in gait speed, balance, self-reported mobility, and fall safety, while using the MPK + 1M10 combination. The improvement in scores were within range of scores achieved by individuals with K3 functional level as reported in previous studies. Conclusions Individuals with transfemoral amputation from dysvascular conditions designated MFCL level K2 benefited from using an MPK + appropriate foot. The inference and evidence from this longitudinal clinical trial will add to the knowledgebase related to reimbursement policy-making. Trial registration This study is registered on clinical trials.gov with the study title “Functional outcomes in dysvascular transfemoral amputees” and the associated ClinicalTrials.gov Identifier: NCT01537211. The trial was retroactively registered on February 7, 2012 after the first participant was enrolled. Supplementary Information The online version contains supplementary material available at 10.1186/s12984-021-00879-3.
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Affiliation(s)
- Chandrasekaran Jayaraman
- Max Näder Lab for Rehabilitation Technologies and Outcomes Research, Shirley Ryan AbilityLab, Chicago, USA.,Department of Physical Medicine and Rehabilitation, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - Chaithanya K Mummidisetty
- Max Näder Lab for Rehabilitation Technologies and Outcomes Research, Shirley Ryan AbilityLab, Chicago, USA
| | - Mark V Albert
- Department of Physical Medicine and Rehabilitation, Northwestern University Feinberg School of Medicine, Chicago, USA.,Department of Computer Science and Engineering, University of North Texas, Denton, USA.,Department of Biomedical Engineering, University of North Texas, Denton, USA
| | - Robert Lipschutz
- Max Näder Lab for Rehabilitation Technologies and Outcomes Research, Shirley Ryan AbilityLab, Chicago, USA
| | - Shenan Hoppe-Ludwig
- Max Näder Lab for Rehabilitation Technologies and Outcomes Research, Shirley Ryan AbilityLab, Chicago, USA
| | - Gayatri Mathur
- Max Näder Lab for Rehabilitation Technologies and Outcomes Research, Shirley Ryan AbilityLab, Chicago, USA
| | - Arun Jayaraman
- Max Näder Lab for Rehabilitation Technologies and Outcomes Research, Shirley Ryan AbilityLab, Chicago, USA. .,Department of Physical Medicine and Rehabilitation, Northwestern University Feinberg School of Medicine, Chicago, USA.
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O'Banion LA, Dirks R, Farooqui E, Kaups K, Qumsiyeh Y, Rome C, Davis J. Outcomes of major lower extremity amputations n dysvascular patients: Room for improvement. Am J Surg 2020; 220:1506-1510. [PMID: 32891397 DOI: 10.1016/j.amjsurg.2020.08.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 07/14/2020] [Accepted: 08/19/2020] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Dysvascular patients account for >80% of major amputations in the US. We sought to determine if early mobilization and discharge disposition decreased post-operative hospital length of stay (PO-LOS) and expedited independent ambulation. METHODS A retrospective review of dysvascular patients undergoing major amputations was performed. Primary outcomes included PO-LOS, discharge disposition, and days to ambulation. RESULTS 130 patients were included. Patients evaluated by Physical Therapy (PT) within 1 day of formal amputation had decreased PO-LOS (5.6 vs 6.5 days, p = 0.029). Patients discharged to rehab had a shorter PO-LOS (4 days) than those discharged to SNF or home (8 and 5 days, respectively; p = 0.008). Time to ambulation was shorter for patients discharged to rehab (109 days vs home = 153 days; SNF = 175 days; p = 0.033). CONCLUSION Modifiable factors, including early PT and rehab placement, decreased PO-LOS and expedited time to ambulation. A need exists for a standardized multidisciplinary team approach to improve outcomes.
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Affiliation(s)
- Leigh Ann O'Banion
- UCSF Department of Surgery, 2823 Fresno St, 1st Floor Surgery, Fresno, CA, 93721, USA.
| | - Rachel Dirks
- UCSF Department of Surgery, 2823 Fresno St, 1st Floor Surgery, Fresno, CA, 93721, USA.
| | - Emaad Farooqui
- UCSF Department of Surgery, 2823 Fresno St, 1st Floor Surgery, Fresno, CA, 93721, USA.
| | - Krista Kaups
- UCSF Department of Surgery, 2823 Fresno St, 1st Floor Surgery, Fresno, CA, 93721, USA.
| | - Yazen Qumsiyeh
- UCSF Department of Surgery, 2823 Fresno St, 1st Floor Surgery, Fresno, CA, 93721, USA.
| | - Cambia Rome
- UCSF Department of Surgery, 2823 Fresno St, 1st Floor Surgery, Fresno, CA, 93721, USA.
| | - James Davis
- UCSF Department of Surgery, 2823 Fresno St, 1st Floor Surgery, Fresno, CA, 93721, USA.
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Davies K, McGrath M, Savage Z, Stenson A, Moser D, Zahedi S. Using Perforated Liners to Combat the Detrimental Effects of Excessive Sweating in Lower Limb Prosthesis Users. Can Prosthet Orthot J 2020; 3:34610. [PMID: 37614406 PMCID: PMC10443502 DOI: 10.33137/cpoj.v3i2.34610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 08/29/2020] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Excessive sweating of the residual limb has a substantial effect on the daily activities of people with lower limb amputation. Prosthetic liners offer protection and comfort to sensitive areas but often exacerbate perspiration. They act as insulators, trapping sweat on the skin's surface to the detriment of skin health. Recently, liners with perforations have been developed, allowing the moisture to escape. The goal of this study was to assess the impact of such liners. METHODS A sample group of 13 patients with unilateral transtibial amputation, who wore a perforated liner (PL) as part of their current prescription, was compared to 20 control patients who wore non-perforated liners (NPL). During their routine appointments, they completed a survey of scientifically validated outcome measures relating to their limb health, pain and the impact on daily life over a 12-month period. RESULTS Patients using the PL had healthier residual limbs, reporting higher scores on questions relating to limb health, experiencing fewer skin issues (p<0.001) and estimating a 61.8% lower rating in perceived sweat (p=0.004). Perhaps consequentially, there was a lower incidence of residual (p=0.012) and phantom (p=0.001) limb pain when compared to the control group. The prevalence of individual issues affecting the residual limbs of PL users was also lower. Of the issues that remained, only 23% were attributed to sweating in PL users, compared to 49% for the NPL group (p=0.066). PL users missed fewer days of work in the year (2.4 vs 11.6, p=0.267) and were also limited on fewer days (1.4 vs 75.4, p=0.009). CONCLUSION The use of perforated liners shows much promise within prosthetic care, significantly improving the health of the residual limb. The observed effects on perceived sweat reduction, residual skin health, pain levels and patient limitation suggest that perforated liners are highly beneficial to patients.
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Affiliation(s)
- K.C. Davies
- Blatchford Group, Unit D Antura, Bond Close, Basingstoke, RG24 8PZ, UK
| | - M McGrath
- Blatchford Group, Unit D Antura, Bond Close, Basingstoke, RG24 8PZ, UK
| | - Z Savage
- Sheffield Mobility & Specialised Rehabilitation Centre, Northern General Hospital, Sheffield, UK
| | - A Stenson
- Sheffield Mobility & Specialised Rehabilitation Centre, Northern General Hospital, Sheffield, UK
| | - D Moser
- Blatchford Group, Unit D Antura, Bond Close, Basingstoke, RG24 8PZ, UK
| | - S Zahedi
- Blatchford Group, Unit D Antura, Bond Close, Basingstoke, RG24 8PZ, UK
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Norvell DC, Czerniecki JM. Risks and Risk Factors for Ipsilateral Re-Amputation in the First Year Following First Major Unilateral Dysvascular Amputation. Eur J Vasc Endovasc Surg 2020; 60:614-621. [PMID: 32800475 DOI: 10.1016/j.ejvs.2020.06.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 05/01/2020] [Accepted: 06/19/2020] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To identify timing, incidence, and risk factors for ipsilateral re-amputation within 12 months of first dysvascular amputation and to determine specific subgroups of patients at each amputation level that are at increased risk. METHODS A retrospective cohort study evaluating 7187 patients with first unilateral transmetatarsal (TM), transtibial (TT), or transfemoral (TF) amputation secondary to diabetes and/or peripheral artery disease (PAD) were identified in the VA Surgical Quality Improvement Program database between 2004 and 2014. Re-amputation was defined as any subsequent ipsilateral soft tissue/bony revision or amputation to a higher level. Twenty-three potential pre-operative risk factors (and nine potential interactions) were identified. A backward stepwise Cox regression was used to identify risk factors. Incidence rates and hazard ratios (HR) with 95% confidence intervals (CI) were computed. RESULTS The median time to highest level of re-amputation in the first year was 33 (interquartile range, 13-73) days. Risk of requiring at least one re-amputation was 41% (TM), 25% (TT), and 9% (TF). Risk factors associated with requiring re-amputation included chronic obstructive pulmonary disease, elevated white blood cell count, abnormal ankle brachial index (ABI), history of revascularisation, and alcohol misuse. TM patients who had diabetes only (HR 1.9; 95% CI 1.4-2.5), diabetes with an abnormal ankle brachial index (ABI) score (HR 2.4; 95% CI 1.8-3.2), and kidney failure (HR 1.7; 95% CI 1.3-2.1) were at the greatest risk of re-amputation. TT amputees who were smokers were also at an increased risk (HR 1.4; 95% CI 1.2-1.6). CONCLUSION This research identified important risk factors for failure of primary healing and need for re-amputation at the TM and TT level. If considering a TM amputation, caution should be exercised in patients with diabetes, in particular those with an abnormal ABI and/or renal failure. At the TT level, caution should be exercised in those who smoke.
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Affiliation(s)
- Daniel C Norvell
- CLiMB, Centre for Limb Loss and MoBility, VA Puget Sound Health Care System, Seattle, WA, USA.
| | - Joseph M Czerniecki
- CLiMB, Centre for Limb Loss and MoBility, VA Puget Sound Health Care System, Seattle, WA, USA; Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
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Marquez M, Kowgier M, Journeay W. Comorbidity and Non-prosthetic Inpatient Rehabilitation Outcomes After Dysvascular Lower Extremity Amputation. Can Prosthet Orthot J 2020; 3:33916. [PMID: 37614663 PMCID: PMC10443504 DOI: 10.33137/cpoj.v3i1.33916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Accepted: 05/08/2020] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Dysvascular amputations arising from peripheral vascular disease and/or diabetes are common. Patients who undergo amputation often have additional comorbidities that may impact their recovery after surgery. Many individuals undergo post-operative inpatient rehabilitation to improve their non-prosthetic functional independence. Thus far, our characterization of comorbidity in this population and how it is associated with non-prosthetic inpatient functional recovery remains relatively unexplored. OBJECTIVE The objective of this study was to describe comorbidities, using the Charlson Comorbidity Index (CCI), and to examine associations between comorbidity and functional outcomes in a cohort of patients with dysvascular limb loss undergoing non-prosthetic inpatient rehabilitation. METHODOLOGY A retrospective cohort design was used to analyze a group of 143 patients with unilateral, dysvascular limb loss who were admitted to inpatient rehabilitation. Age, sex, amputation level, amputation side, length of stay (LOS), time since surgery, Functional Independence Measure (FIM) scores (Total and Motor at admission and discharge), and CCI scores were collected. FINDINGS The data showed that neither total or specific comorbidities were associated with functional outcomes or LOS in this cohort and rehabilitation model. Multivariate analysis demonstrated an inverse relationship with age and FIM scores, where increased age was associated with lower Total and Motor FIM at admission and discharge. Comorbidities were not associated with functional outcomes. Dementia was negatively associated with FIM scores, however this requires more study given the low number of patients with dementia in this cohort. CONCLUSION These data suggest that regardless of burden of comorbidity or specific comorbidities that patients with dysvascular limb loss may derive similar functional benefit from post-operative non-prosthetic inpatient rehabilitation.
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Affiliation(s)
- M.G Marquez
- Department of Anatomy and Cell Biology, McGill University, Montreal, Canada
| | - M Kowgier
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - W.S Journeay
- Providence Healthcare – Unity Health Toronto, Toronto, ON, Canada
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of Toronto, Toronto, Canada
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Mayo A, Cimino S, Hitzig S. A Depiction of Rehabilitation Patients 65 Years and Younger With Dysvascular Lower Extremity Amputation. Can Prosthet Orthot J 2019; 2:31950. [PMID: 37614808 PMCID: PMC10443480 DOI: 10.33137/cpoj.v2i1.31950] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Accepted: 02/21/2019] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The majority of lower limb amputations (LLA) in Canada are dysvascular due to complications of diabetes and/or vascular disease. Traditionally dysvascular amputations have occurred in the elderly. With younger onset of adult diabetes, amputations are now occurring in non-geriatric populations. An understanding of younger patients with dysvascular LLA is needed to determine their risk factors, and unique health and psychosocial challenges. OBJECTIVES To obtain a depiction of the key demographic and impairment characteristics of adults 65 years and younger with dysvascular LLA undergoing inpatient rehabilitation. METHODOLOGY A retrospective chart review was completed on inpatient adult amputation rehabilitation patients over a five year period. Data extracted included socio-demographics, Functional Independence Measure (FIM) scores, comorbidities, and discharge outcomes. FINDINGS One hundred and forty-three patients who were 65 years and younger were included, which represented almost a quarter of all admissions. Most patients were male (79%) with an average age of 55 years old (SD=8). The majority (72%) were unemployed. The mean number of co-morbidities was 5.2 (SD=8.2). Individuals discharged home (n=122) had higher (p<0.05) FIM scores than those readmitted to acute care or discharged to long-term care (n=20). CONCLUSIONS Similar to the literature on older dysvascular LLA patients, our study found high rates of disability and co-morbidities in younger patients with dysvascular LLA, which might impact their ability to work. Given these challenges, better amputation prevention strategies and targeted rehabilitation programming for this population are needed.
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Affiliation(s)
- A.L. Mayo
- St. John’s Rehab, Sunnybrook Health Sciences Centre, Toronto, Canada
- Faculty of Medicine, University of Toronto, Toronto, Canada
| | - S.R. Cimino
- St. John’s Rehab Research Program, Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, Canada
| | - S.L. Hitzig
- St. John’s Rehab Research Program, Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, Canada
- Rehabilitation Sciences Institute, Faculty of Medicine, University of Toronto, Toronto, Canada
- Department of Occupational Science & Occupational Therapy, Faculty of Medicine, University of Toronto, Toronto, Canada
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Abstract
In 2005, 1.6 million people were estimated to be living with limb loss; by 2050, the rate is expected to double to 3.6 million in the United States. Past data have shown that the rates of dysvascular amputations were increasing. However, recent studies looking at single diseases of peripheral arterial disease and diabetes mellitus show amputations related to these conditions are now decreasing. The authors think that it may not be a single disease process but rather the cumulative illness burden that is leading to amputations. In addition to cause, age, gender, and race continue to play a role in limb loss.
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Affiliation(s)
- Priya Varma
- Department of Physical Medicine and Rehabilitation, University of Pennsylvania, 1800 Lombard Street, 1st floor, Philadelphia, PA 19146, USA
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