Reamputation, mortality, and health care costs among persons with dysvascular lower-limb amputations

OBJECTIVES: To examine 12-month reamputation and mortality rates as well as acute and postacute medical care costs among a large cohort of persons with dysvascular amputations. DESIGN: Retrospective cohort study. SETTING: General community. PARTICIPANTS: Medicare beneficiaries identified from the Centers for Medicare and Medicaid Services data as undergoing a lower-limb amputation secondary to vascular disease in 1996. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Twelve-month reamputation and mortality rates, and acute and postacute medical care costs, by initial amputation level and presence or absence of diabetes. RESULTS: A total of 3565 persons, corresponding to 71,300 Medicare beneficiaries nationwide, were identified from the claims data as undergoing lower-limb amputations in 1996. Twenty-six percent of them required subsequent amputation procedures within 12 months, and more than one third died within 1 year of their index amputation. Acute and postacute medical care costs associated with caring for beneficiaries with a dysvascular amputation exceeded $4.3 billion yearly. There were marked differences in patient characteristics, progression of amputation to higher levels, service use, and mortality among dysvascular amputees with and without a comorbidity of diabetes. Diabetic amputees were younger than those without diabetes; they were also more likely to be men, to have more comorbidities, and to have undergone their first amputation at an earlier age than persons with dysvascular amputations who did not have diabetes. Although diabetic amputees were less likely to die within 12 months of the index amputation, they died at a significantly younger age than their nondiabetic counterparts. Progression to a higher level of limb loss occurred most frequently (34.5%) among persons with an initial foot or ankle amputation. Diabetic amputees were more likely than nondiabetic amputees to experience progression to a higher amputation level for all initial amputation levels. CONCLUSIONS: This study provides information that can be used by physicians when counseling patients about expected outcomes of dysvascular amputations at different levels.     

Traumatic amputation. Mechanisms of injury, treatment, and rehabilitation

Traumatic amputations are one of many injuries that can occur to the body's musculoskeletal systems. Degloving, partial and total amputations are common types of traumatic injuries. Since traumatic amputations are very life threatening, emergency treatment must be initiated quickly and directed toward profuse blood loss and potential hypovolemia. Not only do traumatic amputees undergo extreme physiological changes, but they must also encounter the psychological trauma of an amputation. Due to a loss of body part(s) and alteration in body image, the amputee often experiences the stages of grieving which may take months and years to resolve. Extensive rehabilitation with the use of an interdisciplinary team approach is one of the most successful ways to return the amputee to the work place. A combination of occupational therapy, physical therapy, vocational rehabilitation and psychological support generally promote a sense of well being and return the traumatic amputee to a level of independence.     

Discharge destination after dysvascular lower-limb amputations

OBJECTIVE: To examine postacute care rehabilitation services use after dysvascular amputation. DESIGN: State-maintained hospital discharge data from the Maryland Health Services Cost Review Commission were analyzed. SETTING: Maryland statewide hospital discharge database. PARTICIPANTS: Persons discharged from nonfederal acute care hospitals from 1986 to 1997 with a procedure code for lower-limb amputation (ICD-9-CM code 84.12-.19), excluding toe amputations. Those persons with amputations due to trauma, bone malignancy, or congenital anomalies were excluded. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Postacute care service utilization. RESULTS: There were 16,759 discharges with an amputation procedure over this period. The average age was 69.3+/-14.3 years, and 51.9% were men. Black persons comprised 42.4% of the sample. Diabetes was present in 42.0%, and peripheral vascular disease was noted for 66.1% of amputees. Amputations were at the foot (19.4%), transtibial (38.1%), and transfemoral (42.4%) levels. The largest proportion (40.6%) of patients was discharged directly home after acute care, 37.4% went to a nursing home, 9.2% went home with home care, and 9.6% were discharged to an inpatient rehabilitation unit. From 1986 to 1997, there were downward trends in the rate of discharges directly home and corresponding upward trends in nursing home and inpatient rehabilitation dispositions. CONCLUSIONS: Inpatient rehabilitation use is infrequent after dysvascular amputation. Prospective studies are necessary to examine outcomes for persons receiving rehabilitation services in different care settings to define the optimal rehabilitation venue for functional restoration.     

Prosthetic rehabilitation of geriatric amputee patients: a follow-up study

During a four-year period, 116 lower extremity amputee patients older than 65 years were evaluated and treated by our department. Fifty-nine patients with below-knee (BK) amputations, 22 with above-knee (AK) amputations, and 15 with bilateral amputations were fitted with prostheses and trained in their use. A follow-up study on all patients was done at an average of 22 months after they had completed their training program but not earlier than after 6 months. Of all BK amputees who had been fitted with a prosthesis, 73% were using it fulltime and as their main mode of locomotion; 25% were using it part of the time. The results were less favorable for AK and for bilateral amputee patients: 50% of AK amputees and 33% of the bilateral amputees had become fulltime users of their prostheses. Age alone was not a major determining factor in success or failure of prosthetic rehabilitation. Failures usually were due to concurrent medical disease or mental deterioration. The study indicates that the effort and expense of fitting and training geriatric patients with prostheses may be well worthwhile.     

Prevalence and aetiology of amputation in Kolkata,India: A retrospective analysis

This study is an epidemiological report of the medical records of amputees in Kolkata, West Bengal, India. This retrospective study included 155 amputees who had undergone an amputee physiotherapy rehabilitation program and prosthetic training at the National Institute for the Orthopaedically Handicapped in Kolkata, West Bengal, from January 2008 to January 2010. The paper reports on the prevalence, aetiology, and levels of amputation. The causes of amputation classified under vascular diseases, trauma, and carcinoma are discussed. The most common cause of amputation was trauma (70.3%), the second most common cause being peripheral vascular disease. Lower limb amputation, more common than amputation at the upper limb, accounted for 94.8% of all amputations.     

Racial differences in the incidence of limb loss secondary to peripheral vascular disease: a population-based study

OBJECTIVE: To evaluate racial differences in limb loss caused by peripheral vascular disease in a diverse, statewide population. DESIGN: Retrospective analysis of a cohort of dysvascular amputees. SETTING: Maryland State Hospital Discharge Data from 1986 to 1997. PARTICIPANTS: Persons with a procedure code for lower-limb amputation (ICD9-CM code 84.11-.19) were identified. Patients with limb loss because of trauma, malignancy, or congenital anomalies were excluded. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Incidence rates standardized for age, gender, and race; and time trends. RESULTS: There were 27,149 discharges with dysvascular amputations, yielding an average annual rate of 44.3 per 100,000 persons. Incidence rates for dysvascular amputations increased from 41.4 per 100,000 in 1986 to 47.2 per 100,000 in 1997. For all levels of amputation, annual incidence rates among African Americans were considerably higher than those of other persons. African Americans were 2 to 4 times more likely to lose a lower limb than white persons of similar age and gender. CONCLUSIONS: Rising rates of lower-limb amputations in the general population combined with disproportionately higher rates among African Americans are concerning and warrant further investigation into their underlying causes and consequences.     

Postacute care services use for dysvascular amputees: a population-based study of Massachusetts

OBJECTIVE: Rehabilitation and other postacute care services utilization for persons with a lower limb amputations due to dysvascular disease is important information for physiatrists, therapists, patients, and health-policy planners. The purpose of this study was to examine rates of inpatient rehabilitation services use in a statewide population. DESIGN: Massachusetts Hospital Case Mix and Charge Data for 1997 were used to select persons with dysvascular limb amputations. Disposition locations after amputation were analyzed. RESULTS: There were 2487 persons who incurred a lower limb amputation, with the majority being white (94%), male (58%), and elderly (69 yrs). Most had diabetes (62%) or peripheral vascular disease (51%). The most common disposition was home (33%), with 16% receiving inpatient rehabilitation after amputation. Persons with transtibial and transfemoral amputations were the most likely to receive inpatient rehabilitation, 28% and 19% respectively. CONCLUSIONS: Sixteen percent of dysvascular amputees received inpatient rehabilitation services. This was higher than the 1997 rate for Maryland (12%) and suggests geographic differences in services utilization. Prospective studies are necessary to examine outcomes for persons receiving rehabilitation services in different care settings to define the optimal rehabilitation venue for functional restoration. Development of more specific International Classification of Diseases, Ninth Revision-Clinical Modification codes for dysvascular amputations would further research and public policy efforts.     

Prosthetic rehabilitation in bilateral high above elbow amputation

Rehabilitation in patients with bilateral high above elbow amputation presents a considerable prosthetic problem. A patient with high upper arm amputations after a high-voltage injury is presented. He was successfully fitted with multifunctional myoelectric hand prostheses. The problems in rehabilitation of adult bilateral arm amputees are discussed and the value of fitting these patients with electrically powered prostheses is assessed. The balance between technical and clinical aspects is discussed in relation to patient acceptance. In our case good acceptance and functional benefit was noted. The fact is stressed that the bilateral upper extremity amputee can regain considerable physical function with the fitting of suitable prostheses, even if the limb remnants are short and provide little or no function. An extensive team approach at specialized centres will favour the results.     

Gait analysis in amputees

There are marked differences from normal in both AK and BK gait. Forward velocity of walking is significantly lower in the amputee and is lower in the AK than in the BK subjects. Traumatic AK amputees ambulate with time-distance parameters of velocity, cadence, stride length and gait cycle which are all two standard deviations below normal. The same parameters for the traumatic BK amputee are only one standard deviation below normal. The symmetry of walking seen in the normal subject is not present in the lower extremity amputee. Measurements of single limb support times and motion analysis of the lower extremities as well as of the head, arms and trunk bear this out. This asymmetry of motion increases the excursion of the center of mass during each cycle and thereby increases the energy cost of ambulation. Energy cost of amputee gait often places the dysvascular AK amputee at his limits and strains other amputees severely. Further research is necessary to enable amputees to approach the walking capabilities of normal people.     

Evaluation of rehabilitated bilateral lower limb amputees – an Indian study

Objective: This study assessed activities of daily living (ADL) and ambulation of rehabilitated bilateral lower limb amputees with relation to their level of amputation in an Indian setting. Subjects and Methods: This retrospective study of 25 subjects comprised 12 bilateral Trans-femoral (TF) amputees, 8 bilateral Trans-tibial (TT) amputees and 5 a combination of ipsilateral Trans-femoral and contralateral Trans-tibial amputation. All subjects were contacted by post/telephone, were physically examined and assessed at the Orthopaedic clinic at a mean follow-up of 6.6 years. Physical rehabilitation was evaluated using ADL score and by grading the level of ambulation. Results: ADL scores showed no significant difference according to level of amputation (p > 0.05), but the scores of prosthetic users were significantly higher than non-prosthetic users (p?=?0.002). Only 11/25 amputees became prosthetic ambulators and most (50%, 6/12) were TF amputees. All prosthetically rehabilitated subjects were mobilising with their prostheses at follow-up and graded as unlimited or limited community ambulators. Conclusion: Though it is well documented that the potential for successful rehabilitation is best for bilateral TT amputees, given the subjects’ economic constraints, higher prosthesis rehabilitation among bilateral TF amputees indicates that successful rehabilitation is possible in most subjects irrespective of the level of amputation.

Implications for Rehabilitation

• Rehabilitation of a bilateral lower limb amputee requires a team effort and constitutes a very difficult challenge for the subject.

• Low prosthesis ownership is largely due to subjects’ inability to afford a pair of prostheses in a developing country like India.

• Activities of daily living improve significantly with use of prostheses.

• Though it is well documented that the potential for successful rehabilitation is best for a bilateral TT amputee, higher prosthesis rehabilitation among bilateral TF subjects in this study indicates that successful rehabilitation is possible in most subjects irrespective of the level of amputation.

     

Rehabilitation of patients with end-stage renal failure after lower extremity amputation

Four patients with end-stage renal failure on maintenance hemodialysis and one patient with near end-stage renal failure received inpatient rehabilitation following lower extremity amputation. All were prosthetically restored. Three of the patients had bilateral below-knee amputations and were ambulatory at the time of discharge, including the patient with near end-stage renal failure who was on maintenance hemodialysis at follow-up. One unilateral below-knee amputee was also ambulatory at discharge. The other unilateral below-knee amputee had an ulcer on the other foot and used a pylon for transfers only. To assess the prevalence of patients on maintenance hemodialysis with lower extremity amputations, a survey of 310 patients at four dialysis units was performed. Of the 310 patients 2.9 percent had at least one amputated lower extremity and 1.0 percent had bilateral lower extremity amputations. Preliminary data and the potential for functional results following prosthetic restoration suggest the need for further research concerning prosthetic restoration in the lower extremity amputee with end-stage renal failure.     

Postoperative management of lower extremity amputations

Postoperative management of the lower extremity amputation continues to evolve as a crucial first step in amputee rehabilitation. Although the major goals of early rehabilitation remain fairly constant, external forces continually pressure the rehabilitation team to complete these goals within shorter time frames. The atmosphere of rapid rehabilitation for amputees stresses return to normal function as quickly as possible. Early ambulation is the obvious goal for most new amputees.     

Management of the multiple limb amputee

Issue : Multiple limb amputations involving at least one upper extremity are very uncommon. The amputation of both an upper and lower limb is even more uncommon. Due to the rarity of these amputations therapists are uncertain regarding the most appropriate treatment methods. While the majority of the protocols used for single limb amputations are appropriate for these multiple limb amputees, there are differences. Loss of multiple limbs creates a problem of overheating for the individual. Loss of an arm and leg results in difficulty donning the prostheses and difficulty using crutches and parallel bars during mobilization. Method : A review is given of 16 multiple limb amputees seen in our rehabilitation centre in the last 15 years. Return to work was seen in one third and was not related to the number of the amputations. A higher proportion of these multiple limb amputations occur through alcoholism or attempted suicide behaviour than occurs with either single upper limb amputations or lower limb amputations. This existing behaviour can create a management problem for the rehabilitation team during rehabilitation. Conclusion : Guidelines as to appropriate prosthetic and preprosthetic care are provided to assist the practitioner who has the acute and long term care of these patients. All multiple limb amputees should be referred to a specialized rehabilitation centre to discuss prosthetic options and long term rehabilitation requirements. This paper does not discuss bilateral lower limb amputations when not combined with an upper limb amputation.     

Rehabilitation Outcome in Patients With Lower Limb Amputations Because of Arterial Occlusive Disease: Is it Worth Trying for the Lowest Possible Amputation Level? A Prospective Study

A policy of maximizing the ratio of below-knee to above-knee amputations in patients with severe nonsalvageable limb ischemia is followed. The value of this policy is examined. All the patients that were amputated in our department between 1995 and 1997 were followed up for 2 years after the operation. We correlated the amputation level with 6 different parameters: primary or secondary amputation, perioperative mortality, 2-years mortality, amputation stump healing, artificial limb fitment, and rehabilitation outcome. The results were analyzed statistically. A total of 64 patients were included in the study. The revision rate was 38% in below-knee amputees and 4% in above-knee amputees. The perioperative mortality was 22%. Two years after operation, the limb fitment rate in below-knee amputees was 95% and in above-knee amputees was 64%. The overall artificial limb fitment rate was 50%. A total of 47.6% of the living patients were capable to walk out of their house. Artificial limb fitment and rehabilitation status are greater after a below-knee than an above-knee amputation. Although the morbidity may be higher in below knee procedures, it is worth trying for the lowest level of amputation because of the better rehabilitation results in these patients.     

Management of the multiple limb amputee

Issue : Multiple limb amputations involving at least one upper extremity are very uncommon. The amputation of both an upper and lower limb is even more uncommon. Due to the rarity of these amputations therapists are uncertain regarding the most appropriate treatment methods. While the majority of the protocols used for single limb amputations are appropriate for these multiple limb amputees, there are differences. Loss of multiple limbs creates a problem of overheating for the individual. Loss of an arm and leg results in difficulty donning the prostheses and difficulty using crutches and parallel bars during mobilization.

Method : A review is given of 16 multiple limb amputees seen in our rehabilitation centre in the last 15 years. Return to work was seen in one third and was not related to the number of the amputations. A higher proportion of these multiple limb amputations occur through alcoholism or attempted suicide behaviour than occurs with either single upper limb amputations or lower limb amputations. This existing behaviour can create a management problem for the rehabilitation team during rehabilitation.

Conclusion : Guidelines as to appropriate prosthetic and preprosthetic care are provided to assist the practitioner who has the acute and long term care of these patients. All multiple limb amputees should be referred to a specialized rehabilitation centre to discuss prosthetic options and long term rehabilitation requirements. This paper does not discuss bilateral lower limb amputations when not combined with an upper limb amputation.     

Somatosensation, circulation and stance balance in elderly dysvascular transtibial amputees

OBJECTIVE: To establish the relationship between poor lower limb somatosensory and circulatory status with standing balance, falls history, age and mobility level in dysvascular transtibial amputees (TTAs). DESIGN: Within-subjects evaluation of somatosensation, circulation and stance balance measures in dysvascular transtibial amputees. SETTING: Physiotherapy department of a tertiary metropolitan hospital in Australia. PARTICIPANTS: Twenty-two community-dwelling unilateral dysvascular transtibial amputee volunteers, aged between 54 and 86 recruited from a metropolitan hospital outpatient amputee clinic. MAIN OUTCOME MEASURES: Lower limb vibration sense, light touch sensation and circulatory status were related to centre of pressure excursion during quiet stance, dynamic balance measures of forward and lateral reach distance, and demographic information such as falls history and mobility level. RESULTS: Overall, poor somatosensory status was associated with poor stance balance. There was an association between poor vibration and circulation and increased centre of pressure excursion in quiet stance and reduced reach distance, whereas poor light touch was linked with even weight-bearing in quiet stance. Poor vibration sense was associated with a history of frequent falls. CONCLUSIONS: Compromised lower limb somatosensation and circulation was linked with poor balance and a history of frequent falls in the elderly dysvascular amputee population.     

Adult acquired major upper limb amputation in Norway: prevalence,demographic features and amputation specific features. A population-based survey

Purpose.?To estimate the prevalence of adult acquired major upper limb amputation in Norway. To describe this amputee population regarding demographic features and amputation specific features. To compare our data to data collected internationally.

Method.?Population-based cross-sectional study on adult upper limb amputees with acquired limb loss through or proximal to the radio-carpal joint. Patients were found in the databases of the two companies in Norway that make upper limb prostheses and in the medical records of three of the largest Norwegian hospitals. Data were collected by postal questionnaires.

Results.?We estimated a population prevalence of 11.6 per 100,000 adults (n == 416). Our survey was not 100%% comprehensive and the estimate is conservative. The amputees were predominantly men with traumatic, unilateral, distal amputations at a young age. There were significant gender- and amputation level differences in cause. Most amputees had used prostheses. About four in ten were in paid employment.

Conclusions.?Our findings are mainly consistent with earlier studies from other countries. Implications of our findings related to the planning of future health care for these patients are outlined, including suggestion of regional multidisciplinary rehabilitation emphasising occupational rehabilitation and focus on preventive measures. Potential areas of follow-up are suggested.     

New perspectives on nursing lower limb amputees

New perspectives on nursing lower limb amputees arise from the author's researches into amputee rehabilitation and a summary of other recent research findings. These are dealt with in the context of basic amputee treatment and the nursing process. There is new material on the psychological and neurological sequelae of amputation, the practical problems of loss of a limb and the prosthetic dimension of treatment. The patients' reactions to lower limb amputation were found to vary from intense grief to intense relief, many noting it to be of minor or moderate consequence. The model of sudden and shocking loss is largely incorrect. Attention is drawn to an unrecognized ordinariness which should become part of amputee nursing. Patients have many practical problems. These are social and economic, personal and domestic. The ward environment is unsuited to these needs but, working closely with therapists, nurses can do much to facilitate amputee rehabilitation. The modern purpose of amputation surgery is prosthetic replacement. Nurses should be working with some urgency towards uniting patient and prosthesis. Pain and discomfort are underestimated and research shows them to be a major characteristic of amputation continually and for many years after surgery. A variety of pain syndromes are involved.     

Dysvascular amputations and long-term survival in a 20-year follow-up study

The long-term survival of 21,520 amputations with a 20-year observation period has been calculated. The material includes 5823 amputees with diabetes and 15 697 dysvascular cases without diabetes. The mean age of the amputees with diabetes is 70.6 years and that of the group without diabetes is 75 years. Kaplan-Meier plots of the absolute mortality in relation to age, gender and level of amputation reveals a significant poor prognosis. Among the diabetic individuals, 30% were dead within 6 months and among the non-diabetic individuals 38.4% were dead during this period. The results from this study with a 20-year follow-up period are compared with the corresponding figures for a 12-year period and no clinically important differences are found.