Phantom pain and risk factors: a multivariate analysis

Phantom pain has been given considerable attention in literature. Phantom pain reduces quality of life, and patients suffering from phantom pain make heavy use of the medical system. Many risk factors have been identified for phantom pain in univariate analyses, including phantom sensations, stump pain, pain prior to the amputation, cause of amputation, prosthesis use, and years elapsed since amputation. Multivariate analyses are lacking in the literature and, therefore, no estimation of an overall risk for phantom pain can be made. The aim of this study was to analyze risk factors in a multivariate analysis in 536 subjects (19% upper limb amputees and 81% lower limb amputees). These subjects filled out a questionnaire in which the following items were assessed; side, date, level, and reason of amputation, pre-amputation pain, presence or absence of phantom pain, phantom sensations and or stump pain, and prosthesis use. The prevalence of phantom pain was 72% (95% CI: 68 to 76%) for the total group, 41% (95% CI: 31 to 51%) in upper limb amputees and 80% (95% CI: 76 to 83%) in lower limb amputees. The most important risk factors for phantom pain were “bilateral amputation” and “lower limb amputation.” The risk for phantom pain ranged from 0.33 for a 10-year-old patient with a distal upper limb amputation to 0.99 for a subject of 80 years with a bilateral lower limb amputation of which one side is an above knee amputation.     

Residual limb osteomyelitis: A case series from a national prosthetic centre

Purpose. To examine the impact of residual limb osteomyelitis (RLO) on the rehabilitation of lower limb amputees.

Method. Retrospective review of the casenotes of patients with RLO. Information sought included details of amputation, clinical features of investigations for and management of RLO and its effect on rehabilitation.

Results. There were seven transfemoral and three transtibial amputees. Indications for amputation were vascular disease in nine cases, trauma in one. In each case, delayed wound healing or residual limb pain prompted radiological, hematological and microbiological investigations. Average time between amputation and diagnosis was 187 days. One patient died before treatment commenced. Two transtibial amputees were treated with intravenous antibiotics while rehabilitating using pylons. The remaining seven transfemoral amputees required surgical intervention and intravenous antibiotics. Five achieved independent ambulation following modification to or replacement of the originally cast prosthesis, averaging 408 days between amputation and commencement of rehabilitation. Two patients have not engaged in rehabilitation.

Conclusion. RLO delays rehabilitation and has significant financial implications, incurred by prolonged hospitalisation, radiological investigations and prosthetic modifications. RLO should be considered in any case of delayed wound healing or residual limb pain in amputees, as earlier diagnosis may reduce the time to commencement of rehabilitation and subsequent independent ambulation.     

Mortality and preoperative cardiac function in vascular amputees: an N-terminal pro-brain natriuretic peptide (NT-proBNP) pilot study

OBJECTIVE: To determine preoperative ventricular function in vascular amputees by measuring N-terminal pro-brain natriuretic peptide (NT-proBNP) and to analyse the relationship between NT-proBNP levels and 30-day postoperative mortality. DESIGN: Prospective pilot study. SUBJECTS AND METHODS: In 19 patients planned for a lower limb amputation for non-reconstructable peripheral arterial disease NT-proBNP was measured the day before amputation. RESULTS: Four amputees died within 30 days after the amputation. In 17 of 19 patients NT-proBNP values were found more than 2 standard deviations above the age corrected reference value. Pre-amputation NT-proBNP levels did not differ significantly between non-survivors and survivors (P = 0.162). CONCLUSION: Preoperative NT-proBNP levels are not significantly related to 30-day mortality after lower limb amputation procedure. Preoperative NT-proBNP levels are very high, indicating that serious ventricular dysfunction may be present in vascular amputees.     

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.     

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.     

The menacing phantom: What pulls the trigger?

Phantom phenomena are frequent following amputation, but how this often painful experience is modified or triggered by spontaneous events or sensations often puzzles amputees and clinicians alike. We explored triggers of phantom phenomena in a heterogeneous sample of 264 upper and lower limb adult amputees with phantom sensations. Participants completed a structured questionnaire to determine the prevalence and nature of the triggers of phantom phenomena. The four categories of triggers identified include: (a) a quarter of participants experiencing psychological, emotional or autonomic triggers; (b) half experiencing behavioral triggers, “forgetting” the limb's absence and attempting to use the phantom; (c) one‐fifth experiencing weather‐induced triggers; and (d) one‐third experiencing sensations referred from parts of the body. Upper limb amputees; and were more likely to experience weather‐induced phantom phenomena than lower limb amputees; and upper and lower limb amputees were equally likely to experience referred sensations from the genitals, contradicting the homuncular remapping hypothesis. Traumatic amputees were more likely to report emotional triggers. Further, while those with emotional triggers exhibited poorer acceptance of the limitations of amputation, they were more likely to employ adaptive coping mechanisms. Finally, habitual “forgetting” behaviors were most common soon after amputation, whereas other more adaptive schemata (e.g., self‐defense) were equally likely to be performed at any time following amputation. Various likely inter‐related mechanisms are discussed in relation to phantom triggers. Ultimately, optimizing stump and neuroma management, as well as restoring function of central networks for pain, limb movement, and amputation‐related memories, should help manage spontaneously triggered phantom phenomena.     

Neurology (48)

Phantom pain and phantom sensations in upper limb amputees: an epidemiological study. (University Hospital Groningen, Groningen, The Netherlands) Pain 2000;87:33–41.
This study determined the prevalence and factors associated with phantom pain and phantom sensations in upper limb amputees in The Netherlands. Additionally, the relationship between phantom pain, phantom sensations, and prosthesis use in upper limb amputees was investigated. One hundred twenty-four upper limb amputees participated in the study. Subjects were asked to fill out a self-developed questionnaire scoring the following items: date, side, level, and reason of amputation, duration of experienced pain before amputation, frequencies with which phantom sensations, phantom pain, and stump pain are experienced, amount of trouble and suffering experienced, respectively, related to these sensations, type of phantom sensations, medical treatment received for phantom pain and/or stump pain, and the effects of the treatment, self medication, and prosthesis use. The response rate was 80%. The prevalence of phantom pain was 51%, of phantom sensations 76%, and of stump pain 49%; 48% of the subjects experienced phantom pain a few times per day or more. Moderate to severe suffering from phantom pain was experienced by 64% of the respondents. A significant association was found between phantom pain and phantom sensations (relative risk 11.3) and between phantom pain and stump pain (relative risk 1.9). No other factors associated with phantom pain or phantom sensations could be determined. Only 4 patients received medical treatment for their phantom pain. Phantom pain is a common problem in upper limb amputees that causes considerable suffering for the subjects involved. Only a small number of subjects are treated for phantom pain. Conclude that further research is needed to determine factors associated with phantom pain.     

Phantom pain and phantom sensations in upper limb amputees: an epidemiological study

Phantom pain in subjects with an amputated limb is a well-known problem. However, estimates of the prevalence of phantom pain differ considerably in the literature. Various factors associated with phantom pain have been described including pain before the amputation, gender, dominance, and time elapsed since the amputation. The purposes of this study were to determine prevalence and factors associated with phantom pain and phantom sensations in upper limb amputees in The Netherlands. Additionally, the relationship between phantom pain, phantom sensations and prosthesis use in upper limb amputees was investigated. One hundred twenty-four upper limb amputees participated in this study. Subjects were asked to fill out a self-developed questionnaire scoring the following items: date, side, level, and reason of amputation, duration of experienced pain before amputation, frequencies with which phantom sensations, phantom pain, and stump pain are experienced, amount of trouble and suffering experienced, respectively, related to these sensations, type of phantom sensations, medical treatment received for phantom pain and/or stump pain, and the effects of the treatment, self medication, and prosthesis use. The response rate was 80%. The prevalence of phantom pain was 51%, of phantom sensations 76% and of stump pain 49%; 48% of the subjects experienced phantom pain a few times per day or more; 64% experienced moderate to very much suffering from the phantom pain. A significant association was found between phantom pain and phantom sensations (relative risk 11.3) and between phantom pain and stump pain (relative risk 1.9). No other factors associated with phantom pain or phantom sensations could be determined. Only four patients received medical treatment for their phantom pain. Phantom pain is a common problem in upper limb amputees that causes considerable suffering for the subjects involved. Only a minority of subjects are treated for phantom pain. Further research is needed to determine factors associated with phantom pain.     

A preliminary examination of the relationship between employment,pain and disability in an amputee population

PURPOSE: To examine amputees' use of health, social and voluntary services and to assess the perceived benefit of such use. Additionally, to examine the degree and type of changes made in occupational status in relation to both pain and prosthetic limb use following amputation. METHOD: A survey methodology was employed to examine the services used by amputees and their experiences of occupational change. A response rate of 62% resulted in 315 amputees completing the study. The study sample was drawn from patient records at three artificial limb and appliance centres in the central belt of Scotland. RESULTS: Overall the data suggest that few amputees make use of the available services for general amputation-related problems. Even fewer services were utilized for phantom limb pain or for other pain problems. Moreover, of those services that were used, very few were reported as being helpful. Amputation had severe consequences in terms of employment with 75% of the sample in employment prior to the amputation and only 43.5% remaining following amputation. Additionally, of those who did remain in employment there were a number of changes from pre- to post-amputation occupational classification. Employment status was related to the intensity of phantom limb pain, and daily prosthetic limb use with unemployed amputees reporting higher levels of pain and lower levels of prosthesis use. CONCLUSIONS: The study demonstrates the need for further research to determine whether the results obtained regarding occupational changes following amputation result pain, disability, amputees' attitudes towards themselves in relation to work, or to employers' attitudes and beliefs about their capabilities. Further research is also required to determine why so few amputees make use of available services and why, even when they are used, such services are not perceived as being helpful. Finally, there is a need to clarify the relationship between the extent of daily prostheses use, the experience of phantom limb pain and employment status.     

华西医院地震康复中心地震挤压伤截肢伤员的伤情分析

目的：了解地震截肢伤员的伤情特点,为其康复提供依据。方法：2008年6月～2008年12月31日,华西医院康复中心收治33例地震伤截肢患者,观察分析其伤情特点和康复治疗变化。结果：男性15例（45．5％）,女性18例（54．5％）;男性与女性的年龄相比无统计学意义（P〉0．05）;10～19岁青少年45．45％;学生51．52％,在职人员33．33％;重物砸伤占78．79％;膝上截肢占43．90％,上肢截肢21．95％,下肢78．05％;截肢合并症13种,肾功衰最多,占28．57％;手术次数平均2．55次;残端有2例愈合差,有14名培养出细菌;日常生活活动能力Barthel指数入院时50．92±16．76,出院时77．77±14．37。结论：地震截肢伤员伤情重,残端情况差,康复治疗效果明显。     

Prevalence of Phantom Phenomena in Congenital and Early-Life Amputees

Phantom limb pain (PLP) is a common consequence of the amputation of a limb. Persons with congenital limb absence (congenital amputees) or an acquired limb amputation at an early age seem to rarely experience PLP. However, the number of available studies and their sample sizes are low. In the present cross-sectional study, we assessed the presence of several phantom phenomena in a sample of 99 adult unilateral congenital amputees (con) of whom 34 had a limb correction later in life (limbc) and 153 adult participants with a unilateral amputation before the age of 6 years (subgroups: amputation between birth and 2 years (0-2y; n = 48), 3-4 years (3-4y; n = 46), and 5 to 6 years (5–6y; n = 59)). We found a higher prevalence and intensity of PLP in the 5-6y group compared to the other groups. Residual limb pain (RLP) intensity was higher in the 3 to 4 y and 5 to 6 y groups compared to the con group. Non-painful phantom limb sensation (PLS) intensity and telescoping intensity were higher in the 5 to 6 y group compared to the con and 0 to 2 y groups. Our results indicate that PLP prevalence as well as intensity is low when the limb loss happened before the age of 5 years.PerspectiveThe prevalence of phantom limb pain, residual limb pain, and non-painful phantom limb sensation in congenital amputees and participants with an amputation early in life is low. This might be due to the missing or reduced nociceptive input from the residual limb to the brain and higher development-associated adaptability of the somatosensory system.     

Amputation prevention by vascular surgery and podiatry collaboration in high-risk diabetic and nondiabetic patients. The Operation Desert Foot experience.

OBJECTIVE: To describe a unique multidisciplinary outpatient intervention for patients at high risk for lower-extremity amputation. RESEARCH DESIGN AND METHODS: Patients with foot ulcers and considered to be high risk for lower-extremity amputation were referred to the High Risk Foot Clinic of Operation Desert Foot at the Carl T. Hayden Veterans Affairs' Medical Center in Phoenix, Arizona, where patients received simultaneous vascular surgery and podiatric triage and treatment. Some 124 patients, consisting of 90 diabetic patients and 34 nondiabetic patients, were initially seen between 1 October 1991 and 30 September 1992 and followed for subsequent rate of lower-extremity amputation. RESULTS: In a mean follow-up period of 55 months (range 3-77), only 18 of 124 patients (15%) required amputation at the level of the thigh or leg. Of the 18 amputees, 17 (94%) had type 2 diabetes. The rate of avoiding limb loss was 86.5% after 3 years and 83% after 5 years or more. Furthermore, of the 15 amputees surviving longer than 2 months, only one (7%) had to undergo amputation of the contralateral limb over the following 12-65 months (mean 35 months). Compared with nondiabetic patients, patients with diabetes had a 7.68 odds ratio for amputation (95% CI 5.63-9.74) (P < 0.01). CONCLUSIONS: A specialized clinic for prevention of lower-extremity amputation is described. Initial and contralateral amputation rates appear to be far lower in this population than in previously published reports for similar populations. Relative to patients without diabetes, patients with diabetes were more than seven times as likely to have a lower-extremity amputation. These data suggest that aggressive collaboration of vascular surgery and podiatry can be effective in preventing lower-extremity amputation in the high-risk population.     

A foot care program for diabetic unilateral lower-limb amputees

OBJECTIVE: To assess the efficacy of a specialist foot care program designed to prevent a second amputation and to assess peripheral vascular disease (PVD) and peripheral neuropathy in diabetic unilateral lower-limb amputees. RESEARCH DESIGN AND METHODS: Investigations were carried out in 143 diabetic lower-limb unilateral amputees referred to a subregional rehabilitation center for prosthetic care from a catchment area of approximately 3 million people. Peripheral vascular and nerve assessment, education, and podiatry were provided for each patient. RESULTS: For the patients referred to the foot care program, there were no baseline differences between the patients who proceeded to a bilateral amputation (n = 22) and those who remained as unilateral amputees (n = 121) in their level of foot care knowledge and mean neuropathy scores. Mean ankle-brachial pressure index was significantly lower for the bilateral amputees (0.75 +/- 0.04) compared with the unilateral amputees (0.90 +/- 0.03, mean +/- SEM, P < 0.05), but there was no difference in the level of oxygen in the skin. However, the level of carbon dioxide was significantly lower in patients with bilateral amputation (24.21 +/- 2.16 vs. 31.20 +/- 0.85 mmHg, P < 0.03). Overall, the establishment of a specialist foot care program made no impact on contralateral limb amputation (22 of 143, 15.4%) compared with matched patients without the program (21 of 148, 14%) over a 2-year outcome period for each patient. CONCLUSIONS: PVD is more closely associated with diabetic bilateral amputation than neuropathy or level of foot care knowledge. Preventative foot care programs for diabetic unilateral amputees should therefore place greater emphasis on peripheral vascular assessment to identify patients at risk and on the development of timely intervention strategies.     

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.     

Prospective diary study of nonpainful and painful phantom sensations in a preselected sample of child and adolescent amputees reporting phantom limbs

OBJECTIVE: To prospectively study factors associated with the occurrence of phantom sensations and pains in a pre-selected sample of child and adolescent amputees reporting phantom limbs. DESIGN: Prospective diary study over 1 month. PARTICIPANTS: Fourteen child and adolescent amputees from 10-18 years of age who were missing a limb due to trauma (n = 12) or congenital limb deficiency (n = 2), and who had previously reported having phantom sensations and pain. MAIN OUTCOME MEASURE: Diary used to assess the occurrence of non-painful and painful phantom sensations. Items included age, sex, location and cause of amputation, past experience with stump pain and pre-amputation pain, and intensity, quality, duration, and triggers of the sensations and pains. RESULTS: Thirteen amputees reported having 104 incidents of non-painful phantom sensations with an average intensity of 4.17 (SD = 2.14) on a 0-10 rating scale. Fifty-three incidents of phantom pain with an average intensity of 6.43 (SD = 1.76) were recorded by 8 amputees. Both amputees with a congenital limb deficiency reported phantom phenomena. Girls reported more psychosocial triggers than did boys whereas boys were more likely than girls to report that they could not identify a trigger (P = 0.0001). Boys also reported a higher proportion of physical triggers than psychosocial triggers while there were no differences for girls (P = 0.0001). DISCUSSION: Child and adolescent amputees experience phantom sensations and pains on a regular basis over a 1-month period. Differences in triggers of phantom phenomena between boys and girls may be due to differences in activities, awareness, attribution, and willingness to report psychosocial triggers.     

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.

     

A preliminary examination of the relationship between employment,pain and disability in an amputee population

Purpose : To examine amputees' use of health, social and voluntary services and to assess the perceived benefit of such use. Additionally, to examine the degree and type of changes made in occupational status in relation to both pain and prosthetic limb use following amputation. Method : A survey methodology was employed to examine the services used by amputees and their experiences of occupational change. A response rate of 62% resulted in 315 amputees completing the study. The study sample was drawn from patient records at three artificial limb and appliance centres in the central belt of Scotland. Results : Overall the data suggest that few amputees make use of the available services for general amputation-related problems. Even fewer services were utilized for phantom limb pain or for other pain problems. Moreover, of those services that were used, very few were reported as being helpful. Amputation had severe consequences in terms of employment with 75% of the sample in employment prior to the amputation and only 43.5% remaining following amputation. Additionally, of those who did remain in employment there were a number of changes from pre- to post-amputation occupational classification. Employment status was related to the intensity of phantom limb pain, and daily prosthetic limb use with unemployed amputees reporting higher levels of pain and lower levels of prosthesis use. Conclusions : The study demonstrates the need for further research to determine whether the results obtained regarding occupational changes following amputation result pain, disability, amputees' attitudes towards themselves in relation to work, or to employers' attitudes and beliefs about their capabilities. Further research is also required to determine why so few amputees make use of available services and why, even when they are used, such services are not perceived as being helpful. Finally, there is a need to clarify the relationship between the extent of daily prostheses use, the experience of phantom limb pain and employment status.     

Why traumatic leg amputees are at increased risk for cardiovascular diseases

Background: Post-traumatic lower limb amputees have an increasedmorbidity and mortality from cardiovascular disease. Risk factorsfor this amplified morbidity and the involved pathophysiologicmechanisms have not been comprehensively studied. Methods: The MEDLINE database was reviewed, with case–controlledstudies and nested in cohort studies eligible for inclusionin this analysis. Results: Insulin resistance, psychological stress and patients’deviant behaviors are prevalent in traumatic lower limb amputees.Each of these factors may have systemic consequences on thearterial system and may contribute to the increased cardiovascularmorbidity in traumatic amputees. Abnormalities of arterial flowproximal to the amputation site may hold the explanation forthe linkage between the extent of leg amputation and the magnitudeof the cardiovascular risk: proximal leg amputation is associatedwith greater risk than distal amputation and bilateral amputationwith greater risk than unilateral amputation. This review focuseson hemodynamic culprits (shear stress, circumferential strain,reflected waves), hemodynamic consequences in proximity to theoccluded femoral artery and hemodynamic consequences at a distance. Conclusions: Coronary risk in lower limb amputees may be substantiallygreater than predicted by available algorithms, given that neitherhemodynamic nor psychological factors concern the current predictionmodels. It seems reasonable to take early prophylactic measuresin lower limb amputees by discouraging smoking, excessive alcoholconsumption and adherence to a low fat diet. Studies are neededto evaluate the optimal intensity of physical exercise effectson reflected pulse waves and their possible long-term consequences.Guidelines for optimal blood pressure, blood glucose and lipidcontrol in amputees need to be convened.