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PubMedDate not supplied

Lower limb amputation in three Australian states.

A study has been made of lower limb amputation statistics from morbidity data from the State Health Departments in New South Wales, Queensland, and Western Australia. The incidence of lower limb amputation in these three States was 22.6 in 1981, 22.5 in 1983, and 23.6 in 1984. Incidence was lowest in New South Wales and highest in Western Australia. Below-knee amputation was more common than above-knee except in Western Australia in the years 1981 and 1983. Males had slightly more amputations than females. Incidence increased steadily with age, rising rapidly after 55 years. Vascular disease was the most common cause of major amputation. Of malignancies, skin cancers, both malignant melanoma and other forms, were causes of major and minor amputations in addition to bone malignancies. These three Australian States have a lower incidence of amputation than the United Kingdom or Finland.

Age Factors↗
PubMed2004

Reduction of amputation rates among Alaska Natives with diabetes following the development of a high-risk foot program.

OBJECTIVE: The prevalence of diabetes is increasing rapidly among Alaska's Indian, Eskimo and Aleut populations. Approximately half the Native people with diabetes have no road access to hospitals or physicians, presenting a challenge in the attempt to prevent lower extremity amputation as a complication. In late 1998 funding became available for diabetes prevention and treatment among Native Americans. The tribal health corporations in Alaska decided to use a portion of this funding to implement a high-risk foot program to decrease the amputation rate. PROGRAM DESIGN: The program initially involved a surgical podiatrist who provided training to local staff and performed preventive and reconstructive surgery on several patients with impending amputations. The program then provided training for a physical therapist to become a certified pedorthist. This individual established the long-term maintenance phase of the program by conducting diabetic foot clinics routinely at the Alaska Native Medical Center, a referral center in Anchorage. He also travels to other regions of the state to provide training for village and hospital-based health care providers and to conduct field clinics. A system was established in a common database management program to track the patients' foot conditions. Patient education is emphasized. RESULTS: The overall amputation incidence among all Alaska Native patients with diabetes decreased from 7.6/1,000 in the pre-program period (1996 to 1998) to 2.7/1,000 in the post-program period (1999-2001) (p<.001). The rate among Aleuts, who previously had the highest amputation incidence, decreased from 17.4/1,000 to 3.1/1,000 over the same time periods (p<.001). Among people who had had diabetes at least 10 years, the overall amputation incidence decreased from 16.4/1,000 to 6.8/1,000 (p=.021); among Aleuts the rate fell from 24.5/1,000 to 2.6/1,000 (p=.01). CONCLUSIONS: Though longer follow-up is needed, these data suggest that even in populations living in isolated regions, diabetic amputations can be prevented by a coordinated system to identify high-risk feet and provide preventive treatment and education in the context of a comprehensive diabetes management program in an integrated health system.

Alaska↗
PubMed2000

The Boyd amputation as a treatment for osteomyelitis of the foot.

The Boyd amputation is a surgical technique used to treat osteomyelitis of the foot. This amputation is a technically more difficult procedure to perform than the Syme amputation, but it offers certain advantages. The Boyd amputation provides a more solid stump because it preserves the function of the plantar heel pad. Also, because a portion of the calcaneus is left and fused to the tibia, the weightbearing surface is more solid than in the case of a Syme amputation. The authors recommend a Boyd amputation as an alternative to a Syme or a below-the-knee amputation to treat patients with osteomyelitis of the forefoot and midfoot.

Amputation, Surgical↗
PubMed2002

Decreasing amputation rates in patients with diabetes mellitus. An outcome study.

The lower-extremity amputation rate in people with diabetes mellitus is high, and the wound failure rate at the time of amputation is as high as 28%. Even with successful healing of the primary amputation site, amputation of part of the contralateral limb occurs in 50% of patients within 2 to 5 years. The purpose of this study was to provide valid outcome data before (control period) and 18 months after (test period) implementation of a multidisciplinary team approach using verified methods to improve the institutional care of wounds. Retrospective medical chart review was performed for 118 control patients and 116 test patients. The amputation rate was significantly decreased during the test period, and the amputations that were required were at a significantly more distal level. No above-the-knee amputations were required in 45 patients during the test period, compared with 14 of 76 patients during the control period. These outcome data suggest that unified care is an effective approach for the patient with diabetic foot problems.

Amputation, Surgical↗
PubMed1999

Identifying diabetic patients at high risk for amputation.

Lower-extremity amputation is a much feared complication of diabetes mellitus; however, 40% to 50% of these amputations are preventable. Peripheral neuropathy has been implicated as a cause in some 82% of diabetic amputations. Patient education on foot care is often not enough to prevent foot ulceration and potential amputation. Health care providers can lower the incidence of lower extremity amputation by using a Semmes-Weinstein monofilament to identify protective sensation loss and quickly taking measures to prevent ulceration. Diabetes patients who have a history of foot deformity, ulceration, or amputation of any part of the foot should be referred for special shoes or orthotics. This article reviews the methods for identifying those patients with diabetes that are at high risk for amputation and preventive interventions.

Amputation, Surgical↗
PubMed1999

Diabetic amputations in the VA: are there opportunities for interventions?

Lower limb amputation (LLA) is a devastating complication experienced by some veterans with diabetes. The Veterans Affairs (VA) Healthcare system has identified the prevention of LLA as a priority goal. This study was designed to describe the sources of outpatient care received by veterans with diabetes who have undergone LLA, to determine whether these persons would have been impacted by a VA amputation prevention program. This study was also designed to describe prior amputation history, footwear history, and the pivotal events that led to these amputations. We found that the vast majority of these subjects identified the VA as their primary source of care, and thus would have been available for enrollment in a prevention program. Since over one-half of them had had a prior amputation, diabetics with a prior amputation should be particularly targeted for foot care interventions. Lastly, prescription of protective footwear has the potential to reduce the incidence of shoe-related ulcers and amputations.

Adult↗
PubMed2001

[Factors associated with amputation in diabetic patients with foot ulcer].

OBJECTIVE: To analyse risk factors for amputation in diabetic foot ulcers. METHOD: We have studied 152 diabetic patients (in 14 food ulcers treatment was amputation) who were attendance between January 1996 and June 1998 in the diabetic foot Unit. Subjects with gangrene were excluded. RESULTS: Risk factors for amputation were: previous history of amputation (odds ratio 3.7; 1.0113.7), proliferative retinopathy, osteomielitis, and independently clinical signs of peripheral vasculopathy (7.1; 1.88-27.2) and severe infection (14.4; 2.92-71.2). CONCLUSION: Diabetic subjects with foot ulcers and previous history of amputation, proliferative retinopathy, osteomielitis, clinical signs of peripheral vasculopathy and/or severe infection were a high risk group for amputation and in this group aggressive therapeutical and preventive approaches should be done in order to prevent amputation.

Aged↗
PubMed2000

[Analysis of quality of life in persons after arm amputations].

This study presents an analysis and an evaluation of the quality of life in patients after amputations of the upper extremities, basing on functional anamnesis, tests and a questionnaire about daily activity. Patients after unilateral upper extremity amputations are more proficient at both daily activities and two-handed activities than patients after amputations of both extremities. Patients with amputations below the elbow joint were found to be more proficient at two-handed activities compared to patients with amputations above the elbow joint. Daily activities with performed with the same degree of ease by both patients with amputations below the elbow joint and above the elbow. This proves that that the elbow joint maybe functionally replaced relatively easily. Patients with ambilateral amputations at arm level were more proficient with daily activities than two-handed activities.

Activities of Daily Living↗
PubMedDate not supplied

Survival following lower-limb amputation in a veteran population.

GOAL: We sought to describe the common demographic and comorbid conditions that affect survival following nontraumatic amputation. METHODS: Veterans Administration hospital discharge records for 1992 were linked with death records. The most proximal level during the first hospitalization in 1992 was used for analysis. Demographic information (age, race) and comorbid diagnosis (cardiovascular, cerebrovascular, and renal disease) were used for Kaplan-Meier curves to describe survival following amputation. MAIN OUTCOME MEASURE: Death. RESULTS: Mortality risk increased with advanced age, more proximal amputation level, and renal and cardiovascular disease, and decreased for African Americans. No increased risk for persons with diabetes was noted in the first year following amputation but the risk increased thereafter. A higher risk of mortality in the first year was noted for renal disease, cardiovascular disease, and proximal amputation level. CONCLUSION: Survival following lower-limb amputation is impaired by advancing age, cardiovascular and renal disease, and proximal amputation level. Also, a small survival advantage is seen for African Americans and those with diabetes.

Adult↗
PubMed2001

[Therapeutic approach in vascular injuries of the lower extremity: Amputation or limb salvage].

The management of lower extremity trauma with vasculary involvement should be directed toward to the salvage of the extremity or to the primary amputation according to the additional pathologies, parameters of the patient and the extremity. We investigated the efficiency of Mangled Extremity Severity Score (MESS) system which is proposed as an grading system to evaluate the change to extremity salvage or the risk for onset of systemic complications. 81 patients with lower extremity trauma were analyzed according to MESS criteria. 79 of the patients were men and mean age was 23 +/- 4. Fourteen patients had higher MESS score. (MESS > 7). Seven of them were older than 50 years. Primary amputation was performed in four of these 7 patients. Vascular repair was performed in three of patients. Multiorgan failure was developed in two of them and both patients died. Secondary amputation was performed to another patients underwent vasculary repair who had MESS > 7 score. Primary amputation was not performed directly in young patients who had MESS > 7. Secondary amputation was required in two of these patients. MESS scoring system can easily predict amputation in older patients but may cause unnecessary amputation in young patients.

Adolescent↗
PubMed1998

[Surgical injuries influence on release of endothelin-1 and local blood perfusion of amputated extremities].

OBJECTIVE: To observe influence of amputations and surgical injuries on synthesis and release of endothelium-derived endothelin-1, and local blood perfusion of amputated extremities. METHOD: The plasma endothelin-1 concentrations of 18 patients preoperatively and postoperatively and the endothelin-1 concentrations of femoral artery wall in 80 SD rats were determined using radioimmunoassay technique before and after amputation. Local blood perfusion of amputated extremities in rats were determined using laser Doppler flowmetry. RESULT: The plasma endothelin-1 concentrations in the patients with surgical injuries increased obviously, reached peak value at fourth hour postoperatively, being approximately 3 times of that of the control group. The endothelin-1 concentrations of femoral artery wall in amputated rats also increased, reached peak value at second hour after amputation, being approximately 2 times of that of the control group, and then decreased gradually, at the same time the local blood perfusion decreased, reached its lowest value at second hour after amputation, being only 25 percent of the control value. The endothelin-1 concentration of rat femoral artery wall was negatively relative to local blood perfusion (r = -0.83). CONCLUSION: Injuries enhance synthesis and release of endothelin-1. It is probably one of the main causes of vasospasm after injuries.

Adolescent↗
PubMed2001

[Incidence of lower extremity amputations in diabetics].

The aim of this study was to identify the incidence of lower extremity amputations (LEAs) in diabetics in Poland as background data for comparisons over time and with other communities. This was a cross-sectional study of the incidence of any non-traumatic and non-neoplastic LEAs in the population of Krakow region (1,239,703 inhabitants in its borders before 1.1.1999). It was calculated that for this population size it was sufficient to collect data for one year. The amputees had to be inhabitants of the Krakow region between 1.1.1996 and 31.12.1996. Data was collected from two sources: surgical wards and limb fitting centres. 290 non-traumatic and non-neoplastic LEAs were identified: 283 in the first source (hospital), of which 51 were found in the second (limb fitting centre) while 7 amputations were identified in the second source solely. 72.4% of LEAs were performed in males and this proportion tended to decrease with age, especially in diabetics. Mean age of the amputees was 64.7 years. Diabetics were significantly older (68.2 vs 61.5 years, p < 0.001). The number of amputations was growing with age reaching peak values between 65-74 years in diabetics and 55-64 in non-diabetics. 47.9% of LEAs were performed in diabetics. In 10.8% of cases diabetes was previously unknown. 88.7% of amputations were primary. The following amputation levels were identified: toe--15.5%, metatarsus--6.6%, ankle 1.0%, crus--20.0%, thigh--56.9%. In diabetics 21.6% of amputations were minor (metatarsus and below) comparing to 9.9% in non-diabetics. Incidence rates, calculated per 100,000/year and corrected using capture-recapture method, were as follows (95% confidence intervals in parentheses): 25.9 (10.2-41.6) in the whole population, 186.7 (125.3-248.1) in diabetics, 165.3 (110.5-220.0) primary in diabetics, and 14.4 (3.5-25.4) in non-diabetics. Comparing to data from the literature these were comparatively good results for diabetics of caucasian race. Like in other papers incidence rate in diabetics was almost 15 times higher than in non-diabetics, reaching 24 in females, which suggested that gender protection was reduced by diabetes. In an attempt to lower the rate of amputations several actions should be considered. They may include more active case finding, particularly by GPs, and more effective screening for a high risk diabetic foot.

Adult↗
PubMed2002

Diabetes-related lower extremity amputations in the community: a study based on hospital discharge diagnoses.

BACKGROUND AND AIM: To assess the validity of hospital discharge diagnoses (HDDs) as a means for the surveillance of diabetes-related lower extremity amputations on a population basis, and to compare the demographic and clinical characteristics of diabetic and non-diabetic amputees. METHODS AND RESULTS: All of the 1996 hospital discharge diagnoses reporting ICD-9-CM codes 84.10-84.19 were reviewed in the Campania Region, an area in Southern Italy with 5.7 million inhabitants. Diabetes was defined as any concomitant 250 ICD-9 code. The completeness of ascertainment and accuracy in reporting diabetes were validated in a sub-sample of cases by matching their HDDs with the register of buried limbs and the clinical records of the hospital. During the study period, 701 individuals underwent 738 amputations, 330 (47.1%) of whom had diabetes mentioned in their discharge diagnosis. All of the amputations reported in the buried limbs register were identified by the HDDs, whereas some minor amputations recorded in the HDDs were not reported in the registers. On the basis of the clinical charts, the diagnosis of diabetes was underreported by 10%. The proportion of females was significantly higher among the diabetic amputees (41% vs 35%), whereas the proportion of people aged less than 50 years was significantly lower (5% vs 13%) (p < 0.002). The duration of hospitalisation was similar for the diabetics and non-diabetics (23 +/- 20 vs 22 +/- 18 days). Minor amputations were significantly more frequent in the individuals with diabetes (38.8% vs 29.1%; p < 0.001), as was reamputation (7.2% vs 2.9%; p < 0.01). CONCLUSION: These findings confirm the markedly increased risk of amputation among diabetics and demonstrate that HDDs represent a suitable procedure for the surveillance of lower extremity amputations.

Adult↗
PubMed1961

Supracondylar amputation in the aged.

Of 105 consecutive supracondylar amputations done at the San Diego County General Hospital during the five-year period, 1953-58, 88 were in patients more than 60 years of age. Occlusive arterial disease was the reason for operation in 85 of the 88 cases. Presenting complaints at the time of amputation were gangrene in 45 cases, pre-gangrene associated with severe pain in 34. Acute arterial occlusion as a cause of thigh amputation was infrequent. The average age of patients requiring thigh amputation from complications of arteriosclerosis obliterans was 78.3 years; for those with diabetic arteriosclerosis or embolism it was about seven and a half years less. Supracondylar amputation was considered the procedure of choice in the elderly debilitated patients with far-advanced occlusive diffuse arteriosclerosis, complicated by gangrene, ulcer and infection of the toes or feet. Sympathectomy and direct arterial operation if done early in the course of the disease may postpone or prevent subsequent amputation. The surgical mortality rate (first two weeks) for supracondylar amputation was 12.5 per cent. More than two-thirds of the deaths were due to bronchopneumonia.

Aged↗
PubMed2005

[Primary surgical treatment of amputated fingers and indications for digital replantation].

The amputation of a single finger, or its part, or more fingers results in functional and esthetic changes in the patient's life. Until 1965 when the first thumb ever was replanted, the treatment of amputated digits had been limited by technical facilities of the medical science. Since 1970s, the development of fine suture materials, microsurgical instruments and the operating microscope has made it possible that replantations have become routine procedures in hand surgery. Both surgical procedures and indication schemes have also evolved. The primary surgical treatment has been standardized to involve the wrapping of amputated parts in dressing material saturated with isotonic solution and cooling at 4 to 10 degrees C during transport. The first enthusiasm for replantation of everything that had been amputated was replaced, owing to long-term post-operative results, by a more selective approach. Even an absolute indication for digital replantation, such as amputation of a thumb, two or more fingers, amputation in the palm and all amputations in children, must be put aside when life-threatening injuries or serious diseases are present. The benefit of replantation should always outweigh the trauma of any operative procedure because this must not harm the patient.

Amputation, Traumatic↗
PubMed1992

Changing patterns in the predisposition for amputation of the lower extremities.

The purpose of this study was to evaluate and determine the role of diabetes and other common predisposing factors in amputation of the lower extremities. A retrospective review of 110 patients with peripheral vascular disease who underwent amputation between 1987 and 1990 at Hahnemann University Hospital (Philadelphia, PA) was performed. Patients who underwent amputations for trauma or cancer were excluded from this analysis. The patients were divided into four groups according to the site of amputation: Above Knee (n = 43), Below Knee (n = 26), Foot (n = 7) and Transmetatarsal (n = 34). The mean age was 60 years. Fifty-five patients (51%) were white. Sixty-four patients (58%) were men. Twenty-nine patients (26%) were cigarette smokers; sixteen smokers (55%) had above-knee amputation. Thirty-five patients (32%) had previous vascular surgery of the lower extremities. The combination of diabetes and hypertension was present in 40 patients (36%). When either diabetes or hypertension alone was present in a patient, hypertension, not diabetes, was more commonly the dominant underlying medical condition in patients with amputation (32 hypertension-alone patients vs. 10 diabetes-alone patients). The high frequency of hypertension suggests that enhanced control of this disease may affect peripheral vascular disease and related amputations in the future.

Age Factors↗
PubMed2006

The relationship of the transcutaneous oxygen tension, pulse waves and systolic pressures to the risk for limb amputation in patients with peripheral arterial disease and skin ulcers or gangrene.

AIM: Our aim was to determine how the risk associated with presence of low transcutaneous oxygen tension (tcPO2) for subsequent major amputation in patients with skin ulcers or gangrene and peripheral arterial disease, compares with the risks associated with low peripheral pressures and low amplitude of pulse waves. Secondly, we determined whether combination of measurements of oxygen tension with that of the pressures or pulse wave amplitude predicts amputation better than pressure, wave or oxygen tension measurements alone. METHODS: Measurements were carried out to obtain foot tcPO2, ankle and toe pressures, pressure indices, and toe pulse wave amplitude in 75 limbs with skin lesions and arterial disease of 66 patients referred to the vascular laboratory. These variables were related to the risk of a subsequent major amputation during a median time of 4.2 years, using Cox proportional hazards model. RESULTS: Low oxygen tension was associated with increased risk of amputation (relative risks 2.16 and 2.55 for tcPO2 < or = 10 mmHg and < or = 20 mmHg, respectively, P<0.05; relative risk 2.22 for tcPO2 < or = 30 mmHg, P=0.07). The relative risks associated with cutoff values of ankle and toe pressures and pressure indices varied from 2.53 (toe < or = 20 mmHg, P<0.05) to 5.83 (ankle < or = 50 mmHg, P<0.001) and the relative risk associated with low wave amplitude (< or = 4 mm) was 3.41, P<0.01. The cutoff values of tcPO2 became insignificant when included in the models together with each pressure variable or pulse amplitude separately. In contrast, wave amplitude remained significantly associated with increased risk of amputation after controlling for each pressure variable (P<0.05). CONCLUSIONS: TcPO2 < or = 10 mmHg and < or = 20 mmHg are related significantly to increased risk of amputation in patients with skin lesions and arterial disease, but these relative risks are similar in magnitude or smaller than those associated with low cutoff values of pressures, pressure indices or pulse wave amplitude. Low wave amplitude does provide significant information in addition to peripheral pressures with respect to the risk of amputation. On the other hand, low tcPO2 does not provide significant information in addition to peripheral pressures or pulse wave amplitude.

Aged↗
PubMed2006

Transmetatarsal amputation: predictors of healing.

The objective of this study is to determine the predictors of healing after transmetatarsal amputations (TMA) and factors leading to a higher level of amputation. A total of 33 TMA was performed in 31 patients during the 5 years between January 2000 and Jul 2005. All patients were men between the ages of 44 and 82 years (mean, 68 years). The mean follow-up period was 36 months (range, 1-65 months). Twelve (40%) TMA required a subsequent higher level of amputation. Seventeen (57%) TMA were successful. The average time until further proximal amputation after TMA was 3.5 months. Risk factors for subsequent higher amputation by univariate analysis included infrapopliteal arterial occlusion (P < 0.05), tobacco smoking greater than 20 years (P < 0.05), and further TMA debridement (P < 0.05). Upon multivariate analysis, only patients undergoing further TMA debridement were at risk for TMA failure (P = 0.01). The difference in ankle-to-brachial pressure ratio (ABI) between the higher amputation group (ABI = 0.51) and the successful TMA group (ABI = 0.54) was not significant. There were no perioperative deaths after TMA. Five (18%) deaths occurred at a mean of 8.2 months after the TMA. In patients who are walking preoperatively, aggressive TMA is warranted in an attempt to maintain ambulation, recognizing that requirement for further debridement, smoking history, and infrapopliteal occlusion may be predictors of nonhealing and subsequent higher amputation.

Adult↗