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PubMed2005

Contemporary series of morbidity and mortality after lower limb amputation.

OBJECTIVES: This study was performed in order to assess morbidity and mortality associated with major lower extremity amputation according to an extensive complication registration system used in our hospital. METHODS: All consecutive patients who underwent lower limb major extremity amputation were included from January 1996 until December 2002. Complications were prospectively registered according to our standard complication registration system. RESULTS: In 97 patients 122 amputations were performed including 45 above (AKA) and 77 below (BKA) knee amputations. The conversion rate from below to above knee amputation was 14%. In 65 patients 107 complications occurred (67%). The incidence of wound infection was 10% in the BKA group and 2% in the AKA group. The most frequently reported complications were pressure sores (8%) or originating from the urinary tract (13%). The hospital mortality for BKA was 9% and for AKA 18%. Long-term survival was 62% at 1 year, 50% at 2 years and 29% at 5 years. CONCLUSIONS: An extensive registration system provides us with a detailed insight into the incidence, consequence and cause of complications. Major lower extremity amputations are still associated with considerable morbidity and mortality.

Adult↗
PubMed2006

Use of a pneumatic tourniquet improves outcome following trans-tibial amputation.

BACKGROUND: It is traditionally taught that a pneumatic tourniquet is contraindicated for trans-tibial amputations in patients with peripheral arterial disease. However, tourniquets are used successfully during total knee arthroplasty in elderly patients. Vascular patients undergoing a trans-tibial amputation have a high perioperative mortality and morbidity-notably the need for wound revision or a higher amputation level. We hypothesised that a tourniquet, used during amputation, would reduce blood loss and subsequent complications without compromising healing. METHODS: This was a prospective non-randomized study of 89 adult patients who underwent a trans-tibial amputation between January 2001 and December 2003. The endpoints were: haemoglobin levels, the need for blood transfusion, perioperative morbidity, revision rate and mortality. Patients were divided into two groups: a group with a pneumatic tourniquet (n=42) and a group without (n=47). RESULTS: The haemoglobin fall was 14.8% in the non-tourniquet group and 5.6% in the tourniquet group, with a higher need for transfusion in the non-tourniquet group. The revision rate was 14.3% in the tourniquet group and significantly higher in the non-tourniquet group (38.3%). Mortality was similar in both groups: 7.1% for the tourniquet and 6.4% for the non-tourniquet group. CONCLUSION: The use of a pneumatic tourniquet is safe and significantly reduces both blood loss and transfusion requirements during trans-tibial amputation. A pneumatic tourniquet reduces revision rates by over 50%, with subsequent cost savings.

Adult↗
PubMed2005

Prevention of major amputations in nonischemic lower limb lesions.

BACKGROUND: Major lower limb amputations continue to be performed at an increasing rate, the major cause being the rising prevalence of adult onset diabetes. It can be demonstrated that a reduction in amputation rate can be achieved at institutes with a higher level of academic and specialty interest, by avoiding errors of management and by newer technical innovations in wound closure. STUDY DESIGN: A simpler method of wound closure that is easily taught and learned and is readily available to the medical community and the patient population can play a substantial role in reducing the number of amputations. Satisfactory closure of open lesions by full-thickness skin and subcutaneous tissue carries with it a lower incidence of recurrence, reduces costs by avoiding or reducing length of hospitalization, and minimizes use of general anesthesia, a serious matter in immunocompromised older patients. Avoiding errors of technique will additionally reduce amputation rate. RESULTS: In the last 10 years, 125 patients, mostly diabetic and elderly, with major and recurrent lesions of the lower extremities, have been treated by closure of the debrided wound with a combination of external tissue expansion and wound toilette. Major lower limb amputations have been avoided. CONCLUSIONS: Experience confirms that the relationship between high hospital volume, specialty interest, higher level of academic care; avoiding technical errors; and simplifying the methodology, lead to a reduction in need for major amputations. A lower mortality in the patient population at risk is achieved and a reduction in costs, which have risen beyond the 132 billion dollars level, can be expected.

Adult↗
PubMed2005

Coping strategies as predictors of psychosocial adaptation in a sample of elderly veterans with acquired lower limb amputations.

This study examines the contribution of demographic/amputation-related variables and coping strategies to the prediction of psychosocial adaptation in veterans with acquired lower limb amputations. Multiple indicators of the psychosocial adjustment of 796 individuals in the UK aged between 26-92 years with lower limb amputations were assessed. Hierarchical linear regressions were performed to investigate relationships between demographic/amputation-related variables (i.e. age, time since amputation, amputation level and amputation aetiology), the dimensions of coping (namely problem solving, seeking social support and avoidance) and self-reported adaptation to amputation, as well as symptoms of intrusion, anxiety and depression. Results indicated that coping styles were important predictors of psychosocial adaptation. Avoidance was strongly associated with psychological distress and poor adjustment. In contrast, problem solving was negatively associated with depressive and anxious symptomatology whereas seeking social support was negatively associated with symptoms of depression and positively associated with social adaptation. These findings suggest the potential for interventions designed to promote particular coping strategies to improve psychosocial outcomes.

Adaptation, Psychological↗
PubMed1995

Predictors of amputation for popliteal artery injuries.

BACKGROUND: Popliteal artery injuries continue to result in limb loss. This study identifies risk factors that predict amputation. METHODS: Over a 5-year period, a retrospective chart review was conducted of 80 consecutive patients with 81 popliteal artery injuries. RESULTS: The overall amputation rate was 16.5%. Blunt trauma carried a higher rate of amputation (47%) than penetrating injuries (6.2%); P < 0.0001). Associated fractures had a higher amputation rate, regardless of mechanism (odds ratio +2.7, 95% confidence limits 1.2 to 6.2). Fasciotomy at the time of operation was associated with reduced amputation rate. CONCLUSIONS: Blunt injuries and associated fractures carry an increased risk for amputation. Compartmental pressures should be appropriately monitored postoperatively. Fasciotomy at the time of vascular repair may be considered even without evidence of compartment syndrome.

Adolescent↗
PubMed2001

[Quality of life of vascular disease patients following amputation].

STUDY AIM: The purpose of this study was to assess the quality of life following lower limb amputation for vascular disease. PATIENTS AND METHODS: Thirty-six vascular patients operated on for 40 major amputations were reviewed to assess demographic and clinical characteristics, possibilities of prosthesis, perception of health problems and social adaptation. These data were correlated with general satisfaction and quality of life ratings, using the Nottingham Health Profile. RESULTS: The average stay in hospital was 109 days. Thirteen patients (36%) died in hospital, 23 others (64%) were discharged, but only ten patients (28%) were able to go back home. The global mortality rate at 1 year was 44%. Eighteen patients (78%) were initially fitted but only seven (30%) were fully independent. Eight patients only (35%) were satisfied at the end of treatment. Patient's satisfaction was influenced by the level of his amputation, the presence of residual pain and by his mobility, but it was independent of prosthetic equipment. CONCLUSION: Quality of life of vascular amputated patients is poor and marked by persistent pain and considerable handicaps in mobility, limiting social activities and relationship. The patients' satisfaction and quality of life appear to be related to their ability to manage social relations. Amputation should be considered as the first step towards rehabilitation and not the end of the treatment. It is only through a multidisciplinary approach that the quality of life of amputated patients can be improved.

Activities of Daily Living↗
PubMed1997

Mortality following lower extremity amputation in minorities with diabetes mellitus.

The aim of this study was to identify the age adjusted and level specific mortality rate in African-Americans, Hispanics and non-Hispanic whites (NHW) during the perioperative period following a lower extremity amputation. We identified amputation data obtained from the Office of Statewide Planning and Development in California for 1991 from ICD-9-CM codes 84.11-84.18 and diabetes mellitus from any 250 related code. Amputations were categorized as foot (84.11-84.12), leg (84.13-84.16) or thigh (84.17-84.18). Death was coded under discharge status. Age adjusted and level specific mortality rates per 1000 amputees were calculated for each race/ethnic group. The age adjusted mortality was highest for African-Americans (41.39) compared to Hispanics (19.69) and NHW's (34.98). Mortality was consistently more frequent for proximal amputations. We conclude that mortality rates for persons with diabetes hospitalized for an amputation varied by race, gender and level of amputation. Higher prevalence or severity of risk factors may explain the excess mortality observed in African-Americans.

Adult↗
PubMed1997

Methodological issues affect variability in reported incidence of lower extremity amputations due to diabetes.

The aim of this study is to evaluate the influence of different methodological techniques commonly utilized to identify the incidence of diabetes related lower extremity amputations. Medical records for each hospitalization for an amputation in 1993 in six metropolitan statistical areas in South Texas were abstracted. Every hospitalization, amputation and amputee was identified to allow separate analysis. Furthermore, data was categorized by ethnicity, level and age. Diabetes was verified using WHO criteria. Incidence rates were calculated per 10,000 diabetic patients at risk per year, both diagnosed only (DO) and diagnosed and undiagnosed combined (DUC). In total 1922 amputations were carried out during 1228 hospitalizations for 1043 amputees. The incidence rates per 10,000 diabetic patients (DO) were: 157.6 amputations, 101.2 hospitalizations and 87.0 amputees. When calculated using the DUC population at risk the rates were: 92.8 amputations, 59.6 hospitalizations and 51.2 amputees. Trends were found to be similar when analyzed by gender and ethnicity. The variability detected using of different methodological techniques to determine incidence rates is considerable and may have significant consequences when rates from different studies are compared.

Adult↗
PubMed1977

Traumatic amputation of digits: the fate of remaining blood. An experimental and clinical study.

Experimental studies on rabbit ears amputated by either a clean sharp division or severed by a crushing blow showed that twice as much blood remained in the crush group. Microthrombi and tissue thrombi were seen in this group only. A review of 142 digital replantations performed over a 10 year period showed 126 survivals. Ninety-three were complete amputations and 80 of these survived; 49 were incomplete amputations and 46 survived after revascularization attemps. Of 74 clear amputations, 68 survived; of 68 crush-type amputations, 58 survived. Circulatory disturbances occurred in 36 replanted digits; 16 could not be salvaged. The primary cause of complications was venous obstruction. In 80 digital replantations done from January, 1974, to December, 1975, success was obtained in 75 (93.75 percent). Irrigation of vessels of the severed part is done only in cases of double level amputation, severely crushed or those due to avulsion. Heparin, low molecular weight dextran, urokinase, and antibiotics are given for several days after operation.

Amputation, Traumatic↗
PubMed1995

Deep vein thrombosis associated with lower extremity amputation.

PURPOSE: Patients undergoing lower extremity amputation are perceived to be at high risk for deep vein thrombosis (DVT). Limited data are available, however, to confirm this impression. The purpose of this study is to prospectively document the incidence of DVT complicating lower extremity amputation. METHODS: During a recent 28-month period, 72 patients (71 men, 1 woman; mean age 68 years) undergoing major lower extremity amputation (31 above-knee and 41 below-knee) were prospectively evaluated with perioperative duplex scanning for DVT. RESULTS: DVT was documented in nine (12.5%) patients (one bilateral, four ipsilateral, and four contralateral to amputation). Patients with a history of venous disease were at significantly higher risk for development of DVT (p = 0.02). Thrombi were located at or proximal to the popliteal vein in eight patients and were isolated to the tibial veins in one patient. DVT was identified before operation in six patients and after operation in three. Patients with DVT were treated with heparin anticoagulation, with no patient experiencing clinical symptoms compatible with pulmonary embolism. CONCLUSIONS: In our recent experience, lower extremity amputation is associated with DVT at or proximal to the popliteal vein in 11% of patients. Documentation of DVT prevalence is essential to assist surgeons in planning a management strategy for prevention, diagnosis, and treatment of DVT associated with lower extremity amputation.

Aged↗
PubMed1997

Impact of arterial surgery and balloon angioplasty on amputation: a population-based study of 1155 procedures between 1973 and 1992.

BACKGROUND: Limited population-based data are available on trends in the incidence of arterial surgery, balloon angioplasty, and amputation for arterial occlusive disease of the legs over the past two decades. METHODS: We identified all elective and emergency arterial operations, balloon angioplasty procedures, and amputations performed for all residents of a defined community, Olmsted County, Minn., between 1973 and 1992. We focused on gender mix, type of procedure, and secular trends in utilization. RESULTS: A total of 1155 procedures were performed, including 733 arterial surgical procedures, 59 balloon angioplasty procedures, and 363 amputations (288 major and 75 minor). Emergency procedures were performed in 12%. Suprainguinal inflow procedures were the most common arterial reconstruction (60%) compared with infrainguinal procedures (40%). The incidence of all revascularization procedures increased in the first decade but reached a plateau after 1985. Utilization rates of revascularization procedures from 1988 to 1992 were higher for men (141.9/100,000 person-years [p-yr]) than women (57.4/100,000 p-yr.). Angioplasty (17.0/100,000 p-yr) rates lagged behind surgery until 1985, but tripled in the past 10 years and have not yet reached a plateau. Although minor amputation rates remain unchanged in 20 years, major amputation rates have been reduced by 50% from 36.7/100,000 p-yr between 1973 and 1977 to 19.0/100,000 p-yr from 1988 to 1992. CONCLUSIONS: From this long-term population-based analysis (1973 to 1992), we conclude that increased vascular surgery and balloon angioplasty rates have coincided with a significant reduction in major amputation rates in the past 10 years.

Adult↗
PubMed1994

Vascular surgery reduces the frequency of lower limb major amputations.

In June 1988 a Department of Vascular Surgery was established in the county of Viborg, Denmark. In this retrospective study of the periods 1986-87 and 1989-90, we have observed a significant rise in the number of patients evaluated by a vascular surgeon before amputation, from 19 to 49%. At the same time the number of major lower limb amputations significantly decreased. This reduction was most marked in 1990 probably due to a rise of 43% in the number of distal reconstructions. The distribution between below knee, through knee and mid-thigh amputation was unaffected by the increased vascular surgical activity. The frequency of major amputations in the county in 1986-87 of 40.9 per 100,000 per year declined by 25% to 30.9 per 100,000 per year in 1989-90. We conclude that vascular surgery reduces the number of major lower limb amputations and consequently all patients threatened with amputation must be evaluated if vascular reconstruction is possible.

Aged↗
PubMed1988

Immediate and chronic changes in responses of somatosensory cortex in adult flying-fox after digit amputation.

The somatosensory cortex of adult mammals has been shown to have a capacity to reorganize when inputs are removed by cutting afferent nerves or amputating a part of the body. The area of cortex that would normally respond to stimulation of the missing input can become responsive to inputs from other parts of the body surface. Although a few animals have been studied with repeat recording, no attempt has been made to follow the time-course of changes at cortical loci and the immediate effects of a small amputation have not been reported. We have followed the changes in response in the primary somatosensory cortex in the flying-fox following amputation of the single exposed digit on the forelimb. Immediately after amputation, neurons in the area of cortex receiving inputs from the missing digit were not silent but responded to stimulation of adjoining regions of the digit, hand, arm and wing. In the week following amputation, the enlarged receptive fields shrank until they covered only the skin around the amputation wound. The immediate response is interpreted as a removal of inhibition and the subsequent shrinking of the field may be due to re-establishment of the inhibitory balance in the affected cortex and its inputs.

Amputation, Surgical↗
PubMed2001

Variation in clinical decision making is a partial explanation for geographical variation in lower extremity amputation rates.

BACKGROUND: Rates of lower extremity amputation vary significantly both between and within countries. The variation does not appear to support differences in need as an explanation. This study set out to see if variations in clinical decision making might contribute to the explanation. METHODS: Based on an extensive audit database of lower extremity amputations and revascularization operations, a decision model was produced. Drawing on items in this model allowed the selection of six clinical cases that differed in their probability of having amputation as the outcome. Two cases had 80 per cent or more, two cases had 45--55 per cent and two cases had 20 per cent or less probability of amputation. Each of ten consultant vascular surgeons looked at these cases without knowledge of their probability of outcome and decided on amputation or revascularization. RESULTS: Overall the chance-adjusted level of agreement (kappa coefficient) between the decisions made by ten surgeons on the six clinical cases and the actual outcome was 0.46, indicating a moderate level of agreement. The kappa coefficient for individual surgeons showed complete agreement (kappa = 1) for four, substantial agreement (kappa = 0.66) for four, fair agreement (kappa = 0.32) for one and no agreement other than at a chance level (kappa = 0) for one surgeon. CONCLUSION: Variations in the clinical decisions made by vascular surgeons given the same patient are likely to explain at least a part of the observed geographical variation in rates of lower extremity amputation. Consensus guidelines may enable more consistent decision making for this problem.

Aged↗
PubMed1999

Nontraumatic lower extremity amputations in the Medicare end-stage renal disease population.

BACKGROUND: Nontraumatic lower limb amputation is a serious complication of both diabetic neuropathy and peripheral vascular disease. Many people with end-stage renal disease (ESRD) suffer from advanced progression of these diseases. This study presents descriptive information on the rate of lower limb amputation among people with ESRD who are covered by the Medicare program. METHODS: Using hospital bill data for the years 1991 through 1994 from the Health Care Financing Administration's ESRD program management and medical information system (PMMIS), amputations were based on ICD9 coding. These hospitalizations were then linked back to the PMMIS enrollment database for calculation of rates. RESULTS: The rate of lower limb amputation increased during the four-year period from 4.8 per 100 person years in 1991 to 6.2 in 1994. Among persons whose renal failure was attributed to diabetic nephropathy, the rates in 1991 and 1994 were 11.8 and 13.8, respectively. The rate among diabetic persons with ESRD was 10 times as great as among the diabetic population at large. Two thirds died within two years following the first amputation. CONCLUSIONS: The ESRD population is at an extremely high risk of lower limb amputation. Coordinated programs to screen for high-risk feet and to provide regular foot care for those at high risk combined with guidelines for treatment and referral of ulceration are needed.

Adolescent↗
PubMed2001

Do patients with critical limb ischaemia undergo multiple amputations after infrainguinal bypass surgery?

BACKGROUND: it has been suggested that an aggressive policy of bypass for limb salvage in critical ischaemia may result in patients subsequently undergoing multiple amputations. The aim of this study was to test this suggestion in the context of a dedicated Vascular Surgical Unit in a U.K. teaching hospital. METHODS: three hundred and sixty-eight patients undergoing lower limb bypass operations for critical limb ischaemia between April 1991 and March 1999 were studied retrospectively. Their median age was 69 years (IQR 64--75) and 243 (66%) were men. RESULTS: seventy-five operations were followed by one or more amputation (20%). Only 2% were multiple amputations. Age and sex had no effect on amputation rates, but emergency bypass operations led to a higher rate of amputation in those with critical limb ischaemia. CONCLUSION: patients with critical limb ischaemia who undergo lower limb bypass surgery rarely have subsequent multiple amputation.

Aged↗
PubMedDate not supplied

A retrospective study of patients with diabetes mellitus after partial foot amputation and hyperbaric oxygen treatment.

A retrospective chart review was conducted of 35 patients (40 feet) who received hyperbaric oxygen (HBO) therapy after partial foot amputation between 1990 and 2000. Preoperative transcutaneous partial pressure of oxygen (tcPO2) levels, the number of hyperbaric treatments, time to final outcome, use of revascularization procedures, and postsurgical outcome were extracted from the charts. Seventy percent (n = 28) had a successful outcome, defined as complete healing and absence of ulceration at the amputation site, and lack of further surgical procedures to heal the amputation site; whereas 30% (n = 12) had a failed outcome, defined as lack of healing or the presence of an ulcer at the site of amputation or the need for further surgery to heal the amputation site. The level of amputation, use of revascularization procedures, time to final outcome, and number of hyperbaric treatments were not significantly different (P > .05) between the 2 postsurgical outcome groups. The mean preoperative tcPO2 levels were greater (P < .01) in the successful (24 +/- mm Hg) than in the failed (11 +/- mm Hg) outcome groups. All patients with a tcPO2 level > 29 mm Hg had a successful outcome. Patients with a successful postsurgical outcome had a mean of 20 HBO treatments and took 44 days to final outcome, while those with a failed postsurgical outcome had 16 HBO treatments and took 216 days to final outcome.

Amputation, Surgical↗
PubMed2000

Thumb reconstruction with a wraparound free flap according to the level of amputation.

We surgically treated 37 thumbs amputated distal or proximal to the metacarpophalangeal (MCP) joint using a wraparound free flap from the great toe for the reconstruction. We studied the functional results of the procedure according to the level of amputation and the fixation angle of the iliac bone block. The cases were divided into 2 groups: group 1, which comprised 25 cases with the level of amputation distal to the MCP joint, and group 2, which comprised 12 cases with the level of amputation at or proximal to the MCP joint. Opposition of the reconstructed thumb to the other fingers was completely possible in all cases in group 1. In group 2 opposition was completely possible in 6 cases in which the iliac bone block was fixated into the position of 30 degrees flexion and 45 degrees internal rotation; in the remaining 6 cases, in which the graft was fixated into the position of 30 degrees flexion and 30 degrees internal rotation, complete opposition of the reconstructed thumb to the ring and little fingers was not possible. We found that amputation of the thumb proximal to the MCP joint is not an absolute contraindication for the wraparound free flap reconstruction. We recommend fixating the iliac bone block into 30 degrees flexion and 45 degrees internal rotation to obtain better functional outcome in cases with amputation at or proximal to the MCP joint.

Adolescent↗