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PubMed1997

Institutionalization following diabetes-related lower extremity amputation.

PURPOSE: We are unaware of any report in the medical literature that has discussed risk factors for both mortality and discharge disposition following lower extremity amputation (LEA). Our aim was to report risk factors associated with in-hospital mortality and the need for institutional care in diabetics with LEAs. PATIENTS AND METHODS: We abstracted data for every hospitalization for a LEA from January 1 to December 31, 1993 in six metropolitan statistical areas in South Texas. Amputation level was categorized as foot, leg, or thigh. Discharge status categories were: home, nursing home, rehabilitation facility, and death. We used the Kaplan scale of cogent comorbidities to determine the relationship of 12 disease categories and their association with discharge status. RESULTS: There were 1,043 LEAs in South Texas in 1993. Although only 2.3% of the population was admitted from an institutional care facility, over 25% were discharged to one. Of the total population, 18.5% were discharged to a nursing home and 7.0% to a rehabilitation facility, and 5.1% died within the period of hospitalization. We performed a univariate analysis. Factors with a P <0.25 were included in a stepwise logistic regression analysis with an alpha of 0.05. High level (leg or thigh) amputation, peripheral vascular disease, male gender, and absence of advanced locomotor impairment were associated with discharge to a rehabilitation facility. For discharge to a nursing home, significant associations were found with: female gender, advanced age (>65 years), single marital status, high level amputation, and advanced cerebrovascular disease and locomotor impairment. Death following LEA was strongly associated with female gender, high level amputation, advanced renal disease, anemia, and congestive heart failure. CONCLUSION: A significant number of patients either die or require long-term care following a diabetes-related LEA, thus further adding to the burden of this sequela. Several clinical parameters are significantly associated with discharge status after this procedure. More prospective clinical research is needed to verify the associations and to clarify their application in practice.

Aged↗
PubMed2003

Psychometric properties of the Activities-specific Balance Confidence Scale among individuals with a lower-limb amputation.

OBJECTIVE: To evaluate the internal consistency, test-retest reliability, and construct validity of the Activities-specific Balance Confidence (ABC) Scale among people who have a lower-limb amputation. DESIGN: Retest design. SETTING: A university-affiliated outpatient amputee clinic in Ontario. PARTICIPANTS: Two samples of individuals who have unilateral transtibial and transfemoral amputation. Sample 1 (n=54) was a consecutive and sample 2 (n=329) a convenience sample of all members of the clinic population. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Repeated application of the ABC Scale, a 16-item questionnaire that assesses confidence in performing various mobility-related tasks. Correlation to test hypothesized relationships between the ABC Scale and the 2-minute walk (2MWT) and the timed up-and-go (TUG) tests; and assessment of the ability of the ABC Scale to discriminate among groups based on amputation cause, amputation level, mobility device use, automatic stepping ability, wearing time, stair climbing ability, and walking distance. RESULTS: Test-retest reliability (intraclass correlation coefficient) of the ABC Scale was .91 (95% confidence interval [CI], .84-.95) with individual item test-retest coefficients ranging from .53 to .87. Internal consistency, measured by Cronbach alpha, was .95. Hypothesized associations with the 2MWT and TUG test were observed with correlations of .72 (95% CI, .56-.84) and -.70 (95% CI, -.82 to -.53), respectively. The ABC Scale discriminated between all groups except those based on amputation level. CONCLUSIONS: Balance confidence, as measured by the ABC Scale, is a construct that provides unique information potentially useful to clinicians who provide amputee rehabilitation. The ABC Scale is reliable, with strong support for validity. Study of the scale's responsiveness is recommended.

Accidental Falls↗
PubMed1997

Muscle metabolism changes with training in the nonamputated limb after vascular amputation: interest of phosphorus 31 NMR spectroscopy.

OBJECTIVE: To determine by 31P nuclear magnetic resonance (NMR) spectroscopy the efficacy of training in improving aerobic metabolism of calf muscle in nonamputated limb after recent vascular amputation; to assess the possible associated microcirculatory changes; and to evaluate the need for noninvasive monitoring techniques during training in the nonamputated limb after recent vascular amputation. DESIGN: Prospective study, before and after training. Subjects served as their own controls and were compared with a control group. SETTING: Rehabilitation center of a university hospital. PATIENTS: Ten unilateral vascular amputated patients were included with ankle systolic index between 0.5 and 0.8 in the nonamputated limb, and 10 control subjects without cardiovascular disease or risk factors of atherosclerosis with ankle systolic index of >.95. INTERVENTION: Walking with prosthesis at self-selected velocity over increasing walking distance, arm training at a workload of 60% of a maximal arm test, and analytical exercises of the nonamputated leg (dynamic contractions against low resistance). Subjects received training as inpatients, 5 days a week. MAIN OUTCOME MEASURES: Before and after training, ankle systolic index, forefoot transcutaneous oxygen tension (TcPO2) and veno-arteriolar reflex, and digital plethysmography of the second toe with reactive hyperemia test were studied. Changes in calf muscle pH, phosphocreatine (PCr), and inorganic phosphate (Pi) were measured by 31P NMR spectroscopy at rest and during a plantar flexion-type incremental protocol. RESULTS: There was no significant difference in ankle systolic index (.63 +/- .10 vs .64 + .07) or in TcPO2 (42 +/- 11 vs 44 +/- 10mmHg), and there was reappearance of veno-arteriolar reflex in 3 cases, of a plethysmographic signal in 2 cases, and of the positivity of the reactive hyperemia test in 3 cases. No differences were found with 31P NMR spectroscopy at rest before and after training. At the same workload (1 watt) the difference of the ratio (PCr/(PCr + Pi)) of rest to effort (PCr depletion) was significantly increased in the amputated patients (.423 +/- .159 vs .145 +/- .058; p < .01). This difference of ratio was lower after training (.360 +/- .158 vs .423 +/- .159; p < .05). The pH was less acid between the two periods. CONCLUSION: Vascular monitoring with systolic index and TcPO2 is necessary to follow and to prevent serious ischemia of the nonamputated limb. Claudication is often not detected because of early exhaustion during walking. Training after recent vascular amputation improves the skeletal muscle oxidative capacity.

Amputation, Surgical↗
PubMed1998

Prosthesis evaluation questionnaire for persons with lower limb amputations: assessing prosthesis-related quality of life.

OBJECTIVE: To develop a self-report questionnaire for persons with lower limb amputations who use a prosthesis. The resulting scales were intended to be suitable to evaluate the prosthesis and life with the prosthesis. The conceptual framework was health-related quality of life. DESIGN: Multiple steps of scale development, terminating with test-retest of the Prosthesis Evaluation Questionnaire (PEQ) by mail. SOURCE OF SAMPLE: Records from two Seattle hospitals. PATIENTS: Ninety-two patients with lower limb amputations who varied by age, reason for amputation, years since amputation, and amputation level. MAIN OUTCOME MEASURES: The 10 scales used were 4 prosthesis function scales (Usefulness, Residual Limb Health, Appearance, and Sounds), 2 mobility scales (Ambulation and Transfers), 3 psychosocial scales (Perceived Responses, Frustration, and Social Burden), and 1 Well-being scale. Validation measures were the Medical Outcomes Study Short Form-36, the Social Interaction subscale from the Sickness Impact Profile, and the Profile of Mood States-short form. RESULTS: Nine PEQ scales demonstrated high internal consistency. All met test-retest criteria for comparing group results. Validity was described based on methods used to gather original items, distribution of scores, and comparison of scores with criterion variables. CONCLUSIONS: The PEQ scales displayed good psychometric properties. Future work will assess responsiveness of PEQ scales to changes in prosthetic components. We conclude that they will be useful in evaluation of prosthetic care.

Activities of Daily Living↗
PubMed1998

NMDA receptor-dependent long term hyperalgesia after tail amputation in mice.

Amputation of the mouse tail tip (2.5 cm) caused long term thermal and mechanical hyperalgesia in the remaining part of the tail. Hyperalgesia of the hindpaw to noxious heat (55 degrees C) and cold (0 degrees C) stimuli were also observed. Hyperalgesia at both the tail and hindpaw had a rapid onset (< or = 30 min) and long lasting (> or = 7 days) effect. Skin temperature of the remaining tail or hindpaw was not significantly affected by the amputation. Heat injury of the tail in normal mice induced short but not long term hyperalgesia (< or = 48 h). Intrathecal pretreatment with NMDA receptor antagonists significantly attenuated long term hyperalgesia caused by tail amputation. These results strongly suggest that spinal NMDA receptors are critical for the induction of hyperalgesia by tail amputation, and the current mouse model may prove useful for investigating mechanisms of persistent pain after amputation.

2-Amino-5-phosphonovalerate↗
PubMed1976

Amputation of the toes for vascular disease: fate of the affected leg.

53 patients coming to amputation of one or more toes for the late results of degenerative vascular disease were studied prospectively. By a median time of thirteen months, 26 of the 53 had undergone a major amputation of the affected side. Diabetes was associated with the same prognosis as atherosclerosis obliterans uncomplicated by diabetes. A palpable pedal pulse or a functioning arterial reconstruction carried a virtual guarantee of success for the toe amputation. The presence of a popliteal pulse, however, was not associated with any better prognosis than the presence of a femoral pulse alone. Smoking seemed to exert little influence. With the passage of time, the major-amputation rate rose steadily, and by 3 1/2 years almost three-quarters of the patients had come to major amputation.

Aged↗
PubMed1996

Nail regeneration in digits replanted after amputation through the distal phalanx.

Nail regeneration was studied in 48 digits replanted after amputation through the distal phalanx. Twenty-seven were amputated through Tamai's zone I, at the nailbed level, and 21 digits were amputated through zone II, proximal to the nail. The nails of 9 digits in zone I and 14 in zone II showed almost normal nail regeneration. We observed that replantation after amputations distal to the lunula will show near normal nail regeneration if there is minimal postoperative circulatory disturbance. Amputations proximal to the lunula, however, have a greater chance of causing damage to the germinal matrix, which results in more problems with nail growth.

Adolescent↗
PubMed1991

Selection of amputation level: a review.

Preservation of the knee joint in a patient undergoing lower limb amputation for critical ischaemia is associated with improved postoperative rehabilitation and mobility. Yet, for most surgeons the below-knee to above-knee amputation ratio remains less than one. Poor wound healing and a high reamputation rate for below knee stumps are important factors mitigating against below-knee amputations. Many tests (Doppler indices, segmental pressures, skin blood flow, skin perfusion pressure, TcpO2, thermography) have been described to predict the likelihood of successful healing of an amputation stump but none appears to have gained widespread acceptance. Clinical judgement alone is insufficient to predict the success or failure of an amputation stump. In this review, we have looked at the evidence in support of these tests, particularly those routinely available to most surgeons.

Amputation, Surgical↗
PubMed1988

Further experience in the healing rate of lower limb amputations.

Results of lower limb amputation in the Tayside Region in the years 1981-1985 have been analysed. Three-hundred and twenty-four amputations were performed on three-hundred and eight patients. Two-hundred and thirty-six amputations were attempted at the below-knee level. Only 19 required proximal revision. Prior to amputation, all patients should have a detailed vascular assessment, and the operation should be performed by experienced amputation surgeons using meticulous technique.

Adult↗
PubMed1995

Quality of life following infragenicular bypass and lower limb amputation.

AIMS: To objectively assess the quality of life after femorodistal bypass and compare this to quality of life achieved following primary limb amputation. DESIGN: Retrospective review. SETTING: Leicester Royal Infirmary, U.K., 1988-1993. METHODS: A self-assessment postal questionnaire containing scales measuring emotional disorder, social functioning and mobility was sent to 112 patients who had previously undergone femorodistal bypass (n = 86) or primary limb amputation (n = 26). RESULTS: Further analysis demonstrated that a secondary procedure (PTA or graft revision) to maintain graft patency did not adversely affect quality of life. Additionally, patients undergoing secondary amputation after graft failure had an identical quality of life to those undergoing primary amputation. CONCLUSIONS: These data illustrate that the quality of life after successful femorodistal bypass is higher than after primary or secondary amputation. To attain the maximum quality of life in patients with critical ischaemia, femorodistal bypass should be performed wherever feasible.

Aged↗
PubMed1997

Falling incidence of amputations for peripheral occlusive arterial disease in Western Australia between 1980 and 1992.

OBJECTIVES: To assess temporal trends in the incidence of surgical procedures for peripheral occlusive arterial disease (POAD) and associated changes in outcome as measured by the rate of major lower limb amputations for POAD. DESIGN: A retrospective descriptive population-based study was conducted of the geographically isolated population of Western Australia between 1980 and 1992. METHODS: Vascular procedures with an accompanying diagnosis of POAD were identified in a computerised system of name-identified records of all discharges from hospital for the population. These procedures were detected using relevant codes from the International Classification of Diseases and Procedures. Records of angioplasty and thrombolysis procedures were augmented by searches of hospital-based registers of invasive radiological procedures. The data for the remaining procedures were validated by a review of a random sample of medical records. RESULTS: Over the 13 years of the study, rates of major amputations fell significantly for women under 70 years of age and for men under 80 years from 1983. At the same time there was a significant fall in non-amputation vascular surgery for individuals under the age of 60. In addition, rather than an overall rise in surgery there was shift away from sympathectomy and thromboendarterectomy to angioplasty and bypass surgery. Furthermore, an increasing proportion of all major amputations had a prior attempt at arterial reconstruction. CONCLUSION: These observations suggest the decrease in major amputations for POAD may reflect a fall in the incidence of POAD, possibly aided by more effective surgery, rather than increased rates of vascular surgery.

Adult↗
PubMed1997

The concept of knee salvage: why does a failed femorocrural/pedal arterial bypass not affect the amputation level?

OBJECTIVES: There is continued controversy over whether a failed distal bypass influences the level of amputation. This issue is important as the number of arterial bypass grafts undertaken for critical ischaemia is increasing, followed by an increasing number of failed grafts. SETTING: Teaching hospital. STUDY DESIGN AND MATERIALS: A prospective analysis of 109 consecutive femorocrural/pedal bypass grafts performed between June 1991 and January 1995 on patients presenting with severe critical lower limb ischaemia (CLI) to a single vascular unit. A further 43 amputations for non-reconstructible distal disease were also analysed. CHIEF OUTCOME MEASURES: Mortality, amputation, rehabilitation, survival and knee salvage rates. The Kaplan-Meier method was used for comparison of factors associated with knee preservation. RESULTS: Primary amputees had a higher in-hospital mortality (18% vs. 10%) but similar 3 year survival rates (30%) compared with secondary amputees (36.6%). Patients with successful grafts showed a trend towards better survival (61.9% at 3 years) compared to amputees (38.6% at 42 months, p = 0.061). Below- to above-knee amputation ratio was similar in the two groups (0.85 in secondary vs. 0.95 in primary amputees). Factors significantly associated with knee salvage at 3 years were shown to be: the condition of the inflow (81.9% for good vs. 43.1% for impaired, p = 0.000) the state of the profunda femoris artery (good 93%, impaired 71%, occluded 37% p = 0.0001) and the graft material (vein 81.8% vs. PTFE 59.8%, p = 0.033). The presence of tissue loss (p = 0.0523) and secondary procedures (p = 0.0879) showed a trend to become significant. Multivariate and Cox regression analysis showed that the most important factors were the inflow (p = 0.001), the state of the profunda (p = 0.001), the graft material (p = 0.034) and previous revascularisation attempts (p = 0.019). CONCLUSIONS: The factors which determine knee loss are a compromised inflow state, the presence of an inadequate profunda femoris, previous revascularisation attempts and the use of synthetic graft material. Most of these factors (with the exception of infection related to revascularisation) are present before reconstructive arterial surgery is performed and this study shows that failure of a distal graft does not affect the final amputation level.

Aged↗
PubMed2003

Amputations among diabetics in Reunion Island.

OBJECTIVES: Our study allowed us to exhaustively list up all the cases of lower limb amputation carried out in the hospitals of the island from May 1st, 2000 to April 30, 2001. METHODS: We studied the medical files of all the diabetic patients having undergone a non traumatic amputation and they all had an interview with an inquiring doctor. RESULTS: 406 amputations (including 11 traumatic ones) have been carried out over the 12 months of our study. On a total of 395 non traumatic amputations, 70% were made among diabetics and concerned 278 patients among whom 179 are type 2 diabetics. Men are more concerned than women. If the distribution of amputation levels does not differ between diabetics and non-diabetics, the former more often undergo multiple interventions. 72% of the patients have a level of primary education, 59% have difficulties reading, and most of them have a very limited knowledge on their disease and do not practise any prevention for podologic traumatism. CONCLUSION: In a region where 718 220 inhabitants live and where the rate of diabetes prevalence is high (17.7% for 30-69 years), we could be afraid for the years to come of an important increase of the prevalence and diabetes chronic complications incidence rates. Authorities have to become aware of the current risks and of increasing equipments and personnel for the prevention and the follow-up of this insidious pathology. Programmes for the prevention of podologic complications should be supported by taking into account local specificities.

Adult↗
PubMed2003

Amputation for soft-tissue sarcoma.

Soft-tissue sarcomas are a group of rare malignant tumours, many of which arise in the limbs. Most are treated with a combination of wide local excision and radiotherapy, but a small number--including proximal, large, high-grade, or recurrent tumours, or those involving major neurovascular structures--necessitate major amputation including forequarter or hindquarter amputation. These uncommon operations should remain in the surgical armamentarium for carefully selected patients. Those being considered for amputation should be referred to a tertiary sarcoma unit for examination of all other options, such as limb-salvage surgery, tumour downstaging with chemotherapy or radiotherapy (perhaps with subsequent limb-salvage surgery), or novel techniques such as isolated limb perfusion. Only after careful assessment should amputation be carried out. Outcomes after major amputation are highly variable, but such procedures can confer useful palliation to patients with distressing symptoms (pain, bleeding, fungation), long-term disease-free survival with reasonable function in carefully selected patients, and cure in some.

Amputation, Surgical↗
PubMed1996

Outcomes associated with diabetes-related amputations in The Netherlands and in the state of California, USA.

OBJECTIVE: The purpose of this study is to compare the incidence, relative risk, in-hospital mortality and hospital stay of diabetes-related lower extremity amputations in the state of California and the Netherlands in the year 1991. RESEARCH DESIGN AND METHODS: We used established data obtained from the Office of Statewide Planning and Development for the state of California and from SIG Health Care Information in the Netherlands to identify all hospitalisations for lower extremity amputations. We used age- and sex-specific prevalence rates of diabetes mellitus from the National Health and Nutrition Examination Survey and the Hispanic Health and Nutrition Examination Survey for the state of California and rates from the Central Bureau of Statistics for the Netherlands. A direct standardisation technique with the 1991 Netherlands population as the standard population was used to calculate age-adjusted incidence rates. Age was categorised into four different groups: 25-44, 45-64, 65-74 and 75+. Amputations were defined by four levels; toe, foot, leg and thigh. RESULTS: The age-adjusted incidence of diabetes-related lower extremity amputations was significantly higher in the state of California than in the Netherlands (49.9 vs. 36.1 per 10000 diabetics, P < 0.01). The relative risk, comparing the risk in the diabetic with that in the non-diabetic population, was California 23.7 vs. the Netherlands 19.7. The length of hospital stay was significantly higher in the Netherlands: 40.8 vs. 16.0 (P < 0.01). CONCLUSIONS: There are some significant differences in the outcomes associated with diabetes-related lower extremity amputations. Some of these differences may be explained by differences in access to health care.

Adult↗
PubMed2002

Risk of diabetes-related amputation in South Asians vs. Europeans in the UK.

AIMS: To compare the risk of and risk factors for diabetes-related amputation in South Asians and Europeans. METHODS: This was a population-based case control study based in the health districts of Bolton, Oldham and Central Manchester in the UK. Cases with diabetes-related amputation performed between 1992 and 1997 (n = 172) and controls with diabetes and no amputation (n = 376) were selected from the primary care-based North-west Diabetes Foot Study database. Risk factor data were also collected. RESULTS: Age at diagnosis adjusted odds ratio (OR) of amputation in South Asians compared with Europeans was 0.26, 95% confidence interval (CI) 0.11-0.65, P = 0.004. In the control population, South Asians were less likely than Europeans to have peripheral vascular disease (PVD) (9% vs. 24%, P = 0.02), neuropathy (30% vs. 54%, P = 0.003), and less likely to have ever been smokers (31% vs. 57%, P = 0.03). When these factors were added to the model, the OR was attenuated to 0.84, 95% CI 0.23-3.08, P = 0.8. CONCLUSIONS: South Asians with diabetes have about a quarter of the risk of amputation of Europeans. This is mostly explained by low rates of PVD and neuropathy in South Asians, in part associated with low rates of smoking. The reasons for the South Asian protection from both PVD and neuropathy deserve further exploration.

Age of Onset↗
PubMed2002

Amputations and diabetes: a case-control study.

AIMS: Data concerning the relative risk of amputations in diabetic patients compared with the general population are scarce. Therefore, we carried out a case control study to quantify the relationship between diabetes and amputations. METHODS: In 20 hospitals in seven German cities and counties we obtained complete lists of non-traumatic lower limb amputations performed in 1990 and 1991. CONTROLS were selected from patients of the same surgical departments operated on in the same years. We drew a random sample of patients with procedures not likely to be associated with diabetes. Diabetic status was determined from patients' records in both cases and controls. We calculated age- and sex-specific and, using logistic regression, adjusted odds ratios (OR) and attributable risks. RESULTS: N = 2400, mean age 61.7 (SD 16.3) years. CASES: n = 729; 486 (66.7%) of them had diabetes. CONTROLS: n = 1671; 127 (7.6%) of them had diabetes. Adjusted OR: 18.2 (confidence interval (CI) 14.2-23.6). Adjusted attributable risk among exposed (ARE): 0.95 (CI 0.93-0.96). Adjusted population attributable risk (PAR): 0.62 (CI 0.57-0.66). CONCLUSIONS: This study has demonstrated a strong association between the risk of amputation and diabetes. The odds ratios and attributable risks for diabetic individuals are higher in the younger than in the older age groups. Population attributable risks are great. We conclude that the reduction of amputations in the general population will be achieved by improving foot care in people with diabetes.

Age Factors↗
PubMed2000

Chronic phantom sensations, phantom pain, residual limb pain, and other regional pain after lower limb amputation.

OBJECTIVES: To determine the characteristics of phantom limb sensation, phantom limb pain, and residual limb pain, and to evaluate pain-related disability associated with phantom limb pain. DESIGN: Retrospective, cross-sectional survey. Six or more months after lower limb amputation, participants (n = 255) completed an amputation pain questionnaire that included several standardized pain measures. SETTING: Community-based survey from clinical databases. PARTICIPANTS: A community-based sample of persons with lower limb amputations. MAIN OUTCOME MEASURES: Frequency, duration, intensity, and quality of phantom limb and residual limb pain, and pain-related disability as measured by the Chronic Pain Grade. RESULTS: Of the respondents, 79% reported phantom limb sensations, 72% reported phantom limb pain, and 74% reported residual limb pain. Many described their phantom limb and residual limb pain as episodic and not particularly bothersome. Most participants with phantom limb pain were classified into the two low pain-related disability categories: grade I, low disability/low pain intensity (47%) or grade II, low disability/high pain intensity (28%). Many participants reported having pain in other anatomic locations, including the back (52%). CONCLUSIONS: Phantom limb and residual limb pain are common after a lower limb amputation. For most, the pain is episodic and not particularly disabling. However, for a notable subset, the pain may be quite disabling. Pain after amputation should be viewed from a broad perspective that considers other anatomic sites as well as the impact of pain on functioning.

Adult↗