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PubMed2000

Perioperative and rehabilitative outcomes after amputation for ischaemic leg gangrene.

INTRODUCTION: Amputation of the severely ischaemic leg is often done when limb salvage is not possible or the patient is not fit enough for it. It is therefore important to determine the natural history of these amputees as our understanding of this will have significant impact on decision making. The aim of this study was to determine the early and late morbidity and mortality rates and rehabilitative outcome of these patients with lower limb amputation for end-stage arterial occlusive disease. MATERIALS AND METHODS: A retrospective study was done on 72 patients with 77 lower limb amputations for critical limb ischaemia (rest pain, gangrene, ischaemic ulcers) from 1993 to 1998 at the Singapore General Hospital. RESULTS: The mean age of the amputees was 69.7 years. Fifty-one per cent of the patients were male. Forty-five (58%) of the amputations were performed because the limb vasculature was not reconstructable, 12 (16%) because the limbs were too late for salvage and the remaining 20 (26%) because vascular reconstruction failed. Below knee amputations account for 63.6% of all amputations, above knee amputations account for 35.1% and through knee amputations account for 1.3%. Fifteen (19%) of the amputations had wound infection and 8% of amputations required re-amputation at a higher level for wound infection or failure of wound healing. The contralateral amputation rate was 21%. The 30-day mortality for all amputations was 11.1% and the commonest cause was acute myocardial infarction which accounted for 37.5%. Vascular reconstruction did not alter the overall or perioperative mortality rate. Cumulative survival figures showed that at the end of four years, only 38% of all amputees were still alive. 52.5% of amputees were wheelchair-bound, only 15% were household ambulators and 27.5% were community ambulators. Of all the patients with unilateral below knee amputations, 40% could walk out of home while only 20% of unilateral above amputations and 12.5% of bilateral below knee amputations could walk out of home. CONCLUSION: Early and late rehabilitation after amputation for critical limb ischaemia remain poor and efforts should be made to salvage critically ischaemic limbs wherever possible in patients who are fit enough.

Adult↗
PubMed1999

Parameters of multiple organ dysfunction fail to predict secondary amputation following limb salvage in multiply traumatized patients.

OBJECTIVE: The purpose of this retrospective analysis was to evaluate whether systemic parameters that are used to characterize multiple organ dysfunction could also be used to predict the optimal time for amputation in patients failing limb salvage surgery following severe extremity injury. METHODS: The principal criterion for the study group was a lower limb amputation following a type IIIb or IIIc open tibial shaft fracture in multiply traumatized patients. This group was then divided into one group of primary amputation (group A) and one group of secondary amputation (group B). Beside these groups a third group of total traumatic lower limb amputation was recruited (group C). Data analysis included demographics, injury severity according to the ISS, evaluation of the limb injury by three different salvage scores (HFS, MESS and NISSSA) and organ function monitoring by the Denver MOD Score over a 14-day period posttrauma or up to 7 days after secondary amputation. RESULTS: Within the period 1987-1997 a total of 15 patients were recruited for group A (primary amputation), 10 patients for group B (secondary amputation) and nine patients for group C (traumatic amputation). The MOD score was only positive for pulmonary dysfunction, also reflected by the Horovitz quotient, in those patients that died later in either group. Mortality was higher in group A (three out of 15) compared with group B (one out of 10), which may be due to a higher ISS in group A (mean ISS 28.2 vs. 21.0 of group B). Although the MOD score of all recovered patients revealed no significant difference between group A and B, secondary amputation resulted in significantly longer demand of mechanical ventilation. According to our results secondary amputation may lead to transiently decreased pulmonary function but does not necessarily end in multiple organ dysfunction. The need for amputation in failed limb salvage was not indicated by systemic parameters. CONCLUSION: The right time for secondary amputation in order to prevent subsequent pulmonary dysfunction cannot be predicted by parameters otherwise indicating organ dysfunction. As the risk of secondary amputation for developing pulmonary dysfunction apparently cannot be estimated the decision for amputation or limb salvage should be made initially after trauma and should be the definite one.

Adolescent↗
PubMed2005

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.

Aged↗
PubMed2007

Muscle adaptation patterns of children with a trans-tibial amputation during walking.

BACKGROUND: Many studies have shown that trans-tibial amputation involves modifications of resultant muscle patterns during gait. However, these experiments did not estimate the contribution of simultaneous agonist and antagonist muscle action (co-contraction) during gait tasks. Diminution of co-contraction could create joint instability and, thus, change joint integrity, which is particularly important in the etiology of degenerative diseases, such as osteoarthritis, present at the knees of amputated limbs, and particularly in non-amputated limbs. The purpose of this study was to determine if there is any difference in the production of co-contraction about the knee between able-bodied children and children with a trans-tibial amputation during gait. METHODS: Six children with a trans-tibial amputation vs. six able-bodied children paired for gender, age, weight and height participated in this study. Four one-way ANOVAs (P<0.05) were used to observe differences in resultant, agonist and antagonist moments, power, and co-contraction index during different phases of gait between able-bodied children limbs, the amputated and the non-amputated limbs of children with trans-tibial amputation. FINDINGS: Children with a trans-tibial amputation modified muscle patterns at their amputated limb and produced smaller co-contraction (P<0.05) during single limb support, for both the non-amputated and amputated limbs when compared to able-bodied children. INTERPRETATION: These results suggest that children with a trans-tibial amputation altered their muscle patterns to perform locomotion. These changes produced a diminution of co-contraction during single limb support for both the amputated and non-amputated limbs and, thus, could create joint instability.

Amputation, Surgical↗
PubMed1998

Amputation rate in 147 Turkish patients with diabetic foot: the Hacettepe University Hospital experience.

To determine the lower extremity amputation rate and the risk factors for amputation, we analysed the medical records of 147 Turkish diabetic patients who have been referred to the clinic with diabetic foot. Eleven patients (7.5%) had type 1, and 136 patients (92.5%) had type 2 diabetes mellitus. Fifty-four patients (36.7%) have undergone amputation due to diabetic foot. Femoropopliteal by-pass has been performed in 4 patients in the non-amputees group who did not have gangrene. None of the patients in the amputees group has undergone a revascularisation procedure. Considering all lower-extremity amputations in the group studied, 25.9% were transphalangial amputations, 3.7% were transmetatarsal amputations, 7.4% were Syme type amputations, 51.9% were below-knee amputations, and 11.1% were above-knee amputations. In a logistic regression model, age, gender, duration of diabetes, smoking history, hypertension, retinopathy, nephropathy, and peripheral neuropathy were insignificant factors in determining the risk of amputation. In contrast, presence of peripheral vascular disease (odds ratio 4.0, 95% CI 1.17-13.4; p = 0.03), osteomyelitis (odds ratio 3.73, 95% CI 1.08-12.6; p = 0.04) and gangrene (odds ratio 30.8, 95% CI 7.39-121.5; p < 0.0001) were found to be the significant predictors of amputation. The mortality rate due to amputation during hospital stay was 13.2%. These data suggest that lower extremity amputation is a frequently encountered outcome of the hospitalized patients in Turkish diabetic population with diabetic foot which mainly occur due to peripheral vascular disease, osteomyelitis and gangrene. Lack of adequate vascularisation procedures might have contributed to a high percentage of major amputations in the group studied. Population-based studies should be undertaken in order to determine the status of lower extremity amputation as a whole in Turkish diabetic population.

Adult↗
PubMed1997

Amputation and reamputation of the diabetic foot.

The authors compare the level of foot amputation by age, prevalence of arterial disease as a precipitating factor, gender, and ethnicity in persons with diabetes mellitus. Medical records were abstracted for each hospitalization for a lower extremity amputation from January 1 to December 31, 1993, in six metropolitan statistical areas in south Texas. Amputation level was defined by ICD-9-CM codes and were categorized as foot, leg, and thigh amputations. Foot-level amputations were further subcategorized as hallux or first ray, middle, fifth, multiple digit or ray, and midfoot amputations. Only the highest amputation level for each individual was used in the analysis. Of 1,043 subjects undergoing a lower extremity amputation in south Texas in the year 1993, 477 received their amputation at the level of the foot. African-Americans requiring a foot-level amputation were at significantly higher risk to undergo a midfoot-level amputation than was the rest of the population. Nearly 40% of all subjects undergoing a foot-level amputation had a previous history of amputation. However, nearly 40% of subjects undergoing foot amputations had not been diagnosed either before or during admission with peripheral arterial occlusive disease, suggesting a causal pathway dependent primarily on neuropathy. This implies that better screening of diabetic patients with appropriate risk-directed treatment at the primary care level may significantly impact the large number of preventable diabetes-related lower extremity amputations.

Black or African American↗
PubMed2000

Body mass index in patients with amputations on peritoneal dialysis: error of uncorrected estimates and proposed correction.

UNLABELLED: "Weight-height" indices including percent of ideal weight (%IW) and body mass index (BMI) are used to estimate degree of obesity in populations and are predictors of survival in dialysis patients. Amputation affects the relationship between weight and height independently of the degree of obesity. Corrections of both %IW and BMI for amputation have been published, but a National (U.S.) computer nutrition program used in the authors' institution uses only the correction for %IW. This study had two parts: (1) To test whether the weight-height cut-off values for weight deficit (%IW 90%, BMI 20 kg/m2) and obesity (%IW 120%, BMI 30 kg/m2) are compatible, we performed linear regression of BMI on %IW in peritoneal dialysis (PD) patients without amputations. In 349 men, BMI = 0.834 + 0.226 (%IW), r = 0.979. From this regression, the 95% confidence interval (CI) of BMI is 19.2-23.1 kg/m2 if %IW is 90%, and 26.1-29.9 kg/m2 if %IW is 120%. In 260 women, BMI = 2.194 + 0.184 (%IW), r = 0.974. From this regression, the 95% CI of BMI is 15.7-21.8 kg/m2 if %IW is 90%, and 21.3-27.3 kg/m2 if %IW is 120%. (2) To identify the direction and magnitude of the error of uncorrected BMI (BMIu) in dialysis patients with amputations, we analyzed weight-height indices in two groups of men by the computer nutrition program, which corrects %IW, but not BMI for amputation, and by the corrected BMI (BMIc) formula. In group A (amputation without height loss, n = 11), %IW = 110.2% +/- 16.9%, BMIu = 23.6 +/- 2.7 kg/m2, BMIc = 26.4 +/- 3.8 kg/m2 (p < 0.001, BMIc vs BMIu), and 5 of the 11 BMIu values fell below the 95% confidence band of the regression of BMI on %IW in patients without amputations. In group B (amputation with loss of height, n = 6), %IW = 92.7% +/- 19.9%, BMIu = 33.9 +/- 10.7 kg/m2, BMIc = 22.1 +/- 4.4 kg/m2 (p < 0.005, BMIc vs BMIu), and 5 of the 6 BMIu values fell above the 95% confidence band of the regression of BMI on %IW in patients without amputations. CONCLUSIONS: (1) The weight deficit cut-offs for %IW and BMI are compatible in non amputated men and women. (2) The obesity cut-offs for %IW and BMI are compatible in non amputated men, but not in non amputated women. (3) Amputation without height loss decreases BMIu, while amputation with height loss increases, in general, BMIu. (4) BMI should be corrected in PD patients with amputations.

Amputation, Surgical↗
PubMed1994

The contribution of non-insulin-dependent diabetes to lower-extremity amputation in the community.

BACKGROUND: Despite the significant public health burden of lower-extremity amputations in diabetes mellitus, few data are available on the epidemiology of lower-extremity amputations in diabetes mellitus in the community setting. METHODS: A retrospective incidence cohort study based in Rochester, Minn, was conducted. RESULTS: Among the 2015 diabetic individuals free of lower-extremity amputation at the diagnosis of diabetes mellitus, 57 individuals underwent 79 lower-extremity amputations (incidence, 375 per 100,000 person-years; 95% confidence interval, 297 to 467). Among the 1826 patients with non-insulin-dependent diabetes mellitus, 52 underwent 73 lower-extremity amputations, and the subsequent incidence of lower-extremity amputation among these residents was 388 per 100,000 person-years (95% confidence interval, 304 to 487). Of the 137 insulin-dependent diabetic patients, four subsequently underwent five lower-extremity amputations (incidence, 283 per 100,000 person-years; 95% confidence interval, 92 to 659). Twenty-five years after the diagnosis of diabetes mellitus, the cumulative risk of one lower-extremity amputation was 11.2% in insulin-dependent diabetes mellitus and 11.0% in non-insulin-dependent diabetes mellitus. When compared with lower-extremity amputation rates for Rochester residents without diabetes, patients with non-insulin-dependent diabetes mellitus were nearly 400 times more likely to undergo an initial transphalangeal amputation (rate ratio, 378.8) and had almost a 12-fold increased risk of a below-knee amputation (rate ratio, 11.8). In this community, more than 60% of lower-extremity amputations were attributable to non-insulin-dependent diabetes mellitus. CONCLUSIONS: These population-based data document the magnitude of the elevated risk of lower-extremity amputation among diabetic individuals. Efforts should be made to identify more precisely risk factors for amputation in diabetes and to intervene in the processes leading to amputation.

Amputation, Surgical↗
PubMed2006

Return to driving after lower-extremity amputation.

OBJECTIVES: To study driving behaviors after major lower-extremity amputations and to determine which factors influence return to driving after amputation. DESIGN: A cross-sectional study. SETTING: Data were collected from patients attending an outpatient amputee and prosthetics clinic between February 2001 and September 2001. PARTICIPANTS: A convenience sample (N=123). Inclusion criteria were: age greater than 18 years, unilateral or bilateral major lower-extremity amputation, minimum 1 year since prosthetic fitting, and active automobile driver within 6 months prior to amputation. Subjects had an average age of 63.4+/-12.1 years and were on average 6.8+/-8.3 years since amputation. Common causes for amputation were peripheral vascular disease (73.2%), trauma (13.8%), and tumor (12.2%). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Driving habits after lower-extremity amputation. RESULTS: Overall, 80.5% of participants were able to return to driving an average of 3.8 months after amputation, although the majority reported a decreased driving frequency. Female sex (odds ratio [OR]=.08; 95% confidence interval [CI], .02-.34), age of 60 years or greater (OR=.16; 95% CI, .03-.74), right-sided amputation (OR=.13; 95% CI, .03-.52), and preamputation driving frequency of less than every day (OR=.18; 95% CI, .05-.69) were all significantly related to a reduced likelihood of return to driving postamputation. Items that did not have a statistically significant association with return to driving included level of amputation, reason for amputation, preamputation automobile transmission, and accessibility to public transit. Subjects with left-sided amputation had significantly fewer concerns about driving, while those with a right amputation frequently required vehicle modifications (40.6%) or switch to a left-foot driving style for braking (81.3%) and accelerating (65.6%). Common barriers to return to driving included preference not to drive, fear and/or lack of confidence, and related medical conditions. CONCLUSIONS: The majority of subjects with major lower-extremity amputation were able to return to driving after major lower-extremity amputation. Major automobile modifications are commonly performed by right-sided amputees. Several predictors of return to driving and barriers preventing return to driving were identified.

Aged↗
PubMed1986

Changing pattern of lower limb amputation for vascular disease.

In 1980 a review of lower limb amputation over a 3.5 year period between 1974 and 1978 was reported from our centre. More recently 193 amputations were performed for peripheral vascular disease over a similar 3.5 year period, representing an increase of 33 per cent in the amputation rate during the last 6 years. This cannot be explained by the increasing age of the population alone. Fewer below-knee amputations (BKA) (33.0 per cent) and more Gritti-Strokes amputations (GSA) (32.0 per cent) were performed and the overall incidence of re-amputation for stump breakdown was 13.5 per cent. Twenty-eight per cent of below-knee amputation stumps required re-amputation at higher levels, but when successful were associated with a 75 per cent incidence of rehabilitation with an artificial limb. Eight per cent of GSA stumps required re-amputation and were associated with a twenty-eight per cent incidence of successful rehabilitation. Thirty-seven per cent of patients had undergone reconstructive vascular surgery before amputation. Of the 26 patients requiring re-amputation 58 per cent had undergone arterial reconstruction in an attempt to salvage the limb (chi 2 = 5.65, P less than 0.02) and in 26.9 per cent of cases this was performed within the week before amputation. We feel that injudicious attempts at arterial reconstruction, when amputation appears inevitable, may adversely affect the subsequent level of amputation and jeopardize rehabilitation.

Age Factors↗
PubMedDate not supplied

The impact of diabetes-related lower-extremity amputations in The Netherlands.

The purpose of this study is to identify the incidence of diabetes-related lower-extremity amputations in the Netherlands. We used discharge records from SIG Health Care Information for every hospitalization for a lower-extremity amputation in all hospitals in the Netherlands in 1992. Age- and gender-specific population figures and diagnosed cases of diabetes were obtained from the Central Bureau of Statistics. Age- and gender-adjusted amputation incidences were identified at four different levels (toe, foot, leg, and thigh). Multiple amputations were analyzed by the highest level. Of all lower-extremity amputations, 1,575 (47%) were in persons with diabetes mellitus. Age- and gender-adjusted lower-extremity amputation rates per 10,000 persons with diabetes by level were the following: toe 12.39, foot 2.42, leg 7.82, thigh 2.54, and total 25.17. People with diabetes were 20.3 times more likely to experience a lower-extremity amputation than people without diabetes. Males were at a significantly higher risk of experiencing an amputation than females. There was a significant increase in the age-specific incidence of amputations as age increased. The most common amputation procedure performed was the toe amputation. There was a significant increase in thigh amputations as age increased, indicating that as people get older they suffer higher levels of amputations. Although the incidence of lower-extremity amputations was lower than previous reports, they still have a serious impact on the health-care system in the Netherlands.

Adult↗
PubMed2003

Major lower extremity amputations at a Veterans Affairs hospital.

BACKGROUND: This study was made to evaluate the experience at a Department of Veterans Affairs (VA) hospital with consecutive major lower extremity amputations over a period of 7 years. METHODS: The records of 229 patients (221 male and 8 female) who underwent 296 consecutive major lower extremity amputations (119 above-knee amputations [AKA] and 177 below-knee amputations [BKA]) over a period of 86 months (September 1994 to October 2001) were retrospectively analyzed. All amputations were performed by members of the vascular surgery department. RESULTS: Forty of the 229 patients (17%) eventually required a contralateral amputation, 27 patients (12%) had BKAs that eventually necessitated conversion to AKA, and 44 amputations (15%) required an initial guillotine amputation. The 30-day mortalities for BKA, AKA, and BKA to AKA operations were 12%, 17%, and 7%, respectively. Eighty-eight of the amputations (30%) developed wound complications, and required 137 revisions. Seventy-seven of the amputations (26%) had undergone prior revascularization, of which 31 (48%) had an early failed bypass. The average preoperative ankle/brachial index (ABI) was 0.57. Of the patients undergoing amputation, 97 (42%) complained of rest pain, 91 (40%) complained of claudication, and 158 (69%) had tissue loss or gangrene at the time of their operation. One hundred and forty-six patients (64%) were diabetic. Twenty-two patients (9%) were dialysis dependent and 81 patients (35%) admitted to smoking. Of the known causes of death, 21 resulted from myocardial infarction, 22 from congestive heart failure, 14 from respiratory failure, 13 from disseminated cancer, 10 from sepsis, 7 from stroke, and 6 from renal failure. Preoperative functional status determinations revealed that of 272 patients with enough information to assess functional status, 43 were totally dependent, 97 were partially independent, and 132 were independent. Of the 229 patients, 168 (73%) were ambulatory prior to their amputation, and at the completion of this review only 53 patients (23%) were ambulatory. CONCLUSIONS: Most patients undergoing major lower extremity amputations have many comorbidities; hence morbidity and mortality rates are high, with the most common causes of death being cardiac and respiratory in nature. These data suggest that major lower extremity amputations highlight a very high-risk population with only 39% survival at 7 years, as well as a costly subset secondary to prolonged hospitalization times (average 15 days, range 3 to 105), in addition to the extraordinary cost associated with diminished functional status.

Amputation, Surgical↗
PubMed2004

Survival after lower-extremity amputation.

BACKGROUND: Lower extremity amputation has long been considered an end-of-life event and it is unclear if survival after amputation has improved over time. STUDY DESIGN: A retrospective cohort comprised from a statewide, hospital discharge database was used to determine if survival after amputation improved with time. The cohort included all patients (older than 18 years) with nontraumatic, lower extremity amputations (1987 to 2000). Survival analysis was used to determine the adjusted hazard ratio of survival as it related to the era of amputation. RESULTS: A total of 13,807 patients (mean age +/- SD, 67 +/- 15, 58.5% men) underwent amputation. The gender and age standardized frequency of amputation remained essentially stable, with a 0.01% increase per year (95% CI, 0.006-0.01%). During followup, 49.2% (6,795/13,807) of patients died, with significantly (p < 0.001) worse outcomes for more proximal levels of amputation. After controlling for potential confounders, including age, gender, level of amputation, comorbid illness, emergency status of procedure, hospital type, and payer of the procedure, patients undergoing amputation in more recent years (1995 to 2000) had a 28% lower hazard of dying (hazard ratio 0.72 [95% CI, 0.67-0.77%) during the study period than those undergoing operation before 1995. Thirty-day survival did not improve by era (p = 0.2), although 1- and 5-year survival after amputation was significantly greater for all levels of amputation (p < 0.001). CONCLUSIONS: Although 30-day survival associated with amputation has remained stable in the state of Washington over the past 14 years, longterm survival after amputation has improved considerably with time. The reasons underlying this improvement should be explored so that further gains may be achieved.

Aged↗
PubMed2005

Preoperative clinical factors predict postoperative functional outcomes after major lower limb amputation: an analysis of 553 consecutive patients.

BACKGROUND: Despite being a major determinant of functional independence, ambulation after major limb amputation has not been well studied. The purpose, therefore, of this study was to investigate the relationship between a variety of preoperative clinical characteristics and postoperative functional outcomes in order to formulate treatment recommendations for patients requiring major lower limb amputation. METHODS: From January 1998 through December 2003, 627 major limb amputations (37.6% below knee amputations, 4.3% through knee amputations, 34.5% above knee amputations, and 23.6% bilateral amputations) were performed on 553 patients. Their mean age was 63.7 years; 55% were men, 70.2% had diabetes mellitus, and 91.5% had peripheral vascular disease. A retrospective review was performed correlating various preoperative presenting factors such as age at presentation, race, medical comorbidities, preoperative ambulatory status, and preoperative independent living status, with postoperative functional endpoints of prosthetic usage, survival, maintenance of ambulation, and maintenance of independent living status. Kaplan-Meier survival curves were constructed and compared by using the log-rank test. Odds ratios (OR) and hazard ratios (HR) with 95% confidence intervals were constructed by using multiple logistic regressions and Cox proportional hazards models. RESULTS: Statistically significant preoperative factors independently associated with not wearing a prosthesis in order of greatest to least risk were nonambulatory before amputation (OR, 9.5), above knee amputation (OR, 4.4), age > 60 years (OR, 2.7), homebound but ambulatory status (OR, 3.0), presence of dementia (OR, 2.4), end-stage renal disease (OR, 2.3), and coronary artery disease (OR, 2.0). Statistically significant preoperative factors independently associated with death in decreasing order of influence included age > or = 70 years (HR, 3.1), age 60 to 69 (HR, 2.5), and the presence of coronary artery disease (HR, 1.5). Statistically significant preoperative factors independently associated with failure of ambulation in decreasing order of influence included age > or = 70 years (HR, 2.3), age 60 to 69 (HR, 1.6), bilateral amputation (HR, 1.8), and end-stage renal disease (HR, 1.4). Statistically significant preoperative factors independently associated with failure to maintain independent living status in decreasing order of influence included age > or = 70 years (HR, 4.0), age 60 to 69 (HR, 2.7), level of amputation (HR, 1.8), homebound ambulatory status (HR, 1.6), and the presence of dementia (HR, 1.6). CONCLUSIONS: Patients with limited preoperative ambulatory ability, age > or = 70, dementia, end-stage renal disease, and advanced coronary artery disease perform poorly and should probably be grouped with bedridden patients, who traditionally have been best served with a palliative above knee amputation. Conversely, younger healthy patients with below knee amputations achieved functional outcomes similar to what might be expected after successful lower extremity revascularization. Amputation in these instances should probably not be considered a failure of therapy but another treatment option capable of extending functionality and independent living.

Aged↗
PubMed2006

Clinical outcomes after closed, staged, and open forefoot amputations.

BACKGROUND: Surgical approaches for forefoot osteomyelitis include amputation with immediate wound closure or resection followed by either staged re-resection and wound closure or local care of the open wound for secondary healing. This study evaluated the effectiveness of closed, staged, and open forefoot amputations in preventing major leg amputation and identified those variables that are associated with successful limb preservation. METHODS: From July 2002 to June 2004, 208 patients with forefoot osteomyelitis or gangrene underwent minor amputation according to a standard treatment algorithm. Wounds with limited cellulitis underwent immediate wound closure (CLOSED), wounds with marginally viable soft tissue underwent open amputation followed by wound closure at 2 to 7 days (STAGED), and wounds with tenosynovitis or extensive necrosis underwent débridement with no attempt at wound closure (OPEN). Patient demographics, need for further operative interventions, time to complete healing, and progression to major amputation were recorded. RESULTS: With four subjects lost to follow-up, 204 patients (98%) (94 CLOSED, 56 STAGED, and 54 OPEN) were monitored to complete healing, major amputation, or death. OPEN amputations had a significantly reduced initial healing rate (37%, P < .001) and a frequent need for repeat operative intervention (43%), although successful limb salvage was ultimately achieved in 70% of the cases. Initial healing in the CLOSED and STAGED amputation groups was similar (71% and 78%, respectively), leading to excellent early limb salvage (86% and 91%). The median time to healing for closed, staged, and open amputations was 1.2, 1.6, and 4.6 months, respectively (P < .001). Follow-up evaluation demonstrated the initial improvements in limb salvage with the CLOSED and STAGED groups were lost, resulting in similar amputation rates among the three groups of 30% to 35% over 36 months. CONCLUSIONS: Although open amputation of extensive forefoot infections frequently requires repeat operative interventions and a prolonged time to complete healing, this approach provides limb salvage rates approaching those observed for less invasive infections amenable to immediate closure. Staged closure offers an improved time to healing without negatively impacting the risk of major limb amputation. Independent of their initial operative approach, these patients frequently progress to early leg amputation.

Activities of Daily Living↗
PubMed1999

Factors predicting lower extremity amputations in patients with type 1 or type 2 diabetes mellitus: a population-based 7-year follow-up study.

OBJECTIVES: The aim of the study was to find factors predicting lower extremity amputation in patients with type 1 or type 2 diabetes mellitus through a 7-year follow-up period. DESIGN: Follow-up study. SUBJECTS: Altogether 733 diabetic patients. aged 10-79 years, were drawn from the national drug reimbursement register. METHODS: At baseline, the patients underwent a podiatric, circulatory and neurophysiological examination. Seven years later a follow-up study was performed based on clinical and register data. Patient data for those who died during the follow-up were collected from hospital records and death certificates. All amputations were recorded. The patients with amputation were compared with the other patients and also, in a case-control manner, by taking three nonamputated patients matched by sex, type of diabetes, and age for each patient with amputation. RESULTS: The number of amputations was 25 in the sample. Compared with all patients without amputation, patients with amputation differed in altogether 24 variables concerning diabetes and its complications. Compared with the matched non-amputated patients, the amputated patients had longer duration of diabetes, lower ankle/brachial pressure index (ABI), more often history of retinopathy, nephropathy, and hypertension, more often visual handicap, elevated serum creatinine level, abnormal neurophysiological indices and electrophysiological findings. In the logistic regression analysis, vibration perception threshold, low ABI, history of retinopathy, visual handicap, and male sex were independently associated with lower extremity amputation. CONCLUSIONS: Lower extremity amputations were strongly associated with retinopathy, nephropathy, and neuropathy. The presence of any of these complications should lead to intensified actions in order to prevent amputations. As far as arterial circulation is concerned, claudication or absent peripheral pulses were not good predictors of amputation, whereas low ABI, despite its known weaknesses, was a reliable indicator of future amputation.

Adolescent↗
PubMed2002

Trends in rehabilitation after amputation for geriatric patients with vascular disease: implications for future health resource allocation.

OBJECTIVE: To assess the effect of demographic changes on rehabilitation of geriatric patients after amputation and the implications for future health resource allocation. DESIGN: Population-based study. SETTING: Olmsted County, MN. PARTICIPANTS: Residents over the age of 65 years who had a major lower-extremity amputation because of peripheral arterial disease between 1956 and 1995. Patients who had amputations between 1956 and 1973 (earlier cohort) were compared with those who had amputations between 1974 and 1995 (later cohort). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Demographic and clinical features, total number of amputations, amputation rates, and rate of successful prosthetic fitting over time. RESULTS: Of 292 patients, 93 had amputations between 1956 and 1973 and 199 between 1974 and 1995. Amputation rates declined after 1985, but the total number of amputations was unchanged. Patients in the later cohort were more likely to have a below-knee amputation (P<.001) and cerebrovascular disease (P=.008) and to be discharged to a nursing home (P<.001). There was no significant difference in median age at amputation, survival, or rates of successful prosthetic fitting over time. CONCLUSION: Although amputation rates have declined, the total number of amputations has increased. The rate of successful prosthetic fitting in the geriatric population has not changed significantly over 40 years. Amputations in the geriatric population in the United States will probably double from 28,000 to 58,000 per year by 2030, requiring considerable resources.

Aged↗
PubMed1998

Diabetes and lower-limb amputations in the community. A retrospective cohort study. DARTS/MEMO Collaboration. Diabetes Audit and Research in Tayside Scotland/Medicines Monitoring Unit.

OBJECTIVE: There are few U.K. data on the incidence rates of amputation in diabetic subjects compared with the nondiabetic population. RESEARCH DESIGN AND METHODS: We performed a historical cohort study of first lower-extremity amputations based in Tayside, Scotland (population 364,880) from 1 January 1993 to 31 December 1994. The Diabetes Audit and Research in Tayside Scotland (DARTS) database was used to identify a prevalence cohort of 7,079 diabetic patients on 1 January 1993. We estimated age-specific and standardized incidence rates of lower-limb amputations in the diabetic and nondiabetic cohorts. Results were compared with a previous study that evaluated lower-extremity amputations in diabetic patients in Tayside in 1980-1982. RESULTS: There were 221 subjects who underwent a total of 258 nontraumatic amputations. Of the 221 subjects, 60 (27%) patients were diabetic (93% NIDDM), and 63% were first amputations. The median duration of diabetes was 6 years (range: newly diagnosed to 41 years). Nonhealing ulceration (31%) and gangrene (29%) were the two main indications for amputation in the diabetic subjects. Of the 161 nondiabetic subjects, 140 (80%) underwent first amputations. The adjusted incidences in the diabetic and nondiabetic groups were 248 and 20 per 100,000 person-years, respectively. Tayside patients with diabetes thus had a 12.3-fold risk of an amputation compared with nondiabetic residents (95% CI 8.6-17.5). The estimated proportion of diabetic patients in the population rose from 0.81% in 1980-1982 to 1.94% in 1993-1994, whereas the absolute rate of amputation in diabetic subjects was unchanged from that in 1980-1982. CONCLUSIONS: These population-based U.K. amputation data are similar to amputation rates in the U.S. Amputation rates appear to have decreased significantly since 1980-1982. The impact of diabetes education and prevention programs that target the processes leading to amputation can now be evaluated.

Adolescent↗