Decrease In Amputation Rates Research Articles

Peripheral vascular trauma - basic management, diagnosis and treatment.

Peripheral vascular injuries occur in 1-3% of all traumas in civilian settings. The management of these injuries is often based on experience derived from war medicine where these injuries are more common. The goal of this article is to summarize basic guidelines for the diagnosis and treatment of vascular injuries. Western Trauma Association (WTA) and Eastern Association for the Surgery of Trauma (EAST) both have their own guidelines for vascular trauma management. Vascular injuries occur both in penetrating and blunt traumas. Complete vessel disruption occurs more frequently in penetrating traumas. In the case of blunt trauma, intimal defects are more common, resulting in dissection, false aneurysm, or intramural hematoma. The limb is mostly endangered due to ischemia, reperfusion injury and the compartment syndrome. Prompt diagnosis and treatment are paramount. Vascular trauma management is part of the ATLS protocol and life-over-limb principle. The primary goal is to stop the massive external bleeding. Clinical examination and CT angiography are the most helpful for the diagnosis. Surgical revision is indicated when hard signs are present. This can be a damage control surgery with the primary goal to stop the bleeding as quickly as possible. A shunt can be used for temporary reperfusion of the limb. Definitive treatment can take the form of a simple suture, patches or graft interposition; both prosthetic and autologous grafts are used. Sufficient debridement and fasciotomy are important steps in the therapy. In some cases, endovascular treatment can be used. Over the last century, the treatment strategy changed dramatically. Data from recent military conflicts show a decrease in amputation rates, and limb salvage has become a standard.

Epidemiology of peripheral artery disease

Peripheral artery disease (PAD) is the clinical manifestation of atherosclerosis that primarily affects peripheral arteries within the lower extremities. In this brief review, we describe the epidemiology and burden of disease of PAD within the United States, particularly among high-risk populations. Although the prevalence of PAD continues to increase and is typically higher among the elderly as well as men, women in lower socioeconomic strata are affected at rates two times that of men. Among racial/ethnic groups, Black and African-American patients both experience higher rates of disease as well as lower rates of access to preventative care. Moreover, despite an overall decrease in amputation rates among all patients with PAD, high-risk populations remain disproportionally affected. Specifically, patients in rural areas, African-American and Native-American patients, and those of low socioeconomic status carry the highest risk of amputation. Efforts to improve care among PAD patients should target these high-risk populations and offer comprehensive, evidence-based preventative care. Wide adoption and integration of these practices into comprehensive care models may help to mitigate amputation in the highest-risk populations. As our treatment pathways continue to evolve, we must place further emphasis on patient input and quality of life as we work toward continual improvement in the care of patients with PAD.

Analysis of the Efficacy of Iloprost Treatment in Amputations Due to Burn.

The aim of our study was to demonstrate the decrease in amputation rates with iloprost treatment in patients who develop vascular injury due to burns. The data of 366 adult burn patients who were admitted to the emergency department of our hospital between 2016 and 2019 were analyzed. Demographic characteristics, burn factors, vascular examination findings, medical treatments, amputation rates, and levels were recorded. The amputation rates of the patients who were treated with iloprost and who were not treated with iloprost were compared. The mean age of 366 adult patients treated for burns was 37.8 ± 16.4 years, and of these patients, 220 (59.9%) were under 40 years of age. Although heat burns (n = 331.85%) were the most common burn etiology, it was found that the incidence of vascular injury was higher in burns caused by electricity (11.7%) and cold (3.3%) (P < 0.001). Vascular injury was detected in 60 (16.3%) of the patients and 21 (35%) of these patients were treated with iloprost. Amputation was observed in 20 (5.5%) of all burn patients, but only one of the patients treated with iloprost underwent amputation (P < .001). The individual and social impacts of amputations caused by burns are unquestionable. The authors are of the opinion that iloprost treatment is effective in reducing amputations due to burns.

Increasing the Therapeutic Potential of Stem Cell Therapies for Critical Limb Ischemia.

Peripheral Arterial Disease (PAD) is a progressive, atherosclerotic disease that at its end stage, Critical Limb Ischemia (CLI), results in severely diminished limb perfusion and causes leg pain at rest, non-healing ulcers, and tissue gangrene. Many patients with CLI fail current medical and surgical therapies and thus are deemed “no option” and require limb amputation. Novel therapies to attempt limb salvage in these “no option” patients are needed. Stem cell therapy is one therapeutic angiogenic avenue that has been tested over the last 20 years. To date, clinical trials have shown promise but with only modest improvement and none demonstrated a significant decrease in amputation rates in those treated with stem cell therapy. Thus, recent investigations into improving stem cell therapy have been the focus of our laboratory and many others. This review aims to describe recent advances in increasing the therapeutic potential of stem cell therapies for CLI.

Clinical study on surgical treatment of lower extremity chronic ischemia caused by arteriosclerosis obliterans of lower extremity-analysis of 4 602 cases

Objective The incidence of chronic lower limb ischemia caused by arteriosclerotic obliteration of lower extremities is increasing recent years and there is a high risk of amputation and mortality. This study was to find out the changes in a single center for 16 years. Methods A retrospective analysis of the data of patients in single-center vascular surgery in the past 16 years was carried out. The patients with chronic lower limb ischemia caused by lower limb arteriosclerosis obliterans were screened out, and the data of operation information, amputation, length of stay and hospitalization expenses during hospitalization were collected. Results A total of 4 602 patients were included, of whom 57.39% were diabetic. It was found that the number of patients admitted, the number of endovascular treatment, the average cost of hospitalization increased year by year, and the average length of hospitalization decreased year by year. The amputation rate decreased from 8.12% (from 2002 to 2007) to 0.92% (from 2008 to 2017) (P<0.01). The average days of hospitalization decreased from 28.20 days (from 2002 to 2007) to 11.65 days (from 2008 to 2017) (P<0.01). The average hospitalization cost rose from 54 466.94 yuan (from 2002 to 2007) to 73 685.22 yuan (from 2008-2017) (P<0.01). There was no significant difference in amputation rate, hospitalization days and hospitalization costs between diabetic group and non-diabetic group. In diabetic subgroup, amputation rate decreased from 8.83% (between 2002 and 2007) to 1.05% (between 2008 and 2017) (P<0.01). The average hospitalization days decreased from 30.12 days (between 2002 and 2007) to 12.60 days (between 2008 and 2017) (P<0.01). The average cost of hospitalization rose from 58 530.94 yuan (between 2002 and 2007) to 74 433.75 yuan (between 2008 and 2017) (P<0.01). Conclusions From 2002 to 2017, the number of patients with chronic lower limb ischemia increased gradually, and so as the number of endovascular treatment. While the amputation rate and average hospitalization time decreased, and the average hospitalization cost increased. The same trend was observed in the diabetic subgroup. The significant decrease in amputation rate may be related to the development of endovascular therapy and angiogenesis therapy. Key words: Arteriosclerosis obliterans/CO; Lower extremity/BS; Ischemia/ET; Diabetes mellitus; Amputation

Vascular Reconstruction Is Not Warranted in Most Civilian Traumatic Shank Vascular Injuries

Operative management of traumatic shank vascular injuries (SVI) evolved significantly in the past few decades, thereby leading to a dramatic decrease in amputation rates. However, there is still controversy regarding the minimum number of patent shank arteries sufficient for limb salvage. Between January 2006 and September 2011, 191 adult trauma patients presented to an urban level I trauma center in Miami, Florida, with traumatic lower extremity vascular injuries. Variables collected included age, gender, mechanism of injury, and clinical status at presentation. Surgical data included vessel injury, technical aspects of repair, associated complications, and outcomes. A total of 48 (25.1%) patients were identified comprising 66 traumatic shank arterial injuries. Mean age was 38.2±13.4years, and the majority of patients were men (40 patients, 83.3%) presenting with blunt injuries (35 patients, 72.9%). Ligation was performed in 38 injured arteries (57.6%) and no vascular intervention was required in 20% of the patients. Vascular reconstruction was performed in only 6 patients (9.1%): 4 (6.1%) with concurrent popliteal trauma, 1 (1.5%) isolated anterior tibial, and 1 (1.5%) 3-vessel injury. Autogenous venous interposition conduit and polytetrafluoroethylene grafting were performed in 5 (7.6%) and 1 (1.5%) patient, respectively. All amputations (8 patients, 16.7%) occurred in blunt trauma patients presenting with unsalvageable limbs. The overall mortality rate in this series was 2.1%. Civilian shank arterial injuries are associated with acceptable rates of limb loss. Patients with a single-vessel patent inflow did not require vascular reconstruction in this series. Arterial reconstruction may no longer be determinant for successful management of isolated and double arterial SVI, whereas it is yet essential in the presence of 3-vessel or concurrent above-the-knee vascular injuries. Further investigation including larger number of patients is still warranted to define the role of conservative management in these complex injuries.

Shank vessel injuries: the forgotten vascular injuries.

Vascular injuries in branch vessels of the popliteal artery, such as the tibioperoneal trunk, and shank vessels, such as anterior, posterior tibial, and peroneal vessels, occur in both blunt and penetrating trauma. Their management has evolved significantly in the past few decades. While their incidence is variable, limb loss and morbidity remain significant. Physical examination, along with measuring an Ankle-Brachial Index (ABI), is still sometimes all that is required for diagnosis and can expeditiously triage those that require urgent operation. Despite our technological advancements and newer algorithms for lower extremity vascular trauma, operative intervention and exposure still remain difficult and pose a great challenge for surgeons that normally do not operate on this area. Shank vessel injuries still comprise a significant proportion of combat and civilian vascular injuries, and modern advances have led to a dramatic decrease in amputation rates.

Diagnostics and treatment of the diabetic foot

Every 30 s, a lower limb is amputated due to diabetes. Of all amputations in diabetic patients 85% are preceded by a foot ulcer which subsequently deteriorates to a severe infection or gangrene. There is a complexity of factors related to healing of foot ulcers including strategies for treatment of decreased perfusion, oedema, pain, infection, metabolic disturbances, malnutrition, non-weight bearing, wound treatment, foot surgery, and management of intercurrent disease. Patients with diabetic foot ulcer and decreased perfusion do often not have rest pain or claudication and as a consequence non-invasive vascular testing is recommended for early recognition of ulcers in need of revascularisation to achieve healing. A diabetic foot infection is a potentially limb-threatening condition. Infection is diagnosed by the presence or increased rate of signs inflammation. Often these signs are less marked than expected. Imaging studies can diagnose or better define deep, soft tissue purulent collections and are frequently needed to detect pathological findings in bone. The initial antimicrobial treatment as well as duration of treatment is empiric. There is a substantial delay in wound healing in diabetic foot ulcer which has been related to various abnormalities. Several new treatments related to these abnormalities have been explored in wound healing with various successes. An essential part of the strategy to achieve healing is an effective offloading. Many interventions with advanced wound management have failed due to not recognizing the need for effective offloading. A multidisciplinary approach to wounds and foot ulcer has been successfully implemented in different centres with a substantial decrease in amputation rate.

Improved amputation-free survival in unreconstructable critical limb ischemia and its implications for clinical trial design and quality measurement

Amputation-free survival (AFS), a composite endpoint of mortality and amputation, is the preferred outcome measure in critical limb ischemia (CLI). Given the improvements in systemic management of atherosclerosis and interventional management of limb ischemia over the past 2 decades, we examined whether these outcomes have changed in patients with CLI without revascularization options (no option-critical limb ischemia [NO-CLI]). We reviewed the literature for published 1-year AFS, mortality, and amputation rates from control groups in NO-CLI trials. Summary proportions of events were estimated by conducting a random effects meta-analysis of proportions. To determine whether there had been any change in event rates over time, we performed a random effects meta-regression and a mixed effects logistic regression, both regressed against the variable "final year of recruitment." Eleven trials consisting of 886 patients satisfied search criteria, 7 of which presented AFS data. Summary proportion of events (95% confidence interval) were 0.551 (0.399 to 0.693) for AFS; 0.198 (0.116 to 0.317) for death; and 0.341 (0.209 to 0.487) for amputation. Regression analyses demonstrated that AFS has risen over time as mortality rates have fallen, and these improvements are statistically significant. The decrease in amputation rates failed to reach statistical significance. The lack of published data precluded a quantitative evaluation of any change in the clinical severity or comorbidities in the NO-CLI population. AFS and mortality rates in NO-CLI have improved over the past 2 decades. Due to declining event rates, clinical trials may underestimate treatment effects and thus fail to reach statistical significance unless sample sizes are increased or unless a subgroup with a higher event rate can be identified. Alternatively, comparing outcomes to historical values for quality measurement may overestimate treatment effects. Benchmark values of AFS and morality require periodic review and updating.

How can we reduce amputations?

Never in the history of diabetes has there been so much known about the diabetic foot and yet the number of amputations continues to rise in England, Scotland, Europe1 and the USA.2 Indeed, in the USA the number of amputations has increased from 36,000 in 1980 to 54,000 in 1990 and 86,000 in 1996. Doubtless the increase in the incidence of diabetes has played a role in these rather depressing statistics but the question remains: how can we reduce both the relative and absolute numbers of diabetes-related amputations? In fact, a number of major advances have taken place in the last decade. Diabetic foot programmes that enthusiastically promote preventive foot care, professional protective footwear, education of patients and staff, a multidisciplinary approach to healing ulcers with aggressive management of infection and ischaemia have achieved a substantial decrease in amputation rates.3 But the widespread application of these programmes has been hindered by misunderstandings, misconceptions and simple lack of awareness of advances in foot care. Accurate diagnosis of the neuropathic and the neuroischaemic foot; Efficient relief of the mechanical forces that have led to ulceration; Early diagnosis and aggressive treatment of infection; Regular debridement of ulcers and urgent removal of necrotic tissue from the infected foot; Revascularisation of the neuroischaemic foot with either angioplasty or bypass, if there is extensive tissue deficit or if ulceration does not respond to conservative treatment; The use of modern active wound healing techniques if ulcers do not respond to standard treatment; Tight control of blood glucose to accelerate healing and reduce infection; Early diagnosis of the Charcot foot and immobilisation of same to prevent deformity; Screening all diabetic patients for neuropathy, ischaemia, deformity and oedema, and education of those at risk to protect them from ulceration; The provision of diabetic foot care within a multidisciplinary foot clinic. How can we organise services such that there will be equitable access to a multidisciplinary clinic for all patients? What are the possibilities for an annual foot check for every patient? How can we make distal bypass surgery and distal angioplasty readily available to all patients? Is it right that in one instance a patient with a neuroischaemic foot can have a successful distal bypass and return to full mobility, and another with a similar foot have a below-the-knee amputation and possibly never walk again? Offloading of high pressures in the neuropathic foot is fundamental and the total contact cast may be regarded as a gold standard treatment. Why then is it used so infrequently within Europe and the USA? How far have we progressed with appropriate insoles and footwear? What educational strategies have been developed and proven to work in the diabetic foot? Should diabetic foot patients be admitted to the medical or surgical ward and, after admission, who should look after them? Who is responsible for the overall provision of footwear to all people with diabetes in a health district? The crucial task now is to address these and other questions and to debate how guidelines and consensus can be implemented and transformed into best clinical practice for all diabetic foot patients. We hope this will be facilitated by an ongoing Best Practice Round Table discussion to be held within the diabetesonestop.com website, in association with Practical Diabetes International. As a further step in the process, this year's Practical Diabetes International Foot Conference, to be held at the Royal College of Physicians, London, on 29 November 2001*, will be devoted to the theme of “How can we reduce amputations?” and the results of this debate will be published in the journal and on the web. We hope readers of this journal will attend the meeting and participate in the website discussion. There is good evidence that amputations can be reduced. There is a way, but it requires effort, time and resources. Do we really have the will or shall we just admit that the diabetic foot is too great a burden to bear?

American Diabetes Association 60th Scientific Sessions, 2000: the diabetic foot.

This is the seventh in a continuing series of articles on the American Diabetes Association (ADA) 60th Scientific Sessions held in San Antonio, TX, in June 2000. It covers topics related to the diabetic foot. Gayle E. Reiber, Seattle, WA, gave the Roger Pecoraro Lecture on the economics of lower-limb amputations in diabetes. A number of clinicians over recent decades have implemented programs leading to substantial decreases in amputations among participants in the U.S. and Europe. However, the target of a 40% decrease in amputation rates, based on these studies and set more than a decade ago, has not been met, and rates have actually increased. With the aging of the populations of the U.S. and Europe and the greater prevalence of diabetes, amputation rates and costs may increase further. Using the Veterans Administration system and Medicare data sets in the U.S. and the Cost of Diabetes in Europe, Type 2 (CODE-2) data set, Reiber presented trends for foot ulcers. There are ∼300,000 hospitalizations annually for foot cellulitis, ulcers, and deep infections among individuals with diabetes and 400,000 hospitalizations among individuals without diabetes in the U.S. Amputation rates are increasing among patients with diabetes, while decreasing among those without diabetes. In 1999, there were ∼92,000 amputations among those with and 42,000 among those without diabetes. There are tremendous variations among regions in the U.S. in the frequency of amputations and footwear prescriptions. However, <1% of Medicare patients in the U.S. obtained therapeutic footwear in 1995. Low-level amputations comprise 53% of the total, and this fraction has increased over recent years, suggesting improved limb preservation. Direct costs in the U.S. are ∼$17,000 for an episode of foot infection and $35,000 for a hospitalization leading to amputation. Reiber noted that reimbursement rates are well below these charges. Revascularization rates have tripled over …

Assessment and Management of Foot Disease in Patients with Diabetes

Limb- or life-threatening complications in patients with diabetes can be prevented with an integrated, multidisciplinary approach. Most patients seen in clinical practice are in the early stages of the disease process. Glycemic control retards the progression of neuropathy, which is the most important risk factor for ulceration. Early detection of the loss of protective sensation and implementation of strategies to prevent ulceration will reduce the rates of limb-threatening complications. Clinicians should routinely examine the feet of diabetic patients. Education in foot care, proper footwear, and close follow-up are required to prevent or promptly detect neuropathic injury. If ulceration occurs, removal of pressure from the site of the ulcer and careful management of the wound will allow healing in most cases. The failure to heal despite these measures should prompt a search for associated arterial insufficiency. If infection is present, appropriate antimicrobial therapy combined with immediate surgical intervention, including revascularization when necessary, will increase the chances of saving the limb. With this comprehensive approach, it is possible to achieve the goal of a 40 percent decrease in amputation rates among diabetic patients by the year 2000.

Halving the number of leg amputations: The influence of infrapopliteal bypass

A retrospective review of amputations in patients with vascular disease during 10 years in Bispebjerg Hospital was undertaken. There were 1383 amputations leading to 1167 final level amputations. In previously independent patients there were 482 below knee amputations (BKA), 476 above knee amputations (AKA) and 43 had disarticulations in the ankle, knee or hip. During the period studied the number of final level amputations in independent patients were halved from 122 in 1981 to 58 in 1990. A similar reduction was also found in the total number of amputations: from 171 to 90, and in the number of reamputations: from 35 to 21. However, amputations in patients from long stay institutions remained at a constant level by on average 17 per year. The decrease in amputation rate took place synchronously with an increasing use of bypass to crural and pedal arteries as well as an overall increase in vascular reconstructions and angioplasties of more than 100%. However, the BKA/AKA ratio decreased from 1.12 to 0.67 (p < 0.005).