Dysvascular Lower Limb Amputation Research Articles

Perceptions of physical activity among individuals with limb loss: A qualitative study.

Individuals with lower-limb amputations (LLA) often have deficits in balance and community walking ability. As a result, people with LLA are often sedentary. The aim of this study was to explore perceptions of physical activity from the perspective of people with LLA. A qualitative descriptive study situated within an interpretive research paradigm was conducted. Semistructured interviews were held by telephone or in person with adults living with major LLAs recruited from rehabilitation hospitals and advertisements on social media. Individuals were included if they were age 18 years and older with a major LLA. Purposive sampling was used to ensure variation by sex, cause, and level of amputation. Thirty-three people with LLA participated (22 men/11 women; median age 63 years). The majority of individuals had a unilateral, transtibial amputation (∼50% dysvascular LLA). Three main themes were developed to characterize participants' perceptions of physical activity: (1) physical activity is perceived as important but can be challenging after amputation; (2) physical activity has physical and mental health benefits; and (3) physical activity is a means to maintain independence and engagement in community and social life. Obtaining the perspectives of individuals with LLA about physical activity helps us understand how they think about it, what motivates them, and how we can optimize physical activity levels. Future research is needed to evaluate the effectiveness of interventions to enhance physical activity in this population.

Association of Race, Ethnicity, and Gender to Disparities in Functional Recovery and Social Health After Major Lower Limb Amputation: A Cross-sectional Pilot Study

ObjectiveTo assess if evidence of disparities exists in functional recovery and social health post-lower limb amputation. DesignRace-ethnicity, gender, and income-based group comparisons of functioning and social health in a convenience sample of lower limb prosthetic users. SettingProsthetic clinics in 4 states. ParticipantsA geographically diverse cohort of 56 English and Spanish speaking community-dwelling individuals with dysvascular lower limb amputation, between 18-80 years old. InterventionsNone. Main Outcomes MeasuresPrimary outcomes included 2 physical performance measures, the Timed Up and Go test and 2-minute walk test, and thirdly, the Prosthetic Limb Users Survey of Mobility. The PROMIS Ability to Participate in Social Roles and Activities survey measured social health. ResultsOf the study participants, 45% identified as persons of color, and 39% were women (mean ± SD age, 61.6 (9.8) years). People identifying as non-Hispanic White men exhibited better physical performance than men of color, White women, and women of color by -7.86 (95% CI, -16.26 to 0.53, P=.07), -10.34 (95% CI, -19.23 to –1.45, P=.02), and -11.63 (95% CI, -21.61 to –1.66, P=.02) seconds, respectively, on the TUG, and by 22.6 (95% CI, -2.31 to 47.50, P=.09), 38.92 (95% CI, 12.53 to 65.30, P<.01), 47.53 (95% CI, 17.93 to 77.13, P<.01) meters, respectively, on the 2-minute walk test. Income level explained 14% and 11% of the variance in perceived mobility and social health measures, respectively. ConclusionsStudy results suggest that sociodemographic factors of race-ethnicity, gender, and income level are associated with functioning and social health post-lower limb amputation. The clinical effect of this new knowledge lies in what it offers to health care practitioners who treat this patient population, in recognizing potential barriers to optimal recovery and quality of life. More work is required to assess lived experiences after amputation and provide better understanding of amputation-related health disparities.

Phantom Limb Pain and Painful Neuroma After Dysvascular Lower-Extremity Amputation: A Systematic Review and Meta-Analysis.

Phantom limb pain (PLP) and symptomatic neuroma can be debilitating and significantly impact the quality of life of amputees. However, the prevalence of PLP and symptomatic neuromas in patients following dysvascular lower limb amputation (LLA) has not been reliably established. This systematic review and meta-analysis evaluates the prevalence and incidence of phantom limb pain and symptomatic neuroma after dysvascular LLA. Four databases (Embase, MEDLINE, Cochrane Central, and Web of Science) were searched on October 5th, 2022. Prospective or retrospective observational cohort studies or cross-sectional studies reporting either the prevalence or incidence of phantom limb pain and/or symptomatic neuroma following dysvascular LLA were identified. Two reviewers independently conducted the screening, data extraction, and the risk of bias assessment according to the PRISMA guidelines. To estimate the prevalence of phantom limb pain, a meta-analysis using a random effects model was performed. Twelve articles were included in the quantitative analysis, including 1924 amputees. A meta-analysis demonstrated that 69% of patients after dysvascular LLA experience phantom limb pain (95% CI 53-86%). The reported pain intensity on a scale from 0-10 in LLA patients ranged between 2.3 ± 1.4 and 5.5 ± .7. A single study reported an incidence of symptomatic neuroma following dysvascular LLA of 5%. This meta-analysis demonstrates the high prevalence of phantom limb pain after dysvascular LLA. Given the often prolonged and disabling nature of neuropathic pain and the difficulties managing it, more consideration needs to be given to strategies to prevent it at the time of amputation.

Disparities in functional recovery after dysvascular lower limb amputation are associated with employment status and self-efficacy

Purpose Employment status is considered a determinant of health, yet returning to work is frequently a challenge after lower limb amputation. No studies have documented if working after lower limb amputation is associated with functional recovery. The study's purpose was to examine the influence of full-time employment on functioning after lower limb amputation. Methods Multisite, cross-sectional study of 49 people with dysvascular lower limb amputation. Outcomes of interest included performance-based measures, the Component Timed-Up-and-Go test, the 2-min walk test, and self-reported measures of prosthetic mobility and activity participation. Results Average participant age was 62.1 ± 9.7 years, 39% were female and 45% were persons of color. Results indicated that 80% of participants were not employed full-time. Accounting for age, people lacking full-time employment exhibited significantly poorer outcomes of mobility and activity participation. Per regression analyses, primary contributors to better prosthetic mobility were working full-time (R 2 ranging from 0.06 to 0.24) and greater self-efficacy (R 2 ranging from 0.32 to 0.75). Conclusions This study offers novel evidence of associations between employment and performance-based mobility outcomes after dysvascular lower limb amputation. Further research is required to determine cause-effect directionalities. These results provide the foundation for future patient-centered research into how work affects outcomes after lower limb amputation. IMPLICATIONS FOR REHABILITATION Lower limb amputation can pose barriers to employment and activity participation, potentially affecting the quality of life. This study found that the majority of people living with lower limb amputation due to dysvascular causes were not employed full-time and were exhibiting poorer prosthetic outcomes. Healthcare practitioners should consider the modifiable variable of employment when evaluating factors that may affect prosthetic mobility. The modifiable variable of self-efficacy should be assessed by healthcare professionals when evaluating factors that may affect prosthetic mobility.

Self-reported health condition severity and ambulation status postmajor dysvascular limb loss.

Individuals with dysvascular lower limb amputations (LLA) secondary to complications of peripheral arterial disease (PAD) and/or diabetes have high rates of co-morbidities. To describe self-reported health condition severity and their association with sociodemographic factors and ambulations status among individuals with major dysvascular LLA. Cross sectional telephone and in person survey with adults with major dysvascular LLA living in the community setting in Ontario, Canada. Survey by phone/in person, and completion of the Dysvascular Conditions Scale and Special Interest in Amputee Medicine Mobility (SIGAM) Grade by each participant. Two hundred thirty-one individuals with major dysvascular LLAs participated in the study. Most of them were male individuals (80.5%) and had undergone a transtibial amputation (74%). On average, participants were 3.4 years postlimb loss and had five identified Dysvascular Conditions Scale health conditions. The top five reported health conditions were diabetes, hypertension, phantom limb pain, musculoskeletal pain, and back pain. With the exclusion of hypertension, these conditions were also perceived by respondents to be quite severe for their impact. Vision impairment was also rated as being severe in nature. Lower mobility Special Interest Group in Amputee Medicine grades were associated with higher health condition severity scores. Individuals with dysvascular limb loss experience high multimorbidity with perceived negative impact on their overall wellness and function. Rehabilitation and self-management strategies to help patients with dysvascular LLAs to manage chronic health conditions may improve outcomes.

Psychosocial Factors Influence Physical Activity after Dysvascular Amputation: A Convergent Mixed-Methods Study.

Physical function is a common target of rehabilitation intervention to improve disability and physical activity after dysvascular lower-limb amputation (LLA); yet, the influence of psychosocial factors on physical activity is unclear. To identify psychosocial factors with potential to influence clinically relevant measures of physical activity, physical function, and disability in light of participants' narratives. Convergent mixed-methods. General community. Twenty participants with dysvascular LLA were enrolled if their most recent LLA was at least 1year prior, they were ambulating independently with a prosthesis, and were between 45 and 88 years old. Not applicable. Quantitative data included physical activity (activPAL; steps/d), physical function (Timed Up-and-Go; TUG), and disability (World Health Organization Disability Assessment Schedule 2.0; WHODAS 2.0). Qualitative data were collected via semistructured interviews. Higher steps/d was moderately correlated with better TUG time (r = -.58, P< .01), but was not correlated with WHODAS 2.0 score (r = -0.18; P> .10). Qualitative analysis of interviews, using an inductive, team-based, phenomenological approach, identified four themes: (1) perceptions of their prosthesis, (2) fear during mobility, (3) influence of LLA on life activities, and (4) positive outlook within social interactions. Mixed-methods analysis used an iterative approach to interpret and describe how psychosocial factors influence physical activity in four exemplar cases. Physical activity in people with dysvascular LLA results from an interaction among perceptions of their prosthesis, fear during mobility, influence of LLA on life activities, and positive outlook within social interactions. The overlapping nature of these themes suggests that interventions targeting psychosocial factors may be associated with improved physical activity, physical function, and subsequent disability after dysvascular LLA.

Falls After Dysvascular Transtibial Amputation: A Secondary Analysis of Falling Characteristics and Reduced Physical Performance.

Over half of all people with lower limb amputation (LLA) experience at least one fall annually. Furthermore, the majority of LLAs result from dysvascular health complications, contributing to balance deficits. However, fall-related research specific to dysvascular LLA remains limited. To characterize falls among adults with dysvascular LLA, using an existing Fall-Type Classification Framework and to describe the functional characteristics of participants across the framework categories. Secondary data analysis from two randomized controlled trials. Outpatient setting. People (n = 69) 6 months to 5 years from dysvascular lower extremity amputation, who were ≥50 years of age and independently ambulatory using a prosthesis. None. Descriptions of self-reported falls were collected on a weekly basis for 12 weeks, and analyzed using an existing Fall-Type Classification Framework. Fall frequencies, estimated count, and estimated proportions were compared across all framework categories, with 95% confidence intervals. Functional measures (Timed Up and Go, Two Minute Walk, Five Meter Walk, and average step count) were collected, and averages for each participant who experienced a fall were calculated. Thirty participants (43.5%) reported 42 falls within 12 weeks. A variety of fall types were described. Incidence of falls was highest for intrinsic destabilization sources, from incorrect weight shift patterns during transfer activities. Patients with dysvascular LLAs experience a variety of fall types. The high frequency of intrinsically sourced, incorrect weight-shift falls during transfer activities emphasizes the need to focus rehabilitation efforts on improving postural control in patients with dysvascular LLAs during activities such as reaching, turning, and transferring.

Mortality, Reamputation, and Preoperative Comorbidities in Patients Undergoing Dysvascular Lower Limb Amputation

Historically, mortality rates after major lower limb amputations (LLAs) have been very high. However, there are inconsistencies regarding the risk factors. The reamputation rate after major LLAs is largely unknown. The aim of this study is to report the 30-day and 1-year mortality and 1-year reamputation rates after major LLA and to identify potential risk factors. An observational cohort study in which all patients undergoing dysvascular major LLA in 2012-2013 in 12 hospitals in the northern region of the Netherlands is included. Of total 382 patients, who underwent major LLA, 65% were male and the mean age (standard deviation [SD]) was 71.9±12.5years. Peripheral arterial disease was observed in 88% and diabetes mellitus (DM), in 56% of patients. No revascularization or prior LLA on the amputated side was observed among 26%, whereas 56% had no minor or major LLA on either limb before the study period. The 30-day and 1-year mortality rates were 14% and 34%, respectively. Patients aged 75-84 and>85years had 3-4 times higher odds of dying within 1year. Transfemoral amputations (odds ratio [OR], 2.2), history of heart failure (OR, 2.3), myocardial infarction (OR, 1.7), hemodialysis (OR, 5.7), immunosuppressive medication (OR, 2.8), and guillotine amputations (OR, 5.1) were independently associated with 1-year mortality. Twenty-six percent underwent ipsilateral reamputation within 1year, for which no risk factors were identified. The mortality rate in the first year after major LLA is high, particularly among those undergoing transfemoral amputations, which is likely to be indicative of more severe vascular disease. Higher mortality among the most elderly patients, those with more severe cardiac disease and who underwent hemodialysis reflects the frailty of this population. Interestingly, DM, revascularization history, and prior minor or major LLA were not associated with mortality rates.

The Perspectives and Experiences of Individuals with Dysvascular Lower Limb Amputation: A Qualitative Study

The Perspectives and Experiences of Individuals with Dysvascular Lower Limb Amputation: A Qualitative Study

Physical Function and Pre-Amputation Characteristics Explain Daily Step Count after Dysvascular Amputation.

People with dysvascular lower limb amputation (LLA) achieve one-third of the recommended steps per day and experience severe disability. Although physical function improves with rehabilitation after dysvascular LLA, physical activity remains largely unchanged, and factors contributing to limited daily step count are unknown. To identify factors that contribute to daily step count after dysvascular LLA. Cross-sectional, secondary data analysis. Outpatient rehabilitation facilities. Fifty-eight patients with dysvascular major LLA (age: 64 ± 9 years, body mass index: 30 ± 8 kg/m2 , male: 95%, transtibial LLA: 95%). Data were collected by a blinded assessor after dysvascular LLA. Candidate explanatory variables included (1) demographics, (2) LLA characteristics, (3) comorbidities and health behaviors, and (4) physical function. Variables with univariate associations with log steps/day (transformed due to non-normality) were included in a multiple linear regression model using backward elimination to identify factors that explained significant variability in log steps/day. The primary outcome, daily step count, was measured with accelerometer-based activity monitors worn by participants for 10 days. Participants took an average (± SD) of 1450 ± 1309 steps/day. After backward elimination, the final model included four variables explaining 62% of the overall daily step count (P < .0001): 2-minute walk distance (32%), assistive device use (11%), cardiovascular disease (10%), and pre-amputation walking time (11%). Average daily step count of 1450 steps/day reflects the lowest category of sedentary behavior. Physical function, cardiovascular disease, and pre-amputation walking time explain 62% of daily step count after dysvascular LLA. Although physical rehabilitation commonly focuses on improving physical function, interventions to increase daily step count after dysvascular LLA should also consider chronic disease and health behaviors that predate LLA. III.

A Depiction of Rehabilitation Patients 65 Years and Younger With Dysvascular Lower Extremity Amputation.

The majority of lower limb amputations (LLA) in Canada are dysvascular due to complications of diabetes and/or vascular disease. Traditionally dysvascular amputations have occurred in the elderly. With younger onset of adult diabetes, amputations are now occurring in non-geriatric populations. An understanding of younger patients with dysvascular LLA is needed to determine their risk factors, and unique health and psychosocial challenges. To obtain a depiction of the key demographic and impairment characteristics of adults 65 years and younger with dysvascular LLA undergoing inpatient rehabilitation. A retrospective chart review was completed on inpatient adult amputation rehabilitation patients over a five year period. Data extracted included socio-demographics, Functional Independence Measure (FIM) scores, comorbidities, and discharge outcomes. One hundred and forty-three patients who were 65 years and younger were included, which represented almost a quarter of all admissions. Most patients were male (79%) with an average age of 55 years old (SD=8). The majority (72%) were unemployed. The mean number of co-morbidities was 5.2 (SD=8.2). Individuals discharged home (n=122) had higher (p<0.05) FIM scores than those readmitted to acute care or discharged to long-term care (n=20). Similar to the literature on older dysvascular LLA patients, our study found high rates of disability and co-morbidities in younger patients with dysvascular LLA, which might impact their ability to work. Given these challenges, better amputation prevention strategies and targeted rehabilitation programming for this population are needed.

Pre-operative rehabilitation for dysvascular lower-limb amputee patients: A focus group study involving medical professionals.

BackgroundMajor lower-limb amputation (LLA) predisposes patients post-operatively to a significant decline in daily-life functioning. The physical condition of amputee patients prior to surgery is significantly deteriorated due to chronic peripheral vascular disease (PVD) and diabetes, which accounts for the majority of LLAs in the adult population. A common strategy called pre-rehabilitation has been used in multiple patient populations to prepare the patient for undergoing a surgical event and to improve post-operative patient outcomes. Pre-rehabilitation might enhance the outcome of dysvascular LLA patients and reduce the high post-operative mortality rates. However, experience of experts with pre-rehabilitation and feasibility of a pre-rehabilitation program in this group remains unknown.ObjectiveTo investigate the experiences of medical professionals and researchers in the field of LLA with the use of pre-rehabilitation in general and in particular PVD patients. Additionally, the study examines their opinions regarding need for and feasibility of a pre-rehabilitation program for dysvascular patients at risk for an LLA.MethodsTwo explorative focus group discussions were organized with in total 16 experts in the field of treatment and research of LLA. Transcribed data were coded using the Atlas.ti software package. Thematic analysis with inductive approach was opted to arrange and interpret codes.ResultsThe experiences of the experts with pre-rehabilitation in dysvascular patients were scarce. The experts described dysvascular patients at risk for an LLA as a difficult group for pre-rehabilitation due to short time window prior to surgery, older age, multiple co-morbidities and lack of motivation for behavioral change. The experts concluded that a pre-rehabilitation program should focus on patients who have sufficient time in advance before the amputation for pre-rehabilitation and who are motivated to participate.ConclusionAlthough in general the effects of pre-rehabilitation are promising, pre-operative rehabilitation in dysvascular patients at risk for an LLA seems not feasible. Future research could focus on a better monitoring of dysvascular patients and the development of pre-rehabilitation in subgroups of younger dysvascular LLA patients.

Age and health-related quality of life, general self-efficacy, and functional level 12 months following dysvascular major lower limb amputation: a prospective longitudinal study

Aim: This study investigates the effect of time and age on health-related quality of life, general self-efficacy, and functional level 12 months following dysvascular major lower limb amputation (LLA).Methods: A prospective cohort study design with assessments at baseline and follow-up 3, 6, and 12 months post-amputation. Data were collected via in-person interviews using Short Form 36, the General Self-efficacy scale and Barthel Index 100. Out of a consecutive sample of 103 patients having dysvascular major LLA (tibia, knee, or femoral), 38 patients completed the study. Outcome at follow-up was compared with baseline and analyzed in age groups.Results: All SF36 subscale scores were below population norms at baseline. At 12 months, two out of eight scores—physical function and role-physical—had not improved. Different patterns of change over the 12 months were detected among the subscales, and psychosocial problems persisted and fluctuated throughout the 12 months in all age groups. Large differences were identified between age groups in physical function with the loss of physical function almost solely evident among the oldest (aged 75+ years) patients.Conclusions: Special attention should be given to the oldest patients need for rehabilitation so that they gain higher quality of life.Implications for rehabilitationPsychosocial problems persist and fluctuate throughout the first 12 months after major LLAs in all age groups and rehabilitation services should include psychosocial support throughout the first year to all patients independent of age.Waiting for an unnecessarily long period of time for a prosthesis can negatively impact both physical and psychosocial aspects of health-related QOL, and interventions to reduce waiting time are warranted.Differences between age groups in functional level after 12 months exist, with the loss of function almost solely evident among the oldest patients (aged 75+ years). A special focus should be given to the oldest patients’ need of everyday rehabilitation to regain basic physical functions.

A prospective study of short-term functional outcome after dysvascular major lower limb amputation

This study investigates functional status on Day 21 after dysvascular major lower limb amputation compared with one month pre-amputation and evaluates factors potentially influencing outcome. MethodsA prospective cohort study design was used. Data were collected via in-person interviews using structured instruments and covered functional level (Barthel index 100) one month pre-amputation and on Day 21. Out of a consecutive sample of patients having major lower limb amputation (tibia, knee or femoral) (n = 105), 51 participated on Day 21 follow-up. Clinical, demographic, body function and environmental data were analysed as factors potentially influencing outcome. ResultsFrom pre-amputation to Day 21, participants' functional level decreased significantly in all ten activities of daily living activities as measured by the Barthel Index.Almost 60% of participants were independent in bed-chair transfer on Day 21. Being independent in transfer on Day 21 was positively associated with younger age and attending physiotherapy after discharge. ConclusionsThe findings indicate that short-term functional outcome is modifiable by quality of the postoperative care provided and thus highlights the need for increased focus on postoperative care to maintain basic function as well as establish and provide everyday rehabilitation in the general population of patients who have dysvascular lower limb amputations.

Guest Editorial Wearable Robotics for Motion Assistance and Rehabilitation

The number of people aged 60 years and over has tripled since 1950, and reached 600 million in 2000 and 700 million in 2006. This number is now projected to surpass 2 billion by 2050 [1]. The rise in life expectancy combined with falling birth rates will accelerate the ageing of the population; prevalence and incidence of age-related diseases are expected to increase in the years to come. Therefore, we can expect that pathologies like stroke, dysvascular lower limb amputations, Parkinson disease, and/or the more common consequences of the ageing process, such as falls and biomechanics degradation, will increase the number of humans with severe to mild level of movement impairments: this will definitely threaten the sustainability of our welfare systems. Facing this problem or reducing its effect would have a great societal impact by improving the quality of life and regaining people independence to make them active in society and live active, fulfilling and independent lives.

Physical activity behavior change for older veterans after dysvascular amputation

ObjectiveDetermine the feasibility of using a physical-activity behavior-change (PABC) intervention for increasing physical activity and reducing disability in Veterans 1–5years following dysvascular lower-limb amputation (LLA). DesignCross-over, feasibility trial SettingVA Geriatric Research Education and Clinical Center and Veterans Homes Participants32 Veterans with dysvascular LLA (1–5years after major LLA) InterventionThe home-based study, using telerehabilitation technology, is intended to reduce participant burden by removing transportation and time barriers. Participants will be randomized into two participation periods of three months (Months 1–3 and 4–6). PABC intervention will occur Months 1–3 for GROUP1 and Months 4–6 for GROUP2. During PABC Intervention, participants engage in weekly video interaction with a physical therapist, who uses a collaborative approach to develop self-monitoring, barrier identification, problem solving and action planning skills to improve physical activity. GROUP2 will participate in a no physical activity intervention, attention control in Months 1–3. GROUP1 will have a no contact, intervention “wash-out” period in Months 4–6. Main outcome measuresFeasibility will be determined using measures of 1) participant retention, 2) dose goal attainment, 3) participant acceptability, 4) safety, and 5) initial effect size. Effect size will be based on accelerometer-based physical activity and self-report disability using the Late-Life Function and Disability Index. ConclusionsThis study focuses on a prevalent and understudied population with low physical activity and high levels of disability due to dysvascular LLA. The results of this study will guide future development of targeted rehabilitation research to improve long term physical activity and disability outcomes.

Energy cost of walking measurements in subjects with lower limb amputations: A comparison study between floor and treadmill test

Measuring the energy cost of walking (ECW) is a valid way of assessing the walking efficiency of subjects who were prosthetic users following lower limb amputation. The aim of this study was to determine whether, in these subjects, treadmill and floor ECW measurements are comparable. We tested 24 subjects who had undergone unilateral lower limb amputations for vascular diseases as they walked at a self-selected comfortable speed on the floor and on a treadmill. The tests were conducted at the end of rehabilitative treatment to fit prosthesis. Eight subjects underwent transtibial and 16 transfemoral amputation. The measurements were taken with a portable gas analyzer. The self-selected comfortable speed on the treadmill was significantly lower than that on the floor, where the patients adopted the aid they normally used for walking; oxygen consumption was the same in the two tests. Therefore, for both transtibial and transfemoral patients, ECW was greater during walking on the treadmill. Steady-state heart rate did not differ in the two tests. The data show that the ECW values of the amputated subjects obtained on the treadmill at the end of rehabilitation did not correspond with those they obtained on the floor. The floor test is the one that may better reflect walking with prostheses and aids in everyday life, in subjects with dysvascular lower limb amputation, using the prosthesis for a short time.

Reamputation, Mortality, and Health Care Costs Among Persons With Dysvascular Lower-Limb Amputations

Reamputation, Mortality, and Health Care Costs Among Persons With Dysvascular Lower-Limb Amputations

Reamputation, mortality, and health care costs among persons with dysvascular lower-limb amputations

Dillingham TR, Pezzin LE, Shore AD. Reamputation, mortality, and health care costs among persons with dysvascular lower-limb amputations. ObjectivesTo 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. DesignRetrospective cohort study. SettingGeneral community. ParticipantsMedicare beneficiaries identified from the Centers for Medicare and Medicaid Services data as undergoing a lower-limb amputation secondary to vascular disease in 1996. InterventionsNot applicable. Main outcome measuresTwelve-month reamputation and mortality rates, and acute and postacute medical care costs, by initial amputation level and presence or absence of diabetes. ResultsA 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. ConclusionsThis study provides information that can be used by physicians when counseling patients about expected outcomes of dysvascular amputations at different levels.

Discharge destination after dysvascular lower-limb amputations

Dillingham TR, Pezzin LE, MacKenzie EJ. Discharge destination after dysvascular lower-limb amputations. Arch Phys Med Rehabil 2003;84:1662–8. Objective To examine postacute care rehabilitation services use after dysvascular amputation. Design State-maintained hospital discharge data from the Maryland Health Services Cost Review Commission were analyzed. Setting Maryland statewide hospital discharge database. Participants Persons discharged from nonfederal acute care hospitals from 1986 to 1997 with a procedure code for lower-limb amputation (ICD-9-CM code 84.12–.19), excluding toe amputations. Those persons with amputations due to trauma, bone malignancy, or congenital anomalies were excluded. Interventions Not applicable. Main outcome measure Postacute care service utilization. Results There were 16,759 discharges with an amputation procedure over this period. The average age was 69.3±14.3 years, and 51.9% were men. Black persons comprised 42.4% of the sample. Diabetes was present in 42.0%, and peripheral vascular disease was noted for 66.1% of amputees. Amputations were at the foot (19.4%), transtibial (38.1%), and transfemoral (42.4%) levels. The largest proportion (40.6%) of patients was discharged directly home after acute care, 37.4% went to a nursing home, 9.2% went home with home care, and 9.6% were discharged to an inpatient rehabilitation unit. From 1986 to 1997, there were downward trends in the rate of discharges directly home and corresponding upward trends in nursing home and inpatient rehabilitation dispositions. Conclusions Inpatient rehabilitation use is infrequent after dysvascular amputation. Prospective studies are necessary to examine outcomes for persons receiving rehabilitation services in different care settings to define the optimal rehabilitation venue for functional restoration.