Major Lower Limb Amputation Research Articles

Tourniquet use for people with peripheral arterial disease undergoing major lower limb amputations

Tourniquet use for people with peripheral arterial disease undergoing major lower limb amputations

Factores relacionados con el éxito en la protetización de amputados de extremidad inferior de etiología vascular

ObjectiveRestoring the ambulation ability with prostheses in lower limb amputeesis essential to improve their functional independence. The aim of this study was to determine the factors involved in achieving prosthesis fitting in vascular amputees. Material and methodObservational longitudinal study of patients with major lower limb amputation of vascular etiology performed from April 1st 2017 to April 1st 2020. The following variables were compared between the group of patients who were prosthetized and those who were not: age, gender, body-mass index, comorbidity (Charlson index), independence in the activities of daily living (Barthel index) and ambulation ability (FAC test) before and a year after the amputation. The prosthetic use after a year was measured with the Houghton scale. ResultsA total of 80 patients were amputated with a mean age of 70.5 years old, 78.8% were male. The amputation level was supracondilealin 42 patients and infracondilealin 38 patients. The number of prosthetized patients was 35. The variables related to the possibility of prosthesis fitting were: younger age (P=0.020), less comorbidity (P=0.000), infracondileal amputation (P=0.024) and greater functional independence and ambulation ability prior to amputation (P=0.000). After a year 22 patients had died, only one of those who had been prosthetized. ConclusionsAlthough there are no clear recommendations to determine which amputees should be prosthetic fitting, in our patients the presence of fewer comorbidities and a good previous functional situation, younger age and infracondileal amputation, are related to greater success in achieving this objective.

AB035. SOH22ABS080. Comparison of major lower limb amputation rates and outcomes pre and post coronavirus disease 2019 (COVID-19) and association to delayed access to outpatient care

Background: Several short-term single centre studies have shown an initial rise in major amputation rates following coronavirus disease 2019 (COVID-19) driven interruptions to services, however there is a lack of long-term data showing the impact of multiple lockdowns and restriction levels.

Indications for and outcomes of major lower limb amputations at a tertiary-referral centre in Australia.

Major amputations are classically associated with significant morbidity and mortality. With the increasing prevalence of risk factors for amputation, namely, diabetes and peripheral arterial disease, we sought to identify the major indications for lower limb amputation in an Australian cohort. A secondary aim was to assess the outcomes, namely, mortality, of amputees over the previous decade. This study assessed all patients undergoing major lower limb amputations between 2012 and 2020. Variables analysed included comorbidities, indication for amputation, in-hospital complications and mortality, duration of hospital stay, and out-patient mortality. 317 amputations were performed on 269 patients. 55% of amputations were below knee, 45% above knee, with one through-knee amputation. Indications included ischaemia (55.2%), infection (30.6%), malignancy (6.9%), trauma (4.4%), and chronic pain or instability (2.5%). In-patient mortality rate was 7.6%, with mortality rates of 21.5% at one year, and 70.1% at 10years. Post-operative complications occurred in 43% of amputations. Rural, regional, and remote (RRR) patients did not suffer disproportionately from major amputations, however, were more likely to require amputations for ischaemia. Patients undergoing amputation for infective causes demonstrated lower mid-term mortality rates compared to those undergoing amputations for ischaemia (56.1 vs 60.4% at 5years, p = 0.007). Major amputations continue to be associated with significant morbidity and mortality, both in the short and long term. Patients undergoing amputations for ischaemic causes demonstrate poorer outcomes than their infective counterparts, with outcomes being even worse in RRR populations. Prevention of amputations via intense management of comorbidities would benefit both patients and the healthcare system.

Impact of Socioeconomic Status on Major Amputation in Patients with Peripheral Vascular Disease and Diabetes Mellitus

Both peripheral vascular disease (PVD) and diabetes mellitus (DM) are leading causes of lower extremity amputation. The Area Deprivation Index (ADI) is a tool used to estimate socioeconomic status (SES) based off a person's 9-digit zip code, and this value has been shown to correlate with poor health outcomes. We sought to understand the effect of SES on major amputation in diabetic patients with PVD in a single healthcare system. All patients presenting to a single healthcare system with dual diagnosis of PVD and DM from January 2012 to December 2017 were identified using International Classification of Diseases (ICD) 9/10 codes. Patients undergoing major amputation (below-knee and above-knee) were identified by Current Procedural Terminology (CPT) codes and compared to those who did not have amputation. The ADI score and comorbid disease processes were identified. The Mann-Whitney U-test was performed to compare ADI scores between the amputation and nonamputation groups. Categorical variables were analyzed using the Chi-squared or Fisher's exact test, and t-tests were used for continuous variables. A logistic regression was performed to test the association between SES and amputation status. A total of 2,009 patients were identified, of which 85 underwent major amputation. After adjusting for comorbidities, patients in the amputation group had higher ADI scores as compared to those who did not have amputation (median ADI score 8 vs. 6, P < 0.05). Logistic regression modeling demonstrated an Odds Ratio of 1.10 (95% confidence interval: 1.01-1.19), indicating the odds of being in the amputation group are increased by 10% for every 1-point increase in the ADI score. After controlling for comorbidities, patients with PVD and DM residing in neighborhoods with lower SES have increased odds of undergoing major lower-limb amputation than those from neighborhoods with higher SES despite receiving care at the same healthcare system. Further study is warranted to determine factors contributing to this difference.

Saving limbs and lives: Building out an Ontario lower limb preservation strategy

There are over 1,200 non-traumatic major lower-limb amputations every year in Ontario, the majority resulting from complications of vascular disease, diabetes or both. This equates to one lower-limb amputation every seven hours, and results in approximately $140 million in direct amputation health-care costs annually. CorHealth Ontario is collaborating with a provincial Advisory Committee to develop a multi-year provincial Lower-Limb Preservation Strategy. The strategy aims to facilitate a coordinated, integrated and patient-centred approach to lower-limb preservation care in Ontario.

P137. HIGH-RISK OPIOID PRESCRIBING AND PERSISTENT OPIOID USE AFTER MAJOR LOWER LIMB AMPUTATION AMONG MEDICARE BENEFICIARIES

PURPOSE: Recently, quality improvement efforts have focused on mitigating opioid related harms among postamputation patients. However, the prevalence of high-risk opioid prescribing practices is not well described, nor the risk factors associated with persistent opioid use among major lower limb amputation patients. METHODS: We reviewed 2009-2018 Medicare claims of major lower limb amputation patients. Prolonged opioid use was defined as one opioid prescription filled within 90-days after discharge and another within 90-180 days. High-risk opioid prescribing included overlapping opioid prescriptions, overlapping benzodiazepine-opioid prescriptions, high daily-doses>100 OMEs, multiple prescribers, and new long-acting opioid use within 90-days postoperatively. We used the Cochran-Armitage-Trend-Test to determine trends in high-risk prescribing over time, and multilevel mixed-effects logistic regression to determine predictors of prolonged use. RESULTS: In total, 5,191 patients were included (Chronic opioid-users=1,432; Intermittent opioid-users=2,195; Opioid-Naïve=1,564). Rates of high-risk prescribing did not change significantly during the study period, and 82.3% chronic (p=0.65), 37.2% non-chronic (p=0.08), and 15.5% opioid-naïve (p=0.74) users were exposed to high-risk prescribing. Individuals with prior opioid fills were more likely to have prolonged use (chronic users OR=2.21, p=0.033; non-chronic users OR=4.46, p<0.001). Among non-chronic users, age<55 years (OR=1.41, p=0.04), concurrent gabapentinoid fills (OR=1.92, p<0.001), and sedative/anxiolytic fills (OR=1.75, p<0.001) were associated with prolonged use. CONCLUSION: Among major lower extremity amputation patients high-risk prescribing practices are common, and have not changed over time. Interventions that focus on tailoring postoperative pain management to preoperative risk factors, including preoperative opioid exposure, will be of high-value to optimize postamputation pain and encourage safe opioid stewardship.

Development of a coordinated acute diabetic foot pathway for management of acute diabetic foot infection and ulceration.

Diabetic foot ulceration (DFU) has become an increasingly common emergency presentation. These patients are presenting at a younger age and with increasingly complex co-morbidities. They require frequent hospitalisation for management of DFU which has significant consequences for management of health resources but also for quality of life in the diabetic patient population. The aim of this study was to evaluate the impact of the development of a coordinated, streamlined acute diabetic foot pathway for management of in-patients presenting as emergencies with DFU on length of stay, re-admission to hospital and minor and major amputations. A dedicated acute diabetic foot pathway was introduced to St. Vincent's University Hospital (SVUH) in April 2016. Management of patients admitted urgently to the emergency department or out-patient clinics of St. Vincent's University Hospital during the 3-year period before April 2016 was compared to that of patients admitted in the 3years after April 2016 following introduction of the acute diabetic foot pathway. Demographic data hospital length of stay, need for re-admission, major and minor amputations performed and cost of hospital stay were compared before and after introduction of the pathway. There were 931 admissions with acute diabetic foot ulceration or infection between January 2012 and December 2019; 419 were admitted between January 2012 and March 2016 and 512 between April 2016 and December 2019. There was no difference in demographic data between the two time periods. Length of stay decreased from 13 +/- 4.24 to 3 +/- 1.41days between the two time periods (p < 0.001). Re-admission rates within 30days decreased from 21.7 to 10.1% (p < 0.05). The number of major lower limb amputations decreased over the two time periods from 8.8 to 7.2% with a concomitant increase in minor amputations from 16.7 to 25.3%. Risk of major lower limb amputation was significantly higher in those patients living more than 20km from the hospital. Costs associated with in-patient stay for management of DFU decreased from €9,247,700 to €8,988,100 despite an 18% increase in the number of patients treated and a 9.9% increase in hospital admissions. Introduction of a dedicated, streamlined pathway involving multi-disciplinary input resulted in a significant improvement in patient management as assessed by length of hospital stay and need for re-admission. While the number of major lower limb amputations has decreased there has been a significant increase in the number of minor amputations.

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.

Outcomes in Lower Limb Amputation Rehabilitation

Abstract Introduction: Lower leg amputations affect mobility and can be solved with prosthesis. Despite being included in the Package of Rehabilitation Interventions created by the World Health Organisation, there are lacks in rehabilitation outcome research. Objectives: Reveal the rehabilitation outcomes and, secondarily, determine predictors of prosthesis use for at least two years. Methods: Retrospective cohort study of patients with major lower limb amputations aged between 18 and 70 years with no other disabilities. Rehabilitation outcomes and the predictors of prosthesis use at discharge (time II) compared to the two-year follow-up (time III) were evaluated. Results: 703 patients were included. At time II, 95.73% (673) completed the treatment, with a prosthetic gait rate of 73.12%. Age was a predictor for prosthetic gait, as each one-year increase in age corresponded to a 3.29% decrease in prosthesis use. At time III, 54.21% of the patients had higher prosthetic gait performance, for 2 years at least, requiring a new device. Conclusion: The rehabilitation ensures mobility though high-performance prosthetic gait regardless of age, sex, or aetiology, for at least 2 years from rehabilitation discharge. Though with a lower prosthesis use rate with increasing age.

Patient and Geographical Disparities in Functional Outcomes After Major Lower Limb Amputation in Australia

Major lower limb amputations are associated with considerable disability, low quality of life, and poor rates of returning to work, all of which are often attributed to the poor level of functional mobility that amputees experience postoperatively. This study aimed to quantify ambulatory outcomes after major lower limb amputation and identify potential prognostic factors for patients most likely to achieve ambulation and prosthesis use, with the hypothesis that variation in outcomes correlates to age, level of amputation, and place of residence at the time of amputation. This retrospective cohort study identified functional outcomes for patients who had lower limb amputations between 2012 and 2020. Patients were identified from the 10th revision of the International Classification of Diseases Australian Modification (ICD-10-AM)-coded state-wide government-maintained hospital administrative data by procedure codes for lower limb amputation. The primary outcomes were ambulation at the time of discharge from acute hospital stay, discharge destination, and prosthesis use. Variables for adjustment included patient age, comorbidity, level of amputation, and place of residence. Three-hundred and seventeen amputations were performed in 269 patients. Most procedures were transtibial amputations (56.4%) and for ischemic/infective indications (84%). Thirty-seven percent of patients were ambulating independently at the time of discharge and 55.9% demonstrated independent mobility with prosthesis at follow-up. Ambulation at the time of discharge predicted patients who were more likely to return home rather than residential or hospital care (odds ratio [OR] 1.8 95%; confidence interval [CI] 1.0-3.2). Patients with transtibial amputation were more likely to achieve prosthesis use than transfemoral (OR 4.4, 95% CI 2.1-9.5), after adjusting for age, comorbidity, and geographical factors. Mobility and prosthesis use was lowest in patients who were older, had transfemoral amputations, and resided in regional or rural areas. The significant outcome disparities identified in this cohort study highlight the need for targeted quality interventions aimed at improving functional outcomes for patients undergoing major amputation for peripheral artery disease.

The adverse impact of pre-operative anaemia on survival following major lower limb amputation.

Approximately 5000 major lower-limb amputations (MLLA) for PAD occur per-annum in the UK with clinical outcomes being poor for this high-risk cohort of patients. Existing evidence suggests that anaemic surgical patients have an increased 30-day mortality, but this has not been explored in the context of MLLA. Recent prioritization processes suggested that MLLAs are a target area for research into outcome improvement. This cohort study evaluates the impact of anaemia on the outcome of MLLA to understand if optimization might improve outcomes. All PAD patients undergoing MLLA during 2015-2018 at a tertiary vascular centre were reviewed. Patients were stratified into groups; non-anaemia (>12g/dL), mild-anaemia (12-10g/dL) and severe-anaemia (<10g/dL) by pre-operative haemoglobin (Hb). Primary outcome was overall survival by Kaplan-Meier. Secondary outcomes included length of stay (LOS), post-operative blood-transfusion, surgical-site infection (SSI) and myocardial infarction (MI). Cox-proportional-hazard and receiver-operator characteristics (ROC) analyses were conducted. 345 patients were followed up over (mean) 23months. 105 were non-anaemic, 111 mildly anaemic and 129 severely anaemic. Patients with severe-anaemia had a higher incidence of heart and renal failure (p = 0.003) than those with non- or mild-anaemia. Overall survival worsened significantly with increasing anaemia (p = 0.001). LOS was significantly longer in mild-anaemia which is 26 (16-43) days, (p = 0.006) and severe-anaemia of 28 days (17-40), (p < 0.001) compared to non-anaemia of 18 (10-30) days. Post-operative blood-transfusion (RBC) was required more frequently in 70.5% of severely anaemic patients (p < 0.001), compared to mildly anaemic (24.3%) and non-anaemic (7.6%) patients, with those receiving RBCs having a significantly worse survival. There was no difference in MI, SSI or wound dehiscence. Anaemia was significantly associated with mortality; (HR 1.7 (1.04-2.78), p = 0.03). A minimum-Hb of 10.4g/L (by ROC) was identified as a cutoff Hb for an increased risk of mortality. Pre-operative anaemia is associated with worse outcome following MLLA, with increasing severity of anaemia associated with increasing mortality and RBC transfusion being potentially detrimental. More work is required to prospectively evaluate this relationship in this complex and multi-morbid cohort of patients.

Prehabilitation-plus for patients undergoing major lower limb amputation may reduce acute hospital and total hospital length of stay: a retrospective, matched, case-controlled pilot service evaluation

Background/Aims ‘Prehabilitation’ refers to interventions that seek to enhance a person's functional capacity to help withstand a forthcoming stressor, such as major surgery. There is little research evaluating prehabilitation before major lower limb amputation. This study evaluated if a comprehensive multidisciplinary pre-admission programme, which included prehabilitation plus other interventions (eg education, home assessment and modifications), hereinafter called ‘prehabilitation-plus’, might shorten hospital length of stay by allowing earlier discharge home from hospital after major lower limb amputation. The aim of this study was to investigate the effect of prehabilitation-plus on hospital length of stay and discharge destination for patients undergoing major lower limb amputation. Methods Seven patients receiving prehabilitation-plus were retrospectively matched with seven control patients in this case-controlled pilot service evaluation. Prehabilitation-plus was provided by a multidisciplinary team. Hospital length of stay was compared using Mann–Whitney U tests and discharge destination using Fisher's exact test. Results Acute hospital and total hospital length of stay were significantly lower in the prehabilitation-plus group than the control group (P=0.038 and 0.011 respectively). No significant difference was seen for rehabilitation hospital length of stay (P=0.400). More prehabilitation-plus patients were discharged directly home after their acute hospital stay, but this was not significant (P=0.286). Conclusions Patients who received prehabilitation-plus had reduced acute hospital and total hospital length of stay compared to matched control patients. While these preliminary results are promising for the ability of programmes such as prehabilitation-plus to reduce hospital length of stay, further studies with more robust designs are required to confirm and extend this finding.

Abstract P105: Bypasses To Below-Knee Arteries May Expedite Amputation In Patients With Claudication

Objective: Claudication is an early-stage subtype of peripheral artery disease that may result in surgical intervention. The purpose of this study was to compare the types of elective bypass in a population of Black and White patients with claudication and to identify actionable areas that may explain the higher limb amputation rates observed in Black patients. Methods: We identified Black and White patients undergoing elective infrainguinal bypass for claudication using data from the Vascular Quality Initiative registry (2011-2018). Distal bypass target was classified as 1) at or above the popliteal artery (above-knee) or 2) below the popliteal, including all tibial, peroneal, dorsalis pedis and tarsal/plantar arteries (below-knee). Graft conduit was categorized as vein or prosthetic. We calculated one-year risk of major lower limb amputation with 95% confidence intervals (CI) for all combinations of target and conduit, stratified by race. We then forced an intervention on the data to estimate the post-intervention incidence of amputation and the proportion of racial disparity eliminated and 95% CI if everyone received the gold standard treatment (above-knee, vein). Results: We identified 8,401 infrainguinal bypass revascularizations for claudication (12% Black/88% White); 82% were performed above-knee and 44% of those used a vein conduit. The remaining 18% of bypasses were to below-knee arteries, of which 78% used a vein conduit. The remaining 1,534 (18.3%) bypasses were to below-knee arteries, including 1,197 (78.4%) using vein and 330 (21.6%) using prosthetic material. One-year incidence of major limb amputation was 1.6% (1.3%,1.9%) among all grafts, 1.2% (1.0%,1.5%) in above-knee grafts, and 3.3% (2.4%,4.2%) in below-knee grafts. Black patients had higher incidence of amputation across bypass target/conduit groups compared to White patients; the difference was greatest for below-knee revascularizations (8.9%, 95% CI: 4.8%,12.3% v 2.1%, 95% CI: 0.9%,2.9%). Pre-intervention amputation incidence was 1.3% (1.0%,1.5%) in White patients and 3.6% (1.9%,5.2%) in Black patients. Overall amputation incidence decreased significantly after our gold standard intervention was applied for both White (1.0%; 0.7%,1.2%) and Black (2.0%; 0.7%,3.2%) patients. The risk difference (i.e. the disparity gap) between Black and White patients was lessened post-intervention by 56.8% (31.9%,116.3%). Conclusions: We observed risk of amputation higher than would be expected based on other studies of the natural history of claudication without bypass surgery; future work should identify the mechanisms that alter the natural history of claudication via open bypass surgery. Interventions below-knee or using a prosthetic graft were particularly harmful and their harm was concentrated in Black patients.

Abstract P155: Differential Incidence Trends In Non-traumatic Lower Limb Amputations In The Province Of Quebec, Canada: Does The Reduction Applies Equally In Both Sexes?

Introduction: Non-traumatic lower limb amputations (LLA) represent an important complication of diabetes (DM) and peripheral arterial disease (PAD). In Quebec, Canada, the latest data between 1996 to 2004 suggested a reduction in the incidence of LLA while other Canadian provinces observed a recent increase between 2010 and 2016. Our objective was to update the incidence trends of LLA in Quebec from fiscal years 2006 to 2019. Methods: Age-standardized incidence of LLA among individuals ≥40 years was assessed using the Quebec Integrated Chronic Disease Surveillance System (n=4,527,533 in 2019). The mean age of incident cases and the presence / duration of DM and/or PAD was collected. Estimations were presented for all, by sexes and by types of LLA (minor: below the knee; major: knee and above), with 99% confidence intervals (CI). Results: Between 2006 and 2019, incident cases of LLA increased from 818 to 1,099 but age-standardized incidence remained stable (Figure 1) for both sexes. Men had a higher age-standardized incidence of LLA then women (32.7 per 100,000 [99% CI: 29.7-35.9] vs 12.9 per 100,000 [11.2-14.9] in 2019). From 2006 to 2019, the age-standardized incidence of major LLA showed a relative decrease of 48% while minor LLA remained stable (Figure 1). Reduction in age-standardized incidence of major LLA was attributable to men (3.8 per 100,000 [2.7-5.3] to 1.7 per 100,000 [1.1-2.6]). The mean age of incident cases went from 68.2 to 69.5 years from 2006 to 2019 (72.4 for women and 68.3 for men in 2019). Ninety-eight percent of LLA had DM, while 95% had PAD and 95% had both in 2019. Between 2006 and 2019, the average time between the first LLA and DM diagnosis increased from 7.0 to 14.7 years and from 2.0 to 2.6 years for PAD. Conclusions: Although the age-standardized incidence of LLA is stable, men remain at higher risk then women. The portrait of incident cases is changing towards an older average age, longer DM duration and a reduction of major LLA. These results emphasize the importance to improve further preventive care of LLA in Quebec.

Incidence and Nerve Distribution of Symptomatic Neuromas and Phantom Limb Pain after Below-Knee Amputation.

Patients with major lower limb amputations suffer from symptomatic neuromas and phantom-limb pain due to their transected nerves. Peripheral nerve surgery techniques, such as targeted muscle reinnervation and regenerative peripheral nerve interface, aim to physiologically prevent this nerve-specific pain. No studies have specifically reported on which nerves most frequently cause chronic pain. The authors studied the nerve-specific incidence of symptomatic neuroma formation and phantom limb pain in patients undergoing a below-knee amputation, to better tailor use of targeted muscle reinnervation and regenerative peripheral nerve interface. This was a retrospective review of all patients undergoing a below-knee amputation from January 1, 2013, to December 31, 2018, at MedStar Georgetown University Hospital. All below-knee amputations were performed with a posterior skin flap, myotenodesis, and traction neurectomies of all nerves. Postoperative notes were reviewed for the presence of a symptomatic neuroma, defined as localized pain and a Tinel sign over a known sensory nerve, and nerve-specific phantom limb pain, defined as pain of the missing limb corresponding to a known dermatome. One hundred ninety-eight patients were included in this study. The rate of symptomatic neuroma formation was 14.6 percent (29 of 198), with the superficial peroneal and saphenous nerves most often involved. Diabetes and obesity were protective against symptomatic neuroma formation. The rate of nerve-specific phantom limb pain was 12.6 percent (25 of 198) and highly correlated with the presence of a symptomatic neuroma. To optimize outcomes for amputees, it is critical that surgeons best understand what nerves are more likely to form symptomatic neuromas and lead to nerve-specific phantom limb pain, so that surgeons can best tailor primary or secondary management of the major sensory nerves. Risk, III.

Impact of Socioeconomic Status on Major Amputation In Patients With Peripheral Vascular Disease And Diabetes Mellitus

<h3>INTRODUCTION</h3> Both peripheral vascular disease (PVD) and diabetes mellitus (DM) are leading causes of lower extremity amputation. The Area Deprivation Index (ADI) is a tool used to estimate socioeconomic status based off a persons' 9 digit zip-code, and this value has been shown to correlate with poor health outcomes. We sought to understand the effect of socioeconomic status on major amputation in diabetic patients with PVD in a single center. <h3>METHODS</h3> All patients presenting to a single center with dual diagnosis of PVD and DM from 2012 to 2017 were identified using ICD 9/10 codes. Patients undergoing major amputation (below knee and above) were compared to those who did not have amputation. ADI as well as comorbid disease processes were identified. Categorical variables were analyzed using Chi-Square or Fisher's exact test, and t-tests were used for continuous variables. Logistic regression was performed to test the association between socioeconomic status and amputation status. <h3>RESULTS</h3> A total of 2009 patients were identified, of which 85 underwent major amputation. After adjusting for comorbidities, patients in the amputation group had higher ADI scores as compared to those who did not have amputation (median ADI score 8 vs. 6, p<0.05). Logistic regression modeling demonstrated an Odds Ratio of 1.10 (95% confidence interval: 1.01-1.19) indicating the odds of being in the amputation group was increased by 10% for every 1 point increase in the ADI score. <h3>CONCLUSION</h3> After controlling for comorbidities, patients with DM and PVD residing in neighborhoods with lower socioeconomic status have increased odd of undergoing major lower-limb amputation than those from neighborhoods with higher socioeconomic status despite receiving care at the same institution. Further study is warranted to determine factors contributing to this difference.

Association Between Balance Self-efficacy and Walking Ability in Those With New Lower Limb Amputations.

A relationship between walking ability and self-efficacy has been demonstrated in various rehabilitation patient populations. In experienced prosthetic ambulators, walking ability is related to self-efficacy of balance, however, this relationship has not been quantified for those with newly acquired lower limb amputations (LLA). To investigate the association between walking performance (objective) and self-reported walking abilities (subjective) on balance self-efficacy in those with LLA. Cross-sectional study of 27 people (17 men; mean age=63.57±9.33) at discharge from inpatient prosthetic rehabilitation for first major unilateral LLA. Individuals completed 6m straight path walking and the L-Test under single- and dual-task conditions. The Prosthesis Evaluation Questionnaire (PEQ) was administered, and the Ambulation subscale provided subjective measures of walking ability. A single PEQ question on satisfaction with walking (16B) was also used as a proxy for subjective walking ability. The Activities-specific Balance Confidence Scale measured balance self-efficacy. Multivariable linear regression was used to evaluate the strength of association between walking ability (objective and subjective) and balance self-efficacy (dependent variable). Walking velocity on the 6m straight path under single-task (p=0.011) and dual-task conditions (p=0.039), the single-task L-Test (p=0.035) and self-reported satisfaction with walking (p=0.019) were associated with self-efficacy of balance. Objective measures of walking ability that were independently associated with balance self-efficacy included straight path walking velocity under single and dual-task conditions and the single-task L-Test. Satisfaction with walking was also associated with balance self-efficacy. This highlights the interplay between physical and psychological factors during rehabilitation. More research in the area of self-efficacy and walking ability is needed to establish self-efficacy as a target during prosthetic rehabilitation for those with LLA.

PrEdiction of Risk and Communication of outcomE followIng major lower limb amputation: a collaboratiVE study (PERCEIVE)—protocol for the PERCEIVE qualitative study

IntroductionDeciding whether to proceed with a major lower limb amputation is life-changing and complex, and it is crucial that the right decision is made at the right time. However, medical...

Diabetes as an Isolated Cause of Minor Lower Limb Amputations.

Amputation is a devastating but preventable complication of diabetes and peripheral arterial disease. The aim of the present study was to investigate whether diabetes mellitus is an important isolated cause of toe amputation. A cross-sectional study was conducted involving the records of 108 patients with minor lower limb amputations and 80 with major lower limb amputations. Association between diabetes/chronic arterial insufficiency and level of amputation was tested. Statistical analysis was performed using Fisher's exact test. The prevalence of diabetes was 87.5% among patients submitted to minor amputations and 52.5% among those submitted to major amputations with or without chronic arterial disease. This difference was statistically significant (p<0.0001, Fisher's exact test). A total of 44.44% of the patients submitted to minor amputations had diabetes alone (no chronic arterial insufficiency), whereas only 14.81% of the patients submitted to major amputations did not have chronic arterial insufficiency. Thus, diabetes was significantly associated with minor lower limb amputations (p<0.0004, Fisher's exact test). Based on the present findings, patients with diabetes are at greater risk of toe amputation compared to those with chronic arterial disease.