Major Lower Limb Amputation Research Articles

Predictive ability of the pedal medial arterial calcification (pMAC) score for major adverse limb events among patients with Chronic Limb-Threatening Ischemia

ObjectivePedal medial arterial calcification (pMAC) is a potential predictor of major adverse limb events (MALE) among patients with critical limb-threatening ischemia (CLTI). This study aims to validate the prognostic value of the pMAC score in predicting major lower limb amputation (MLLA) and need for re-do revascularisation. MethodsA single centre study involving 196 patients diagnosed with CLTI, reviewed between 2012 and 2022. Patients’ pMAC scores were obtained through X-ray assessments. Correlations between pMAC scores and the incidence of MALE and re-do revascularisation, were analysed. A power analysis using G* Power 3 software determined a needed sample size of 157 participants. Statistical analysis employed SPSS 26, utilising descriptive statistics, Chi Square, Mann-Whitney, Kaplan-Meier with log-rank test, and Cox regression for predictor identification. ResultsThe cohort was predominantly male (79.1%) and diabetic (59.2%). Re-do revascularisation need was 15.3%, increasing with pMAC scores: 3.3% (low), 24.5% (medium), and 50% (high) (p<0.001). MLLA frequency also rose with pMAC scores: 6.7%, 27.5%, and 50% respectively (p<0.001). Higher pMAC scores correlated with a higher incidence of MALE (p=0.029). Multivariate analysis showed medium pMAC (HR 4.159, p=0.002), high pMAC (HR 7.366, p=0.015), and GLASS stage 3 (HR 3.529, p=0.011) as independent MLLA predictors. Re-do revascularisation predictors included female sex (HR 2.106, p=0.063), Black race (HR 64.498, p=0.001), medium pMAC (HR 6.812, p=0.002), high pMAC (HR 11.455, p=0.008), and GLASS stage 3 (HR 2.899, p=0.037). ConclusionThe pMAC score effectively predicts MALE in CLTI patients and enhances risk stratification. Using both, pMAC scores and GLASS stages enhances predictive accuracy, identifying patients at higher risk for MLLA, Informing clinical decision-making and therapeutic strategies.

Improving the provision of emotional support for patients following major lower limb amputation

Major lower limb amputation (MLLA) is a lifesaving but life-altering surgical procedure. Psychological distress is common and typically heightened in the acute postoperative period. Despite the negative impact that poor...

Characteristics of Individuals Admitted to Vascular Surgery Service for a Major Lower Limb Amputation From 2017 to 2021 With Present on Admission Pressure Injuries.

The purpose of this study was to describe characteristics of persons admitted from 2017 to 2021 with peripheral arterial disease (PAD) who required a below knee amputation (BKA) or above knee amputation (AKA), including present on admission pressure injuries (POA-PIs). Descriptive, cross-sectional retrospective research design. The sample comprised 196 patients who underwent a total of 258 major lower limb amputations. A majority (65.9 %n=170) underwent BKAs and 88 (34.1 %) underwent AKAs. Coronary artery disease was present in 107 (54.6 %) and 143 (73.0%) had diabetes mellitus. The study site was a 670-bed level 1 trauma center in the Southeastern United States. A retrospective chart review of patients undergoing major lower limb amputations using CPT codes 27880 BKA, and 27590 AKA was completed. Variables extracted included age, sex, race, and comorbid conditions such as smoking, cardiovascular disease, diabetes mellitus, end stage renal disease requiring dialysis, and POA-PI. Descriptive statistics (frequencies, percentages, and means) were used to describe the sample. There were 25 (12.8%) individuals with POA-PI compared with 171 (87.2%) who did not have POA-PI. None of the reviewed significantly differed when patients with or without POA-PI were compared. Age was closest to statistical significance (P=.052). In addition, analysis revealed that 73% (n=143) of individuals had diabetes mellitus in addition to having PAD. Approximately 13% of a group of patients with PAD had POA-PI when admitted to hospital for major limb amputation. Analysis of multiple factors found that none significantly differed between patients with or without POA-PI. Age came nearest to statistical significance and we hypothesize that older age may increase the risk for POA-PI; additional research in samples with greater power to detect this effect are needed. Findings also indicate that diabetes mellitus is a common risk factor for major lower limb amputation. It is important to educate staff/patients/caregivers on the importance of PI prevention especially in the elderly vascular population who are at risk for undergoing major lower limb amputations.

Innovations in Gritti-Stokes Amputation: A Focused Analysis of Immobile Patient Outcomes.

Background Major lower limb amputation is a surgical operation performed for different reasons, including life-threatening infection, ischemia, trauma, and tumors. This study aims to investigate the viability of Gritti-Stokes amputation as a suitable alternative for individuals with impaired mobility and peripheral vascular disease. Patients and methods This was a descriptive, retrospective, and observational study. All patients who met the criteria and underwent Gritti-Stokes amputation were included. The study had a duration of one year, commencing in December 2022 and concluding in December 2023. The data was processed using statistical software (SPSS, version 21; IBM Corp., Armonk, NY, US). Results Twenty-four patients were included. Concerning the complications, 16 patients (66.7%) did not experience any complications, while 7 patients (29.2%) had stump infections. Three of them ultimately required more extensive amputation. A phantom limb was observed in a single patient, accounting for a mere 4.2% of the total. Total of 21 patients, 87.5% reported great stability and lever motion when transitioning from bed to chair, as well as vice versa. Furthermore, wound healing was observed in 21 individuals (87.5%), encompassing both primary and secondary wound healing. Conclusion The Gritti-Stokes amputation provides patients with excellent stability and lever function to facilitate movement. The Gritti-Stokes amputation is a suitableoption for immobile and high-risk patients.

ThP8.1 - Long-Term Impact of COVID-19 related disruption of NHS Elective services on Emergency Major Lower Limb Amputations

Abstract Background The COVID-19 pandemic has affected the healthcare systems worldwide since the dawn of 2020. In March 2020, the United Kingdom government announced the first national lockdown which severely disturbed all NHS healthcare elective services. Our aim is to assess the long-term impact of COVID-19 related disruption of NHS elective services on emergency major lower limb amputations. Method Patients' data for emergency major lower limb amputations (MLLA) for critical limbthreatening ischemia and diabetic foot infections performed at Aberdeen Royal Infirmary was collected through Trakcare® and divided into the control pre-pandemic group (April 2018 to March 2020) and the pandemic group (April 2020 to March 2022). The statistical analysis was conducted using the IBM SPSS software [v28.0.1.1 (14)]. Results A total of 358 patients underwent MLLA and 206 (57.5%) of these had diabetes mellitus. There was a 17% increase in the number of urgent referrals and every one in five of these finally underwent an amputation. There was an increase in the absolute number of Above- and Below-Knee amputations. There was a statistically significant increase by 33% in emergency MLLAs during the pandemic period (p-value &amp;lt;0.05). A total of 165 postoperative deaths up to December 2022 were recorded with 30-day mortality rate of 7.26% (n=26). Conclusion NHS vascular management groups should update themselves with evolving technologies to optimise the care provided during future unprecedented times. Furthermore, more effective measures should also be implemented to avoid delayed presentations, which can potentially lead to higher rates of major limb amputations.

Economic impact of limb-salvage strategies in chronic limb-threatening ischaemia: modelling and budget impact study based on national registry data.

Missed opportunities to reduce numbers of primary major lower-limb amputation and increase limb-salvage procedures when treating chronic limb-threatening ischaemia have previously been identified in the literature. However, the potential economic savings for healthcare providers when salvaging a chronic limb-threatening ischaemia-affected limb have not been well documented. A model using National Health Service healthcare usage and cost data for 1.6 million individuals and averaged numbers of primary surgical procedures for chronic limb-threatening ischaemia from England and Wales in 2019-2021 was created to perform a budget impact analysis. Two scenarios were tested: the averaged national rates of major lower-limb amputation (above the ankle joint), angioplasty, open bypass surgery or arterial endarterectomy in the National Vascular Registry (current scenario); and revascularization rates adjusted based on the lowest amputation rate reported by the National Vascular Registry at the time of the study (hypothetical scenario). The primary outcome was the net impact on costs to the National Health Service over 12 months after the index procedure. In the current scenario, the proportions of different index procedures were 10% for lower-limb major amputation, 55% for angioplasty, 25% for open bypass surgery and 10% for arterial endarterectomy. In the hypothetical scenario, the procedure rates were 3% for major lower-limb amputation, 59% for angioplasty, 27% for open bypass surgery and 11% for arterial endarterectomy. For 16 025 index chronic limb-threatening ischaemia procedures, the total care cost in the current scenario was €243 924 927. In the hypothetical scenario, costs would be reduced for index procedures (-€10 013 814), community care (-€633 943) and major cardiovascular events (-€383 407), and increased for primary care (€59 827), outpatient appointments (€120 050) and subsequent chronic limb-threatening ischaemia-related surgery (€1 179 107). The net saving to the National Health Service would be €9 645 259. A shift away from primary major lower-limb amputation towards revascularization could lead to substantial savings for the National Health Service without major cost increases later in the care pathway, indicating that care decisions taken in hospitals have wider benefits.

Prospective Multi-Center Longitudinal Study to Validate Accuracy of the Global Anatomic Staging System (GLASS) Score in Predicting Major Acute Limb Events in Patients With Chronic Limb Threatening Ischemia Undergoing Endovascular Intervention: The PROMOTE-GLASS Study Protocol.

Developed by the Global Vascular Guidelines committee, the Global Limb Anatomic Staging System (GLASS) is an angiographic scoring system used for quantifying infrainguinal disease extent and predicting treatment success with endovascular techniques (EVT). Currently, no other risk prediction model is available for patients with chronic limb threatening ischemia (CLTI) undergoing EVT. GLASS' validation and adoption outside academic institutions for research are limited. Thus, this longitudinal multicenter prospective study aims to examine GLASS' validity and reliability in predicting major acute limb events and overall survival (OS) in patients with CLTI undergoing EVT. This prospective, international, multicenter, observational study will include patients with CLTI undergoing EVT (PROMOTE-GLASS) (ClinicalTrials.gov; ID: NCT06186544) identified through routine clinical referrals and emergency visits to vascular units in participating centers. Only patients who are referred for EVT will be recruited. The primary outcomes are immediate technical success, immediate technical failure, and 1-year limb base patency. The secondary outcomes are major adverse limb events, major lower limb amputation, and OS in patients presenting with CLTI who undergo EVT up to 1 year after the procedure. Clinical and imaging data will be analyzed at the end of follow-up to validate risk prediction. This protocol outlines our approach for identifying cases, GLASS score calculation, outcome measures assessment, and a statistical analysis plan. PROMOTE-GLASS holds significant implications and can potentially revolutionize clinical decision-making by assisting clinicians in identifying patients who are likely to benefit from EVT. Ultimately, reduce the need for more invasive procedures and improve patient outcomes. Furthermore, PROMOTE-GLASS can provide useful information, including patient selection, for future randomized controlled trials (RCTs) investigating EVT for CLTI. PROMOTE-GLASS anticipated implications on the vascular community are rooted in its potential to improve patient care, inform future research, and address limitations in existing literature regarding CLTI treatment outcomes.

Tourniquet Use in Major Lower Limb Amputation: Useful or Harmful?

Tourniquet Use in Major Lower Limb Amputation: Useful or Harmful?

Reamputation Rate, Mortality, and the Incidence of Risk Factors for Ipsilateral Reamputation Among Patients with Dysvascular Major Lower Limb Amputation

A major lower-limb amputation (LLA) for dysvascular disease carries the risk of disturbed wound healing necessitating reamputation at a higher level. A reamputation causes a delay in prosthetic fitting and recovery of walking ability. The combination of a prolonged open wound and inability to walk can worsen of the physical and psychological situation. Prevention of reamputation seems therefore important. This study aims to identify risk factors for reamputation, and to evaluate a possible altered mortality rate after a dysvascular major LLA. These issues are crucial for shared decision-making prior to surgery. Retrospective study investigating a Dutch regional cohort of patients with a dysvascular below-knee, through-knee, or above-knee LLA. 516 Dysvascular major LLAs were included (2014-2018). One hundred reamputations were performed within 1 year after initial amputation (19.4%). Risk factors for ipsilateral reamputation were diabetes mellitus, lipid-lowering drugs usage, and lower level of amputation (respectively P = < 0.01, 0.037, and < 0.01). The 30-day mortality rates were 1% and 12% for the reamputation group and the non-reamputation group respectively (P = < 0.01). The 1-year mortality rates were 23% and 27% for the reamputation group and the non-reamputation group respectively (P = 0.423). Ipsilateral reamputation within one year after initial amputation is common. Several risk factors for reamputation were identified. The 30-day and 1-year mortality rate is high, but not significantly different after one year. A clinical decision tool for dysvascular patients needs to be developed to improve shared decision-making, reduce reamputation rates, and improve survival.

Non-surgical interventions for preventing contralateral tissue loss and amputation in dysvascular patients with a primary major lower limb amputation.

Major lower limb amputation (LLA, above the ankle) is performed for people with intractable pain, life-threatening infections, or non-functional limbs. Of 7500 LLAs carried out in England between 2015 and 2018, the majority of these were performed in dysvascular patients. Dysvascularity is the absence of adequate blood supply to maintain a limb's usual function (ischaemia, usually caused by peripheral arterial disease or diabetes mellitus), ultimately leading to pain and tissue injury (ulcers, gangrene, sometimes referred to as tissue loss). Among those who undergo dysvascular LLA, 5.7% and 11.5% will likely undergo contralateral LLA at one and five years respectively, which is associated with greater disability and lower likelihood of returning to work, increasing the psychological burden to the patient and socioeconomic cost to the patient and health service. While extensive research has been carried out in the management of peripheral arterial disease and the care of diabetic feet, there are no guidelines for practice on prevention of contralateral amputation. To assess the effects of non-surgical interventions versus placebo, no intervention, or other non-surgical interventions on contralateral limb (CLL) tissue loss and amputation in dysvascular patients with a primary major LLA. The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL and PEDro databases and the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers until 20 March 2023. We also checked the references of identified studies and contacted study authors and manufacturers of relevant products. We aimed to include all randomised controlled trials (RCTs) and quasi-RCTs (e.g. randomised by birthdate) comparing the effectiveness of a non-surgical intervention with placebo, no intervention, or other non-surgical intervention, in adults with a primary major LLA due to dysvascularity. Interventions could be physical, pharmacological, educational, behavioural, or organisational, and delivered by a healthcare professional or carer. Our critical and important outcomes of interest were as follows. Critical outcomes • Incidence of new localised tissue injury or ulceration (tissue loss) of the CLL, regardless of stage or classification at given time points. • Time to the development of any localised tissue injury or ulceration (tissue loss) of the CLL, regardless of stage or classification. • Incidence of new minor amputation (through the ankle, foot, or toe(s)) of the CLL at given time points. • Time to new minor amputation (through the ankle, foot, or toe(s)) of the CLL. • Incidence of new major amputation (whole limb or partial limb, above the ankle) of the CLL at given time points. • Time to new major amputation (whole limb or partial limb, above the ankle) of the CLL. Important outcomes • Survival (time to death from all causes) at 12 months. • Patient-reported outcome measures of health-related quality of life (HRQoL) using validated scales such as the 12-item Short Form Health Survey (SF-12) and EQ-5D. • Adverse events (e.g. infections in the CLL). • Hospital readmission. We used Cochrane's RoB 1 tool to assess risk of bias in the included study. We were only able to perform a narrative review due to lack of data. We reported risk ratios (RR) with 95% CIs for dichotomous outcomes. We used GRADE to assess the certainty of evidence for each outcome. We found one eligible study, which compared electrostimulation of the gastrocnemius muscle and standard rehabilitation against standard rehabilitation in 50 dysvascular amputees. There was no new incidence of tissue loss reported. The following outcomes were not reported: time to new tissue loss; time to and incidence of minor amputation; HRQoL outcomes; adverse events; and hospital readmissions. Electrostimulation was associated with a three-fold reduction in the incidence of new major amputation of the CLL (RR 0.33, 95% CI 0.04 to 2.99), although time to new major amputation was not reported. There was no difference between groups in 12-month survival (RR 1.0, 95% CI 0.85 to 1.18). We judged the overall certainty of the evidence (GRADE) as very low across all outcomes, with unclear risk of selection and detection bias and high risk of performance bias. Despite the care of the CLL being identified as a key research priority by two separate consensus papers, there is insufficient high-quality evidence to address this priority to date. We found only a single RCT suitable for inclusion, and this study was subject to risk of bias. Contralateral limb outcomes should be recorded in future research on dysvascular amputees. Until better evidence and clearer recommendations are available, this topic is likely to remain a research priority. This Cochrane review had no dedicated funding. Protocol available via DOI 10.1002/14651858.CD013857.

Comment on: Long-term risk prediction after major lower limb amputation: 1-year results of the PERCEIVE study

Comment on: Long-term risk prediction after major lower limb amputation: 1-year results of the PERCEIVE study

Provision of Inpatient Rehabilitation to Individuals with Lower-Limb Amputation in Canada: An Epidemiological Analysis

ABSTRACT Objective The aim of this study was to determine the proportion of individuals with major lower-limb amputation (LLA) who received inpatient rehabilitation in Canadian provinces, their rehabilitation length, and their functional independence level at admission and discharge. Methods Major LLA records from April 1, 2006, to March 31, 2012, were obtained from the Canadian Institute for Health Information and linked to National Rehabilitation Reporting System data (Quebec data were unavailable). The proportions of individuals who received inpatient rehabilitation, mean length of stay, and Functional Independence Measure (FIM) scores (admission and discharge) were calculated. Results A total of 16,114 new individuals had major LLAs in nine Canadian provinces over the study period; 18% received inpatient rehabilitation. The mean (SD) length of stay was 37.3 (25.2) days. Nova Scotia and Ontario had the highest provision of inpatient rehabilitation (n = 235, 28.6% and n = 1779, 23.4%, respectively). Newfoundland and Labrador had the longest mean (SD) inpatient rehabilitation stay, 62.6 (36.6) days. Prince Edward Island had the highest FIM scores at admission and discharge (mean = 105.3, SD = 12.8; mean = 111.3, SD = 12.9 days, respectively). Conclusions We found that 18% of individuals with major LLA received inpatient rehabilitation across nine Canadian provinces. Costs and resource demands may prevent inpatient rehabilitation provision. Novel, cost-effective strategies may facilitate the provision of rehabilitation services. Clinical Relevance Despite the benefits of rehabilitation for individuals with major LLA, especially those whose amputations resulted from a traumatic incident, only 18% of patients with major LLA received inpatient rehabilitation across nine provinces between 2006 and 2012. Provinces with longer durations of inpatient rehabilitation reported higher levels of functional independence when patients with LLA were discharged.

Evaluating the Prognostic Accuracy of AMPREDICT in Predicting 1-Year Mortality Following Major Lower Limb Amputation

Accurately predicting postoperative outcomes is fundamental to informed clinical decision making, and alignment of patient, and family expectations. The AMPREDICT Decision Support Tool is a predictive tool designed to assess the probability of mortality one year after major and minor amputations. We aimed to evaluate the prognostic accuracy of AMPREDICT in our Veteran patient population. Retrospective review of lower extremity amputations completed at the West Los Angeles Veterans Affairs hospital from 2000 to 2020. Staged open amputations, and previous minor amputations were excluded. Using the AMPREDICT tool, the probability of mortality one-year post-surgery for single stage transfemoral and transtibial amputations was calculated, then compared with observed patient outcomes. Observed to predicted mortality was compared through boxplots, at one year after surgery, confidence intervals were calculated, and group means were compared using Students T-test. Receiver operator curves were constructed to assess discriminatory capacity of the tool. Significance was set at p < 0.05. 423 patients underwent 650 lower extremity amputations during our study period. 267 patients underwent single stage transfemoral or transtibial amputations comprising our study cohort. The average age at amputation was 66 years with an average age of death at 71 years. AMPREDICT tool's prognostic capability varied across the two amputations studied. For single staged transfemoral amputations, prediction aligned closely with observed outcomes, as indicated by a significant p-value of 0.0002 (C.I. 12.73 - 36.37). For single stage transtibial amputations, the predictions were also significant, p-value 0.0017 (C.I. 5.25 - 21.20), though had a wider prediction range. Our study confirms the reliability of the AMPREDICT tool in predicting one-year mortality for patients undergoing major lower limb amputations. The predictive accuracy was found to be statistically significant for both single staged transfemoral and transtibial amputations. These findings suggest that AMPREDICT may be a valuable tool in the clinical setting for patients undergoing major lower limb amputation.

Vascular service provision during the COVID-19 pandemic worsened major amputation rates in socially deprived diabetic populations.

The Coronavirus Disease - 2019 (COVID-19) pandemic significantly impacted healthcare service provision and put diabetic patients at increased risk of adverse health outcomes. We aimed to assess the impact of the COVID-19 pandemic on the incidence and demographic shift of major lower-limb amputation in diabetic patients. We performed a retrospective analysis of diabetic patient records undergoing major lower-limb amputation between 01/03/2019 and 01/03/2021 at the Royal Sussex County Hospital, the regional arterial hub for Sussex. Primary outcomes were amputation incidence rates and patient demographics compared between the prepandemic and pandemic cohorts. The incidence rate ratio of major lower-limb amputations shows a drop in amputations during the pandemic compared to pre-pandemic (IRR 0.82; 95% CI 0.57-1.18). Data suggests a shift in the social deprivation background of patients receiving amputations to disproportionately affect those in the more deprived 50% of the population (p=0.038). Younger patients received more amputations during the pandemic compared to prepandemic levels (p=0.001). Results suggest that during the COVID-19 pandemic there was a paradoxical reduction in amputations compared to prepandemic levels. However, changes to the demographic makeup of patient's receiving amputations are alarming as younger, and more deprived patients have been disproportionately affected by the pandemic.

Prophylactic Regenerative Peripheral Nerve Interface (RPNI) Surgery in Pediatric Lower Limb Amputation Patients.

To evaluate the prophylactic effect of Regenerative Peripheral Nerve Interface (RPNI) surgery on pediatric post-amputation pain. Chronic post-amputation pain is a debilitating and refractory sequela of limb amputation affecting up to 83% of pediatric patients with limb loss, resulting in disability and decreased quality of life. We postulate that prophylactic RPNI surgery performed during amputation may decrease the incidence of symptomatic neuroma and development of phantom limb pain, as well as limit analgesic use among pediatric patients with limb loss. Retrospective chart review was performed on pediatric patients between the ages of 8 and 21 years who underwent major lower limb amputation with and without RPNI surgery. Documented neuroma and phantom limb pain scores as well as analgesic use was recorded. Narcotic use was converted to milligrams morphine equivalents per day (MME/day) while overall analgesic use was converted to Medication Quantification Scale version III (MQSIII) scores. Analysis was performed using Stata. Forty-four pediatric patients were identified; 25 RPNI patients and 19 controls. Seventy-nine percent of control patients developed chronic post-amputation pain versus 21% of RPNI patients (P<0.001). Among the patients who developed post-amputation pain, 20% of controls developed clinical neuroma pain, compared to 0% of RPNI patients (P<0.001). Additionally, RPNI patients demonstrated a significant decrease in pain score (P=0.007) and narcotic usage (P<0.01), compared to controls. Overall analgesic use did not vary significantly between groups. Prophylactic RPNI surgery shows promise for pediatric patients undergoing major lower limb amputation by preventing both symptomatic neuromas and possibly the development of phantom limb pain.

Risk factors in persons with diabetes who underwent major and minor lower limb amputations during 2010-2016

Risk factors in persons with diabetes who underwent major and minor lower limb amputations during 2010-2016

Anxiety and Depressive Symptoms in Moroccan Patients Following Major Lower Limb Amputation: A Three-Month Follow-Up.

Major amputation of a lower limb is a traumatic experience that causes physical and psychosocial disabilities. This study set out to ascertain how anxiety and depression symptoms changed during the three months following the amputation. A prospective longitudinal observational study was conducted between October 1, 2019, and January 1, 2021, in the Department of Vascular Surgery and the Department of Orthopedic Traumatology of the Ibn Sina Hospital Center in Rabat, Morocco. The study assessessymptoms of anxiety and depression in patients who have undergone a major lower limb amputation over a three-month interval. In patients who had undergone a major lower limb amputation, the prevalence of anxiety and depression symptoms was very high immediately postoperatively (47.4% and 79.2%, respectively), with a significant decrease in these symptoms. Three months later, anxiety was reported in 24.4% of cases, and depressive symptoms in 65.1% of cases. Age, amputation level, stump pain, phantom limb pain, re-amputation, and emergency amputation were all associated with an increased risk of anxiety and depression. The patient's psychological preparation prior to the amputation, the anesthetic technique used during the procedure, the patient's mobility, and the patient's post-amputation professional status were all protective factors. Our research findings bolster the necessity of promptly evaluating and managing anxiety and depression in the initial three months following major lower limb amputation. Thus, we believe that amputee patients ought to receive a formal psychological evaluation, which could be helpful, particularly for those whose anxiety or depression symptoms did not improve after three months.

Risk Factors for Mortality and Promoting Factors for Ambulation After Major Lower Limb Amputation for End-Stage Arterial Disease: A Multicenter Study

Around 1%-2% of patients with peripheral arterial disease will require a lower limb amputation at some point. Despite advancements in prevention and treatment, mortality after major amputation remains high. The aim of this study was to investigate the risk factors related to mortality and promoting factors for ambulation postamputation. A multicenter retrospective study of consecutive major lower limb amputation patients performed at the department of thoracic and vascular surgery of the University Hospitals Ghent and Leuven between January 2008 and December2017. Three hundred and thirteen patients met the inclusion criteria. Overall, 1-year mortality rate was 29.7% with age being the most important risk factor. Above-knee amputations had significantly higher mortality (37%) than below-knee amputations (22%) at 1year. Diabetes and number of vascular interventions were not linked to higher mortality. Age, amputation level, and presence of hypertension were the most important determining factors for successful ambulation. Maintaining the independency of patients, whether this is obtained by maximizing limb salvage or primary amputation, is critical. Knowledge about the factors that play a role in the risk of death and the chance of regaining ambulation is important to include in the decision-making conversation with the patient.

Rehabilitation experiences following major lower limb amputation due to complications of vascular disease: a UK qualitative study

Purpose Rehabilitation experiences of lower limb amputees with poorer physical health have not been fully explored. This study aimed to qualitatively explore experiences of rehabilitation amongst patients who had recently undergone amputation due to complications of vascular disease. Methods Semi-structured, face-to-face interviews were conducted with 14 patients participating in the PLACEMENT randomised controlled feasibility trial (ISRCTN: 85710690; EudraCT: 2016-003544-37), which investigated the effectiveness of using a perineural catheter for postoperative pain relief following major lower limb amputation. Framework analysis was used to identify key themes and compare participant data. Findings Three main themes and corresponding sub-themes were identified: (i) other patients as inspiration; (ii) other patients as competition; and (iii) imagined futures. Perceptions relating to other patients played a key role in rehabilitation, providing a source of motivation, support, and competition. Participants’ imagined futures were uncertain, and this was compounded by a lack of information and delays in equipment and/or adaptations. Conclusions Findings highlight the importance of fellow patients in supporting rehabilitation following lower limb amputation. Enabling contact with other patients should thus be a key consideration when planning rehabilitation. There is a clear unmet need for realistic information relating to post-amputation recovery, tailored to the needs of individual patients.

Mobility Rates After Lower-Limb Amputation for Patients Treated with Physician-Led Collaborative Care Model

Clinical outcomes after major lower-limb amputation have been historically poor. The current care provided to most amputees is often disorganized and without physician supervision. The primary purpose of this study is to examine rates of postamputation mobility achieved with a prosthesis by patients with chronic limb-threatening ischemia and/or diabetes who required major lower-limb amputation and were treated under an established physician-led collaborative care pathway. The secondary purpose is to describe the structure and utilization of the care pathway by multiple independent vascular surgery practices in the United States to enable future exploration of its impact on key clinical outcomes within this patient population. Clinical records of 2,475 patients from 6 vascular practices that adopted this collaborative care pathway between 2017 and 2020 were retrospectively reviewed. Only records with sufficient documented histories of amputation surgeries, prosthetic services, and mobility status were included. Of 2,475 patient records reviewed, 1,787 patients (2,157 major amputations) were eligible for analysis. Sixty-two-point 2 percent (n=1,111) of patients achieved mobility with the collaborative care pathway. Mobility rate varied by amputation level in the study. Prosthetic mobility was achieved in 73.5% of transtibial amputations, 40.4% of transfemoral amputations, and 35.7% of through-knee amputations, regardless of patient laterality, which is superior or equivalent to the best published rates of mobility. The study describes the structure and utilization of a physician-led collaborative care pathway for treating patients who require lower-limb amputation that meets 5 of the 7 recommendations from the 2019 Global Vascular Guidelines on the Management of Chronic Limb Threatening Ischemia. Internal data analysis results suggest that patients treated via this care pathway can potentially achieve improved mobility rates with a prosthesis following amputation. This collaborative care pathway should be further evaluated for its ability to directly improve mobility and other clinically relevant amputation outcomes.