Dataset Information

Risks and Risk Factors for Ipsilateral Re-Amputation in the First Year Following First Major Unilateral Dysvascular Amputation.

ABSTRACT: OBJECTIVE:To identify timing, incidence, and risk factors for ipsilateral re-amputation within 12 months of first dysvascular amputation and to determine specific subgroups of patients at each amputation level that are at increased risk. METHODS:A retrospective cohort study evaluating 7187 patients with first unilateral transmetatarsal (TM), transtibial (TT), or transfemoral (TF) amputation secondary to diabetes and/or peripheral artery disease (PAD) were identified in the VA Surgical Quality Improvement Program database between 2004 and 2014. Re-amputation was defined as any subsequent ipsilateral soft tissue/bony revision or amputation to a higher level. Twenty-three potential pre-operative risk factors (and nine potential interactions) were identified. A backward stepwise Cox regression was used to identify risk factors. Incidence rates and hazard ratios (HR) with 95% confidence intervals (CI) were computed. RESULTS:The median time to highest level of re-amputation in the first year was 33 (interquartile range, 13-73) days. Risk of requiring at least one re-amputation was 41% (TM), 25% (TT), and 9% (TF). Risk factors associated with requiring re-amputation included chronic obstructive pulmonary disease, elevated white blood cell count, abnormal ankle brachial index (ABI), history of revascularisation, and alcohol misuse. TM patients who had diabetes only (HR 1.9; 95% CI 1.4-2.5), diabetes with an abnormal ankle brachial index (ABI) score (HR 2.4; 95% CI 1.8-3.2), and kidney failure (HR 1.7; 95% CI 1.3-2.1) were at the greatest risk of re-amputation. TT amputees who were smokers were also at an increased risk (HR 1.4; 95% CI 1.2-1.6). CONCLUSION:This research identified important risk factors for failure of primary healing and need for re-amputation at the TM and TT level. If considering a TM amputation, caution should be exercised in patients with diabetes, in particular those with an abnormal ABI and/or renal failure. At the TT level, caution should be exercised in those who smoke.

SUBMITTER: Norvell DC

PROVIDER: S-EPMC7530068 | biostudies-literature | 2020 Oct

REPOSITORIES: biostudies-literature

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Risks and Risk Factors for Ipsilateral Re-Amputation in the First Year Following First Major Unilateral Dysvascular Amputation.

Norvell Daniel C DC Czerniecki Joseph M JM

European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery 20200813 4

<h4>Objective</h4>To identify timing, incidence, and risk factors for ipsilateral re-amputation within 12 months of first dysvascular amputation and to determine specific subgroups of patients at each amputation level that are at increased risk.<h4>Methods</h4>A retrospective cohort study evaluating 7187 patients with first unilateral transmetatarsal (TM), transtibial (TT), or transfemoral (TF) amputation secondary to diabetes and/or peripheral artery disease (PAD) were identified in the VA Surg ...[more]

PMID: 32800475

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Project description:BackgroundPeople 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.ObjectivesTo identify factors that contribute to daily step count after dysvascular LLA.DesignCross-sectional, secondary data analysis.SettingOutpatient rehabilitation facilities.ParticipantsFifty-eight patients with dysvascular major LLA (age: 64 ± 9 years, body mass index: 30 ± 8 kg/m2 , male: 95%, transtibial LLA: 95%).MethodsData 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.Primary outcome measureThe primary outcome, daily step count, was measured with accelerometer-based activity monitors worn by participants for 10 days.ResultsParticipants 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%).ConclusionsAverage 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.Level of evidenceIII.

Project description:BackgroundFollowing an amputation, the human postural control system develops neuromuscular adaptations to regain an effective postural control. We investigated the compensatory mechanisms behind these adaptations and how sensorimotor integration is affected after a lower-limb transfemoral amputation.MethodsCenter of pressure (CoP) data of 12 unilateral transfemoral amputees and 12 age-matched able-bodied subjects were recorded during quiet standing with eyes open (EO) and closed (EC). CoP adjustments under each leg were recorded to study their contribution to posture control. The spatial structure of the CoP displacements was characterized by measuring the mean distance, the mean velocity of the CoP adjustments, and the sway area. The Entropic Half-Life (EnHL) quantifies the temporal structure of the CoP adjustments and was used to infer disrupted sensory feedback loops in amputees. We expanded the analysis with measures of weight-bearing imbalance and asymmetry, and with two standardized balance assessments, the Berg Balance Scale (BBS) and Timed Up-and-Go (TUG).ResultsThere was no difference in the EnHL values of amputees and controls when combining the contributions of both limbs (p = 0.754). However, amputees presented significant differences between the EnHL values of the intact and prosthetic limb (p < 0.001). Suppressing vision reduced the EnHL values of the intact (p = 0.001) and both legs (p = 0.028), but not in controls. Vision feedback in amputees also had a significant effect (increase) on the mean CoP distance (p < 0.001), CoP velocity (p < 0.001) and sway area (p = 0.007). Amputees presented an asymmetrical stance. The EnHL values of the intact limb in amputees were positively correlated to the BBS scores (EO: ρ = 0.43, EC: ρ = 0.44) and negatively correlated to the TUG times (EO: ρ = - 0.59, EC: ρ = - 0.69).ConclusionThese results suggest that besides the asymmetry in load distribution, there exist neuromuscular adaptations after an amputation, possibly related to the loss of sensory feedback and an altered sensorimotor integration. The EnHL values suggest that the somatosensory system predominates in the control of the intact leg. Further, suppressing the visual system caused instability in amputees, but had a minimal impact on the CoP dynamics of controls. These findings points toward the importance of providing somatosensory feedback in lower-limb prosthesis to reestablish a normal postural control.Trial registrationDRKS00015254 , registered on September 20th, 2018.

Project description:BACKGROUND:Prosthesis rehabilitation after dysvascular transtibial amputation (TTA) is focused on optimizing functional capacity with limited emphasis on promoting health self-efficacy. Self-efficacy interventions decrease disability for people living with chronic disease, but the influence of self-efficacy on disability is unknown for people with dysvascular TTA. OBJECTIVES:To identify if self-efficacy mediates the relationship between self-reported functional capacity and disability after dysvascular TTA. DESIGN:Cross-sectional, secondary data analysis. SETTING:Outpatient rehabilitation facilities. PARTICIPANTS:Thirty-eight men (63.6 ± 9.1 years old) with dysvascular TTA. METHODS:Participants had been living with an amputation for less than 6 months and using walking as their primary form of locomotion using a prosthesis. The independent variable, functional capacity, was measured using the Prosthesis Evaluation Questionnaire-Mobility Scale (PEQ-MS). The proposed mediator, self-efficacy, was measured with the Self-Efficacy of Managing Chronic Disease questionnaire (SEMCD). MAIN OUTCOME MEASURE:Disability was measured using the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) questionnaire. RESULTS:The relationship between self-reported functional capacity and disability is partially mediated by self-efficacy. Relationships between WHODAS 2.0 and PEQ-MS (r = -0.61), WHODAS 2.0 and SEMCD (r = -0.51), and PEQ-MS and SEMCD (r = 0.44) were significant (P < .01). Controlling for SEMCD (P = .04), the relationship between PEQ-MS and WHODAS 2.0 remained significant (P < .01). Statistically significant mediation was determined by a bootstrap method for the product of coefficients (95% confidence interval: -2.23, -7.39). CONCLUSIONS:This study provides initial evidence that the relationship between self-reported functional capacity and disability is partially mediated by self-efficacy after dysvascular TTA. The longitudinal effect of self-efficacy should be further examined to identify causal pathways of disability after dysvascular amputation. Furthermore, additional factors contributing to the relationship between self-reported functional capacity and disability need to be identified. LEVEL OF EVIDENCE:III.

Dataset Information

Risks and Risk Factors for Ipsilateral Re-Amputation in the First Year Following First Major Unilateral Dysvascular Amputation.

Publications

Risks and Risk Factors for Ipsilateral Re-Amputation in the First Year Following First Major Unilateral Dysvascular Amputation.

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