Background: Quality of life (QoL) is increasingly being recognized as an important outcome for rehabilitation programs, and has mainly been used to compare the efficacy of interventions or to compare amputees with other diseased populations. There is relatively a limited number of studies primarily focusing on analyzing the multitude of factors influencing QoL in amputees.Objectives: To identify important background and amputation related factors which affect quality of life (QoL) in lower limb amputees, and to compare QoL profile of amputees’ to that of general population.Study design: Cross-sectional.Methods: Lower limb amputees 18 years and above from a rehabilitation centre, a limb-fitting centre and four limb-fitting camps were interviewed (n = 605). Structured questionnaires included patient background and amputation characteristics, and the MOS short-form health survey (SF-36) for assessing QoL. The SF-36 was administered to a general adult population using purposive sampling (n = 184).Results: SF-...

https://poi.sagepub.com/content/35/1/90.full.pdf

Factors affecting quality of life in lower limb amputees

Objective: To compare the incidence of vascular lower limb amputation (LLA) in the diabetic and nondiabetic general population. Research design & methods: A population-based cohort study was conducted in a representative Swedish region. All vascular LLA (at or proximal to transmetatarsal level) performed from 1997 through 2006 were consecutively registered and classified into initial unilateral amputation, contralateral amputation or re-amputation. The incidence rates were estimated in the diabetic and nondiabetic general population aged 45 years or older. Results: During the 10-year period, LLA was performed on 62 women and 71 men with diabetes and on 79 women and 78 men without diabetes. The incidence of initial unilateral amputation per 100,000 person-years (95% CI) was for diabetic women 192 (145-241) and for diabetic men 197 (152-244) and for nondiabetic women 22 (17-26) and for nondiabetic men 24 (19-29). The incidence increased from the age of 75 years. 74% of all amputations were transtibial. The incidence of contralateral amputation and of re-amputation per 100 amputee-years (95% CI) in diabetic women amputees was 15 (7-27) and 16 (8-28) and in diabetic men 18 (10-29) and 21 (12-32), respectively, and in nondiabetic women amputees were 14 (7-24) and 18 (10-28) and in men 13 (6-22) and 24 (15-35), respectively. Conclusions: In the general population aged 45 years or older the incidence of vascular lower limb amputation at or proximal to transmetatarsal level is 8 times higher in diabetic than in nondiabetic persons. One in four amputees may require contralateral amputation and/or re-amputation.

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Incidence of Lower-Limb Amputation in the Diabetic and Nondiabetic General Population A 10-year population-based cohort study of initial unilateral and contralateral amputations and reamputations

High mortality rates have been reported after major amputations of a lower limb secondary to diabetes and peripheral vascular disease. However, the mortality rates have varied across studies. A systematic review of the 5-year mortality after nontraumatic major amputations of the lower extremity was conducted. A data search was performed of Medline using OVID, CINHAL, and Cochrane, 365 abstracts were screened, and 79 full text articles were assessed for eligibility. After review, 31 studies met the inclusion and exclusion criteria. Overall, the 5-year mortality rate was very high among patients with any amputation (major and minor combined), ranging from 53% to 100%, and in patients with major amputations, ranging from 52% to 80%. Mortality after below-the-knee amputation ranged from 40% to 82% and after above-the-knee amputation from 40% to 90%. The risk factors for increased mortality included age, renal disease, proximal amputation, and peripheral vascular disease. Although our previous systematic review of the 5-year mortality after ulceration had much lower rates of death, additional studies are warranted to determine whether amputation hastens death or is a marker for underlying disease severity.

Mortality After Nontraumatic Major Amputation Among Patients With Diabetes and Peripheral Vascular Disease: A Systematic Review

Care of veterans and servicemembers with major traumatic limb loss from combat theaters is one of the highest priorities of the Department of Veteran Affairs. We achieved a 62% response rate in our Survey for Prosthetic Use from 298 Vietnam war veterans and 283 servicemembers/veterans from Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) who sustained major traumatic limb loss. Participants reported their combat injuries; health status; quality of life; and prosthetic device use, function, rejection, and satisfaction. Despite the serious injuries experienced, health status was rated excellent, very good, or good by 70.7% of Vietnam war and 85.5% of OIF/OEF survey participants. However, many health issues persist for Vietnam war and OIF/OEF survey participants (respectively): phantom limb pain (72.2%/76.0%), chronic back pain (36.2%/42.1%), residual-limb pain (48.3%/62.9%), prosthesis-related skin problems (51.0%/58.0%), hearing loss (47.0%/47.0%), traumatic brain injury (3.4%/33.9%), depression (24.5%/24.0%), and posttraumatic stress disorder (37.6%/58.7%). Prosthetic devices are currently used by 78.2% of Vietnam war and 90.5% of OIF/OEF survey participants to improve function and mobility. On average, the annual rate for prosthetic device receipt is 10.7-fold higher for OIF/OEF than for Vietnam war survey participants. Findings from this cross-conflict survey identify many strengths in prosthetic rehabilitation for those with limb loss and several areas for future attention.

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Servicemembers and veterans with major traumatic limb loss from Vietnam war and OIF/OEF conflicts: survey methods, participants, and summary findings.

A Meta-analysis of Long-term Mortality and Associated Risk Factors following Lower Extremity Amputation.

The purpose of the study was to evaluate possible differences between genders in amputation incidence, revascularization activity before and survival after amputation. This population-based study was carried out in a well-defined geographical area, where all vascular surgical consultations and reconstructions are performed in one university hospital. All amputations performed in the region during 1990 - 1999 were identified from the hospital central registers. According to patient's identity codes, the Cause of Death Registry of Statistics Finland provided death data. Amputation data were cross-linked with the local vascular registry using identity codes. Women were found to be 8 years older than men (p < 0.0001). Major amputations comprised 73.4% in males and 77.7% in females. The age-standardized amputation incidence among males was 338 and among females 226 (per 10(6) inhabitants/year) (p < 0.001). The most prominent difference was seen in amputations due to trauma, where the age-adjusted major amputation incidence was over three-fold among males compared to females. The proportion of patients who had undergone vascular procedure before amputation was 23% in both genders. Median survival after amputation was 943 days in men and 716 in women (p = 0.01). When the higher age of women was considered, there was no significant difference between the genders. Survival was poorer among diabetics in both genders and the difference was significant in males. The amputation incidence was found to be higher in men compared to women in all etiologic subgroups except malignant tumour. Almost one in 4 patients had undergone vascular surgical reconstruction before amputation in both genders. There was no significant difference between the genders in survival after amputation. Subjects with diabetes had a poorer survival after major amputation than those without diabetes.

https://poi.sagepub.com/content/31/3/277.full.pdf

Lower limb amputations: Differences between the genders and long-term survival

Objective: To evaluate the role of subjective symptoms, grade of disability and axial reflux in superficial veins in different clinical stages of varicose veins (VVs). Methods: A total of 172 legs with primary venous insufficiency from 126 patients were studied. The examination involved evaluation of the CEAP clinical class and clinical disability score (CDS), recording of any symptoms of varicose disease, and a hand-held Doppler (HHD) examination of the superficial veins. Colour-flow duplex imaging (CFDI) was also performed in 22% of the legs. Results: The rate of insufficiency of the great saphenous vein (GSV) was 83% in complicated legs (C4-6), and 68% in uncomplicated legs (C2-3), (P>0.05). There was a difference between complicated and uncomplicated legs in the insufficiency of the whole GSV [C4-6: n=18 (39%) versus C2-3: n=12 (12%), P<0.005]. Sensation of pain was noted in 68% of the legs in class C1, 60% of those in class C2-3 and 81% of those in class C4-6. Sensation of oedema was recorded in 70% of the legs in class C1, 65% of those in class C2-3 and 86% of those in class C4-6, respectively. CDS classes 2-3 were significantly more frequent among complicated legs (C4-6: 54% versus C2-3 12%, P<0.005). Conclusions: Leg symptoms are frequent throughout classes C1-6. Their clinical usefulness is therefore limited. CDS parallels well with the clinical classification. In complicated disease the whole saphenous vein is more frequently insufficient.

Symptoms, clinical disability scores and reflux in complicated and uncomplicated primary varicose veins:

BACKGROUND AND AIMS: The purpose of this prospective clinical study was to evaluate the reliability and adequacy of preoperative physical examination in determining the quality of vessels prior to primary vascular access procedure by performing peroperative completion fistulography. MATERIAL AND METHODS: 26 consecutive patients who were scheduled for primary vascular access surgery, between July 2001 and June 2002, were included. Findings between the preoperative physical examination and peroperative completion fistulography were compared. RESULTS: Of the 26 patients that were initially enrolled in the study, 4 patients were excluded because physical examination showed poor superficial arm veins and 2 patients had not undergone access procedure by the end of the study. The remaining twenty patients constituted the actual study group. The arteriovenous fistula could be performed at the chosen level and way in all 20 patients. The findings between preoperative physical examination and peroperative fistulography were compatible and the specificity of physical examination to detect patent inflow and outflow vessels was 100%. Due to the fact that 4 patients in whom a poor vein was suspected were excluded, the sensitivity could not be assessed. CONCLUSIONS: Preoperative physical examination seems to be reliable and adequate method in determining vessel quality prior primary vascular access surgery. According to our study, its specificity is high in determining patent inflow and out-flow vessels. However, because of exclusion of patients with suspected problem, sensitivity cannot be determined.

J. Virkkunen

Papers

Lower limb amputations: Differences between the genders and long-term survival

Symptoms, clinical disability scores and reflux in complicated and uncomplicated primary varicose veins:

Preoperative physical examination for primary vascular access--reliability in determining vessel quality.