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Jan 25, 2001 - Couch, N. P., David, J. K., Tiney, N. L., and Crane, C. (1977). ... Sayers, R. D., Thompson, M. M., Varty, K., Jagger, C., and Bell, P. R. F. (1993).
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International Journal of Rehabilitation and Health [ijrh]

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International Journal of Rehabilitation and Health, Vol. 5, No. 1, 2000

Rehabilitation Outcome in Patients With Lower Limb Amputations Because of Arterial Occlusive Disease: Is it Worth Trying for the Lowest Possible Amputation Level? A Prospective Study Alexandros G. Gugulakis,1 Andreas M. Lazaris,1,2 Spyros N. Vasdekis,1 Miltiadis I. Matsagas,1 Sotirios G. Giannakakis,1 Petros K. Hadjigakis,1 Anastasios N. Macheras,1 Dimitrios P. Mandrekas,1 and Michael N. Sechas1

A policy of maximizing the ratio of below-knee to above-knee amputations in patients with severe nonsalvageable limb ischemia is followed. The value of this policy is examined. All the patients that were amputated in our department between 1995 and 1997 were followed up for 2 years after the operation. We correlated the amputation level with 6 different parameters: primary or secondary amputation, perioperative mortality, 2-years mortality, amputation stump healing, artificial limb fitment, and rehabilitation outcome. The results were analyzed statistically. A total of 64 patients were included in the study. The revision rate was 38% in below-knee amputees and 4% in above-knee amputees. The perioperative mortality was 22%. Two years after operation, the limb fitment rate in below-knee amputees was 95% and in above-knee amputees was 64%. The overall artificial limb fitment rate was 50%. A total of 47.6% of the living patients were capable to walk out of their house. Artificial limb fitment and rehabilitation status are greater after a below-knee than an above-knee amputation. Although the morbidity may be higher in below knee procedures, it is worth trying for the lowest level of amputation because of the better rehabilitation results in these patients. KEY WORDS: rehabilitation status; lower limb amputation; arterial occlusive disease.

The decision regarding appropriate amputation level (above or below knee) for an ischemic, nonsalvageable limb needs to take into consideration the operation’s feasibility, patient’s ability to overcome perioperative difficulties, and amputee’s necessity for rehabilitation. Patients are more likely to walk after below-knee (BK) amputations than after above-knee (AK) amputations (Conch et al., 1977), but quite often BK stumps fail to heal and require a reamputation to a higher level (Houghton et al., 1992; Sarin et al., 1991). On the contrary, AK stumps usually heal primarily but subsequent walking with a prosthetic limb is difficult. It is obvious that we definitely need a procedure that offers the best 1 3rd

Surgical Department, Sotiria Hospital, University of Athens, 152, Mesogion Street, Athens, Greece. whom correspondence should be addressed at 72, Sevastopoulou Street, 11524 Athens, Greece; e-mail: [email protected].

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65 C 2000 Plenum Publishing Corporation 1068-9591/00/0100-0065$18.00/0 °

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rehabilitation results as well as the least perioperative mortality and morbidity. A policy of maximizing the ratio of BK to AK amputations is usually followed (Sarin et al., 1991; Tsang et al., 1991). The application of this policy will be questionable if the resultant walking rate of the BK amputees is not superior or their perioperative morbidity and mortality is higher in these patients than in the AK amputees.

PATIENTS AND METHODS We designed a prospective study that started in 1995 and lasted 48 months. All the patients in the study suffered from critical ischemia (acute or chronic) that led them to limb amputation. The operations took place in our department between 1995 and 1997. After their amputation, patients received follow up care for 24 months. We kept detailed medical records for each patient; medical records contained all the necessary data from the perioperative period as well as the period of follow up. We assessed each patient’s rehabilitation condition at 6, 12, 18, and 24 months after amputation. Different investigators performed these periodical examinations with the examinations based on a clinical follow-up questionnaire. Patients indicated whether they used their artificial limb for walking (with or without aid) and, if so, whether they confined their walking to their home or routinely ventured outdoors using their artificial limb. On this basis, we categorized patients as “home walkers” and “outdoor walkers.” We must note that there is not a rehabilitation branch in our hospital. So, the great majority of patients were under the supervision of their own families or private physiotherapists at their home. We used Yates corrected chi-square test for statistical analysis of our results. We used Fisher’s exact test as an alternative to the fourfold chi-square test if the total number of observations was less than 20 or any of the expected frequencies were less than five.

RESULTS Between 1995 and 1997, we had performed 64 lower-limb amputations on the same number of patients (45 males and 19 females) because of arterial occlusive disease. We excluded from the study all patients that underwent a bilateral amputation. Mean age of the patients was 74.2 years. The 64 lower-limb amputations comprised 42 BK and 22 AK amputations. A long posterior flap technique was the technique used for all BK amputations. A fish mouth technique was the technique used in the AK procedures. The ratio of BK to AK amputations was 1.9:1. Primary amputation occurred in 52% of the patients (33 out of 62), and 48% of the patients (31 out of 62) had a previous arterial reconstruction (bypass grafting) attempted. Arterial reconstruction was more likely before BK than before AK amputations (59% vs. 43%), but this was not a statistically significant finding ( p = .332—Yates corrected chisquare test; Table I). Among the BK amputations, impaired stump healing requiring reamputation to a higher level than previously performed was a problem in 14 cases (33%). One AK amputation required a hip disarticulation (5%) due to poor healing. Thus, after reamputations, the total of 64 amputations comprised 28 BK amputations, 35 AK amputations, and 1 hip disarticulation. Statistical analysis confirmed that a second operation because of poor stump healing

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Table I. Primary and Secondary Amputation Versus Amputation Level Group

n

Primary

Secondary

Below knee Above knee pa pb

22 42

9 24 0.3316 0.3317

13 31

a Chi-square test (Yates corrected). b Fisher’s exact test (doubled one sided).

was significantly greater in BK amputations than in AK amputations ( p = .023—Yates corrected chi-square test; Table II). Using the Odds ratio analysis, we concluded that for every 10.5 second operations in BK amputees we have 1 second operation for AK amputees. Overall perioperative mortality of our series was 22% (14 out of 64 patients). Perioperative mortality for BK amputation was 14% and for AK amputations was 36% ( p = .09—Fisher’s exact test; Table III). Overall mortality 2 years after amputation was 16% (15% for BK amputations and 17% for AK amputations, p > .99—Fisher’s exact test; Table IV). The main causes of death were cardiac and brain complications. Two years after their amputation, 24% of the living patients (10 of 42) were unsuitable for walking training and did not undergo fitting for a prosthesis. The reason for nonfitment was presence of another major disability, such as previous stroke, poor vision, or severe psychiatric illness. We had provided and fitted artificial limbs for the remaining 32 patients. Thus, the overall fitment rate was 50% (32 of 64 patients). The limb fitment rate was 95% (16 out of 17 patients) among patients with BK amputations and 64% (16 out of 25) among patients with AK amputations. This was a statistically important finding ( p = .052— Fisher’s exact test; Table V). Patients’ rehabilitation status depended on amputation level: 47.6% of the living patients (20 out of 42) were capable to walk out of their house without aid (“outdoor walkers”), and 52.4% of them (22 out of 42) either walked inside the house with aid or were wheelchair bound (“home walkers”). Among the outdoor walkers, 35% (7 out of 20) were patients with AK amputations and 65% (13 out of 20) were patients with BK amputations. Among home walkers, 68% (15 out of 22) had AK amputations and 32% (7 out of 22) had BK amputations ( p = .066—Yates corrected chi-square test; Table VI). DISCUSSION AND CONCLUSIONS Despite the increasing incidence of lower limb vascular reconstruction, amputation rates remain relatively static (Sayers et al., 1993) in patients with end stage arterial occlusive Table II. Number of Operations Because of Impaired Stump Healing Versus Amputation Level Group

n

One operation

Two operations

Below knee Above knee pa pb

42 22

28 21 0.0231 0.0158

14 1

a Chi-square test (Yates corrected). b Fisher’s exact test (doubled one sided).

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Gugulakis et al. Table III. Perioperative Mortality Versus Amputation Level Group

n

Dead

Alive

Below knee Above knee pa pb

42 22

6 8 0.0871 0.0912

36 14

a Chi-square test (Yates corrected). b Fisher’s exact test (doubled one sided).

disease. In such cases, it is necessary to balance a patient’s ability to remain independently mobile with use of a prosthetic limb against an acceptable level of morbidity and mortality. In this study the BK-to-AK ratio for patients with end stage arterial occlusive disease was 1.9. A widely held belief is that a BK-to-AK amputation rate of 2.5 is the minimum acceptable standard for clinical units providing a lower-limb amputation service. In fact, the ratio of BK to AK amputations is usually very much below the recommended figure (Houghton et al., 1992; McWhinnie et al., 1994; Sarin et al., 1991; Tsang et al., 1991). This perhaps reinforces the impression that results from a single highly generalized center often does not reflect what actually happens in a wider population (Dormandy et al., 1999). In our series, 52% of the patients received primary amputation. This is similar to results of other investigators in the literature (Campbell et al., 1994; Larsson and Risberg, 1988; Sethia et al., 1986). Relevance of previous major arterial reconstruction in influencing level of final amputation remains unclear. In this study, previous ipsilateral reconstruction was more common among patients with BK amputations, although this was not a statistically significant finding ( p = .33). Other studies to the contrary notice an opposed correlation (McWhinnie et al., 1994). Overall revision surgery rate to a higher amputation level than the initial surgery was 23%, higher than the 9% of McWhinnie et al. (1994) and 13% of Campbell et al. (1994). Several risk factors influence stump healing and revision rates. Interestingly, a previously reported finding is the significant influence of the experience of the operating surgeon. White et al. (1997) believe that senior trainees or consultants should perform operations for patients deemed suitable for ambulatory training following surgery. Early hospital mortality varies from 3% to 10% for BK amputations and is near 20% for AK amputations (Dormandy et al., 1999). In our series, we noticed 14% and 36% respectively; this is almost statistically significant ( p = .08). We believe that the increased mortality in our results compared to other series is directly attributable to the high-risk patients with severe coexisting medical conditions (such as diabetes, cardiovascular, cerebrovascular, and respiratory disease) who were in our group. This mortality difference after 2 years in our series was 15% for BK amputations and 17% for AK amputations. Table IV. Two-Years Mortality Versus Amputation Level Group

n

Dead

Alive

Below knee Above knee pa pb

20 30

3 5 >0.9999 >0.9999

17 25

a Chi-square test (Yates corrected). b Fisher’s exact test (doubled one sided).

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Table V. Fitment Rate by Amputation Level Group

n

Prosthesis

No prosthesis

Below knee Above knee pa pb

17 25

16 16 0.0601 0.0516

1 9

a Chi-square test (Yates corrected). b Fisher’s exact test (doubled one sided).

The overall limb fitment rate of 50% (32 of 64 patients) in our series is greater than the 25% reported by Kald et al. (1989) from Motala, Sweden, but similar to the 57% noted by Houghton et al. (1989) from Guy’s Hospital, London. The limb fitment rate in our living patients was significantly greater after BK than after AK amputations ( p = .05). At 2 years after amputation, 31% of our commencement group of the 64 patients (or 48% of the 42 living patients) were successful outdoor walkers. Kald et al. (1989) and Houghton et al. (1989) reported an overall rehabilitation rate at 2 years of 15% and 17% respectively, but McWhinnie (1994) reported a similar rate to our series (34%). Dawson et al. (1995) reported 73% of the surviving amputees walking independently at 3 years after operation, more than our 48% at 2 years. Our patients were more likely to walk again after BK than after AK amputation ( p = .06), something that other authors (Cutson and Bongiorni, 1996; Malone et al., 1981) report as well. On the contrary, McWhinnie et al. (1994) did not find any clear functional benefit in favor of BK compared with AK amputations. After amputation, it is important to set realistic goals for patients aiming at their best adaptation to the new environment either using an artificial limb or a wheelchair. Existence of consultation rehabilitation committees that evaluate each patient after amputation has proven to be valuable (McWhinnie et al., 1994). On the other hand, specialist rehabilitation physiotherapists have a serious influence in patients’ postoperative mobility. Malone et al. (1981) demonstrated that patients rehabilitated in such centers can get discharged successfully four times sooner than patients without such a privilege. It is important to note that most of our patients did not have the option of inside-hospital rehabilitation care because there is not a rehabilitation department in our hospital, and there are not a sufficient number of hospitals with rehabilitation departments in the general area to cover all the existing needs. We believe that although the morbidity (especially impaired stump healing) is higher in BK procedures than in AK procedures, it is worth the effort to try for the lowest level of amputation because BK amputations offer a better rehabilitation result as compared to AK amputations. Table VI. Rehabilitation Status by Amputation Level Group

n

Outdoor

Indoor

Below knee Above knee pa pb

20 22

13 7 0.0656 0.0645

7 15

a Chi-square test (Yates corrected). b Fisher’s exact test (doubled one sided).

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