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Rhode Island Medical Journal (2013) May 2020The prevalence of amputation and post-amputation pain (PAP) is rising. There are two main types of PAP: residual limb pain (RLP) and phantom limb pain (PLP), with an... (Review)
Review
INTRODUCTION
The prevalence of amputation and post-amputation pain (PAP) is rising. There are two main types of PAP: residual limb pain (RLP) and phantom limb pain (PLP), with an estimated 95% of people with amputations experiencing one or both. Medical Management: The majority of chronic PAP is due to phantom limb pain, which is neurogenic in nature. Common medications used include tricyclic antidepressants, gabapentin, and opioids. Newer studies are evaluating alternative drugs such as ketamine and local anesthetics. Rehabilitation Management: Mirror visual feedback and cognitive behavioral therapy are often effective adjunct therapies and have minimal adverse effects. Surgical Management: Neuromodulatory treatment and surgery for neuromas have been found to help select patients with PAP.
CONCLUSION
PAP is a complex condition with mechanisms that can be located at the residual limb, spinal cord, and brain - or a combination. This complex pain can be difficult to treat. The mainstays of treatment are largely medical, but several surgical options are also being studied.
Topics: Amputation, Surgical; Humans; Pain; Pain Management; Pain Measurement; Phantom Limb
PubMed: 32357588
DOI: No ID Found -
Arteriosclerosis, Thrombosis, and... Aug 2020Peripheral artery disease (PAD) stems from atherosclerosis of lower extremity arteries with resultant arterial narrowing or occlusion. The most severe form of PAD is...
Peripheral artery disease (PAD) stems from atherosclerosis of lower extremity arteries with resultant arterial narrowing or occlusion. The most severe form of PAD is termed chronic limb-threatening ischemia and carries a significant risk of limb loss and cardiovascular mortality. Diabetes mellitus is known to increase the incidence of PAD, accelerate disease progression, and increase disease severity. Patients with concomitant diabetes mellitus and PAD are at high risk for major complications, such as amputation. Despite a decrease in the overall number of amputations performed annually in the United States, amputation rates among those with both diabetes mellitus and PAD have remained stable or even increased in high-risk subgroups. Within this cohort, there is significant regional, racial/ethnic, and socioeconomic variation in amputation risk. Specifically, residents of rural areas, African-American and Native American patients, and those of low socioeconomic status carry the highest risk of amputation. The burden of amputation is severe, with 5-year mortality rates exceeding those of many malignancies. Furthermore, caring for patients with PAD and diabetes mellitus imposes a significant cost to the healthcare system-estimated to range from $84 billion to $380 billion annually. Efforts to improve the quality of care for those with PAD and diabetes mellitus must focus on the subgroups at high risk for amputation and the disparities they face in the receipt of both preventive and interventional cardiovascular care. Better understanding of these social, economic, and structural barriers will prove to be crucial for cardiovascular physicians striving to better care for patients facing this challenging combination of chronic diseases.
Topics: Amputation, Surgical; Diabetes Complications; Health Care Costs; Humans; Peripheral Arterial Disease; Risk; Risk Factors
PubMed: 32580632
DOI: 10.1161/ATVBAHA.120.314595 -
The Cochrane Database of Systematic... Dec 2021Diabetes and vascular disease are the leading causes of lower limb amputation. Currently, 463 million adults are living with diabetes, and 202 million with peripheral... (Review)
Review
BACKGROUND
Diabetes and vascular disease are the leading causes of lower limb amputation. Currently, 463 million adults are living with diabetes, and 202 million with peripheral vascular disease, worldwide. When a lower limb amputation is considered, preservation of the knee in a below-knee amputation allows for superior functional recovery when compared with amputation at a higher level. When a below-knee amputation is not feasible, the most common alternative performed is an above-knee amputation. Another possible option, which is less commonly performed, is a through-knee amputation which may offer some potential functional benefits over an above-knee amputation.
OBJECTIVES
To assess the effects of through-knee amputation compared to above-knee amputation on clinical and rehabilitation outcomes and complication rates for all patients undergoing vascular and non-vascular major lower limb amputation.
SEARCH METHODS
The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL databases; the World Health Organization International Clinical Trials Registry Platform; and the ClinicalTrials.gov trials register to 17 February 2021. We undertook reference checking, citation searching, and contact with study authors to identify additional studies.
SELECTION CRITERIA
Published and unpublished randomised controlled trials (RCTs) comparing through-knee amputation and above-knee amputation were eligible for inclusion in this study. Primary outcomes were uncomplicated primary wound healing and prosthetic limb fitting. Secondary outcomes included time taken to achieve independent mobility with a prosthesis, health-related quality of life, walking speed, pain, and 30-day survival.
DATA COLLECTION AND ANALYSIS
Two review authors independently reviewed all records identified by the search. Data collection and extraction were planned in line with recommendations outlined in the Cochrane Handbook for Systematic Reviews of Interventions. We planned to assess the certainty of evidence using the GRADE approach.
MAIN RESULTS
We did not identify RCTs that met the inclusion criteria for this review.
AUTHORS' CONCLUSIONS
No RCTs have been conducted to determine comparative clinical or rehabilitation outcomes of through-knee amputation and above-knee amputation, or complication rates. It is unknown whether either of these approaches offers improved outcomes for patients. RCTs are needed to guide practice and to ensure the best outcomes for this patient group.
Topics: Adult; Amputation, Surgical; Humans; Lower Extremity; Peripheral Vascular Diseases; Randomized Controlled Trials as Topic; Systematic Reviews as Topic; Walking
PubMed: 34904714
DOI: 10.1002/14651858.CD013839.pub2 -
Archives of Physical Medicine and... Jan 2021To present recent evidence on the prevalence, incidence, costs, activity limitations, and work limitations of common conditions requiring rehabilitation.
A Systematic Review of the Incidence, Prevalence, Costs, and Activity and Work Limitations of Amputation, Osteoarthritis, Rheumatoid Arthritis, Back Pain, Multiple Sclerosis, Spinal Cord Injury, Stroke, and Traumatic Brain Injury in the United States: A 2019 Update.
OBJECTIVES
To present recent evidence on the prevalence, incidence, costs, activity limitations, and work limitations of common conditions requiring rehabilitation.
DATA SOURCES
Medline (PubMed), SCOPUS, Web of Science, and the gray literature were searched for relevant articles about amputation, osteoarthritis, rheumatoid arthritis, back pain, multiple sclerosis, spinal cord injury, stroke, and traumatic brain injury.
STUDY SELECTION
Relevant articles (N=106) were included.
DATA EXTRACTION
Two investigators independently reviewed articles and selected relevant articles for inclusion. Quality grading was performed using the Methodological Evaluation of Observational Research Checklist and Newcastle-Ottawa Quality Assessment Form.
DATA SYNTHESIS
The prevalence of back pain in the past 3 months was 33.9% among community-dwelling adults, and patients with back pain contribute $365 billion in all-cause medical costs. Osteoarthritis is the next most prevalent condition (approximately 10.4%), and patients with this condition contribute $460 billion in all-cause medical costs. These 2 conditions are the most prevalent and costly (medically) of the illnesses explored in this study. Stroke follows these conditions in both prevalence (2.5%-3.7%) and medical costs ($28 billion). Other conditions may have a lower prevalence but are associated with relatively higher per capita effects.
CONCLUSIONS
Consistent with previous findings, back pain and osteoarthritis are the most prevalent conditions with high aggregate medical costs. By contrast, other conditions have a lower prevalence or cost but relatively higher per capita costs and effects on activity and work. The data are extremely heterogeneous, which makes anything beyond broad comparisons challenging. Additional information is needed to determine the relative impact of each condition.
Topics: Absenteeism; Amputation, Surgical; Arthritis, Rheumatoid; Back Pain; Brain Injuries, Traumatic; Health Expenditures; Humans; Incidence; Multiple Sclerosis; Osteoarthritis; Physical Functional Performance; Prevalence; Spinal Cord Injuries; United States
PubMed: 32339483
DOI: 10.1016/j.apmr.2020.04.001 -
Journal of Vascular Surgery Apr 2020Multiple single-center studies have reported significant reductions in major amputations among patients with diabetic foot ulcers after initiation of multidisciplinary...
OBJECTIVE
Multiple single-center studies have reported significant reductions in major amputations among patients with diabetic foot ulcers after initiation of multidisciplinary teams. The purpose of this study was to assess the association between multidisciplinary teams (ie, two or more types of clinicians working together) and the risk of major amputation and to compile descriptions of these diverse teams.
METHODS
We searched PubMed, Scopus, Cumulative Index to Nursing and Allied Health, and Cochrane Central Register of Controlled Trials from inception through May 24, 2019 for studies reporting the association between multidisciplinary teams and major amputation rates for patients with diabetic foot ulcers. We included original studies if ≥50% of the patients seen by the multidisciplinary team had diabetes, they included a control group, and they reported the effect of a multidisciplinary team on major amputation rates. Studies were excluded if they were non-English language, abstracts only, or unpublished. We used the five-domain Systems Engineering Initiative for Patient Safety Model to describe team composition and function and summarized changes in major amputation rates associated with multidisciplinary team care. A meta-analysis was not performed because of heterogeneity across studies, their observational designs, and the potential for uncontrolled confounding (PROSPERO No. 2017: CRD42017067915).
RESULTS
We included 33 studies, none of which were randomized trials. Multidisciplinary team composition and functions were highly diverse. However, four elements were common across teams: teams were composed of medical and surgical disciplines; larger teams benefitted from having a "captain" and a nuclear and ancillary team member structure; clear referral pathways and care algorithms supported timely, comprehensive care; and multidisciplinary teams addressed four key tasks: glycemic control, local wound management, vascular disease, and infection. Ninety-four percent (31/33) of studies reported a reduction in major amputations after institution of a multidisciplinary team.
CONCLUSIONS
Multidisciplinary team composition was variable but reduced major amputations in 94% of studies. Teams consistently addressed glycemic control, local wound management, vascular disease, and infection in a timely and coordinated manner to reduce major amputation for patients with diabetic foot ulcerations. Care algorithms and referral pathways were key tools to their success.
Topics: Amputation, Surgical; Diabetic Foot; Humans; Limb Salvage; Patient Care Team
PubMed: 31676181
DOI: 10.1016/j.jvs.2019.08.244 -
Journal of Foot and Ankle Research Mar 2020In 2007, we reported a summary of data comparing diabetic foot complications to cancer. The purpose of this brief report was to refresh this with the best available data...
BACKGROUND
In 2007, we reported a summary of data comparing diabetic foot complications to cancer. The purpose of this brief report was to refresh this with the best available data as they currently exist. Since that time, more reports have emerged both on cancer mortality and mortality associated with diabetic foot ulcer (DFU), Charcot arthropathy, and diabetes-associated lower extremity amputation.
METHODS
We collected data reporting 5-year mortality from studies published following 2007 and calculated a pooled mean. We evaluated data from DFU, Charcot arthropathy and lower extremity amputation. We dichotomized high and low amputation as proximal and distal to the ankle, respectively. This was compared with cancer mortality as reported by the American Cancer Society and the National Cancer Institute.
RESULTS
Five year mortality for Charcot, DFU, minor and major amputations were 29.0, 30.5, 46.2 and 56.6%, respectively. This is compared to 9.0% for breast cancer and 80.0% for lung cancer. 5 year pooled mortality for all reported cancer was 31.0%. Direct costs of care for diabetes in general was $237 billion in 2017. This is compared to $80 billion for cancer in 2015. As up to one-third of the direct costs of care for diabetes may be attributed to the lower extremity, these are also readily comparable.
CONCLUSION
Diabetic lower extremity complications remain enormously burdensome. Most notably, DFU and LEA appear to be more than just a marker of poor health. They are independent risk factors associated with premature death. While advances continue to improve outcomes of care for people with DFU and amputation, efforts should be directed at primary prevention as well as those for patients in diabetic foot ulcer remission to maximize ulcer-free, hospital-free and activity-rich days.
Topics: Amputation, Surgical; Arthropathy, Neurogenic; Diabetic Foot; Health Care Costs; Humans; Lower Extremity; Neoplasms
PubMed: 32209136
DOI: 10.1186/s13047-020-00383-2 -
Endocrinology, Diabetes & Metabolism Jan 2021The IWGDF 2019 Updated Guidelines for prevention of foot ulcers in diabetes advise that nerve decompression surgery not be considered. This nerve decompression option...
The IWGDF 2019 Updated Guidelines for prevention of foot ulcers in diabetes advise that nerve decompression surgery not be considered. This nerve decompression option has similar scientific supporting evidence to other surgeries which are recommended. The sanction ignores a large body of non-Level 1 evidence demonstrating various beneficial outcomes of ND including pain relief, DFU prevention, and protection from recurrence and amputation.
Topics: Amputation, Surgical; Diabetes Mellitus; Diabetic Foot; Foot Ulcer; Humans; Recurrence; Ulcer
PubMed: 33532611
DOI: 10.1002/edm2.169 -
PloS One 2020Phantom limb pain (PLP)-pain felt in the amputated limb-is often accompanied by significant suffering. Estimates of the burden of PLP have provided conflicting data. To... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Phantom limb pain (PLP)-pain felt in the amputated limb-is often accompanied by significant suffering. Estimates of the burden of PLP have provided conflicting data. To obtain a robust estimate of the burden of PLP, we gathered and critically appraised the literature on the prevalence and risk factors associated with PLP in people with limb amputations.
METHODS
Articles published between 1980 and July 2019 were identified through a systematic search of the following electronic databases: MEDLINE/PubMed, PsycINFO, PsycArticles, Cumulative Index to Nursing and Allied Health Literature, Africa-Wide Information, Health Source: Nursing/Academic Edition, SCOPUS, Web of Science and Academic Search Premier. Grey literature was searched on databases for preprints. Two reviewers independently conducted the screening of articles, data extraction and risk of bias assessment. The meta-analyses were conducted using the random effects model. A statistically significant level for the analyses was set at p<0.05.
RESULTS
The pooling of all studies demonstrated a prevalence estimate of 64% [95% CI: 60.01-68.05] with high heterogeneity [I2 = 95.95% (95% CI: 95.10-96.60)]. The prevalence of PLP was significantly lower in developing countries compared to developed countries [53.98% vs 66.55%; p = 0.03]. Persistent pre-operative pain, proximal site of amputation, stump pain, lower limb amputation and phantom sensations were identified as risk factors for PLP.
CONCLUSION
This systematic review and meta-analysis estimates that six of every 10 people with an amputation report PLP-a high and important prevalence of PLP. Healthcare professionals ought to be aware of the high rates of PLP and implement strategies to reduce PLP by addressing known risk factors, specifically those identified by the current study.
Topics: Amputation, Surgical; Clinical Decision-Making; Humans; Phantom Limb; Prevalence; Risk Factors
PubMed: 33052924
DOI: 10.1371/journal.pone.0240431 -
Journal of Vascular Surgery Jan 2021
Topics: Amputation, Surgical; Humans
PubMed: 33349392
DOI: 10.1016/j.jvs.2020.08.026 -
Vascular Dec 2022Through-knee amputation is an umbrella term for several different surgical techniques, which may affect clinical and functional outcomes. This makes it hard to evaluate... (Review)
Review
OBJECTIVES
Through-knee amputation is an umbrella term for several different surgical techniques, which may affect clinical and functional outcomes. This makes it hard to evaluate the benefits and need for a through-knee amputation approach. This article seeks to (1) determine the number of through-knee amputation performed compared with other major lower limb amputations in England over the past decade; (2) identify the theoretical concepts behind through-knee amputation surgical approaches and their potential effect on functional and clinical outcomes and (3) provide a platform for discussion and research on through-knee amputation and surgical outcomes.
METHODS
National Health Service Hospital Episodes Statistics were used to obtain recent numbers of major lower limb amputations in England. EMBASE and MEDLINE were searched using a systematic approach with predefined criteria for relevant literature on through-knee amputation surgery.
RESULTS
In the past decade, 4.6% of major lower limb amputations in England were through-knee amputations. Twenty-six articles presenting through-knee amputation surgical techniques met our criteria. These articles detailed three through-knee amputation surgical techniques: the classical approach, which keeps the femur intact and retains the patella; the Mazet technique, which shaves the femoral condyles into a box shape and the Gritti-Stokes technique, which divides the femur proximal to the level of the condyles and attaches the patella at the distal cut femur.
CONCLUSIONS
Through-knee amputation has persisted as a surgical approach over the past decade, with three core approaches identified. Studies reporting clinical, functional and biomechanical outcomes of through-knee amputation frequently fail to distinguish between the three distinct and differing approaches, making direct comparisons difficult. Future studies that compare through-knee amputation approaches to one another and to other amputation levels are needed.
Topics: Humans; State Medicine; Disarticulation; Amputation, Surgical; Lower Extremity; England
PubMed: 34844469
DOI: 10.1177/17085381211045183