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Lower Limb Amputation in Patients with Vascular Disease

Johannesson, Anton LU (2009) In Lund University, Faculty of Medicine Doctoral Dissertation Series 2009:34.
Abstract (Swedish)
Popular Abstract in Swedish

Antalet personer som är amputerade ovanför tålederna i Sverige kan uppskattas till mellan 5000 och 5500. (ca 0.06 % av befolkningen). Största delen av dessa är amputerade pg.a. av kärlsjukdom (≈ 80 %). Antalet årligen nytillkomna benamputerade i Sverige kan uppskattas till mellan 1000-1100 och mindre än 5 % av dessa fall är relaterade till andra orsaker, t.ex. trauma eller cancer.

Benamputationer utförda på kärlsjuka patienter är inte enbart kritiska ur mobilitetssynpunkt utan är också slutskedet på ett sjukdomsförlopp ofta relaterat till smärta, depression och ångest för patienten och en hög kostnad för samhället. Benamputationers orsak och antal skiljer sig mellan och inom länder... (More)
Popular Abstract in Swedish

Antalet personer som är amputerade ovanför tålederna i Sverige kan uppskattas till mellan 5000 och 5500. (ca 0.06 % av befolkningen). Största delen av dessa är amputerade pg.a. av kärlsjukdom (≈ 80 %). Antalet årligen nytillkomna benamputerade i Sverige kan uppskattas till mellan 1000-1100 och mindre än 5 % av dessa fall är relaterade till andra orsaker, t.ex. trauma eller cancer.

Benamputationer utförda på kärlsjuka patienter är inte enbart kritiska ur mobilitetssynpunkt utan är också slutskedet på ett sjukdomsförlopp ofta relaterat till smärta, depression och ångest för patienten och en hög kostnad för samhället. Benamputationers orsak och antal skiljer sig mellan och inom länder p.g.a. åldersfördelning, antal individer som lider av kärlsjukdom och hur stor andel av dess som är diabetiker. Under 10 års tid registrerades alla de patienter bosatta i Nordöstra Skånes sjukvårdsdistrikt som amputerades ovanför tålederna p.g.a. kärlsjukdom. I delarbete I sammanställs resultaten för beräkning av incidens och dödlighet hos de 290 patienter som genomgick amputation. Patienterna följdes under 1 till 11 år. Ålder, kön, diagnos samt sida och nivå för amputationen registrerades och definierades som initial amputation (d.v.s. första amputationen), kontralateral amputation (d.v.s. första amputation på andra benet) och som re-amputation (d.v.s. ny amputation om den förra inte läkte eller p.g.a. ytterligare försämrad blodcirkulation). Årlig incidens av kärlsjukdomsrelaterade amputationer uppskattades för diabetiker och icke-diabetiker för populationen äldre än 45 år. Under perioden genomgick 133 diabetiker (53 % män) och 157 icke-diabetiker (50 % män) sin första amputation.

Den generella incidensen av initial amputation hos diabetiker var åtta gånger högre än hos icke-diabetiker, 195 jämfört med 23 per 100,000 personer/år. Den vanligaste nivån var underbensnivån (transtibial) som utgjorde 75 % av alla initiala amputationer. Incidensen av amputationer på andra benet hos amputerade diabetiker var 17 per 100 amputerade/år jämfört med 13 hos icke-diabetiker. Den vanligaste amputationsnivån på det andra benet hos både diabetiker och icke-diabetiker var också transtibial. Incidensen av re-amputationer hos amputerade diabetiker var 19 per 100 amputerade/år jämfört med 14 hos icke-diabetiker. Den vanligaste re-amputationsnivån hos diabetiker var underbensnivå till skillnad från lårbensnivå hos icke-diabetiker. Ettårsdödlighet visade ingen skillnad mellan diabetiker och icke-diabetiker när man justerat för ålder och könsskillnader.

I delarbete II presenterar vi den svenska versionen av funktionsmätinstrumentet Locomotor Capabilities Index (LCI) som är ett frågeformulär. LCI utvärderades för reliabilitet (reproducerbarhet) och validitet. Den svenska versionen av LCI som översatts och kulturellt anpassats visades vara reliabel och valid, framför allt hos äldre amputerade med låg eller medelhög aktivitetsnivå. Därmed skulle LCI kunna fungera som det första utvärderingsinstrument (frågeformulär) för benamputerade i Sverige som också kan användas vid internationella jämförelser.

I delarbete III jämförs två olika förband som används direkt efter underbensamputation. Det traditionella cirkulära gipsförbandet (CRD) och ett nytt vakuumformat förband (ORD®) som lätt kan justeras och om nödvändigt tvättas och återplaceras. Utfallsvariabler som analyserades var andel läkta sår, tid till protesförsörjning, funktion med protes (där två mätinstrument, ett subjektivt (LCI) och ett objektivt (Timed ”Up and Go”), användes), antal hylsbyten under första året samt möjlighet att återgå till sitt tidigare boende. Totalt inkluderades 27 patienter, varav alla var amputerade p.g.a. kärlsjukdom och accepterade att delta i studien. Protesförsörjning lyckades i 23 fall (14 män, medelålder 76 år (43-91)). Samma efterbehandling och rehabilitering användes i båda grupperna. För att minska påverkan av proteshylsformen vid funktionstest användes ICEX -hylsteknik på alla amputerade. Det nya förbandet (ORD) verkar ge samma resultat gällande sårläkning, tid till protesförsörjning, antal hylsbyten första året och möjlighet att återgå till sitt tidigare boende jämfört med det traditionella förbandet (CRD).

I delarbete IV undersöktes utfallet av en ny behandlingsstrategi vid underbensamputation på 219 patienter. Vid denna behandling användes som standard sagitellt snitt och stelt förband i 5-7 dagar. Detta efterföljdes av kompressionsbehandling med silikonhylsa. Träning med tuberstödjande protes användes under rehabiliteringsfasen så snart gipset tagits bort, men utan att lägga belastning på underbenet. Ny teknik vid hylstillverkning, ICEX , som bygger på att tillverka och leverera en träningsfärdig protes vid ett och samma besök, användes. Gångförmågan före insjuknandet bedömdes. Vid utskrivning från rehabilitering bedömdes gångförmågan med protes. Gångfunktionen bedömdes som god om den amputerade kunde använda protesen dagligen och gå utan stöd inomhus eller med stöd utomhus. Gångfunktionen bedömdes som dålig om den amputerade inte använde protesen dagligen, inte kunde gå utan stöd inomhus eller använde rullstol större delen av tiden. I denna grupp ingick också de patienter som inte fick protes.

Alla proteserna gick att tillverka och leverera vid första besöket. Mer än hälften (55 %) av alla underbensamputerade fick protes, i genomsnitt 41 dagar efter amputationen. Närmare två tredjedelar uppnådde god funktion med protes vid utskrivning från rehabilitering. Av de patienter som bedömdes ha god gångförmåga före amputationen och som överlevde mer än 90 dagar efter amputationen fick 80 % protes och 68 % uppfyllde kriterierna för god funktion med protes. Dessa patienters överlevnadstid var i genomsnitt tre och ett halvt år. (Less)
Abstract
The current prevalence of persons amputated at transmetatarsal level or higher in Sweden can be estimated to be between 5000 and 5500 persons (approx. 0.06 % of the population). The majority of these are patients with vascular disease (≈ 80%). In Sweden between 1000 and1100 new amputees can be expect every year. Less than 5% of all amputations will be related to causes other than vascular disease.

Lower limb amputation (LEA) in patients with vascular disease may not only be highly disabling but also costly in hospital management. The incidence differs between countries due to age structure of the population, prevalence of vascular disease and the prevalence of diabetes. In Paper I we prospectively evaluated LLA performed at... (More)
The current prevalence of persons amputated at transmetatarsal level or higher in Sweden can be estimated to be between 5000 and 5500 persons (approx. 0.06 % of the population). The majority of these are patients with vascular disease (≈ 80%). In Sweden between 1000 and1100 new amputees can be expect every year. Less than 5% of all amputations will be related to causes other than vascular disease.

Lower limb amputation (LEA) in patients with vascular disease may not only be highly disabling but also costly in hospital management. The incidence differs between countries due to age structure of the population, prevalence of vascular disease and the prevalence of diabetes. In Paper I we prospectively evaluated LLA performed at transmetatarsal level or higher during 10 years. The overall incidence of initial unilateral amputation in the diabetic population was eight times higher compared with that in the nondiabetic population (195 vs. 23 per 100,000 person-years). The incidence of contralateral amputation among diabetic amputees was 17 and among the nondiabetic amputees 13 per 100 amputee-years. The most frequent contralateral amputation level among the diabetic and nondiabetic patients was trans-tibial. The incidence of re-amputation among the diabetic amputees was 19 and among the nondiabetic amputees 14 per 100 amputee-years. The most frequent re-amputation level among diabetic patients was trans-tibial and among nondiabetic patients was trans-femoral.

The 1-year mortality rate, adjusted for age and gender, did not differ significantly between the two groups.

In Paper II we introduce a Swedish version of the Locomotor Capabilities Index (LCI) outcome instrument and evaluate its reliability and validity. Following the process of translation and cultural adaptation, the Swedish version of the LCI was found to be reliable and valid instrument that can provide a standardized measure of amputee-centered outcomes.

In Paper III we tested two different dressings after trans-tibial amputation, the conventional rigid dressing of plaster of Paris and a new vacuum-formed removable rigid dressing. The primary outcome measure was time to prosthetic fitting while the secondary outcomes included function with the prosthesis 3 months after amputation measured with the LCI and the Timed “Up and Go” (TUG) test. Twenty-seven consecutive patients were included and prosthetic fitting was achieved in 23 patients (mean age 76 years). The same postoperative treatment and rehabilitation was applied in both groups. To minimize the possible influence of using different types of prostheses in measuring functional outcome ICEX prosthetic sockets were used in all patients. The new vacuum-formed removable rigid dressing appear to yield similar results regarding wound healing, time to prosthetic fitting and function, rate of socket changes during the first year or return to previous dwelling when compared with conventional plaster of Paris rigid dressing.

In Paper IV we prospectively evaluated the outcome of a standardized surgical and rehabilitation program in trans-tibial amputation in a large consecutive and population-based series of 219 patients. We analyzed the outcome regarding rate of prosthetic fitting, walking ability and mortality. A circular, plaster of Paris rigid dressing was applied by the surgeon in the operating room. This rigid dressing was removed after 5 to 7 days and compression treatment with a silicone liner was started. Ambulation with an ischial weight bearing training prosthesis was started when the plaster of Paris dressing was removed, with no load on the residual limb. A prosthetic socket that is cast and made directly on the residual limb using pressure casting technique, resulting in a definitive socket was used. Functioning was defined as good if the patient wore the prosthesis daily and was able to walk alone or with assistance outdoors or alone indoors. Functioning was defined as poor if the patient did not wear the prosthesis daily and was unable to walk indoors without assistance or used a wheelchair most or all the time or did not receive prosthesis. All prostheses were produced and delivered on the same visit to the prosthetic workshop. More than half of all amputees could be fitted with a prosthesis after a median time of six weeks and almost two-thirds have good function 3 months after amputation and the functional status remained unchanged at 1 year. Poor functional outcomes correlated with delayed prosthetic fitting and not living independently before amputation. Of the patients who could walk with or without an aid prior to the amputation and who survived at least 90 days after amputation, more than 80% could be provided with a prosthesis with 68% achieving good function. These patients can expect a median survival of approximately 3.5 years. (Less)
Please use this url to cite or link to this publication:
author
supervisor
opponent
  • Professor Karlsson, Jón, Sahlgrenska Universitetssjukhuset, Göteborg
organization
publishing date
type
Thesis
publication status
published
subject
keywords
rehabilitation outcome, prosthetic, mortality, amputation, Incidence, limb
in
Lund University, Faculty of Medicine Doctoral Dissertation Series
volume
2009:34
pages
48 pages
publisher
Department of Clinical Sciences, Lund University
defense location
Utbildningslokalen Hanö-Lindö, gula byggnaden plan 2 korridor H, Centralsjukhuset i Kristianstad
defense date
2009-04-24 13:00
ISSN
1652-8220
ISBN
978-91-86253-21-9
language
English
LU publication?
yes
id
a83e5f2b-c2d3-48fc-ab06-729c4da3c5cd (old id 1366188)
date added to LUP
2009-04-03 13:19:10
date last changed
2016-09-19 08:44:51
@phdthesis{a83e5f2b-c2d3-48fc-ab06-729c4da3c5cd,
  abstract     = {The current prevalence of persons amputated at transmetatarsal level or higher in Sweden can be estimated to be between 5000 and 5500 persons (approx. 0.06 % of the population). The majority of these are patients with vascular disease (≈ 80%). In Sweden between 1000 and1100 new amputees can be expect every year. Less than 5% of all amputations will be related to causes other than vascular disease.<br/><br>
Lower limb amputation (LEA) in patients with vascular disease may not only be highly disabling but also costly in hospital management. The incidence differs between countries due to age structure of the population, prevalence of vascular disease and the prevalence of diabetes. In Paper I we prospectively evaluated LLA performed at transmetatarsal level or higher during 10 years. The overall incidence of initial unilateral amputation in the diabetic population was eight times higher compared with that in the nondiabetic population (195 vs. 23 per 100,000 person-years). The incidence of contralateral amputation among diabetic amputees was 17 and among the nondiabetic amputees 13 per 100 amputee-years. The most frequent contralateral amputation level among the diabetic and nondiabetic patients was trans-tibial. The incidence of re-amputation among the diabetic amputees was 19 and among the nondiabetic amputees 14 per 100 amputee-years. The most frequent re-amputation level among diabetic patients was trans-tibial and among nondiabetic patients was trans-femoral.<br/><br>
The 1-year mortality rate, adjusted for age and gender, did not differ significantly between the two groups. <br/><br>
In Paper II we introduce a Swedish version of the Locomotor Capabilities Index (LCI) outcome instrument and evaluate its reliability and validity. Following the process of translation and cultural adaptation, the Swedish version of the LCI was found to be reliable and valid instrument that can provide a standardized measure of amputee-centered outcomes.<br/><br>
In Paper III we tested two different dressings after trans-tibial amputation, the conventional rigid dressing of plaster of Paris and a new vacuum-formed removable rigid dressing. The primary outcome measure was time to prosthetic fitting while the secondary outcomes included function with the prosthesis 3 months after amputation measured with the LCI and the Timed “Up and Go” (TUG) test. Twenty-seven consecutive patients were included and prosthetic fitting was achieved in 23 patients (mean age 76 years). The same postoperative treatment and rehabilitation was applied in both groups. To minimize the possible influence of using different types of prostheses in measuring functional outcome ICEX prosthetic sockets were used in all patients. The new vacuum-formed removable rigid dressing appear to yield similar results regarding wound healing, time to prosthetic fitting and function, rate of socket changes during the first year or return to previous dwelling when compared with conventional plaster of Paris rigid dressing.<br/><br>
In Paper IV we prospectively evaluated the outcome of a standardized surgical and rehabilitation program in trans-tibial amputation in a large consecutive and population-based series of 219 patients. We analyzed the outcome regarding rate of prosthetic fitting, walking ability and mortality. A circular, plaster of Paris rigid dressing was applied by the surgeon in the operating room. This rigid dressing was removed after 5 to 7 days and compression treatment with a silicone liner was started. Ambulation with an ischial weight bearing training prosthesis was started when the plaster of Paris dressing was removed, with no load on the residual limb. A prosthetic socket that is cast and made directly on the residual limb using pressure casting technique, resulting in a definitive socket was used. Functioning was defined as good if the patient wore the prosthesis daily and was able to walk alone or with assistance outdoors or alone indoors. Functioning was defined as poor if the patient did not wear the prosthesis daily and was unable to walk indoors without assistance or used a wheelchair most or all the time or did not receive prosthesis. All prostheses were produced and delivered on the same visit to the prosthetic workshop. More than half of all amputees could be fitted with a prosthesis after a median time of six weeks and almost two-thirds have good function 3 months after amputation and the functional status remained unchanged at 1 year. Poor functional outcomes correlated with delayed prosthetic fitting and not living independently before amputation. Of the patients who could walk with or without an aid prior to the amputation and who survived at least 90 days after amputation, more than 80% could be provided with a prosthesis with 68% achieving good function. These patients can expect a median survival of approximately 3.5 years.},
  author       = {Johannesson, Anton},
  isbn         = {978-91-86253-21-9},
  issn         = {1652-8220},
  keyword      = {rehabilitation outcome,prosthetic,mortality,amputation,Incidence,limb},
  language     = {eng},
  pages        = {48},
  publisher    = {Department of Clinical Sciences, Lund University},
  school       = {Lund University},
  series       = {Lund University, Faculty of Medicine Doctoral Dissertation Series},
  title        = {Lower Limb Amputation in Patients with Vascular Disease},
  volume       = {2009:34},
  year         = {2009},
}