Amputations: no longer the end of the road

B.W. TURNEY, S.J.S. KENT, R.T. WALKER and I.M. LOFTUS
Departments of Surgery and Physiotherapy, Peterborough District Hospital, Peterborough, UK

Introduction Patients and methods Results

Discussion References

Background: The aim of this prospective study was to assess the effect of an intensive in-patient rehabilitation programme upon the mobility of amputees. Methods: All major lower limb amputations between 1997 and 1999 received a pre-operative mobility assessment and, where appropriate, were referred for a vigorous rehabilitation programme. Results: 92 lower limb amputations were performed in 87 patients (57 below knee, 33 above knee, two hip disarticulations). Overall, 63% of patients were able to ambulate independently following rehabilitation. Univariate analysis revealed that the only predictor of mobility was the level of amputation, below knee gaining better mobility than above knee (p=0.002). Conclusion: Lower limb amputees should participate in an aggressive in-patient physiotherapy regimen since reasonable mobility can be achieved in the majority of patients.

Keywords: amputation, physiotherapy, rehabilitation

J.R.Coll.Surg.Edinb., 46, October 2001, 271-273

INTRODUCTION

Whilst aggressive policies of vascular reconstruction and endovascular intervention have been advocated to prevent limb loss, amputation rates remain relatively static, with around 5000 lower limb amputations for vascular disease alone performed annually in the UK. Recent studies have shown that very few amputees (from 12% to 26%) achieve reasonable mobility.^1-6 The aim of this prospective study was to assess whether an intensive in-patient rehabilitation programme could compare more favourably. 

PATIENTS AND METHODS

All patients undergoing major lower limb amputations in Peterborough District Hospital between October 1997 and September 1999 received a pre-operative mobility assessment. Patients with any mobility, or any potential for mobility, were identified for vigorous in-patient rehabilitation by an integrated rehabilitation team consisting of vascular surgeons, rehabilitation doctors, physiotherapists and occupational therapists. Physiotherapy was continued on an out-patient basis when the patient was safe for discharge.

Amputation stump length was within a standard range in all patients according to guidelines established from previous internal audit (data unpublished). This optimised the balance of preservation of knee joint function versus stability of limb prosthesis in the below knee amputees, and maximised stability of the patient and prosthesis in the above knee amputee. All below knee amputations were long posterior flaps and above knee, equal anterior and posterior flaps. Following amputation loose, non-rigid dressings were applied to the stump. Daily physiotherapy commenced preoperatively if appropriate, and resumed as soon as possible after the amputation, usually at 48 or 72 hours. All patients remained in-patients until a prosthetic limb was cast and fitted, and mobility achieved. Temporary ambulatory aids were not utilised routinely. In a minority of below knee amputations with slow wound healing above knee pylons were used. A successful home visit was completed before discharge, after which patients were reviewed regularly in the physiotherapy department for assessment of their progress.

The Wood/Stanmore mobility scale was used by the physiotherapists to score each patient’s predicted and maximum achieved mobility. Mobility was defined as those patients achieving grade 3 or higher, where grade 3 represents independent mobility within the home, grade 4 outdoor mobility with walking aids and grade 5 independent outdoor walkers (Table 1).

RESULTS

Over the 2-year study period, 87 patients (median age 74) underwent 92 lower limb amputations. This group comprised 27 women and 60 men. Of the 87 patients, 43 underwent unilateral below knee amputations (BKA), 27 had unilateral above knee amputations (AKA) and two had hip disarticulations. There were 15 bilateral amputates (five patients with both amputations performed during the study period); 11 bilateral below knee amputations, two patients with one BKA and one AKA, and two patients with bilateral AKAs.3 Failed BKAs were converted to AKAs.

Fifty-four patients were admitted as emergencies and 35 were diabetic. The majority of amputations (70) were performed for critical ischaemia, 18 having undergone previous vascular surgery. The remainder were performed for a variety of orthopaedic, ulcerative, and oncological reasons. Only four patients were deemed pre-operatively to be unsuitable for limb fitting and intensive rehabilitation.

Mobility was achieved in 55 patients (63%), the details of which are shown in Table 2. Twelve patients died in the peri-operative period (i.e. before being discharged from hospital), of which only one had achieved mobility. A further nine patients died over the 2-year period, of whom three had achieved mobility. The overall mobility of the survivors was 77%.

The median duration of stay was 45 days (range 2-278) with no significant difference between the mobile and immobile groups (45 versus 49 days). The median duration of follow-up was 354 days from operation.

Mobility was significantly better in those patients with a unilateral BKA compared with a unilateral AKA (34/43 or 79% versus 10/27 or 37%, respectively, chi-squared analysis p=0.001). Univariate analysis found that no other factors affected mobility, in particular age, sex, diabetes, emergency admission, indication for amputation and previous vascular surgery.

Table 1: Summary of the Wood/Stanmore classification of mobility

DISCUSSION

A rigorous in-patient-based rehabilitation programme for amputees can achieve mobility in a large proportion of patients. We have employed a vigorous programme of physiotherapy and rehabilitation, which usually commences pre-operatively and continues daily until discharge. The results from this study are much more promising than previous reports showing mobility in as few as 12% of amputees.2 In these studies, a much smaller proportion of patients are referred for rehabilitation and limb fitting. Previous studies have suggested that poor results are due to a larger proportion of vascular patients with the associated morbidity.1 However, the majority of amputations were performed in this study for vascular disease, and there was no difference in mobility between those performed for vascular indications compared with orthopaedic or other causes. Whilst the poor health and poor overall prognosis of these patients is recognised, (reflected in a mortality rate of 24% during our 2-year study period), vigorous rehabilitation of the survivors resulted in a mobility of 77%, which prolongs a better quality of life and independence.

There are obvious cost implications for the provision of an intensive in-patient physiotherapy service. This has been estimated to cost around £8,500 per patient.8 This needs to be counter-balanced with the cost, which is very difficult to estimate, of care in the community for the immobile housebound-amputee. We feel that the median length of stay in this group of patients is acceptable given the success in achieving mobility.

The only predictor of poor mobility is the level of amputation. This has been shown previously9 and is unsurprising, but reinforces the need to strive to preserve the knee joint whenever possible.

In conclusion, the majority of amputees are suitable for early mobilisation and intensive rehabilitation and units performing large numbers of amputations should be able to provide such a service.

Table 2: Main characteristics of 87 patients and their post-operative mobility

REFERENCES

1. White SA, Thompson MM, Zickerman AM, Broomhead P, Critchley P, Barrie WW, Bell PRF. Lower limb amputation and grade of surgeon. Br J Surg 1997; 84:509-11
2. Houghton AD, Taylor PR, Thurlow S, Rootes E, McColl I. Success rates for rehabilitation of vascular amputees: implications for pre-operative assessment and amputation level. Br J Surg 1992; 79:753-5
3. Kald A, Carlsson R, Nilsson E. Major amputation in a defined population: incidence, mortality and results of treatment. Br J Surg 1989; 76:308-10
4. McWhinnie DL, Gordon AC, Collin J, Gray DWR, Morrison JD. Rehabilitation outcome 5 years after 100 lower-limb amputations. Br J Surg 1994; 81:1596-9
5. Campbell WB, Kernick VFM, St Johnston JA, Rutter EA. Lower limb amputation: striking the balance. Ann R Coll Surg Engl 1994; 76: 205-9
6. Kannellopoulos G, Sabharwal A, Macgregor C, Cooper GC, Engeset J. Major lower limb amputation for vascular disease in the Grampian area: the outcome of rehabilitation. J R Coll Surg Edinb 1996; 41: 114-15
7. Collin C, Collin J. Mobility after lower limb amputation. B J Surg 1995; 82: 1010-11
8. Connor H. The economic impact of diabetic foot disease. In: Connor H, Boulton AJM, Ward JD, eds. The foot in diabetes. Chichester: Wiley, 1994: 145-49
9. Fyfe NC. An audit of amputation levels in patients referred for prosthetic rehabilitation. Prosthet Orthot Int 1990; 14: 67-70

Copyright date: 4th May 2001

Correspondence: I. Loftus, The University Department of Surgery, Leicester Royal Infirmary, PO Box 65, Leicester LE2 7LX, UK

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