Risk factors associated with mortality in veteran population following transtibial or transfemoral amputation.
Peripheral vascular disease Peripheral Vascular Disease Definition
Peripheral vascular disease is a narrowing of blood vessels that restricts blood flow. It mostly occurs in the legs, but is sometimes seen in the arms. (PVD PVD
peripheral vascular disease
PVD Peripheral vascular disease, see there ) and diabetes mellitus diabetes mellitus
Disorder of insufficient production of or reduced sensitivity to insulin. Insulin, synthesized in the islets of Langerhans (see Langerhans, islets of), is necessary to metabolize glucose. In diabetes, blood sugar levels increase (hyperglycemia). are the most common reasons for lower-limb amputations [1-11]. Diabetes mellitus increases an individual's risk for amputation amputation (ăm'pyətā`shən), removal of all or part of a limb or other body part. Although amputation has been practiced for centuries, the development of sophisticated techniques for treatment and prevention of infection has greatly twelve- to fifteen-fold and accounts for over 50 percent of all nontraumatic amputations in the United States United States, officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area. annually [12-13]. Glycemic Glycemic
The presence of glucose in the blood.
Mentioned in: Cholesterol, High
pertaining to the level of glucose in the blood. control, systolic blood pressure Systolic blood pressure
Blood pressure when the heart contracts (beats).
Mentioned in: Hypertension , microvascular complications (such as neuropathy, retinopathy retinopathy /ret·i·nop·a·thy/ (ret?i-nop´ah-the) any noninflammatory disease of the retina.
circinate retinopathy , and nephropathy nephropathy /ne·phrop·a·thy/ (ne-frop´ah-the) disease of the kidneys.nephropath´ic
analgesic nephropathy ), and history of stroke have been found to be independent predictors of amputation .
Mortality following a lower-limb amputation is quite high. Thirty-day mortality rates range from 6.3 to 42.3 percent [14-15]. Pohjolainen, Alaranta, and Wikstrom reported that 25.5 percent of patients with lower-limb amputations in Finland died within 2 months of the amputation and nearly 40 percent within 1 year . Survival rates at 2 to 5 years are also poor, with over 50 percent of patients dying at 2 years and roughly 70 percent by 5 years [1,6-8,14-15].
Little has been written about the implications of high mortality rates in a population of patients typically considered for rehabilitation following surgery. This article explores the factors associated with mortality following transtibial or transfemoral amputation or hip disarticulation disarticulation /dis·ar·tic·u·la·tion/ (dis?ahr-tik?u-la´shun) exarticulation; amputation or separation at a joint.
n. and considers the affect on the rehabilitation decision-making process.
Description of Data Sources
To capture diagnostic information from different aspects of the patient care process, our analyses included four separate database sources of administrative data from the Veterans Health Administration (VHA VHA Veterans Health Administration
VHA Variable Housing Allowance
VHA Villages Homeowners Association
VHA Voluntary Hospitals Association
VHA Virtual Home Agent
VHA Very High Altitude
VHA Vapor Hazard Area
VHA Vermont Holstein-Friesian Association ). The first source was the Patient Treatment File (PTF PTF - Program Temporary Fix ) database, including the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes relevant to the entire inpatient hospital stay. One variable in the PTF is the principal diagnosis (Dx Prime), and nine additional variables are available to express secondary diagnoses. Another variable describes the diagnosis most responsible for the major part of the patient's full length of stay (Dx Lsf). The PTF record associated with the hospitalization within which the primary amputation (Surg.) an amputation for injury performed as soon as the shock due to the injury has passed away, and before symptoms of inflammation supervene.
See also: Primary surgery occurred is called the "index PTF" and is the baseline patient record.
The second source was a database that includes multiple individual "bed section" records that capture diagnostic information collected on patients receiving care on particular services (surgery, intensive care unit, medicine, etc.) during the entire hospital stay. Each bed section record includes a variable describing the medical condition most responsible for the length of stay in the bed section and four variables for secondary diagnoses directly related to care received during that treatment period. Patients typically have multiple bed section records for each hospitalization (associated with the index PTF). Each bed section record has admission and discharge dates which, when linked, correspond to the full PTF stay.
The third database source describes outpatient visits. During each outpatient visit, a principal diagnosis intended to describe the reason for the visit is coded (Dx Lsf) in one variable. Nine additional variables are available for secondary diagnostic information.
Finally, the fourth database was the Department of Veterans Affairs Veterans Affairs is a term of the business that deals with the relation between a government and its veteran communities, usually administered by the designated government agency. (VA) Beneficiary Identification Records Locator Subsystem (BIRLS) death file. The PTF identifies patients who died in a VA hospital. The BIRLS database contains records of all beneficiaries, including veterans whose survivors applied for death benefits . Combining the BIRLS with the PTF will provide a thorough list of the veterans with lower-limb amputations who died. Neither the PTF nor the BIRLS provides specific cause of death information as indicated by an ICD-9-CM code.
We combined ICD-9-CM codes from the PTF, bed section, and outpatient files to distinguish between diagnoses that likely contributed directly to amputation, otherwise known as etiological etiological
pertaining to etiology.
the name of a disease which includes the identification of the causative agent, e.g. Streptococcus agalactiae mastitis. conditions, and concurrent conditions less likely to be directly related to the amputation, or comorbidities. The etiological and comorbid conditions were captured with ICD-9-CM codes in each PTF case record. Two physician authors established the list of etiological diagnoses in conjunction with a literature review and the conditions in the Dx Prime and Dx Lsf variables of the PTF [2,5,17-18]. Clinically, similar ICD-9-CM codes were grouped into 11 etiological categories (Table 1).
Rather than seeking to assign a single etiological cause for the amputation, we considered the cause of limb loss to be multifactorial, recognizing that many clinical conditions interact and ultimately lead to limb loss. Groups of ICD-9-CM codes evidencing trauma, systemic sepsis, skin breakdown, device infection, local significant infection, previous amputation complication, diabetes mellitus (types 1 and 2), chronic osteomyelitis chronic osteomyelitis Clinical medicine Osteomyelitis with bone necrosis due to compromised vascular supply, which may persist for yrs Risk factors Recent trauma, DM, hemodialysis, IV drug abuse. See Osteomyleitis. , problems with peripheral circulation, congenital disorders, and cancer of the lower limb were included as etiologies. The etiological variables captured diagnostic information from the index PTF and all outpatient files where the date of contact fell within 3 months preceding the index PTF admission date. The etiological variables also included diagnostic codes from any bed section record where the admission date occurred no earlier than 3 months preceding the index PTF admission date. Codes from bed sections with admission dates after the surgical date were not included.
Comorbidity was expressed by the Elixhauser Measure. The Elixhauser consists of 31 separate measures expressing each condition separately by combining sets of related ICD-9-CM codes . The conditions include ICD-9-CM codes describing congestive heart failure congestive heart failure, inability of the heart to expel sufficient blood to keep pace with the metabolic demands of the body. In the healthy individual the heart can tolerate large increases of workload for a considerable length of time. , arrhythmias, valvular valvular /val·vu·lar/ (val´vu-ler) pertaining to, affecting, or of the nature of a valve.
Relating to, having, or operating by means of valves or valvelike parts. disease, pulmonary circulation pulmonary circulation
The passage of blood from the right ventricle through the pulmonary artery to the lungs and back through the pulmonary veins to the left atrium. disease, PVD, hypertension, hypertension with complication, paralysis, other neurological disorders, chronic obstructive pulmonary disease chronic obstructive pulmonary disease
n. Abbr. COPD
A chronic lung disease, such as asthma or emphysema, in which breathing becomes slowed or forced. (COPD COPD chronic obstructive pulmonary disease.
chronic obstructive pulmonary disease
Chronic obstructive pulmonary disease (COPD) ), diabetes mellitus, diabetes mellitus with complication, hypothyroidism hypothyroidism: see thyroid gland. , renal failure renal failure
Acute or chronic malfunction of the kidneys resulting from any of a number of causes, including infection, trauma, toxins, hemodynamic abnormalities, and autoimmune disease, and often resulting in systemic symptoms, especially edema, , liver disease Liver Disease Definition
Liver disease is a general term for any damage that reduces the functioning of the liver.
The liver is a large, solid organ located in the upper right-hand side of the abdomen. , peptic ulcer disease Peptic ulcer disease (PUD)
A stomach disorder marked by corrosion of the stomach lining due to the acid in the digestive juices.
Mentioned in: Indigestion
peptic ulcer disease See Duodenal ulcer, Gastric ulcer, GERD. , acquired immune deficiency syndrome Acquired immune deficiency syndrome (AIDS)
A viral disease of humans caused by the human immunodeficiency virus (HIV), which attacks and compromises the body's immune system. , lymphoma, metastatic cancer Metastatic cancer
A cancer that has spread to an organ or tissue from a primary cancer located elsewhere in the body.
Mentioned in: Liver Cancer
metastatic cancer , solid tumor without metastases Metastasis (plural, metastases)
A tumor growth or deposit that has spread via lymph or blood to an area of the body remote from the primary tumor.
Mentioned in: Malignant Melanoma , rheumatoid arthritis rheumatoid arthritis
Chronic, progressive autoimmune disease causing connective-tissue inflammation, mostly in synovial joints. It can occur at any age, is more common in women, and has an unpredictable course. , coagulopathy, obesity, weight loss, fluid and electrolyte disorders Electrolyte Disorders Definition
An electrolyte disorder is an imbalance of certain ionized salts (i.e., bicarbonate, calcium, chloride, magnesium, phosphate, potassium, and sodium) in the blood. , chronic blood loss anemia, deficiency anemias, alcohol abuse, drug abuse, psychoses, and depression. Although less commonly reported in the literature than the Deyo version of the Charlson index , the Elixhauser Measure includes a broader array of diagnostic conditions. Some evidence has shown that it is a superior predictor of mortality . Diabetes mellitus, diabetes mellitus with complication, and PVD were not included among the Elixhauser conditions, since they were already included as contributing etiological conditions. An individual could have multiple etiological or comorbid diagnoses. Each etiological or comorbid condition was coded "1" if present and "0" if absent.
This study included all 2,375 patients who were admitted to 100 VA medical centers (VAMCs) around the nation for transtibial or transfemoral amputation and hip disarticulation and had acute hospital discharge dates between October 1, 2002, and September 30, 2003. The hospital stay at the time the surgical amputation occurred represented the "index stay." Patients were excluded if they had amputations that involved toes only or had a record of a previous lower-limb amputation within the 12 months preceding the index surgical amputation. Surgical amputation that includes transtibial, transfemoral, and hip disarticulation was captured with the surgical ICD-9-CM procedure codes 84.10, 84.13-84.19, and 84.91 .
Approach to Modeling
Using the statistical analyses, we developed a multivariate model to determine the clinical factors most associated with mortality following amputation. The analyses began with a series of cross-tabulations between each explanatory variable and mortality at three time-points: in-hospital, 3-month, and 1-year. The presence versus absence of each etiological and comorbid condition was expressed as a dichotomous di·chot·o·mous
1. Divided or dividing into two parts or classifications.
2. Characterized by dichotomy.
di·chot indicator. Sociodemographic variables included age and sex. Age was entered as a series of segmented dummy variables, with 50 years and younger as the reference group. Females were the reference group for sex. Variables that predicted mortality were included in multivariate models only when expected values were five or more individuals. No case from our sample had an ICD-9-CM code for obesity as defined by the Elixhauser Measure. We used logistic regression In statistics, logistic regression is a regression model for binomially distributed response/dependent variables. It is useful for modeling the probability of an event occurring as a function of other factors. modeling to control for multiple variables simultaneously and to compute 95 percent confidence interval confidence interval,
n a statistical device used to determine the range within which an acceptable datum would fall. Confidence intervals are usually expressed in percentages, typically 95% or 99%. (CI) around each odds ratio (OR). We assessed the impact of increasingly detailed information on the likelihood of mortality through a series of fixed multiple logistic regressions, where sets of clinically related variables were entered in sequential models. Amputation level and sociodemographic variables were entered together as a block, followed by contributing etiological diagnoses, and finally by comorbidities. The C statistic assessed model performance corresponding to the area under the receiver operating characteristic curve receiver operating characteristic curve
see roc curve. . C statistics closer to 1.0 denote greater model prediction power. We applied the Hosmer-Lemeshow goodness-off-it statistic to test-fit the data to the model. Statistical significance at p < 0.05 was used to reject the hypothesis of fit . Analyses were performed with SAS (1) (SAS Institute Inc., Cary, NC, www.sas.com) A software company that specializes in data warehousing and decision support software based on the SAS System. Founded in 1976, SAS is one of the world's largest privately held software companies. See SAS System. Version 9.1 (SAS Institute SAS Institute Inc., headquartered in Cary, North Carolina, USA, has been a major producer of software since it was founded in 1976 by Anthony Barr, James Goodnight, John Sall and Jane Helwig. , Cary, North Carolina North Carolina, state in the SE United States. It is bordered by the Atlantic Ocean (E), South Carolina and Georgia (S), Tennessee (W), and Virginia (N). Facts and Figures
Area, 52,586 sq mi (136,198 sq km). Pop. ). The p-values were two-sided, with p < 0.05 being considered statistically significant. An association is statistically significant at this level if its 95 percent CI does not include 1.0.
Among the 2,375 veterans included in the study, 98.9 percent were male, average age was 67.3 years (standard deviation [SD] = 11.0), and average length of stay was 28.6 days (SD = 52.3). Over one-half or 59.5 percent of the amputations were transtibial, 39.7 percent were transfemoral, and 0.7 percent were hip. Four cases had an unknown level of amputation. Their level of amputation was imputed using hot-deck methods . The in-hospital mortality rate was 7.6 percent, the 3-month mortality rate was 15.5 percent, and the 1-year mortality rate was 26.7 percent. Table 2 characterizes the population by indicating mortality prevalence associated with each candidate predictor variable Noun 1. predictor variable - a variable that can be used to predict the value of another variable (as in statistical regression)
variable quantity, variable - a quantity that can assume any of a set of values . Table 3 shows the adjusted OR for each explanatory variable according to according to
1. As stated or indicated by; on the authority of: according to historians.
2. In keeping with: according to instructions.
3. the completely saturated models of in-hospital, 3-month, and 1-year mortality. The C statistic for the model predicting in-hospital mortality based on age, sex, and level of amputation was 0.66. With the addition of the contributing etiological conditions, it increased to 0.73. With the addition of the Elixhauser conditions, the C statistic increased to 0.80. C statistic increases were similar for the 3-month and 1-year regressions; however, as shown by Table 3, model performance was slightly better for in-hospital than for 3-month and 1-year mortalities.
In-hospital mortality and likelihood of mortality at all subsequent time periods were most strongly associated with systemic sepsis in the perioperative perioperative /peri·op·er·a·tive/ (-op´er-ah-tiv) pertaining to the period extending from the time of hospitalization for surgery to the time of discharge.
adj. period after the adjustment for sociodemographic differences, level of amputation, and comorbidities. Likelihood of mortality was not significantly increased according to any of the other etiological factors. In-hospital rates of mortality were significantly lower among patients identified as having diabetes mellitus type 2 and 3-month mortality rates were lower for those coded with chronic osteomyelitis. Two of the eleven etiological category variables, congenital deformity Deformity
See also Lameness.
Calmady, Sir Richard
born without lower legs. [Br. Lit.: Sir Richard Calmady, Walsh Modern, 84]
embittered young man with club foot seeks fulfillment. [Br. Lit. (one case) and lower-limb cancer (zero cases), were not analyzed in the multivariate models because of insufficient prevalence.
Level of Amputation
After adjusting for age, etiological factors, and comorbidities, we found almost a thirteenfold increased risk of in-hospital mortality among patients with hip disarticulation compared with those with transtibial amputation (OR = 12.94; 95% CI = 3.36-49.86). In-hospital mortality was also elevated for veterans with transfemoral amputations compared with transtibial (OR = 2.52; 95% CI = 1.75-3.63). No association was found between increased likelihood of 1-year mortality and hip disarticulation, whereas mortality risk remained elevated among those with transfemoral amputations compared with transtibial (OR = 2.00; 95% CI = 1.61-2.48).
Using logistic regression models, we found that adjusted in-hospital, 3-month, and 1-year mortalities were significantly elevated among patients with evidence of congestive heart failure, renal failure, and liver disease. Three-month mortality likelihood was significantly increased with coagulopathy. In-hospital and 3-month mortality rates were higher among those who experienced in-hospital fluid and electrolyte disorders. Those patients with documented metastatic cancer had higher 3-month and 1-year mortality rates. Among those with solid tumor without metastases and those with COPD, 1-year mortality, but not 3-month or in-hospital, was elevated. Patients with hypertension listed among their diagnoses had a reduced likelihood of in-hospital, 3-month, and 1-year mortality.
Unadjusted risk of mortality increased with age. Strength of this association decreased progressively with the addition of more diagnostic details. The association between in-hospital mortality and age was no longer statistically significant after adjusting for level of amputation, etiological contributing factors, and comorbid conditions. In contrast, the association between longer-term mortality and age diminished but remained statistically significant among the oldest veterans with amputations. When compared with those aged 70 or younger, veterans with amputations aged 71 and older had higher adjusted 3-month mortality risks. Only those aged 81 and older had higher adjusted 1-year mortality risks. We found nearly a fourfold increased risk of mortality at 1 year, even after removing the effects of perioperative medical complexity among those over the age of 86 (OR = 3.86; 95% CI = 1.91-7.79). Among those over the age of 86 (OR = 6.86; 95% CI = 2.53-18.59), close to a sevenfold increase in likelihood of mortality at 3 months was found.
The in-hospital mortality rate found in this study is consistent with previously reported data; however, the 1-year survival rate was slightly higher in this population than in other VA reports and among those treated in the private sector (Table 4) [6,14,25-27]. Some trend has shown that over the years, survival rates have improved; however, based on a post hoc post hoc
adv. & adj.
In or of the form of an argument in which one event is asserted to be the cause of a later event simply by virtue of having happened earlier: random-effects model, survival rates were not statistically significantly higher than those found in the other studies. The trend toward higher survival rates found in our study may be related to overall improvements in technology that were not available to clinicians when the earlier studies were conducted. It may also be that VA patients have better access to the full continuum of services ranging from emergent to long-term and nursing home care than private sector patients. Perhaps veterans who have a lower-limb amputation performed in the VA healthcare system are provided a more coordinated and vertically integrated approach to postacute services, which in turn may affect longer-term survival.
Systemic sepsis was the single most predictive etiological factor of mortality in our analysis. In a recent retrospective study retrospective study,
a study in which a search is made for a relationship between one phenomenon or condition and another that occurred in the past (e.g. at an academic tertiary care center tertiary care center Hospital care A hospital or medical center for Pts often referred from secondary care centers, which provides subspecialty expertise
Tertiary care center
Surgery , Aulivola et al. found that cardiac complications were the leading cause of death within 30 days following lower-limb amputation (10/35), followed by sepsis (5/35) and pneumonia (4/35) . The 30-day mortality rate was 8.6 percent in this population, and patients with sepsis requiring guillotine amputation guillotine amputation A sharply defined loss or autoamputation of part or entire segments of extremities, ranging from digits to major amputations, seen in the congenital aglossia-adactylia syndrome had a significantly higher 30-day mortality rate of 14.3 percent .
Age has been noted to predict mortality following nontraumatic lower-limb amputation [15,25]. However, in this analysis, except for very elderly patients, the importance of age as a factor declined with the addition of more diagnostic details. This finding suggests that the associated burden of illness, rather than age, most influences mortality among persons with lower-limb amputation. Comorbidities appeared to affect mortality rates postamputation in logical ways. Severe progressive conditions including renal failure, liver disease, and congestive heart failure predicted mortality at all three postoperative time-points. Unsurprisingly, fluid and electrolyte disorders during the hospitalization were associated with higher rates of in-hospital and 3-month mortality. Also reasonable was that the presence of metastatic cancer and solid tumor without metastases significantly increased likelihood of mortality at 3 months and 1 year, respectively.
The comorbid conditions found to be positive predictors of mortality are consistent with other studies. Collins et al. identified COPD, renal dysfunction, and poor functional status preoperatively as indicators for 30-day mortality . Using VA National Surgical Quality Improvement Program data, O'Hare et al. found that mortality rates within 30 days following lower-limb nontraumatic amputation were quite high in patients on dialysis and that patients with even moderate renal insufficiency renal insufficiency A defect in renal ability to 'clear' waste products, a sign of inadequate glomerular filtration were at higher mortality risk than those with mild or no renal disease Renal disease
Mentioned in: Glycogen Storage Diseases
hypertension High blood pressure Cardiovascular disease An abnormal ↑ systemic arterial pressure, corresponding to a systolic BP of > 160 mm Hg . Kantonen et al. likewise found the presence of coronary artery disease coronary artery disease, condition that results when the coronary arteries are narrowed or occluded, most commonly by atherosclerotic deposits of fibrous and fatty tissue. and renal dysfunction to be associated with higher postoperative mortality rates . The presence of complex medical conditions See carpal tunnel syndrome, computer vision syndrome, dry eyes and deep vein thrombosis. such as congestive heart failure, hypothyroidism, renal failure, coagulopathies, and fluid and electrolyte disorders signals the need for vigilant acute and longer-term medical management of patients with a lower-limb amputation. In one VA study, nearly 50 percent of the veterans with congestive heart failure died within 1 year .
Our findings that diabetes mellitus and hypertension appeared protective regarding mortality are clinically counterintuitive coun·ter·in·tu·i·tive
Contrary to what intuition or common sense would indicate: "Scientists made clear what may at first seem counterintuitive, that the capacity to be pleasant toward a fellow creature is ... , but consistent with the findings of others. Patients who have these conditions documented in their administrative records have significantly lower rates of mortality [29-30]. Perhaps the coding of more severe acute and complicating conditions among the seriously ill takes precedence. Or, perhaps because these patients have chronic conditions, they are monitored more carefully, and when problems do arise, they are caught early and do not develop into fatal issues.
Our finding that hip disarticulation was strongly associated with in-hospital mortality, but not longer-term mortality, suggests that the need for this high level of amputation is signaling greater perioperative acuity and complications but may not be associated with comorbidities associated with mortality. Other studies have shown lower survival rates for more proximal amputation levels [8,31-32]. Pohjolainen et al. reported survival rates at 2 months of 83.3 percent for patients with transtibial amputations, dropping to 67.7 percent for transfemoral . By 1 year, survival was 69.9 and 53.8 percent, respectively .
For rehabilitation of patients following a nontraumatic lower-limb amputation, care teams need a better understanding of mortality risk in the months and years following surgery to target services to this population. For patients at high risk of mortality within 6 months to 1 year, early intervention ear·ly intervention
n. Abbr. EI
A process of assessment and therapy provided to children, especially those younger than age 6, to facilitate normal cognitive and emotional development and to prevent developmental disability or delay. and rehabilitation goals that focus on appropriate mobilization, activities of daily living, and quality-of-life issues become critical. A better understanding of mortality risk factors would help care teams develop improved, integrated treatment plans for frail dysvascular patients at high mortality risk. A balance between early intervention and longer-term goals is the key.
Evidence suggests that with early and aggressive rehabilitation following stroke, patients improved faster, which led to higher functioning levels more quickly, even though the control group caught up to them within 9 months . For a patient with a recent amputation, our data showed that 3 months or 1 year is a large percentage of the patient's remaining life span and that rehabilitation must focus on appropriate activities that help patients function more quickly, thus adding quality to their remaining lifetime. While mortality following a lower-limb amputation for vascular disease is high, many patients who survive the immediate postoperative period receive a prosthesis prosthesis (prŏs`thĭsĭs): see artificial limb.
Artificial substitute for a missing part of the body, usually an arm or leg. [1,7,9,34-38]. These patients function reasonably well, at least in the short term. When one considers the high-mortality and long-term outcomes, optimal postoperative care postoperative care,
n care after surgery or other invasive procedures, usually of a supportive nature. following a lower-limb amputation requires close collaboration and a team approach involving surgery, medicine, and rehabilitation to identify the most appropriate treatments, goals, and location of care.
While numerous clinical practice guidelines clinical practice guidelines Clinical policies, practice guidelines, practice parameters, practice policies Medtalk Systematically developed statements to assist practitioner and Pt decisions about appropriate health care for specific clinical circumstances. See Psychology. exist for the poststroke population [39-42], review of the literature found none for the postamputation population. Providing early and aggressive rehabilitation following lower-limb amputation makes intuitive sense, but evidence is lacking and should be a focus of future research. Development of a rehabilitation clinical pathway clinical pathway Critical pathway, treatment pathway Clinical medicine A standardized algorithm of a consensus of the best way to manage a particular condition Modalities used Teletherapy, brachytherapy, hyperthermia and stereotactic radiation. for patients with amputation would be one possible method of ensuring early postamputation involvement of rehabilitation professionals and could help in the careful analysis of the impact of early intervention. Because our sample was primarily male, the degree to which findings would generalize to female is unknown.
High mortality rates attest to the frailty of the post-amputation veteran population. Rehabilitation strategies targeted to enhance the function of this larger population of patients with amputations need to address the shortened life span of many of these patients, and rehabilitation goals need to be adjusted accordingly. Careful medical oversight in the weeks and months following a nontraumatic amputation is critical in helping these patients achieve their highest functioning levels.
Abbreviations: BIRLS = Beneficiary Identification Records Locator Subsystem; CI = confidence interval; COPD = chronic obstructive pulmonary disease; ICD-9-CM = International Classification of Diseases, 9th Revision, Clinical Modification; OR = odds ratio; PTF = Patient Treatment File; PVD = peripheral vascular disease; SD = standard deviation; VA = Department of Veterans Affairs; VAMC VAMC Veterans Affairs Medical Center
VAMC Veterans Administration Medical Center
VAMC Virginia Advanced Medical Center (Centreville, VA) = VA medical center; VHA = Veterans Health Administration.
This material is based upon work supported in part by the National Institutes of Health (R01 HD042588). It is also supported by resources and the use of facilities at the Samuel S. Stratton
Albany is the capital of the State of New York and the county seat of Albany County. Albany lies 136 miles (219 km) north of New York City, and slightly to the south of the juncture of the Mohawk and Hudson Rivers. , and the Kansas City Kansas City, two adjacent cities of the same name, one (1990 pop. 149,767), seat of Wyandotte co., NE Kansas (inc. 1859), the other (1990 pop. 435,146), Clay, Jackson, and Platte counties, NW Mo. (inc. 1850). VAMC, Kansas City, Missouri Kansas City is the largest city in the state of Missouri. It encompasses parts of Jackson, Clay, Cass, and Platte counties and is the anchor city of the Kansas City Metropolitan Area, the second largest in Missouri, which includes counties in both Missouri and Kansas. .
The opinions and conclusions of the authors are not necessarily those of the sponsoring agencies.
The authors have declared that no competing interests exist.
Submitted for publication March 23, 2006. Accepted in revised form August 30, 2006.
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Barbara Bates, MD; (1-2) * Margaret G. Stineman, MD; (3-4) Dean M. Reker, PhD, RN; (5-6) Jibby E. Kurichi, MPH; (3) Pui L. Kwong, MPH (3)
(1) Samuel S. Stratton Department of Veterans Affairs (VA) Medical Center (VAMC), Albany, NY; (2) Department of Physical Medicine and Rehabilitation physical medicine and rehabilitation
or physiatry or physical therapy or rehabilitation medicine
Medical specialty treating chronic disabilities through physical means to help patients return to a comfortable, productive life despite a medical , Albany Medical College Albany Medical College (AMC) is a medical school located in Albany, New York, United States. It was founded in 1839. The college is part of the Albany Medical Center, which includes the Albany Medical Center Hospital. , Albany, NY; (3) Department of Physical Medicine and Rehabilitation, University of Pennsylvania (body, education) University of Pennsylvania - The home of ENIAC and Machiavelli.
Address: Philadelphia, PA, USA. , Philadelphia, PA; (4) VA Center for Health Equity Research and Promotion, Philadelphia, PA; (5) Kansas City VAMC, Kansas City, MO; (6) The University of Kansas The University of Kansas (often referred to as KU or just Kansas) is an institution of higher learning in Lawrence, Kansas. The main campus resides atop Mount Oread. Medical Center, Kansas City, KS
* Address all correspondence to Barbara Bates, MD, Associate Chief of Staff for Quality Management; Samuel S. Stratton VAMC, 113 Holland Avenue, Albany, NY 12208; 518626-5817; fax: 518-626-5467. Email: email@example.com DOI (Digital Object Identifier) A method of applying a persistent name to documents, publications and other resources on the Internet rather than using a URL, which can change over time. : 10.1682/JRRD.2006.03.0030
Table 1. Conditions contributing to etiology of amputation and their International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes. Condition Diagnostic Description ICD-9-CM Codes Chronic Chronic osteomyelitis of 730.15-730.17 Osteomyelitis pelvic region and thigh, lower leg, ankle, and foot. Congenital Transverse deficiency of lower 755.31-755.39 Deformity limb, longitudinal deficiency of lower limb. Device Infection Vascular device, internal 996.1, 996.4, orthopedic device, tissue 996.52, 996.62, graft, joint prosthesis. 996.66, 996.67, 996.69, 996.7, 996.74 Diabetes Diabetes mellitus type 1 with 250-250.93 and without manifestations, diabetes mellitus type 2 with and without manifestations. Local Significant Gangrene, actinomycotic 040.0, 395, Infection infections, cellulitis, 440.24, 681.10, pyogenic arthritis, infective 682.6-682.8, myositis, necrotizing 711.06, 728.0, fasciitis. 728.86, 729.4, 785.4 Lower-Limb Cancer Malignant neoplasm of pelvic 170.6-170.8, bones, sacrum, coccyx, long 171.3, 172.7, and short bones of lower limb, 173.7 connective tissue of lower limb including hip, skin of lower limb including hip. Previous Infected amputation residual 997.62 Amputation limb. Complication Problems with Atherosclerosis, aortic 440.0-441.9, Peripheral aneurysm, venous thrombosis, 442.3, Circulation arterial stricture or 443.1-443.9, stricture of graft, 444.0, 444.81, circulatory disease, venous 447.1, 453.8, insufficiency, organ or tissue 459.81-459.9, replaced by blood vessel, 557.1-557.9, gangrene, vascular 785.4, 997.79, complications of other 434 (procedure), vessels. 38.48 (procedure) Skin Breakdown Ulcer or decubitus ulcer of 440.23, 454.0, lower limb. 454.2, 707.0, 707.10, 707.12-707.9 Systemic Sepsis Septicemia, gram negative 038.11, 038.40, septicemia, E. coli, other 038.42, 038.8, type of systemic sepsis, 038.9, 790.7 bacteremia. Trauma Acute osteomyelitis, closed or 730.05-730.08, open fractures to lower limbs, 820.8, 821.21, fracture of one or more 821.23, 821.30, phalanges of foot, trauma to 823.82, 823.92, above-knee amputation or 824.1, 826.0, below-knee amputation, open 837.0, wound to lower limb, burns of 890.1-890.2, lower limb, fracture of lower 891.1-891.2, limb, open wound of lower 892.1-892.2, limb, late effects of 893.1-893.2, injuries, poisonings, toxic 894.1-894.2, effects and other external 897.0-897.2, causes, crushing injury of 905.4, lower limb. 928.0-928.8, 945.22, 945.25-945.26, 945.32-945.33, 959.6-959.7 Table 2. Characteristics of study sample (N = 2,375) according to mortality. Characteristic Prevalence Survival Age (mean [+ or -] SD) 67.3 [+ or -] 11.0 66.0 [+ or -] 10.9 Sex, No. (%) Male 2,349 (98.9) 1,722 (73.3) Female 26 (1.1) 19 (73.1) Level of Amputation, No. (%) Transtibial 1,413 (59.5) 1,119 (79.2) Transfemoral 942 (39.7) 607 (64.4) Hip Disarticulation 16 (0.7) 11 (68.8) Nonchronic Etiologies, No. (%) * Device Infection 266 (11.2) 204 (76.7) Local Significant 1,850 (77.9) 1,337 (72.3) Infection Previous Amputation 197 (8.3) 156 (79.2) Complication Skin Breakdown 1,509 (63.5) 1,112 (73.7) Systemic Sepsis 250 (10.5) 143 (57.2) Trauma 326 (13.7) 253 (77.6) Chronic Etiologies, No. (%) * Chronic Osteomyelitis 157 (6.6) 129 (82.2) Diabetes Mellitus Type 1 416 (17.5) 310 (74.5) Diabetes Mellitus Type 2 1,546 (65.1) 1,151 (74.5) Problems with Peripheral 2,063 (86.9) 1,487 (72.1) Circulation Chronic Conditions, No. (%) * Acquired Immune Deficiency 17 (0.7) 13 (76.5) Syndrome Alcohol Abuse 130 (5.5) 105 (80.8) Arrhythmias 382 (16.1) 226 (59.2) Chronic Blood Loss Anemia 45 (1.9) 28 (62.2) Chronic Obstructive 477 (20.1) 298 (62.5) Pulmonary Disease Coagulopathy 104 (4.4) 65 (62.5) Congestive Heart Failure 539 (22.7) 330 (61.2) Deficiency Anemias 451 (19.0) 313 (69.4) Depression 211 (8.9) 162 (76.8) Drug Abuse 54 (2.3) 46 (85.2) Fluid and Electrolyte 447 (18.8) 287 (64.2) Disorders Hypertension 1,390 (58.5) 1,047 (75.3) Hypertension with 13 (0.5) 9 (69.2) Complication Hypothyroidism 89 (3.7) 57 (64.0) Liver Disease 81 (3.4) 54 (66.7) Lymphoma 9 (0.4) 5 (55.6) Metastatic Cancer 32 (1.3) 14 (43.8) Other Neurological 72 (3.0) 46 (63.9) Disorders Paralysis 93 (3.9) 77 (82.8) Peptic Ulcer Disease with 35 (1.5) 28 (80.0) Bleeding Psychoses 164 (6.9) 124 (75.6) Pulmonary Circulation 17 (0.7) 7 (41.2) Disease Renal Failure 410 (17.3) 242 (59.0) Rheumatoid Arthritis 32 (1.3) 24 (75.0) Solid Tumor Without 166 (7.0) 98 (59.0) Metastases Valvular Disease 111 (4.7) 61 (55.0) Weight Loss 109 (4.6) 74 (67.9) Mortality Characteristic In-Hospital 3-Month Age (mean [+ or -] SD) 70.0 [+ or -] 10.3 71.4 [+ or -] 10.3 Sex, No. (%) Male 178 (7.6) 362 (15.4) Female 2 (7.7) 6 (23.1) Level of Amputation, No. (%) Transtibial 66 (4.7) 152 (10.8) Transfemoral 109 (11.6) 211 (22.4) Hip Disarticulation 5 (31.3) 5 (31.3) Nonchronic Etiologies, No. (%) * Device Infection 21 (7.9) 40 (15.0) Local Significant 141 (7.6) 296 (16.0) Infection Previous Amputation 12 (6.1) 20 (10.2) Complication Skin Breakdown 108 (7.2) 222 (14.7) Systemic Sepsis 54 (21.6) 79 (31.6) Trauma 16 (4.9) 30 (9.2) Chronic Etiologies, No. (%) * Chronic Osteomyelitis 5 (3.2) 9 (5.7) Diabetes Mellitus Type 1 32 (7.7) 48 (11.5) Diabetes Mellitus Type 2 96 (6.2) 213 (13.8) Problems with Peripheral 161 (7.8) 334 (16.2) Circulation Chronic Conditions, No. (%) * Acquired Immune Deficiency 2 (11.8) 3 (17.6) Syndrome Alcohol Abuse 9 (6.9) 17 (13.1) Arrhythmias 52 (13.6) 97 (25.4) Chronic Blood Loss Anemia 6 (13.3) 13 (28.9) Chronic Obstructive 47 (9.9) 101 (21.2) Pulmonary Disease Coagulopathy 18 (17.3) 32 (30.8) Congestive Heart Failure 67 (12.4) 125 (23.2) Deficiency Anemias 35 (7.8) 79 (17.5) Depression 12 (5.7) 27 (12.8) Drug Abuse 2 (3.7) 3 (5.6) Fluid and Electrolyte 61 (13.6) 105 (23.5) Disorders Hypertension 85 (6.1) 186 (13.4) Hypertension with 1 (7.7) 2 (15.4) Complication Hypothyroidism 8 (9.0) 15 (16.9) Liver Disease 11 (13.6) 21 (25.9) Lymphoma 2 (22.2) 4 (44.4) Metastatic Cancer 5 (15.6) 16 (50.0) Other Neurological 11 (15.3) 16 (22.2) Disorders Paralysis 4 (4.3) 8 (8.6) Peptic Ulcer Disease with 3 (8.6) 5 (14.3) Bleeding Psychoses 13 (7.9) 26 (15.9) Pulmonary Circulation 4 (23.5) 6 (35.3) Disease Renal Failure 59 (14.4) 98 (23.9) Rheumatoid Arthritis 1 (3.1) 4 (12.5) Solid Tumor Without 16 (9.6) 31 (18.7) Metastases Valvular Disease 15 (13.5) 30 (27.0) Weight Loss 8 (7.3) 25 (22.9) Mortality Characteristic 1-Year Age (mean [+ or -] SD) 71.0 [+ or -] 10.6 Sex, No. (%) Male 627 (26.7) Female 7 (26.9) Level of Amputation, No. (%) Transtibial 294 (20.8) Transfemoral 335 (35.6) Hip Disarticulation 5 (31.3) Nonchronic Etiologies, No. (%) * Device Infection 62 (23.3) Local Significant 513 (27.7) Infection Previous Amputation 41 (20.8) Complication Skin Breakdown 397 (26.3) Systemic Sepsis 107 (42.8) Trauma 73 (22.4) Chronic Etiologies, No. (%) * Chronic Osteomyelitis 28 (17.8) Diabetes Mellitus Type 1 106 (25.5) Diabetes Mellitus Type 2 395 (25.5) Problems with Peripheral 576 (27.9) Circulation Chronic Conditions, No. (%) * Acquired Immune Deficiency 4 (23.5) Syndrome Alcohol Abuse 25 (19.2) Arrhythmias 156 (40.8) Chronic Blood Loss Anemia 17 (37.8) Chronic Obstructive 179 (37.5) Pulmonary Disease Coagulopathy 39 (37.5) Congestive Heart Failure 209 (38.8) Deficiency Anemias 138 (30.6) Depression 49 (23.2) Drug Abuse 8 (14.8) Fluid and Electrolyte 160 (35.8) Disorders Hypertension 343 (24.7) Hypertension with 4 (30.8) Complication Hypothyroidism 32 (36.0) Liver Disease 27 (33.3) Lymphoma 4 (44.4) Metastatic Cancer 18 (56.3) Other Neurological 26 (36.1) Disorders Paralysis 16 (17.2) Peptic Ulcer Disease with 7 (20.0) Bleeding Psychoses 40 (24.4) Pulmonary Circulation 10 (58.8) Disease Renal Failure 168 (41.0) Rheumatoid Arthritis 8 (25.0) Solid Tumor Without 68 (41.0) Metastases Valvular Disease 50 (45.0) Weight Loss 35 (32.1) Note: Only one person was coded with a congenital deformity, and no persons were coded with either lower-limb cancer or obesity. * Cases associated with etiologies and chronic conditions do not sum to total sample size because a person can have multiple conditions. SD = standard deviation. Table 3. Odds ratio (OR) with 95% confidence interval (CI) for likelihood of mortality in total population (N = 2,375). OR (95% CI) Variable In-Hospital 3-Month Age (Ref: 50 or Younger) 51-55 1.43 (0.44-4.64) 1.27 (0.50-3.23) 56-60 1.86 (0.58-5.92) 2.22 (0.91-5.39) 61-65 2.05 (0.64-6.62) 2.40 (0.98-5.91) 66-70 2.41 (0.77-7.51) 2.24 (0.92-5.43) 71-75 2.43 (0.79-7.47) 3.45 (1.45-8.20) * 76-80 2.51 (0.81-7.78) 3.46 (1.45-8.23) * 81-85 2.04 (0.61-6.85) 5.20 (2.11-12.77) * 86 3.43 (0.91-12.98) 6.86 (2.53-18.59) * Level of Amputation (Ref: Transtibial) Transfemoral 2.52 (1.75-3.63) * 2.06 (1.59-2.68) * Hip Disarticulation 12.94 (3.36-49.86) * 4.54 (1.22-16.85) * Sex (Ref: Female) Male 0.61 (0.13-2.86) 0.45 (0.16-1.22) Nonchronic Etiologies Device Infection 0.87 (0.51-1.48) 0.97 (0.65-1.44) Local Significant 0.95 (0.61-1.49) 1.04 (0.74-1.45) Infection Previous Amputation 1.02 (0.53-1.96) 0.76 (0.46-1.27) Complication Skin Breakdown 0.92 (0.64-1.32) 0.93 (0.71-1.21) Systemic Sepsis 4.28 (2.87-6.39) * 3.08 (2.20-4.32) * Trauma 0.67 (0.37-1.19) 0.65 (0.42-1.00) Chronic Etiologies Chronic Osteomyelitis 0.42 (0.16-1.10) 0.37 (0.18-0.77) Diabetes Mellitus Type 1 1.23 (0.77-1.94) 0.76 (0.53-1.10) Diabetes Mellitus Type 2 0.63 (0.43-0.93) 0.88 (0.66-1.16) Problems with Peripheral 1.17 (0.65-2.12) 1.26 (0.80-1.99) Circulation Chronic Conditions Acquired Immune 1.71 (0.27-10.73) 1.43 (0.33-6.21) Deficiency Syndrome Alcohol Abuse 1.06 (0.49-2.31) 0.98 (0.53-1.79) Arrhythmias 1.35 (0.90-2.02) 1.26 (0.93-1.71) Chronic Blood Loss 1.77 (0.67-4.67) 1.91 (0.91-4.00) Anemia Chronic Obstructive 1.04 (0.70-1.56) 1.23 (0.92-1.65) Pulmonary Disease Coagulopathy 1.84 (1.00-3.39) 2.01 (1.22-3.30) * Congestive Heart Failure 1.81 (1.24-2.64) * 1.66 (1.25-2.20) * Deficiency Anemias 0.81 (0.53-1.24) 0.98 (0.72-1.33) Depression 0.85 (0.43-1.67) 1.00 (0.62-1.59) Drug Abuse 0.95 (0.20-4.46) 0.68 (0.19-2.41) Fluid and Electrolyte 1.87 (1.29-2.71) * 1.46 (1.09-1.96) * Disorders Hypertension 0.67 (0.48-0.94) * 0.70 (0.55-0.90) * Hypertension with 0.52 (0.05-5.40) 0.72 (0.13-3.90) Complication Hypothyroidism 0.92 (0.40-2.12) 0.80 (0.42-1.51) Liver Disease 2.29 (1.04-5.02) * 3.07 (1.66-5.68) * Lymphoma 1.90 (0.27-13.28) 2.94 (0.58-14.86) Metastatic Cancer 1.86 (0.64-5.43) 5.24 (2.40-11.43) * Other Neurological 3.20 (1.55-6.61) * 1.84 (0.99-3.43) Disorders Paralysis 0.42 (0.14-1.23) 0.48 (0.22-1.07) Peptic Ulcer Disease 1.71 (0.47-6.27) 1.41 (0.50-3.94) with Bleeding Psychoses 1.10 (0.57-2.11) 1.08 (0.66-1.76) Pulmonary Circulation 2.16 (0.57-8.22) 2.00 (0.64-6.26) Disease Renal Failure 2.29 (1.55-3.38) * 1.87 (1.38-2.53) * Rheumatoid Arthritis 0.26 (0.03-2.26) 0.64 (0.19-2.13) Solid Tumor Without 1.51 (0.84-2.73) 1.19 (0.76-1.86) Metastases Valvular Disease 1.09 (0.57-2.07) 1.31 (0.80-2.15) Weight Loss 0.61 (0.27-1.39) 1.28 (0.75-2.16) C Statistic for Full Model 0.80 0.77 Hosmer-Lemeshow p-Value 0.99 0.60 OR (95% CI) Variable 1-Year Age (Ref: 50 or Younger) 51-55 0.68 (0.38-1.22) 56-60 0.78 (0.44-1.37) 61-65 0.99 (0.56-1.76) 66-70 0.93 (0.54-1.62) 71-75 1.60 (0.94-2.74) 76-80 1.54 (0.90-2.65) 81-85 2.13 (1.19-3.82) * 86 3.86 (1.91-7.79) * Level of Amputation (Ref: Transtibial) Transfemoral 2.00 (1.61-2.48) * Hip Disarticulation 2.47 (0.74-8.23) Sex (Ref: Female) Male 0.82 (0.32-2.10) Nonchronic Etiologies Device Infection 0.87 (0.62-1.21) Local Significant 1.11 (0.84-1.46) Infection Previous Amputation 0.85 (0.58-1.26) Complication Skin Breakdown 0.98 (0.79-1.22) Systemic Sepsis 2.26 (1.67-3.06) * Trauma 0.95 (0.70-1.30) Chronic Etiologies Chronic Osteomyelitis 0.68 (0.43-1.08) Diabetes Mellitus Type 1 1.00 (0.76-1.32) Diabetes Mellitus Type 2 0.99 (0.78-1.25) Problems with Peripheral 1.23 (0.86-1.76) Circulation Chronic Conditions Acquired Immune 1.05 (0.30-3.69) Deficiency Syndrome Alcohol Abuse 0.81 (0.49-1.35) Arrhythmias 1.30 (1.00-1.69) Chronic Blood Loss 1.49 (0.76-2.91) Anemia Chronic Obstructive 1.65 (1.29-2.10) * Pulmonary Disease Coagulopathy 1.36 (0.85-2.16) Congestive Heart Failure 1.65 (1.30-2.09) Deficiency Anemias 1.05 (0.82-1.35) Depression 1.05 (0.73-1.52) Drug Abuse 0.93 (0.40-2.13) Fluid and Electrolyte 1.28 (1.00-1.64) Disorders Hypertension 0.78 (0.63-0.96) * Hypertension with 0.94 (0.25-3.58) Complication Hypothyroidism 1.14 (0.69-1.89) Liver Disease 2.04 (1.19-3.50) * Lymphoma 1.12 (0.24-5.20) Metastatic Cancer 3.16 (1.47-6.80) * Other Neurological 1.81 (1.06-3.10) Disorders Paralysis 0.55 (0.31-1.00) Peptic ulcer Disease 0.92 (0.38-2.25) with Bleeding Psychoses 0.89 (0.59-1.35) Pulmonary Circulation 2.31 (0.79-6.79) Disease Renal Failure 2.21 (1.71-2.85) * Rheumatoid Arthritis 0.89 (0.37-2.18) Solid Tumor Without 1.94 (1.36-2.78) * Metastases Valvular Disease 1.50 (0.98-2.32) Weight Loss 1.15 (0.73-1.82) C Statistic for Full Model 0.75 Hosmer-Lemeshow p-Value 0.09 * Statistically significant, p = 0.05. Ref = reference (for group). Table 4. Comparison of survival rates (%) over time within Department of Veterans Affairs (VA) and non-VA sectors. Year Data VA Author Published Collected Population Bates et al.  2006 2002-2003 Yes Feinglass et al.  2001 1991-1995 Yes Mayfield et al.  2001 1992 Yes Aulivola et al.  2004 1990-2001 No Pohjolainen and 1998 1984-1985 No Alaranta  Rommers et al.  1997 1991-1992 No Pohjolainen et al.  1989 1984-1985 No In-Hospital (%) Hip Author Transtibial Transfemoral Disarticulation Bates et al.  95.3 88.4 68.7 Feinglass et al.  93.7 86.7 -- Mayfield et al.  93.0 88.9 -- Aulivola et al.  94.3 83.5 -- Pohjolainen and -- -- -- Alaranta  Rommers et al.  89.0 * 89.0 * -- Pohjolainen et al.  -- -- -- 1-Year (%) Hip Author Transtibial Transfemoral Disarticulation Bates et al.  79.2 64.6 68.7 Feinglass et al.  77.0 59.0 -- Mayfield et al.  -- -- -- Aulivola et al.  74.5 50.6 -- Pohjolainen and 70.0 -- -- Alaranta  Rommers et al.  -- -- -- Pohjolainen et al.  69.9 53.8 71.4 * Survival was not reported by level of amputation. (1.) Bates B, Stineman MG, Reker DM, Kurichi JE, Kwong PL. Risk factors associated with mortality in veteran population following transtibial or transfemoral amputation. J Rehabil Res Dev. 2006;43(7):917-28. (2.) Feinglass J, Pearce WH, Martin GJ, Gibbs J, Cowper D, Sorensen M, Henderson WG, Daley J, Khuri S. Postoperative and late survival outcomes after major amputation: Findings from the Department of Veterans Affairs National Surgical Quality Improvement Program. Surgery. 2001;130(1):21-29. [PMID: 11436008] (3.) Mayfield JA, Reiber GE, Maynard C, Czerniecki JM, Caps MT, Sangeorzan BJ. Survival following lower-limb amputation in a veteran population. J Rehabil Res Dev. 2001;38(3):341-45. [PMID: 11440266] (4.) Aulivola B, Hile CN, Hamdan AD, Sheahan MG, Veraldi JR, Skillman JJ, Campbell DR, Scovell SD, LoGerfo FW, Pomposelli FB Jr. Major lower extremity amputation: Outcome of a modern series. Arch Surg. 2004;139(4):395-99. [PMID: 15078707] (5.) Pohjolainen T, Alaranta H. Ten-year survival of Finnish lower limb amputees. Prosthet Orthot Int. 1998;22(1):10-16. [PMID: 9604271] (6.) Rommers GM, Vos LD, Groothoff JW, Schuiling CH, Eisma WH. Epidemiology of lower limb amputees in the north of the Netherlands: Aetiology, discharge destination and prosthetic use. Prosthet Orthot Int. 1997;21(2):92-99. [PMID: 9285952] (7.) Pohjolainen T, Alaranta H, Wikstrom J. Primary survival and prosthetic fitting of lower limb amputees. Prosthet Orthot Int. 1989;13(2):63-69. [PMID: 2780262]