Article on Amputee Demographics
I had a chance in the new year to catch up on the backlog of journals that have been piling up on my bedside stand for months. The final year 2000 issue of Prosthetics & Orthotics International has an outstanding article on the demographics of new lower limb amputees from a group of Dutch colleagues. [Pernot, Winnubst, Cluitmans, and De Witte "Amputees in Limberg: incidence, morbidity & mortality, prosthetic supply, care utilisation and functional level after one year" Pros Orthot Intl 24:90-96; 2000]
These six pages contain a wealth of data that are probably very comparable to the US situation or to almost any developed country in the world. The most significant aspect of this retrospective study is that they tracked 100% of all patients in the province of Limberg who sustained major lower limb amputations in 1994 over time. [Since Limberg's population was 1,119,900 at that time, comparable US numbers can be estimated by multiplying their totals by 250; 250 times 1.119 million = 279.5 million.]
Equally important, this study excluded minor amputations such as loss of toes or parts of the feet that are often managed with orthoses or without any rehab devices at all. This study focused solely on the population we are likely to care for in our prosthetic practices.
Among the key findings were that 14% of the original group died during the hospitalization period, and nearly the same percentage died after discharge but prior to the one year follow-up survey. This reflects the fact that, thanks to advanced in medical care, today's new amputee is older and often sicker than was the case 20 years ago. In the study group, most of the new amputees were males 60 years of age or older, and 87% had dysvascular disease - with or without associated diabetes.
The illustration below illustrates the level of amputation sustained in this group. Note the large number of knee disarticulations compared to the US custom; most of these would likely sustain transfemoral amputation in North America.
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Of those who survived more than a few months, approximately equal numbers received inpatient rehabilitation, outpatient rehabilitation, and nursing home placement. This is illustrated in the following pie chart:
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The article then analyzes that subset of patients who agreed to participate in the follow-up interviews and were evaluated for prosthetic fitting. The overwhelming majority [89%] received a "functional prosthesis" suitable for ambulation while only 3% used a purely cosmetic limb. Only 5 [8%] did not receive an artificial limb.
The final illustration shows the functional results for this subset at one year follow-up. Nearly one in five were not walking, for a variety of reasons including worsening of their physical or medical condition. An almost equal number could walk more than 500 meters, suggesting they were unlimited community ambulators. About one in four could walk but not more than 50 meters, which should be sufficient for independent household ambulation. The largest number [46%] could walk between 50 and 500 meters, a functional capacity similar to Medicare Level Three community ambulators.
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This fascinating study concludes by reporting the scores of some from the follow-up group on several objective outcomes scales, including the Barthel Index and the Get Up and Go Test. They note the very high correlation between walking speed, walking distance, ability to walk without balance aids, and safe ambulation. This supports the clinical impression that those amputees who have the strength and balance to walk quickly, can most likely also walk safely for reasonable distances without using crutches, canes, or a walker. Overall, this study found that as a group, these elderly amputees were more dependent that the average stroke survivor but more independent than typical patients with spinal cord injuries.
One important caveat: these data refer primarily to new elderly dysvascular amputees. A large percentage of prostheses provided each year are fitted for younger, active amputees who are generally much more independent with their artificial limbs. Because younger amputees have a longer average lifespan than the elderly, they will receive prostheses many times over the years, and therefore form a larger proportion of those fitted than their raw percentage of amputees by etiology suggests.