Foot & Ankle

PALM BEACH, FLA. – Locoregional anesthesia boosts the success rate of lower-extremity amputations, while time-saving shortcuts and relying too heavily on surgical residents to perform the surgery raise the risk that an amputation patient will run into problems following surgery, according to a review of nearly 9,000 U.S. patients.

Based on these findings, "we use locoregional anesthesia when possible," and focus on "careful and meticulous handling of tissue," Dr. P. Joshua O’Brien said at the annual meeting of the Southern Surgical Association. "This is the first paper to suggest that locoregional anesthesia may have a protective effect and improve outcomes."

The study results also made Dr. O’Brien and his colleagues at Duke University in Durham, N.C., more aware that amputations "are an important procedure" even though they are often a "junior-level case frequently overseen by a senior resident." The study results prompted Duke attending surgeons to maintain "careful observation of the residents until they feel comfortable that they [the residents] adequately understand the art of performing an amputation," said Dr. O’Brien, a vascular surgeon at Duke.

The analysis he and his associates performed used data collected during 2005-2010 by the National Surgical Quality Improvement Program of the American College of Surgeons. The study included patients who underwent an above-the-knee amputation (3,415 patients – 38%), a below-the-knee amputation (4,258 patients – 48%), or a transmetatarsal amputation (1,205 patients – 14%), but excluded patients who had another surgical procedure with their amputation, prior surgery within 30 days of the amputation, a preoperative do-not-resuscitate order, or missing data; 63% of all the amputation patients had diabetes.

During 30-day postsurgical follow-up, the overall rate of amputation failure was 13%, death occurred in 7%, wound complications affected 9%, and nonwound complications affected 21%. The patients averaged a 6-day postsurgical hospital length of stay.

Early amputation failure showed a statistically significant link with the type of amputation. Patients with a transmetatarsal amputation had a 26% early failure rate, those who underwent a below-the-knee procedure had a 13% failure rate, while above-the-knee amputations failed 8% of the time.

In a multivariate analysis that controlled for patient- and procedure-related factors, several variables linked with statistically significant increases or decreases in the rate of amputation failure. Notable among the factors that increased failure rates were emergency surgery, which boosted the failure rate 2.2-fold compared with nonemergency surgery, and participation of a surgical trainee, which raised the rate 37% compared with the rate when no trainee participated. Trainee participation was common, occurring in 59% of the 8,878 amputations included in the analysis.

Among the factors significantly linked with a reduced rate of amputation failures were use of locoregional anesthesia, which cut the failure rate by 25% compared with general anesthesia, and operative times of at least 40 minutes, which cut failure rates compared with surgery times of less than 40 minutes. The lowest failure rates occurred when the duration of amputation surgery lasted at least 60 minutes. Among patients included in the study, 20% received locoregional anesthesia.

The results also highlighted the important association of amputation failure with other measures of poor surgical outcomes in these amputation patients. Patients who developed amputation failure within 30 days of their surgery also had a nearly sevenfold increased rate of wound complications, and a twofold increased rate of nonwound complications; the average hospital length of stay was 10 days compared with 5 days among patients without amputation. Amputation failure had no significant impact on postoperative mortality, Dr. O’Brien said.

He said he had no relevant financial disclosures.

m.zoler@elsevier.com

On Twitter @mitchelzoler

PALM BEACH, FLA. – Locoregional anesthesia boosts the success rate of lower-extremity amputations, while time-saving shortcuts and relying too heavily on surgical residents to perform the surgery raise the risk that an amputation patient will run into problems following surgery, according to a review of nearly 9,000 U.S. patients.

Based on these findings, "we use locoregional anesthesia when possible," and focus on "careful and meticulous handling of tissue," Dr. P. Joshua O’Brien said at the annual meeting of the Southern Surgical Association. "This is the first paper to suggest that locoregional anesthesia may have a protective effect and improve outcomes."

The study results also made Dr. O’Brien and his colleagues at Duke University in Durham, N.C., more aware that amputations "are an important procedure" even though they are often a "junior-level case frequently overseen by a senior resident." The study results prompted Duke attending surgeons to maintain "careful observation of the residents until they feel comfortable that they [the residents] adequately understand the art of performing an amputation," said Dr. O’Brien, a vascular surgeon at Duke.

The analysis he and his associates performed used data collected during 2005-2010 by the National Surgical Quality Improvement Program of the American College of Surgeons. The study included patients who underwent an above-the-knee amputation (3,415 patients – 38%), a below-the-knee amputation (4,258 patients – 48%), or a transmetatarsal amputation (1,205 patients – 14%), but excluded patients who had another surgical procedure with their amputation, prior surgery within 30 days of the amputation, a preoperative do-not-resuscitate order, or missing data; 63% of all the amputation patients had diabetes.

During 30-day postsurgical follow-up, the overall rate of amputation failure was 13%, death occurred in 7%, wound complications affected 9%, and nonwound complications affected 21%. The patients averaged a 6-day postsurgical hospital length of stay.

Early amputation failure showed a statistically significant link with the type of amputation. Patients with a transmetatarsal amputation had a 26% early failure rate, those who underwent a below-the-knee procedure had a 13% failure rate, while above-the-knee amputations failed 8% of the time.

In a multivariate analysis that controlled for patient- and procedure-related factors, several variables linked with statistically significant increases or decreases in the rate of amputation failure. Notable among the factors that increased failure rates were emergency surgery, which boosted the failure rate 2.2-fold compared with nonemergency surgery, and participation of a surgical trainee, which raised the rate 37% compared with the rate when no trainee participated. Trainee participation was common, occurring in 59% of the 8,878 amputations included in the analysis.

Among the factors significantly linked with a reduced rate of amputation failures were use of locoregional anesthesia, which cut the failure rate by 25% compared with general anesthesia, and operative times of at least 40 minutes, which cut failure rates compared with surgery times of less than 40 minutes. The lowest failure rates occurred when the duration of amputation surgery lasted at least 60 minutes. Among patients included in the study, 20% received locoregional anesthesia.

The results also highlighted the important association of amputation failure with other measures of poor surgical outcomes in these amputation patients. Patients who developed amputation failure within 30 days of their surgery also had a nearly sevenfold increased rate of wound complications, and a twofold increased rate of nonwound complications; the average hospital length of stay was 10 days compared with 5 days among patients without amputation. Amputation failure had no significant impact on postoperative mortality, Dr. O’Brien said.

He said he had no relevant financial disclosures.

m.zoler@elsevier.com

On Twitter @mitchelzoler

PALM BEACH, FLA. – Locoregional anesthesia boosts the success rate of lower-extremity amputations, while time-saving shortcuts and relying too heavily on surgical residents to perform the surgery raise the risk that an amputation patient will run into problems following surgery, according to a review of nearly 9,000 U.S. patients.

Based on these findings, "we use locoregional anesthesia when possible," and focus on "careful and meticulous handling of tissue," Dr. P. Joshua O’Brien said at the annual meeting of the Southern Surgical Association. "This is the first paper to suggest that locoregional anesthesia may have a protective effect and improve outcomes."

The study results also made Dr. O’Brien and his colleagues at Duke University in Durham, N.C., more aware that amputations "are an important procedure" even though they are often a "junior-level case frequently overseen by a senior resident." The study results prompted Duke attending surgeons to maintain "careful observation of the residents until they feel comfortable that they [the residents] adequately understand the art of performing an amputation," said Dr. O’Brien, a vascular surgeon at Duke.

The analysis he and his associates performed used data collected during 2005-2010 by the National Surgical Quality Improvement Program of the American College of Surgeons. The study included patients who underwent an above-the-knee amputation (3,415 patients – 38%), a below-the-knee amputation (4,258 patients – 48%), or a transmetatarsal amputation (1,205 patients – 14%), but excluded patients who had another surgical procedure with their amputation, prior surgery within 30 days of the amputation, a preoperative do-not-resuscitate order, or missing data; 63% of all the amputation patients had diabetes.

During 30-day postsurgical follow-up, the overall rate of amputation failure was 13%, death occurred in 7%, wound complications affected 9%, and nonwound complications affected 21%. The patients averaged a 6-day postsurgical hospital length of stay.

Early amputation failure showed a statistically significant link with the type of amputation. Patients with a transmetatarsal amputation had a 26% early failure rate, those who underwent a below-the-knee procedure had a 13% failure rate, while above-the-knee amputations failed 8% of the time.

In a multivariate analysis that controlled for patient- and procedure-related factors, several variables linked with statistically significant increases or decreases in the rate of amputation failure. Notable among the factors that increased failure rates were emergency surgery, which boosted the failure rate 2.2-fold compared with nonemergency surgery, and participation of a surgical trainee, which raised the rate 37% compared with the rate when no trainee participated. Trainee participation was common, occurring in 59% of the 8,878 amputations included in the analysis.

Among the factors significantly linked with a reduced rate of amputation failures were use of locoregional anesthesia, which cut the failure rate by 25% compared with general anesthesia, and operative times of at least 40 minutes, which cut failure rates compared with surgery times of less than 40 minutes. The lowest failure rates occurred when the duration of amputation surgery lasted at least 60 minutes. Among patients included in the study, 20% received locoregional anesthesia.

The results also highlighted the important association of amputation failure with other measures of poor surgical outcomes in these amputation patients. Patients who developed amputation failure within 30 days of their surgery also had a nearly sevenfold increased rate of wound complications, and a twofold increased rate of nonwound complications; the average hospital length of stay was 10 days compared with 5 days among patients without amputation. Amputation failure had no significant impact on postoperative mortality, Dr. O’Brien said.

He said he had no relevant financial disclosures.

m.zoler@elsevier.com

On Twitter @mitchelzoler

BARCELONA – People with knee and hip osteoarthritis tend to overstate their walking disability, but timed walking tests provide an accurate assessment of their lameness, according to a new study.

Dr. Luke Brunton, orthopedic surgeon and researcher at the musculoskeletal research unit at the University of Bristol (England), and his colleagues wanted to find out whether patient self-reports of walking could be used to accurately represent their walking ability. "We found a very poor correlation between self-reports and objective tests," said Dr. Brunton at the World Congress on Osteoarthritis.

He added that "the observers found that patients were performing much more easily than they reported. There was a much better correlation between the observers’ reports and the tests than the patient’s self-reported walking ability."

According to Dr. Brunton, walking impairment in patients with hip and knee OA was particularly important because it was part of the reason for patients’ reduced life span, is linked to social isolation, and has been associated with dementia.

"Questions on walking are very often used to assess function, quality of life, and disability in people with OA. People are commonly asked to self-report on either walking restrictions or distance limitations, however, simply asking patients may not give the whole picture," said Dr. Brunton.

The researchers looked at the correlations between self-reported walking ability and functional tests, and observers’ assessments and the same functional tests of walking ability.

Data from a large U.K. community based cohort study known as the South West and Avon Survey of Health (SASH) cohort were used including demographic and disease-related data.

Self-assessment questions were taken from the commonly used Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and the Lequesne assessment. WOMAC asked, ‘What degree of difficulty have you experienced walking on flat ground in the last week due to your hips or knees?’ while Lequesne asked, "What is the maximum distance you can walk with pain?"

The study involved 806 participants with a mean age of 68 years and body mass index of 28.6 kg/m². They were asked to carry out a timed 6-meter walking test and a "get up and go" test. The latter test times how long patients take to stand up from a sitting position, walk 3 meters, turn around, and sit down again.

In particular, research observers looked at whether patients had any difficulties walking and how far they said they could walk. They correlated these findings with the 6-meter walk and the "get-up and go" test results, and compared this to the correlation between patient self-reports and the same objective tests.

"We tell the observers it doesn’t matter how long the person is taking. The important thing is how easy it is for the patient to complete the test or not," explained Dr. Brunton.

A stronger association was found between observer evaluation of walking ability and the timed walk (ANOVA r2 = 0.58; P less than .001) and "get up and go" tests (ANOVA r2= 0.56; P less than .001), than patient self-reports (SF-36; ANOVA r2 = 0.23; P less than .001 and Lequesne ANOVA r2 = 0.27; P less than .001) with the objective tests. ANOVA r2 is a measure of the statistical correlation between the two variables

"It is notable that the observers were watching the patients actually carry out a test whereas patients were asked generally how well they walked," he continued, admitting it was a very different scenario being assessed. "But if you are only asking patients one question on walking you are assuming that their self-assessment and their functional test should be very similar. We have showed this isn’t the case."

The data showed most people did the test with similar times how they rated their own walking ability.

"You can’t just take a questionnaire but you may need to undertake a functional assessment too. Most clinicians would assess patients themselves rather than relying solely on questionnaires. For research, I think we also need a combination of the two methods," he said.

Dr. Brunton has reported no relevant financial disclosures. The meeting was sponsored by the Osteoarthritis Research Society International.

BARCELONA – People with knee and hip osteoarthritis tend to overstate their walking disability, but timed walking tests provide an accurate assessment of their lameness, according to a new study.

Dr. Luke Brunton, orthopedic surgeon and researcher at the musculoskeletal research unit at the University of Bristol (England), and his colleagues wanted to find out whether patient self-reports of walking could be used to accurately represent their walking ability. "We found a very poor correlation between self-reports and objective tests," said Dr. Brunton at the World Congress on Osteoarthritis.

He added that "the observers found that patients were performing much more easily than they reported. There was a much better correlation between the observers’ reports and the tests than the patient’s self-reported walking ability."

According to Dr. Brunton, walking impairment in patients with hip and knee OA was particularly important because it was part of the reason for patients’ reduced life span, is linked to social isolation, and has been associated with dementia.

"Questions on walking are very often used to assess function, quality of life, and disability in people with OA. People are commonly asked to self-report on either walking restrictions or distance limitations, however, simply asking patients may not give the whole picture," said Dr. Brunton.

The researchers looked at the correlations between self-reported walking ability and functional tests, and observers’ assessments and the same functional tests of walking ability.

Data from a large U.K. community based cohort study known as the South West and Avon Survey of Health (SASH) cohort were used including demographic and disease-related data.

Self-assessment questions were taken from the commonly used Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and the Lequesne assessment. WOMAC asked, ‘What degree of difficulty have you experienced walking on flat ground in the last week due to your hips or knees?’ while Lequesne asked, "What is the maximum distance you can walk with pain?"

The study involved 806 participants with a mean age of 68 years and body mass index of 28.6 kg/m². They were asked to carry out a timed 6-meter walking test and a "get up and go" test. The latter test times how long patients take to stand up from a sitting position, walk 3 meters, turn around, and sit down again.

In particular, research observers looked at whether patients had any difficulties walking and how far they said they could walk. They correlated these findings with the 6-meter walk and the "get-up and go" test results, and compared this to the correlation between patient self-reports and the same objective tests.

"We tell the observers it doesn’t matter how long the person is taking. The important thing is how easy it is for the patient to complete the test or not," explained Dr. Brunton.

A stronger association was found between observer evaluation of walking ability and the timed walk (ANOVA r2 = 0.58; P less than .001) and "get up and go" tests (ANOVA r2= 0.56; P less than .001), than patient self-reports (SF-36; ANOVA r2 = 0.23; P less than .001 and Lequesne ANOVA r2 = 0.27; P less than .001) with the objective tests. ANOVA r2 is a measure of the statistical correlation between the two variables

"It is notable that the observers were watching the patients actually carry out a test whereas patients were asked generally how well they walked," he continued, admitting it was a very different scenario being assessed. "But if you are only asking patients one question on walking you are assuming that their self-assessment and their functional test should be very similar. We have showed this isn’t the case."

The data showed most people did the test with similar times how they rated their own walking ability.

"You can’t just take a questionnaire but you may need to undertake a functional assessment too. Most clinicians would assess patients themselves rather than relying solely on questionnaires. For research, I think we also need a combination of the two methods," he said.

Dr. Brunton has reported no relevant financial disclosures. The meeting was sponsored by the Osteoarthritis Research Society International.

BARCELONA – People with knee and hip osteoarthritis tend to overstate their walking disability, but timed walking tests provide an accurate assessment of their lameness, according to a new study.

Dr. Luke Brunton, orthopedic surgeon and researcher at the musculoskeletal research unit at the University of Bristol (England), and his colleagues wanted to find out whether patient self-reports of walking could be used to accurately represent their walking ability. "We found a very poor correlation between self-reports and objective tests," said Dr. Brunton at the World Congress on Osteoarthritis.

He added that "the observers found that patients were performing much more easily than they reported. There was a much better correlation between the observers’ reports and the tests than the patient’s self-reported walking ability."

According to Dr. Brunton, walking impairment in patients with hip and knee OA was particularly important because it was part of the reason for patients’ reduced life span, is linked to social isolation, and has been associated with dementia.

"Questions on walking are very often used to assess function, quality of life, and disability in people with OA. People are commonly asked to self-report on either walking restrictions or distance limitations, however, simply asking patients may not give the whole picture," said Dr. Brunton.

The researchers looked at the correlations between self-reported walking ability and functional tests, and observers’ assessments and the same functional tests of walking ability.

Data from a large U.K. community based cohort study known as the South West and Avon Survey of Health (SASH) cohort were used including demographic and disease-related data.

Self-assessment questions were taken from the commonly used Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and the Lequesne assessment. WOMAC asked, ‘What degree of difficulty have you experienced walking on flat ground in the last week due to your hips or knees?’ while Lequesne asked, "What is the maximum distance you can walk with pain?"

The study involved 806 participants with a mean age of 68 years and body mass index of 28.6 kg/m². They were asked to carry out a timed 6-meter walking test and a "get up and go" test. The latter test times how long patients take to stand up from a sitting position, walk 3 meters, turn around, and sit down again.

In particular, research observers looked at whether patients had any difficulties walking and how far they said they could walk. They correlated these findings with the 6-meter walk and the "get-up and go" test results, and compared this to the correlation between patient self-reports and the same objective tests.

"We tell the observers it doesn’t matter how long the person is taking. The important thing is how easy it is for the patient to complete the test or not," explained Dr. Brunton.

A stronger association was found between observer evaluation of walking ability and the timed walk (ANOVA r2 = 0.58; P less than .001) and "get up and go" tests (ANOVA r2= 0.56; P less than .001), than patient self-reports (SF-36; ANOVA r2 = 0.23; P less than .001 and Lequesne ANOVA r2 = 0.27; P less than .001) with the objective tests. ANOVA r2 is a measure of the statistical correlation between the two variables

"It is notable that the observers were watching the patients actually carry out a test whereas patients were asked generally how well they walked," he continued, admitting it was a very different scenario being assessed. "But if you are only asking patients one question on walking you are assuming that their self-assessment and their functional test should be very similar. We have showed this isn’t the case."

The data showed most people did the test with similar times how they rated their own walking ability.

"You can’t just take a questionnaire but you may need to undertake a functional assessment too. Most clinicians would assess patients themselves rather than relying solely on questionnaires. For research, I think we also need a combination of the two methods," he said.

Dr. Brunton has reported no relevant financial disclosures. The meeting was sponsored by the Osteoarthritis Research Society International.