A population-based assessment of the post-operative complications rates and 30-day mortality associated with lower limb amputations at a tertiary care center in Riyadh, Saudi Arabia

Objectives: There is no consensus on the postoperative 30-day mortality, complication rates, and their risk factors post lower limb amputations (LLA) in the literature, especially in Saudi Arabia. To address this gap, we assessed these three parameters in our patients who underwent LLAs. Methods: We conducted a retrospective cross-sectional study in King Abdulaziz Medical City, Riyadh, Saudi Arabia, between 2015 and 2019. Using non-probability purposive sampling, we targeted 318 adults who underwent LLA at our hospital. The primary outcome variables were postoperative 30-day mortality and complications, such as stump pain, wound infections, hemorrhage, and acute kidney injury. In addition, we collected data on demographics, comorbidities, and clinical course from electronic medical records. Results: We assessed 318 patients (mean age = 65.7 [SD = 0.840] years), most of whom were male patients (68.6%) with endocrine and metabolic disorders (92.1%). Most amputees (87.1%) had peripheral vascular diseases as the main indication for LLA at an above-knee level (62.6%). The 30-day mortality and complication rates were 6.6% and 74%, respectively. Intermediate complications predominated (57%), with stump pain (17.3%) and phantom limb pain (15.4%) being the most common. Thirty-day mortality was significantly associated with some patient characteristics and comorbid kidneys and neurological disorders. The immediate, intermediate, and late complications were significantly related to smoking and several renal, vascular, and respiratory disorders. Conclusion: Calculating the 30-day mortality and complication rates after LLA and mapping the associated risk factors helped identify high-risk patients, deliver better treatment, lower medical costs, and establish protective measures.

488 An Evaluation of Pain Related Outcomes Following Nerve Sheath Catheter Insertion after Major Lower Limb Amputations

Aim Limb amputations have many post-op complications, including pain. The evidence supporting the use of nerve sheath catheters (NSC) to manage post-op pain is mixed. Current literature suggests NSC reduces post-op opioid requirements but does not reduce pain score, phantom limb pain or chronic stump pain. This study compared post-op pain in those with and without NSC after above knee amputations (AKA) and below knee amputations (BKA). Method Retrospective data from April 2014 – March 2017 was reviewed. Information regarding indication, anaesthetic, morphine requirement at 72 hours, phantom limb, chronic limb pain and a pain scale (1-10) at 24, 48 and 72 hours were collected. Results 32 patients were involved in the study. 11 had NSC for pain control. Of those patients without NSC, 43% experienced no pain. In comparison, 33% of those with NSC experienced no post-op pain. Phantom limb pain was experienced in a higher proportion of patients with NSC (18%) and in those with AKA (11%). 18% of patients with NSC experienced chronic limb pain, compared to 33% without NSC. 62% of patients with NSC required morphine at 72 hours and at higher dosages compared to those without. However, two patients used large amounts of morphine potentially giving spurious results. Conclusions Though limited by small patient group, patients with NSC were more likely to require morphine at 72 hours and at higher dosages but were less likely to experience chronic limb pain thus proving the role of NSC in post-op pain control.

Physical therapy evaluation in the immediate post-operative period of patients with lower limbs amputation assisted at the hospital bedside

Lower limb (LL) amputation compromises the individual's quality of life and functionality, requiring immediate rehabilitation through the assistance of a multi-professional team. This research describes the sociodemographic and physical-functional profile of the LL amputee, evaluated at the hospital bedside in the immediate postoperative period. This is a descriptive and cross-sectional study in which patients from the Unified Health System were evaluated, who underwent LL of any etiology in a public hospital. The collection was designated through notifications from the hospital staff regarding cases of newly amputees, totaling fourteen subjects. The average age of the participants was 44 years old, being 86% male. The etiology of the predominant amputation was automobile trauma due to motorcycle accidents and transtibial level. From the perimetry, it was found that 43% of the individuals presented edema in the stump when compared to the contralateral limb. Regarding stump pain, 93% of subjects reported feeling, while 78% reported feeling phantom pain and phantom sensation. Concerning normal muscle strength in the amputated limb, it was present in only 1% of patients, in contrast to the intact limb was present in 48% of individuals for any muscle group. In bed mobility, 32% of individuals had complete independence. In unipodal orthostatism, no patient was able to stand independently. From the collected data it was possible to conclude that the physical therapist should pay attention to the muscular strength, bed mobility, and static balance of the amputee to avoid muscle contractures and facilitate prosthesis.

Peripheral nerve stimulator for terminal sciatic nerve neuromas in an amputee

Neuromas are a difficult-to-treat peripheral nerve pathology that can cause crippling pain. Optimal treatment is widely debated as pharmacological intervention frequently is not sufficient and surgical interventions are plagued with recurrence. The majority of amputees report severe and chronic stump pain. Avoiding complex surgery at the stump site would prevent infection or wound dehiscence. Recent advances in neuromodulation with external pulse emitters allow for pain relief with localized nerve stimulation. The authors describe the novel placement of a sciatic nerve stimulator in a 77-year-old man for painful stump neuromas of the common peroneal and tibial nerves.The video can be found here: https://youtu.be/96kKs3qjtqc

Chronic musculoskeletal pain, phantom sensation, phantom and stump pain in veterans with unilateral below-knee amputation

Background and aims Many individuals with lower limb loss report concerns about other musculoskeletal symptoms resulting from amputation. The objective of this study was to assess chronic musculoskeletal pain in Iranian veterans with unilateral below-knee amputation. Methods The participants agreed to take part in a health needs assessment and were interviewed face-to-face by trained interviewers. The assessment consisted of demographic information, wearing a prosthesis, pain locations in extremities, stump complications, severity of pains related to amputation and low back pain. Results Of 247 unilateral below knee amputees, 97.9% wore a prosthetic limb and times walking or standing with the prosthesis were 12.47 ± 3.84 and 4.22 ± 3.53 h a day, respectively. Low soft tissue coverage of the stump (15.4%) and symptomatic osteoarthritis in the contralateral lower extremity (40.1%) were the most common complications. The prevalence of stump pain, phantom sensations, phantom pain, low back pain, and knee pain was 84.2%, 77.3%, 73.7%, 78.1%, and 54.7% respectively. The odds ratio of stump pain in amputees with phantom pain was 2.22 times higher than those who did not experience phantom pain [OR = 2.22 (CI: 1.19–4.17); p = 0.012] and the odds ratio of low back pain was higher in amputees with stump pain [OR = 3.06 (CI: 1.50–6.21); p = 0.002]. Conclusions This research enhances our understanding of comorbid musculoskeletal problems in below-knee amputees which can help health providers to identify rehabilitation needs and emphasizes the importance of regular assessments. Implications These findings underline the importance of paying closer attention to different dimensions and aspects of musculoskeletal complications in veterans with unilateral below-knee amputation.