Epistemology of lower limb amputations and debridements at Hospital Universitário de Maringá

ORIGINAL ARTICLE

Epistemology of lower limb amputations and debridements at Hospital Universitário de Maringá

Amélia Cristina Seidel^I; Andréia K. Nagata^II; Hemerli C. de Almeida^III; Márcia Bonomo^III

^IPhD, Universidade Federal de São Paulo – Escola Paulista de Medicina (UNIFESP-EPM), São Paulo, SP, Brazil. Associate professor, Angiology and Vascular Surgery, Universidade Estadual de Maringá (UEM), Maringá, PR, Brazil. Vascular ultrasonographer and specialist in Cardiovascular Surgery, SBACV and Colégio Brasileiro de Radiologia (CBR).

^IIPhysician, UEM, Maringá, PR, Brazil.

^IIIMedical student (6th year), UEM, Maringá, PR, Brazil.

ABSTRACT

BACKGROUND: There are no precise data on the number of amputations performed every year. However, the decrease in quality of life of patients submitted to amputation is well-known, as is the need to involve a multidisciplinary team in the rehabilitation of these individuals.

OBJECTIVE: To analyze all lower limb amputations performed by the Angiology and Vascular Surgery at Hospital Universitário Regional de Maringá, from 2000 to 2006.

METHODS: A descriptive and retrospective study was performed to review medical records of patients submitted to amputation or surgical debridement of lower limbs to treat vascular diseases or trauma.

RESULTS: A total of 116 procedures were carried out (84.5% amputations and 15% debridements) in 111 patients; 78 were males and 33 were females, with a mean age of 63.4 years (4-100 years). The main etiological factors were vascular diseases (92.8%) and trauma (7.2%). The most prevalent comorbidities and risk factors were hypertension (66%), diabetes mellitus (60%), tobacco (28%) and cardiac arrhythmia (0.9%). As to schooling, 52.2% of the patients had complete elementary school, 6.5% had complete or incomplete high school, and 41.3% were illiterate. Primary amputation was performed in 94.9% of patients, and secondary amputation in 5.1%. However, there was a progressive reduction in amputation rate at each year.

CONCLUSIONS: Incidence of lower limb amputation was greater in males, had atherosclerotic disease as its main cause, but had progressive reduction.

Keywords: Amputation, lower limbs, vascular disease, diabetic vascular disease, trauma.

RESUMO

CONTEXTO: Não há estatísticas precisas sobre o número de amputações realizadas anualmente, mas é conhecido o comprometimento da qualidade de vida desses indivíduos e a necessidade de uma equipe multiprofissional para sua reabilitação.

OBJETIVO: Analisar todas as amputações de membros inferiores realizadas pelo Serviço de Angiologia e Cirurgia Vascular do Hospital Universitário Regional de Maringá entre 2000 e 2006.

MÉTODOS: Estudo descritivo e retrospectivo a partir dos prontuários de pacientes submetidos a amputação ou desbridamento cirúrgico de membros inferiores por trauma ou doença vascular.

RESULTADOS: Ocorreram 116 procedimentos, sendo 84,5% amputações e 15% desbridamentos cirúrgicos, em 111 pacientes, sendo 78 homens e 33 mulheres, cuja média das idades foi de 63,4 anos (4 a 100 anos), sendo os principais fatores etiológicos: doenças vasculares (92,8%) e trauma (7,2%). As comorbidades e fatores de risco mais prevalentes foram: hipertensão arterial sistêmica (66%), diabetes melito (60%), tabaco (28%) e arritmia cardíaca (0,9%). Quanto à escolaridade, se observou que 52,2% dos pacientes cursaram apenas o ensino fundamental, 6,5% fizeram o ensino médio, completo ou incompleto, e 41,3% eram analfabetos. A percentagem de pacientes submetidos à amputação primária foi de 94,9%, e secundárias, 5,1%. No entanto, houve diminuição progressiva do coeficiente desses procedimentos a cada ano.

CONCLUSÕES: Este trabalho permite inferir que a incidência de amputação de membros inferiores foi maior no sexo masculino e teve como principal causa a doença aterosclerótica, mas apresentou uma redução progressiva.

Palavras-chave: Amputação, membros inferiores, doenças vasculares, doenças vasculares diabéticas, traumatismos.

Introduction

The main factors related to lower limb or upper limb amputations are currently attributed to peripheral occlusive atherosclerotic disease (POAD) and diabetes mellitus (DM).^1-6 However, trauma is an expressive cause of peripheral amputations, especially in young patients.^7-14

A careful examination of the limb and investigation of the degree of arterial impairment will dictate the appropriate level for amputation, which should preserve the longest possible limb segment, aiming at a better patient recovery.¹⁵ Infection commonly associated with gangrene is common in diabetics and deserves proper treatment, avoiding poor evolution.^1,16

Appropriate treatment of infected ulcers is also important. They should have a multidisciplinary approach and are often associated with several therapeutic modalities, allowing reduction in proliferation of microorganisms of a pathogenic character. Revascularizations, debridements, use of antibiotics, and hyperbaric oxygen therapy play a cooperative role;^17-19 however, they should be started as early as possible and never alone.⁸

Similarly, early diagnosis in cases of vascular trauma is extremely important, especially in case of severe and complex lesions. However, amputation is often necessary and decisive to save the patient's life and improve his quality of life.^1,13,17

This study aims at analyzing all lower limb amputations exclusively performed by the Angiology and Vascular Surgery Service of Hospital Universitário Regional de Maringá (HUM) from 2000 to 2006.

Method

This is a retrospective, descriptive and analytic cohort study, which was carried out after approval by the Ethics Committee of Universidade Estadual de Maringá based on the medical records of patients submitted to lower limb amputation and/or debridement from January 2000 to January 2006, considering the following: age, gender, schooling, comorbidities and risk factors, in addition to work-up methods. All patients were included.

Descriptive analysis considered all the variables mentioned above. Chi-square or Fisher's exact tests were used in quantitative analyses to evaluate data homogeneity or by observation of minimal and maximal values and calculation of means and standard deviation. Significance level previously defined to reject the null hypothesis was 5% (p < 0.05) when applicable.

Results

During the study period 116 procedures were analyzed out of a total of 111 patients, whose mean age was 63.4 years (4-100 years) and median was 65 years. The great majority (78 patients) were male, and 33 were female (ratio 2.4:1). Amputations were divided as follows: 98 (84.5%) amputations (37.7% transfemoral; 23.5% transtibial; and 38.8% in feet), and 18 (15.5%) cases of surgical debridement.

Stratification of patients according to age showed that 17.1% were younger than 50 years; 46.8% were aged 51-70 years; and 36% were older than 70 years.

With regard to schooling, 52.2% had elementary school, 6.5% had complete or incomplete high school, and 41.3% were illiterate (Table 1).

Table 1 - Click to enlarge

The main etiological factors were trauma, eight cases (7.2%); and vascular diseases, 103 cases (92.8%), 99% of which resulting from POAD and 1% caused by thromboembolic disease. The most prevalent comorbidities in cases of amputations due to vascular diseases were hypertension (66%), DM (60%), smoking (59%), renal failure (11%), and cardiac arrhythmia (0.9%), which was responsible for transfemoral amputation in a 92-year-old man as a consequence of embolic obstruction of the external iliac artery (Tables 2, 3 and 4).

Table 2 - Click to enlarge

Table 3 - Click to enlarge

Table 4 - Click to enlarge

The percentage of patients submitted to primary amputation was 94.9%, and secondary amputations occurred in 5.1% of cases, mainly due to thrombosis and infection.

On the other hand, there was annual progressive reduction in coefficients of amputations secondary to POAD, since 38.8% of cases occurred from 2000 to 2003; 35.7% from 2003 to 2004; 22.4% from 2004 to 2005; and only 3.1% from 2005 to 2006.

Amputations due to lower limb trauma were performed by irreversible damage to the limb without conditions of revascularization as preventive amputation measure. Young men (87.5%) were predominant (mean age 30.7 years, 4-60 years). Three transfemoral (37.5%), one transtibial (12.5%) and four foot (50%) amputations were performed. Only two cases of transfemoral amputation required creatinine (3.3 and 0.68 mg/dL, respectively); for the other cases no complementary examinations were requested.

As to preoperative work-up of patients with non-traumatic vascular disease, 14 (13.6%) were submitted to angiography, and Doppler vascular ultrasound was used in only three (2.9%) cases.

In this group, 18 debridements (16.6%) and 90 (83.3%) amputations were performed. According to procedure location, there were 34 (37.8%) transfemoral, 23 (25.5%) transtibial, and 34 (37.8%) in the foot.

Discussion

Limb amputation has worldwide incidence of more than 1 million a year. At the same time this number tends to be significantly reduced if correct treatment and prevention are performed,¹⁷ it also tends to increase due to higher life expectancy,²⁰ which is correlated with higher incidence of plurimetabolic syndromes (DM, dyslipidemia, obesity, etc.), worse quality of life (incorrect eating habits, sedentary lifestyle, high level of stress, abuse of harmful substances, such as alcohol and tobacco) and increased risk of chronic and systemic diseases (cardiovascular diseases, lung diseases, neoplasms, hypertension, nephropathies, etc.).²¹

Although studies on incidence and profile of patients submitted to amputations are extremely important in this world scenario, they are still rare.² Amputation, independent of being a posttrauma or disease sequela, is definitely perceived as a mutilation and affects the life of any individual, which justifies this study.⁶

The retrospective and descriptive model aims at determining the incidence of amputations performed at HUM after implantation of a vascular surgery service, considering trauma or vascular diseases as indication for surgeries, similar to the study by Carmona et al.,² in which the predominant cause was peripheral vascular failure.

Data collection from medical records was difficult, which is considered by Almeida Filho & Rouquayrol²² as inherent to retrospective studies, indicating the need of a control group, but being difficult to determine why certain individuals would be allocated to either one or another group and with the advantage of conducting the study in a short time and at a low cost.

Sixty-five medical records lacked information on schooling, but it could be observed that, in the remaining sample (46 patients), the number of illiterate individuals was high (41%). This information is compatible with the type of population receiving care by the Brazilian Unified Health System (SUS) in Paraná.²³ In this population occurrence of amputation is usually higher, since learning of individual care of limbs for prevention is more difficult, despite its importance. In addition, it is known that this population is highly dependent on Primary Health Care, a program that still has major problems in Brazil.²⁴

In the evaluation of the sample there was a reduction in procedures related to vascular causes every year, shown by time of each intervention in relation to the beginning of the study. During implantation of the service and because it was a public hospital, many patients who sought treatment for a long time but had no economic conditions were given care, leading to disease worsening, which progressed to an irreversible status, culminating in amputation. After resolution of these cases and standardization of care from the vascular perspective, amputation cases were reduced.

Anyhow, this is a world trend, since prevention of amputation is a public health objective worldwide, especially paying more attention to the association of more prevalent systemic diseases.^2,25

Analysis of the causal factor proved to be very relevant and of great impact, as most patients were young, male and, according to Meirelles, in their most productive time in life.²⁶ Knowing that the most common causes of amputation in childhood are related to trauma in preschool and school children,²⁷ there was a 4-year-old patient in this group submitted to minor amputation (foot) due to irreparable crush injury, with bone and soft tissue loss.

People aged 50 years or older accounted for 82.8%; in this period diseases associated with risk of amputation are more frequent.²⁸ Mean age was lower for men, in agreement with data found in other studies,² although there was an increase in number of surgeries with age, similar to other studies.^2,29

Prevalence of male gender, with a 2.4:1 ratio, was also similar to literature data.¹⁵

Despite the small number of the sample as to schooling level, Fisher's test did not show significant association between gender and schooling level (Table 1, p = 0.177), but in the female gender there was lower number of amputations, similar to the results found in Bergamini's study.²³

The profile of prevalence of a population with low socioeconomic level and low schooling is a common mistake in this type of observational study in exclusive SUS tertiary hospitals, since it creates a selection bias, which may lead to over- or underestimation of certain risk factors, as well as prevalence and incidence in relation to the general population,²² a fact that might have occurred in this study.

There was an important association between vascular failure and associated factors, which have their relationship established with increased risk of evolution to amputation. DM is one of the main aggravating factors,² as it is a factor that confirmedly increases risk of vascular failure, raising the chances of resulting in a lower limb ulcer or even amputations,^15,21,25 but there was no significant association between DM and procedures performed in this sample using the chi-square test (Table 2, p = 0.551).

Hypertension alone is considered a risk, because one of its long-term consequences is hypertensive ulcer, which may progress to infection and amputation;^29.30 however, in this study, similar to DM, there was no significant association between hypertension and procedures (debridements and amputations), as shown by the chi-square test (Table 3, p = 0.380).

Smoking and increased risk of amputation are well documented, especially in association with DM. It is a fact that the chances of amputation are higher in the diabetic foot; however, if the patient stops smoking such risk can be reduced over time.^21,31 This study had the data of 83 patients regarding the habit of smoking; 59% were smokers or former smokers. Fisher's exact test (Table 4, p = 1.000) did not show significant association between smoking and surgical procedures, but the importance of preventing this habit should be stressed, although the number of programs for tobacco dependents is still small and not available or not offered to everyone.³²

The precise relation between associated factors and vascular failure cannot be calculated, since associated factors cause confounding errors.^22,33

Serum creatinine levels with higher or altered borderline values may reveal tissue injury and/or renal component by basal disease,³⁴ but in this study most patients (76%) had creatinine levels lower than 1.4 mg/dL.

More complex examinations, such as angiography and Doppler vascular ultrasound, were rarely used, therefore it is difficult to hold a discussion on this issue.

The characteristics of the interventions showed a higher number of amputations (84.5%) than debridements (15.5%), perhaps due to the recent implantation of a vascular surgery service at a SUS hospital in its region; thus, a large part of cases were already admitted at an advanced stage, requiring amputation, and not only surgical debridement as treatment. According to Almeida Filho²² and Sackett et al.,³³ this is an example of a common selection bias in this type of study.

The protocols of clinical investigation should indicate educational and care actions in this area, such as good metabolic control, good adherence to clinical treatments, good cutaneous integrity (proper hygiene, insensibility in feet detected by trauma with use of inappropriate shoes and other objects, nail cutting, correctly treated onychomychosis and onychocryptosis, professionals trained to remove plantar calluses avoiding accidents, etc.), early identification of neuroischemic lesions and sudden signs of peripheral ischemia.^20,35,36

These measures can be achieved using available resources. The consequences would have a major impact on prevention of these disabilities, extremely expensive and that lead to irreversible physical, mental and social problems.³⁷ In large urban centers, with more availability of health services, especially medium and high complexity, there are barriers to the access and offer of basic actions.²⁴ It is estimated that, applying these measures and having a trained multidisciplinary team, amputations can be reduced by 45-85%.²⁵

The team should be composed of vascular surgeon, orthopedist, endocrinologist, specialized nurse, chiropodist, and an administrative team.²⁵

Conclusion

Incidence of lower limb amputation was higher in the male gender, age group 51-70 years, had POAD as its main cause and had progressive reduction.

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Correspondence

Publication Dates

• Publication in this collection
  30 Jan 2009
• Date of issue
  Dec 2008

History

• Accepted
  28 Aug 2008
• Received
  07 Oct 2007