Br. J. Surg. 1992, Vol. 79, August, 753-755
A. D. Houghton, P. R . Taylor, S. Thurlow, E. Rootes and I. McColl Department of Surgery, Guy's Hospital, London SEI 9RT, UK Correspondence to: Lord McColl
Success rates for rehabilitation of vascular amputees: implications for preoperative assessment and amputation level All lower limb amputations performed during 1986 and 1988 in eight hospitals in the south-east region were assessed. Of 440 amputations f o r vascular disease, 193 were above-knee, 193 below-knee, 15 Gritti-Stokes, 15 through-knee and 24 bilateral. Of the 440 patients, 75 died in hospital, 113 were considered unsuitable f o r a prosthesis and 252 ( 5 7 per cent j were referred for prostheses. Rehabilitation questionnaires were sent to 179 patients ( 4 1 per cent), as a further 54 had died and 19 had become known non-wearers before the study commenced. The response rate was 81 per cent; 102 patients completed the questionnaire, 21 were reported dead, and 22 were non-wearers. Of a maximum rehabilitation score of 12, 52 patients scored 6 or more (consistent with mobility on their artijicial limb around the home), and 21 scored 9 or more ( a standard accepted as successful rehabilitation). It is concluded that 10-15per cent of amputees achieve mobility around the home on their prosthesis. Only 5 per cent, however, rehabilitate well and become independent of their wheelchair. When amputation is inevitable, more consideration should be given to surgery that optimizes wheelchair rehabilitation.
A total of 5000 lower limb amputations for vascular disease are performed annually in the UK', and below-knee ( B K ) amputation results in the best rehabilitation2-'. When a more proximal amputation is needed, the above-knee ( A K ) level is often preferred to more distal amputations, such as through-knee ( T K ) or Gritti-Stokes (GS), because of the high rate of successful primary healing and the cosmetically more attractive prosthesis*. However, there have been several recent studies suggesting that rehabilitation after T K amputation may be better than that a t the AK levelg-". After surgery, one of the main concerns is successful mobilization. However, many patients will never walk on an artificial limb, and realistic appraisal in these cases will judge a good wheelchair to be more appropriate than a prosthesis. This knowledge might affect amputation level. In the wheelchair-bound patient the G S amputation, with its long lever and good record of primary healing, is superior to the AK o p e r a t i ~ n ' ~ - ' ~ . Information on amputees under the care of the disablement services centres (DSCs) suggests that 50 per cent of them rehabilitate successfully and only 5 per cent are totally dependent on their wheelchairs' '*I5. Studies based on the DSCs are, however, inevitably biased towards current limb wearers, many of whom are young traumatic amputees who rehabilitate well. Very little is known about the outcome for more elderly amputees with vascular disease. How many are referred for prosthetic fitting and how many rehabilitate successfully? Are too many patients referred for prostheses? Should more GS or TK amputations be performed in patients who are likely to be wheelchair bound? Knowledge of the outcome of operations should help surgeons to tailor amputations to the needs of individual patients. This study was designed to answer the above questions.
revision was determined as was the number of patients dying while in hospital. The number of patients referred. from each hospital for prosthetic fitting was then assessed by access to the DSC notes. The reasons for patients not being referred for prosthetic fitting related to a mix of medical, social and psychological factors and were not studied in detail. By scrutiny of the DSC notes and from questionnaires it was determined how many patients had died o r become non-wearers since referral for prosthetic fitting. Questionnaires were then sent to all the recorded current limb wearers. Rehabilitation was assessed by the answers t o four standard questions: 1. Do you use your limb to walk: ( a ) less than 25 per cent of waking hours (score 0 ) ( b ) between 25 and 50 per cent of waking hours (score 1 ) ( c ) more than 50 per cent of waking hours (score 2 ) ( d ) all waking hours (score 3 ) 2. Do you use your limb to walk: ( a ) just when visiting your doctor o r limb-fitting centre (score 0 ) ( b ) at home but not to go outside (score 1 ) (c) outside the home on occasions (score 2 ) ( d j inside and outside all the time (score 3 ) 3. When going outside wearing your limb do you: (a) use a wheelchair (score 0 ) ( b ) use two crutches, two sticks or a walking frame (score 1 ) ( c ) use one stick (score 2 ) ( d ) use nothing (score 3) 4. When walking with your limb outside do you feel unstable when: ( a ) walking on the flat (No: score 1 ) ( b j walking on slopes (No: score 1 ) ( c ) walking on rough ground (No: score 1 ) (Yes to any of (a)-(c): score 0 ) (Amputees who used a wheelchair outside scored0 for this question.) The patients were also asked whether they had a wheelchair and for how many of their waking hours they used it. The answers to these questions were analysed to assess the patient's wheelchair dependence. Statistical differences between the types of amputation were assessed using the Mann-Whitney U test.
Patients and methods Operating theatre records were examined to determine the date and level of all amputations for vascular disease performed at eight hospitals in the south-east region for the periods January to December 1986, and January to December 1988. The number of amputations requiring
ooO7-1323/92/08075343 0 1992 Butterworth-Heinemann Ltd
Results In the 2 years studied, 440 vascular lower limb amputations were performed in the eight hospitals: 232 in 1986 and 208 in
753
Rehabilitation of vascular amputees: A. D. Houghton et al.
Table 1 Age distribution andnumber of the different ampuiation types Amputation
n
Median age (years)
Above-knee Below-knee Gritti-Stokes Through-knee Bilateral
193 193 15 15 24
72 70 79 81 72
(39-90) (39-93) (65-94) (44-90) (50-85)
Values in parentheses are ranges
Table 2 Age and rehabilitation of limb users responding to the questionnaire
Amputation
n
Median age (Years)
Above-knee Below-knee Gritti-Stokes Through-knee Bilateral
31 56 3 1 11
68 68 81 81 67
(50-85) (49-88) (78-86) (50-85)
Median rehabilitation score 4 (1-9) 6 (0-11) 9 (3-9) 7 1(1-10)
Values in parentheses are ranges
1988. Of 212 BK amputations (48 per cent), 19 failed to heal, resulting in a revised higher amputation. Of the 440 healed amputations, 193 were AK, 193 BK, 15 GS, 15 TK and 24 bilateral. The age distribution is shown in Table 1 . A total of 25 amputations had required revision (19 of which were BK to AK). Of the 440 patients, 75 (17 per cent) died without leaving hospital and 113 (26 per cent) were considered unsuitable for artificial limbs. There were 252 amputees (57 per cent) referred for prosthetic fitting. Before the start of the study, 54 patients in this group were known to have died and 19 had become non-wearers. The rehabilitation questionnaire was therefore sent to 179 patients. Information was received from 81 per cent of these, with 21 patients being reported dead, 22 to be non-wearers, and 102 filling in the questionnaire. Thus, of the original 252 referred for prosthetic fitting, 75 (30 per cent) had died (49 from 1986 and 26 from 1988) and 41 had become non-wearers (25 from 1986 and 16 from 1988). Of the original 440 patients, 102 (23 per cent ) completed the rehabilitation questionnaire, reporting on 31 AK, 56 BK, 11 bilateral, three GS and one TK amputations. The rehabilitation scores and age distribution of these patients are shown in Table 2. It should be noted that no reply was received from 19 per cent of patients, despite attempts to telephone and visit them at home. Rehabilitation
A score of 9 was accepted as satisfactory rehabilitation and one of 6 as indicating mobility on the prosthesis around the home; 52 patients scored 6 or more and 21 9 or more. Therefore, 12 per cent of the initial 440 amputees became mobile on their limb around the home, but only 5 per cent achieved satisfactory rehabilitation. Of the 177 amputees referred for limb fitting who were still alive, 29 per cent were mobile on their limb around the home and 12 per cent were satisfactorily rehabilitated. BK amputees performed better than AK ones. Of all the current limb wearers 55 per cent were BK and 30 per cent AK amputees (the original numbers of AK and BK amputees were the same). The remaining 15 per cent comprised bilateral (11 per cent), GS (3per cent) and TK (1 per cent). The numbers of these amputation types were too small to assess comDarative rehabilitation. Of the original 193 BK amputees, 31 (16 per cent) had a rehabilitation score of 6 or more and 5 Per cent of 9 or more. This compares with respective figures of 9 and 4 per cent for AK amputees. The BK amputees also had a higher median rehabilitation score, although this was
754
not statistically significant. Of the original 24 bilateral amputees, four (17 per cent) rehabilitated satisfactorily to a Score of 9 or more. Wheelchair use Of limb users, 91 per cent from 1986 and 96 per cent from 1988 possessed a wheelchair. Of these, 26 per cent never used it, 19 per cent used it for between one-quarter and half of their waking hours, 41 per cent used it for more than half of their waking hours, and 15 per cent used it all the time.
Discussion The numbers of patients who were satisfactorily rehabilitated in this study (5 per cent) and who became mobile around the home (12 per cent) are in agreement with the results of a previous Swedish study, in which 13 per cent of 126 amputees used their prosthesis 2 years after amputation16. These findings do, however, contrast with figures of around 50 per cent in other studies' ',which involved only limb wearers under the care of DSCs. In the current series all patients undergoing surgery were followed, and the much lower rates of successful rehabilitation take into account those who died or were not referred to DSCs. This emphasizes that amputees comprise two distinct groups: relatively fit and often young traumatic patients who survive for a long time and rehabilitate well", and older medically unfit amputees with vascular disease and a poor prognosis. In the present series, the median age of the amputees was 70 years or more. Although amputation for trauma comprises only 7 per cent of all operations", because of the long survival in this group it represents over 50 per cent of amputees under the care of DSCs". Only half of the amputees in the present series were referred for prosthetic fitting, and two-thirds of these either died within 3 years or did not wear their artificial limb. Almost twice as many BK amputees became mobile around the home on their prosthesis as AK amputees. This supports the conclusion from other series that the knee joint should be preserved wherever Very few TK or GS amputations were performed in this study and no conclusions can be drawn regarding these. We believe that realistic advice on prostheses before surgery is very important for the vascular patient, who should be assessed before operation by an amputation team that includes a physiotherapist and an occupational therapist. The presence of arthritis, gait abnormality or neurological deficit might contribute to non-referral for limb fitting. It should be possible to develop criteria that will help to predict whether a patient will achieve successful mobilization on a prosthesis. These could then be used as guidelines for the surgeon and patient in deciding the level of amputation. After operation, every effort should be made to avoid delays in mobilization and rehabilitation7. If the intention is to fit a prosthesis, BK amputation is preferred to all other levels. If this is impossible, consideration should be given to the TK procedure. In many patients poor blood supply contraindicates both the BK and TK levels, but a few may still be suitable for TK amputation. The TK operation has fallen into disrepute because of its lower primary healing rate compared with the AK level. It does, however, have certain advantages, including a lower in-hospital and subsequent mortality rate", increased stability when transferring and sitting, reduced dependence on long-term nursing care", and better rehabilitation on a total end-bearing stump9-' '. If prosthetic fitting is not considered appropriate, the longer stump of the GS or TK amputation may be preferable to the standard AK amputation. Of these two, the GS is preferable as the primary healing rate is superior' 2-1 4. '3'
References 1.
Ratcliffe D, Clyne C, Chant A, Webster J. Prediction of amputation wound healing: the role of transcutaneous PO, assessment. Br J Surg 1984; 74: 219-22.
Br. J. Surg.. Vol. 79, No. 8, August 1992
Rehabilitation of vascular amputees: A. D. Houghton et al.
Francis W, Renton C . Mobility after major limb amputation for arterial occlusive disease. Prosthet Orthot Inr 1987; 11: 85-9. 3. Harrison JD, Southworth S,Callum K. Experience with the ‘skew flap’ below-knee amputation. Br J Surg 1987; 74: 930-1. 4. Campbell W, Morris P. A prospective randomised comparison of healing in Gritti-Stokes and through-knee amputations. Ann R Coll Surg Engl 1986; 68: 1-4. 5. Couch N, David J, Tilney N, Crane C. Natural history of the leg amputee. Am J Surg 1977; 133: 469-73. 6. Fyfe N. An audit of amputation levels in patients referred for prosthetic rehabilitation. Prosthet Orthot Int 1990; 14: 67-70. 7. Pohjolainen T, Alaranta H, Wikstrom J. Primary survival and prosthetic fitting of lower limb amputees. Prosthet Orthot I n t 1989; 13: 63-9. 8. Harris W. Lower limb amputation in elderly patients. Can 7 Surg 1987; 30: 315. 9. Baumgartner R. Failures in through knee amputation. Prosthet Orthot I n t 1983; 7: 116-18. 10. Moran B, Buttenshaw P, Mulcahy M, Robinson K. Throughknee amputation in high-risk patients with vascular disease: indications, complications and rehabilitation. Br J Surg 1990; 77: I 118-20. 11. Houghton A, Allen A, Luff R, McColl I. Rehabilitation after lower limb amputation: a comparative study of above-knee, 2.
12. 13. 14. 15. 16. 17. 18. 19.
through-knee and Gritti-Stokes amputations. Br J Surg 1989; 76: 622-4. Sethia K, Berry A, Morrison J, Collin J, Murie J, Morris P. Changing pattern of lower limb amputation for vascular disease. Br J Surg 1986; 73: 701-3. Doran J, Hopkinson B, Makin G . The Gritti-Stokes amputation inischaemia:areview of 134cases. BrJSurg 1978;65: 135-7. Middleton M, Webster C. Clinical review of the Gritti Stokes amputation. BMJ 1962; ii: 574-6. Narang I, Mathur B, Singh P, Jape V. Functional capabilities of lower limb amputees. Prosther Orthor I n t 1984; 8: 43-51. Kald A, Carlsson R, Nilsson E. Major amputation in a defined population: incidence, mortality and results of treatment. Br J Surg 1989; 76: 308-10. Purry N, Hannon M. How successful is below-knee amputation for injury? Injury 1989; 20: 32-6. Statistics and Research Division of the DHSS. Amputation Statistics for England, Wales and Northern Ireland. London: HMSO, 1987. Steen Jensen J. Life expectancy and social consequences of through-kneeamputations. Prosthet Orthotlnt 1983; 7: 113-15.
Paper accepted 20 February 1992
Short note Br. J. Surg. 1992, Vol. 79, August, 755-756
Continuous ambulatory peritoneal dialysis in patients with aortic grafts J. D . T . Morgan, J.V.T.Tilsed, P. R . F. Bell*, P. S. Veitch and P. K. Donnelly Departments of Surgery, Leicester General Hospital and *Leicester Royal Infirmary, Leicester, UK Correspondence to: M r J. D. T. Morgan, Department of Surgery, Leicester General Hospital, Leicester LE5 4PW, UK
In the UK there are over 7600 patients maintained on dialysis for treatment of renal failure’; 56 per cent are managed by haernodialysis and 44 per cent by continuous ambulatory peritoneal dialysis (CAPD). Since its introduction’ in 1976, CAPD has found increasing application in these patients334. Many aetiological factors are common to both renal failure and peripheral vascular disease, and as dialysis is made available to an older population the incidence of dual pathology will increase. Aortic reconstruction using synthetic vascular grafts is an established surgical procedure and the avoidance of septic complications is of paramount importance because subsequent management is accompanied by high mortality and morbidity rates5. Patients undergoing long-term haemodialysis require surgical formation of an arteriovenous fistula for dialysis access6. In arteriopathic patients with poor vasculature the creation of a fistula may be impossible and such patients are more suitable for CAPD. However, there has been understandable reluctance to introduce CAPD catheters into the peritoneal cavity of a patient with an aortic graft because of the high
0007-1 323/92/080755-02
0 1992 Butterworth-Heinemann
Ltd
incidence of peritonitis associated with this form of dialysis7 and the subsequent risk of graft infection. Five patients with synthetic aortic grafts in whom end-stage renal failure was successfully managed using CAPD are reported.
Patients and methods There are currently 264 patients with end-stage renal failure being treated at Leicester General Hospital: 158 by CAPD and 106 by haemodialysis. There has been a policy in the past 3 years to use CAPD wherever possible in patients with aortic grafts. Six patients with a history of synthetic aortic reconstruction were identified in whom end-stage renal failure was managed using either CAPD (five patients) or haemodialysis (one). All the patients undergoing CAPD were men, with an age range of 36-69 (mean 59.2) years. Two had been maintained on dialysis before aortic surgery: one had undergone haemodialysis for 15 years, the other CAPD for 15 months. This patient was transferred for perioperative haemodialysis. In two patients renal failure was precipitated by aortic surgery. Although both of these had pre-existing renal disease, their aneurysms arose below the renal arteries. In the fifth patient renal failure occurred 7 years after aortic reconstruction. Patient details are summarized in Table 1. Vascular reconstruction was undertaken using a woven Dacron (Du Pont, Stevenage, U K ) prosthesis in all cases. Three patients received bifurcation grafts and two had straight grafts. In all patients undergoing aneurysm repair the wall of the aneurysm was closed around the graft. The aorta was reperitonealized in all but one case, in which this procedure was found to be technically impossible. All CAPD catheters were inserted using a standard procedure. Under general anaesthesia a short infraumbilical incision was made and the peritoneum approached via a longitudinal paramedian rectus abdominis split. The peritoneum was opened and a silicone peritoneal dialysis catheter with an extraperitoneal Dacron cuff (Quinton, Uxbridge, U K ) placed in the rectovesical pouch. The catheter was tunnelled subcutaneously away from the incision. All patients received antibiotic prophylaxis with 1.5 g cefuroxime intravenously on induction of anaesthesia. Minor difficulties arose from intra-abdominal adhesions both to the previous scar and within the pelvis; however, these did not prevent successful catheter placement.
755
A. D. Houghton, P. R . Taylor, S. Thurlow, E. Rootes and I. McColl Department of Surgery, Guy's Hospital, London SEI 9RT, UK Correspondence to: Lord McColl
Success rates for rehabilitation of vascular amputees: implications for preoperative assessment and amputation level All lower limb amputations performed during 1986 and 1988 in eight hospitals in the south-east region were assessed. Of 440 amputations f o r vascular disease, 193 were above-knee, 193 below-knee, 15 Gritti-Stokes, 15 through-knee and 24 bilateral. Of the 440 patients, 75 died in hospital, 113 were considered unsuitable f o r a prosthesis and 252 ( 5 7 per cent j were referred for prostheses. Rehabilitation questionnaires were sent to 179 patients ( 4 1 per cent), as a further 54 had died and 19 had become known non-wearers before the study commenced. The response rate was 81 per cent; 102 patients completed the questionnaire, 21 were reported dead, and 22 were non-wearers. Of a maximum rehabilitation score of 12, 52 patients scored 6 or more (consistent with mobility on their artijicial limb around the home), and 21 scored 9 or more ( a standard accepted as successful rehabilitation). It is concluded that 10-15per cent of amputees achieve mobility around the home on their prosthesis. Only 5 per cent, however, rehabilitate well and become independent of their wheelchair. When amputation is inevitable, more consideration should be given to surgery that optimizes wheelchair rehabilitation.
A total of 5000 lower limb amputations for vascular disease are performed annually in the UK', and below-knee ( B K ) amputation results in the best rehabilitation2-'. When a more proximal amputation is needed, the above-knee ( A K ) level is often preferred to more distal amputations, such as through-knee ( T K ) or Gritti-Stokes (GS), because of the high rate of successful primary healing and the cosmetically more attractive prosthesis*. However, there have been several recent studies suggesting that rehabilitation after T K amputation may be better than that a t the AK levelg-". After surgery, one of the main concerns is successful mobilization. However, many patients will never walk on an artificial limb, and realistic appraisal in these cases will judge a good wheelchair to be more appropriate than a prosthesis. This knowledge might affect amputation level. In the wheelchair-bound patient the G S amputation, with its long lever and good record of primary healing, is superior to the AK o p e r a t i ~ n ' ~ - ' ~ . Information on amputees under the care of the disablement services centres (DSCs) suggests that 50 per cent of them rehabilitate successfully and only 5 per cent are totally dependent on their wheelchairs' '*I5. Studies based on the DSCs are, however, inevitably biased towards current limb wearers, many of whom are young traumatic amputees who rehabilitate well. Very little is known about the outcome for more elderly amputees with vascular disease. How many are referred for prosthetic fitting and how many rehabilitate successfully? Are too many patients referred for prostheses? Should more GS or TK amputations be performed in patients who are likely to be wheelchair bound? Knowledge of the outcome of operations should help surgeons to tailor amputations to the needs of individual patients. This study was designed to answer the above questions.
revision was determined as was the number of patients dying while in hospital. The number of patients referred. from each hospital for prosthetic fitting was then assessed by access to the DSC notes. The reasons for patients not being referred for prosthetic fitting related to a mix of medical, social and psychological factors and were not studied in detail. By scrutiny of the DSC notes and from questionnaires it was determined how many patients had died o r become non-wearers since referral for prosthetic fitting. Questionnaires were then sent to all the recorded current limb wearers. Rehabilitation was assessed by the answers t o four standard questions: 1. Do you use your limb to walk: ( a ) less than 25 per cent of waking hours (score 0 ) ( b ) between 25 and 50 per cent of waking hours (score 1 ) ( c ) more than 50 per cent of waking hours (score 2 ) ( d ) all waking hours (score 3 ) 2. Do you use your limb to walk: ( a ) just when visiting your doctor o r limb-fitting centre (score 0 ) ( b ) at home but not to go outside (score 1 ) (c) outside the home on occasions (score 2 ) ( d j inside and outside all the time (score 3 ) 3. When going outside wearing your limb do you: (a) use a wheelchair (score 0 ) ( b ) use two crutches, two sticks or a walking frame (score 1 ) ( c ) use one stick (score 2 ) ( d ) use nothing (score 3) 4. When walking with your limb outside do you feel unstable when: ( a ) walking on the flat (No: score 1 ) ( b j walking on slopes (No: score 1 ) ( c ) walking on rough ground (No: score 1 ) (Yes to any of (a)-(c): score 0 ) (Amputees who used a wheelchair outside scored0 for this question.) The patients were also asked whether they had a wheelchair and for how many of their waking hours they used it. The answers to these questions were analysed to assess the patient's wheelchair dependence. Statistical differences between the types of amputation were assessed using the Mann-Whitney U test.
Patients and methods Operating theatre records were examined to determine the date and level of all amputations for vascular disease performed at eight hospitals in the south-east region for the periods January to December 1986, and January to December 1988. The number of amputations requiring
ooO7-1323/92/08075343 0 1992 Butterworth-Heinemann Ltd
Results In the 2 years studied, 440 vascular lower limb amputations were performed in the eight hospitals: 232 in 1986 and 208 in
753
Rehabilitation of vascular amputees: A. D. Houghton et al.
Table 1 Age distribution andnumber of the different ampuiation types Amputation
n
Median age (years)
Above-knee Below-knee Gritti-Stokes Through-knee Bilateral
193 193 15 15 24
72 70 79 81 72
(39-90) (39-93) (65-94) (44-90) (50-85)
Values in parentheses are ranges
Table 2 Age and rehabilitation of limb users responding to the questionnaire
Amputation
n
Median age (Years)
Above-knee Below-knee Gritti-Stokes Through-knee Bilateral
31 56 3 1 11
68 68 81 81 67
(50-85) (49-88) (78-86) (50-85)
Median rehabilitation score 4 (1-9) 6 (0-11) 9 (3-9) 7 1(1-10)
Values in parentheses are ranges
1988. Of 212 BK amputations (48 per cent), 19 failed to heal, resulting in a revised higher amputation. Of the 440 healed amputations, 193 were AK, 193 BK, 15 GS, 15 TK and 24 bilateral. The age distribution is shown in Table 1 . A total of 25 amputations had required revision (19 of which were BK to AK). Of the 440 patients, 75 (17 per cent) died without leaving hospital and 113 (26 per cent) were considered unsuitable for artificial limbs. There were 252 amputees (57 per cent) referred for prosthetic fitting. Before the start of the study, 54 patients in this group were known to have died and 19 had become non-wearers. The rehabilitation questionnaire was therefore sent to 179 patients. Information was received from 81 per cent of these, with 21 patients being reported dead, 22 to be non-wearers, and 102 filling in the questionnaire. Thus, of the original 252 referred for prosthetic fitting, 75 (30 per cent) had died (49 from 1986 and 26 from 1988) and 41 had become non-wearers (25 from 1986 and 16 from 1988). Of the original 440 patients, 102 (23 per cent ) completed the rehabilitation questionnaire, reporting on 31 AK, 56 BK, 11 bilateral, three GS and one TK amputations. The rehabilitation scores and age distribution of these patients are shown in Table 2. It should be noted that no reply was received from 19 per cent of patients, despite attempts to telephone and visit them at home. Rehabilitation
A score of 9 was accepted as satisfactory rehabilitation and one of 6 as indicating mobility on the prosthesis around the home; 52 patients scored 6 or more and 21 9 or more. Therefore, 12 per cent of the initial 440 amputees became mobile on their limb around the home, but only 5 per cent achieved satisfactory rehabilitation. Of the 177 amputees referred for limb fitting who were still alive, 29 per cent were mobile on their limb around the home and 12 per cent were satisfactorily rehabilitated. BK amputees performed better than AK ones. Of all the current limb wearers 55 per cent were BK and 30 per cent AK amputees (the original numbers of AK and BK amputees were the same). The remaining 15 per cent comprised bilateral (11 per cent), GS (3per cent) and TK (1 per cent). The numbers of these amputation types were too small to assess comDarative rehabilitation. Of the original 193 BK amputees, 31 (16 per cent) had a rehabilitation score of 6 or more and 5 Per cent of 9 or more. This compares with respective figures of 9 and 4 per cent for AK amputees. The BK amputees also had a higher median rehabilitation score, although this was
754
not statistically significant. Of the original 24 bilateral amputees, four (17 per cent) rehabilitated satisfactorily to a Score of 9 or more. Wheelchair use Of limb users, 91 per cent from 1986 and 96 per cent from 1988 possessed a wheelchair. Of these, 26 per cent never used it, 19 per cent used it for between one-quarter and half of their waking hours, 41 per cent used it for more than half of their waking hours, and 15 per cent used it all the time.
Discussion The numbers of patients who were satisfactorily rehabilitated in this study (5 per cent) and who became mobile around the home (12 per cent) are in agreement with the results of a previous Swedish study, in which 13 per cent of 126 amputees used their prosthesis 2 years after amputation16. These findings do, however, contrast with figures of around 50 per cent in other studies' ',which involved only limb wearers under the care of DSCs. In the current series all patients undergoing surgery were followed, and the much lower rates of successful rehabilitation take into account those who died or were not referred to DSCs. This emphasizes that amputees comprise two distinct groups: relatively fit and often young traumatic patients who survive for a long time and rehabilitate well", and older medically unfit amputees with vascular disease and a poor prognosis. In the present series, the median age of the amputees was 70 years or more. Although amputation for trauma comprises only 7 per cent of all operations", because of the long survival in this group it represents over 50 per cent of amputees under the care of DSCs". Only half of the amputees in the present series were referred for prosthetic fitting, and two-thirds of these either died within 3 years or did not wear their artificial limb. Almost twice as many BK amputees became mobile around the home on their prosthesis as AK amputees. This supports the conclusion from other series that the knee joint should be preserved wherever Very few TK or GS amputations were performed in this study and no conclusions can be drawn regarding these. We believe that realistic advice on prostheses before surgery is very important for the vascular patient, who should be assessed before operation by an amputation team that includes a physiotherapist and an occupational therapist. The presence of arthritis, gait abnormality or neurological deficit might contribute to non-referral for limb fitting. It should be possible to develop criteria that will help to predict whether a patient will achieve successful mobilization on a prosthesis. These could then be used as guidelines for the surgeon and patient in deciding the level of amputation. After operation, every effort should be made to avoid delays in mobilization and rehabilitation7. If the intention is to fit a prosthesis, BK amputation is preferred to all other levels. If this is impossible, consideration should be given to the TK procedure. In many patients poor blood supply contraindicates both the BK and TK levels, but a few may still be suitable for TK amputation. The TK operation has fallen into disrepute because of its lower primary healing rate compared with the AK level. It does, however, have certain advantages, including a lower in-hospital and subsequent mortality rate", increased stability when transferring and sitting, reduced dependence on long-term nursing care", and better rehabilitation on a total end-bearing stump9-' '. If prosthetic fitting is not considered appropriate, the longer stump of the GS or TK amputation may be preferable to the standard AK amputation. Of these two, the GS is preferable as the primary healing rate is superior' 2-1 4. '3'
References 1.
Ratcliffe D, Clyne C, Chant A, Webster J. Prediction of amputation wound healing: the role of transcutaneous PO, assessment. Br J Surg 1984; 74: 219-22.
Br. J. Surg.. Vol. 79, No. 8, August 1992
Rehabilitation of vascular amputees: A. D. Houghton et al.
Francis W, Renton C . Mobility after major limb amputation for arterial occlusive disease. Prosthet Orthot Inr 1987; 11: 85-9. 3. Harrison JD, Southworth S,Callum K. Experience with the ‘skew flap’ below-knee amputation. Br J Surg 1987; 74: 930-1. 4. Campbell W, Morris P. A prospective randomised comparison of healing in Gritti-Stokes and through-knee amputations. Ann R Coll Surg Engl 1986; 68: 1-4. 5. Couch N, David J, Tilney N, Crane C. Natural history of the leg amputee. Am J Surg 1977; 133: 469-73. 6. Fyfe N. An audit of amputation levels in patients referred for prosthetic rehabilitation. Prosthet Orthot Int 1990; 14: 67-70. 7. Pohjolainen T, Alaranta H, Wikstrom J. Primary survival and prosthetic fitting of lower limb amputees. Prosthet Orthot I n t 1989; 13: 63-9. 8. Harris W. Lower limb amputation in elderly patients. Can 7 Surg 1987; 30: 315. 9. Baumgartner R. Failures in through knee amputation. Prosthet Orthot I n t 1983; 7: 116-18. 10. Moran B, Buttenshaw P, Mulcahy M, Robinson K. Throughknee amputation in high-risk patients with vascular disease: indications, complications and rehabilitation. Br J Surg 1990; 77: I 118-20. 11. Houghton A, Allen A, Luff R, McColl I. Rehabilitation after lower limb amputation: a comparative study of above-knee, 2.
12. 13. 14. 15. 16. 17. 18. 19.
through-knee and Gritti-Stokes amputations. Br J Surg 1989; 76: 622-4. Sethia K, Berry A, Morrison J, Collin J, Murie J, Morris P. Changing pattern of lower limb amputation for vascular disease. Br J Surg 1986; 73: 701-3. Doran J, Hopkinson B, Makin G . The Gritti-Stokes amputation inischaemia:areview of 134cases. BrJSurg 1978;65: 135-7. Middleton M, Webster C. Clinical review of the Gritti Stokes amputation. BMJ 1962; ii: 574-6. Narang I, Mathur B, Singh P, Jape V. Functional capabilities of lower limb amputees. Prosther Orthor I n t 1984; 8: 43-51. Kald A, Carlsson R, Nilsson E. Major amputation in a defined population: incidence, mortality and results of treatment. Br J Surg 1989; 76: 308-10. Purry N, Hannon M. How successful is below-knee amputation for injury? Injury 1989; 20: 32-6. Statistics and Research Division of the DHSS. Amputation Statistics for England, Wales and Northern Ireland. London: HMSO, 1987. Steen Jensen J. Life expectancy and social consequences of through-kneeamputations. Prosthet Orthotlnt 1983; 7: 113-15.
Paper accepted 20 February 1992
Short note Br. J. Surg. 1992, Vol. 79, August, 755-756
Continuous ambulatory peritoneal dialysis in patients with aortic grafts J. D . T . Morgan, J.V.T.Tilsed, P. R . F. Bell*, P. S. Veitch and P. K. Donnelly Departments of Surgery, Leicester General Hospital and *Leicester Royal Infirmary, Leicester, UK Correspondence to: M r J. D. T. Morgan, Department of Surgery, Leicester General Hospital, Leicester LE5 4PW, UK
In the UK there are over 7600 patients maintained on dialysis for treatment of renal failure’; 56 per cent are managed by haernodialysis and 44 per cent by continuous ambulatory peritoneal dialysis (CAPD). Since its introduction’ in 1976, CAPD has found increasing application in these patients334. Many aetiological factors are common to both renal failure and peripheral vascular disease, and as dialysis is made available to an older population the incidence of dual pathology will increase. Aortic reconstruction using synthetic vascular grafts is an established surgical procedure and the avoidance of septic complications is of paramount importance because subsequent management is accompanied by high mortality and morbidity rates5. Patients undergoing long-term haemodialysis require surgical formation of an arteriovenous fistula for dialysis access6. In arteriopathic patients with poor vasculature the creation of a fistula may be impossible and such patients are more suitable for CAPD. However, there has been understandable reluctance to introduce CAPD catheters into the peritoneal cavity of a patient with an aortic graft because of the high
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incidence of peritonitis associated with this form of dialysis7 and the subsequent risk of graft infection. Five patients with synthetic aortic grafts in whom end-stage renal failure was successfully managed using CAPD are reported.
Patients and methods There are currently 264 patients with end-stage renal failure being treated at Leicester General Hospital: 158 by CAPD and 106 by haemodialysis. There has been a policy in the past 3 years to use CAPD wherever possible in patients with aortic grafts. Six patients with a history of synthetic aortic reconstruction were identified in whom end-stage renal failure was managed using either CAPD (five patients) or haemodialysis (one). All the patients undergoing CAPD were men, with an age range of 36-69 (mean 59.2) years. Two had been maintained on dialysis before aortic surgery: one had undergone haemodialysis for 15 years, the other CAPD for 15 months. This patient was transferred for perioperative haemodialysis. In two patients renal failure was precipitated by aortic surgery. Although both of these had pre-existing renal disease, their aneurysms arose below the renal arteries. In the fifth patient renal failure occurred 7 years after aortic reconstruction. Patient details are summarized in Table 1. Vascular reconstruction was undertaken using a woven Dacron (Du Pont, Stevenage, U K ) prosthesis in all cases. Three patients received bifurcation grafts and two had straight grafts. In all patients undergoing aneurysm repair the wall of the aneurysm was closed around the graft. The aorta was reperitonealized in all but one case, in which this procedure was found to be technically impossible. All CAPD catheters were inserted using a standard procedure. Under general anaesthesia a short infraumbilical incision was made and the peritoneum approached via a longitudinal paramedian rectus abdominis split. The peritoneum was opened and a silicone peritoneal dialysis catheter with an extraperitoneal Dacron cuff (Quinton, Uxbridge, U K ) placed in the rectovesical pouch. The catheter was tunnelled subcutaneously away from the incision. All patients received antibiotic prophylaxis with 1.5 g cefuroxime intravenously on induction of anaesthesia. Minor difficulties arose from intra-abdominal adhesions both to the previous scar and within the pelvis; however, these did not prevent successful catheter placement.
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