5 December 2005

Ossur Scientific E-letter Issue #2 2005

Dear readers,

The last issue of the Ossur Scientific E-letter of 2005 includes seven different scientific papers related to the field of the treatment of amputees. The articles cover the subjects of amputation, postoperative treatment, rehabilitation, prosthetics/biomechanics and quality management. Five of the selected papers have been published in 2005, one 2004 and one in 2000.

Amputation

Risk factors for major limb amputations in diabetic foot gangrene patients Susumu Miyajima, , Akira Shirai, Shiori Yamamoto, Natsuko Okada and Tetsuya Matsushita

Diabetes Res Clin Pract. 2005 Aug 30 In Press, Corrected Proof.

With the aim to investigate the risk factors for major limb amputations Susumu et al performed a retrospective study on 210 diabetic foot lesion patients treated over the past 9 years.

They found that arteriosclerosis obliterans with multiple stenosis, haemodialysis and HbA1c were independent risk factors for major amputation. The 3-year survival rate was 24.1% in the major amputation group and 93.0% in the minor or non-amputation group, and the life expectancy was significantly lower for the major amputees than the minor or non-amputees.

To avoid major amputation this study concluded that it is important with early detection and treatment of foot lesions, good blood glucose control and early management of systemic complications such as nephropathy and arteriosclerosis.

Reamputation, mortality, and health care costs among persons with dysvascular lower-limb amputations
Timothy R. Dillingham M , Liliana E. Pezzin PhD and Andrew D. Shore PhD

Archives of Physical Medicine and Rehabilitation Volume 86, Issue 3 , March 2005, Pages 480-486

Despite considerable information on the incidence of dysvascular limb loss, little is known about the rate of reamputations in a broader population and the progression to amputation in higher levels and mortality. To find that information Dillingham et al performed a national retrospective cohort study of a total of 3565 persons, who underwent lower limb amputation in a period of twelve months during 1996. They also wanted to investigate the medical care costs for this group.

During that year 26% of the group required subsequent amputation, more than one third died within 1 year of their first amputation. The cost of acute and post acute medical care together with the cost for beneficiaries exceeded $4.3 billion yearly.

Differences in patient characteristics, progression of amputation to higher levels, use of service and mortality among the dysvascular amputees were investigated with and without the comorbidity of diabetes. Younger amputees, more men, patients with more comorbidities and a higher rate of a progression to a higher level of amputation were found in the diabetic group compared to the dysvascular group without diabetes. Further the authors found that the diabetic patients were less likely to die within twelve months of their first amputation, though it was found they died in a significantly younger age than the non-diabetic group. If the initial amputation was at the foot or ankle it was a higher rate of a subsequent amputation at a higher level.

Postoperative

Early treatment of trans-tibial amputees: retrospective analysis of early fitting and elastic bandaging.
van Velzen AD, Nederhand MJ, Emmelot CH, Ijzerman MJ.
Prosthet Orthot Int. April 2005;29(1):Pages 3-12.

Van Velzen et al performed a study to explore the effects of early fitting in transtibial amputees. They assumed that rigid early dressing would result in quicker wound healing and thereby an earlier ambulation compared to elastic bandaging. To prove their assumption a retrospective file search on 145 persons was carried out in three different hospitals, which each used different postoperative care; elastic bandaging; plaster cast immediate applicated postoperatively and delayed application of the plaster cast (within one week post amputation). The study group analysed the time to the first prosthesis, the incidence of complications (general and local) and the functional outcome after discharge of the hospital. A significantly decreased time from amputation to the first regular prosthesis (110 days vs. 50 days) was found in the group treated with rigid dressing (early or delayed) and a decreased risk of knee flexion contractures. An increase in pressure sores in other places than the stump was observed in the early fitting group. Delayed fitting was associated with a higher risk of reamputation.

The authors concluded that their study indicates that early fitting by rigid dressing is the best treatment of trans-tibial amputees. If it is possible to apply a plaster cast in the operating room they prefer the immediate fitting method.

Rehabilitation

Use and satisfaction with prosthetic limb devices and related services
Liliana E. Pezzin PhD, Timothy R. Dillingham MD, MS, Ellen J. MacKenzie PhD, Patti Ephraim MPH and Paddy Rossbach RN

Arch Phys Med Rehabil. 2004 May;85(5):723-9

To examine the use and satisfaction with prosthetic limb devices and satisfaction with prosthetists' services a retrospective cohort study of 935 persons, with major upper or lower limb loss in USA was performed by Pezzin et al. The test subjects were structurally telephone interviewed.

A significantly higher frequency of using and satisfaction with the prosthesis were found among those amputees with shorter timing to first prosthesis fitting. Other contributing factors, like sociodemographic and amputation characteristics did not affect that significant result.

94% of the group used their prosthesis extensively (71h/week).
75,7% were satisfied with their overall performance of their prosthesis.
Nearly 1/3 expressed dissatisfaction with the comfort of the prosthesis.

No significant differences in prosthesis use, satisfaction, or assessment of prosthetists' quality based on the etiology of the amputation or the level of the amputation were seen.

Generally the amputees had positive assessment of their prosthesists' qualification. Though less favourable ratings were related to the prosthetists' interpersonal skills. By performing a multivariate analyses it was found that men and black persons had less positive perceptions about their prosthetist across all dimensions of provider quality, compared to the female or white counterparts. Test subjects with fewer years of schooling were also less satisfied with their prosthetists' interpersonal manner.

Pezzin et al concluded that efforts should be directed to minimize the time from amputation to the fitting of the first prosthesis. They also stated the importance of good communication between patients and prosthetists in order to improve the quality of care.

Prosthetics/biomechanics

A clinical comparison of variable-damping and mechanically passive prosthetic knee devices.
Johansson JL, Sherrill DM, Riley PO, Bonato P, Herr H.

Am J Phys Med Rehabil. 2005 Aug;84(8):563-75.

Johansson et al performed a randomized controlled trial on two variable damping knees; the hydraulic-based Otto Bock C-leg and the magnetorheological-based Ossur Rheo with the mechanically passive, hydraulic-based Mauch SNS. The aim of the study was assess the advantages of variable-damping knee prostheses over mechanically passive prostheses to transfemoral amputees in self-selected walking speed.

For each prosthesis, metabolic, kinematic, and electromyographic data were collected on eight unilateral amputees walking at self-selected speeds at an indoor track and a 10-m walkway in a laboratory.

When using the rheo it was found that the metabolic rate decreases by 5% compared with the Mauch and by 3% compared with the C-leg. Also biomechanical advantages was seen for the C-leg and Rheo knee devices, compared to the mechanically passive Mauch. The results showed an improved smoothness of gait, a reduced hip work production, a lower peak hip flexion moment at terminal stance, and a decrease in peak hip power generation at toe-off.

The authors concluded that the results of their study indicate that variable-damping knee prostheses offer advantages over mechanically passive designs for unilateral transfemoral amputees walking at self-selected ambulatory speeds, they further suggest that a magnetorheological-based system may have advantages over hydraulic based designs.

Quality management

Errors in health care management: what do they cost? Rigby K D, Litt J C B

Quality in Health Care 2000;9: 216-221

Rigby and Litt wanted to determine the direct costs associated with iatrogenic injuries (=unintended or unnecessary harm or suffering arising from any aspect of health care management) occurring in a hospital setting. They used an Australian and an American report of health care quality, found to be a representative national source of information on the incidence, disability, and preventability of iatrogenic injuries. Costs were calculated using information from Australian disease related groups relative to the injury categories.

The result gave the cost of just 12 preventable iatrogenic injuries to be significant - 0.25 million US dollars. Those facts show that costing iatrogenic injuries is an important component of the impact of these events. The authors mean it is important identifying the incidence of these injuries, monitoring trends, and providing data for cost estimates and economic evaluations.

The contribution of measurement and information infrastructure to TQM success Taylor W A, Wright G H.

Omega, Volume 34, Issue 4, August 2006, Pages 372-384. Available online 11th February 2005.

Taylor and Wright performed a study to find facts contributing to the debate if TQM practices such as leadership, human resource management, and customer focus have more impact than benchmarking, process analysis or performance measurement. Their central hypothesis was that measurement and performance outcome was essential for TQM success.

They analysed the measurement of 67 TQM firms in practices in a longitudinal cohort study, and reported the changes in their measurement behaviour over time. They analyzed seven measurement dimensions relating to customer satisfaction, employee satisfaction, process performance, impact of TQM on costs, impact of TQM on sales, self-assessment, and benchmarking. Based on how many of these seven parameters were measured, the authors calculate a measurement-intensity score for each firm.

The result clearly showed that increased measurement intensity is strongly associated with perceived TQM success. The authors concludes that to achieve the highest levels of TQM success, it is important to engage in the measurement practices of self-assessment and benchmarking, their data suggest that an appropriate measurement framework needs to be in place beforehand.

Empower Health Care Solutions wish you all the best for the coming holidays and is looking forward to provide you interesting scientific news in February 2006!

Best regards,
Louise Klevbo