背景:研究表明,下肢大截肢(LEA)后的下床活动低,而LEA后的死亡率高。LEA后成功的假肢安装具有显着的生活质量效益,然而,目前尚不清楚LEA后死亡率是否有获益.我们的目的是检查接受LEA治疗的当代患者队列,并确定是否适合假体与死亡率之间存在关联。
方法:我们回顾了2015年至2022年在一个大城市的两个学术医疗保健系统中接受LEA的所有患者。感兴趣的暴露是LEA后的假体装配。主要结果是随访1年和3年内的死亡率。LEA后的步行被定义为有或没有辅助设备的步行。排除先前患有LEA的患者。使用具有时间依赖性暴露的扩展Cox模型来评估1年和3年随访时假体安装与死亡率之间的关系。
结果:在702名接受LEA的患者中,平均(SD)年龄为64.3(12.6)岁,有329(46.6%)适合假肢。研究人群主要是男性(n=488,69.5%),主要是非西班牙裔黑人(n=410,58.4%),在LEA之前,近五分之一的人无法走动(n=139,19.8%)。值得注意的是,14.3%的受试者在LEA后的某个时间点不能走动,术前不能走动的患者中,有28.5%在LEA后最终可以走动。在接受假肢的人中,1年的死亡率为12.0/100人年,在3年的随访中,死亡率为5.8/100人年,而在未接受假肢的人中,在1年和3年的随访中,死亡率分别为55.7/100人年和50.7/100人年,分别。在调整了几个社会人口统计学数据点后,合并症,COVID大流行前或后的时间框架,和程序因素,假肢安装与随访1年内(校正后风险比[aHR]0.24;95%CI,0.14-0.40)和3年内(aHR0.40;95%CI,0.29-0.55)死亡率降低相关.
结论:假体拟合与提高生存率相关,术前功能状态并不总是预测术后功能状态。表征患者,外科,与LEA后接受假体相关的康复因素可能会改善这些患者的长期生存率。VA采用的工艺措施,例如对所有截肢者的假肢部门评估,可能代表“最佳实践”。
BACKGROUND: Studies suggest that ambulation after major lower extremity amputation (LEA) is low and mortality after LEA is high. Successful prosthetic fitting after LEA has a significant quality of life benefit; however, it is unclear if there are benefits in post-LEA mortality. Our objective was to examine a contemporary cohort of patients who underwent LEA and determine if there is an association between fitting for a prosthetic and mortality.
METHODS: We reviewed all patients who underwent LEA between 2015 and 2022 at two academic health care systems in a large metropolitan city. The exposure of interest was prosthetic fitting after LEA. The primary outcomes were mortality within 1 and 3 years of follow-up. Ambulation after LEA was defined as being ambulatory with or without an assistive device. Patients with prior LEA were excluded. Extended Cox models with time-dependent exposure were used to evaluate the association between prosthetic fitting and mortality at 1 and 3 years of follow-up.
RESULTS: Among 702 patients who underwent LEA, the mean (SD) age was 64.3 (12.6) years and 329 (46.6%) were fitted for prosthetic. The study population was mostly male (n = 488, 69.5%), predominantly non-Hispanic Black (n = 410, 58.4%), and nearly one-fifth were non-ambulatory before LEA (n = 139 [19.8%]). Of note, 14.3% of all subjects who were nonambulatory at some point after LEA, and 28.5% of patients not ambulatory preoperatively were eventually ambulatory after LEA. The rate of death among those fitted for a prosthetic was 12.0/100 person-years at 1 year and 5.8/100 person-years at 3 years of follow-up; among those not fitted for a prosthetic, the rate of death was 55.7/100 person-years and 50.7/100 person-years at 1 and 3 years of follow-up, respectively. After adjusting for several sociodemographic data points, comorbidities, pre- or post- coronavirus disease 2019 pandemic timeframe, and procedural factors, prosthetic fitting is associated with decreased likelihood of mortality within 1 year of follow-up (adjusted hazard ratio, 0.24; 95% confidence interval, 0.14-0.40) as well as within 3 years (adjusted hazard ratio, 0.40; 95% confidence interval, 0.29-0.55).
CONCLUSIONS: Prosthetic fitting is associated with improved survival, and preoperative functional status does not always predict postoperative functional status. Characterizing patient, surgical, and rehabilitation factors associated with receipt of prosthetic after LEA may improve long-term survival in these patients. Process measures employed by the Department of Veterans Affairs, such as prosthetic department evaluation of all amputees, may represent a best practice.