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Correlations with Patients' Perspectives of the Result of Lower-Extremity Amputation*
Susanna L. Matsen, B.S.†; Dee Malchow, R.N.‡; Frederick A. MatsenIII, M.D.†
View Disclosures and Other Information
Investigation performed at the Department of Orthopaedics, University of Washington, and Harborview Medical Center, Seattle, Washington
*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.
†Department of Orthopaedics, University of Washington, Box 356500, 1959 N.E. Pacific, Seattle, Washington 98195-6500.
‡Department of Orthopaedics, Harborview Medical Center, Box 359798, 325 Ninth Avenue, Seattle, Washington 98104.

The Journal of Bone & Joint Surgery.  2000; 82:1089-1089 
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Abstract

Background: Patients' perceptions of the result of lower-extremity amputation vary widely, yet the factors associated with this variability are not well understood. Our objective was to identify important correlations with the perceived result that may help to indicate the factors that deserve particular emphasis in the management of patients who have had an amputation.

Methods: In this retrospective study, 148 patients who had had a major lower-extremity amputation completed a standardized questionnaire designed to assess the demographic characteristics, comorbidities, amputation characteristics, prosthetic function, and social function at a mean of seven years after surgery. We correlated each of these variables with four result metrics: general satisfaction, quality of life, freedom from frustration, and walking distance.

Results: The four result metrics were significantly and strongly correlated with (1) the comfort of the residual limb; (2) the condition of the contralateral limb; (3) the comfort, function, and appearance of the prosthesis; (4) social factors; and (5) the ability to exercise recreationally (p < 0.0001). Interestingly, the level and laterality of the amputation were not significantly correlated with the patients' perceived result.

Conclusions: The perceived result of amputation is not associated with the amount of the limb that was amputated but rather with factors that may be optimized by surgical, prosthetic, and social management.

Figures in this Article
    Lower-extremity amputation involves removal of parts of the limb that are necessary for walking and basic social function. The goal of modern management of patients who have had an amputation is to restore the form and function of the limb in a way that optimizes quality of life. Previous investigators have explored some of the factors that are potentially associated with the result of lower-extremity amputation1-16; however, little attention has been directed at understanding the many factors that affect the result as perceived by the patient.
    We hypothesized that patient satisfaction and quality of life following an amputation are correlated with a complex of variables, including those related to the individual's demographic characteristics, comorbidities, the amputation itself, symptoms in the residual limb, functioning of the prosthesis, and social factors. We obtained data from a population of 148 patients who had had a lower-extremity amputation and correlated these variables with four patient-assessed metrics: general satisfaction, quality of life, walking distance, and infrequency of frustration.
     
    Anchor for JumpAnchor for Jump
    +Fig. 1:Graph showing the distribution of responses with regard to the quality of life.
     
    Anchor for JumpAnchor for Jump
    +Fig. 2:Graph showing the distribution of responses with regard to general satisfaction.
     
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    +Fig. 3:Graph showing the distribution of responses with regard to the infrequency of frustration.
     
    Anchor for JumpAnchor for JumpTABLE I:  Demographic Characteristics of the One Hundred and Forty-eight Patients Who Had a Lower-Extremity Amputation
    *The values are given as the mean and the standard deviation.
    Male (percent)72
    Age* (yrs.)  50.1 ± 16.2
    Height* (in. [cm])  69 ± 10 (175 ± 25)
    Weight with prosthesis* (lbs. [kg])181 ± 50 (82 ± 23)
    Weight without prosthesis* (lbs. [kg])176 ± 44 (80 ± 20)
    Married (percent)54
     
    Anchor for JumpAnchor for JumpTABLE II:  Comorbidities in the One Hundred and Forty-eight Patients Who Had a Lower-Extremity Amputation*
    *Some patients had more than one comorbidity.
    TypePercent of Patients
    Type-I diabetes  4
    Type-II diabetes16
    Lung disease  5
    Heart disease  8
    Vascular disease22
    Use of prescription medications64
     
    Anchor for JumpAnchor for JumpTABLE III:  Side and Level of Amputation in the One Hundred and Forty-eight Patients Who Had a Lower-Extremity Amputation*
    *Eighty-seven percent of the patients had had a unilateral amputation.
    RightLeft
    Side of amputation (percent)5954
    Level of amputation (percent)
      Transmetatarsal  1  4
      Ankle disarticulation   1  0
      Syme  4  2
      Long below-the-knee  3  3
      Mid-diaphyseal below-the-knee1719
      Short below-the-knee  911
      Knee disarticulation   9  1
      Long above-the-knee  7  5
      Mid-diaphyseal above-the-knee  5  5
      Short above-the-knee  2  2
      Hip disarticulation   1  2
     
    Anchor for JumpAnchor for JumpTABLE IV:  Reason for Amputation*
    *The values are given as the percent of patients. Some patients listed more than one reason for the amputation.
    Right SideLeft Side
    Injury5049
    Infection1825
    Birth defect17  7
    Vascular disease1111
    Diabetes11  9
    Tumor  4  0
     
    Anchor for JumpAnchor for JumpTABLE V:  Interdependence of Result Metrics
    *P < 0.0001 for all correlation coefficients.
    Correlation Coefficient*
    General satisfaction and quality of life0.667
    General satisfaction and walking0.528
    General satisfaction and infrequency of frustration0.662
    Quality of life and walking distance0.513
    Quality of life and infrequency of frustration0.525
    Walking distance and infrequency of frustration0.396
     
    Anchor for JumpAnchor for JumpTABLE VI:  Correlation of Perceived Result with Comorbidities
    *P < 0.0001 for all correlation coefficients.
    Perceived ResultComorbidityCorrelation Coefficient*
    General satisfactionCondition of contralateral limb  0.447
    Quality of lifeCondition of contralateral limb  0.489
    Walking distanceVascular disease-0.428
    Use of prescription medications-0.431
    Condition of contralateral limb  0.484
     
    Anchor for JumpAnchor for JumpTABLE VII:  Scores for Perceived Result According to Level and Laterality of Amputation*
    *The values are given as the mean score, with the standard deviation given for groups of ten patients or more who had had an amputation at the same level. The values for the unilateral amputations are given as right/left amputation.
    Level of Amputation General Satisfaction (points)Quality of Life (points)Walking Distance (points)Infrequency of Frustration (points)
    Unilateral
      Transmetatarsal-/3.6-/3.8-/3.7-/4.1
      Ankle disarticulation 2.5/-4.0/-5.0/-2.5/-
      Syme3.2/5.04.0/5.04.0/5.02.6/4.0
      Long below-the-knee4.6/3.24.5/4.14.7/4.03.5/2.8
      Mid-diaphyseal below-the-knee3.4 ± 1.2/3.8 ± 1.23.6 ± 1.1/3.7 ± 1.03.4 ± 1.2/3.9 ± 0.73.6 ± 1.1/3.5 ± 1.1
      Short below-the-knee2.8 ± 1.3/3.8 ± 0.82.9 ± 1.0/3.7 ± 0.93.0 ± 1.1/3.7 ± 0.93.2 ± 1.0/3.4 ± 1.1
      Knee disarticulation 3.3 ± 1.1/3.03.1 ± 0.9/3.03.5 ± 1.1/3.02.9 ± 0.8/3.0
      Long above-the-knee2.9/2.52.8/2.63.4/2.83.3/2.2
      Mid-diaphyseal above-the-knee3.9/3.03.9/2.73.6/2.83.6/3.1
      Short above-the-knee5.0/3.35.0/3.82.5/4.04.0/2.8
      Hip disarticulation 3.3/2.54.3/3.33.0/3.02.3/2.0
    Bilateral3.4 ± 1.23.6 ± 1.23.1 ± 1.33.4 ± 1.3
     
    Anchor for JumpAnchor for JumpTABLE VIII:  Correlation of Perceived Result with Variables Related to the Prosthesis*
    *The values are given as the correlation coefficient, with a positive value indicating a positive feature of the prosthesis. Each of the correlation coefficients was found to be significant (p < 0.0001).
    General SatisfactionQuality of LifeWalking DistanceInfrequency of Frustration
    Fit0.482-0.5540.457
    Comfort0.514-0.5350.504
    Ability to balance--0.5440.408
    Ease of application0.509-0.4350.560
    Appearance0.414---
    Clothing limitations0.5250.4640.4900.518
    Shoe limitations0.4980.4980.4020.413
    Ability to walk in close spaces0.5370.4730.5650.508
    Ability to walk on slippery surfaces0.4960.5430.6390.549
    Ability to walk with load0.5640.6010.7290.550
    Ability to walk up stairs0.4580.5400.5620.447
    Ability to get in or out of automobile0.5220.502-0.580
     
    Anchor for JumpAnchor for JumpTABLE IX:  Correlation of Perceived Result with Social Variables*
    *The values are given as the correlation coefficient, with a positive value indicating a positive feature of the social function. Each of the correlation coefficients was found to be significant (p < 0.0001).
    General SatisfactionQuality of LifeWalking DistanceInfrequency of Frustration
    Comfortable with strangers0.412--0.445
    No burden on family-0.492-0.501
    Ability to provide care for others0.5310.5820.5840.457
    Hours prosthesis worn--0.687-
    Freedom from walking aids--0.5210.425
    Ability to perform aerobic exercise--0.448-
    Ability to run-0.4260.565-
    Our medical center database includes data on patients who had had an amputation as long ago as 1920. We reviewed this database through 1998 and identified 1180 patients who had had lower-extremity amputation ranging from the hip level to the transmetatarsal level. Upon approval of the study by the Human Subjects Review Committee at our institution, we mailed a self-assessment questionnaire and a consent form to 1035 of these patients for whom we could identify an address (although we did not know if it was current). One hundred and forty-eight patients responded and consented to participate in the present study. No attempt was made to locate the patients who had not responded.
    Each of the 148 patients completed a five-page self-assessment packet with questions on his or her demographic characteristics, comorbidities, reason for the amputation, level of the amputation, quality of the residual limb (comfort, swelling, skin condition, phantom pain, and so on), and social function (the desire to avoid strangers, the family's reaction, the burden on the family, the ability to provide care for others, interactions with providers and with other individuals with an amputation, basic ambulatory functions, and so on), prosthetic function, and quality of life9 (Table I, Table II, Table III, and Table IV).
    Four result metrics were used, and each was graded by the patient with use of a 5-point visual analog scale, with 1 point indicating the worst outcome and 5 points indicating the best outcome. The questions, with the range of possible responses in parentheses, were: (1) "How satisfied have you been with how things have worked out since your amputation?" ("extremely dissatisfied" to "extremely satisfied"); (2) "How is your quality of life?" ("worst possible life" to "best possible life"); (3) "How frequently have you been frustrated with your prosthesis?" ("all of the time" to "never"); and (4) "How far can you walk comfortably?" ("cannot walk" to "five miles or farther").
    We explored the relationship between the four result metrics and the demographic, comorbidity, amputation, residual-limb, prosthetic, and social variables by determining the correlation coefficients and applying Fisher's r-to-z test for significance. The threshold for a meaningful correlation was set at a correlation coefficient value of 0.4, and the level of significance was set at p < 0.005 in consideration of the multiple comparisons that were examined. The data were compared with Statview statistical software (version 5.0.1; SAS Institute, Cary, North Carolina).
    In general, the patients characterized the results in positive terms. The mean score (and standard deviation) on the visual analog scale was 3.4 ± 1.2 points for general satisfaction, 3.5 ± 1.1 points for quality of life, 3.3 ± 1.1 points for infrequency of frustration, and 3.5 ± 1.1 points (between one block and one mile [1.6 kilometers]) for walking distance. However, substantial variability among the respondents with respect to the perceived result was demonstrated by large standard deviations (which were approximately 30 percent of the mean) and broad ranges (which included the lower and upper extremes for each of the result metrics) (Fig. 1, Fig. 2, and Fig. 3). For example, 7 percent of the patients were not able to walk, 11 percent could walk inside the house, 29 percent could walk one city block, 34 percent could walk up to one mile, and 18 percent could walk five miles (eight kilometers) or farther.
    The four result metrics were strongly correlated with each other; thus, they were not independent characterizations of a successful outcome (Table V). However, none of the correlation factors were greater than 0.667, and therefore general satisfaction, quality of life, walking distance, and infrequency of frustration each capture somewhat different elements of the patient's perceived result. We analyzed the correlations between each of these metrics and the demographic, amputation, comorbidity, prosthetic, residual-limb, and social variables.

    Correlation of Perceived Result with the Variables

    Demographic Characteristics

    Only the age of the patient met our standard for meaningful and significant correlation with walking distance (correlation coefficient, -0.44; p < 0.0001). None of the other demographic variables were correlated (that is, none had a correlation coefficient of at least 0.4 and a p value of less than 0.005) with any result metric.

    Comorbidities

    Vascular disease, use of prescription medications, and the condition of the contralateral limb were correlated with walking distance; in addition, the condition of the contralateral limb was correlated with the quality of life and general satisfaction (Table VI).

    Level and Laterality of the Amputation

    It was of great interest that the four result measures were not strongly correlated with the level of amputation or even with the unilateral or bilateral nature of the amputation (Table VII). General satisfaction, quality of life, walking distance, and infrequency of frustration were not significantly different for the different levels of amputation. The perceived result measures for patients who had had a bilateral amputation were similar to those of the patients who had had a unilateral amputation.

    Other Variables Related to the Amputation

    The comfort of the residual limb was the only amputation variable that was strongly correlated with general satisfaction (correlation coefficient, 0.625; p < 0.0001) and infrequency of frustration (correlation coefficient, 0.587; p < 0.0001). Some other variables (such as quality of the skin, phantom pain, and limb swelling) had significant correlations with the result metrics, but the coefficients were less than 0.4.

    Prosthestic Variables

    Among all of the categories, the one with the most variables that were correlated with the result metrics was the prosthetic category - that is, the comfort, appearance, and function of the prosthesis and the ability of the individual to perform the basic functions of daily life with use of the affected extremity (Table VIII).

    Social Variables

    Analysis of the variables related to social interaction revealed many strong correlations with the result metrics (Table IX). Patients were more likely to perceive a positive result if they felt comfortable being active in the presence of strangers, did not consider themselves a burden on their family, could provide care for others, experienced few frustrating events, and perceived a positive change in their lifestyle. The ability to exercise recreationally, to wear the prosthetic limb for longer times, and to be free of crutches or a cane also had a strong, positive correlation with the perceived result.
    On the whole, the patients in the present study characterized the amputation and the prosthetic management as moderately successful in terms of the result metrics for general satisfaction, quality of life, walking distance, and infrequency of frustration. While these measures were highly intercorrelated, each reflected a somewhat different perspective on the result of the amputation.
    The variability in the patients' responses was striking, spanning the full range for each of the result metrics and with standard deviations approaching one-third of the mean for each measure. The purpose of our study was to identify some of the factors that correlated with a more successful result after amputation and prosthetic management.
    We used the Prosthesis Evaluation Questionnaire9 as well as questions on demographic characteristics, comorbidity, and level of amputation. In the past, numerous other instruments (such as the Short Form-36 (SF-36)3,9,15; the Sickness Impact Profile2,4,9; the Profile of Mood States9; the International Classification of Impairments, Disabilities, and Handicaps4; the Functional Independence Measure10,11; the Life Satisfaction Questionnaire2; and the Frenchay Activities Index1) have been used to assess the results of amputation. We selected the Prosthesis Evaluation Questionnaire because of its focus on the patient's assessment of the amputation and the prosthesis and because of its demonstrated validity9.
    Aside from the correlation of younger age with greater walking distance, demographics were not found to have a major correlation with the perceived result in our patient population. Muecke et al. did not find a correlation between outcome and age in their study of sixty-eight patients11. Greive and Lankhorst suggested an association between age and functional outcome after amputation, although statistical tests were not performed4. Kegel et al. found that functional independence decreased with increasing age7. Pohjolainen and Alaranta found a negative correlation between age and walking distance, time for which the patient could walk, ability to walk outdoors, and need for walking aids in a group of 125 patients who had had a lower-limb amputation14.
    Comorbidities, especially vascular disease, the condition of the contralateral limb, and the use of prescription medications, were correlated with the result metrics in our study. Hoaglund et al. pointed out that the comfort and function of the residual limb following amputation for vascular disease were substantially worse than those following a traumatic amputation; however, this conclusion was not subjected to statistical analysis5. Pinzur et al. suggested that patients with peripheral vascular disease had low rates of functional prosthetic use13. Greive and Lankhorst found that the functional outcome after amputation was inferior for diabetic patients compared with that for nondiabetic patients, although statistical tests were not used4. Kegel et al. reported that patients who had had an amputation because of a tumor fared better than those who had had an amputation because of congenital, traumatic, or dysvascular reasons7. Muecke et al. observed that individuals who had the worst function after amputation had a higher prevalence of hypertension, coronary artery disease, and non-insulin-dependent diabetes, although these effects were not found to be significant11. Pohjolainen and Alaranta reported a negative association between function and both cerebrovascular disease and smoking14. Melchiorre et al. found a correlation between functional independence and medical morbidities in twenty-four patients who had had an amputation because of a traumatic event or vascular disease10.
    It was of substantial interest that the level of the amputation was not found to be correlated with any of the four result metrics in our study. Greive and Lankhorst made a similar observation4. In contrast, Kegel et al.6,7, Kolind-Sorensen8, and Datta et al.1 suggested that patients who had had an above-the-knee amputation had a higher rate of dissatisfaction. Pohjolainen and Alaranta found a positive correlation between the length of the stump and walking distance in a study of patients who had had a below-the-knee amputation14. Walker et al. also suggested a relationship between walking distance and the level of amputation16.
    The perceived result of bilateral amputation in our study was not significantly worse than that of unilateral amputation. This finding is consistent with the observations of Kegel et al.7. The only amputation variable that was strongly correlated with our result metrics was the comfort of the residual limb.
    The most common correlations in our study were in the domain of prosthetic variables. The four result metrics were particularly correlated with the variables relating to the appearance, fit, comfort, and ease of application of the prosthesis and the freedom from limitation with regard to the types of clothing and shoes that could be worn. Equally important correlations were apparent with respect to the ability of the individual wearing the prosthesis to perform the activities of daily living, such as walking in a confined space, walking on a slippery surface, walking up the stairs, walking while carrying a load, showering and bathing, and getting in and out of an automobile. Hoaglund et al. found a high prevalence of inadequate socket fit, improper shape, and skin irritation, as well as faulty suspension and alignment associated with the prostheses worn by fifty-four veterans who had had a lower-extremity amputation5. Walker et al. described similar findings16. Those investigators also noted the importance of the cosmetic appearance of the prosthesis5,16. Kegel et al. called attention to the importance of the function, comfort, and cosmetic appearance of lower-extremity prostheses7. They stated that patients who have a spectrum of demographic characteristics and amputation etiologies may achieve similar functional status with a high-quality and patient-specific prosthesis. Smith et al. pointed out that the ability to perform the activities of daily living and the freedom from phantom pain are important determinants of the patient's perception of the result15.
    Social variables, especially the feelings of the patients toward family and strangers, were important correlates in our study population. In addition, strong associations were found between the result metrics and the ability of the patients to exercise and to be free of walking aids. Kegel et al. advocated the need for psychological counseling and for training in the use and care of the limb and the prosthesis7.
    The data in the present report have certain limitations. First, the recognition of a substantial and significant correlation does not prove cause and effect. Second, we performed a large number of comparisons; thus, some of the correlations might have appeared by chance alone. To minimize this risk, we set the threshold for practical significance at a correlation coefficient of 0.4 or greater and the threshold for significance at p < 0.005. Review of our data indicates that most of the correlations are significant even at a threshold of p < 0.0005. Additional limitations include the fact that the data were obtained exclusively from the perspective of the patients; we did not attempt to verify the data with a review of the medical records or a physical examination. Finally, the respondents did not necessarily constitute a representative sample of patients who had had an amputation. At our medical center, amputations are often performed in individuals in poor health and with a low economic status. Thus, although the mean duration of follow-up in this study was long, the follow-up rate was low. As a result, while the data and the conclusions can be applied to the group of patients characterized in the present study, they do not necessarily apply to other groups of patients who have had an amputation.
    The present study is one of the largest published investigations involving statistical correlation of patient-assessed results with a broad range of demographic, comorbidity, amputation, prosthetic, and social variables. While a number of previous studies have described the demographics, symptoms, and lifestyle impediments of patients who have had an amputation1-5,10,11,13-16, there has been little rigorous statistical analysis of the correlations of patient-perceived results with the broad range of potentially important variables. As Pernot et al. noted in a 1997 review of the literature, "Quality of life has not been taken into account in any of the studies."12
    The findings of our study suggest that most of the factors that correlate with the quality of the perceived result of amputation and the prosthetic management are unrelated to the amount of the limb that was amputated. Instead, the most important correlations appear to be related to the function of the prosthesis itself and to the patient's ability to manage social activities and interactions. This observation suggests that the challenge facing surgeons who perform amputations and prosthetists is to better understand these factors and to manage them in a way that optimizes the outcome perceived by the patient.
    Datta, D.; Nair, P. N.; and Payne, J.: Outcome of prosthetic management of bilateral lower-limb amputees. Disabil. and Rehab.,14: 98-102, 1992.1498  1992 
     
    De Fretes, A.; Boonstra, A. M.; and Vos, L. D.: Functional outcome of rehabilitated bilateral lower limb amputees. Prosthet. and Orthot. Internat.,18: 18-24, 1994.1818  1994 
     
    Duggan, M. M.; Woodson, J.; Scott, T. E.; Ortega, A. N.; and Menzoian, J. O.: Functional outcomes in limb salvage vascular surgery. Am. J. Surg.,168: 188-191, 1994.168188  1994  [PubMed]
     
    Greive, A. C., and Lankhorst, G. J.: Functional outcome of lower-limb amputees: a prospective descriptive study in a general hospital. Prosthet. and Orthot. Internat,20: 79-87, 1996.2079  1996 
     
    Hoaglund, F. T.; Jergesen, H. E.; Wilson, L.; Lamoreux, L. W.; and Roberts, R.: Evaluation of problems and needs of veteran lower-limb amputees in the San Francisco Bay Area during the period 1977-1980. J. Rehab. Res. and Devel.,20: 57-71, 1983.2057  1983 
     
    Kegel, B.; Carpenter, M.; and Burgess, E. M.: A survey of lower-limb amputees: prostheses, phantom sensations, and psychosocial aspects. Bull. Prosthet. Res.,10: 43-60, 1977.1043  1977  [PubMed]
     
    Kegel, B.; Carpenter, M. L.; and Burgess, E. M.: Functional capabilities of lower extremity amputees. Arch. Phys. Med. and Rehab.,59: 109-120, 1978.59109  1978 
     
    Kolind-Sorensen, V.: Follow-up of lower-limb amputees. Acta Orthop. Scandinavica,45: 97-104, 1974.4597  1974 
     
    Legro, M. W.; Reiber, G. D.; Smith, D. G.; del Aguila, M.; Larsen, J.; and Boone, D.: Prosthesis Evaluation Questionnaire for persons with lower limb amputations: assessing prosthesis-related quality of life. Arch. Phys. Med. and Rehab.,79: 931-938, 1998.79931  1998 
     
    Melchiorre, P. J.; Findley, T.;, and Boda, W.:: Functional outcome and comorbidity indexes in the rehabilitation of the traumatic versus the vascular unilateral lower limb amputee. Am. J. Phys. Med. and Rehab.,,75: 9-14, 1996.759  1996 
     
    Muecke, L.; Shekar, S.; Dwyer, D.; Israel, E.;, and Flynn, J. P.:: Functional screening of lower-limb amputees: a role in predicting rehabilitation outcome?. Arch. Phys. Med. and Rehab.,,73: 851-858, 1992.73851  1992 
     
    Pernot, H. F.; de Witte, L. P.; Lindeman, E.;, and Cluitmans, J.:: Daily functioning of the lower extremity amputee: an overview of the literature. Clin. Rehab.,11: 93-106, 1997.1193  1997 
     
    Pinzur, M. S.; Gottschalk, F.; Smith, D.; Shansfield, S.; de Andrade, R.; Osterman, H.; Roberts, J. R.; Orlando-Crombleholme, P.; Larsen, J.; Rappazzini, P.; and Bockelman, P.: Functional outcome of below-knee amputation in peripheral vascular insufficiency. A multicenter review. Clin. Orthop.,286: 247-249, 1993.286247  1993  [PubMed]
     
    Pohjolainen, T., and Alaranta, H.: Predictive factors of functional ability after lower-limb amputation. Ann. Chir. Gynaec.,80: 36-39, 1991.8036  1991 
     
    Smith, D. G.; Horn, P.; Malchow, D.; Boone, D. A.; Reiber, G. E.; and Hansen, S. T., Jr.: Prosthetic history, prosthetic charges, and functional outcome of the isolated, traumatic below-knee amputee. J. Trauma,,38: 44-47, 1995.3844  1995 
     
    Walker, C. R.; Ingram, R. R.; Hullin, M. G.; and McCreath, S. W.: Lower limb amputation following injury: a survey of long-term functional outcome. Injury,25: 387-392, 1994.25387  1994  [PubMed]
     

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    Anchor for JumpAnchor for Jump
    +Fig. 1:Graph showing the distribution of responses with regard to the quality of life.
    Anchor for JumpAnchor for Jump
    +Fig. 2:Graph showing the distribution of responses with regard to general satisfaction.
    Anchor for JumpAnchor for Jump
    +Fig. 3:Graph showing the distribution of responses with regard to the infrequency of frustration.
    Anchor for JumpAnchor for JumpTABLE I:  Demographic Characteristics of the One Hundred and Forty-eight Patients Who Had a Lower-Extremity Amputation
    *The values are given as the mean and the standard deviation.
    Male (percent)72
    Age* (yrs.)  50.1 ± 16.2
    Height* (in. [cm])  69 ± 10 (175 ± 25)
    Weight with prosthesis* (lbs. [kg])181 ± 50 (82 ± 23)
    Weight without prosthesis* (lbs. [kg])176 ± 44 (80 ± 20)
    Married (percent)54
    Anchor for JumpAnchor for JumpTABLE II:  Comorbidities in the One Hundred and Forty-eight Patients Who Had a Lower-Extremity Amputation*
    *Some patients had more than one comorbidity.
    TypePercent of Patients
    Type-I diabetes  4
    Type-II diabetes16
    Lung disease  5
    Heart disease  8
    Vascular disease22
    Use of prescription medications64
    Anchor for JumpAnchor for JumpTABLE III:  Side and Level of Amputation in the One Hundred and Forty-eight Patients Who Had a Lower-Extremity Amputation*
    *Eighty-seven percent of the patients had had a unilateral amputation.
    RightLeft
    Side of amputation (percent)5954
    Level of amputation (percent)
      Transmetatarsal  1  4
      Ankle disarticulation   1  0
      Syme  4  2
      Long below-the-knee  3  3
      Mid-diaphyseal below-the-knee1719
      Short below-the-knee  911
      Knee disarticulation   9  1
      Long above-the-knee  7  5
      Mid-diaphyseal above-the-knee  5  5
      Short above-the-knee  2  2
      Hip disarticulation   1  2
    Anchor for JumpAnchor for JumpTABLE IV:  Reason for Amputation*
    *The values are given as the percent of patients. Some patients listed more than one reason for the amputation.
    Right SideLeft Side
    Injury5049
    Infection1825
    Birth defect17  7
    Vascular disease1111
    Diabetes11  9
    Tumor  4  0
    Anchor for JumpAnchor for JumpTABLE V:  Interdependence of Result Metrics
    *P < 0.0001 for all correlation coefficients.
    Correlation Coefficient*
    General satisfaction and quality of life0.667
    General satisfaction and walking0.528
    General satisfaction and infrequency of frustration0.662
    Quality of life and walking distance0.513
    Quality of life and infrequency of frustration0.525
    Walking distance and infrequency of frustration0.396
    Anchor for JumpAnchor for JumpTABLE VI:  Correlation of Perceived Result with Comorbidities
    *P < 0.0001 for all correlation coefficients.
    Perceived ResultComorbidityCorrelation Coefficient*
    General satisfactionCondition of contralateral limb  0.447
    Quality of lifeCondition of contralateral limb  0.489
    Walking distanceVascular disease-0.428
    Use of prescription medications-0.431
    Condition of contralateral limb  0.484
    Anchor for JumpAnchor for JumpTABLE VII:  Scores for Perceived Result According to Level and Laterality of Amputation*
    *The values are given as the mean score, with the standard deviation given for groups of ten patients or more who had had an amputation at the same level. The values for the unilateral amputations are given as right/left amputation.
    Level of Amputation General Satisfaction (points)Quality of Life (points)Walking Distance (points)Infrequency of Frustration (points)
    Unilateral
      Transmetatarsal-/3.6-/3.8-/3.7-/4.1
      Ankle disarticulation 2.5/-4.0/-5.0/-2.5/-
      Syme3.2/5.04.0/5.04.0/5.02.6/4.0
      Long below-the-knee4.6/3.24.5/4.14.7/4.03.5/2.8
      Mid-diaphyseal below-the-knee3.4 ± 1.2/3.8 ± 1.23.6 ± 1.1/3.7 ± 1.03.4 ± 1.2/3.9 ± 0.73.6 ± 1.1/3.5 ± 1.1
      Short below-the-knee2.8 ± 1.3/3.8 ± 0.82.9 ± 1.0/3.7 ± 0.93.0 ± 1.1/3.7 ± 0.93.2 ± 1.0/3.4 ± 1.1
      Knee disarticulation 3.3 ± 1.1/3.03.1 ± 0.9/3.03.5 ± 1.1/3.02.9 ± 0.8/3.0
      Long above-the-knee2.9/2.52.8/2.63.4/2.83.3/2.2
      Mid-diaphyseal above-the-knee3.9/3.03.9/2.73.6/2.83.6/3.1
      Short above-the-knee5.0/3.35.0/3.82.5/4.04.0/2.8
      Hip disarticulation 3.3/2.54.3/3.33.0/3.02.3/2.0
    Bilateral3.4 ± 1.23.6 ± 1.23.1 ± 1.33.4 ± 1.3
    Anchor for JumpAnchor for JumpTABLE VIII:  Correlation of Perceived Result with Variables Related to the Prosthesis*
    *The values are given as the correlation coefficient, with a positive value indicating a positive feature of the prosthesis. Each of the correlation coefficients was found to be significant (p < 0.0001).
    General SatisfactionQuality of LifeWalking DistanceInfrequency of Frustration
    Fit0.482-0.5540.457
    Comfort0.514-0.5350.504
    Ability to balance--0.5440.408
    Ease of application0.509-0.4350.560
    Appearance0.414---
    Clothing limitations0.5250.4640.4900.518
    Shoe limitations0.4980.4980.4020.413
    Ability to walk in close spaces0.5370.4730.5650.508
    Ability to walk on slippery surfaces0.4960.5430.6390.549
    Ability to walk with load0.5640.6010.7290.550
    Ability to walk up stairs0.4580.5400.5620.447
    Ability to get in or out of automobile0.5220.502-0.580
    Anchor for JumpAnchor for JumpTABLE IX:  Correlation of Perceived Result with Social Variables*
    *The values are given as the correlation coefficient, with a positive value indicating a positive feature of the social function. Each of the correlation coefficients was found to be significant (p < 0.0001).
    General SatisfactionQuality of LifeWalking DistanceInfrequency of Frustration
    Comfortable with strangers0.412--0.445
    No burden on family-0.492-0.501
    Ability to provide care for others0.5310.5820.5840.457
    Hours prosthesis worn--0.687-
    Freedom from walking aids--0.5210.425
    Ability to perform aerobic exercise--0.448-
    Ability to run-0.4260.565-
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