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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 15  |  Issue : 1  |  Page : 37-42

Amputation clinic: Need for an Umbrella care approach in developing nations


1 SRF, Physiotherapist, Division of Trauma Surgery and Critical Care, JPNATC, AIIMS, New Delhi, India
2 Physiotherapist, JPNATC, AIIMS, New Delhi, India
3 JRF, Division of Trauma Surgery and Critical Care, JPNATC, AIIMS, New Delhi, India
4 Professor, Division of Trauma Surgery and Critical Care, JPNATC, AIIMS, New Delhi, India

Date of Submission07-Dec-2020
Date of Decision14-Jul-2021
Date of Acceptance19-Jul-2021
Date of Web Publication19-Aug-2021

Correspondence Address:
Prof. Sushma Sagar
Room No 229, Second Floor, Division of Trauma Surgery and Critical Care, Jai Prakash Narayan Apex Trauma Centre, AIIMS, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/PJIAP.PJIAP_57_20

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  Abstract 


BACKGROUND: Amputation of body parts following trauma leads to severe impairment and disability to the patient. Advances in perioperative care and rehabilitation have improved the outcomes following amputation. Jai Prakash Narayan Apex Trauma Centre being a specialty center caters to a large number of patients following road traffic injury (RTI) and other injuries. Hospitals managing such kind of patients need to know the concept of amputation clinic where a multidisciplinary team (MDT) of professionals takes care of such patients.
AIMS AND OBJECTIVES: This study was conducted to evaluate the demography of patients who underwent amputation between January 2017 and December 2019 and to assess the need of holistic approach in managing patients with traumatic amputation.
MATERIALS AND METHODS: It is a retrospective cohort design, and data from hospital record have been retrieved and documented.
RESULTS: Majority of the amputations seen are males between the age groups of 13 and 59 years, and the most common amputations were lower limb amputations and the most common cause was RTI. 5.3% of patients had more than one site of amputation.
CONCLUSION: Amputation clinic had proven to be a boon for managing such cases as it involved a holistic approach comprising MDT.

Keywords: Amputation clinic, census, multidisciplinary team, traumatic amputation


How to cite this article:
Mir N, Hussain A, Moorthy A S, Khatri G, Sagar S. Amputation clinic: Need for an Umbrella care approach in developing nations. Physiother - J Indian Assoc Physiother 2021;15:37-42

How to cite this URL:
Mir N, Hussain A, Moorthy A S, Khatri G, Sagar S. Amputation clinic: Need for an Umbrella care approach in developing nations. Physiother - J Indian Assoc Physiother [serial online] 2021 [cited 2021 Dec 3];15:37-42. Available from: https://www.pjiap.org/text.asp?2021/15/1/37/324132




  Introduction Top


Disabling injuries resulting from road traffic crashes, train accidents, agricultural equipment, machine cut, and electrical mishaps lead to amputation of various body parts.[1] An estimated 12% of the world population encounter some form of disability or impairment resulting from loss of body parts.[2]

Surgical removal of limb is one of the oldest of all surgical procedures, with a history of more than 2500 years dating back to the time of Hippocrates.[3] The first one to use ligatures to control bleeding after amputation was Ambroise Pare, and he also designed a relatively sophisticated prosthesis.[4] Amputations are performed as a last hope when limb salvage is not possible or is dead or dying.[5] Amputation leads to permanent disability, especially lower-limb amputations which are much more common than upper-limb amputations and directly affect the quality of life. Traumatic limb amputation may lead to prolonged hospital stay and psychological consequences for an amputee. Recovery may get complicated due to associated problems such as depression, anxiety, confusion, problems with daily routine activities, phantom limb sensation, and pain.[6],[7] Amputations resulting from injuries usually occur more in males, especially in the fourth and fifth decade of their life, probably because males tend to engage more in unsafe activities as compared to females.[8],[9]

The multidisciplinary team (MDT) is a team of professionals with members from various backgrounds who organize, with little overlap, the participation of each professional. A specialized MDT has been shown to deliver the best outcomes for the patient.[10]

Care for an amputee is a challenging task and requires support from multiple specialties to

  • Create a patient-centered care plan containing detailed expertise and best practices of each discipline
  • Reduce the risk of missing potential complications which may adversely affect operational and rehabilitation outcomes
  • Boost health care for patients and families.


Along with surgical technique and perioperative care, there is a significant role of good physiotherapy sessions tailor made to aid postamputation mobility from crutch walking to final gait training with prosthesis. The prevalence of psychiatric disorders among amputees has been found to be in the range of 32%–84% including depression rates 10.4%–63%, posttraumatic stress disorder 3.3%–56.3%, and phantom limb phenomenon 14%–92%.[11],[12],[13]

Lack of demographic data and prevalence of amputation studies in our country has led to improper planning, policies, and programs for the same, hence the need to maintain registry data of an amputee is the need of hour to frame policies at different levels for prevention and treatment and to guarantee their good health and better opportunities in life and rehabilitation.

Aims and objectives of the study

  1. To evaluate the demography of patients who underwent amputation during the period from January 2017 to December 2019
  2. To assess the need of holistic approach in managing patients with traumatic amputation.


Design

This was a retrospective cohort design.


  Materials and Methods Top


The concept of MDT is functional at Jai Prakash Narayan Apex (JPNA) Trauma Centre, AIIMS, New Delhi. Our center acts as a referral hospital, where traumatic patients are referred from across the country for specialized services. Approximately 70,000 patients are received annually at our center, out of which 5085 patients require admission in different departments of trauma center, in which around 1750–1800 require admission under Trauma Surgery Division and around 200 patients undergo amputation of either of the extremity or both the extremities. With this heavy load of patients at our center, the concept of amputation clinic was introduced in January 2013 to meet the special needs of an amputee in comparison to those with more serious injuries. Amputees were lost among other seriously injured patients who required immediate medical attention.

As amputee care requires a holistic approach toward their management, so this concept of MDT came into existence as amputation clinic which comprised a team of surgeons, physiotherapists, wound care nurses, psychologists, Prosthetist, and medical social workers to meet the demands of an amputee without any hassle or further delay. Our aim of forming MDT was to reduce the time spent in amputee rehabilitation. The ultimate goal for an amputee is prosthetic application and back to normal life as early as possible which has a very important role in improving their quality of life and mental well-being. Our center is running a dedicated amputation clinic operational once a week in the afternoon for more than 8 years now.

Early discharges of amputation patients, reduced hospital stays, early mobility during hospital stays, psychiatric referral of all amputees to detect any psychiatric disorder caused by trauma, education and counselling for both patients and family members, and knowledge about prosthesis procurement are some of the additional benefits of MDT that we have seen at our center. Along with this, MDT at our center coordinates with the Physical Medical Rehabilitation Department, Physiology Department, and Pain Clinic of the institute for any of the lacunae left in amputee rehabilitation.

Multiple research work is carried out at our center in recent times on amputees, and the only aim was early rehabilitation of the amputation patients and improved their quality of life. In 2017, we received a grant fromDepartment of Science and Technology (DST) to conduct a study on lower-limb amputation patients and see the impact of yoga under Yoga SATYAM program. Research work by surgeons on reducing the surgical site infection of a stump was also carried out in recent times.

Data from the hospital medical record section have been retrieved for the number of amputations done, their age, gender, involved extremity, mechanism of injury, and site of amputation from January 2017 to December 2019 at JPNA Trauma Centre, AIIMS, New Delhi.

Data were obtained from the medical record and further assessed for pediatric, adult, and geriatric age groups. Institute Ethics Committee approval was obtained before starting the data collection work. No informed consent was required as the study involved is retrospective and only reviewing the medical records.

Data analysis

All the data were analyzed by descriptive statistics using SPSS software (SPSS Software, IBM, Chicago, Illinois, USA).


  Results Top


Level I Trauma Centre has a capacity of 300 in-patient beds, 30 casualty beds, and 38 intensive care unit beds currently. A total number of amputations done during this period were 522 patients, either single extremity or more than one extremity.

The average hospital stay of the patients ranged between 3 and 7 days. A special clinic in the name of amputation clinic is functional every Monday which is dedicated only to amputee patients. Patients were asked to follow up in this clinic every Monday till stump was prepared for prosthesis application.

There were 522 patients with traumatic amputation who visited Level I Trauma Centre during the period between January 2017 and December 2019. All of the patients were enrolled in the study.

Patient demographic data

The age of amputees ranged from 1 year to 80 years. The most common age group for amputation was aged 21–30 and accounted for 34.8% of all amputees. The next common age group is 31–40 accounting for 22.9% of all amputee patients [Figure 1].
Figure 1: Demographic age distribution (class interval)

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5.3% (28 patients) of the patients belonged to the age group below 12 years of age. Eighty-seven percent (454 patients) of the patients belonged to the age group between 13 and 59 years of age and 7.7% (40 patients) were 60 and above years of age [Figure 2].
Figure 2: Demographic age distribution (frequency variable)

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There were more male amputees than females with 87.8%. Females contributed to 12.2% of the total amputee patients [Figure 3].
Figure 3: Gender demographic distribution data

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Mechanism of injury

In this study, out of 522 patients, 335 patients (64.2%) were victims of road traffic injury (RTI), making it the most common cause of amputation. RTI was the most common cause of amputation in all age group patients. One hundred and five patients (20.1%) suffered railway track injury leading to amputation of the limb. Forty-one (7.9%) were machine cut injury patients. Twelve patients (2.2%) were high-velocity trauma patients which included gunshot injury, cylinder blast, and bomb blast injury. Twenty-nine patients (5.6%) were having other causes for amputation, mainly fall of heavy object and diabetic patients [Figure 4].
Figure 4: Mechanism of injury

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Site of amputation

The amputations of the lower limbs are much more frequent than those of the upper limbs. In our study, 390 patients (74.8%) of all amputations were lower-limb amputations. Upper-limb amputations constituted 123 patients (23.5%). There were 9 patients (1.7%) who had both upper-limb and lower-limb amputations [Figure 5].
Figure 5: Site of amputation

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Thirty-two patients (6.1%) underwent shoulder disarticulation, 60 patients (11.5%) were above-elbow amputees, 19 patients (3.8%) were below-elbow amputees, 17 patients (3.2%) were wrist and hand amputees, 5 patients (1%) were hemipelvectomy, 21 patients (4%) were hip disarticulation, 193 patients (37%) were above-knee amputees, 21 patients (4%) were knee disarticulation, 99 patients (19%) were below-knee amputees, and 27 (5.1%) were ankle and foot amputees. More than one site of amputation was performed on 28 patients (5.3%) [Figure 6].
Figure 6: Level of amputation

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  Discussion Top


According to Metz, the global prevalence of disability is 4% in developing countries and 7% in industrialized countries.[14] The prevalence of disability in India according to a census report in 2001 is 1.8%–2.2%.[2]

The present study was a hospital-based, retrospective study based in New Delhi. This study of traumatic amputation in Indian population is of its first kind in northern India, especially for Delhi state. This center provides a good source of data because it is Level I Trauma Centre which serves not only Delhi NCR but also neighboring states of Delhi. Patients also are referred for advanced treatment to this center and patients are given long-term follow-ups. Despite all this, it is difficult to obtain a true measure of the frequency of amputations as some patients may not be referred to the center. Out of 522 patients enrolled in this study with traumatic amputations, 74.8% were lower-limb amputees and 23.5% were upper-limb amputees. These results are in agreement with the study done by Ahmad et al. in 2016,[1] who have found that 69.8% were lower-limb amputees and 30.1% had an upper-limb loss, whereas Roche et al. found that 81% were lower-limb amputees in 2011 and 19% were upper-limb amputees.[15] This may be because of the distal portion of a limb being usually more likely to be injured.

For this sample, the younger age group from teenagers to 30 years accounted for 245 patients (46.9%), thereby making up the leading amputation age group. These results are similar to the study done by Pooja and Sangeeta in 2013,[16] wherein it was found the same age group being the most affected age group. Our findings also are close to the study done by Obalum and Okeke who studied only lower-limb amputees and stated that the peak age group was 21–30 years.[5] This may be due to the fact that most amputations were due to trauma, which occurs more often in younger people who lead more active lives.

Reports on causes of amputation vary from country to country. Sansam et al.[14] stated in 2009 that trauma accounted for majority of amputations in India and dysvascularity was the predominant cause in most developed countries. Research done by Pooja and Sangeeta[16] at Kolkata found that 70.3% of amputations were due to trauma making this the most common cause of amputation. Our results are also in agreement with the above-stated publications.

The leading cause of amputation in different countries is affected by the degree of industrialization, transportation system, and the medical care available. In Delhi, trauma may be the leading cause of amputation because of rapid growth of industries and wide amount of high-speed traffic.

RTI and train-associated injury incidence in India is very high as compared to developed countries. Major causes of traffic accidents in India are attributed to speeding over the speed limit, driving under the influence of alcohol, and not using helmets and seat belts.

The concept of running a specialized and dedicated clinic in the name of Amputation Clinic at Trauma Centre, AIIMS, is a decade old now. The purpose of this clinic was to provide umbrella care to amputee patients. Before the start of clinic, many patients were lost to follow-up and/or were found dissatisfied with the follow-up as they had to move to various clinics for the benefit of physiotherapy or psychological counseling. Medical social workers and prosthetists were also not available on the day of visit. Another crucial factor was the inability to make themselves reach early or get an access to the heavy line of other waiting patients due to their supports/walking aids or wheelchairs. With the start of dedicated clinic, many such issues were solved and it also acted as a group therapy as they all could identify their pain among each other. Discussion on which prosthesis is more affordable or adaptable also became much easier now as compared to previous times.

This clinic plays a vital role to help the patient return to the highest level of function and independence possible, while improving the overall quality of life – physically, emotionally, and socially.

Limitations

Even though this research was carried out in one of the leading trauma centers of the country which is located in the National Capital Territory of India, it did not take into account the data from all the hospitals of the entire state of Delhi. Data from other major hospitals who deal with amputations may be a good and reliable measure for outcome. Another limitation of the study is small size which may not reflect the entire population. Lack of awareness and facility to transport patients from the remote areas adjacent to the Delhi state is another limitation of this study as entire population could not be included in this study.


  Conclusion Top


RTI followed by railway track injury is the most common reason for traumatic amputation in our country. Most commonly affected are males between the age groups of 20 and 30 years. A significant number of working-age amputees reported being retired due to disability, thereby reducing their productivity mainly in their most productive years of life. This has led to a reduction in either daily or social activities, which might lead to an increase in the economic burden on the state. Lower-limb amputations predominate amputees. Despite MDT which is functional at trauma center in the form of amputation clinic, very less number seek rehabilitation and go back to their previous lives. There is a lack of resources and registry data on such patients. Developing awareness campaigns for early recovery as well as early prosthetic fitting will prevent the amputee community from being a burden on the state. A more humane approach is needed.

Future vision in amputee care

  • Our center is conducting research application of immediate postoperative prosthesis in below-knee amputation patients
  • Application of osseointegration techniques
  • Nerve to muscle transfer for phantom limb pain management
  • Use of bionic arms in upper-limb amputees
  • Phantom limb pain management through regional blocks, Repetitive Transcranial Magnetic Stimulation (rTMS).


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ahmad J, Gupta AK, Sharma VP, Kumar D, Yadav G, Singh S. Traumatic amputations in children and adolescents: A demographic study from a tertiary care center in northern India. J Pediatr Rehabil Med 2016;9:265-9.  Back to cited text no. 1
    
2.
World Health Organization. World Health Organization Disability and Rehabilitation: WHO Action Plan 2006-2011. Geneva: World Health Organization; 2005.  Back to cited text no. 2
    
3.
Sabzi Sarvestani A, Taheri Azam A. Amputation: A ten-year survey. Trauma Mon 2013;18:126-9.  Back to cited text no. 3
    
4.
Kim YC, Park CI, Kim DY, Kim TS, Shin JC. Statistical analysis of amputations and trends in Korea. Prosthet Orthot Int 1996;20:88-95.  Back to cited text no. 4
    
5.
Obalum DC, Okeke GC. Lower limb amputations at a Nigerian private tertiary hospital. West Afr J Med 2009;28:24-7.  Back to cited text no. 5
    
6.
Letton RW, Chwals WJ. Patterns of power mower injuries in children compared with adults and the elderly. J Trauma 1994;37:182-6.  Back to cited text no. 6
    
7.
Farley FA, Senunas L, Greenfield ML, Warschausky S, Loder RT, Kewman DG, et al. Lower extremity lawn-mower injuries in children. J Pediatr Orthop 1996;16:669-72.  Back to cited text no. 7
    
8.
Masood Jawaid IA, Kaimkhani GM. Current indications for major lower limb amputations at Civil Hospital, Karachi. Pak J Surg 2008;24:228-31.  Back to cited text no. 8
    
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Kidmas AT, Nwadiaro CH, Igun GO. Lower limb amputation in Jos, Nigeria. East Afr Med J 2004;81:427-9.  Back to cited text no. 9
    
10.
Government of South Australia, Statewide Rehabilitation Clinical Network. Model of Amputee Rehabilitation in South Australia; 2012.  Back to cited text no. 10
    
11.
Sahu A, Sagar R, Sarkar S, Sagar S. Psychological effects of amputation: A review of studies from India. Ind Psychiatry J 2016;25:4-10.  Back to cited text no. 11
[PUBMED]  [Full text]  
12.
Parkes CM. Components of the reaction to loss of a lamb, spouse or home. J Psychosom Res 1972;16:343-9.  Back to cited text no. 12
    
13.
Kingdon D, Pearce T. Psychosocial assessment and management of the amputee. In: Banarjee S, editor. Rehabilitation Management of the Amputees. Baltimore, MD: Williams and Wilkins; 1982. p. 350-71.  Back to cited text no. 13
    
14.
Sansam K, Neumann V, O'Connor R, Bhakta B. Predicting walking ability following lower limb amputation: A systematic review of the literature. J Rehabil Med 2009;41:593-603.  Back to cited text no. 14
    
15.
Roche AJ, Selvarajah K. Traumatic amputations in children and adolescents: Demographics from a regional limb-fitting centre in the United Kingdom. J Bone Joint Surg Br 2011;93:507-9.  Back to cited text no. 15
    
16.
Pooja GD, Sangeeta L. Prevalence and aetiology of amputation in Kolkata, India: A retrospective analysis. Hong Kong Physiother J 2013;31:36-40.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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