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Post-operative Inpatient Falls Among Major Lower Limb Amputees

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Abstract

Purpose of Review

Amputees are at the highest risk of any subgroup to experience a fall during their inpatient stay. This review seeks to enhance the understanding of amputee falls risk and explore ways to prevent or mitigate damage due to inpatient falls.

Recent Findings

Falls among lower limb amputees occur at a rate of 16.5% immediately after surgery while in the acute care hospital and 20.5 to 35% during inpatient rehabilitation. Three percent of patients experience a fall significant enough to require revision surgery and almost half of those are revised to a higher level. Unilateral transtibial amputation and diabetes mellitus as an indication for amputation are independently associated risks of an inpatient fall. In addition to assorted benefits, removable rigid dressings have been demonstrated to protect the residual limb from damage due to inpatient falls.

Summary

Devices designed to protect the residual limb from possible damage due to an inpatient fall should be routinely considered in order to mitigate a possible return to the operating room for revision surgery and allow the rehabilitation process to continue uninterrupted.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Dillingham TR, Pezzin LE, MacKenzie EJ. Limb amputation and limb deficiency: epidemiology and recent trends in the United States. South Med J. 2002;95(8):875–83. https://doi.org/10.1097/00007611-200208000-00018.

    Article  PubMed  Google Scholar 

  2. Owings MF, Kozak LJ. Ambulatory and inpatient procedures in the United States, 1996. Vital Health Stat. 1998;13(139):1–119.

    Google Scholar 

  3. Newhall K, Spangler E, Dzebisashvili N, Goodman DC, Goodney P. Amputation rates for patients with diabetes and peripheral arterial disease: the effects of race and region. Ann Vasc Surg. 2016;30:292–8.e1. https://doi.org/10.1016/j.avsg.2015.07.040.

    Article  PubMed  Google Scholar 

  4. Ziegler-Graham K, MacKenzie EJ, Ephraim PL, Travison TG, Brookmeyer R. Estimating the prevalence of limb loss in the United States: 2005 to 2050. Arch Phys Med Rehabil. 2008;89(3):422–9. https://doi.org/10.1016/j.apmr.2007.11.005.

    Article  PubMed  Google Scholar 

  5. World Health Organization (WHO). WHO global report on falls prevention in older age. Ganeva; 2007 {cited 2022 September 6}. Available from : http://www.who.int/aging/publications/Falls_prevention7March.pdf.

  6. Oliver D, Healey F, Haines TP. Preventing falls and fall-related injuries in hospitals. Clin Geriatr Med. 2010;26(4):645–92. https://doi.org/10.1016/j.cger.2010.06.005.

    Article  PubMed  Google Scholar 

  7. Schwendimann R, Bühler H, De Geest S, Milisen K. Characteristics of hospital inpatient falls across clinical departments. Gerontology. 2008;54(6):342–8. https://doi.org/10.1159/000129954.

    Article  PubMed  Google Scholar 

  8. Lee JE, Stokic DS. Risk factors for falls during inpatient rehabilitation. Am J Phys Med Rehabil. 2008;87(5):341–50; quiz 351, 422. https://doi.org/10.1097/PHM.0b013e31816ddc01.

    Article  PubMed  Google Scholar 

  9. Hunter SW, Batchelor F, Hill KD, Hill AM, Mackintosh S, Payne M. Risk factors for falls in people with a lower limb amputation: a systematic review. PM R. 2017;9(2):170–180.e1. https://doi.org/10.1016/j.pmrj.2016.07.531.

    Article  PubMed  Google Scholar 

  10. Zochodne DW. Diabetes mellitus and the peripheral nervous system: manifestations and mechanisms. Muscle Nerve. 2007;36(2):144–66. https://doi.org/10.1002/mus.20785.

    Article  CAS  PubMed  Google Scholar 

  11. Hermodsson Y, Ekdahl C, Persson BM, Roxendal G. Standing balance in trans-tibial amputees following vascular disease or trauma: a comparative study with healthy subjects. Prosthet Orthot Int. 1994;18(3):150–8. https://doi.org/10.3109/03093649409164400.

    Article  CAS  PubMed  Google Scholar 

  12. Yu JC, Lam K, Nettel-Aguirre A, Donald M, Dukelow S. Incidence and risk factors of falling in the postoperative lower limb amputee while on the surgical ward. PM R. 2010;2(10):926–34. https://doi.org/10.1016/j.pmrj.2010.06.005.

    Article  PubMed  Google Scholar 

  13. Gooday HM, Hunter J. Preventing falls and stump injuries in lower limb amputees during inpatient rehabilitation: completion of the audit cycle. Clin Rehabil. 2004;18(4):379–90. https://doi.org/10.1191/0269215504cr738oa.

    Article  PubMed  Google Scholar 

  14. Pauley T, Devlin M, Heslin K. Falls sustained during inpatient rehabilitation after lower limb amputation: prevalence and predictors. Am J Phys Med Rehabil. 2006;85(6):521–32; quiz, 533-5. https://doi.org/10.1097/01.phm.0000219119.58965.8c.

    Article  PubMed  Google Scholar 

  15. Dyer D, Bouman B, Davey M, Ismond KP. An intervention program to reduce falls for adult in-patients following major lower limb amputation. Healthc Q. 2008;11(3):117–21. https://doi.org/10.12927/hcq.2008.19661.

    Article  PubMed  Google Scholar 

  16. Miller WC, Speechley M, Deathe AB. Balance confidence among people with lower-limb amputations. Phys Ther. 2002;82(9):856–65.

    Article  PubMed  Google Scholar 

  17. Gauthier-Gagnon C, Grisé MC, Potvin D. Enabling factors related to prosthetic use by people with transtibial and transfemoral amputation. Arch Phys Med Rehabil. 1999;80(6):706–13. https://doi.org/10.1016/s0003-9993(99)90177-6.

    Article  CAS  PubMed  Google Scholar 

  18. Miller WC, Deathe AB. The influence of balance confidence on social activity after discharge from prosthetic rehabilitation for first lower limb amputation. Prosthet Orthot Int. 2011;35(4):379–85. https://doi.org/10.1177/0309364611418874.

    Article  PubMed  Google Scholar 

  19. Behar TA, Burnham SJ, Johnson G Jr. Major stump trauma following below-knee amputation. Outcome and recommendations for therapy. J Cardiovasc Surg (Torino). 1991;32(6):753–6.

    CAS  PubMed  Google Scholar 

  20. Gonzalez EG, Mathews MM. Femoral fractures in patients with lower extremity amputations. Arch Phys Med Rehabil. 1980;61(6):276–80.

    CAS  PubMed  Google Scholar 

  21. Lewallen RP, Johnson EW Jr. Fractures in amputation stumps: review of treatment of 16 fractures. Mayo Clin Proc. 1981;56(1):22–6.

    CAS  PubMed  Google Scholar 

  22. Stasik CN, Berceli SA, Nelson PR, Lee WA, Ozaki CK. Functional outcome after redo below-knee amputation. World J Surg. 2008;32(8):1823–6. https://doi.org/10.1007/s00268-008-9500-5.

    Article  PubMed  Google Scholar 

  23. Vlahov D, Myers AH, Al-Ibrahim MS. Epidemiology of falls among patients in a rehabilitation hospital. Arch Phys Med Rehabil. 1990;71(1):8–12.

    CAS  PubMed  Google Scholar 

  24. Aligne C, Farcot M, Favre JP, Alnashawati G, De Simone F, Barral X. Primary closure of below-knee amputation stumps: a prospective study of sixty-two cases. Ann Vasc Surg. 1990;4(2):143–6. https://doi.org/10.1007/BF02001369.

    Article  CAS  PubMed  Google Scholar 

  25. Valentine RJ, Myers SI, Inman MH, Roberts JR, Clagett GP. Late outcome of amputees with premature atherosclerosis. Surgery. 1996;119(5):487–93. https://doi.org/10.1016/s0039-6060(96)80255-8.

    Article  CAS  PubMed  Google Scholar 

  26. Bunt TJ, Manship LL, Bynoe RP, Haynes JL. Lower extremity amputation for peripheral vascular disease. A low-risk operation. Am Surg. 1984;50(11):581–4.

    CAS  PubMed  Google Scholar 

  27. Kihn RB, Warren R, Beebe GW. The “geriatric” amputee. Ann Surg. 1972;176(3):305-314. doi:https://doi.org/10.1097/00000658-197209000-00006.

  28. Rush DS, Huston CC, Bivins BA, Hyde GL. Operative and late mortality rates of above-knee and below-knee amputations. Am Surg. 1981;47(1):36–9.

    CAS  PubMed  Google Scholar 

  29. Castronuovo JJ Jr, Deane LM, Deterling RA Jr, O'Donnell TF Jr, O'Toole DM, Callow AD. Below-knee amputation: is the effort to preserve the knee joint justified? Arch Surg. 1980;115(10):1184–7. https://doi.org/10.1001/archsurg.1980.01380100032007.

    Article  PubMed  Google Scholar 

  30. Couch NP, David JK, Tilney NL, Crane C. Natural history of the leg amputee. Am J Surg. 1977;133(4):469–73. https://doi.org/10.1016/0002-9610(77)90133-7.

    Article  CAS  PubMed  Google Scholar 

  31. de Cossart L, Randall P, Turner P, Marcuson RW. The fate of the below knee amputee. Ann R Coll Surg Engl. 1983;65(4):230–2 PMID: 6870128; PMCID: PMC2494354.

    PubMed  PubMed Central  Google Scholar 

  32. Taylor SM, Kalbaugh CA, Blackhurst DW, Hamontree SE, Cull DL, Messich HS, Robertson RT, Langan EM 3rd, York JW, Carsten CG 3rd, Snyder BA, Jackson MR, Youkey JR. Preoperative clinical factors predict postoperative functional outcomes after major lower limb amputation: an analysis of 553 consecutive patients. J Vasc Surg. 2005;42(2):227–35. https://doi.org/10.1016/j.jvs.2005.04.015.

    Article  PubMed  Google Scholar 

  33. Toursarkissian B, Shireman PK, Harrison A, D'Ayala M, Schoolfield J, Sykes MT. Major lower-extremity amputation: contemporary experience in a single Veterans Affairs institution. Am Surg. 2002;68(7):606–10.

    Article  PubMed  Google Scholar 

  34. Yip VS, Teo NB, Johnstone R, Robertson AG, Robertson JH, Welch GH, Kettlewell S. An analysis of risk factors associated with failure of below knee amputations. World J Surg. 2006;30(6):1081–7. https://doi.org/10.1007/s00268-005-0737-y.

    Article  PubMed  Google Scholar 

  35. Currie LM. Fall and injury prevention. Annu Rev Nurs Res. 2006;24:39–74.

    Article  PubMed  Google Scholar 

  36. Miake-Lye IM, Hempel S, Ganz DA, Shekelle PG. Inpatient fall prevention programs as a patient safety strategy: a systematic review. Ann Intern Med. 2013;158(5 Pt 2):390–6. https://doi.org/10.7326/0003-4819-158-5-201303051-00005.

    Article  PubMed  Google Scholar 

  37. Center for Disease Control and Prevention. (2015). Falls among older adults: an overview . Retrieved September 6, 2022 from https://www.cdc.gov/falls/index.html.

  38. Mello MM, Studdert DM, Thomas EJ, Yoon CS, Brennan TA. Who pays for medical errors? An analysis of adverse event costs, the medical liability system, and incentives for patient safety improvement. J Empir Leg Stud. 2007;4:835–60. https://doi.org/10.1111/j.1740-1461.2007.00108.x.

    Article  Google Scholar 

  39. Bates DW, Pruess K, Souney P, Platt R. Serious falls in hospitalized patients: correlates and resource utilization. Am J Med. 1995 Aug;99(2):137–43. https://doi.org/10.1016/s0002-9343(99)80133-8.

    Article  CAS  PubMed  Google Scholar 

  40. Eskreis TR. Seven common legal pitfalls in nursing. Am J Nurs. 1998;98(4):34–40 quiz 41.

    CAS  PubMed  Google Scholar 

  41. Inouye SK, Brown CJ, Tinetti ME. Medicare nonpayment, hospital falls, and unintended consequences. N Engl J Med. 2009;360(23):2390–3. https://doi.org/10.1056/NEJMp0900963.

    Article  CAS  PubMed  Google Scholar 

  42. Medicare Program: changes to the hospital inpatient prospective payment system and fiscal year 2008 rates, 42 CFR parts 411, 412, 413, and 489 [CMS-1533-FC]. (2007). Retrieved September 6, 2022 from http://www.cms.gov/Medicare-Fee-for-Service-Payment/AcuteinpatientPPS/downloads/CMS-1533-FC.pdf.

  43. Waters TM, Daniels MJ, Bazzoli GJ, Perencevich E, Dunton N, Staggs VS, Potter C, Fareed N, Liu M, Shorr RI. Effect of Medicare’s nonpayment for hospital-acquired conditions: lessons for future policy. JAMA Intern Med. 2015;175(3):347–54. https://doi.org/10.1001/jamainternmed.2014.5486.

    Article  PubMed  PubMed Central  Google Scholar 

  44. Agency for Healthcare Research and Quality. (2015). Saving lives and saving money: hospital-acquired conditions update. Retrieved September 6, 2022 from https://www.ahrq.gov/hai/pfp/2014-final.html.

  45. Barker AL, Morello RT, Wolfe R, Brand CA, Haines TP, Hill KD, Brauer SG, Botti M, Cumming RG, Livingston PM, Sherrington C, Zavarsek S, Lindley RI, Kamar J. 6-PACK programme to decrease fall injuries in acute hospitals: cluster randomised controlled trial. BMJ. 2016;26(352):h6781. https://doi.org/10.1136/bmj.h6781.

    Article  CAS  Google Scholar 

  46. Fehlberg EA, Lucero RJ, Weaver MT, McDaniel AM, Chandler AM, Richey PA, Mion LC, Shorr RI. Impact of the CMS no-pay policy on hospital-acquired fall prevention related practice patterns. Innov. Aging. 2017;1(3):igx036. https://doi.org/10.1093/geroni/igx036.

    Article  Google Scholar 

  47. Ang E, Mordiffi SZ, Wong HB. Evaluating the use of a targeted multiple intervention strategy in reducing patient falls in an acute care hospital: a randomized controlled trial. J Adv Nurs. 2011;67(9):1984–92. https://doi.org/10.1111/j.1365-2648.2011.05646.x.

    Article  PubMed  Google Scholar 

  48. Wong CA, Recktenwald AJ, Jones ML, Waterman BM, Bollini ML, Dunagan WC. The cost of serious fall-related injuries at three Midwestern hospitals. Jt Comm J Qual Patient Saf. 2011;37(2):81–7. https://doi.org/10.1016/s1553-7250(11)37010-9.

    Article  PubMed  Google Scholar 

  49. Meier RH 3rd, Melton D. Ideal functional outcomes for amputation levels. Phys Med Rehabil Clin N Am. 2014;25(1):199–212. https://doi.org/10.1016/j.pmr.2013.09.011.

    Article  PubMed  Google Scholar 

  50. Wu Y, Keagy RD, Krick HJ, Stratigos JS, Betts HB. An innovative removable rigid dressing technique for below-the-knee amputation. J Bone Joint Surg Am. 1979;61(5):724–9.

    Article  CAS  PubMed  Google Scholar 

  51. Reichmann JP, Stevens PM, Rheinstein J, Kreulen CD. Removable rigid dressings for postoperative management of transtibial amputations: a review of published evidence. PM R. 2018 May;10(5):516-523. https://doi.org/10.1016/j.pmrj.2017.10.002. This is the first comprehensive review published that assembled all of the peer-reviewed medical evidence on removable rigid dressings, ranked the strength of the evidence on research design, and made an evidence-based practice recommendation.

  52. Koonalinthip N, Sukthongsa A, Janchai S. Comparison of removable rigid dressing and elastic bandage for residual limb maturation in transtibial amputees: a randomized controlled trial. Arch Phys Med Rehabil. 2020 Oct;101(10):1683-1688. https://doi.org/10.1016/j.apmr.2020.05.009. Erratum in: Arch Phys Med Rehabil. 2021 Aug;102(8):1668. This randomized controlled trial provided supporting evidence the use of removable rigid dressings resulted in a significantly shorter period to residual limb maturation compared to using traditional elastic bandages.

  53. Fencel R, Fitzpatrick S, Dunlap E, Nagarsheth K. Utilizing of removable rigid dressing to decrease below the knee amputations to above the knee amputations conversion rates. Am Surg. 2022 May 13:31348221101482. https://doi.org/10.1177/00031348221101482. Authors made a practice recommendation, consistent with Reichmann et al., that removable rigid dressings should be considered post-operatively as first-line therapy for patients receiving a below-knee amputation after discovering revisions to an above-knee amputation caused by falls or poor wound healing were reduced from 42.86 to 7.55%.

  54. Hughes S, Ni S, Wilson S. Use of removable rigid dressing for transtibial amputees rehabilitation: a Greenwich Hospital experience. Aust J Physiother. 1998;44(2):135–7. https://doi.org/10.1016/s0004-9514(14)60374-3.

    Article  PubMed  Google Scholar 

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Correspondence to James P. Reichmann.

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Reichmann declares he has no conflict of interest. Kreulen receives royalties and consulting fees from Arthrex and consulting fees from Restor3d.

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Reichmann, J.P., Kreulen, C.D. Post-operative Inpatient Falls Among Major Lower Limb Amputees. Curr Phys Med Rehabil Rep 11, 1–5 (2023). https://doi.org/10.1007/s40141-023-00378-7

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