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Chapter 26

### INTRODUCTION

The rehabilitative care of adults with acquired amputation of the lower extremity as a result of trauma or dysvascular disease is a challenging area of specialization within the field of physical medicine and rehabilitation. Management relies on careful evaluation of the patient, obtained through the history and physical examination, and presupposes a good understanding of the constantly evolving componentry for prosthetic fitting and rehabilitation.

### EPIDEMIOLOGY

More than 100,000 major amputations occur each year in the United States. This number is steadily growing as a result of the increasing incidence of diabetes mellitus and dysvascular disease, and the steadily increasing number of individuals older than 65 years. Dysvascular disease accounts for 82% of all amputations, with 97% of these in the lower limb. Trauma accounts for 16% of amputations, with only 32% of these involving the lower limb. Cancer and infection together account for roughly 1% of amputations, with 75% of these involving the lower limb. The remaining 1% of amputations are the result of congenital deficiency or deformity.

There are more than 1.6 million amputee survivors in the United States, and this number is also steadily increasing. One third of these patients are survivors of dysvascular disease; the other two thirds represent traumatic amputation. The long-term survival of the former group is dramatically lower than that of patients with trauma-related amputation.

The perioperative survival rate following lower limb amputation due to vascular disease is 94% for patients with amputation below the knee and 83% for patients with amputation above the knee. The 5-year survival rate for patients with amputation below the knee is 48%, and only 22% for patients with amputation above the knee. The long-term survival rate for patients with traumatic amputation is near normal. The rate of revision surgery for the vascular population is 18–25%, with nearly 10% converting from below-the-knee to above-the-knee amputation. Amputation of the remaining limb is also a significant concern. The risk of having amputation of the remaining limb is greater than 50% at 5 years. The rate of revision surgery for the traumatic population is approximately 14%, with a wound infection rate of 34%. Consequently, although many more amputations due to diabetes and dysvascular disease are performed annually compared with amputations from trauma, the long-term survival of the trauma patient is much better and much longer. The “50–50” rule remains unchanged for the dysvascular population: approximately 50% of vascular amputees die within 5 years of the first amputation, and of the survivors, 50% will lose a portion of the remaining lower limb.

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