Perceived Concerns of Patients at Risk for Lower Extremity Amputation

Despite a good understanding of risk factors for amputation and the development of multidisciplinary amputation prevention teams, thousands of lower limb amputations are performed on a daily basis. These amputations are often transformative events in the lives of patients with functional, psychological, social, and economic implications. Objective. The objective of this investigation is to qualitatively and quantitatively explore the perceived concerns of patients with chronic wounds at risk for lower extremity amputation. Materials and Methods. A guided, physician-administered survey was completed by consenting participants. The survey consisted of both open-ended questions and a 10-point scale for specific questions on a variety of potential patient concerns. Results. Although some questions resulted in relatively high and low mean scores, 9 of the 13 specific questions produced a range of responses on a 10-point modified Likert scale. This indicates that there are not necessarily universal patient concerns and that every patient is different and should be treated as such. With that being said, however, the highest levels of concern (mean measurements ≥ 7/10) had to do with recurrence, function, walking, and self-sufficiency. The lowest levels of concern (mean measurement ≤ 5/10) had to do with pain, shoe gear considerations, cost, and cosmetic appearance of an amputation. Conclusions. It is the authors’ hope that this investigation provides wound care professionals with information that will benefit their approach to the education and treatment of patients at risk for amputation as well as lead to future investigations into the emotional and psychological state of patients with chronic lower extremity wounds. 

There are millions of people in the world at risk for lower extremity amputation as a consequence of chronic wounds, usually a result of the diabetes mellitus disease process. Despite a good understanding of the risk factors for amputation and the development of multidisciplinary amputation prevention teams, thousands of limb amputations are performed on a daily basis.^1-11 These amputations are often transformative events in patients’ lives with functional, psychological, social, and economic implications.^12-22 Understandably, most are initially resistant to the recommendation of amputation and demonstrate a range of emotions (eg, grief and fear), even in advanced disease states when amputation is a seemingly inevitable outcome.^23-27 

Although there have been previous investigations exploring patients’ perceived risk of diabetic complications and studies examining how patients cope with amputation postoperatively,^28-36 providers are unaware of any analysis into patients’ perceived post amputation concerns prior to the actual event. This information could be helpful with respect to the education and treatment of high-risk patients and arguably important for appropriate informed consent in order to fully advise patients of the potential risks and complications of performing an amputation. It also may help physicians better understand patient concerns, allow for better communication, and improve the physician-patient relationship. Hence, the objective of this investigation is to qualitatively and quantitatively explore the perceived concerns of patients at risk for lower extremity amputation as a consequence of having a chronic wound. 

Following approval from Temple University Hospital Institution Review Board (Protocol #23088), a guided, physician-administered survey was completed by verbally consenting participants. The survey consisted of both open-ended questions and a 10-point modified Likert scale for specific questions on a variety of potential patient concerns (Figure). The survey topics and potential patient concerns were derived from the authors’ collective clinical experiences. Inclusion criteria consisted of participants with chronic lower extremity wounds being treated at a wound care center and limb salvage center in an urban US environment, without a history of minor or major limb amputation, and who were considered to be at risk for a minor or major limb amputation. These were primarily participants with an already-established patient-physician relationship with the study authors and who were aware of their amputation risk. There was no time limit placed on completion of the survey in an attempt to generate an open discussion with participants.  

Basic descriptive statistics (mean ± standard deviation; range) of the scale of the specific questions were performed. Representative summaries of the responses to the open-ended questions were derived.

Fifteen participants completed the survey over a 1-month data collection period. The specific scale questions with their respective descriptive statistics are presented in Table 1. 

The open-ended questions generated a range of responses (Table 2). Participants were first asked: “What general feelings do you have about an amputation involving your foot?” Several patients mentioned the terms anxiety, fear, and even doom. Some had come to realize that it would be a necessary thing. One specifically mentioned how eye-opening the process was because the disease process moved so fast. 

Participants were asked: “What are you most concerned with regarding an amputation involving your foot?” This question generated the widest range of responses. Several were most concerned about a loss of mobility or loss of self-sufficiency. Others specifically mentioned pain and concerns with undergoing anesthesia. One was most concerned with developing a postoperative infection.

Participants were asked: “Do you personally know anyone who has undergone an amputation involving their foot; if yes, what was their experience?” Interestingly, all 15 participants had known someone who had undergone an amputation, whether it be a family member or friend. About half had undergone a relatively good experience while the other half had undergone a relatively bad experience. 

Participants were asked: “What have been the most challenging aspects of dealing with your foot problems?” Most stated that the most difficult aspect was dealing with recurrence or ups and downs with the process. Some reported pain, mobility, and dealing with a rehab center as the most challenging aspects.

Participants were asked: “What differences do you see between an amputation involving your toes, a more substantial portion of your foot, or the entire foot below the knee?” Fairly consistent answers were reported with more proximal amputations resulting in problems with mobility, walking, and balance.

As with any scientific investigation, critical readers are encouraged to review the study design and specific results in order to reach their own conclusions, while the following represents the conclusions based on the preceding results. The authors believe this investigation was able to provide unique results of the perceived concerns of patients at risk for lower extremity amputation. It is unique because it evaluated patients who were at risk for minor or major amputation but who had not yet undergone the procedure. The authors intended to elucidate information, which in turn could lead to better patient education by lower extremity wound professionals as well as a more accurate informed consent process prior to an actual amputation. Although the authors do not consider any data to be definitive, they believe these results indicate at least some interesting trends.

First, they observed a wide range and variability in terms of the responses to the quantitative questions answered by patients. Although some questions resulted in relatively high and low mean scores, 9 of the 13 questions produced a range of responses on the 1–10 scale. This indicates that there are not necessarily universal patient concerns and that every patient is different and should be treated/educated as such. With that being said, however, the highest levels of concern (mean measurements ≥ 7/10) had to do with recurrence, function, walking, and self-sufficiency. The lowest levels of concern (mean measurement ≤ 5/10) had to do with pain, shoe gear considerations, cost, and the cosmetic appearance of an amputation.

Second, they observed interesting responses to the open-ended questions which might provide physicians with further insight into patient concerns and might be utilized to further develop a physician-patient relationship. In the authors’ practices, they most appreciated that many patients did experience feelings of anxiety and fear and that most of these concerns seemed to have to do with worries about loss of function and self-sufficiency following an amputation.

All scientific investigations have limitations, and this investigation had several important ones to consider. Data were collected from a limited number of patients from 2 urban US health care centers, so these results might not be representative of a broader population sampling. This might be particularly true of other geographic areas consisting of different patient demographic factors and socioeconomic statuses. Caution also should be utilized to not draw broad conclusions from a relatively small cohort size. Finally, some inherent selection bias of consenting patient volunteers might be present. Those who agreed to participate in the survey might have had a different outlook of their disease process than those who refused to participate.

It is the authors’ hope that this investigation provides lower extremity wound professionals with information that will benefit their approach toward the education and treatment of patients at risk for amputation as well as lead to future investigations into the emotional and psychological states of patients with chronic lower extremity wounds. 

From the Delaware County Memorial Hospital Center for Wound Healing and Hyperbaric Medicine, Drexel Hill, PA; and Clinical Associate Professor, Department of Podiatric Surgery, Temple University School of Podiatric Medicine, Philadelphia, PA

Address correspondence to:
Andrew Meyr, DPM
TUSPM Department of Surgery
8th at Race Street
Philadelphia, PA 19107
ajmeyr@gmail.com 

Disclosure: The authors disclose no financial or other conflicts of interest.