Patient-, treatment-, and facility-level structural characteristics associated with the receipt of preoperative lower extremity amputation rehabilitation.

OBJECTIVES: To determine patient, treatment, or facility characteristics that influence decisions to initiate a rehabilitation assessment before transtibial or transfemoral amputation within the Veterans Affairs (VA) health care system. DESIGN: Retrospective database study. SETTING: VA medical centers. PARTICIPANTS: A total of 4226 veterans with lower extremity amputations discharged from a VA medical center between October 1, 2002, and September 30, 2004. OUTCOME: Evidence of a preoperative rehabilitation assessment after the index surgical stay admission but before the surgical date. RESULTS: Evidence was found that 343 of 4226 veterans (8.12%) with lower extremity amputations received preoperative rehabilitation assessments. Veterans receiving preoperative rehabilitation were more likely to be older, admitted from home, or transferred from another hospital. Patients who underwent surgical amputation at smaller-sized hospitals or in the South Central or Mountain Pacific regions were more likely to receive preoperative rehabilitation compared with patients in mid-sized hospitals or in the Northeast, Southeast, or Midwest regions. Patients with evidence of paralysis, patients treated in facilities with programs accredited by the Commission on Accreditation of Rehabilitation Facilities (P < .01), and patients in the second data wave were less likely to receive preoperative rehabilitation. After accounting for patient-, treatment-, and facility-level structural characteristics, we found that older patients were more likely to receive preoperative rehabilitation services (odds ratio [OR] 1.01, 95% confidence interval [CI] 1.01-1.02). Patients with a contributing amputation etiology of a previous amputation complication were more likely to receive preoperative consultation rehabilitation services (OR 1.50, 95% CI 1.02-2.19) compared with patients who did not have this etiology. Compared with patients treated in the Southeast region of the United States, those treated in the South Central region (OR 2.52, 95% CI 1.82-3.48) or Mountain Pacific region (OR 1.62, 95% CI 1.11-2.37) were more likely to receive preoperative consultation rehabilitation services. Patients with evidence of paralysis were less likely to receive preoperative rehabilitative services compared with patients who did not have this condition (OR 0.29, 95% CI 0.09-0.93), and patients treated in mid-sized hospitals also were less likely to receive preoperative rehabilitative services compared with patients treated in smaller-sized facilities (OR 0.38, 95% CI 0.27-0.53). Veterans in the second data year were less likely to receive services compared with patients in the first year (OR 0.74, 95% CI 0.58-0.94). CONCLUSIONS: Rehabilitation assessment before lower extremity amputation surgery is a rare occurrence in the VA health care system. Practice patterns appear to be driven by location and not by patient characteristics.

Technique of forequarter (interscapulothoracic) amputation.

In the anterior approach to forequarter amputation, a segment of clavicle is removed and early dissection and division of the subclavian vessels are done. In the posterior approach after division of the trapezius and muscles attached to the vertebral border of the scapula, the trunks of the brachial plexus and the subclavian vessels are serially ligated and divided, while the pectoral muscles are intact. In both approaches, the dissection around the subclavian vessels can be slow and tedious to avoid bleeding, which could be difficult to control because the vessels have not been cleared circumferentially for application of a vascular clamp. Our technique combines an anterior and a posterior approach, which rapidly divides all the relevant muscles and clavicle, and leaves at the end the division of the nerves and subclavian vessels as the extremity is gently supported to avoid undue traction on the vessels. The trunks of the brachial plexus are divided posteriorly and the subclavian vessels at the thoracic inlet, allowing a greater proximal margin than that achieved by the anterior or posterior approach. When extra skin has to be removed from the axilla because of tumor involvement, a fasciocutaneous deltoid flap may provide coverage of the defect.

Retroperitoneal sarcomas: grade and survival.

BACKGROUND: The survival of patients with retroperitoneal sarcomas depends on the feasibility of complete resection and the grade of the tumor. HYPOTHESIS: A high rate of complete resection, wide rather than local excision when feasible, and a policy of prompt reoperation for local recurrence all improve survival. METHODS: A review of 130 consecutive patients with retroperitoneal soft tissue sarcomas (1977-2001). RESULTS: The complete resectability rate was 95%, being 99% (78/79) for the primary tumors and 90% (46/51) for tumors referred with local recurrence. Local recurrence after complete resection occurred in 41% (32/79) of those with primary tumors and in 61% (31/51) of those referred with local recurrence (P =.06). The local recurrence rate was 63% after local excision and 39% after wide resection (P =.02). Of 83 patients with relapse, 37 (45%) were rendered surgically disease free. The estimated 5-year (10-year in parentheses) survival from the first surgery at our center was 65% (56%) for patients with primary tumors and 53% (34%) for patients referred with local recurrence (P =.23). For the primary tumors, the 5- and 10-year survival rates were 70% and 60%, respectively, after wide resection and 47% and 39%, respectively, after local excision (P =.04). For the primary tumors, the 5-year survival was 92%, 54%, and 48% for grades I, II, and III, respectively (P =.02). For those referred with local recurrence, the figures were 76%, 45%, and 19% for grades I, II, and III, respectively (P<.001). CONCLUSIONS: A high resectability rate (95%) is possible in retroperitoneal sarcomas. The survival estimates are similar to those following resection of extremity soft tissue sarcomas given an effective reoperation policy for local recurrences. Wide resection lowers the local recurrence and improves survival significantly. Survival varies significantly according to the grade of the tumor.