Quality of life for patients who have undergone a major lower limb amputation is an issue of great concern. Hence there has been quite an extensive investigation into this facet of the post-operative experience. The overall Quality of life in this study was determined to be below standard when compared to population norms for Trinidad and Tobago [4]. Additionally, individuals who ambulated with a prosthesis were found to have a better quality of life than those who did not. However, no statistical difference was seen for above versus below-knee amputees. Although this provides some insight into the post-amputation Quality of life, caution should be exercised as there can be some misconception. Poor Quality of life for the entire cohort was obtained, and therefore this is one possible reason no difference was observed between above knee and below-knee amputees. Admittedly, many of the countries for which the average overall index values were compared to are of the first-world status, with superior health care systems. This cohort had a higher overall index value when compared to Scottish, Swedish and Chinese data [19–21]. Although many of these studies have used the EQ 5D-5L or 3L Quality of life assessment tools, there is a variation of the time elapsed post amputation and when the assessment was performed. This poses a significant barrier to comparison as the time to prosthetic acquisition as well as rehabilitation programs varies across all health systems and regions. The considerable degree of disparity regarding demographic, geographic, social and economic factors amongst the populations studied, unfortunately with no real solution.
Furthermore, there are several Quality of life assessment tools which have been developed and used to obtain this information. These include SF-36, WHO BREF, EQ 5D, just to name a few [17, 18, 22, 23]. Due to this high degree of variability amongst the population and the absence of a standard assessment tool, the applicability of findings established internationally cannot be extrapolated to our population [24]. In the Caribbean, there has been several studies which have characterised and placed perspective on major lower limb amputations [1–3]. Several reports highlighting the challenges of limb amputations have emerged from countries such as Barbados, Jamaica and Trinidad [2, 25–27]. Despite this, there remains a paucity of data assessing the Quality of life experienced by amputees and remains unchartered territory for the Caribbean region.
The EURO QOL 5D-5L assessment tool was used in this study as it was simple, easy to understand, short and assessed the major aspects of Quality of life (mobility, self-care, usual activity, pain/discomfort, depression/anxiety and overall health). Several studies have been performed evaluating various populations in an attempt to document standard population utility indices [28–31] Moreover, this is an international, validated health-related quality of life assessment tool, which an index value can be obtained and used to cross-reference with several other countries internationally [24]. The real value of using the EQ 5D tool is derived from the existing value indices for Trinidad and Tobago published by Bailey et al. Although the population norm indices were obtained using the older version of the EQ 5D tool, this was easily overcome by translation of the EQ 5D-3L indices into the EQ 5D-5L equivalent [4, 18]. There have been several of the statistical methods used for this purpose, which have been studied as well as validated internationally and has been deemed acceptable by the Euro QOL Study Group [17].
This study demonstrated that amputees below the age of 50 years experienced a better quality of life than those over 50 years. These findings are not surprising as Quality of life tends to decrease with advancing age [4]. Furthermore, older patients are more likely to have co-morbid conditions which can all contribute to delayed rehabilitation, affect mobility and therefore result in a poor quality of life. Rehabilitation of the older patient, therefore, needs to be performed in a tailored, aggressive manner, which may require pre-operative conditioning/or selection of these patients. The goals for rehabilitation should, therefore, be set in the pre-operative phase, we believe all other aspects of care even the surgical intervention necessary be tailored to this.
Mobility is of one of the most critical aspects of quality of life post-amputation, as it is most directly affected, and it influences all other elements. Limb preservation is the single most influential factor on the degree of mobility in a patient having either a minor or major lower limb amputation. The literature is clear and has proposed that having a below-knee amputation is more favourable as mobility, attaining for a prosthesis is more likely, and less energy is required when compared to an AKA [6, 32, 33]. Although the overall mean index value (.627) for transtibial amputees (TTA) was higher than the mean index value (.568) for transfemoral amputees (TFA) this difference was not significant (p value = .96). This trend can be explained by the fact that the amputee population in the study had a poor quality of life overall and therefore, differences between the two groups were indistinguishable.
Further subgroup analysis revealed that the method of ambulation impacted significantly on Quality of life. Quality of life index values for amputees who ambulated with a prosthesis (overall, TTA and TFA, 0.759) were higher than other modes of ambulation (0.562) as well as non-ambulant patients (0.269), p value .0003 and .0004 respectively. Additionally, those amputees who were non-ambulant had significantly worse Quality of life than the other two groups who ambulated. Based on this information, we can, therefore, infer that the ideal mode of ambulation for an amputee is with a prosthesis. Furthermore, mobilisation with another device such as a Zimmer frame, crutches or a wheelchair, although not ideal is superior to not ambulating at all. There is strong evidence in the literature to suggest that ambulating with a prosthesis is the most influential factor on an amputee's Quality of life [14]. Hence adaptation of a similar approach to major lower limb amputation as proposed by the Vascular Society in their guidelines for holistic care is a step in the right direction [12]. One of the primary goals of this programme which involves a multi-disciplinary team, with multiple stages of interventions (pre-operative to rehabilitation), was to reduce the 90-day mortality rate to less than 10%. There have also been other reports which have emphasised a multi-staged, multi-disciplinary approach in an attempt to achieve better outcomes of Quality of life [5].
The 30-day mortality rate observed for this cohort of patients was 14%, which doubled to 27% at 1 -year. These rates are comparable to those from Sweden, New Zealand study as well as several other regions [19, 34, 35]. Moreover, the hospital mortality rate of 9% was marginally lower to that published by Solomon et al. in a locally conducted study [1]. These rates are higher than the target, which has been set by the Vascular Society and therefore, further highlights that significant improvement is necessary.
To date, this study is one of very few evaluating the of Quality of life in major lower limb amputees emerging Anglo-speaking Caribbean. Several factors have been identified such as age, ambulation and prosthetic use which is positively associated with a better quality of life. Hence this data can be used to change the approach to major lower limb amputees locally and regionally. Finally, the use of the Euro Qol 5D-5L tool has been shown to be of value in the amputee population. The authors would recommend including it prospectively in the future for any amputee to address issues which may arise in the five domains of health-related Quality of life. This will allow these issues to be addressed in a timely manner and achieve better outcomes. Additionally, this study can pave the way for further investigation into health-related Quality of life in other sub-groups of surgically treated patients.