Due to poor anatomical conditions and a high postoperative re-occlusion rate, 20–50% of CLI patients, which are also called no-option CLI (NO-CLI) patients, are not suitable for traditional interventions such as surgical or endovascular treatment.13 AICLI, which shows a propensity for affecting the distal small or microvessels and destroying the anatomic run-off, composes a remarkable proportion of the NO-CLI population. However, AICLI patients, in which most patients were TAO-induced, were characterized with young age and a large proportion of males. In the current study, 171 patients (170 were male) with a mean age of 41.9 ± 9.6 years were enrolled and analyzed. Therefore, successful RTW is of vital significance not only to AICLI patients and their families but also to the society. In this single center retrospective study, approximately two thirds of the patients returned to work in the year after hospitalization for AICLI, indicating that cell therapy could not only achieve the recovery of physical well-being but also satisfactory psychological health.
Vohra et al. reported that the postoperative employment status of patients with claudication who underwent lower limb revascularization was positively influenced by younger age.14 Burger et al. reported that patients’ RTW after limb amputation depended on general factors including age.15 In the current study, age ≥ 40 years old was a negative independent risk factor for AICLI patients’ RTW within 12 months. We infer the role that age played in the RTW progress might be explained with several aspects. First, the relief of ischemia was partly up to the function of cell product including angiogenesis and vasculogenesis. The auto-implants of aged patients were reported to be related to impaired angiogenic potency and younger age was reported to be associated with better therapeutic effect of cell therapy in the treatment of NO-CLI patients.16–20 Second, younger patients were characterized with better general condition and less comorbidities, thus lowering the risk of adverse events including death, organ dysfunction and cardio-cerebrovascular diseases which might occur during the follow-up and further stop patients from RTW. In 2019, we reported a study in terms of factors associated with the 6-month CLI remission among AICLI patients who underwent cell transplantation.21 In the previous study, age ≥ 50 years old was reported to be the independent factors of the 6-month CLI remission. However, in the current study, the age identified was younger (40 years old). We speculate that this may be partly explained by the fact that AICLI patients in their 50s are more likely to retire early even after total relief of CLI, given that the legal retirement age in China is 60 years old (for men).22 Though in studies in terms of RTW of patients with coronary heart diseases or cerebral artery diseases, age was seldom reported to be a predictive factor ,23–27 considering that cardio-cerebrovascular diseases tended to occur in the elderly and most patients they enrolled in the studies were over 50 years old, it’s reasonable that younger age was not reported to be associated with RTW.
Patients’ preoperative job type, together with education and income, are important indicators of socioeconomic status, and it may capture some or all of the effect of income and education.28 Some studies also reported that different job types to be indicators of patients’ RTW after orthopedic surgery.29,30 In the current study, preoperatively working as a mental worker was identified as a positive independent risk factor for patients’ RTW. This can be reasonable, for that mental work generally demand less physical expenditure compared with other types of work thus lowering the physical threshold needed for RTW. Among all the job types in the current study, mental worker was the one with not only the highest RTW ratio (39/41, 95.1%) but also the highest return to the same work ratio (31/41, 75.6%). In contrast, for jobs which require a certain amount of physical activity, including manual worker and farmer, the proportion of non-RTW patients and patients who change work owing to AICLI were relatively high. Like we mentioned before, job type could also reflect worker’s education to some extent. Jiang et al. reported that college education was associated with a higher likelihood of return to work after acute myocardial infarction.23 Wang et al. reported higher educational level was a significant factor associated with RTW in patients with severe traumatic brain injury.31 In the current study, 7.0% (12/171) of patients were with a bachelor degree and RTW was achieved in 10 patients in whom 8 were preoperatively working as metal workers.
Out of 171 patients, 150 (87.7%) were in RC 5 with an ulcer/gangrene at admission and 13.4% (23/171) of them were with infection during the perioperative period. Infection is a factor which generally increases oxygen consumption further aggravates the ischemic degree and tissue loss in patients with CLI. Lu et al. reported that infection was an important independent risk factors of amputation in patients with diabetes-induced CLI.32 On the other hand, patients with limb infection often require relative long-term anti-infective treatment including antibiotics treatment, regularly dressing change and even elective debridement. This process not only prolongs the time period for rehabilitation but also makes patients pay over attention to their ischemic limbs for fear of recurrence thus delaying or even canceling their plans to RTW.
RTW is associated with the relief of ischemia after cell transplantation. However, not all patients return to work after total relief of CLI. Many RTW patients claimed to be free of pain in the transplanted limb and started working again within the 12-month follow-up while a 2-class pians evaluated by Wong-Baker FACES Pain Rating Scale (WBFPS) could still be observed. On the other hand, there were also many patients who were resistant to re-employment even after total relief of limb ischemia and one was even diagnosed with depression. Therefore, both physical and mental well-being are essential for RTW and considering the fact that the retirement age for many jobs in China has been increasing to 65 years, RTW will be a more and more important indicator in measuring treatment methods.
The biggest limitation of the current study lies in its essence as a single-center retrospective study. However, as to our knowledge, there is little studies focusing on the postoperative RTW for CLI patients, especially AICLI patients, who underwent cell transplantation.