Discharge to Inpatient Rehab Improves Prosthesis Use and Functional Mobility Following Unilateral Major Amputation

BACKGROUND: Patients who undergo major lower extremity amputation (MLA) have impaired postoperative mobility. Inpatient rehabilitation (IRF) has demonstrated benefits for patient fitness and freedom from readmission compared to home discharge or skilled nursing facility (SNF) in other disease processes. However, the impact of discharge disposition on 1-year mobility and long-term mortality are less well known in an MLA patient cohort. METHODS: Patients with MLA, including below-the-knee and above-the-knee amputation, within the Vascular Quality Initiative database from January 2011 to January 2025 were included. After excluding those without follow-up data, patients were separated based on discharge disposition: IRF, SNF, or home. Primary outcomes include 1-year functional mobility, a composite metric of prosthesis use, ambulation, and physical therapy, and long-term mortality. One-year functional mobility was interrogated using propensity score matched comparisons of in IRF versus home and IRF versus SNF. Five-year mortality rates were tested using Kaplan-Meier survival analysis. RESULTS: A total of 12,046 MLA patients were identified: 5,784 (48.0%) were discharged to IRF, 3,200 (26.6%) to SNF, and 3,062 (25.4%) home. Of the matched groups, patients in the IRF group were more likely to use a prosthesis (P < 0.001) and had better composite functional mobility (P = 0.012) than those in the home or SNF groups. Compared with patients discharged to home, those discharged to IRF were associated with a higher likelihood of 1-year prosthesis use (odds ratio [OR]: 1.4, 95% confidence interval [CI]: 1.2-1.6), whereas those discharged to SNF were associated with a lower likelihood of prosthesis use by 1 year (OR: 0.8, 95% CI: 0.5-0.7). Other factors associated with increased prosthesis use included commercial insurance coverage (OR: 1.3, 95% CI: 1.1-1.5), use of rigid removable dressing (OR: 1.5, 95% CI: 1.2-1.9), and independent ambulation at discharge (OR: 1.4, 95% CI: 1.3-1.7). Also, fixed plaster cast compared with gauge only (OR: 0.5, 95% CI: 0.3-0.8), indication of tissue loss (OR: 0.7, 95% CI: 0.5-0.9), and joint contracture (OR: 0.3, 95% CI: 0.2-0.6) were negatively associated with the ability to walk independently. All-cause mortality was the lowest in patients who were discharged to IRF through 5 years after index procedure (P < 0.001). CONCLUSION: Patients who are discharged to IR after MLA had higher functional mobility at 1 year, reduced all-cause mortality at 5 years and were more likely to utilize a prosthesis postamputation. Identified factors that support prosthesis use including inpatient ambulation status may be optimal targets for quality improvement in this patient population.