Evolution of a Specialized Multidisciplinary Amputee Care Clinic: Referral Patterns and Patient Satisfaction

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Raasveld, Omar Moussa, Otis C. Varsseveld, Jenna L. Daddario, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8289177/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 14 You are reading this latest preprint version Abstract Introduction: The rising prevalence of limb amputations, combined with increasing awareness of post-amputation pain and the need for functional rehabilitation, has created a pressing demand for comprehensive, multidisciplinary care models for patients with limb loss. This study describes the patient population and satisfaction outcomes of a specialized amputee care clinic. Methods Adult amputees treated at our institution’s Interdisciplinary Care for Amputees Network (ICAN) clinic between 2017–2024 were retrospectively reviewed. Demographics, surgical characteristics, and referral patterns were analyzed. Patient satisfaction was assessed cross-sectionally using the Short Assessment of Patient Satisfaction (SAPS) questionnaire. Results Of 318 operative amputee patients (median follow-up 2.0 years (IQR:0.8–3.4)), 90.6% underwent lower extremity amputation (58.5% transtibial, 27.7% transfemoral), primarily due to trauma (43.7%) or infection (25.2%). Referrals originated primarily from academic medical centers (71.1%), with orthopaedic specialties (46.9%) as predominant source. All operative patients underwent Targeted Muscle Reinnervation (TMR) and/or Regenerative Peripheral Nerve Interface (RPNI), performed primarily during amputation in 158 patients (49.7%), and secondarily for established neuropathic pain in 160 patients (50.3%). Among 270 eligible patients contacted, 156 (57.8%) completed the satisfaction survey. Overall satisfaction was 86.5% (42.3% “very satisfied”, 44.2% “satisfied”), with the highest ratings for provider thoroughness (94.5%) and respect (96.6%), and the lowest for time spent with providers (78.9%). Patients with anxiety were significantly more likely to express dissatisfaction (p = 0.017). Conclusions The implementation of a specialized multidisciplinary amputee care model achieved high satisfaction across care domains. These findings support integrated approaches to amputee management and suggest potential benefits from broader adoption. Level of Evidence: III – therapeutic Amputee care multidisciplinary care targeted muscle reinnervation regenerative peripheral nerve interface patient satisfaction healthcare delivery model interdisciplinary Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Introduction The prevalence of limb amputations continues to rise globally, with projections indicating a doubling of the amputee population in coming decades due to aging demographics and increasing rates of diabetes mellitus and peripheral vascular disease. An estimated 1.6 million individuals were living with limb loss in the United States in 2005, with this number projected to more than double to 3.6 million by 2050. 1 This growing healthcare challenge demands multifaceted models of care delivery that prioritize both patient satisfaction and clinical cost-effectiveness. Traumatic amputations account for more than 13 million new cases worldwide each year, contributing to substantial healthcare and societal costs 2 – 4 Historically, care for amputees has focused primarily on surgical intervention. This approach has evolved toward comprehensive care models that address the complex physical and psychosocial needs of patients with limb loss 5 . Advances in pain management, particularly for post-amputation pain syndromes, have shifted emphasis toward preventive strategies and early intervention 6 , 7 . These developments have driven the emergence of multidisciplinary care models that integrate various specialties, including orthoplastic surgery, physiatry, psychosocial support, and rehabilitation services. 8 – 10 The Interdisciplinary Care for Amputees Network (ICAN) was established to implement such a comprehensive care model in 2017, combining orthoplastic surgical intervention with post-operative functional and psychosocial rehabilitation 11 . This program provides coordinated care from orthopaedics, plastic surgery, physiatry, infectious diseases, physical/occupational therapy, prosthetists, and pain management specialists. A key component of the model is a multifaceted approach to pain management, recognizing the significant influence of psychosocial factors on patient outcomes. After several years of implementation and development, we sought to evaluate our model by analyzing the demographics and characteristics of patients seeking care at our center, as well as their satisfaction with the services provided. This assessment aims to refine our approach and optimize resource allocation to better meet the needs of this patient population. Methods Study design and patient selection Following institutional review board approval (IRB #2020P003555), a retrospective review was conducted of all adult amputees (≥18 years) treated at ICAN between 2017 and September 2024 (n = 318). This analysis focused exclusively on patients who underwent surgery; 53.8% (370/688) of referred patients did not undergo surgery (but potentially did receive non-surgical treatments) and were excluded for this study. Subsequently, a cross-sectional satisfaction and demographic survey was administered to eligible patients. Exclusions included deceased patients (n = 34), non-English speakers (n = 10), or those admitted to the hospital at the time of survey (n = 4). Of the 270 (85.0%) eligible patients who were contacted between September and December 2024, 156 (57.8%) completed the survey (Fig. 1 ). Data acquisition Demographics, surgical characteristics, and referral patterns were extracted from electronic medical records. Demographic data included sex, age at surgery, body mass index (BMI), race/ethnicity, insurance type, education level, employment status, and geographic location by state or country. Comorbidity data included smoking status, alcohol use, diabetes mellitus, hypothyroidism, psychiatric diagnoses (depression, anxiety, personality disorder, and post-traumatic stress disorder (PTSD)), peripheral vascular disease (PVD), chronic kidney disease (CKD), history of chronic pain, complex regional pain syndrome (CPRS), and pre- and postoperative use of opioids and neuromodulating medications. The Elixhauser Comorbidity Index (ECI) was calculated for each patient to quantify overall comorbidity burden. Surgical data included amputation laterality and level (categorized as upper extremity: shoulder disarticulation, transhumeral, transradial, or partial hand; and lower extremity: hip disarticulation, transfemoral, knee disarticulation, transtibial, or partial foot), indication (trauma, infection/sepsis, malignancy, pain/dysfunctional limb, peripheral vascular disease, or congenital deformity), and mechanism of injury for trauma patients. Details regarding the type of peripheral nerve surgery - whether Targeted Muscle Reinnervation (TMR), Regenerative Peripheral Nerve Interface (RPNI), or a combination of both techniques applied to different nerves during the same procedure - were recorded, along with whether the surgery was performed to treat preexisting neuropathic pain (secondary stage) or prophylactically at the time of amputation (primary stage). For secondary procedures, the interval from amputation to surgery was documented. Hospital length of stay (LOS) was recorded, including same-day discharge (SDD). Finally, referral characteristics included referring institution type (academic medical center, community hospital, specialized center, community health center, rehabilitation center, Veterans Affairs center, or international facility), referring department, and discharge disposition following surgery at the ICAN clinic (home-based care, rehabilitation hospital, facility-based care, end-of-life care, or other). Satisfaction Survey Patient satisfaction was assessed using the validated Short Assessment of Patient Satisfaction (SAPS) questionnaire, administered via telephone or electronic survey between September and December 2024 12 . The SAPS is a 7-item instrument that evaluates key domains of healthcare satisfaction including treatment effect, provider care quality, comprehensiveness of information, participation in decision-making, respect from providers, time spent with providers, and overall satisfaction. Each item is scored on a 5-point scale (0–4), with total scores ranging from 0–28. Patients were categorized as “very satisfied” (score 27–28), “satisfied” (score 19–26), “dissatisfied” (score 11–18), or “very dissatisfied” (score 0–10). To identify patient factors associated with dissatisfaction, SAPS score was further dichotomized in “satisfied” (SAPS≥19) and “dissatisfied” (SAPS < 19). Statistical analysis All collected data were assessed for normality of distribution using histograms and Shapiro-Wilk tests. Normally distributed continuous variables are presented as means with standard deviations (± SD), while non-normally distributed variables are presented as medians with interquartile ranges (IQR). Categorical variables are reported as numbers with percentages. Descriptive statistics were calculated for the entire cohort and separately for the patients who completed the survey. Exploratory bivariate analyses using Fisher’s exact, t-tests, or Mann-Whitney U were conducted to assess patient factors associated with dissatisfaction. Data were registered using Research Electronic Data Capture (REDCap), which is a HIPAA-compliant database and survey tool. Data analysis was conducted using R (version 4.4.1, R Core Team, Vienna, Austria), and SAMPL guidelines were adhered to 13 . A non-responder analysis was conducted to assess whether survey data were missing completely at random (MCAR). P-values < 0.05 were considered statistically significant. Results PART I: ICAN patient characteristics A total of 318 patients were treated at the ICAN clinic during the study period. The median age at surgery was 54.2 years (IQR 39.2–64.7), and 110 patients (34.6%) were female. The median BMI was 27.8 kg/m² (IQR 23.5–32.5). Median follow-up was 2.0 years (IQR 0.8–3.4) Patients were predominantly white (82.7%) and most patients (82.1%) had private insurance. Among the 156 patients (49.1%) who completed the satisfaction survey, demographic characteristics were broadly similar to the overall cohort. Educational data showed that most patients (30.8%) had a high school diploma or equivalent, or a college/bachelor's degree (24.4%). Regarding employment status, most patients were retired (30.8%) or disabled (30.1%), while 31.1% were employed full- or part-time. Patients came from 19 US states and international locations, with international patients comprising 2.5% of the cohort (n = 8). Of the 310 U.S.-based patients (97.5%), most resided in Massachusetts (67.8%), followed by Maine (12.9%), New Hampshire (8.7%), and Rhode Island (2.9%) (Fig. 2 ). Table 1 shows all demographic characteristics. Table 1 Demographic Characteristics of ICAN Patients Characteristic All included patients (n = 318 (100%)) Patients who completed survey (n = 156 (49.1%)) Sex, female 110 (34.6) 63 (40.4) Age at ICAN surgery (years) 54.2 (39.2–64.7) 56.3 (42.4–65.1) Body Mass Index (kg/m²) 27.8 (23.5–32.5) 27.8 (23.9–32.6) Total follow-up (years) 2.0 (0.8–3.4) 2.7 (1.8-4.0) Deceased 34 (10.7) 0 (0.0) Race/Ethnicity African American or Black 24 (7.5) 9 (5.8) Asian 5 (1.6) 3 (1.9) Latin (Hispanic) 15 (4.7) 5 (3.2) Middle Eastern (Arab) 7 (2.2) 2 (1.3) Native American or Alaska Native 1 (0.3) 0 (0.0) Other 3 (0.9) 1 (0.6) White 263 (82.7) 136 (87.2) Insurance type Government-sponsored 24 (7.5) 7 (4.5) Private 261 (82.1) 130 (83.3) Self-pay/uninsured 15 (4.7) 10 (6.4) Workers’ compensation 18 (5.7) 9 (5.8) Education level † Associate’s/Tech degree 30 (9.4) 30 (19.2) College/Bachelor's degree 38 (11.9) 38 (24.4) Secondary School not completed/less than High School 4 (1.3) 4 (2.6) Doctoral/postgraduate education 26 (8.2) 26 (16.7) High school diploma or equivalent 48 (15.1) 48 (30.8) Some Secondary or High school 10 (3.1) 10 (6.4) Employment status ‡ Disabled 47 (14.8) 47 (30.1) Full time 42 (13.2) 41 (26.3) Part time 6 (1.9) 6 (3.8) Retired 48 (15.1) 48 (30.8) Unemployed 13 (4.1) 13 (8.3) †n = 157/318 (49.4%) ‡n = 156/318 (49.1%) Categorical variables are reported as number (percentage). Continuous variables have a non-normal distribution and are displayed as median (IQR). Psychiatric comorbidities were highly prevalent, with 202 patients (63.5%) having at least one diagnosis. A history of chronic pain was reported in 254 patients (79.9%), and CRPS was documented in 21 patients (6.6%). Diabetes mellitus affected 96 patients (30.2%), and PVD was diagnosed in 88 patients (27.7%). CKD (10.1%), hypothyroidism (14.5%), alcoholism (8.2%), and smoking (25.8%) were also present in the cohort. The median ECI was 4.0 (IQR 2.0–7.0). Opioids were used by 240 patients (75.5%) preoperatively and by 149 patients (46.9%) postoperatively. Neuromodulating medication use was reported in 199 patients (62.6%) preoperatively and 183 patients (57.5%) postoperatively. All comorbidity characteristics are presented in Table 2 . Table 2 Comorbidity Characteristics of ICAN Patients Characteristic All included patients (n = 318 (100%)) Patients who completed survey (n = 156 (49.1%)) Alcoholism 26 (8.2) 11 (7.1) Smoking 82 (25.8) 28 (17.9) Diabetes mellitus 96 (30.2) 46 (29.5) Hypothyroidism 46 (14.5) 31 (19.9) Psychiatric comorbidity 202 (63.5) 91 (58.3) Depression 147 (46.2) 64 (41.0) Anxiety disorder 163 (51.3) 71 (45.5) Personality disorder 13 (4.1) 4 (2.6) Post-traumatic stress disorder 46 (14.5) 19 (12.2) Peripheral vascular disease 88 (27.7) 39 (25.0) Chronic kidney disease 32 (10.1) 15 (9.6) History of chronic pain 254 (79.9) 124 (79.5) Complex regional pain syndrome 21 (6.6) 14 (9.0) Elixhauser comorbidity index, median (IQR) 4.0 (2.0–7.0) 4.0 (2.0–6.0) Pre-operative opioid use 240 (75.5) 115 (73.7) Post-operative opioid use 149 (46.9) 69 (44.2) Pre-operative neuropathic pain medication 199 (62.6) 94 (60.3) Post-operative neuropathic pain medication 183 (57.5) 86 (55.1) Categorical variables are reported as number (percentage). Lower extremity amputations accounted for the majority of cases (90.6%), with transtibial amputations being the most common (58.5%), followed by transfemoral amputations (27.7%). Upper extremity amputations (9.4%) included transhumeral (4.4%), transradial (4.1%), and partial hand (1.9%) levels. Of all amputees, 3.5% were bilateral. The most frequent indication for amputation was trauma (43.7%), followed by infection or sepsis (25.2%), malignancy (12.9%), pain or dysfunctional limb (10.13%), peripheral vascular disease (5.7%), and congenital deformity (1.3%) (Table 3 ). Table 3 Surgery Characteristics of ICAN Patients Characteristic All included patients (n = 318 (100%)) Patients who completed survey (n = 156 (49.1%)) Laterality Left 161 (50.6) 78 (50.0) Right 146 (45.9) 73 (46.8) Bilateral 11 (3.5) 5 (3.2) Amputation level Upper Extremity 30 (9.4) 13 (8.3) Shoulder disarticulation 2 (0.6) 0 (0.0) Transhumeral 14 (4.4) 5 (3.2) Transradial 13 (4.1) 5 (3.2) Partial hand 6 (1.9) 4 (2.6) Lower Extremity 288 (90.6) 143 (91.7) Hip disarticulation 4 (1.3) 3 (1.9) Transfemoral 88 (27.7) 42 (26.9) Transtibial 186 (58.5) 94 (60.62) Knee disarticulation 2 (0.6) 1 (0.6) Partial foot 3 (0.9) 2 (1.3) Amputation indication Trauma 139 (43.7) 71 (45.5) Infection or Sepsis 80 (25.2) 35 (22.4) Malignancy 41 (12.9) 21 (13.5) Pain or dysfunctional limb 36 (10.13) 20 (12.8) Peripheral Vascular Disease 18 (5.7) 7 (4.5) Congenital Deformity 4 (1.3) 2 (1.3) Mechanism of injury for trauma patients Blast 13 (4.1) 6 (3.8) Crush 22 (6.9) 10 (6.4) GSW 2 (0.6) 1 (0.6) MCC 38 (11.9) 23 (14.7) MVC 32 (10.1) 15 (9.6) Other 35 (11.0) 20 (12.8) Type of active nerve surgery performed TMR only 225 (70.8) 115 (73.7) RPNI only 14 (4.4) 4 (2.6) TMR and RPNI 79 (24.8) 37 (23.7) Timing of active nerve surgery Primary 158 (49.7) 79 (50.6) Secondary 160 (50.3) 77 (49.4) Time from amputation to nerve surgery (years) Primary 0 (0–0) 0 (0–0) Secondary 5.1 (1.8–13.2) 6.5 (2.8–18.6) Length of hospital stay (days) 3.0 (1.0–7.0) 3.0 (1.0–6.0) Primary 6 (3–9) 9 (3–9) Same-Day Discharge* 3 (1.9) 0 (0.0) Secondary 3 (1–3) 2 (1–3) Same-Day Discharge 24 (15.2) 11 (14.3) Abbreviations: TMR = Targeted Muscle Reinnervation; RPNI = Regenerative Peripheral Nerve Interface, GWS = Gun shot wound; MCC = Motor vehicle crash; MVC = Motor vehicle crash Categorical variables are reported as number (percentage). Continuous variables have a non-normal distribution and are displayed as median (IQR). *Primary TMR patients who underwent Same-Day surgery were all partial hand amputees Regarding nerve surgical procedures, TMR alone was performed in 225 patients (70.8%), RPNI alone in 14 patients (4.4%), and combined TMR and RPNI in 79 patients (24.8%). Primary procedures at the time of amputation were performed in 160 patients (50.3%), while secondary procedures for established neuropathic pain were performed in 158 patients (49.7%). For secondary patients, the median interval from amputation to nerve surgery was 5.1 years (IQR:1.8–13.2). The annual number of TMR and RPNI surgeries increased steadily over the study period, from 20 cases in 2018 to a mean 61 (± 4) cases between 2020 and 2024 (Fig. 3 ). Since 2021, primary TMR/RPNI procedures have outnumbered secondary procedures. LOS varied by procedure type, with a median of 3.0 (IQR 1.0–7.0) days overall, with a median of 6 (IQR 3–9) days for primary cases and 3 (IQR 1–3) days for secondary cases. Same-day discharge was more common for secondary procedures (n = 24 (15.2%)) than for primary procedures (n = 3 (1.9%), occurring only in partial hand amputees). Most referrals came from academic medical centers (71.1%), followed by community hospitals (11.9%), specialized centers (4.1%), Veterans Affairs centers (1.6%), rehabilitation centers (1.6%), community health centers (0.3%), or international facilities (2.5%). Within referring departments, orthopaedic specialties collectively accounted for the largest proportion of referrals (46.9%), followed by various other specialties including rehabilitation medicine (6.0%), vascular surgery (5.7%), plastic surgery (5.0%), and primary care (1.3%). Prosthetists accounted for 1.6% of referrals. For 21.4% of patients, the referring department was not specified. After surgery at ICAN, most patients (55.7%) were discharged to home-based care, 25.2% to Spaulding Rehabilitation Hospital (Charlestown, MA), and 13.2% to other facility-based care. All Referral characteristics are presented in Table 4 and Fig. 4 . Table 4 Referral Characteristics of ICAN Patients Characteristic All included patients (n = 318 (100%)) Patients who completed survey (n = 156 (49.1%)) Referring institution Academic Medical Center 226 (71.1) 107 (68.6) Community Hospital 38 (11.9) 25 (16.0) Specialized Center 13 (4.1) 6 (3.8) Community Health Center 1 (0.3) 1 (0.6) Rehabilitation Center 5 (1.6) 2 (1.3) Veterans Affairs Center 5 (1.6) 3 (1.9) International Facility 6 (1.9) 2 (1.3) Not Specified 24 (7.5) 10 (6.4) Referring department Rehabilitation Medicine 19 (6.0) 10 (6.4) Pain Management 4 (1.3) 2 (1.3) Vascular Surgery 18 (5.7) 6 (3.8) Trauma Surgery 6 (1.9) 2 (1.3) Surgical Oncology 3 (0.9) 1 (0.6) Plastic and Reconstructive Surgery 16 (5.0) 9 (5.8) Orthopaedic-Foot and Ankle 26 (8.2) 16 (10.3) Orthopaedic-General 21 (6.6) 9 (5.8) Orthopaedic-Hand and Upper Extremity 6 (1.9) 1 (0.6) Orthopaedic-Joint Reconstruction 7 (2.2) 3 (1.9) Orthopaedic-Oncology 41 (12.9) 22 (14.1) Orthopaedic-Sports Medicine 1 (0.3) 1 (0.6) Orthopaedic-Trauma 45 (14.2) 22 (14.1) Orthotics/Prosthetics 5 (1.6) 3 (1.9) Specialized Orthopaedic Surgery 2 (0.6) 0 (0.0) Podiatry 7 (2.2) 2 (1.3) Primary Care 4 (1.3) 4 (2.6) Wound Care 1 (0.3) 0 (0.0) Burn Surgery 2 (0.6) 1 (0.6) Emergency Medicine 7 (2.2) 3 (1.9) General Surgery 4 (1.3) 1 (0.6) Infectious Disease 1 (0.3) 1 (0.6) Internal Medicine 3 (0.9) 1 (0.6) Neurosurgery 1 (0.3) 0 (0.0) Not Specified 68 (21.4) 36 (23.1) Discharge disposition Home-based Care 177 (55.7) 102 (65.4) Spaulding Rehabilitation Hospital 80 (25.2) 35 (22.4) Facility-based Care 42 (13.2) 16 (10.3) End-of-Life Care 1 (0.3) 0 (0.0) Expired 1 (0.3) 0 (0.0) Other 1 (0.3) 0 (0.0) Not Specified 16 (5.0) 3 (1.9) Categorical variables are reported as number (percentage). PART II: Patient Satisfaction Outcomes Of the 156 patients who completed the survey (57.8% response rate), the overall satisfaction rate was 86.5%, with 42.3% reporting being “very satisfied” and 44.2% “satisfied”. In contrast, 10.9% were “dissatisfied”, and 2.6% “very dissatisfied” (Fig. 5 ). Satisfaction with treatment effect was reported by 81.0% of respondents. Healthcare professionals were perceived as thorough in their examinations by 94.5% of respondents. Moreover, 96.6% of patients felt respected during healthcare interactions, and 87.1% expressed satisfaction regarding patient autonomy in healthcare decisions. Information provision was rated satisfactory by 84.4% of patients. Satisfaction with received care was reported by 93.6% of patients. The lowest satisfaction scores were observed for time allocation during consultations, with 78.9% of patients reporting satisfaction with the time available during appointments. This was the only domain where less than 80% satisfaction was reported (Supplementary Digital Content 1). Overall, 13.5% of respondents expressed some degree of dissatisfaction with their care experience (SAPS < 19). Exploratory bivariate association analysis showed that patients who were dissatisfied were significantly more likely to have a formal diagnosis of anxiety compared to satisfied patients (p = 0.017, Fig. 6 ). No difference was seen between patients who underwent primary versus secondary TMR/RPNI (p = 0.490). No other patient factors showed statistically significant associations with overall SAPS satisfaction scores (Supplementary Digital Content 2). Non-responder analysis indicated no significant differences between both groups (p > 0.05), and data were missing completely at random (MCAR) (p = 0.322, Supplementary Digital Content 3). Discussion This study provides a comprehensive analysis of the ICAN clinic following the implementation of our specialized multidisciplinary amputee care model. Our diverse patient population, characterized by complex comorbidities, achieved high satisfaction rates (86.5%) across multiple domains of care delivery. The predominance of lower extremity amputations (90.6%), primarily due to trauma (43.7%) and infection (25.2%), reflects the broader epidemiological distribution of amputation causes. All patients underwent TMR and/or RPNI procedures, with nearly equal distribution between preventive (50.1%) and therapeutic (49.1%) approaches, reflecting our increasing emphasis on proactive pain management strategies. These results support the effectiveness of our integrated approach while highlighting specific areas for further refinement. ICAN population The ICAN clinic serves a geographically and clinically diverse population, treating patients from 19 states and several international locations (Fig. 2 ). This wide catchment area likely reflects both the clinic’s reputation and the limited availability of comprehensive amputee care services, particularly those offering prophylactic pain management strategies such as TMR and RPNI. The predominance of lower extremity amputations (90.6%) in our cohort reflects the epidemiologic distribution of amputation causes in the general population. While trauma-related amputations currently represent the largest proportion of our patient volume, this pattern may reflect the institutional structure in which dysvascular and infection-related amputations are primarily managed by the vascular surgery department 14 , 15 . Nevertheless, rising global rates of diabetes, obesity, and peripheral vascular disease suggest that dysvascular and infection-related amputations will become increasingly common 16 . Referral Patterns and Healthcare Ecosystem The referral patterns observed in our study provide important insights into the healthcare ecosystem surrounding amputee care. Academic medical centers (71.1%) were the predominant referral source to our clinic, reflecting recognition of our multidisciplinary approach within tertiary care networks. Orthopaedic specialties collectively accounted for the largest proportion of referrals (46.9%), highlighting their central role in amputation care pathways, particularly for traumatic amputations. Prosthetists and physical therapists also represent major referral sources, underscoring the importance of rehabilitation professionals in identifying patients who could benefit from our specialized interventions. However, the limited referrals from community hospitals (11.9%) and community health centers (0.3%) indicate opportunities to expand outreach to settings where many amputees initially receive care 17 , 18 . Evolution of Peripheral Nerve Surgery Techniques The evolution of TMR and RPNI practice at our institution demonstrates a clear shift toward prevention-focused strategies 6 , 19 , 20 . Our data show a progressive increase in primary procedures performed at the time of amputation, reflecting growing evidence supporting preemptive nerve management. 7 , 21 – 23 Notably, since 2021, the annual number of primary TMR/RPNI procedures has consistently surpassed that of secondary procedures at our institution, marking a definitive shift toward prevention-focused care (Fig. 3 ). Primary TMR and/or RPNI has now become the standard of care at our institution for all elective amputations and, when technically feasible and clinically appropriate, during emergent amputation procedures as well 24 . Although not every amputee develops neuropathic pain 25 – 28 , this preventive approach aims to interrupt the development of neuroma-related pain before it becomes established, potentially reducing the need for subsequent interventions and improving long-term quality of life for amputees 29 . Concurrent with this evolution, our group has expanded the application of TMR surgery beyond the amputee population 30 , 31 . As a result, a greater share of operative time was allocated to these cases, contributing to the lower numbers of primary and secondary amputee procedures in 2023–2024. Patient Satisfaction and Areas for Improvement The satisfaction outcomes from our survey provide encouraging data for the effectiveness of the ICAN model from a patient’s perspective. The high overall satisfaction rate (86.5%) demonstrates that patients value the comprehensive, patient-centered approach provided by our multidisciplinary team. Particularly noteworthy are the high ratings for provider thoroughness (94.5%), respectful treatment (96.6%), and treatment effect (81.0%), which indicate that patients perceive both the interpersonal aspects of care and clinical outcomes positively 32 . However, the identification of time constraints as the lowest-rated aspect of care (78.9% satisfaction) provides important feedback for future improvement 33 . Multidisciplinary care inherently involves coordination among multiple specialists, which can challenge the allocation of sufficient time for each patient encounter. This suggests that optimizing clinic flow, appointment scheduling, and provider availability may be important targets for enhancing patient experience. Potential strategies might include digital resources, extended appointment times for complex cases, improved pre-appointment preparation, and more efficient coordination of multi-specialist evaluations 34 . Psychiatric Comorbidities and Care Satisfaction The high prevalence of psychiatric comorbidities in our cohort (63.5%) aligns with previous research on amputee populations, and highlights the significant psychosocial burden associated with limb loss 35 – 39 . Notably, patients with formal anxiety diagnoses were significantly more likely to express dissatisfaction with care. This association suggests that anxiety may influence not only pain perception and functional outcomes, as previously documented, but also satisfaction with healthcare interactions 40 .. Routine screening for anxiety and other psychiatric conditions may help identify patients who might benefit from additional tailored psychosocial support 41 . Additionally, provider communication strategies tailored to anxious patients, such as enhanced information provision and additional reassurance, might improve these patients' healthcare experiences and overall satisfaction 42 . Limitations and Future Directions These findings must be interpreted within the context of several limitations. As a relatively new program, our follow-up period remains limited (mean 2.0 years (IQR: 0.8–3.4)). Additionally, our single-center experience may not be fully generalizable to other healthcare settings with different resources or patient populations. However, our results provide important insights into the implementation of a comprehensive amputation care program that may inform development of similar programs at other institutions 43 . Future directions for our clinic include enhanced integration of prosthetist services, expansion of psychosocial support, broader referral networks, and integration of digital resources, including remote care capabilities 44 . Continued collection of long-term outcome data will be crucial for validating our treatment approaches and identifying areas for improvement 45 . Prospective assessment of patient-reported outcomes will further refine our understanding of the impact of integrated care models on amputee quality of life and functional status 46 . Elements of Successful Implementation Our ICAN clinic experience highlights several key findings regarding patient demographics, surgical interventions, and the benefits of a comprehensive interdisciplinary approach to amputee care. Since its inception 11 , the ICAN clinic model has evolved from individual specialty approaches to a coordinated framework incorporating orthopaedic surgery, plastic surgery, physiatry, physical and occupational therapy, and psychosocial support services. The effectiveness of this approach is supported by growing evidence demonstrating improved outcomes with early orthoplastic collaboration 47 – 49 . The foundational aspects of our orthoplastic approach align with findings from Hoyt et al., who demonstrated that increased surgical volume and interdisciplinary collaboration were associated with improved outcomes in flap-based limb salvage 50 . Similarly, Klifto et al. demonstrated that early collaborative orthoplastic care for lower extremity trauma was associated with decreased time to bone fixation, reduced use of negative pressure wound therapy, and lower infection rates 9 . Successful implementation of a combined orthoplastic clinic requires several critical elements identified through our experience. Dedicated clinic space and consistent scheduling facilitate coordination among multiple specialists, allowing for simultaneous evaluation by surgical, rehabilitation, and support services. This infrastructure streamlines care planning and improves efficiency 11 . Standardized patient workflows ensure comprehensive assessment of functional goals, pain management needs, and psychosocial support requirements 51 . While our high-volume academic center supports dedicated multidisciplinary staffing, the core principles of the ICAN model are adaptable for smaller institutions. Key transferable elements include standardized pain assessment protocols, early prosthetist involvement, formal interdepartmental communication pathways, and coordination of prophylactic nerve procedures with amputation surgeries. Smaller centers can implement these principles through modified approaches such as shared clinic days, telemedicine partnerships, or regional collaborations with specialized centers. Conclusion The successful implementation of the ICAN clinic over nearly a decade demonstrates that an interdisciplinary approach to amputee care is both feasible and beneficial within an academic medical center. By integrating orthopaedic surgery, plastic surgery, physiatry, prosthetists, physical and occupational therapy, and psychological support services into a coordinated framework, the clinic has established a comprehensive care model that addresses both the immediate surgical and long-term rehabilitative needs of amputee patients. Adapted versions of this model can be implemented successfully in both high-volume academic centers and smaller institutions to optimize amputee care. Our experience demonstrates that this comprehensive care model can be effectively adapted across different institutional settings and resource levels. Future efforts should focus on expanding access to comprehensive amputation care through the development and collaboration of additional interdisciplinary centers across various institutional scales, while continuing to evaluate long-term outcomes and refine treatment protocols. Declarations Ethics approval and consent to participate This study was approved by the Institutional Review Board of Massachusetts General Hospital, Harvard Medical School (Protocol #2020P003555). Verbal consent was obtained from all participants prior to enrollment. All methods were performed in accordance with the relevant guidelines and regulations, including the Declaration of Helsinki. Consent for publication Not applicable. This manuscript does not contain any individual person’s data in any form (including individual details, images, or videos). Competing Interests IV is a consultant for AxoGen Inc., Checkpoint Surgical Inc., and Integra Lifesciences Inc. KE is a consultant for AxoGen Inc., Checkpoint Surgical Inc., Integra Lifesciences Inc., Tissium, Tulavi Therapeutics Inc., and Biocircuit Technologies Inc. FR is a consultant for Meta Platforms Inc. OM, OV, JD., KT, DH, AH, and DC have no competing interests to declare. Funding This work was supported by the National Institutes of Health (grant number NINDS U19NS130617); the Jesse B. Jupiter Research Fund/Wyss Medical Foundation. Author Contribution FR contributed to study conceptualization, methodology, data collection, data analysis and visualization, interpretation, and writing the manuscript. OM contributed to data collection and writing the manuscript. OV contributed to data collection and manuscript review.JD contributed to patient enrollment and data collection. KT, DH, AH, and DC contributed to manuscript review. IV contributed to study conceptualization, supervision, and manuscript review. KE contributed to study conceptualization, methodology, supervision, funding acquisition, and manuscript review. Acknowledgement The figures were created with BioRender.com. This work was conducted with statistical support from Harvard Catalyst. Data Availability The datasets used and analyzed during are available from the corresponding author on reasonable request. References Ziegler-Graham K, MacKenzie EJ, Ephraim PL, Travison TG, Brookmeyer R. Estimating the prevalence of limb loss in the United States: 2005 to 2050. Arch Phys Med Rehabil. 2008;89(3):422–9. 10.1016/J.APMR.2007.11.005 . Yuan B, Hu D, Gu S, Xiao S, Song F. The global burden of traumatic amputation in 204 countries and territories. Front Public Health. 2023;11:1258853. 10.3389/FPUBH.2023.1258853/BIBTEX . Schaefer C, Sadosky A, Mann R, Daniel S, Parsons B. 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IV is a consultant for AxoGen Inc., Checkpoint Surgical Inc., and Integra Lifesciences Inc. KE is a consultant for AxoGen Inc., Checkpoint Surgical Inc., Integra Lifesciences Inc., Tissium, Tulavi Therapeutics Inc., and Biocircuit Technologies Inc. FR is a consultant for Meta Platforms Inc. OM, OV, JD., KT, DH, AH, and DC have no competing interests to declare. Supplementary Files ICANSatisfactionJOSRSDC1.png ICANSatisfactionJOSRSDC2.docx ICANSatisfactionJOSRSDC3.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 09 Mar, 2026 Reviews received at journal 05 Mar, 2026 Reviews received at journal 05 Mar, 2026 Reviews received at journal 04 Mar, 2026 Reviewers agreed at journal 24 Feb, 2026 Reviews received at journal 24 Feb, 2026 Reviewers agreed at journal 23 Feb, 2026 Reviewers agreed at journal 19 Feb, 2026 Reviewers agreed at journal 19 Feb, 2026 Reviewers agreed at journal 19 Feb, 2026 Reviewers invited by journal 19 Feb, 2026 Editor assigned by journal 08 Dec, 2025 Submission checks completed at journal 08 Dec, 2025 First submitted to journal 05 Dec, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8289177","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":595906470,"identity":"e764b8a1-0a6a-4ae6-b027-93436f248429","order_by":0,"name":"Floris V. 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International patients (n=8) are excluded from this map.\u003c/p\u003e","description":"","filename":"ICANSatisfactionJOSRFigure2.png","url":"https://assets-eu.researchsquare.com/files/rs-8289177/v1/41099fc33b3e1998e03f0ea4.png"},{"id":103383265,"identity":"88949935-cfc3-4f79-adf4-483e1d04301b","added_by":"auto","created_at":"2026-02-25 06:11:27","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":701518,"visible":true,"origin":"","legend":"\u003cp\u003ePrimary vs. Secondary Peripheral Nerve Surgical Approach Over Time\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAbbreviations: TMR, Targeted Muscle Reinnervation; RPNI, Regenerative Peripheral Nerve Interface\u003c/em\u003e \u003cem\u003ePrimary procedures were performed at the time of amputation; secondary procedures were performed for established neuropathic pain. \u003c/em\u003eWhile the main study cohort includes patients treated through September 2024, all amputee cases from calendar year 2024 were included in reporting the total number of procedures conducted with primary versus secondary procedures.\u003c/p\u003e","description":"","filename":"ICANSatisfactionJOSRFigure3.png","url":"https://assets-eu.researchsquare.com/files/rs-8289177/v1/889971cbef7e6164a164fee4.png"},{"id":103383339,"identity":"6f8f0126-a443-4886-af82-937158eb4199","added_by":"auto","created_at":"2026-02-25 06:11:42","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":1075674,"visible":true,"origin":"","legend":"\u003cp\u003eReferral Patterns and Discharge Disposition\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eA)\u003c/strong\u003e Referring Institution Types\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eB)\u003c/strong\u003e Referring Department Types\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eC)\u003c/strong\u003e Discharge Disposition Categories\u003c/p\u003e","description":"","filename":"Picture1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8289177/v1/e85cfa945ee5d8560b4f80c3.jpg"},{"id":103383310,"identity":"556c3d32-4dc3-46a0-b6b0-b9c85cb6a71a","added_by":"auto","created_at":"2026-02-25 06:11:33","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":669082,"visible":true,"origin":"","legend":"\u003cp\u003eDistribution of SAPS Total Scores \u003cem\u003eAbbreviations\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePatients were categorized as “very satisfied” (score 27-28), “satisfied” (score 19-26), “dissatisfied” (score 11-18), or “very dissatisfied” (score 0-10).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAbbreviations: SAPS, Short Assessment of Patient Satisfaction\u003c/em\u003e\u003c/p\u003e","description":"","filename":"ICANSatisfactionJOSRFigure5.png","url":"https://assets-eu.researchsquare.com/files/rs-8289177/v1/cfde1529c3deb8c8b35bafbe.png"},{"id":103383351,"identity":"b7181725-c8a9-405d-93d4-2dec930bcaa0","added_by":"auto","created_at":"2026-02-25 06:11:48","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":688390,"visible":true,"origin":"","legend":"\u003cp\u003eDissatisfaction Rates by Patients with Anxiety.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePatients with formal anxiety diagnoses were significantly more likely to express dissatisfaction with care (p=0.017).\u003c/em\u003e\u003c/p\u003e","description":"","filename":"ICANSatisfactionJOSRFigure6.png","url":"https://assets-eu.researchsquare.com/files/rs-8289177/v1/97c5aca096c3175bc7251aa3.png"},{"id":103383489,"identity":"5666cf83-2660-464d-bbef-54530fa13cf9","added_by":"auto","created_at":"2026-02-25 06:12:16","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":7232304,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8289177/v1/2774aa06-61e2-49ed-ba53-06a9fd81e120.pdf"},{"id":103383322,"identity":"10c133fa-ea75-454b-a7cf-e9860394b65c","added_by":"auto","created_at":"2026-02-25 06:11:35","extension":"png","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":732275,"visible":true,"origin":"","legend":"","description":"","filename":"ICANSatisfactionJOSRSDC1.png","url":"https://assets-eu.researchsquare.com/files/rs-8289177/v1/13a92d21d436b602844ab820.png"},{"id":103383332,"identity":"306c0f8f-2116-4789-81d0-768f6733caa6","added_by":"auto","created_at":"2026-02-25 06:11:40","extension":"docx","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":17363,"visible":true,"origin":"","legend":"","description":"","filename":"ICANSatisfactionJOSRSDC2.docx","url":"https://assets-eu.researchsquare.com/files/rs-8289177/v1/eec93a75f63f7d02394a2f7f.docx"},{"id":103383221,"identity":"a12446d9-bf50-4f76-8da6-bf7f4b1d923b","added_by":"auto","created_at":"2026-02-25 06:11:10","extension":"docx","order_by":6,"title":"","display":"","copyAsset":false,"role":"supplement","size":25285,"visible":true,"origin":"","legend":"","description":"","filename":"ICANSatisfactionJOSRSDC3.docx","url":"https://assets-eu.researchsquare.com/files/rs-8289177/v1/a7fb7c5936c93a12f7f94b04.docx"}],"financialInterests":"Competing interest reported. IV is a consultant for AxoGen Inc., Checkpoint Surgical Inc., and Integra Lifesciences Inc. KE is a consultant for AxoGen Inc., Checkpoint Surgical Inc., Integra Lifesciences Inc., Tissium, Tulavi Therapeutics Inc., and Biocircuit Technologies Inc. FR is a consultant for Meta Platforms Inc. OM, OV, JD., KT, DH, AH, and DC have no competing interests to declare.","formattedTitle":"Evolution of a Specialized Multidisciplinary Amputee Care Clinic: Referral Patterns and Patient Satisfaction","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe prevalence of limb amputations continues to rise globally, with projections indicating a doubling of the amputee population in coming decades due to aging demographics and increasing rates of diabetes mellitus and peripheral vascular disease. An estimated 1.6\u0026nbsp;million individuals were living with limb loss in the United States in 2005, with this number projected to more than double to 3.6\u0026nbsp;million by 2050.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e This growing healthcare challenge demands multifaceted models of care delivery that prioritize both patient satisfaction and clinical cost-effectiveness. Traumatic amputations account for more than 13\u0026nbsp;million new cases worldwide each year, contributing to substantial healthcare and societal costs\u003csup\u003e\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eHistorically, care for amputees has focused primarily on surgical intervention. This approach has evolved toward comprehensive care models that address the complex physical and psychosocial needs of patients with limb loss\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e. Advances in pain management, particularly for post-amputation pain syndromes, have shifted emphasis toward preventive strategies and early intervention\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. These developments have driven the emergence of multidisciplinary care models that integrate various specialties, including orthoplastic surgery, physiatry, psychosocial support, and rehabilitation services.\u003csup\u003e\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe Interdisciplinary Care for Amputees Network (ICAN) was established to implement such a comprehensive care model in 2017, combining orthoplastic surgical intervention with post-operative functional and psychosocial rehabilitation\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. This program provides coordinated care from orthopaedics, plastic surgery, physiatry, infectious diseases, physical/occupational therapy, prosthetists, and pain management specialists. A key component of the model is a multifaceted approach to pain management, recognizing the significant influence of psychosocial factors on patient outcomes.\u003c/p\u003e \u003cp\u003e After several years of implementation and development, we sought to evaluate our model by analyzing the demographics and characteristics of patients seeking care at our center, as well as their satisfaction with the services provided. This assessment aims to refine our approach and optimize resource allocation to better meet the needs of this patient population.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and patient selection\u003c/h2\u003e \u003cp\u003eFollowing institutional review board approval (IRB #2020P003555), a retrospective review was conducted of all adult amputees (\u0026ge;18 years) treated at ICAN between 2017 and September 2024 (n\u0026thinsp;=\u0026thinsp;318). This analysis focused exclusively on patients who underwent surgery; 53.8% (370/688) of referred patients did not undergo surgery (but potentially did receive non-surgical treatments) and were excluded for this study. Subsequently, a cross-sectional satisfaction and demographic survey was administered to eligible patients. Exclusions included deceased patients (n\u0026thinsp;=\u0026thinsp;34), non-English speakers (n\u0026thinsp;=\u0026thinsp;10), or those admitted to the hospital at the time of survey (n\u0026thinsp;=\u0026thinsp;4). Of the 270 (85.0%) eligible patients who were contacted between September and December 2024, 156 (57.8%) completed the survey (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eData acquisition\u003c/h3\u003e\n\u003cp\u003eDemographics, surgical characteristics, and referral patterns were extracted from electronic medical records. Demographic data included sex, age at surgery, body mass index (BMI), race/ethnicity, insurance type, education level, employment status, and geographic location by state or country. Comorbidity data included smoking status, alcohol use, diabetes mellitus, hypothyroidism, psychiatric diagnoses (depression, anxiety, personality disorder, and post-traumatic stress disorder (PTSD)), peripheral vascular disease (PVD), chronic kidney disease (CKD), history of chronic pain, complex regional pain syndrome (CPRS), and pre- and postoperative use of opioids and neuromodulating medications. The Elixhauser Comorbidity Index (ECI) was calculated for each patient to quantify overall comorbidity burden.\u003c/p\u003e \u003cp\u003eSurgical data included amputation laterality and level (categorized as upper extremity: shoulder disarticulation, transhumeral, transradial, or partial hand; and lower extremity: hip disarticulation, transfemoral, knee disarticulation, transtibial, or partial foot), indication (trauma, infection/sepsis, malignancy, pain/dysfunctional limb, peripheral vascular disease, or congenital deformity), and mechanism of injury for trauma patients. Details regarding the type of peripheral nerve surgery - whether Targeted Muscle Reinnervation (TMR), Regenerative Peripheral Nerve Interface (RPNI), or a combination of both techniques applied to different nerves during the same procedure - were recorded, along with whether the surgery was performed to treat preexisting neuropathic pain (secondary stage) or prophylactically at the time of amputation (primary stage). For secondary procedures, the interval from amputation to surgery was documented. Hospital length of stay (LOS) was recorded, including same-day discharge (SDD). Finally, referral characteristics included referring institution type (academic medical center, community hospital, specialized center, community health center, rehabilitation center, Veterans Affairs center, or international facility), referring department, and discharge disposition following surgery at the ICAN clinic (home-based care, rehabilitation hospital, facility-based care, end-of-life care, or other).\u003c/p\u003e\n\u003ch3\u003eSatisfaction Survey\u003c/h3\u003e\n\u003cp\u003ePatient satisfaction was assessed using the validated Short Assessment of Patient Satisfaction (SAPS) questionnaire, administered via telephone or electronic survey between September and December 2024\u003csup\u003e12\u003c/sup\u003e. The SAPS is a 7-item instrument that evaluates key domains of healthcare satisfaction including treatment effect, provider care quality, comprehensiveness of information, participation in decision-making, respect from providers, time spent with providers, and overall satisfaction. Each item is scored on a 5-point scale (0\u0026ndash;4), with total scores ranging from 0\u0026ndash;28. Patients were categorized as \u0026ldquo;very satisfied\u0026rdquo; (score 27\u0026ndash;28), \u0026ldquo;satisfied\u0026rdquo; (score 19\u0026ndash;26), \u0026ldquo;dissatisfied\u0026rdquo; (score 11\u0026ndash;18), or \u0026ldquo;very dissatisfied\u0026rdquo; (score 0\u0026ndash;10). To identify patient factors associated with dissatisfaction, SAPS score was further dichotomized in \u0026ldquo;satisfied\u0026rdquo; (SAPS\u0026ge;19) and \u0026ldquo;dissatisfied\u0026rdquo; (SAPS\u0026thinsp;\u0026lt;\u0026thinsp;19).\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eAll collected data were assessed for normality of distribution using histograms and Shapiro-Wilk tests. Normally distributed continuous variables are presented as means with standard deviations (\u0026plusmn;\u0026thinsp;SD), while non-normally distributed variables are presented as medians with interquartile ranges (IQR). Categorical variables are reported as numbers with percentages. Descriptive statistics were calculated for the entire cohort and separately for the patients who completed the survey. Exploratory bivariate analyses using Fisher\u0026rsquo;s exact, t-tests, or Mann-Whitney U were conducted to assess patient factors associated with dissatisfaction. Data were registered using Research Electronic Data Capture (REDCap), which is a HIPAA-compliant database and survey tool. Data analysis was conducted using R (version 4.4.1, R Core Team, Vienna, Austria), and SAMPL guidelines were adhered to\u003csup\u003e13\u003c/sup\u003e. A non-responder analysis was conducted to assess whether survey data were missing completely at random (MCAR). P-values\u0026thinsp;\u0026lt;\u0026thinsp;0.05 were considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003ePART I: ICAN patient characteristics\u003c/h2\u003e \u003cp\u003eA total of 318 patients were treated at the ICAN clinic during the study period. The median age at surgery was 54.2 years (IQR 39.2\u0026ndash;64.7), and 110 patients (34.6%) were female. The median BMI was 27.8 kg/m\u0026sup2; (IQR 23.5\u0026ndash;32.5). Median follow-up was 2.0 years (IQR 0.8\u0026ndash;3.4) Patients were predominantly white (82.7%) and most patients (82.1%) had private insurance. Among the 156 patients (49.1%) who completed the satisfaction survey, demographic characteristics were broadly similar to the overall cohort. Educational data showed that most patients (30.8%) had a high school diploma or equivalent, or a college/bachelor's degree (24.4%). Regarding employment status, most patients were retired (30.8%) or disabled (30.1%), while 31.1% were employed full- or part-time. Patients came from 19 US states and international locations, with international patients comprising 2.5% of the cohort (n\u0026thinsp;=\u0026thinsp;8). Of the 310 U.S.-based patients (97.5%), most resided in Massachusetts (67.8%), followed by Maine (12.9%), New Hampshire (8.7%), and Rhode Island (2.9%) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows all demographic characteristics.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic Characteristics of ICAN Patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAll included patients\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;318 (100%))\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePatients who completed survey\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;156 (49.1%))\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex, female\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e110 (34.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e63 (40.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge at ICAN surgery (years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54.2 (39.2\u0026ndash;64.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e56.3 (42.4\u0026ndash;65.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBody Mass Index (kg/m\u0026sup2;)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27.8 (23.5\u0026ndash;32.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27.8 (23.9\u0026ndash;32.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal follow-up (years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.0 (0.8\u0026ndash;3.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.7 (1.8-4.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDeceased\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34 (10.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRace/Ethnicity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAfrican American or Black\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24 (7.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (5.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAsian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (1.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (1.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLatin (Hispanic)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (4.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (3.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMiddle Eastern (Arab)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (2.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (1.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNative American or Alaska Native\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (0.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (0.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e263 (82.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e136 (87.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInsurance type\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGovernment-sponsored\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24 (7.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (4.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrivate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e261 (82.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e130 (83.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSelf-pay/uninsured\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (4.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (6.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWorkers\u0026rsquo; compensation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (5.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (5.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducation level\u003c/b\u003e\u003csup\u003e\u003cb\u003e\u0026dagger;\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAssociate\u0026rsquo;s/Tech degree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30 (9.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (19.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCollege/Bachelor's degree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38 (11.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38 (24.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecondary School not completed/less than High School\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (1.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (2.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDoctoral/postgraduate education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26 (8.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26 (16.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh school diploma or equivalent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48 (15.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48 (30.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSome Secondary or High school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (3.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (6.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEmployment status\u003c/b\u003e\u003csup\u003e\u003cb\u003e\u0026Dagger;\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisabled\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e47 (14.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47 (30.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFull time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42 (13.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41 (26.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePart time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (1.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (3.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRetired\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48 (15.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48 (30.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (4.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (8.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026dagger;n\u0026thinsp;=\u0026thinsp;157/318 (49.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026Dagger;n\u0026thinsp;=\u0026thinsp;156/318 (49.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eCategorical variables are reported as number (percentage).\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eContinuous variables have a non-normal distribution and are displayed as median (IQR).\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003ePsychiatric comorbidities were highly prevalent, with 202 patients (63.5%) having at least one diagnosis. A history of chronic pain was reported in 254 patients (79.9%), and CRPS was documented in 21 patients (6.6%). Diabetes mellitus affected 96 patients (30.2%), and PVD was diagnosed in 88 patients (27.7%). CKD (10.1%), hypothyroidism (14.5%), alcoholism (8.2%), and smoking (25.8%) were also present in the cohort. The median ECI was 4.0 (IQR 2.0\u0026ndash;7.0). Opioids were used by 240 patients (75.5%) preoperatively and by 149 patients (46.9%) postoperatively. Neuromodulating medication use was reported in 199 patients (62.6%) preoperatively and 183 patients (57.5%) postoperatively. All comorbidity characteristics are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComorbidity Characteristics of ICAN Patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAll included patients\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;318 (100%))\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePatients who completed survey\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;156 (49.1%))\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlcoholism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26 (8.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (7.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSmoking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e82 (25.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28 (17.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes mellitus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e96 (30.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46 (29.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypothyroidism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46 (14.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31 (19.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePsychiatric comorbidity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e202 (63.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e91 (58.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDepression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e147 (46.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e64 (41.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnxiety disorder\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e163 (51.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e71 (45.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePersonality disorder\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (4.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (2.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePost-traumatic stress disorder\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46 (14.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (12.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePeripheral vascular disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e88 (27.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39 (25.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChronic kidney disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32 (10.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (9.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHistory of chronic pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e254 (79.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e124 (79.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComplex regional pain syndrome\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21 (6.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (9.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eElixhauser comorbidity index, \u003cem\u003emedian (IQR)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.0 (2.0\u0026ndash;7.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.0 (2.0\u0026ndash;6.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePre-operative opioid use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e240 (75.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e115 (73.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePost-operative opioid use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e149 (46.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e69 (44.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePre-operative neuropathic pain medication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e199 (62.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e94 (60.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePost-operative neuropathic pain medication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e183 (57.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e86 (55.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eCategorical variables are reported as number (percentage).\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eLower extremity amputations accounted for the majority of cases (90.6%), with transtibial amputations being the most common (58.5%), followed by transfemoral amputations (27.7%). Upper extremity amputations (9.4%) included transhumeral (4.4%), transradial (4.1%), and partial hand (1.9%) levels. Of all amputees, 3.5% were bilateral. The most frequent indication for amputation was trauma (43.7%), followed by infection or sepsis (25.2%), malignancy (12.9%), pain or dysfunctional limb (10.13%), peripheral vascular disease (5.7%), and congenital deformity (1.3%) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSurgery Characteristics of ICAN Patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAll included patients\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;318 (100%))\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePatients who completed survey\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;156 (49.1%))\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLaterality\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeft\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e161 (50.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e78 (50.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e146 (45.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e73 (46.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBilateral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (3.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (3.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAmputation level\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUpper Extremity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30 (9.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (8.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShoulder disarticulation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (0.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTranshumeral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (4.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (3.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTransradial\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (4.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (3.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePartial hand\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (1.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (2.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLower Extremity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e288 (90.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e143 (91.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHip disarticulation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (1.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (1.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTransfemoral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e88 (27.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42 (26.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTranstibial\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e186 (58.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e94 (60.62)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKnee disarticulation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (0.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (0.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePartial foot\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (0.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (1.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAmputation indication\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTrauma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e139 (43.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e71 (45.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInfection or Sepsis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e80 (25.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35 (22.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMalignancy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41 (12.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21 (13.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePain or dysfunctional limb\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36 (10.13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (12.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePeripheral Vascular Disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (5.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (4.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCongenital Deformity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (1.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (1.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMechanism of injury for trauma patients\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlast\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (4.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (3.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCrush\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22 (6.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (6.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGSW\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (0.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (0.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMCC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38 (11.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23 (14.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMVC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32 (10.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (9.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35 (11.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (12.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eType of active nerve surgery performed\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTMR only\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e225 (70.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e115 (73.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRPNI only\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (4.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (2.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTMR and RPNI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e79 (24.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37 (23.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTiming of active nerve surgery\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e158 (49.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e79 (50.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e160 (50.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e77 (49.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTime from amputation to nerve surgery (years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0\u0026ndash;0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0\u0026ndash;0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.1 (1.8\u0026ndash;13.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.5 (2.8\u0026ndash;18.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLength of hospital stay (days)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.0 (1.0\u0026ndash;7.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.0 (1.0\u0026ndash;6.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (3\u0026ndash;9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (3\u0026ndash;9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSame-Day Discharge*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (1.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (1\u0026ndash;3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (1\u0026ndash;3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSame-Day Discharge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24 (15.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (14.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eAbbreviations: TMR\u0026thinsp;=\u0026thinsp;Targeted Muscle Reinnervation; RPNI\u0026thinsp;=\u0026thinsp;Regenerative Peripheral Nerve Interface, GWS\u0026thinsp;=\u0026thinsp;Gun shot wound; MCC\u0026thinsp;=\u0026thinsp;Motor vehicle crash; MVC\u0026thinsp;=\u0026thinsp;Motor vehicle crash\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eCategorical variables are reported as number (percentage).\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eContinuous variables have a non-normal distribution and are displayed as median (IQR).\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003cem\u003e*Primary TMR patients who underwent Same-Day surgery were all partial hand amputees\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eRegarding nerve surgical procedures, TMR alone was performed in 225 patients (70.8%), RPNI alone in 14 patients (4.4%), and combined TMR and RPNI in 79 patients (24.8%). Primary procedures at the time of amputation were performed in 160 patients (50.3%), while secondary procedures for established neuropathic pain were performed in 158 patients (49.7%). For secondary patients, the median interval from amputation to nerve surgery was 5.1 years (IQR:1.8\u0026ndash;13.2). The annual number of TMR and RPNI surgeries increased steadily over the study period, from 20 cases in 2018 to a mean 61 (\u0026plusmn;\u0026thinsp;4) cases between 2020 and 2024 (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Since 2021, primary TMR/RPNI procedures have outnumbered secondary procedures. LOS varied by procedure type, with a median of 3.0 (IQR 1.0\u0026ndash;7.0) days overall, with a median of 6 (IQR 3\u0026ndash;9) days for primary cases and 3 (IQR 1\u0026ndash;3) days for secondary cases. Same-day discharge was more common for secondary procedures (n\u0026thinsp;=\u0026thinsp;24 (15.2%)) than for primary procedures (n\u0026thinsp;=\u0026thinsp;3 (1.9%), occurring only in partial hand amputees).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eMost referrals came from academic medical centers (71.1%), followed by community hospitals (11.9%), specialized centers (4.1%), Veterans Affairs centers (1.6%), rehabilitation centers (1.6%), community health centers (0.3%), or international facilities (2.5%). Within referring departments, orthopaedic specialties collectively accounted for the largest proportion of referrals (46.9%), followed by various other specialties including rehabilitation medicine (6.0%), vascular surgery (5.7%), plastic surgery (5.0%), and primary care (1.3%). Prosthetists accounted for 1.6% of referrals. For 21.4% of patients, the referring department was not specified. After surgery at ICAN, most patients (55.7%) were discharged to home-based care, 25.2% to Spaulding Rehabilitation Hospital (Charlestown, MA), and 13.2% to other facility-based care. All Referral characteristics are presented in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eReferral Characteristics of ICAN Patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAll included patients\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;318 (100%))\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePatients who completed survey\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;156 (49.1%))\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReferring institution\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcademic Medical Center\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e226 (71.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e107 (68.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCommunity Hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38 (11.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (16.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpecialized Center\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (4.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (3.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCommunity Health Center\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (0.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRehabilitation Center\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (1.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (1.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVeterans Affairs Center\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (1.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (1.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInternational Facility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (1.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (1.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot Specified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24 (7.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (6.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eReferring department\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRehabilitation Medicine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 (6.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (6.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePain Management\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (1.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (1.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVascular Surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (5.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (3.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTrauma Surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (1.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (1.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgical Oncology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (0.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (0.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePlastic and Reconstructive Surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (5.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (5.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOrthopaedic-Foot and Ankle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26 (8.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (10.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOrthopaedic-General\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21 (6.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (5.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOrthopaedic-Hand and Upper Extremity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (1.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (0.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOrthopaedic-Joint Reconstruction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (2.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (1.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOrthopaedic-Oncology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41 (12.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22 (14.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOrthopaedic-Sports Medicine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (0.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOrthopaedic-Trauma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45 (14.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22 (14.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOrthotics/Prosthetics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (1.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (1.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpecialized Orthopaedic Surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (0.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePodiatry\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (2.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (1.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary Care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (1.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (2.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWound Care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBurn Surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (0.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (0.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmergency Medicine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (2.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (1.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeneral Surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (1.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (0.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInfectious Disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (0.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInternal Medicine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (0.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (0.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeurosurgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot Specified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e68 (21.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36 (23.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDischarge disposition\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHome-based Care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e177 (55.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e102 (65.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpaulding Rehabilitation Hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e80 (25.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35 (22.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFacility-based Care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42 (13.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (10.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEnd-of-Life Care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExpired\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot Specified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (5.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (1.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003cem\u003eCategorical variables are reported as number (percentage).\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePART II: Patient Satisfaction Outcomes\u003c/h3\u003e\n\u003cp\u003eOf the 156 patients who completed the survey (57.8% response rate), the overall satisfaction rate was 86.5%, with 42.3% reporting being \u0026ldquo;very satisfied\u0026rdquo; and 44.2% \u0026ldquo;satisfied\u0026rdquo;. In contrast, 10.9% were \u0026ldquo;dissatisfied\u0026rdquo;, and 2.6% \u0026ldquo;very dissatisfied\u0026rdquo; (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). Satisfaction with treatment effect was reported by 81.0% of respondents. Healthcare professionals were perceived as thorough in their examinations by 94.5% of respondents. Moreover, 96.6% of patients felt respected during healthcare interactions, and 87.1% expressed satisfaction regarding patient autonomy in healthcare decisions. Information provision was rated satisfactory by 84.4% of patients. Satisfaction with received care was reported by 93.6% of patients. The lowest satisfaction scores were observed for time allocation during consultations, with 78.9% of patients reporting satisfaction with the time available during appointments. This was the only domain where less than 80% satisfaction was reported (Supplementary Digital Content 1).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eOverall, 13.5% of respondents expressed some degree of dissatisfaction with their care experience (SAPS\u0026thinsp;\u0026lt;\u0026thinsp;19). Exploratory bivariate association analysis showed that patients who were dissatisfied were significantly more likely to have a formal diagnosis of anxiety compared to satisfied patients (p\u0026thinsp;=\u0026thinsp;0.017, Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e). No difference was seen between patients who underwent primary versus secondary TMR/RPNI (p\u0026thinsp;=\u0026thinsp;0.490). No other patient factors showed statistically significant associations with overall SAPS satisfaction scores (Supplementary Digital Content 2). Non-responder analysis indicated no significant differences between both groups (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05), and data were missing completely at random (MCAR) (p\u0026thinsp;=\u0026thinsp;0.322, Supplementary Digital Content 3).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003e This study provides a comprehensive analysis of the ICAN clinic following the implementation of our specialized multidisciplinary amputee care model. Our diverse patient population, characterized by complex comorbidities, achieved high satisfaction rates (86.5%) across multiple domains of care delivery. The predominance of lower extremity amputations (90.6%), primarily due to trauma (43.7%) and infection (25.2%), reflects the broader epidemiological distribution of amputation causes. All patients underwent TMR and/or RPNI procedures, with nearly equal distribution between preventive (50.1%) and therapeutic (49.1%) approaches, reflecting our increasing emphasis on proactive pain management strategies. These results support the effectiveness of our integrated approach while highlighting specific areas for further refinement.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eICAN population\u003c/h2\u003e \u003cp\u003eThe ICAN clinic serves a geographically and clinically diverse population, treating patients from 19 states and several international locations (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). This wide catchment area likely reflects both the clinic\u0026rsquo;s reputation and the limited availability of comprehensive amputee care services, particularly those offering prophylactic pain management strategies such as TMR and RPNI. The predominance of lower extremity amputations (90.6%) in our cohort reflects the epidemiologic distribution of amputation causes in the general population. While trauma-related amputations currently represent the largest proportion of our patient volume, this pattern may reflect the institutional structure in which dysvascular and infection-related amputations are primarily managed by the vascular surgery department\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e. Nevertheless, rising global rates of diabetes, obesity, and peripheral vascular disease suggest that dysvascular and infection-related amputations will become increasingly common\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eReferral Patterns and Healthcare Ecosystem\u003c/h2\u003e \u003cp\u003eThe referral patterns observed in our study provide important insights into the healthcare ecosystem surrounding amputee care. Academic medical centers (71.1%) were the predominant referral source to our clinic, reflecting recognition of our multidisciplinary approach within tertiary care networks. Orthopaedic specialties collectively accounted for the largest proportion of referrals (46.9%), highlighting their central role in amputation care pathways, particularly for traumatic amputations. Prosthetists and physical therapists also represent major referral sources, underscoring the importance of rehabilitation professionals in identifying patients who could benefit from our specialized interventions. However, the limited referrals from community hospitals (11.9%) and community health centers (0.3%) indicate opportunities to expand outreach to settings where many amputees initially receive care\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eEvolution of Peripheral Nerve Surgery Techniques\u003c/h2\u003e \u003cp\u003eThe evolution of TMR and RPNI practice at our institution demonstrates a clear shift toward prevention-focused strategies\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e,\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. Our data show a progressive increase in primary procedures performed at the time of amputation, reflecting growing evidence supporting preemptive nerve management.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e Notably, since 2021, the annual number of primary TMR/RPNI procedures has consistently surpassed that of secondary procedures at our institution, marking a definitive shift toward prevention-focused care (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Primary TMR and/or RPNI has now become the standard of care at our institution for all elective amputations and, when technically feasible and clinically appropriate, during emergent amputation procedures as well\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e. Although not every amputee develops neuropathic pain\u003csup\u003e\u003cspan additionalcitationids=\"CR26 CR27\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e, this preventive approach aims to interrupt the development of neuroma-related pain before it becomes established, potentially reducing the need for subsequent interventions and improving long-term quality of life for amputees\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e. Concurrent with this evolution, our group has expanded the application of TMR surgery beyond the amputee population\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e,\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e. As a result, a greater share of operative time was allocated to these cases, contributing to the lower numbers of primary and secondary amputee procedures in 2023\u0026ndash;2024.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003ePatient Satisfaction and Areas for Improvement\u003c/h2\u003e \u003cp\u003eThe satisfaction outcomes from our survey provide encouraging data for the effectiveness of the ICAN model from a patient\u0026rsquo;s perspective. The high overall satisfaction rate (86.5%) demonstrates that patients value the comprehensive, patient-centered approach provided by our multidisciplinary team. Particularly noteworthy are the high ratings for provider thoroughness (94.5%), respectful treatment (96.6%), and treatment effect (81.0%), which indicate that patients perceive both the interpersonal aspects of care and clinical outcomes positively\u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e. However, the identification of time constraints as the lowest-rated aspect of care (78.9% satisfaction) provides important feedback for future improvement\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e. Multidisciplinary care inherently involves coordination among multiple specialists, which can challenge the allocation of sufficient time for each patient encounter. This suggests that optimizing clinic flow, appointment scheduling, and provider availability may be important targets for enhancing patient experience. Potential strategies might include digital resources, extended appointment times for complex cases, improved pre-appointment preparation, and more efficient coordination of multi-specialist evaluations\u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003ePsychiatric Comorbidities and Care Satisfaction\u003c/h2\u003e \u003cp\u003eThe high prevalence of psychiatric comorbidities in our cohort (63.5%) aligns with previous research on amputee populations, and highlights the significant psychosocial burden associated with limb loss\u003csup\u003e\u003cspan additionalcitationids=\"CR36 CR37 CR38\" citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u003c/sup\u003e. Notably, patients with formal anxiety diagnoses were significantly more likely to express dissatisfaction with care. This association suggests that anxiety may influence not only pain perception and functional outcomes, as previously documented, but also satisfaction with healthcare interactions\u003csup\u003e\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u003c/sup\u003e.. Routine screening for anxiety and other psychiatric conditions may help identify patients who might benefit from additional tailored psychosocial support\u003csup\u003e\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u003c/sup\u003e. Additionally, provider communication strategies tailored to anxious patients, such as enhanced information provision and additional reassurance, might improve these patients' healthcare experiences and overall satisfaction\u003csup\u003e\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eLimitations and Future Directions\u003c/h2\u003e \u003cp\u003eThese findings must be interpreted within the context of several limitations. As a relatively new program, our follow-up period remains limited (mean 2.0 years (IQR: 0.8\u0026ndash;3.4)). Additionally, our single-center experience may not be fully generalizable to other healthcare settings with different resources or patient populations. However, our results provide important insights into the implementation of a comprehensive amputation care program that may inform development of similar programs at other institutions\u003csup\u003e\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eFuture directions for our clinic include enhanced integration of prosthetist services, expansion of psychosocial support, broader referral networks, and integration of digital resources, including remote care capabilities\u003csup\u003e\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e\u003c/sup\u003e. Continued collection of long-term outcome data will be crucial for validating our treatment approaches and identifying areas for improvement\u003csup\u003e\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e\u003c/sup\u003e. Prospective assessment of patient-reported outcomes will further refine our understanding of the impact of integrated care models on amputee quality of life and functional status\u003csup\u003e\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eElements of Successful Implementation\u003c/h2\u003e \u003cp\u003e Our ICAN clinic experience highlights several key findings regarding patient demographics, surgical interventions, and the benefits of a comprehensive interdisciplinary approach to amputee care. Since its inception\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e, the ICAN clinic model has evolved from individual specialty approaches to a coordinated framework incorporating orthopaedic surgery, plastic surgery, physiatry, physical and occupational therapy, and psychosocial support services. The effectiveness of this approach is supported by growing evidence demonstrating improved outcomes with early orthoplastic collaboration\u003csup\u003e\u003cspan additionalcitationids=\"CR48\" citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e\u003c/sup\u003e. The foundational aspects of our orthoplastic approach align with findings from Hoyt et al., who demonstrated that increased surgical volume and interdisciplinary collaboration were associated with improved outcomes in flap-based limb salvage\u003csup\u003e\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e\u003c/sup\u003e. Similarly, Klifto et al. demonstrated that early collaborative orthoplastic care for lower extremity trauma was associated with decreased time to bone fixation, reduced use of negative pressure wound therapy, and lower infection rates\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eSuccessful implementation of a combined orthoplastic clinic requires several critical elements identified through our experience. Dedicated clinic space and consistent scheduling facilitate coordination among multiple specialists, allowing for simultaneous evaluation by surgical, rehabilitation, and support services. This infrastructure streamlines care planning and improves efficiency\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. Standardized patient workflows ensure comprehensive assessment of functional goals, pain management needs, and psychosocial support requirements\u003csup\u003e\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e\u003c/sup\u003e. While our high-volume academic center supports dedicated multidisciplinary staffing, the core principles of the ICAN model are adaptable for smaller institutions. Key transferable elements include standardized pain assessment protocols, early prosthetist involvement, formal interdepartmental communication pathways, and coordination of prophylactic nerve procedures with amputation surgeries. Smaller centers can implement these principles through modified approaches such as shared clinic days, telemedicine partnerships, or regional collaborations with specialized centers.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe successful implementation of the ICAN clinic over nearly a decade demonstrates that an interdisciplinary approach to amputee care is both feasible and beneficial within an academic medical center. By integrating orthopaedic surgery, plastic surgery, physiatry, prosthetists, physical and occupational therapy, and psychological support services into a coordinated framework, the clinic has established a comprehensive care model that addresses both the immediate surgical and long-term rehabilitative needs of amputee patients. Adapted versions of this model can be implemented successfully in both high-volume academic centers and smaller institutions to optimize amputee care. Our experience demonstrates that this comprehensive care model can be effectively adapted across different institutional settings and resource levels. Future efforts should focus on expanding access to comprehensive amputation care through the development and collaboration of additional interdisciplinary centers across various institutional scales, while continuing to evaluate long-term outcomes and refine treatment protocols.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThis study was approved by the Institutional Review Board of Massachusetts General Hospital, Harvard Medical School (Protocol #2020P003555). Verbal consent was obtained from all participants prior to enrollment. All methods were performed in accordance with the relevant guidelines and regulations, including the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable. This manuscript does not contain any individual person\u0026rsquo;s data in any form (including individual details, images, or videos).\u003c/p\u003e\n\u003ch2\u003eCompeting Interests\u003c/h2\u003e\n\u003cp\u003eIV is a consultant for AxoGen Inc., Checkpoint Surgical Inc., and Integra Lifesciences Inc. KE is a consultant for AxoGen Inc., Checkpoint Surgical Inc., Integra Lifesciences Inc., Tissium, Tulavi Therapeutics Inc., and Biocircuit Technologies Inc. FR is a consultant for Meta Platforms Inc. OM, OV, JD., KT, DH, AH, and DC have no competing interests to declare.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThis work was supported by the National Institutes of Health (grant number NINDS U19NS130617); the Jesse B. Jupiter Research Fund/Wyss Medical Foundation.\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eFR contributed to study conceptualization, methodology, data collection, data analysis and visualization, interpretation, and writing the manuscript. OM contributed to data collection and writing the manuscript. OV contributed to data collection and manuscript review.JD contributed to patient enrollment and data collection. KT, DH, AH, and DC contributed to manuscript review. IV contributed to study conceptualization, supervision, and manuscript review. KE contributed to study conceptualization, methodology, supervision, funding acquisition, and manuscript review.\u003c/p\u003e\n\u003ch2\u003eAcknowledgement\u003c/h2\u003e\n\u003cp\u003eThe figures were created with BioRender.com. This work was conducted with statistical support from Harvard Catalyst.\u003c/p\u003e\n\u003ch2\u003eData Availability\u003c/h2\u003e\n\u003cp\u003eThe datasets used and analyzed during are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eZiegler-Graham K, MacKenzie EJ, Ephraim PL, Travison TG, Brookmeyer R. Estimating the prevalence of limb loss in the United States: 2005 to 2050. Arch Phys Med Rehabil. 2008;89(3):422\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/J.APMR.2007.11.005\u003c/span\u003e\u003cspan address=\"10.1016/J.APMR.2007.11.005\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYuan B, Hu D, Gu S, Xiao S, Song F. The global burden of traumatic amputation in 204 countries and territories. 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Arch Phys Med Rehabil. 2006;87(3 SUPPL):34\u0026ndash;43. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.apmr.2005.11.026\u003c/span\u003e\u003cspan address=\"10.1016/j.apmr.2005.11.026\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-orthopaedic-surgery-and-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"josr","sideBox":"Learn more about [Journal of Orthopaedic Surgery and Research](http://josr-online.biomedcentral.com)","snPcode":"13018","submissionUrl":"https://submission.nature.com/new-submission/13018/3","title":"Journal of Orthopaedic Surgery and Research","twitterHandle":"@MSKmedBMC","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Amputee care, multidisciplinary care, targeted muscle reinnervation, regenerative peripheral nerve interface, patient satisfaction, healthcare delivery model, interdisciplinary","lastPublishedDoi":"10.21203/rs.3.rs-8289177/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8289177/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction:\u003c/h2\u003e \u003cp\u003eThe rising prevalence of limb amputations, combined with increasing awareness of post-amputation pain and the need for functional rehabilitation, has created a pressing demand for comprehensive, multidisciplinary care models for patients with limb loss. This study describes the patient population and satisfaction outcomes of a specialized amputee care clinic.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eAdult amputees treated at our institution\u0026rsquo;s Interdisciplinary Care for Amputees Network (ICAN) clinic between 2017\u0026ndash;2024 were retrospectively reviewed. Demographics, surgical characteristics, and referral patterns were analyzed. Patient satisfaction was assessed cross-sectionally using the Short Assessment of Patient Satisfaction (SAPS) questionnaire.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOf 318 operative amputee patients (median follow-up 2.0 years (IQR:0.8\u0026ndash;3.4)), 90.6% underwent lower extremity amputation (58.5% transtibial, 27.7% transfemoral), primarily due to trauma (43.7%) or infection (25.2%). Referrals originated primarily from academic medical centers (71.1%), with orthopaedic specialties (46.9%) as predominant source. All operative patients underwent Targeted Muscle Reinnervation (TMR) and/or Regenerative Peripheral Nerve Interface (RPNI), performed primarily during amputation in 158 patients (49.7%), and secondarily for established neuropathic pain in 160 patients (50.3%). Among 270 eligible patients contacted, 156 (57.8%) completed the satisfaction survey. Overall satisfaction was 86.5% (42.3% \u0026ldquo;very satisfied\u0026rdquo;, 44.2% \u0026ldquo;satisfied\u0026rdquo;), with the highest ratings for provider thoroughness (94.5%) and respect (96.6%), and the lowest for time spent with providers (78.9%). Patients with anxiety were significantly more likely to express dissatisfaction (p\u0026thinsp;=\u0026thinsp;0.017).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe implementation of a specialized multidisciplinary amputee care model achieved high satisfaction across care domains. These findings support integrated approaches to amputee management and suggest potential benefits from broader adoption.\u003c/p\u003e\u003ch2\u003eLevel of Evidence:\u003c/h2\u003e \u003cp\u003eIII \u0026ndash; therapeutic\u003c/p\u003e","manuscriptTitle":"Evolution of a Specialized Multidisciplinary Amputee Care Clinic: Referral Patterns and Patient Satisfaction","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-25 06:09:02","doi":"10.21203/rs.3.rs-8289177/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-09T05:45:10+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-05T15:21:24+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-05T14:10:50+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-05T02:40:03+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"126786343543337699040001872963436482092","date":"2026-02-24T21:31:22+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-24T15:26:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"16192464525033319369369632958399118135","date":"2026-02-23T21:59:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"83210983821746220681119241954165240938","date":"2026-02-19T15:17:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"305913440376539980565686684259011492954","date":"2026-02-19T10:51:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"122785886104250210140893309532607348597","date":"2026-02-19T08:27:14+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-19T07:56:41+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-08T15:08:34+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-08T15:05:36+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Orthopaedic Surgery and Research","date":"2025-12-05T15:33:22+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-orthopaedic-surgery-and-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"josr","sideBox":"Learn more about [Journal of Orthopaedic Surgery and Research](http://josr-online.biomedcentral.com)","snPcode":"13018","submissionUrl":"https://submission.nature.com/new-submission/13018/3","title":"Journal of Orthopaedic Surgery and Research","twitterHandle":"@MSKmedBMC","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5d080bca-890f-4c63-a6f5-089c3bd2145f","owner":[],"postedDate":"February 25th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-23T11:12:22+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-25 06:09:02","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8289177","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8289177","identity":"rs-8289177","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}