International Variations in Amputation Practice: A VASCUNET Report

Pain Pressure Threshold as a Non-Linear Marker of Neural Adaptation in Amputees: Evidence from the DEFINE Cohort

BACKGROUND

Amputation poses significant physical, psychological, and emotional challenges, with chronic pain being one of the most debilitating outcomes. Pain Pressure Threshold (PPT), a measure of nociceptive sensitivity, is a valuable tool for assessing changes in pain perception. Understanding PPT modulation in amputees is crucial for uncovering the mechanisms underlying pain and developing targeted interventions for pain management.

OBJECTIVE

This study aimed to evaluate PPT in amputees and identify factors associated with PPT variation in this population.

METHODS

This cross-sectional study analyzed neurophysiological, clinical, and demographic data from 86 amputee patients. PPT was assessed as the primary outcome, and its associations with demographic and clinical predictors were examined using both linear and quadratic regression models.

RESULTS

Multivariate analysis identified a significant association between PPT and biological sex, with females exhibiting lower PPT values than males. Quadratic regression analyses revealed inverted U-shaped associations between PPT and age, BMI, and duration since amputation. PPT increased with age, peaking at 45.8 years, followed by a decline. Similar patterns were observed for BMI, peaking at 27.0 kg/m2, and for amputation duration, peaking at 26.6 months.

CONCLUSIONS

Our findings indicate that sex, age, BMI, and time since amputation are significant factors influencing PPT in amputees, with nonlinear relationships observed for age, BMI, and amputation duration. These results suggest that physiological and disease-related factors (such as age, BMI, and duration of injury) have specific peaks for optimal PPT, highlighting their role in the brain's compensatory system and potential implications for targeted pain management strategies.

Biomechanical effects of saddle height changes in leisure cycling with unilateral transtibial prostheses: A simulated study

Cycling is a beneficial physical activity for rehabilitating individuals with lower-limb amputations and serves as a feasible leisure sport. However, the optimal bicycle configuration for cycling with a unilateral transtibial prosthesis at leisure levels has not been investigated. For saddle height at professional cycling levels, existing literature suggests utilizing the same configuration as that used by intact cyclists, where the knee reaches 25-35° at maximum extension. However, leisure cyclists tend to select lower saddle heights, and cycling with a unilateral transtibial prosthesis infers altered biomechanics during cycling practice. This study aimed to investigate the effects of cycling at different saddle heights with a simulated unilateral prosthesis. Ten able-bodied participants wore orthoses to simulate prosthetic conditions. The experimental task was performed on an ergometer at 40 W resistance, 60 rpm to simulate leisure cycling. Standard saddle height was defined as maximum knee extension of 45°. This height was used as the control condition and its trials were performed without orthoses. The variable heights were set as height percentage variations (-7%, -3.5%, 0, +3.5%, and +7%). Muscle activity, joint movement, force application to the pedals, perceived exertion, and comfort were evaluated. The -3.5% and -7% saddle heights resulted in joint movement and muscle activity levels closer to those in the control conditions, which also showed improved power symmetry between the affected and non-affected legs. In addition, the -3.5% height increased comfort level in participants. In conclusion, selecting lower saddle heights may be beneficial for unilateral transtibial amputees during leisure cycling. The optimal saddle height for this population may maintain maximum knee extension within the 37-45° range, dynamically measured on the affected side.

Risk factors and rates of revision amputation following ischemic lower major limb amputations: A 10-year retrospective analysis

OBJECTIVES

This study aimed to evaluate the rates and risk factors associated with revision amputation following ischemic lower major limb amputations, focusing on cases related to peripheral arterial disease.

PATIENTS AND METHODS

This retrospective study included 253 patients (174 males, 79 females; mean age: 73.1±12.2 years; range, 44 to 99 years) who underwent ischemic foot amputation between December 2012 and December 2022. Eligible patients were over 18 years old and had major lower extremity amputations due to peripheral arterial disease or chronic arterial occlusion. Exclusions were made for amputations due to diabetic foot conditions, trauma, tumors, or osteomyelitis and minor lower extremity amputations.

RESULTS

Above-knee amputations were the most common type of amputation, accounting for 56.5% (n=143) of cases. Revision amputations occurred in 27.3% (n=69) of patients, with significantly higher rates in those with open wounds at first admission (chi-square [χ2 ]=9.81, p=0.002). Patients with occlusion at the popliteal artery level had a higher rate of revision amputation following below-knee amputation (p=0.034). Each additional year of age decreased the likelihood of revision amputation by 2.3% (p=0.049). Vacuum-assisted closure therapy was associated with higher revision rates (χ2 =22.71, p<0.001). Patients who developed infections (n=40) had a significantly higher rate of revision amputations (n=26, p<0.001). Elevated preoperative C-reactive protein levels were also correlated with an increased risk of revision (p=0.006).

CONCLUSION

Patients with ischemic lower limb amputations, particularly those presenting with open wounds, are at higher risk for revision amputation. Elevated preoperative C-reactive protein levels, infections, age, and the initial level of amputation significantly impact the likelihood of reamputation.

Quantification of the Survival Disadvantage Associated with Major Amputation in Patients with Peripheral Arterial Disease

Objective: Despite advancements in vascular surgery, the mortality among peripheral arterial disease (PAD) patients undergoing major amputations remains high. While a large body of evidence has previously covered survival rates after major amputation, there is less evidence regarding the associated survival penalty from an epidemiological perspective. The present analysis aimed at quantifying the survival disadvantage after major lower limb amputation while investigating which factors are associated with mortality in this patient cohort. Methods: Data from 246 PAD patients undergoing major amputations were retrospectively collected and matched with mortality records from the Austrian National Death Registry. Life expectancy was estimated using population-based life tables, and differences between observed and expected survival were analyzed across subgroups. Results: The median follow-up was 492 days (Q1-Q3: 73-1438), and 82.5% (n = 203) of patients died, with cardiovascular events being the leading cause (41%). A profound discrepancy between estimated (4697 days, Q1-Q3: 2962-6236) and observed survival (457 days, Q1-Q3: 73-1438, p < 0.001) was seen. In men, an associated median survival penalty of 11.2 years was observed, equivalent to a proportionate reduction in life expectancy of over 90%, while the difference in women was 8.7 years, equaling a reduction of 84.6%. In a multiple regression model, 1 year in life expectancy was associated with a survival penalty of -0.96 years, thereby affecting younger patients with the highest life expectancies the most. Conclusions: Major amputation in PAD patients is associated with a significant reduction in survival compared to standardized mortality rates in the general population. The survival disadvantage exceeds 70% of estimated survival times in over 70% of patients. Elevated mortality rates after major amputation in PAD patients should not be interpreted as a causal relationship but as a surrogate for impaired systemic cardiovascular health.

Lower Extremity Amputations Among Patients with Diabetes Mellitus: A Five-Year Analysis in a Clinical Hospital in Bucharest, Romania

Background and Objectives: Lower extremity amputations (LEAs) represent a significant health problem. The aim of our study was to analyse the type and trends of diabetes-related LEAs in patients hospitalized in one surgical centre in Bucharest between 2018 and 2021. The second aim was to assess the impact of the COVID-19 pandemic on the trends of LEAs. Materials and Methods: We performed a retrospective analysis of all lower limb amputations performed between 01 January 2018 and 31 December 2021 in the Department of Surgery, Dr. I. Cantacuzino Clinical Hospital, Bucharest, Romania. We evaluated demographic parameters, type of LEA, the level, the laterality and trends of the amputations, the main aetiologies leading to amputation, and the length of hospitalization. Results: During the study period, 1711 patients underwent an LEA. The mean age was 64.53 ± 9.93 years, 71.6% (n = 1481) being over 60. Men outnumbered women by a ratio of 3.62:1. The most frequent interventions were ray amputations in 41.2% (n = 705) of patients; then, there were amputations of the toe (20.4%, n = 349), transtibial amputations (18.9%, n = 323), transfemoral amputations (10.6%, n = 181), and midfoot amputations (9%, n = 154). Wet gangrene was the most frequent aetiology (40.9%, n = 699). The total number of LEAs decreased constantly throughout the analysed period, such that 616 LEAs were performed in 2018 and 323 LEAs in 2021 (p < 0.001). There was a statistically significant increase in the rate of major LEAs in the pandemic vs. pre-pandemic period (37% vs. 24.4%, p < 0.001). Conclusions: In our study, the total number of LEAs decreased throughout the analysed period, but there was an increase in the rate of major LEAs in the pandemic vs. pre-pandemic period. Being over 65 years of age, leucocytosis, sepsis at presentation, and diabetic polyneuropathy were important risk factors for the necessity of LEA in complicated diabetes-related foot disease.

Complications of major lower limb amputations before prosthetic provision at a tertiary care rehabilitation facility

BACKGROUND

Although postoperative complications of lower limb amputations and complications related to prosthetics are well known, complications before prosthetic fitting are less often emphasized in literature. There are no Saudi studies documenting the complications before prosthetic fitting where there is high rise in dysvascular amputation, and early prosthetic provision remains a challenge.

OBJECTIVES

To investigate the complications following major lower limb amputations (MLLAs).

STUDY DESIGN

Retrospective study.

METHODS

One hundred thirty-six electronic files for individuals with major lower limb amputations were reviewed. Individuals visiting the primary limb loss clinic for the first time, who have not been fitted with a prosthesis before, were included.

RESULTS

Muscle weakness was the most common complication (55.1%), followed by edema (52.9%), while infection was found to be the least frequent (5.1%). Age was significantly associated with etiology ( p value < 0.001), usage of assistive device ( p value = 0.002), and complications ( p value = 0.013). Complications were also significantly associated with time since amputation ( p value = 0.001). In addition, etiology was significantly associated with the usage of assistive device ( p value = 0.012).

CONCLUSIONS

Muscle weakness and edema were the most common complications after MLLA in a cohort of patients with median onset of 8.5 ± 6.8 months since amputation. Presence of various complications in MLLAs before prosthetic evaluation reflect gaps of care including delayed prosthetic evaluation. National strategies need to be introduced to promote early rehabilitation interventions, prevent complications, and improve quality of life of individuals with MLLAs.

Epidemiology and Impact of Limb Loss in the United States and Globally

The main causes of limb loss include trauma, complications from diabetes and peripheral arterial disease, malignancy, and congenital limb deficiency. There are significant geographic variations in the incidence of upper and lower, and major and minor limb loss worldwide. Limb loss is costly for patients and the health care system. The availability of orthotic and prosthetic services, along with cost of services, represents barrier to care and contributes to morbidity and mortality. More research is needed, especially in low-income and middle-income countries to describe the extent of limb loss.

Partial hand and finger amputations in Sweden: an observational study of 6918 patients

BACKGROUND

We aimed to use open source data to understand the incidence, trends, and regional differences of finger and partial hand amputations on a national level in individuals aged 15 or older in Sweden.

METHODS

We analyzed 6,918 patients aged 15 and older who had experienced finger and partial hand amputations. Incidence rates, trends, and regional disparities were assessed using negative binomial regression models and Student's t-tests. Future trend prediction was performed using Poisson regression.

RESULTS

Finger amputations declined most, followed by partial hand and thumb amputations. Regional variations existed, with Stockholm having the lowest and Gotland highest incidence respectively. Overall, the incidence of finger, thumb and partial hand amputations in Sweden decreased slightly. Future trend analysis indicated decreasing incidence.

CONCLUSION

Although, lacking in definition, publicly available data can be used for monitoring of finger, thumb, and partial hand amputation incidence on a national level. Sex, age, and regional differences were observed, suggesting the need for targeted interventions to address disparities and mitigate the burden of finger and partial hand amputations on affected individuals.

International Validation of the Vascular Registry of Switzerland, Swissvasc: A VASCUNET Report

OBJECTIVE

Data validity and completeness are essential for registry data, and a meaningful interpretation of differences between countries can only be made if the data are robust within each of the countries. Therefore, the VASCUNET collaboration has performed validation of several vascular registries and so far published the validation results of national vascular registries of Sweden, Denmark, and Malta. The findings of the validation of the Swissvasc Registry, the vascular registry of Switzerland, are presented here.

METHODS

Five of 34 hospitals participating in Swissvasc were visited by two international validators. Independent evaluation of the procedures of carotid endarterectomy, infrarenal abdominal aortic aneurysm (AAA) repair, and bypass surgery for lower extremity arterial disease (LEAD) was performed. Local administrative data and Swissvasc Registry data were compared for external validation, as well as registry data of 15 randomly picked cases within each group with data from individual patient records for internal validation.

RESULTS

Hospital administrative data identified 265 carotid, 399 AAA, and 399 LEAD procedures, whereas Swissvasc identified 265 carotid, 398 AAA, and 395 LEAD procedures. Four LEAD procedures were found in hospital administrative data but not in Swissvasc. External validity was 100% for carotid, 99.8% for AAA, and 99% for LEAD. In internal validation, 5.2% of the variable data were missing in Swissvasc, and 2.4% were different from data in patient records, resulting in external validity of 92.8% for carotid, 94.4% for AAA, and 90.1% for LEAD.

CONCLUSION

The VASCUNET template was used for international validation of registry data and demonstrated that Swissvasc is a reliable system of quality data collection for the participating vascular centres, with excellent external validity and good internal validity. Quality of the Swissvasc registry data was clearly superior to local administrative data.

Incidence and risk factors for amputation in Chinese patients with diabetic foot ulcers: a systematic review and meta-analysis

Objective

This study aimed to comprehensively analyze the incidence of amputation in Chinese patients with diabetic foot ulcers (DFUs).

Methods

The Preferred Reporting Items for a Systematic Review and Meta-analysis (PRISMA) guidelines were used. The CNKI, Wanfang Data, VIP, PubMed, Web of Science, and Embase databases were searched to collect relevant literature on the incidence of amputation in Chinese patients with DFUs. Two researchers independently screened the literature, extracted data, and evaluated the risk of bias. The data were systematically analyzed using Stata 17.0 software to determine the incidence of amputation in this patient population.

Results

A total of 25 papers were included in the study, revealing an incidence of amputation in Chinese patients with DFUs of 22.4% (95% confidence interval: 18.3-26.5%). The subgroup analysis revealed that a history of ulcers, Wagner grade >3, and diabetic peripheral vascular disease were the primary risk factors associated with a higher incidence of amputation in Chinese patients with DFUs (P<0.05). Among Chinese patients with DFUs, the amputation group and the non-amputation group showed significant differences in body mass index, duration of DFUs, total cholesterol, triglyceride, fasting blood glucose, white blood cell count, hemoglobin A1c, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, high-sensitivity C-reactive protein, and uric acid (P<0.05).

Conclusion

The high incidence of amputation among Chinese patients with DFUs indicates that interventions should be implemented to prevent or minimize amputations.

Systematic review registration

https://www.crd.york.ac.uk/prospero, identifier CRD42023463976.

Editor's Choice - Vascular Registries Contributing to VASCUNET Collaborative Abdominal Aortic Aneurysm Outcome Projects: A Scoping Review

OBJECTIVE

Vascular surgery registries report on procedures and outcomes to promote patient safety and drive quality improvement. International registries have contributed significantly to the VASCUNET collaborative abdominal aortic aneurysm (AAA) outcome projects. This scoping review aimed to outline the national registries in vascular surgery that currently participate in the VASCUNET collaborative AAA projects.

METHODS

A scoping review of all published VASCUNET AAA studies and validation reports between 1997 and 2024 was undertaken. A survey was conducted among representatives of the international vascular registries contributing to VASCUNET collaborative AAA projects.

RESULTS

Currently, vascular registries from 10 countries (Australia, Denmark, Finland, Hungary, Iceland, New Zealand, Norway, Sweden, Switzerland, and the UK) contribute to the current VASCUNET collaborative AAA project, of which eight have national coverage. In the past, three countries (Germany, Malta, and Italy) have participated in previous VASCUNET AAA projects, and a further three countries (Serbia, Greece, and Portugal) have planned participation in future projects. External validity is high for all current registries, with most reporting rates of > 90%. The majority have internal validation processes to assess data accuracy. VASCUNET mediated validation has also been performed by the consortium for five countries to date (Hungary, Sweden, Denmark, Malta, and Switzerland), for which a high degree of external and internal validity was identified. Most registries have established mechanisms for data linkage with national administrative datasets or insurance claims datasets and contribute to quality improvement through regular reporting to participating centres.

CONCLUSION

National vascular registries from nations participating in the VASCUNET collaborative AAA projects are largely comprehensive, with high case ascertainment rates and good quality data with internal quality assurance. This provides a template for new registries wishing to join the VASCUNET collaboration and a benchmark for future research.

Editor's Choice - Analysis of Lower Limb Amputations in Brazil's Public Health System over 13 Years

OBJECTIVE

Understanding the causes of amputation is crucial for defining health policies that seek to avoid such an outcome, but only a few studies have investigated the epidemiology of patients submitted to amputations in developing countries. The objective of this study was to analyse all lower limb amputations performed in the public health system in Brazil over a 13 year period, evaluating trends in the number of cases, patient demographics, associated aetiologies, hospital length of stay, and in hospital mortality rate.

METHODS

This was a retrospective, population based analysis of all lower limb amputations performed in the Brazilian public health system between 1 January 2008 and 31 December 2020. Using a public database, all types of amputations were selected, defining the number of procedures, their main aetiologies, anatomical level of limb loss, demographic data, regional distribution, and other variables of interest.

RESULTS

A total of 633 455 amputations were performed between 2008 and 2020, mostly (55.6%) minor amputations, predominantly in males (67%). There was an upward trend in the number of amputations, determined mainly by the increase in major amputations (50.4% increase in the period). Elderly individuals have the highest rates of amputation. Diabetes mellitus (DM) is becoming the main primary diagnosis associated with amputations over the years. The highest in hospital mortality rate occurred after major amputations and was associated with peripheral arterial disease (PAD).

CONCLUSION

Amputation rates in Brazil show an upward trend. DM is becoming the most frequent associated primary diagnosis, although PAD is the diagnosis most associated with major amputations and in hospital death.

Causes, prevention, and management of diabetes-related foot ulcers

In this Review, we aim to complement the 2023 update of the guidelines of the International Working Group on the Diabetic Foot. We highlight the complexity of the pathological processes that underlie diabetes-related foot ulceration (DFU) and draw attention to the potential implications for clinical management and outcome. Variation observed in the incidence and outcome of DFUs in different communities might result from differences in study populations and the accessibility of care. Comparing differences in incidence, management, and outcome of DFUs in different communities is an essential component of the quality of disease care. Additionally, these comparisons can also highlight the relationship between DFU incidence, management, and outcome and the structure of local clinical services and the availability of staff with the necessary skills. The clinical outcome is, however, also dependent on the availability of multidisciplinary care and the ability of people with DFUs to gain access to that care.

The Incidence and Outcomes of Major Limb Amputation in New Zealand from 2010 to 2021

Background: Major limb amputation (MLA) can be a common outcome due to severe peripheral artery disease (PAD) and diabetic foot disease (DFD), and it carries a significant mortality burden. In New Zealand (NZ), there is little documentation of the incidence rate and mortality after MLA. The aim was to report the national crude and standardised rates and the mortality post MLA. Methods: This retrospective observational study included all MLAs that occurred within NZ from 1/1/2010 to 31/12/2021 due to DFD and/or PAD. Two national databases (National Minimum Dataset and the Australasian Vascular Audit) were utilised. The crude rates were calculated as cases per 100,000 in the NZ population per year including all ages (using the 2013 and 2018 NZ census figures). The age-standardised rates used the World Health Organization standard population. Post-operative mortality was calculated from the date of first hospitalisation for MLA. Results: From 2010 to 2021, there were 5293 MLA procedures in 4242 patients. On average, there were 8.5 MLAs per week and 441.1 MLAs annually. The overall crude rate was 9.44 per 100,000, and the standardised rate was 6.12 per 100,000. Over the 12 years, the crude rate decreased by 22% (p < 0.001), and the standardised rate decreased by 20.4% (p < 0.001). After MLA, the 30-day and 1-year mortality was 9.5% and 29.6%, respectively. From 2010 to 2021, the relative reduction in 30-day mortality was 45.1% (p < 0.001), and the reduction in 1-year mortality was 24.5% (p < 0.001). Increasing age, female sex and end-stage renal failure were predictors of 30-day and 1-year mortality. Conclusions: A considerable number of MLAs occur in NZ, with substantial perioperative mortality; however, the national incidence rates and mortality have improved over the last 12 years. This data might serve as benchmark to further reduce MLAs and improve patient outcomes.

Safety and Effectiveness of Debulking for the Treatment of Infrainguinal Peripheral Artery Disease. Data From the Recording Courses of vascular Diseases Registry in 2910 Patients

We investigated the safety and efficacy of debulking infrainguinal lesions in patients with peripheral artery disease (PAD) undergoing endovascular revascularization (EVR) as part of the RECording Courses of vascular Diseases (RECCORD) registry. Patient and lesion specific characteristics, including the lesion complexity score (LCS) were analyzed. The primary endpoint encompassed: (i) clinical improvement in Rutherford categories, (ii) index limb re-interventions, and (iii) major amputations during follow-up. The secondary endpoint included the need for bail-out stenting. Overall, 2910 patients were analyzed; 2552 without and 358 with debulking-assisted EVR. Patients were 72 (interquartile range (IQR) = 15) years old and 1027 (35.3%) had diabetes. Overall complication rates were similarly low in the debulking vs the non-debulking group (4.7 vs 3.2%, P = .18). However, peripheral embolizations rates were low but more frequent with debulking vs. non-debulking procedures (3.9 vs 1.1%, P < .001). After adjustment for clinical and lesion-specific parameters, including LCS, no differences were noted for the primary endpoint (odds ration (OR) = 0.99, 95%CI = 0.69-1.41, P = .94). Bail-out stenting was less frequently performed in patients with debulking-assisted EVR (OR = 0.5, 95%CI = 0.38-0.65, P < .0001). Debulking-assisted EVR is currently used in ∼12% of EVR with infrainguinal lesions and is associated with lower bail-out stent rates but higher peripheral embolization rates; no differences were found regarding index limb re-intervention and amputation rates.

[Vascular Registry is a tool for quality improvement in vascular medicine]

A 2002 óta működő Érsebészeti Regiszter kezdetben verőérműtétek adatainak gyűjtéséből és a beavatkozások eredményeinek elemzéséből állt. Nagy előrelépést jelentett 2006-ban az Európai Érsebész Társaság VASCUNET Munkacsoportjához történő csatlakozás, mely szervezet azóta globális nemzetközi tudományos együttműködéssé fejlődött. A hazai regiszter adatainak felhasználásával az elmúlt 15 évben számos nagy nemzetközi tanulmányt folytattunk le, és ezek alapján több mint 30 publikáció jelent meg, melyekben aktív szerepet vállaltak a Magyar Angiológiai és Érsebészeti Társaság Regiszter Bizottságának tagjai is. Az egyes országok vascularis ellátásának jellemzőit és eredményeit összehasonlító tanulmányok különösen hasznos következtetések levonását tették lehetővé, ami hozzájárulhat vascularis ellátórendszerünk fejlődéséhez. Az újonnan létrehozott Nemzeti Vaszkuláris Regiszter további jelentősége, hogy a tudományos elemző tevékenység mellett fontos szerepet játszhat az érgyógyászati minőségfejlesztésben is. Orv Hetil. 2024; 165(24–25): 950–954.

Epidemiology of Non-Traumatic Lower Extremities Amputations in West Africa: Nationwide Data from Togo

OBJECTIVE

Non-traumatic lower limb amputation (NT-LLA) has consequences at individual and public health levels. Population based studies in sub-Saharan Africa are scarce and often related to single centre series. This study aimed to estimate the incidence of NT-LLA (minor and major) and to describe epidemiological, clinical, and prognostic aspects in Togo.

METHODS

This was a population based observational study conducted among all patients who underwent NT-LLA. Traumatic amputations were excluded. Sociodemographic, clinical, and work up data were collected from clinical files in any Togolese health centre from 1 January 2016 to 31 December 2021. Incidence rates were adjusted for age.

RESULTS

Over the six year period, 352 patients (59% males) underwent NT-LLA (mean ± standard deviation age 60 ± 15.7 years). The average age adjusted incidence rate of NT-LLA was 8.5 per million/year (95% confidence interval [CI] 7.6 - 9.4). Men were 1.7 times more likely to undergo a NT-LLA than women. The relative risk of NT-LLA was 48 times higher in patients with diabetes than in patients without diabetes. Around 61.0% of the NT-LLAs occurred within the 50 - 74 age group and 54.3% had diabetes mellitus. Among amputees, 54.5% had a diagnosis of peripheral artery disease (PAD) and 52.8% had diabetic ulcers, with co-existence of several factors. Less than 5% of participants had a history of smoking tobacco. Average length of hospital stay was 12 days. The in hospital mortality rate was 8.8% (9.0% for major, 6.7% for minor amputations). Only 18.2% had duplex ultrasound performed and 1.7% angiography prior to amputation. No patient underwent vascular intervention prior to amputation.

CONCLUSION

This is the first study to report nationwide and contemporary epidemiological data on NT-LLAs in West Africa, highlighting several specificities. Large scale interventions are needed to ameliorate the care of diabetes and PAD and improve facilities for optimal management of patients at risk of amputation in Africa.

A Review of Natural Fiber-Reinforced Composites for Lower-Limb Prosthetic Designs

This paper presents a comprehensive review of natural fiber-reinforced composites (NFRCs) for lower-limb prosthetic designs. It covers the characteristics, types, and properties of natural fiber-reinforced composites as well as their advantages and drawbacks in prosthetic designs. This review also discusses successful prosthetic designs that incorporate NFRCs and the factors that make them effective. Additionally, this study explores the use of computational biomechanical models to evaluate the effectiveness of prosthetic devices and the key factors that are considered. Overall, this document provides a valuable resource for anyone interested in using NFRCs for lower-limb prosthetic designs.

Five-Year Trends of Vascular Disease-Related Amputations in Romania: A Retrospective Database Study

Background/Objectives: Lower extremity amputations (LEAs) are a burdensome complication of peripheral artery disease (PAD) and/or arterial embolism and thrombosis (AET). We assessed the trends in PAD- and/or AET-related LEAs in Romania. Methods: This retrospective study (2015-2019) analyzed data on minor and major LEAs in hospitalized patients recorded in the National School for Public Health, Management, and Health Education database. The absolute numbers and incidences of LEAs were analyzed by diagnosis type, year, age, sex, and amputation level. Results: Of 38,590 vascular disease-related amputations recorded nationwide, 36,162 were in PAD and 2428 in AET patients. The average LEA incidence in the general population was 34.73 (minimum: 31.96 in 2015; maximum: 36.57 in 2019). The average incidence of major amputations, amputations above the knee, hip amputations, amputations below the knee, and minor amputations was 16.21 (15.62 in 2015; 16.84 in 2018), 13.76 (13.33 in 2015; 14.28 in 2018), 0.29 (0.22 in 2017; 0.35 in 2019), 2.15 (2.00 in 2015; 2.28 in 2019), and 18.52 (16.34 in 2015; 20.12 in 2019), respectively. Yearly PAD- and/or AET-related amputations were significantly higher in men versus women. The overall number of LEAs increased with age, particularly in patients ≥ 70 years. The increase in the total number of amputations was mainly due to a constant rise in minor amputations for both groups, regardless of gender. Conclusions: PAD- and/or AET-related LEAs in Romania increased from 2015 to 2019, with men having a greater incidence than women. Raising awareness and effective management strategies are needed to prevent LEAs.

Pain in the Context of Sensory Deafferentation

Pain that accompanies deafferentation is one of the most mysterious and misunderstood medical conditions. Prevalence rates for the assorted conditions vary considerably but the most reliable estimates are greater than 50% for strokes involving the somatosensory system, brachial plexus avulsions, spinal cord injury, and limb amputation, with controversy surrounding the mechanistic contributions of deafferentation to ensuing neuropathic pain syndromes. Deafferentation pain has also been described for loss of other body parts (e.g., eyes and breasts) and may contribute to between 10% and upwards of 30% of neuropathic symptoms in peripheral neuropathies. There is no pathognomonic test or sign to identify deafferentation pain, and part of the controversy surrounding it stems from the prodigious challenges in differentiating cause and effect. For example, it is unknown whether cortical reorganization causes pain or is a byproduct of pathoanatomical changes accompanying injury, including pain. Similarly, ascertaining whether deafferentation contributes to neuropathic pain, or whether concomitant injury to nerve fibers transmitting pain and touch sensation leads to a deafferentation-like phenotype can be clinically difficult, although a detailed neurologic examination, functional imaging, and psychophysical tests may provide clues. Due in part to the concurrent morbidities, the physical, psychologic, and by extension socioeconomic costs of disorders associated with deafferentation are higher than for other chronic pain conditions. Treatment is symptom-based, with evidence supporting first-line antineuropathic medications such as gabapentinoids and antidepressants. Studies examining noninvasive neuromodulation and virtual reality have yielded mixed results.

The global burden of traumatic amputation in 204 countries and territories

Background

Traumatic amputation leads to disability and imposes a heavy health burden. This study aims to explore the current status and temporal trends of the global burden of traumatic amputation according to sex, age, amputation site, cause, and reginal level of social development.

Methods

The data were extracted from the Global Burden of Diseases (GBD) Study 2019. Prevalence, incidence, years lived with disability (YLDs) and corresponding age-standardized rate were compared. Estimated annual percentage change (EAPC) was applied to reflect trends in age-standardized rates over a specific period. Spearman rank test and curve fitting methods were used to analyze the relationship between disease burden and Socio-Demographic Index (SDI).

Results

Globally, the incidence and prevalence number of traumatic amputation increased from 11.37 million and 370.25 million in 1990, to 13.23 million and 552.45 million in 2019, with a raise of 16.4 and 49.2%, respectively. But the age-standardized incidence rate (ASIR) (EAPC = -0.56; 95%CI, -0.72 to -0.41) and age-standardize prevalence rate (ASPR) (EAPC = -0.63; 95%CI, -0.74 to -0.52) declined during this period. The YLDs count also increased by 39.2% globally (from 5.28 million to 7.35 million), while the age-standardize YLDs rate (ASYR) decreased by an average of 1.00% per year (95% CI, -1.10 to -0.90) from 1990 to 2019. The incidence, prevalence, and YLDs rate of traumatic amputation continue to increase with age. Traumatic amputations were most common in the fingers, while unilateral lower limb amputation caused the greatest burden of disability. ASIR and SDI were positively correlated (ρ = 0.442, p < 0.001), while ASYR and SDI were not significantly correlated (ρ = -0.030, p = 0.669), and EAPC in ASYR and SDI were negatively correlated (ρ = -0.275, p < 0.001). Exposure to mechanical forces and falls were the leading causes of traumatic amputation.

Conclusion

Despite the declining trends in ASIR, ASPR, and ASYR, the incidence, prevalence, and YLDs counts of traumatic amputation have increased significantly worldwide, especially in the older adults population. With the population aging, targeted health policies are needed to address the increasing global burden of traumatic amputations in the future.

[Objective measurement tools that predict success in the fitting of major unilateral lower limb amputations patients]

The profile of the patient who most frequently suffers lower limb amputations is usually an elderly patient with high comorbidity. Physiatrists need objective tools in the assessment of these patients that predict the results of prosthetic programs to increase patient safety and efficiency of prosthetic rehabilitation programs. Given the need to update scientific knowledge in this field, we have carried out a review of the literature with the aim of defining a proposal for tools that facilitate decision-making in the indication of prosthetic rehabilitation in these patients. A bibliographic search strategy has been carried out using the scientific databases PubMed, Web of Science, Scopus and Cochrane Library. The quality of the selected articles has been assessed according to the tools proposed by CASPe.

Psychosocial patient perspectives following major lower-limb amputation due to vascular aetiology: a protocol for a systematic meta-aggregation study

INTRODUCTION

Persistent psychosocial problems in people with lower-limb amputation due to vascular aetiology indicate a great need for long-lasting holistic rehabilitation. An in-depth understanding of the psychosocial problems is essential for the guidance of health professionals in meeting and normalising patients' experiences and emotions. Furthermore, identifying the psychological problems may help develop effective rehabilitation and counselling programmes. This meta-aggregation study aims to explore the psychosocial perspectives of individuals who have undergone a major lower-limb amputation due to vascular aetiology during the post-discharge rehabilitation phase.

METHODS AND ANALYSIS

A systematic meta-aggregation study will be performed to identify full-text, peer-reviewed journal articles reporting on patients' psychosocial perspectives on major lower-limb amputation due to vascular aetiology from post-discharge to several years afterward. The databases Embase, CINAHL Ultimate, APA PsycInfo, PubMed and Scopus will be searched with no limitations regarding the publication year. Studies that satisfy the eligibility criteria will be critically appraised using an acknowledged checklist and synthesised using the Joanna Briggs Institute three-phase approach for the synthesis of meta-aggregation studies. The GRADE-CERQual (Grading of Recommendations Assessment, Development and Evaluation- Confidence in Evidence from Reviews of Qualitative research) tool will be used to determine the level of confidence in the qualitative evidence, and the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis) reporting guidelines will be followed throughout the review process.

ETHICS AND DISSEMINATION

Ethical approval is not required for the study, as the review is built on pre-existing available data in the literature. Findings from the review will be disseminated through publication in a peer-review journal.

PROSPERO REGISTRATION NUMBER

CRD42022377114.

Analysis of Lower Extremity Amputations from the SerbVasc Registry

BACKGROUND

Peripheral arterial disease (PAD) and diabetes are the major causes of lower extremity amputations (LEAs) worldwide. Morbidity and mortality in patients with LEAs are high with an associated significant burden on the global health system. The aim of this article is to report the overall morbidity and mortality rates after major and minor LEAs from the Serbian Vascular Registry (SerbVasc), with an analysis of predictive factors that influenced adverse outcomes.

MATERIALS AND METHODS

SerbVasc was created in 2019 as a part of the Vascunet collaboration that is aiming to include all vascular procedures from 21 hospitals in Serbia. Prevalence of diabetes among patients with LEAs, previous revascularization procedures, the degree and the type of foot infection and tissue loss, and overall morbidity and mortality rates were analyzed, with a special reference to mortality predictors.

RESULTS

In the period from January 2020 to December 2022, data on 702 patients with LEAs were extracted from the SerbVasc registry, mean age of 69.06±10.63 years. Major LEAs were performed in 59%, while minor LEAs in 41% of patients. Diabetes was seen in 65.1% of the patients, with 44% of them being on insulin therapy. Before LEA, only 20.3% of patients had previous peripheral revascularization. Soft tissue infection, irreversible acute ischemia, and Fontaine III and IV grade ischemia were the most common causes of above-the-knee amputations while diabetic foot was the most common cause of transphalangeal and toe amputations. The infection rate was 3.7%, the re-amputation rate was 5.7%, and the overall mortality rate was 6.9%, with intrahospital mortality in patients with above-the-knee amputation of 11.1%. The most significant intrahospital mortality predictors were age >65 years (p<0.001), chronic kidney disease (CKD) (p<0.001), ischemic heart disease (IHD) (p=0.001), previous myocardial revascularization (p=0.017), emergency type of admission (p<0.001), not using aspirin (p=0.041), using previous anticoagulation therapy (p=0.003), and postoperative complications (p<0.001).

CONCLUSIONS

The main predictors of increased mortality after LEAs from the SerbVasc registry are age >65 years, CKD, IHD, previous myocardial revascularization, emergency type of admission, not using aspirin, using previous anticoagulation therapy, and postoperative complications. Taking into account high mortality rates after LEAs and a small proportion of previous peripheral revascularization, the work should be done on early diagnosis and timely treatment of PAD hopefully leading to decreased number of LEAs and overall mortality.

CLINICAL IMPACT

Mortality after lower limb amputation from the SerbVasc register is high. A small number of previously revascularized patients is of particular clinical importance, bearing in mind that the main reasons for above-the-knee amputations were irreversible ischemia, Fontaine III and Fontaine IV grade ischemia. Lack of diagnostics procedures and late recognition of patients with PAD, led to subsequent threating limb ischemia and increased amputation rates. The work should be done on early diagnosis and timely treatment of PAD in Serbia, hopefully leading to an increased number of PAD procedures, decreased number of LEAs, and lower overall mortality.

Integration of proprioception in upper limb prostheses through non-invasive strategies: a review

Proprioception plays a key role in moving our body dexterously and effortlessly. Nevertheless, the majority of investigations evaluating the benefits of providing supplemental feedback to prosthetics users focus on delivering touch restitution. These studies evaluate the influence of touch sensation in an attempt to improve the controllability of current robotic devices. Contrarily, investigations evaluating the capabilities of proprioceptive supplemental feedback have yet to be comprehensively analyzed to the same extent, marking a major gap in knowledge within the current research climate. The non-invasive strategies employed so far to restitute proprioception are reviewed in this work. In the absence of a clearly superior strategy, approaches employing vibrotactile, electrotactile and skin-stretch stimulation achieved better and more consistent results, considering both kinesthetic and grip force information, compared with other strategies or any incidental feedback. Although emulating the richness of the physiological sensory return through artificial feedback is the primary hurdle, measuring its effects to eventually support the integration of cumbersome and energy intensive hardware into commercial prosthetic devices could represent an even greater challenge. Thus, we analyze the strengths and limitations of previous studies and discuss the possible benefits of coupling objective measures, like neurophysiological parameters, as well as measures of prosthesis embodiment and cognitive load with behavioral measures of performance. Such insights aim to provide additional and collateral outcomes to be considered in the experimental design of future investigations of proprioception restitution that could, in the end, allow researchers to gain a more detailed understanding of possibly similar behavioral results and, thus, support one strategy over another.

Clinimetrics of performance-based functional outcome measures for vascular amputees: A systematic review

BACKGROUND

Objective physical performance-based outcome measures (PerBOMs) are essential tools for the holistic management of people who have had an amputation due to vascular disease. These people are often non-ambulatory, however it is currently unclear which PerBOMs are high quality and appropriate for those who are either ambulatory or non-ambulatory.

RESEARCH QUESTION

Which PerBOMs have appropriate clinimetric properties to be recommended for those who have had amputations due to vascular disease ('vascular amputee')?

DATA SOURCES

MEDLINE, CINAHL, EMBASE, EMCARE, the Cochrane Library, Cochrane Central Register of Controlled Trials (CENTRAL) and Scopus databases were searched for the terms: "physical performance" or "function", "clinimetric properties", "reliability", "validity", "amputee" and "peripheral vascular disease" or "diabetes".

REVIEW METHODS

A systematic review of PerBOMs for vascular amputees was performed following COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) methodology and PRISMA guidelines. The quality of studies and individual PerBOMs was assessed using COSMIN risk of bias and good measurement properties. Overall PerBOM quality was evaluated with a modified GRADE rating. Key clinimetric properties evaluated were reliability, validity, predictive validity and responsiveness.

RESULTS

A total of 15,259 records were screened. Forty-eight studies (2650 participants) were included: 7 exclusively included vascular amputees only, 35 investigated validity, 20 studied predictive validity, 23 investigated reliability or internal consistency and 7 assessed responsiveness. Meta-analysis was neither possible nor appropriate for this systematic review in accordance with COSMIN guidelines, due to heterogeneity of the data. Thirty-four different PerBOMs were identified of which only 4 are suitable for non-ambulatory vascular amputees. The Amputee Mobility Predictor no Prosthesis (AMPnoPro) and Transfemoral Fitting Predictor (TFP) predict prosthesis use only. PerBOMs available for assessing physical performance are the One-Leg Balance Test (OLBT) and Basic Amputee Mobility Score (BAMS).

CONCLUSION

At present, few PerBOMs can be recommended for vascular amputees. Only 4 are available for non-ambulatory individuals: AMPnoPro, TFP, OLBT and BAMS.

The Effect of Motivational Interview-Based Counseling in Individuals With Amputation: A Randomized Controlled Trial in Turkey

AIM

This randomized controlled experimental study determined the effect of motivational interview-based counseling on the coping strategies and perceived social support levels in individuals with amputations due to chronic disease.

DESIGN

A randomized controlled trial was conducted.

METHOD

The study was completed in the orthopedics and traumatology department with 48 patients. Data were collected using a descriptive information form, the Coping Strategies Scale, and the Multidimensional Scale of Perceived Social Support. Independent samples t test, paired t test, and chi-square test were used for data analysis.

RESULTS

The scores of the Coping Strategies Scale and the Perceived Social Support Scale of individuals in the intervention group significantly increased in the posttest after motivational interview-based counseling compared to their pretest scores. It was determined that the Coping Strategies Scale and Perceived Social Support Scale subdimension scores and total mean scores for individuals in the intervention group in the posttest were higher than the mean scores for individuals in the control group. The difference between the groups was significant.

CONCLUSION

The motivational interview-based counseling given to individuals with amputation because of chronic disease increased their coping strategies and perceived social support levels.

Tourniquet use for people with peripheral arterial disease undergoing major lower limb amputations

BACKGROUND

At least 7000 major lower limb amputations (MLLAs) are performed in the UK each year, 80% of which are due to peripheral arterial disease (PAD). Intraoperative blood loss can have a deleterious effect on patient outcomes, and its replacement with transfused blood is not without risk. Tourniquets can be used in lower limb surgical procedures to provide a bloodless surgical field, minimise intraoperative blood loss, and reduce perioperative blood transfusion requirements. Although their safety has been demonstrated in certain orthopaedic operations, their use among people with PAD undergoing MLLA remains controversial. Many clinicians are concerned about tourniquets potentially compromising perfusion of the stump and thereby impacting wound healing through direct tissue injury, damage to the arterial supply of the wound, or both.

OBJECTIVES

To assess the safety and effectiveness of tourniquet use in people undergoing MLLA for complications of PAD, specifically with regard to intraoperative blood loss, change in haemoglobin levels, transfusion rates, wound healing, need for revision surgery, and postoperative complications including mortality.

SEARCH METHODS

We searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL databases and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers from inception to 17 May 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing tourniquet use to no tourniquet use among people with PAD undergoing MLLA.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Primary outcomes were intraoperative blood loss, fall in haemoglobin levels, and perioperative blood transfusion requirement. Secondary outcomes were primary wound-healing rates, stump revision rates, other postoperative complications defined as per Clavien-Dindo classification, and postoperative mortality at 30 days and at maximal follow-up. We used GRADE to assess the certainty of evidence for each outcome.

MAIN RESULTS

One RCT met our inclusion criteria, which was a prospective randomised blinded controlled trial conducted in Sheffield, UK in 2006. In total 64 participants undergoing transtibial amputation for non-reconstructable PAD were randomised to either tourniquet or no tourniquet to assess for intraoperative blood loss, fall in haemoglobin, transfusion requirement, wound healing, stump breakdown and revision. Ten participants were excluded postrandomisation (five from the tourniquet group and five from the no tourniquet group). The reported median volume of intraoperative blood loss was significantly less in the tourniquet group (255 mL (interquartile range (IQR) 150 to 572.5 mL))) compared to the control group (550 mL (IQR 255 to 1050 mL)) (P = 0.014). There was a significantly lower median drop in haemoglobin concentration in the tourniquet group (1.0 g/dL (IQR 0.6 to 2.4 g/dL)) compared to the control group (1.8 g/dL (IRQ 0 to 1.2 g/dL)) (P = 0.035). There was a significantly lower perioperative blood transfusion requirement in the tourniquet group (8 participants, 32%) compared to the control group (14 participants, 48%) (P = 0.047). There were no clear differences in wound breakdown, stump revision, primary wound healing at six weeks, postoperative complications (myocardial infarction, cardiac arrhythmias, pulmonary oedema), and death between groups. We assessed the one included study as at low risk of bias for sequence generation and blinding of outcome assessors; high risk of bias for incomplete outcome data and selective outcome reporting; and unclear risk of bias for allocation concealment, blinding of participants and personnel, and other sources of bias. We assessed the certainty of the evidence as low or very low due to risk of bias, small sample size, and the study being insufficiently powered for most outcomes.

AUTHORS' CONCLUSIONS

This review identified only one small historical RCT evaluating tourniquet use in MLLA. Tourniquets appeared to reduce intraoperative blood loss, drop in haemoglobin, and blood transfusion requirements following transtibial amputations for people with PAD. However, it is unclear whether tourniquets affect wound healing, stump revision rates, postoperative complications, or mortality. High-certainty evidence is required to inform clinical decision-making for the use of tourniquets in these patients.

Diabetic Foot Ulcers: A Review

Importance

Approximately 18.6 million people worldwide are affected by a diabetic foot ulcer each year, including 1.6 million people in the United States. These ulcers precede 80% of lower extremity amputations among people diagnosed with diabetes and are associated with an increased risk of death.

Observations

Neurological, vascular, and biomechanical factors contribute to diabetic foot ulceration. Approximately 50% to 60% of ulcers become infected, and about 20% of moderate to severe infections lead to lower extremity amputations. The 5-year mortality rate for individuals with a diabetic foot ulcer is approximately 30%, exceeding 70% for those with a major amputation. The mortality rate for people with diabetic foot ulcers is 231 deaths per 1000 person-years, compared with 182 deaths per 1000 person-years in people with diabetes without foot ulcers. People who are Black, Hispanic, or Native American and people with low socioeconomic status have higher rates of diabetic foot ulcer and subsequent amputation compared with White people. Classifying ulcers based on the degree of tissue loss, ischemia, and infection can help identify risk of limb-threatening disease. Several interventions reduce risk of ulcers compared with usual care, such as pressure-relieving footwear (13.3% vs 25.4%; relative risk, 0.49; 95% CI, 0.28-0.84), foot skin measurements with off-loading when hot spots (ie, greater than 2 °C difference between the affected foot and the unaffected foot) are found (18.7% vs 30.8%; relative risk, 0.51; 95% CI, 0.31-0.84), and treatment of preulcer signs. Surgical debridement, reducing pressure from weight bearing on the ulcer, and treating lower extremity ischemia and foot infection are first-line therapies for diabetic foot ulcers. Randomized clinical trials support treatments to accelerate wound healing and culture-directed oral antibiotics for localized osteomyelitis. Multidisciplinary care, typically consisting of podiatrists, infectious disease specialists, and vascular surgeons, in close collaboration with primary care clinicians, is associated with lower major amputation rates relative to usual care (3.2% vs 4.4%; odds ratio, 0.40; 95% CI, 0.32-0.51). Approximately 30% to 40% of diabetic foot ulcers heal at 12 weeks, and recurrence after healing is estimated to be 42% at 1 year and 65% at 5 years.

Conclusions and Relevance

Diabetic foot ulcers affect approximately 18.6 million people worldwide each year and are associated with increased rates of amputation and death. Surgical debridement, reducing pressure from weight bearing, treating lower extremity ischemia and foot infection, and early referral for multidisciplinary care are first-line therapies for diabetic foot ulcers.

Limb Related Outcomes of Endovascular vs. Open Surgical Revascularisation in Patients with Peripheral Arterial Occlusive Disease: A Report from the Prospective GermanVasc Cohort Study

OBJECTIVE

The goal of this study was to compare clinical outcomes in patients with peripheral arterial occlusive disease undergoing revascularisation by peripheral endovascular intervention (EVI), bypass surgery, endarterectomy (EA), and hybrid surgery in an unselected real world setting.

METHODS

This was a German, prospective, multicentre, comparative cohort study, enrolling patients at hospital admission for revascularisation at 35 vascular centres with 12 months of follow up. Primary composite endpoints were major amputation or death, major adverse limb events, and any minor or major amputation. Twelve month incidences and hazard ratios (HRs) for the four subgroups and 95% confidence intervals (CIs) were estimated using Kaplan-Meier functions and Cox proportional hazard models. Sociodemographic and clinical characteristics, pharmacological treatment, and comorbidities were used to adjust for patient differentials (unique identifier ClinicalTrials.gov: NCT03098290).

RESULTS

In total, 4 475 patients were analysed (mean age 69 years, 69.4% males, and 31.5% suffering from chronic limb threatening ischaemia). After 12 months of follow up, 5.3% (95% CI 3.6 - 6.9%) of the patients experienced either death or major amputation, 7.2% (95% CI 4.8 - 9.6%) major adverse limb event, and 6.6% (95% CI 5.0 - 8.2%) any minor or major amputation. Compared with EVI, bypass surgery was associated with an increased risk of amputation or death (HR 2.59, 95% CI 1.75 - 3.85), major adverse limb event (HR 1.93, 95% CI 1.11 - 3.36), and any minor or major amputation (HR 2.12, 95% CI 1.42 - 3.16), and hybrid surgery with an increased risk of amputation or death (HR 2.29, 95% CI 1.27 - 4.13) and major adverse limb event (HR 1.62, 95% CI 1.03 - 2.54). After adjusting for patient differentials, no significant differences among study groups remained.

CONCLUSION

More favourable outcomes after EVI were completely attributed to differentials in patient characteristics and not procedure type. The current study emphasised that all competing approaches performed similarly in a real world setting.

Incidence of Lower Extremity Amputation in Romania: A Nationwide 5-Year Cohort Study, 2015-2019

Background and Objectives: The primary objective of this study was to investigate the incidence of lower extremity amputations (LEAs) in a representative population from Romania, in both diabetic and non-diabetic adults, including trauma-related amputations. The secondary objective was to evaluate the trends in LEAs and the overall ratio of major-to-minor amputations. Material and Methods: The study was retrospective and included data from the Romanian National Hospital Discharge Records, conducted between 1 January 2015 and 31 December 2019. Results: The overall number of cases with LEAs was 88,102, out of which 38,590 were aterosclerosis-related LEAs, 40,499 were diabetes-related LEAs, and 9013 were trauma-related LEAs, with an ascending trend observed annually for each of these categories. Of the total non-traumatic amputations, 51.2% were in patients with diabetes. Most LEAs were in men. The total incidence increased from 80.61/100,000 in 2015 to 98.15/100,000 in 2019. Conclusions: Our study reported a 21% increase in total LEAs, 22.01% in non-traumatic LEAs, and 19.65% in trauma-related amputation. The minor-to-major amputation ratio increased over the study period in patients with diabetes. According to these findings, it is estimated that currently, in Romania, there is one diabetes-related amputation every hour and one non-traumatic amputation every 30 min.

The importance of socio-economic determinants of health in the care of patients with peripheral artery disease: A narrative review from VAS

Socio-economic determinants of health (SDoH) include various nonmedical factors in the socio-economic sphere with a potentially significant impact on health outcomes. Their effects manifest through several mediators/moderators (behavioral characteristics, physical environment, psychosocial circumstances, access to care, and biological factors). Various critical covariates (age, gender/sex, race/ethnicity, culture/acculturation, and disability status) also interact. Analyzing the effects of these factors is challenging due to their enormous complexity. Although the significance of SDoH for cardiovascular diseases is well documented, research regarding their impact on peripheral artery disease (PAD) occurrence and care is less well documented. This narrative review explores to what extent SDoH are multifaceted in PAD and how they are associated with its occurrence and care. Additionally, methodological issues that may hamper this effort are addressed. Finally, the most important question, whether this association may contribute to reasonable interventions aimed at SDoH, is analyzed. This endeavor requires attention to the social context, a whole systems approach, multilevel-thinking, and a broader alliance that reaches out to more stakeholders outside the medical sphere. More research is needed to justify the power in this concept to improve PAD-related outcomes like lower extremity amputations. At the present time, some evidence, reasonable consideration, and intuitive reasoning support the implementation of various interventions in SDoH in this field.

Disease-Specific Quality of Life among Patients with Peripheral Artery Disease in Hungary

Peripheral artery disease (PAD) is a progressive atherosclerotic disease significantly impacting functional status and health-related quality of life (HRQoL). This study aimed to investigate HRQoL among PAD patients in Hungary using the validated Hungarian version of the PADQoL questionnaire. Patients with symptomatic PAD were consecutively recruited from the Department of Angiology, Clinical Center, University of Pécs, Hungary. Demographics, risk factors, and comorbidities were registered. Disease severity was measured by Fontaine and WIFI stages. Descriptive statistical analysis, Chi-square test, and non-parametric tests were performed (p < 0.05). Overall, 129 patients (mean age 67.6 ± 11.9 years, men 51.9%) participated in our study. The Hungarian PADQoL demonstrated good internal consistency (α range: 0.745-0.910). Factors on intimate and social relationships gave the best (89.15 ± 20.91; 63.17 ± 26.05) and sexual function (28.64 ± 27.42), and limitations in physical functioning (24.68 ± 11.40) the worst scores. PAD had a significant negative impact on the social relationships of patients aged 21-54 years (51.6 ± 25.4). Fontaine stage IV patients experienced significantly lower HRQoL due to fear and uncertainty (46.3 ± 20.9) and limited physical functioning (33.2 ± 24.8). The Hungarian PADQoL identified central aspects of HRQoL. Advanced PAD was found to impact several areas of HRQoL, primarily physical functioning and psycho-social well-being, drawing attention to the importance of early diagnosis and management.

Demographics and Etiology for Lower Extremity Amputations-Experiences of an University Orthopaedic Center in Germany

Background and Objectives: Currently, the worldwide incidence of major amputations in the general population is decreasing whereas the incidence of minor amputations is increasing. The purpose of our study was to analyze whether this trend is reflected among orthopaedic patients treated with lower extremity amputation in our orthopaedic university institution. Materials and Methods: We conducted a single-center retrospective study and included patients referred to our orthopaedic department for lower extremity amputation (LEA) between January 2007 and December 2019. Acquired data were the year of amputation, age, sex, level of amputation and cause of amputation. T test and Chi² test were performed to compare age and amputation rates between males and females; significance was defined as p < 0.05. Linear regression and multivariate logistic regression models were used to test time trends and to calculate probabilities for LEA. Results: A total of 114 amputations of the lower extremity were performed, of which 60.5% were major amputations. The number of major amputations increased over time with a rate of 0.6 amputation/year. Men were significantly more often affected by LEA than women. Age of LEA for men was significantly below the age of LEA for women (men: 54.8 ± 2.8 years, women: 64.9 ± 3.2 years, p = 0.021). Main causes leading to LEA were tumors (28.9%) and implant-associated complications (25.4%). Implant-associated complications and age raised the probability for major amputation, whereas malformation, angiopathies and infections were more likely to cause a minor amputation. Conclusions: Among patients in our orthopaedic institution, etiology of amputations of the lower extremity is multifactorial and differs from other surgical specialties. The number of major amputations has increased continuously over the past years. Age and sex, as well as diagnosis, influence the type and level of amputation.

Editor's Choice - Incidence of Lower Limb Amputations in Sweden from 2008 to 2017

OBJECTIVE

This study examined the recent national and regional incidence of lower limb amputations (LLAs) in Sweden and their annual changes.

METHODS

This was an observational study using Swedish national register data. All initial amputations were identified in Sweden from 2008 to 2017 in individuals 18 years or older using the national inpatient register. The amputations were categorised into three levels: high proximal (through or above the knee joint), low proximal (through the tibia to through the ankle joint), and partial foot amputations. To examine the national and regional incidence and annual changes, the age, sex, and region specific population count each year was used as the denominator and Poisson regression or negative binomial regression models were used to estimate incidence rate ratios (IRRs) and 95% confidence intervals (CIs) adjusted for age and sex.

RESULTS

The national annual incidence of LLAs was 22.1 per 100 000 inhabitants, with a higher incidence in men (24.2) than in women (20.0). The incidence of LLAs (all levels combined) declined during the study period, with an IRR of 0.984 per year (95% CI 0.973 - 0.994). This was mainly due to a decrease in high proximal amputations (0.985, 95% CI 0.974 - 0.995) and low proximal amputations (0.973, 95% CI 0.962 - 0.984). No change in the incidence of partial foot amputations was observed (0.994, 95% CI 0.974 - 1.014). Such declines in LLA incidence (all levels combined) were observed in nine of the 21 regions. Compared with the national average and with adjustment for age, sex, diabetes, and artery disease, the regional IRR varied from 0.85 to 1.36 for all LLAs, from 0.67 to 1.61 for high proximal amputations, from 0.50 to 1.51 for low proximal amputations, and from 0.13 to 3.68 for partial foot amputations.

CONCLUSION

The incidence of LLAs has decreased in Sweden. However, regional variations in incidence, time trends, and amputation levels warrant further research.

Cross-Sectional Analysis of 180,595 Lower Limb Amputations in the State of Sao Paulo Over 12 Years

BACKGROUND

Lower limb amputations represent a high social, economic and health burden. Most of them are preventable and reflect areas for improvement in health care, making it essential to know their epidemiology.

MATERIALS AND METHODS

This is a retrospective population-based cross-sectional analysis on all lower limb amputations performed in public hospitals in Sao Paulo between 2009 and 2020, the most populous Brazilian state, with 46 million inhabitants. Using a public database, we evaluated types, rates and trends of the amputations performed, main etiologies leading to the indication for amputation, hospital length of stay and in-hospital mortality rates, demographics of the amputees and procedure costs.

RESULTS

In total, 180,595 lower limb amputations and surgical revision of amputations were performed, with toe amputations (45%) and major amputations (33%) being the most frequent types of surgeries, with a recent significant increase in the rates for both these procedures. Peripheral artery disease was the most frequent etiology, followed by diabetes mellitus, with both showing an upward trend over the years. Most patients were male (69.3%), Caucasians (55.6%) and elderly. August was the month with the highest number of amputations in all years. Overall in-hospital mortality after lower limb amputations was 6.6%. Total reimbursed by the government was US$ 67,675,875.55.

CONCLUSIONS

Peripheral artery disease is the most frequent underlying diagnosis for lower limb amputations, followed by diabetes mellitus, with both showing an upward trend over the years. We observed seasonality in procedure rates, with peaks in August in all years.

Epidemiology of Peripheral Artery Disease: Narrative Review

Past decades have witnessed a major epidemiologic transition with a considerable increase in the disease burden associated with atherosclerotic cardiovascular diseases (CVDs), with low-income and middle-income countries (LMICs) experiencing substantial increase in CVDs. As the global population is aging and peripheral artery disease (PAD) is strongly age-related, it is estimated to become increasingly prevalent in the future. PAD shares risk factors with coronary and cerebrovascular risk factors, particularly diabetes mellitus and smoking, and is associated with significant CVD morbidity and mortality. Despite advances in therapeutic modalities, 236 million people were estimated to be suffering from PAD worldwide in 2015, and numbers have been rising since. The prevalence of asymptomatic PAD has remained high; PAD prevalence seems higher among women and is related to ethnicity. Although several epidemiological studies have been published on PAD during the past decades, data from LMICs are scarce. Besides providing up-to-date epidemiological data retrieved from the literature and the Global Burden of Disease (GBD) study database, this narrative review also intends to draw attention to the substantial disease burden of PAD manifesting in more Years of Life Lost (YLL), age-adjusted mortality and amputation rates, with a special focus on some European countries and especially Hungary, i.e., the country with the highest amputation rate in Europe.

Temporal trends in major, minor and recurrent lower extremity amputations in people with and without diabetes in Belgium from 2009 to 2018

AIMS

This study assessed temporal trends in the incidence of lower extremity amputations (LEA) in Belgium from 2009 to 2018, and subsequent secondary amputation rates.

METHODS

Nationwide data on LEA were collected. Sex- and age-adjusted annual incidence rates were calculated. Time trends were analysed in negative binomial models. The incidence of secondary interventions, defined as either any ipsilateral reamputation or any contralateral amputation, was studied with death as competing risk.

RESULTS

41 304 amputations were performed (13 247 major, 28 057 minor). In individuals with diabetes, the amputation rate (first amputation per patient per year) decreased from 143.6/100.000 person-years to 109.7 (IRR 0.97 per year, 95 %CI 0.96-0.98, p < 0.001). The incidence of major LEAs decreased from 56.2 to 30.7 (IRR 0.93, 95 %CI 0.91-0.94, p < 0.001); the incidence of minor amputations showed a non-significant declining trend in women (54.3 to 45.0/100 000 person years, IRR 0.97 per year, 95 %CI 0.96-0.99), while this remained stable in men with diabetes (149.2 to 135.3/100 000 person years, IRR 1.00 per year, 95 %CI 0.98-1.01). In individuals without diabetes, the incidence of major amputation didn't change significantly, whereas minor amputation incidence increased (8.0 to 10.6, IRR 1.04, 95 %CI 1.03-1.05, p < 0.001). In individuals with diabetes, one-year secondary intervention rates were high (31.3% after minor, 18.4% after major LEA); the incidence of secondary amputations didn't change.

CONCLUSIONS

A significant decline in the incidence rate of major LEA was observed in people with diabetes. This decline was not accompanied by a significant rise in minor LEA. The incidence of secondary interventions remained stable.

Major Lower Limb Amputations and Amputees in an Aging Population in Southwest Finland 2007-2017

Purpose

The aim of the present study was to describe and analyze changes in the incidences of lower extremity amputations (LEAs), patient characteristics, vascular history of amputees and survival in Southwest Finland.

Patients and Methods

This is a retrospective patient study in the Hospital District of Southwest Finland. All consecutive patients with atherosclerosis and diabetes-caused LEA, between 1st January 2007 and 31st December 2017, were included. The annual incidences of major LEA patients were statistically standardized. Patients' diagnoses, functional status, previous revascularizations and minor amputations were recorded, and survival was analyzed.

Results

During the 11-year-period major LEAs were performed on 891 patients, 118 (13.2%) were urgent operations. The overall incidence of major LEA was 17.2/100 000 and was age-dependent (3.1 for ≤64 years, 34.3 for 65-74 years, 81.5 for 75-84 years, 216 for ≥85 years). A decrease in incidence was detected in the <65 year-age-group (incidence 4.98 in 2007 and 1.88 in 2017; p = 0.0018). Among older age groups, there was no significant change. Half (50.6%) of all amputees were diabetics. Altogether, 472 patients (53.0%) had a history of revascularization before LEA. 80.1% of index amputations were transfemoral and 19.9% transtibial. Re-surgery was performed on 94 (10.5%) patients. The 1-, 3- and 5-year overall survival were 56%, 30%, and 18%, respectively.

Conclusion

Our results suggest that in an aging population, despite good availability of vascular services, a significant number of patients are not fit for active revascularization, and LEA is the only feasible treatment for critical limb ischemia.

The Incidence of Chronic Limb-Threatening Ischemia in the Midland Region of New Zealand over a 12-Year Period

The epidemiology of severe PAD, as characterized by short-distance intermittent claudication (IC) and chronic limb-threatening ischemia (CLTI), remains undefined in New Zealand (NZ). This was a retrospective observational cohort study of the Midland region in NZ, including all lower limb PAD-related surgical and percutaneous interventions between the 1st of January 2010 and the 31st of December 2021. Overall, 2541 patients were included. The mean annual incidence of short-distance IC was 15.8 per 100,000, and of CLTI was 36.2 per 100,000 population. The annual incidence of both conditions was greater in men. Women presented 3 years older with PAD (p < 0.001). Patients with short-distance IC had lower ipsilateral major limb amputation at 30 days compared to CLTI (IC 2, 0.3% vs. CLTI 298, 16.7%, p < 0.001). The 30-day mortality was greater in elderly patients (<65 years 2.7% vs. ≥65 years 4.4%, p = 0.049), but did not differ depending on sex (females 36, 3.7% vs. males 64, 4.1%, p = 0.787). Elderly age was associated with a worse survival for both short-distance IC and CLTI. There was a worse survival for females with CLTI. In conclusion, PAD imposes a significant burden in NZ, and further research is required in order to reduce this disparity.

CLINICAL AND EPIDEMIOLOGICAL PROFILE OF PATIENTS SUBMITTED TO LOWER LIMB AMPUTATION

Objective: To characterize the clinical and epidemiological profile of patients undergoing lower limb amputation in a public hospital in southern Piauí state, Brazil. Method: Retrospective and descriptive study, with document analysis and quantitative approach. Data collection took place in July and August 2021, using an instrument developed by the researchers. Data were processed using the statistical software Statistical Package for Social Sciences, version 20.0. Results: The sample consisted of 70 patients with a mean age of 65.59 years, most of them male (61.4%), brown (88.6%), married (48.3%), retired (42.9%), coming from other cities of Piauí (87.1%). Most patients (47.1%) had a comorbidity at the time of amputation, with diabetes mellitus (34.3%) being the most prevalent, followed by systemic arterial hypertension (12.9%). Diabetes was the main cause of amputation (48.6%), being the transfemoral level (42.9%) the most affected. All procedures were performed on an emergency basis, and most hospitalizations (94.3%) progressed to discharge. Conclusion: The findings of this study reveal that people with diabetes, males, and the elderly were the individuals who most underwent amputation, with the transfemoral level being the most performed.

PERFIL CLÍNICO E EPIDEMIOLÓGICO DE PACIENTES SUBMETIDOS A AMPUTAÇÃO DE MEMBROS INFERIORES

Objetivo:Caracterizar o perfil clínico e epidemiológico dos pacientes submetidos à amputação de membros inferiores em um hospital público do sul do Piauí. Métodos: Estudo retrospectivo, descritivo, com análise documental e abordagem quantitativa. A coleta de dados ocorreu nos meses de julho e agosto de 2021, sendo realizada por meio de um instrumento elaborado pelos pesquisadores. Os dados foram processados pelo o software estatístico Statistical Package for Social Sciences, versão 20.0. Resultados: A amostra foi composta por 70 pacientes com média de idade de 65,6 anos, a maioria do sexo masculino (61,4%), de cor parda (88,6%), casada (48,3%), aposentada (42,9%), advinda de outras cidades do Piauí (87,1%). A maioria dos pacientes (47,1%) apresentava uma comorbidade no momento da amputação, sendo o diabetes mellitus (34,3%) a mais prevalente, seguido de hipertensão arterial sistêmica (12,9%). O diabetes mellitus foi a principal causa de amputação (48,6%), sendo a nível transfemoral (42,9%) a mais predominante. Todos os procedimentos foram realizados em caráter de urgência, e grande parte das internações (94,3%) evoluiu para alta. Conclusão: Os achados demonstram que pessoas com diabetes mellitus, do sexo masculino e idosas foram as que mais se submeteram a amputação, sendo o nível transfemoral o mais realizado

[Factors related to success in the prosthetic fitting of lower limb amputees from vascular etiology]

OBJECTIVE

Restoring the ambulation ability with prostheses in lower limb amputeesis essential to improve their functional independence. The aim of this study was to determine the factors involved in achieving prosthesis fitting in vascular amputees.

MATERIAL AND METHOD

Observational longitudinal study of patients with major lower limb amputation of vascular etiology performed from April 1st 2017 to April 1st 2020. The following variables were compared between the group of patients who were prosthetized and those who were not: age, gender, body-mass index, comorbidity (Charlson index), independence in the activities of daily living (Barthel index) and ambulation ability (FAC test) before and a year after the amputation. The prosthetic use after a year was measured with the Houghton scale.

RESULTS

A total of 80 patients were amputated with a mean age of 70.5 years old, 78.8% were male. The amputation level was supracondilealin 42 patients and infracondilealin 38 patients. The number of prosthetized patients was 35. The variables related to the possibility of prosthesis fitting were: younger age (P=0.020), less comorbidity (P=0.000), infracondileal amputation (P=0.024) and greater functional independence and ambulation ability prior to amputation (P=0.000). After a year 22 patients had died, only one of those who had been prosthetized.

CONCLUSIONS

Although there are no clear recommendations to determine which amputees should be prosthetic fitting, in our patients the presence of fewer comorbidities and a good previous functional situation, younger age and infracondileal amputation, are related to greater success in achieving this objective.

Spatial analysis of factors impacting lower limb major amputation rates in Hungary

Summary: Background: Lower limb major amputations represent a substantial public health burden in Hungary, where previous research revealed markedly high rates with significant spatial variations. Therefore, we aimed to assess to what extent healthcare and socio-economic factors in the local environment explain the regional disparity. Patients and methods: In a retrospective cohort analysis, based on the healthcare administrative data of the Hungarian population, lower limb major amputations were identified from 1st of January 2017 to 31st of December 2019. The permanent residence of the amputees on the local administrative level (197 geographic units) was used to identify potential healthcare (outpatient care, revascularisation activity) and socio-economic (educational attainment, local infrastructure and services, income and employment) determinants of amputations. Spatial effects were modelled using the spatial Durbin error regression model. Results: 10,209 patients underwent 11,649 lower limb major amputations in the observational period. In our spatial analysis, outpatient care was not associated with local amputation rates. However, revascularisation activity in a geographic unit entailed an increased rate of amputations, while revascularisations in the neighbouring areas were associated with a lower rate of amputations, resulting in an overall neutral effect (β=−0.002, 95% CI: −0.05 – 0.04, p=0.96). The local socio-economic environment had a significant direct inverse association with amputations (β=−7.45, 95% CI: −10.50 – −4.42, p<0.0001) . Our spatial model showed better performance than the traditional statistical modelling (ordinary least squares regression), explaining 37% of the variation in amputations rates. Conclusions: Regional environmental factors explain a substantial portion of spatial disparities in amputation practice. While the socio-economic environment shows a significant inverse relationship with the regional amputation rates, the impact of the local healthcare-related factors (outpatient care, revascularisation activity) is not straightforward. Unravelling the impact of the location on amputation practice requires complex spatial modelling, which may guide efficient healthcare policy decisions.