Lower extremity amputations--a review of global variability in incidence

Correlation Between Bacteria Count Using a Rapid Bacterium Counting System and Changes in Wound Area on Diabetic Foot Ulcers in Indonesia: A Prospective Study

This study aimed to clarify the correlation between changes in bacterial number and wound area in diabetic foot ulcers (DFUs). This study used a prospective longitudinal cohort design. A total of 30 participants met the inclusion criteria. Changes in bacterial number and wound area were evaluated weekly until week 4. The chi-square test indicated no significant correlation between biofilm formation and wound area (p = 0.32) but a significant correlation between bacterial count and wound area (p = 0.05). Logistic regression analysis showed a significant correlation between bacterial count and changes in wound area (odds ratio, 0.60; 95% confidence interval [CI], 0.372-0.997; p = 0.04). The receiver operating characteristic analysis showed an area under the curve of 0.660 (95% CI, 0.52-0.79; p = 0.03) with a sensitivity of 97% and specificity of 88%. The present prospective longitudinal cohort study demonstrated the correlation between bacterial count changes and wound area in DFUs. Our results suggest that changes in bacterial count could help wound healing evaluations.

The frequency of neuropathy and predictive parameters in prediabetic cases from Turkiye

INTRODUCTION

Diabetic sensorimotor peripheral neuropathy causes patients to have foot injuries without realizing it. This condition may progress to diabetic foot ulcer; infections can include osteomyelitis and lower limb amputations. Managing diabetes and screening diabetic neuropathy is crucial to reducing patient mortality, quality of life, functionality, and the cost burden of complications to the healthcare system. We aim to contribute to the literature by comparing diagnostic methods and examining parameters that can predict neuropathy early.

MATERIAL AND METHODS

A total of 108 patients with a neuropathy score Douleur Neuropathique-4 (DN-4) above 4, 54 with known diabetes, and 54 with prediabetes were included. Fasting plasma glucose, oral glucose tolerance test, hemoglobin A1c (HbA1c), LDL-cholesterol, HDL-cholesterol, triglyceride, uric acid, vitamin B12, folic acid, creatinine, and complete urinalysis was performed on 108 patients included. Afterward, a monofilament test, tuning fork test, and electromyography were performed by the neurologist to prove neuropathy.

RESULTS

The frequency of neuropathy in the prediabetes group was found to be 0.40 ± 0.49 % using EMG. This rate is 0.71 ± 0.45 % for diabetic neuropathy. The difference is statistically significant (p = 0.001) in the prediabetic group, the neuropathy score (DN-4 score) was 5.1 ± 0.9, the tuning fork test positivity was 0.18 ± 0.39, and p = 0.001 was statistically significant compared to the diabetic group. Also, in the monofilament test, the rate of neuropathy in the prediabetes group was again statistically significant with 0.68 ± 0.47 (p = 0.027). Total cholesterol (185.1 ± 21.8, p = 0.003), high uric acid (5.11 ± 1.27, p = 0.003), and low folic acid (4.5 ± 1.05, p = 0.026) are found to be statistically significant between diabetic and prediabetic groups.

DISCUSSION AND CONCLUSION

In diagnosing neuropathy, monofilament, and diapason testing can be used in the clinical setting, and they have been found to be successful tests in the diagnosis of neuropathy. Also, our analysis indicates the relationship between low folic acid, high total cholesterol/uric acid levels, and prediabetic neuropathy. The role of intervening blood levels of those factors with medications in preventing neuropathy is unclear. We recommend further investigating all the patient's dietary habits to find possible risk factors, as well as investigating patients with low folic acid and high total cholesterol/ uric acid levels much more cautiously.

RECOMMENDATION

Neuropathy should be screened in prediabetic and diabetic patients, and possible risk factors should be assessed periodically.

Cell Therapy and the Skin: Great Potential but in Need of Optimization

Cell therapy is rapidly growing owing to its therapeutic potential for diseases with currently poor outcomes. Cell therapy encompasses both nonengineered and engineered cells and possesses unique abilities such as sense-and-respond functions and long-term engraftment for persistent curative potential. Cell therapy capabilities have expanded to address a wide spectrum of diseases, and our review is focused on dermatological applications. The use of fibroblasts and keratinocytes as cell therapy has shown promise in skin disorders such as epidermolysis bullosa. Future efforts include testing the ability of fibroblasts to reprogram nonvolar to volar skin to reduce stump dermatoses in patients with limb loss using prosthetics.

Restoring Somatotopic Sensory Feedback in Lower Limb Amputees through Noninvasive Nerve Stimulation

Patients with lower limb amputation experience ambulation disorders since they rely exclusively on visual information in addition to the tactile information they receive from stump-socket interface. The lack of sensory feedback in commercial lower limb prostheses is essential in their abandonment by patients with transtibial amputation (TTA) or transfemoral amputation (TFA). Recent studies have obtained promising results using invasive interfaces with peripheral nervous system presenting drawbacks related to surgery. This paper aims to (a) investigate the potential of transcutaneous electrical nerve stimulation (TENS) as noninvasive means for restoring somatotopic sensory feedback in lower limb amputees and (b) evaluate the effect of the system over a 4-week experimental protocol. The first phase of the study involved 13 participants (6 with TTA and 7 with TFA), and the second one evaluated the long-term effect of TENS on ambulation performance of 2 participants (S1 with TTA and S7 with TFA). The proposed system enhanced participant's ambulation significantly increasing the body weight distribution between legs (S1: from 134% to 143%, P < 0.0055; S7: from 66% to 72%, P < 0.0055) and gait symmetry (S1: step length symmetry index from 11% to 5%, P < 0.0055; S7: stance phase symmetry index from -4% to -2%, P < 0.0055). It led to a postamputation neuropathic pain reduction in S1 (neuropathic pain symptom inventory score diminished from 6 to 0). This demonstrates how TENS enhanced prosthesis embodiment, enabling greater load bearing and more physiological gait patterns. This study highlights TENS as noninvasive solution for restoring somatotopic sensory feedback, addressing the current limitations and paving the way for further research.

The Impact of Nursing Resources on Chronic Wound Management: A Cross-Sectional Analysis

AIM

Evaluate the relationship between hospital nursing resources and outcomes among patients with chronic wounds.

DESIGN

Cross-sectional observational.

METHODS

Hospital-level predictors included the nurse work environment, proportion of Bachelor of Science (BSN)-prepared nurses, and skill mix (i.e., registered nurses [RN] as proportion of nursing personnel). Outcomes included in-hospital and 30-day mortality, discharging to a higher level of care and length of stay. Individual-level nurse data were aggregated to create hospital-level measures of nursing resources. We utilised multi-level modelling with nurses nested within hospitals and outcomes at the patient level.

DATA

Three datasets from 2021: RN4CAST-New York/Illinois survey, Medicare Provider Analysis and Review claims and American Hospital Association Annual Survey.

RESULTS

The sample included 34,113 patients with chronic wounds in 215 hospitals in New York and Illinois. In adjusted models, a 1 standard deviation improvement in the work environment was associated with 12% lower odds of in-hospital mortality, 8% lower odds of discharging to a higher level of care and a shorter length of stay by a factor of 0.96. A 10% increase in BSN composition was associated with 8% reduced odds of in-hospital mortality and 6% reduced odds of 30-day mortality. A 10% increase in skill mix was associated with 12% lower odds of in-hospital mortality and a shorter length of stay by a factor of 0.91.

CONCLUSION

Improved nursing resources are associated with better outcomes among patients with chronic wounds.

IMPLICATIONS

Nurses manage the care of patients with chronic wounds; thus, hospital investment in nursing resources is imperative for good outcomes.

IMPACT

Modifiable hospital nursing resources are associated with outcomes among patients with chronic wounds, a complex population.

REPORTING

STROBE.

Defective Intracortical Inhibition as a Marker of Impaired Neural Compensation in Amputees Undergoing Rehabilitation

Background/Objectives: Lower-limb amputation (LLA) leads to disability, impaired mobility, and reduced quality of life, affecting 1.6 million people in the USA. Post-amputation, motor cortex reorganization occurs, contributing to phantom limb pain (PLP). Transcranial magnetic stimulation (TMS) assesses changes in cortical excitability, helping to identify compensatory mechanisms. This study investigated the association between TMS metrics and clinical and neurophysiological outcomes in LLA patients. Methods: A cross-sectional analysis of the DEFINE cohort, with 59 participants, was carried out. TMS metrics included resting motor threshold (rMT), motor-evoked potential (MEP) amplitude, short intracortical inhibition (SICI), and intracortical facilitation (ICF). Results: Multivariate analysis revealed increased ICF and rMT in the affected hemisphere of PLP patients, while SICI was reduced with the presence of PLP. A positive correlation between SICI and EEG theta oscillations in the frontal, central, and parietal regions suggested compensatory mechanisms in the unaffected hemisphere. Increased MEP was associated with reduced functional independence. Conclusions: SICI appears to be a key factor linked to the presence of PLP, but not its intensity. Reduced SICI may indicate impaired cortical compensation, contributing to PLP. Other neural mechanisms, including central sensitization and altered thalamocortical connectivity, may influence PLP's severity. Our findings align with those of prior studies, reinforcing low SICI as a marker of maladaptive neuroplasticity in amputation-related pain. Additionally, longer amputation duration was associated with disrupted SICI, suggesting an impact of long-term plasticity changes.

A one-two punch of inflammation and oxidative stress promotes revascularization for diabetic foot ulcers

Patients with diabetic foot ulcers (DFU) suffering from severe lower limb ischemia face the risk of amputation. Concomitant oxidative stress and hyperinflammation commonly manifest within the tissue affected by DFU, exacerbating the deterioration of DFU wounds. One-two punch strategy of anti-oxidative damage plus anti-inflammatory is anticipated to tackle the challenge of non-healing diabetic wounds. Here, we introduced a dual-approach treatment strategy involving the probiotic Weissella cibaria (WC) modified with desferrioxamine (DFO). This engineered probiotic, known as WC@DPA, aims to ameliorate oxidative stress within the ischemic microenvironment and stimulate the formation and proliferation of endothelial tubular structures. When applied with chronic wounds and ischemic hindlimb injuries in diabetic mice, WC@DPA gel demonstrated an effective performance in modulating oxidative damage, reducing local vascular inflammation, and facilitating muscle tissue repair and vascular reconstruction. We believe that our engineered probiotic represents a promising therapeutic avenue for managing ischemic injuries associated with DFU.

Epidemiology of first-time major lower extremity amputations- A Danish Nationwide cohort study from 2010 to 2021

BACKGROUND AND AIM

Major lower extremity amputations (MLEA) are common procedures. Potential changes in surgical strategy and patient characteristics over time have not been described previously. The aim of this study was to investigate the incidence rates and surgical strategies of first-time MLEAs over time from 2010 to 2021. Furthermore, to describe patient demographics, and their changes in the same period.

METHODS

This is an observational nationwide register study including all first-time MLEAs performed in patients ≥ 18 years from 2010 to 2021, with data from the Danish National Patient Register.

RESULTS

A total of 12,672 first-time MLEA patients were identified from 2010 to 2021. The annual number of first-time MLEAs each year was unchanged at approx. 1000 annually during the study period. In 2021 the total incidence was 21.3/100,000 inhabitants and the total adjusted incidence rate decreased by 2.3% (95% CI 1.8-2.8) per year. The adjusted frequency of transfemoral amputations increased significantly with 10.9% each year confidence interval (CI) (9.7-12.0), whereas knee disarticulation(-19.4%/year CI (-22.2- -16.5)) and transtibial amputation (-7.3%/year CI (-8.5- -6.1)) significantly decreased. The frequency of primary hip disarticulations were stable throughout the study period (p-value 0.06). When analyzing patient comorbidity profiles we found no major changes over time. When statistically testing for time trends, only dyslipidemia (5.7%/year CI (4.5-7.1)), renal insufficiency (1.8%/year CI(0.2-3.3), peripheral artrial disease (-9.3%/year CI (-10.8- -7.7)) and cardiovascular disease (-3.4%/year CI(-4.6- -2.1)) showed a significant time trend in the study period.

CONCLUSIONS

We observed a decreasing incidence of first-time MLEA in Denmark and a shift towards increased use of transfemoral amputations as initial MLEA level. Investigation of the comorbidity profile of MLEA patients revealed some time trend changes during the study period, but with limited clinical relevance. Hence, the observed prominent shift towards a more proximal first time amputation level in Denmark did not seem to be associated with an altered comorbidity profile of these patients. Whether the change in surgical strategy is to the benefit of the patients should be investigated further.

Evaluation of short-term functional mobility outcomes in patients with traumatic lower limb amputations: A prospective cohort study in India

BACKGROUND

Traumatic amputation of the lower limb is a significant life-changing event. It is associated with substantial functional disability.

OBJECTIVE

To assess the serial improvement in functional mobility outcomes after the rehabilitation provided to traumatic unilateral lower limb amputee (TULLA) over 6 months of follow-up.

METHODS

It is a prospective observational cohort study including 106 TULLA performed in a tertiary care trauma center in North India from January 2021 to December 2021. Patients were followed up at 2 weeks, 3 months and 6 months post-surgery in the focused amputee clinic, where functional mobility care was provided by physical rehabilitation and prosthesis application and patients were evaluated using the Locomotors Capabilities Index (LCI-5) and L-Test of functional mobility.

RESULTS

There was a significant improvement in LCI-5 and L-Test from discharge to follow-up. The mean overall LCI-5 scores were 14.68 ± 6.56, 28.29 ± 9.04 and 42.77 ± 8.94 at 2 weeks, 3 months and 6 months respectively. The mean L-test for overall individuals with limb loss (N = 100) at discharge, 2 weeks, 3 months and 6 months were 178.41 ± 49.62, 126.98 ± 37.76, 98.39 ± 30.09 and 72.82 ± 21.03 respectively. Further, a subgroup analysis showed a significant improvement in LCI-5 and L-test in individuals with above-knee and below-knee limb loss with prostheses compared to those without prostheses.

CONCLUSION

Our multidisciplinary approach helps to improve functional mobility outcomes among TULLA. Focused amputee clinics are the need of the hour to achieve successful functional mobility following amputation.

Effectiveness of Specific Single-Use Incisional Negative Pressure Wound Therapy (PICO System) After Major Lower Extremity Amputation

Lower extremity amputation (LEA), particularly in patients with diabetes or peripheral vascular disease, often results in complications such as surgical site infections (SSIs) and wound dehiscence. This study examined whether utilizing the portable and user-friendly PICO system (Smith and Nephew Medical Ltd, Hull, UK) as incisional negative-pressure wound therapy can reduce post-LEA complications. This study was conducted at a Japanese tertiary medical center and involved a retrospective analysis of LEA cases (n = 32) between January 2021 and December 2022. The PICO dressing group (n = 16) was compared to the conventional dressing group (n = 16) for post-LEA wound management. The primary outcome was the incidence of postoperative wound complications, including SSI and wound dehiscence, within 15 days of LEA. Superficial/deep SSI and wound dehiscence occurred less frequently in the PICO dressing group than in the conventional dressing group (12.5% vs 43.8%; p = .054). There were no cases of deep SSIs in the PICO dressing group. Although this study has limitations owing to its retrospective design and small sample size, the results suggest the potential of the PICO system for improving outcomes in post-LEA wound management.

Nitric oxide-based treatments improve wound healing associated with diabetes mellitus

Non-healing wounds are long-term complications of diabetes mellitus (DM) that increase mortality risk and amputation-related disability and decrease the quality of life. Nitric oxide (NO·)-based treatments (i.e., use of both systemic and topical NO· donors, NO· precursors, and NO· inducers) have received more attention as complementary approaches in treatments of DM wounds. Here, we aimed to highlight the potential benefits of NO·-based treatments on DM wounds through a literature review of experimental and clinical evidence. Various topical NO·-based treatments have been used. In rodents, topical NO·-based therapy facilitates wound healing, manifested as an increased healing rate and a decreased half-closure time. The wound healing effect of NO·-based treatments is attributed to increasing local blood flow, angiogenesis induction, collagen synthesis and deposition, re-epithelization, anti-inflammatory and anti-oxidative properties, and potent broad-spectrum antibacterial effects. The existing literature lacks human clinical evidence on the safety and efficacy of NO·-based treatments for DM wounds. Translating experimental favors of NO·-based treatments of DM wounds into human clinical practice needs conducting clinical trials with well-predefined effect sizes, i.e., wound reduction area, rate of wound healing, and hospital length of stay.

Does preoperative muscle biopsy predict the outcome of lower extremity amputation in diabetic patients? a prospective observational study

BACKGROUND

Determining the most appropriate level of amputation in patients with diabetes mellitus has not been well established. The purpose of this study is to determine whether muscle biopsy reveals predictive information about the success rate of patients undergoing diabetic major lower limb amputation.

METHODS

A prospective observational study was conducted among diabetic patients who underwent below-knee amputation. Skin-subcutaneous and muscle biopsy samples were obtained during the operation from 62 patients who undergo major limb amputation. Depending on the complications after surgery, patients were assigned into three groups: Group 1 consisted of patients with adequate wound healing without any complications; Group 2 included patients with prolonged wound healing requiring additional interventions like debridement; and Group 3 consisted of patients who underwent reamputation at a more proximal level. Biopsy samples of the groups were compared regarding degenerative cells, inflammatory cells, and the presence of infection.

RESULTS

There was a significant difference between Groups 1 and 3 regarding the presence of abscess formation and infection (p < 001). Comparison of Groups 1 and 3 revealed significant differences regarding inflammatory cell count, respectively (p < 001). According to the results of the ROC analysis performed for histopathologic cellular evaluation, 15% for inflammatory cell ratio in muscle samples and 25% for degenerative cell ratio both in muscle and skin samples were determined as cut-off values.

CONCLUSIONS

The presence of increased degenerative cell count and infection in muscle biopsy areassociated with higher rates of reoperation. The present study revealed that preoperative muscle biopsy has predictive value in patients undergoing major limb amputation.

LEVEL OF EVIDENCE

Level II, Prospective observational study.

The influence of nerve surgical techniques at time of amputation on the prevalence of heterotopic ossification in transtibial amputees

BACKGROUND

Heterotopic ossification (HO) can form after amputation and may cause pain and functional impairment. We aimed to describe the prevalence of HO in a civilian population of transtibial amputees. We hypothesized that the decreased rate of symptomatic neuroma following active nerve surgery (Targeted Muscle Reinnervation (TMR) or Regenerative Peripheral Nerve Interface (RPNI)) may subsequently lead to a lower prevalence of HO compared to passive nerve surgery (i.e. traction neurectomy) performed at the time of amputation.

METHODS

Adult patients undergoing transtibial amputation at a tertiary care center between 2000 and 2023 were included. Patient data were collected through chart review. The most recent post-amputation X-ray of the residual limb was assessed for HO presence, according to the Walter Reed classification. A random subset of X-rays (10.0 %) was independently assessed by five clinicians and two radiologists, and inter-rater reliability (IRR) was calculated using Cohen's kappa (κ). Multivariable logistic regression was conducted to identify factors associated with HO presence.

RESULTS

In total, 665 limbs of 632 patients were included. The median time between amputation and X-ray was 1.7 years (IQR: 0.3-6.2). HO was identified in 326 X-rays (49.0 %) and was commonly present on the distal residual tibia (68.1 %) and fibula (69.0 %). Traditional amputations (i.e. those without TMR or RPNI (OR: 2.0, p = 0.014)), and the presence of a symptomatic neuroma (OR: 2.3, p < 0.001), were independently associated with a higher prevalence of HO. The IRR of the two radiologists was κ = 0.99, the overall IRR of all evaluators was κ = 0.92.

CONCLUSIONS

HO is a common finding in transtibial amputees. Peripheral nerve surgerical techniques that actively address amputated nerve endings to reduce symptomatic neuroma formation may decrease the prevalence of HO.

Increased Mortality After Lower Extremity Amputation in a Danish Nationwide Cohort: The Mediating Role of Postoperative Complications

Objective

Patients who undergo major lower extremity amputation (MLEA) have the highest postoperative mortality among orthopedic patient groups. The comorbidity profile for MLEA patients is often extensive and associated with elevated postoperative mortality. This study primarily aimed to investigate the increased short- and long-term mortality following first and subsequent major lower extremity amputation. Secondarily, to examine the mediation role of post-amputation complications.

Study Design and Setting

With data from the Danish National Patient Registry, 11,695 first-time MLEAs in patients aged ≥50 years were identified between January 1, 2010, and December 31, 2021, along with 58,466 unamputated persons matched 1:5 by year of birth, sex, and region of residence. Mediators were identified through diagnosis codes (ICD-10) present in 6 months following MLEA.

Results

The increased mortality following MLEA was highest in the month following MLEA, hazard ratio (HR) 38.7 (95% confidence interval (CI) 30.5-48.9) in women and HR 55.7 (CI 44.3-70.2) in men compared to a matched unamputated cohort. Subsequent amputation resulted in an increased mortality the month after a subsequent amputation (overall HR 3.2 (CI 2.8-3.7) in women and HR 3.2 (CI 2.8-3.6) in men) and almost normalized after the first year. The proportion of the mortality risk that potentially could be reduced by preventing sepsis was 16% (CI 11.7-20.3) for women and 17% (CI 13.4-20.4) for men. For pneumonia, it was 10.5% (CI 7.1-13.9) in women and 14.9% (11.6-18.2) in men.

Conclusion

We observed an increased mortality in the month following MLEA, which remained elevated for years compared to the matched unamputated cohort. A subsequent amputation results in increased mortality in the following year, but declined and normalized after the first year. Sepsis and pneumonia arising after the amputation appeared to be important factors that contributed to the increased postoperative mortality.

Predicting prosthetic gait and the effects of induced stiff-knee gait

Prosthetic gait differs considerably from the unimpaired gait. Studying alterations in the gait patterns could help to understand different adaptation mechanisms adopted by these populations. This study investigated the effects of induced stiff-knee gait (SKG) on prosthetic and healthy gait patterns and the capabilities of predictive simulation. Self-selected speed gait of two participants was measured: one healthy subject and one knee disarticulation subject using a variable-damping microprocessor controlled knee prosthesis. Both performed unperturbed gait and gait with restricted knee flexion. Experimental joint angles and moments were computed using OpenSim and muscle activity was measured using surface electromyography (EMG). The differences between the conditions were analyzed using statistical parametric mapping (SPM). Predictive models based on optimal control were created to represent the participants. Additionally, a hypothetical unimpaired predictive model with the same anthropometric characteristics as the amputee was created. Some patterns observed in the experimental prosthetic gait were predicted by the models, including increased knee flexion moment on the contralateral side caused by SKG in both participants, which was statistically significant according to SPM. With the exception of the rectus femoris muscle, we also found overall good agreement between measured EMG and predicted muscle activation. We predicted more alterations in activation of the hip flexors than other muscle groups due to the amputation and in the activation of the biceps femoris short head, quadratus femoris, and tibialis anterior due to SKG. In summary, we demonstrated that the method applied in this study could predict gait alterations due to amputation of the lower limb or due to imposed SKG.

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.

Risk factors and predictors of prolonged hospital stay in the clinical course of major amputations of the upper and lower extremity a retrospective analysis of a level 1-trauma center

PURPOSE

The objective was to analyze the treatment and complications of the patients after a major amputation of the upper and lower extremities. Risk factors and predictors of a prolonged hospital stay should be outlined.

METHODS

This is a retrospective study of a national Level-1 Trauma center in Germany. In a 10-year period, patients were identified by major amputations in the upper and lower extremities. The medical reports were considered and the results were split into four main groups with analysis on basic-, clinical data, the course on intensive care unit and the outcome. A recovery index was established. The patients' degree of recovery was summed up. Statistical analysis was performed.

RESULTS

81 patients were included. A total of 39 (48.1%) major amputations were carried out on the lower leg and 34 (42.0%) involved the thigh. There were two instances (2.5%) of hip joint disarticulation. 6 major amputations were done on the upper extremities (n = 3 on the upper arm, n = 3 on the forearm). 13.83 ± 17.10 days elapsed between hospital admission and major amputation. The average length of hospital stay was 38.49 ± 26,75 days with 5.06 ± 11.27 days on intensive care unit. Most of the patients were discharged home followed by rehabilitation. A significant correlation was found between the hospital length of stay and the increasing number of operations performed (p = 0.001). The correlation between the hospital length of stay and the CRP level after amputation was significant (p = 0.003).

CONCLUSIONS

Major amputations in trauma patients lead to a prolonged stay in hospital due to severe diseases and complications. Especially infections and surgical revisions cause such lengthenings.

Analyzing research trends and developments in osseointegration in patients with extremity amputations: Systematic bibliometric analysis and research recommendations

BACKGROUND

Bone-anchored protheses (BAPs) by means of osseointegrated implants are increasingly being used in amputees with socket-related issues. Clinical advancements are being published by more and more centers worldwide. Although the number of publications and interest in BAP is growing, a systematic evaluation of scholarly output is lacking.

OBJECTIVE

To identify scholarly output, understand research trends and make research recommendations in the clinical field of BAP.

METHODS

Systematic searches in Medline All, Embase, Web of Science Core Collection, Cochrane Library, and Google Scholar were completed in February 2023. The results were deduplicated, screened, and assessed for quality by independent reviewers. Inclusion criteria were as follows: clinical studies and BAP in the extremities. Articles were excluded if they were animal or fundamental studies, nonclinical reports, had a study population less than 10 patients, or BAP was performed in areas other than extremities.

RESULTS

One hundred twelve articles were included and published between 1993 and 2023. An annual growth rate of 10.3% was found and research was published in 62 different journals. Prosthetics and Orthotics International, Clinical Orthopaedics and Related Research and The Bone & Joint Journal were the most prolific journals. Hagberg K, Aschoff HH, and Branemark R were major contributors to BAP research. Collaborations are predominantly among high-income countries. Main research trends were on rehabilitation, questionnaires, complication managements, and implant treatment.

CONCLUSIONS

Research on BAP shows an increasing global trend, highlighting key research areas and authors. A unified global research agenda, stakeholders' collaborations, and consensus are essential for addressing knowledge gaps and development future direction of BAP.

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.

The experiences and needs of people with dysvascular lower extremity amputations: a qualitative systematic review and meta-synthesis

PURPOSE

The aim of this review is to synthesise the experiences and needs of people who had undergone dysvascular lower extremity amputations. Given the increasing global prevalence of vascular diseases like diabetes mellitus and peripheral arterial disease, the risk of requiring an amputation remains high.

MATERIALS AND METHODS

This systematic review follows the PRISMA and ENTREQ reporting guidelines. Seven databases were searched for qualitative studies from January 2011 to October 2023. In total 6435 studies were obtained, where 1146 were duplicates and 5271 studies failed to meet the eligibility criteria. The remaining 18 studies were synthesised using Sandelowski and Barroso's approach and appraised using the CASP checklist.

RESULTS

Four themes emerged from the meta-synthesis: (1) making the decision to amputate, (2) difficulties in the physical adaptation to limb loss, (3) psychosocial consequences of living with an amputation, and (4) regaining control and building hope.

CONCLUSIONS

Having dysvascular lower extremity amputations is a complicated experience as not only was the pre-amputation pain relieved, but a new set of physical, emotional and social challenges would surface after the amputation. These synthesised findings serve as a platform to explore the factors behind the various experiences faced by these people and how healthcare professionals can help them in their adjustment.

Early Postoperative Pain Course following Primary and Secondary Targeted Muscle Reinnervation: A Temporal Description of Pain Outcomes

BACKGROUND

 Targeted muscle reinnervation (TMR) is an effective surgical treatment of neuropathic pain for amputees. However, limited data exist regarding the early postoperative pain course for patients who undergo either primary (<14 days since amputation) or secondary (≥14 days) TMR. This study aims to outline the postoperative pain course for primary and secondary TMR during the first 6 postoperative months to aid in patient education and expectation management.

METHODS

 Patients were eligible if they underwent TMR surgery between 2017 and 2023. Prospectively collected patient-reported outcome measures of pain scores, Pain Interference, and Pain Intensity were analyzed. Multilevel mixed-effects models were utilized to visualize and compare pain courses between primary and secondary TMR patients.

RESULTS

 A total of 203 amputees were included, with 40.9% being primary and 59.1% being secondary TMR patients. Primary TMR patients reported significantly lower pain scores over the full 6-month postoperative trajectory (p < 0.001) compared with secondary TMR patients, with a difference of Δ -1.0 at the day of TMR (primary = 4.5, secondary = 5.5), and a difference of Δ -1.4 at the 6-month mark (primary = 3.6, secondary = 5.0). Primary TMR patients also reported significantly lower Pain Interference (p < 0.001) and Pain Intensity scores (p < 0.001) over the complete trajectory of their care.

CONCLUSION

 Primary TMR patients report lower pain during the first 6 months postoperatively compared with secondary TMR patients. This may reflect how pre-existing neuropathic pain is more challenging to mitigate through peripheral nerve surgery. The current trends may assist in both understanding the postoperative pain course and managing patient expectations following TMR.

LEVEL OF EVIDENCE

 Therapeutic - IV.

Global trends and current status of amputation: Bibliometrics and visual analysis of publications from 1999 to 2021

OBJECTIVE

To generalize the research status, hotspots, and development trends of amputation-related research.

METHODS

The data from 1999 to 2021 were collected from the Web of Science core collection database, and analyzed through bibliometrics software (CiteSpace and VOSviewer) for the dual-map overlay of journals, top 25 references with the strongest citation bursts, top 25 keywords with the strongest citation bursts, and timeline of keywords.

RESULTS

A total of 8,588 literature studies were involved in this study. The United States ranks the first in terms of H-index, total number of publications, and total citations. US Department of Veterans Affairs, Veterans Health Administration, and University of Washington are the major contributors to amputation. Prosthetics and Orthotics International , Archives of Physical Medicine and Rehabilitation , and Journal of Rehabilitation Research and Development are the main publication channels for articles related to amputation. Geertzen JHB, Czerniecki J, and Dijkstra PU are major contributors to amputation. In addition, research on limb salvage treatment and surgical methods for amputation will become a hotspot in the future.

CONCLUSION

The total number of publications for amputation has generally increased from 1999 to 2021. Our study is beneficial for scientists to specify the research hotspot and development direction of amputation.

A critical literature review highlighting the methodological differences within epidemiological studies: Pedal Amputations in England

INTRODUCTION

There is an absence in the application of standardised epidemiological principles when calculating and reporting on lower extremity amputation (LEA) rates [1]. The rates of minor LEAs in the diabetic population range from 1.2-362.9 per 100,000 and in the population without diabetes 0.9-109.4 per 100,000. The reported rates of major lower limb amputations vary from 5.6-600 per 100,000 in the diabetic population and 3.6-58.7 per 100,000 in the total population [1]. The variation in methodology does not facilitate comparison across populations and time. All studies published using the population from England, UK, describing minor amputations were systematically reviewed and rates and methodologies compared.

METHOD

A systematic search was carried out using (PRISMA) guidelines [2] to reveal primary data of minor lower extremity amputation rates in England between 1988-2018. This was carried out using electronic databases, grey literature and reference list searching. The search yielded eleven studies that were eligible for review.

RESULTS

Significant variation in the reporting of minor lower extremity amputation rates across regional and gender groups in England was found. Rates in the diabetic and non-diabetic population varied from 1.2 to 362.9 per 100,000 and 0.9 to 109.4 per 100,000 respectively. This was predominately a result of poorly describing numerator and denominator populations and defining minor amputations differently. As a result, there was an inability to confidently establish regional, gender and time trends.

CONCLUSION

The inconsistent nature of reporting minor amputations makes drawing conclusions on temporal and population change difficult. Future studies should describe and present basic numerator and denominator population characteristics e.g. number, age and sex and use the standard definition of minor amputation as one that is at or below the ankle.

Below-knee amputation with an ultrasonic scalpel: evaluation of early postoperative clinical outcomes

OBJECTIVE

Despite the development of microscopic reconstructive techniques for lower limb salvage, major limb amputation is still required for critical, unsalvageable lower leg wounds, with steadily increasing estimates of major limb amputations. In this study, the authors highlight a surgical technique for below-knee (BK) amputation using an ultrasonic scalpel, and evaluate its safety and effectiveness compared with the conventional method of using surgical blades.

METHOD

A retrospective chart review was conducted at the Department of Plastic and Reconstructive Surgery, St. Vincent's Hospital, Republic of Korea, on patients who underwent BK amputation between October 2012 and January 2021. Patients were assigned to two groups: amputation using classical methods, such as surgical blades and electrocautery (group A); and amputation using an ultrasonic scalpel (group B). Numerous perioperative factors, such as operation time, intraoperative blood loss, postoperative complications and recovery time were examined. The present study adhered to the STROBE guidelines.

RESULTS

A total of 41 patients (16 in group A and 25 in group B) were included in this study. Operation time was significantly shorter in group B (p=0.001) and intraoperative blood loss was lower (p=0.011). Wound healing time did not vary between groups.

CONCLUSION

In this study, the use of an ultrasonic scalpel for lower limb amputation was effective in reducing operation time and blood loss, which may be helpful in improving outcomes for patients with comorbidities.

Omentin-1 and diabetic foot

Introduction: Diabetic foot disease is an advanced complication of diabetes mellitus, which is associated with severe invalidization and high mortality rate among affected people. Many factors are involved in its pathogenesis but not all of them are fully elucidated. Objectives: Adipose tissue and its hormones - adipokines, are related to diabetic complications and metabolic disorders. Until now, there are limited data on their role in diabetic foot. The aim of this cross-sectional study is to determine the levels of the adipokine omentin-1 in people with and without diabetic foot disease and to look for its potential involvement in this complication. Methods: Eighty patients with type 2 diabetes and mean age of 60.8±10.5 years were included in this study. They were divided into two groups: with (n=36) and without (n=44) diabetic foot disease. Standard antrometric, clinical and laboratory tests were made. Body composition was analyzed by bioelectrical impedance based device. Serum omentin-1 was measured using ELISA method. Results: Levels of omentin-1 were significantly higher among people with diabetic foot disease (700.2±345.1 ng/ml), compared to the other group (560.2±176.7 ng/ml). This difference remained significant even after adjusting for potential confounders. In a regression model omentin-1 proved its predictive value for development of diabetic foot. Conclusion: Adipokines, and particularly omentin-1, might be included in the pathogenesis of diabetic foot disease.

Racial/ethnic disparities in chronic wounds: Perspectives on linking upstream factors to health outcomes

This review explores the complex relationship between social determinants of health and the biology of chronic wounds associated with diabetes mellitus, with an emphasis on racial/ethnic disparities. Chronic wounds pose significant healthcare challenges, often leading to severe complications for millions of people in the United States, and disproportionally affect African American, Hispanic, and Native American individuals. Social determinants of health, including economic stability, access to healthcare, education, and environmental conditions, likely influence stress, weathering, and nutrition, collectively shaping vulnerability to chronic diseases, such as obesity and DM, and an elevated risk of chronic wounds and subsequent lower extremity amputations. Here, we review these issues and discuss the urgent need for further research focusing on understanding the mechanisms underlying racial/ethnic disparities in chronic wounds, particularly social deprivation, weathering, and nutrition, to inform interventions to address these disparities.

The relationships between body image, self-esteem and quality of life in adults with trauma-related limb loss sustained in the Syrian war

BACKGROUND

Numerous military soldiers have lost limbs as a result of the Syrian War. While there are variations between trauma-related amputations in military and civilian populations, both scenarios result in life-changing injuries.

OBJECTIVE

To explore the relationship between body image, self-esteem, and quality of life (QOL) domains following trauma-related major amputation. It will be the first study in Syria on the correlation between self-esteem and body image. It will help improve our quality of care to meet patient needs and increase well-being, which in turn will help to address body image, self-esteem, and QOL.

METHOD

A cross-sectional study that recruited 235 soldiers with amputations in two centers and two military hospitals in Latakia and Tartous. Patients were given an 81-item questionnaire that included the Amputee Body-Image Scale (ABIS), the Rosenberg Self-esteem (RSE) scale, the WHOQOL-BREF questionnaire, and unidimensional pain measures. The ANOVA test, a student's t-test, multiple linear regression, internal consistency, and test-retest reliability were utilized for statistical analysis.

RESULTS

There was a strong relationship between body image, self-esteem, and QOL, with the presence of body image concerns significantly associated with lower self-esteem scores and lower QOL scores (p=0.001). Patients with phantom pain sensation had significantly reduced self-esteem (p =0.001), greater body image concerns (p =0.001), and lower scores in all domains of QOL. We found that body image and self-esteem impacted the psychological, social, and environmental domains. After controlling for pain level and number of co-morbid conditions, body image and self-esteem did not predict WHOQOL-BREF scores, with the exception of the environmental domain, where no pain and low self-esteem predicted better environmental domain scores.

CONCLUSION

Patients' body image and self-esteem were greatly impacted by lower-limb amputations. Additionally, phantom pain further impacted self-esteem, body image, and QOL. The image of the body had a profound effect on psychological, social, and environmental domains, and self-esteem was influenced by almost all aspects of QOL.

Recent progress on smart lower prosthetic limbs: a comprehensive review on using EEG and fNIRS devices in rehabilitation

The global rise in lower limb amputation cases necessitates advancements in prosthetic limb technology to enhance the quality of life for affected patients. This review paper explores recent advancements in the integration of EEG and fNIRS modalities for smart lower prosthetic limbs for rehabilitation applications. The paper synthesizes current research progress, focusing on the synergy between brain-computer interfaces and neuroimaging technologies to enhance the functionality and user experience of lower limb prosthetics. The review discusses the potential of EEG and fNIRS in decoding neural signals, enabling more intuitive and responsive control of prosthetic devices. Additionally, the paper highlights the challenges, innovations, and prospects associated with the incorporation of these neurotechnologies in the field of rehabilitation. The insights provided in this review contribute to a deeper understanding of the evolving landscape of smart lower prosthetic limbs and pave the way for more effective and user-friendly solutions in the realm of neurorehabilitation.

Epidemiology and risk factors for phantom limb pain

Approximately 356 million limb amputations are performed globally every year. In 2005, the prevalence of limb loss in the United States was 1.6 million people; and it is estimated to increase to 3.6 million by 2050. Many post-amputation patients experience chronically altered sensations and pain associated with the amputation, such as phantom limb pain. The risk factors for phantom limb pain are widely debated in the literature due to the heterogeneity of the population being studied. This review will highlight both the non-operative and operative risk factors for phantom limb pain.

Quality of life following non-dysvascular lower limb amputation is contextualized through occupations: a qualitative study

PURPOSE

To understand how persons with non-dysvascular lower limb amputation (LLA) use occupations to contextualize their quality of life (QoL).

METHODS

A qualitative study using an interpretative description approach was conducted. Analysis of the interviews was guided by an occupational perspective, which considers the day-to-day activities that are important to an individual.

RESULTS

Twenty adults with an adult-acquired non-dysvascular amputation (e.g., trauma, cancer or infection) were interviewed. Following thematic analysis, two main themes were developed: (1) sense of self expressed through occupations; and (2) sense of belonging with others influenced by occupations. Participants expressed the way they felt about themselves through their activities and placed high value on whether they could participate in certain occupations. Participants also described how their sense of belonging was changed through the context of their changing occupations.

CONCLUSION

The findings from this work can be leveraged by clinicians and researchers alike to improve care for this population. Rehabilitation programs should consider interventions and programming that help to restore occupations or develop new ones given the importance placed on occupations by persons with non-dysvascular LLA.

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.

Prognosticating Prosthetic Ambulation Ability in People With Lower Limb Amputation in Early Post-operative Phase

OBJECTIVE

To formulate a prognostication model in the early post-operation phase of lower limb amputation to predict patient's ability to ambulate with a prosthesis post rehabilitation.

DESIGN

Retrospective cohort study, using data collected from electronic medical records. Predictive factors and prosthetic ambulation outcomes post rehabilitation were used to develop prognostic models via machine learning techniques.

SETTING

Regional hospital's ambulatory rehabilitation clinic.

PARTICIPANTS

Patients with major lower limb amputation (N=329).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The outcome of prosthetic ambulation ability post rehabilitation collected was categorized in 3 groups: non-ambulant with prosthesis, homebound ambulant with prosthesis (AP), and community AP.

RESULTS

In a 2-class model of non-ambulant and AP (homebound and community), the model with highest accuracy of prediction included ethnicity, total Functional Comorbidity Index (FCI), level of amputation, being community ambulant prior to amputation, and age. The f1-score and area under receiver operator curve (AUROC) of the model is 0.78 and 0.82. In a 3-class model consisting of all 3 groups of outcomes, the model with highest accuracy of prediction required 10 factors. The additional factors from the 2-class model include presence of caregiver, history of congestive heart failure, diabetes, visual impairment, and stroke. The 3-class model has a moderate accuracy with a f1-score and AUROC of 0.60 and 0.79.

CONCLUSION

The 2-class prognostication model has a high accuracy which can be used early post-amputation to predict if patient would be ambulant with a prosthesis post rehabilitation. The 3-class prognostication model has moderate accuracy and is able to further differentiate the walking ability to either homebound or community ambulation with a prosthesis, which can assist in prosthetic prescription and setting realistic rehabilitation goals.

An eight-year analysis of participant characteristics at admission to inpatient prosthetic rehabilitation following a lower limb amputation: a Canadian perspective

PURPOSE

To describe admission and discharge characteristics of participants admitted to prosthetic rehabilitation following a lower limb amputation and determine changes in participant characteristics including if the population has gotten older over time at admission.

METHODS

A retrospective chart audit of consecutive admissions to an amputee rehabilitation program. Study criteria were transtibial level LLA and above and ≥ 18 years old. Admission characteristics included: age, Montreal Cognitive Assessment (MoCA), Functional Comorbidity Index (FCI) and days between amputation surgery and admission. Discharge characteristics included the L -Test of Functional Mobility (L-Test), 2-Minute Walk Test (2MWT), 6-Minute Walk Test (6MWT), and Activities-specific Balance Confidence (ABC) scale. Multivariable linear regression modelling quantified the association between participant characteristics and admission time.

RESULTS

A total of 601 participants (62.3 ± 14.1 years) were included, 63 were (84.9 ± 3.7 years) aged 80 and over. FCI scores [β = 70.34, (95% CI: 20.93, 119.74), p = 0.005] and days between amputation surgery [β = -0.08, (95% CI: -0.13, -0.02), p = 0.011] were independently associated with admission time.

CONCLUSION

People with an LLA are presenting with a higher number of comorbidities at admission over time while being admitted faster from amputation surgery. Future research should investigate the impact of these changing characteristics on rehabilitation outcomes to better assist this population.

Relationship between systemic immune inflammation index and amputation in patients with diabetic foot ulcer

AIM

The systemic immune inflammation index (SII) is a cost-effective biomarker calculated by lymphocyte, neutrophil and platelet counts and is currently being studied in various diseases. Since there is no study examining the relationship between SII and diabetic foot ulcers (DFU) in the literature, our aim was to investigate the relationship between SII and amputation rate in DFU.

METHODS

Type 2 DM 511 patients with DFU were screened from 2017 to 2021. Laboratory data obtained on the first day of hospitalization were considered. Platelet-to-lymphocyte ratio (PLR), neutrophil-to-lymphocyte ratio (NLR) and SII were calculated from routine blood count. Participants were divided into two groups as amputation (Group 1) and non-amputation (Group 2).

RESULTS

Amputation rate was 18.8%. The A1c (8.80 (3.26) % vs. 9.52 (3.10) %, p = 0.007) and HGB (10.17 ± 2.16 g/dL vs. 12.05 ± 2.20 g/dL, p < 0.001) levels, and lymphocyte count (1.81 (1.16) vs. 2.05 (1.11), p = 0.015) were significantly lower in Group 1 than Group 2. The counts of WBC (14.01 (9.16) × 109/L vs. 10.41 (5.82) × 109/L), PLT (393.35 (196.98) × 109/L vs. 312.05 (141.33) × 109/L), neutrophil (11.52 (8.75) × 109/L vs. 6.93 (5.96) × 109/L), PLR (226.04 (159.24) × 109/L vs. 153.12 (101.91) × 109/L), NLR (6.64 (6.93) vs. 3.34 (3.99)) and SII (2505.86 (3957.47) × 109/L vs. 1092.50 (1476.08) × 109/L), and the levels of CRP (14.12 (12.66) mg/dL vs. 3.86 (12.63) mg/dL) and ESR (87.50 (50.50) mm/h vs. 63.00 (57.25) mm/h) were significantly higher in Group 1 than Group 2 (all p < 0.001). AUC of ROC analysis of PLR was 0.666 (95% CI, 0.604-0.728), NLR was 0.695 (95% CI, 0.638-0.752) and SII was 0.716 (95% CI, 0.661-0.772) for the predicting of amputation and the SII had the best AUC with 67.4% sensitivity and 63.3%specificty.

CONCLUSION

SII is a cost-effective and readily available marker, but alone may not be sufficient to predict the risk of amputation in DFU. In our results, the predictive role of SII alone or with other markers for future DFU and its role in predicting other chronic diabetic complications will be evaluated in extensive studies.

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.

Coumarin/β-Cyclodextrin Inclusion Complexes Promote Acceleration and Improvement of Wound Healing

Coumarins have great pharmacotherapeutic potential, presenting several biological and pharmaceutical applications, like antibiotic, fungicidal, anti-inflammatory, anticancer, anti-HIV, and healing activities, among others. These molecules are practically insoluble in water, and for biological applications, it became necessary to complex them with cyclodextrins (CDs), which influence their bioavailability in the target organism. In this work, we studied two coumarins, and it was possible to conclude that there were structural differences between 4,7-dimethyl-2H-chromen-2-one (DMC) and 7-methoxy-4-methyl-2H-chromen-2-one (MMC)/β-CD that were solubilized in ethanol, frozen, and lyophilized (FL) and the mechanical mixtures (MM). In addition, the inclusion complex formation improved the solubility of DMC and MMC in an aqueous medium. According to the data, the inclusion complexes were formed and are more stable at a molar ratio of 2:1 coumarin/β-CD, and hydrogen bonds along with π-π stacking interactions are responsible for the better stability, especially for (MMC)2@β-CD. In vivo wound healing studies in mice showed faster re-epithelialization and the best deposition of collagen with the (DMC)2@β-CD (FL) and (MMC)2@β-CD (FL) inclusion complexes, demonstrating clearly that they have potential in wound repair. Therefore, (DMC)2@β-CD (FL) deserves great attention because it presented excellent results, reducing the granulation tissue and mast cell density and improving collagen remodeling. Finally, the protein binding studies suggested that the anti-inflammatory activities might exert their biological function through the inhibition of MEK, providing the possibility of development of new MEK inhibitors.

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.

Advanced Mass Spectrometry-Based Biomarker Identification for Metabolomics of Diabetes Mellitus and Its Complications

Over the years, there has been notable progress in understanding the pathogenesis and treatment modalities of diabetes and its complications, including the application of metabolomics in the study of diabetes, capturing attention from researchers worldwide. Advanced mass spectrometry, including gas chromatography-tandem mass spectrometry (GC-MS/MS), liquid chromatography-tandem mass spectrometry (LC-MS/MS), and ultra-performance liquid chromatography coupled to electrospray ionization quadrupole time-of-flight mass spectrometry (UPLC-ESI-Q-TOF-MS), etc., has significantly broadened the spectrum of detectable metabolites, even at lower concentrations. Advanced mass spectrometry has emerged as a powerful tool in diabetes research, particularly in the context of metabolomics. By leveraging the precision and sensitivity of advanced mass spectrometry techniques, researchers have unlocked a wealth of information within the metabolome. This technology has enabled the identification and quantification of potential biomarkers associated with diabetes and its complications, providing new ideas and methods for clinical diagnostics and metabolic studies. Moreover, it offers a less invasive, or even non-invasive, means of tracking disease progression, evaluating treatment efficacy, and understanding the underlying metabolic alterations in diabetes. This paper summarizes advanced mass spectrometry for the application of metabolomics in diabetes mellitus, gestational diabetes mellitus, diabetic peripheral neuropathy, diabetic retinopathy, diabetic nephropathy, diabetic encephalopathy, diabetic cardiomyopathy, and diabetic foot ulcers and organizes some of the potential biomarkers of the different complications with the aim of providing ideas and methods for subsequent in-depth metabolic research and searching for new ways of treating the disease.

Retrograde intramedullary nailing of AO/OTA 33C femur fractures in patients with below-knee amputations: technical note and case series

PURPOSE

Intra-articular distal femur fractures in patients with a lower extremity amputation can present a technical challenge for the treating surgeon in what may be otherwise considered a routine procedure in non-amputees. Difficulties with positioning, fracture reduction, limb contractures, and stump osteoporosis can present challenges with treatment. Here, we describe the surgical technique and outcome of a case series of amputee patients with AO/OTA 33C femur fractures.

METHODS

Retrospective case series of five patients with a comminuted supracondylar distal femur fracture with intercondylar extension proximal to a below-knee amputation treated with retrograde intramedullary nail at a single Level 1 trauma center from January 1, 2021, to January 1, 2023. Baseline demographic and clinical data were recorded. Rate of bony union and complications were documented.

RESULTS

Five patients (three females and two males) with a mean age of 48 years who were treated for a comminuted supracondylar distal femur fracture with intercondylar extension proximal to a below-knee amputation were identified. At the time of final follow-up (mean 109.3 days, range 29-183 days), all patients had healed their incisions and were progressing to return of function with their prosthesis. All patients were treated with the surgical technique described in this article, and no postoperative complications were reported.

CONCLUSION

This is an effective and safe technique for surgical treatment of comminuted intra-articular distal femur fractures in patients with an ipsilateral below-knee amputation. We believe that this technique can be utilized by any orthopedic surgeon taking trauma call and can avoid unnecessary transfers or delays to care.

The lower limb-loss rehabilitation continuum (LLRC) - a framework for program design and implementation

Purpose: The multistep journey to prosthetic device-enabled functioning following amputation requires a structured approach for optimal care delivery, but such program structures and outcomes are inadequately characterized. The study is responsive by describing an implementation framework for lower limb loss rehabilitation and evaluating its utility.Materials and methods: The lower limb loss rehabilitation continuum framework (LLRC) was developed using literature-based continuum of care and amputation phase concepts as well as input from limb loss rehabilitation stakeholders. LLRC structure includes five sequential steps (Postsurgical Stabilization (PS), Preprosthetic Rehabilitation (PPR), Limb Healing and Maturation (LHM), Prosthetic Fitting (PF), Prosthetic Rehabilitation (PR)) between six touchpoints of patient-healthcare interaction (Surgery, Preprosthetic Rehabilitation Admission and Discharge, Functioning Evaluation and Prescription, Prosthetic Rehabilitation Admission and Discharge). The utility of this framework was evaluated through LLRC program implementation in a semiurban US setting and program functioning and process outcomes assessment from an IRB-approved, retrospective observational study about patients with unilateral lower-limb amputations completing this program.Results: Program functional (FIM gain; efficiency) scores were greater for PPR(32.6(8);3.1) compared with PR(24.3(8.5);3.8). Program completion duration was 149.7(63.4) days. LHM(75.8(58.5) days) and PF(51.4(24.3) days) were the longest steps. PR duration was significantly longer(p = 0.033) for the transfemoral level.Conclusion: The LLRC framework is useful for the design and implementation of structured limb loss rehabilitation programs.IMPLICATIONS FOR REHABILITATIONThe lower limb-loss rehabilitation continuum (LLRC) is a novel implementation framework with a five-step structure from limb loss to completion of prosthetic rehabilitation between six touchpoints of patient-healthcare interaction, with standardized terminology and baseline and outcome metrics. The utility of the program was demonstrated by successful program development in a suburban health setting and actionable process outcomes and superior functioning outcomes compared with literature.The LLRC can be adapted by health systems, institutions, and care providers for program development. Programs can expect high FIM gains and efficiency for Preprosthetic rehabilitation and Prosthetic rehabilitation steps. With an LLRC completion time of 5 months, long Limb healing and maturation and Prosthetic fitting steps present areas of opportunity for improvement.

The effect of exercise interventions on gait outcomes in subacute and chronic rehabilitation from lower-limb amputation: A systematic review and meta-analysis

Successful walking is a substantial contributor to quality of life in people with lower-limb amputation (PLLA), yet gait difficulties are common. Evidence-based exercise guidelines are necessary for PLLA with different clinical characteristics and at different phases of recovery. To systematically review the literature evaluating effects of exercise interventions on gait outcomes in PLLA at subacute and chronic stages of recovery. Databases MEDLINE, EMBASE, CINAHL, SPORTDiscus, Scopus, and the Cochrane Library were searched (inception to May 10, 2022). Inclusion criteria: randomized controlled trials assessing gait outcomes following exercise intervention; subjects were PLLA ≥18 years of age and used a prosthesis for walking. Meta-analysis using random effects with inverse variance to generate standardized mean differences (SMDs) was completed for primary gait outcomes. Subgroup analysis was conducted for the recovery phase (i.e., subacute and chronic) and level of amputation (e.g., transfemoral and transtibial). Of 16 included articles, 4 studies examined the subacute phase of recovery, whereas 12 examined the chronic phase. Subacute interventions were 30 minutes, 1-7 times/week, for 2-12 weeks. Chronic interventions were 15-60-minutes, 2-3 times/week, for 4-16 weeks. Low-moderate level evidence was shown for a small improvement in the subacute phase (SMD = 0.42, 95% confidence interval [0.06-0.79], I 2 = 46.0%) and a moderate improvement in the chronic phase (SMD = 0.67, 95% confidence interval [0.40-0.94], I 2 = 0.0%) in favor of exercise intervention groups. Multicomponent exercise programs consisting of gait, balance, and strength training are effective at improving gait outcomes in PLLA at subacute and chronic phases of recovery. The optimal duration and frequency of exercise is unclear because of variation between interventions, highlighting an area for future work.

From a Spark to a Flame: The Evolution of Diabetic Foot Disease in the Last Two Decades

Despite many improvements have been achieved, diabetic foot disease (DFD) remains a clinical, social, and economic burden. In the last years, DFD showed an evolution of its characteristics with an increase of the ischaemic/neuro-ischaemic foot in comparison to the pure neuropathic foot. Simultaneously, there was and increased incidence of concomitant cardiovascular co-morbidities, which influences the higher fragility of patients with DFS. Peripheral arterial disease (PAD) in subjects with diabetic foot seems to show a more aggressive pattern, being more distal and difficult to treat. Untreatable PAD remains the unmet need for clinicians and the main risk factor of major amputation in patients with diabetic foot ulcers. Authors aimed to describe the evolution of diabetic foot patients in the last two decades, describing also the current and future treatment which may improve outcomes in the next generations.

Effect of Chinese herbal compound dressings in treating patients with diabetic foot ulcers: A meta-analysis

This meta-analysis aims to systematically investigate the clinical efficacy of Chinese herbal compound dressings in treating patients with diabetic foot ulcers (DFUs). A comprehensive computerised search was conducted in databases including PubMed, Embase, Google Scholar, Cochrane Library, China National Knowledge Infrastructure, and Wanfang databases, from database inception to November 2023, to identify randomised controlled trials (RCTs) concerning the use of Chinese herbal compound dressings in patients with DFU. Two researchers independently screened the literature, extracted data, and assessed the quality based on inclusion and exclusion criteria. Data analysis was performed using Stata 17.0 software. Overall, 18 RCTs involving 1405 DFU patients were included. The analysis indicated that compared to the control group, the group treated with Chinese herbal compound dressings had significantly shorter ulcer healing time (standardised mean difference [SMD] = -2.49, 95% confidence interval [CI]: -3.53 to -1.46, p < 0.001), reduced ulcer surface area (SMD = -3.38, 95% CI: -4.67 to -2.09, p < 0.001), and higher healing rates (odds ratio [OR] = 2.24, 95% CI: 1.72-2.92, p < 0.001) as well as overall effectiveness rates (OR = 4.56, 95% CI: 3.10-6.71, p < 0.001). This study demonstrates that the external application of Chinese herbal compound dressings in patients with DFU can significantly shorten the ulcer healing time and improve wound healing rates.

Transfemoral prosthetic simulators versus amputees: ground reaction forces and spatio-temporal parameters in gait

This study aimed to compare the ground reaction forces (GRFs) and spatio-temporal parameters as well as their asymmetry ratios in gait between individuals wearing a transfemoral prosthetic simulator (TFSim) and individuals with unilateral transfemoral amputation (TFAmp) across a range of walking speeds (2.0-5.5 km h-1). The study recruited 10 non-disabled individuals using TFSim and 10 individuals with unilateral TFAmp using a transfemoral prosthesis. Data were collected using an instrumented treadmill with built-in force plates, and subsequently, the GRFs and spatio-temporal parameters, as well as their asymmetry ratios, were analysed. When comparing the TFSim and TFAmp groups, no significant differences were found among the gait parameters and asymmetry ratios of all tested metrics except the vertical GRFs. The TFSim may not realistically reproduce the vertical GRFs during the weight acceptance and push-off phases. The structural and functional variations in prosthetic limbs and components between the TFSim and TFAmp groups may be primary contributors to the difference in the vertical GRFs. These results suggest that TFSim might be able to emulate the gait of individuals with TFAmp regarding the majority of spatio-temporal and GRF parameters. However, the vertical GRFs of TFSim should be interpreted with caution.

A Minimal and Multi-Source Recording Setup for Ankle Joint Kinematics Estimation During Walking Using Only Proximal Information From Lower Limb

In this study, a minimal setup for the ankle joint kinematics estimation is proposed relying only on proximal information of the lower-limb, i.e. thigh muscles activity and joint kinematics. To this purpose, myoelectric activity of Rectus Femoris (RF), Biceps Femoris (BF), and Vastus Medialis (VM) were recorded by surface electromyography (sEMG) from six healthy subjects during unconstrained walking task. For each subject, the angular kinematics of hip and ankle joints were synchronously recorded with sEMG signal for a total of 288 gait cycles. Two feature sets were extracted from sEMG signals, i.e. time domain (TD) and wavelet (WT) and compared to have a compromise between the reliability and computational capacity, they were used for feeding three regression models, i.e. Artificial Neural Networks, Random Forest, and Least Squares - Support Vector Machine (LS-SVM). BF together with LS-SVM provided the best ankle angle estimation in both TD and WT domains (RMSE < 5.6 deg). The inclusion of Hip joint trajectory significantly enhanced the regression performances of the model (RMSE < 4.5 deg). Results showed the feasibility of estimating the ankle trajectory using only proximal and limited information from the lower limb which would maximize a potential transfemoral amputee user's comfortability while facing the challenge of having a small amount of information thus requiring robust data-driven models. These findings represent a significant step towards the development of a minimal setup useful for the control design of ankle active prosthetics and rehabilitative solutions.

The profile of people undergoing lower limb amputations at Groote Schuur Hospital

Background

The annual incidence of lower limb amputations (LLA) at Groote Schuur Hospital is rising gradually. However, little is known about the sociodemographic and clinical profiles of people undergoing these limb amputations.

Objectives

To collect and analyse data to describe the sociodemographic, health and amputation profiles of people who have undergone LLA at Groote Schuur Hospital.

Method

A descriptive retrospective chart review was conducted using a sample of 107 participants who had undergone LLA at Groote Schuur Hospital between January 2019 and July 2020. A customised assessment tool was used to extract data on the sociodemographic, health and amputation profiles of patients who had LLA. Data were analysed descriptively.

Results

Sixty per cent of the patients who had undergone LLA at Groote Schuur Hospital were women. Most of the patients were over the age of 60 years and had not completed school and were pensioners or unemployed, with very low income and multiple co-morbidities including poorly controlled diabetes.

Conclusions

Complications because of uncontrolled diabetes were the primary indication for LLAs at Groote Schuur Hospital. Therefore, health literacy projects are indicated to address chronic diseases of lifestyle, which, in turn, may reduce the overall burden of LLA, particularly on the South African under-resourced healthcare system.

Contribution

The results of this study may help us identify key factors that predispose patients to LLAs. Consequently, this may help us identify key areas for prevention and better management of diseases that can result in complications that indicate the need for amputation.

The prevalence and risk factors for phantom limb pain: a cross-sectional survey

BACKGROUND

We previously performed a systematic review and meta-analysis which revealed a Phantom Limb Pain (PLP) prevalence estimate of 64% [95% CI: 60.01-68.1]. The prevalence estimates varied significantly between developed and developing countries. Remarkably, there is limited evidence on the prevalence of PLP and associated risk factors in African populations.

METHODS

Adults who had undergone limb amputations between January 2018 and October 2022 were recruited from healthcare facilities in the Western and Eastern Cape Provinces. We excluded individuals with auditory or speech impairments that hindered clear communication via telephone. Data on the prevalence and risk factors for PLP were collected telephonically from consenting and eligible participants. The prevalence of PLP was expressed as a percentage with a 95% confidence interval. The associations between PLP and risk factors for PLP were tested using univariate and multivariable logistic regression analyses. The strength of association was calculated using the Odds Ratio where association was confirmed.

RESULTS

The overall PLP prevalence was 71.73% [95% CI: 65.45-77.46]. Persistent pre-operative pain, residual limb pain, and non-painful phantom limb sensations were identified as risk factors for PLP.

CONCLUSION

This study revealed a high prevalence of PLP. The use of effective treatments targeting pre-amputation pain may yield more effective and targeted pre-amputation care, leading to improved quality of life after amputation.

Mechanical characteristics of diabetic and non-diabetic plantar skin

Diabetic foot ulceration is linked to high amputation and mortality rates, with the substantial associated annual spend on the at-risk diabetic foot reflecting the intensive time and labour involved in treatment. Assessing plantar interactions and developing improved understanding of the formation pathways of diabetic ulceration is important to orthotic interventions and patient outcomes. Plantar skin surrogates which emulate the mechanical and tribological characteristics can help improve physical models of ulceration, reduce reliance on cadaveric use and inform more complex computational modelling approaches. The information available from existing studies to characterise plantar skin is limited, typically featuring ex-vivo representations of skin and subcutaneous tissue combined and given focus to shear studies with time dependency. The aim of this study is to improve understanding of plantar tissue mechanics by assessing the mechanical characteristics of plantar skin in two groups; (1) non-diabetic and (2) diabetic donors without the subcutaneous tissue attachment of previous work in this field. Digital image correlation was used to assess inherent skin pre-tension of the plantar rearfoot prior to dissection. Young's modulus, storage and loss moduli were tested for using tensile stress-strain failure analysis and tensile and compressive dynamic mechanical analysis, which was conducted on excised plantar rearfoot donor specimens for both disease state cohorts at frequencies reflecting those achieved in activities of daily living. Plantar skin thickness for donor specimens were comparable to values obtained using ultrasound acquired in vivo values. Median tensile storage and loss moduli, along with Young's modulus, was higher in the diabetic cohort. With a mean Young's modulus of 0.83 ± 0.49 MPa and 1.33 ± 0.43 MPa for non-diabetic and diabetic specimens respectively. Compressive studies showed consistency between cohorts for median storage and loss moduli. The outcomes from this study show mechanical characteristics of plantar skin without the involvement of subcuteanous tissues under reflective daily achieved loading regimes, showing differences in the non-diabetic and diabetic specimens trialled to support improved understanding of plantar tissue response under tribological interactions.

Early identification of delayed wound healing in complex diabetic foot ulcers treated with a dermal regeneration template: a novel clinical target and its risk factors

BACKGROUND

The dermal regeneration template (DRT), a tissue-engineered skin substitute composing a permanent dermal matrix and an upper temporary silicone layer that serves as the epidermis, has demonstrated efficacy in treating uncomplicated diabetic foot ulcers (DFUs). Our institution has obtained good outcomes with DRT in patients with more complicated DFUs. Because of its chronicity, the authors are working to identify a clinical target that anticipates delayed healing early in the treatment in addition to determining the risk factors linked to this endpoint to increase prevention.

MATERIALS AND METHODS

This retrospective single-center study analyzed patients with DFUs who underwent wound reconstruction using DRT between 2016 and 2021. The patients were categorized into poor or good graft-take groups based on their DRT status on the 21st day after the application. Their relationship with complete healing (CH) rate at day 180 was analyzed. Variables were collected for risk factors for poor graft take at day 21. Independent risk factors were identified after multivariable analysis. The causes of poor graft take were also reported.

RESULTS

This study examined 80 patients (38 and 42 patients in the poor and good graft-take groups, respectively). On day 180, the CH rate was 86.3% overall, but the poor graft-take group had a significantly lower CH rate (76.3 vs. 95.2%, P =0.021) than the good graft-take group. Our analysis identified four independent risk factors: transcutaneous oxygen pressure less than 30 mmHg (odds ratio, 154.14), off-loading device usage (0.03), diabetic neuropathy (6.51), and toe wound (0.20). The most frequent cause of poor graft take was infection (44.7%), followed by vascular compromise (21.1%) and hematoma (15.8%).

CONCLUSION

Our study introduces the novel concept of poor graft take at day 21 associated with delayed wound healing. Four independent risk factors were identified, which allows physicians to arrange interventions to mitigate their effects or select patients more precisely. DRT represents a viable alternative to address DFUs, even in complicated wounds. A subsequent split-thickness skin graft is not always necessary to achieve CH.