Psychological effects of amputation: A review of studies from India

Factors Associated With Major Lower Extremity Amputations in Diabetic Foot Infections at a County Hospital in Guatemala

INTRODUCTION

Outcomes from diabetic foot infections (DFIs) at the major referral hospital (Hospital Nacional de San Benito) in El Petén, Guatemala have not been analyzed. We hypothesized that poor diabetic control might be associated with a high rate of major lower extremity amputations (mLEAs; above the ankle).

METHODS

We performed a retrospective analysis at Hospital Nacional de San Benito between (8/14 and 6/23) in patients presenting with DFIs. Patients receiving mLEAs were compared with all others (AO = [trans-metatarsal amputations, toe amputations, incision and drainage, and antibiotic treatment]). Interviews surgeons were undertaken to ascertain reasons for index operation choice. Univariable and multivariable analyses were undertaken to determine factors associated with mLEAs.

RESULTS

Of 110 patients with DFIs, there were 23 mLEAs (above the knee = 21, below the knee = 2). Age, duration with diabetes, and a prior ipsilateral minor amputation were associated with mLEAs. Multivariable analysis identified white blood cell count as significant for mLEA (odds ratio = 1.5 95% confidence interval [1.0 to 2.5]). Cited reasons for a high rate of above the knee amputation (AKAs) versus below the knee amputation were patient related (advanced disease, patient frailty, and poor compliance), systemic (lack of vascular equipment and knee immobilizer), and surgeon related.

CONCLUSIONS

This cohort of patients presented with an average of 15 years with diabetes mellitus and poor adherence to diabetic treatment (40%). Many of these diabetic patients developed a DFI requiring mLEAs (21%), most of which were AKAs (91%). Efforts to minimize the number of AKA versus below the knee amputation require immediate attention. Programs to adhere to DM control and foot care in patients with DM are urgently needed.

Care Priorities for Individuals with Lower Extremity Amputations: A Patient Delphi Study

OBJECTIVE

To gather preliminary evidence on short- and long-term care priorities for people with lower extremity amputations.

DESIGN

A three-round modified Delphi study using semi-structured interviews.

PARTICIPANTS

A convenience sample of 20 adult participants who had undergone lower extremity amputations at a tertiary public hospital.

MAIN MEASURE

Consensus on each care priority was defined a priori as an agreement of more than 50%. Semi-structured interviews were conducted to understand the rationales for endorsing the care priorities.

RESULTS

Consensus was reached on 24 short-term care priorities and 12 long-term care priorities in the biomedical, practical and psychological and spiritual domains. The rationales for endorsing each of the care priorities generated three themes: preparedness; mental health, psychological and spiritual well-being; and participating in life, with respect and dignity.

CONCLUSIONS

Our results highlight the substantial need to improve patient access to education and planning support prior to undergoing limb amputation, and optimising post-amputation rehabilitation programmes, enabling people with amputations to participate in meaningful life roles that provide them with purpose, dignity, and self-respect. The knowledge of care priorities revealed in this study may promote effective patient-centred care and improve clinical outcomes.

The prevalence of depression in people following limb amputation: A systematic review and meta-analysis

OBJECTIVE

To estimate the prevalence of depression in people with limb amputation. Additionally, factors affecting the prevalence or pattern of depression following limb amputation were explored.

METHODS

Systematic literature search to identify all relevant studies assessing prevalence of depression following limb amputations was conducted through following databases: PubMed/ MEDLINE, Scopus, Embase, and Web of Science. Search period was since inception of database till December 2021. Meta-analyses using random-effects model were conducted to estimate pooled prevalence of depression.

RESULTS

A total of 61 studies comprising 9852 limb amputees were included. Pooled prevalence of depression following limb amputations was 33.85% (95% CI: 27.15% to 40.54%), with significant heterogeneity (I2 = 98.57%; p < 0.001). Sub-group meta-analysis showed that pooled prevalence of depression was significantly higher in studies conducted from middle-income (45.31%, 95% CI: 28.92% to 61.70%) as compared high income countries (28.31%, 95% CI: 23.97% to 32.64%). Greater activity restriction, amputation-related body image disturbances, social discomfort, perceived vulnerability regarding disability, and avoidant coping style were commonly reported factors associated with greater depression symptomatology. Whereas, good perceived social support, and use of more active coping strategies were commonly reported protective factors.

CONCLUSION

About one-third of all limb amputees suffered from clinically significant depression. This emphasizes need to sensitize health care professionals involved in providing care to people following limb amputation regarding the importance of periodically screening this vulnerable group of patients for depression and liaising with psychiatrists. Further, addressing risk factors identified in this review could help in reducing the rates of depression post-amputation.

Bone-anchored prostheses for transfemoral amputation: a systematic review of outcomes, complications, patient experiences, and cost-effectiveness

Introduction

Bone-anchored prostheses (BAP) are an advanced reconstructive surgical approach for individuals who had transfemoral amputation and are unable to use the conventional socket-suspension systems for their prostheses. Access to this technology has been limited in part due to the lag between the start of a new procedure and the availability of evidence that is required before making decisions about widespread provision. This systematic review presents as a single resource up-to-date information on aspects most relevant to decision makers, i.e., clinical efficacy, safety parameters, patient experiences, and health economic outcomes of this technology.

Methods

A systematic search of the literature was conducted by an information specialist in PubMed, MEDLINE, Embase, CINAHL, Cochrane Library, the Core Collection of Web of Science, CADTH's Grey Matters, and Google Scholar up until May 31, 2023. Peer-reviewed original research articles on the outcomes of clinical effectiveness (health-related quality of life, mobility, and prosthesis usage), complications and adverse events, patient experiences, and health economic outcomes were included. The quality of the studies was assessed using the Oxford Centre for Evidence-Based Medicine Levels of Evidence and ROBINS-I, as appropriate.

Results

Fifty studies met the inclusion criteria, of which 12 were excluded. Thirty-eight studies were finally included in this review, of which 21 reported on clinical outcomes and complications, 9 case series and 1 cohort study focused specifically on complications and adverse events, and 2 and 5 qualitative studies reported on patient experience and health economic assessments, respectively. The most common study design is a single-arm trial (pre-/post-intervention design) with varying lengths of follow-up.

Discussion

The clinical efficacy of this technology is evident in selected populations. Overall, patients reported increased health-related quality of life, mobility, and prosthesis usage post-intervention. The most common complication is a superficial or soft-tissue infection, and more serious complications are rare. Patient-reported experiences have generally been positive. Evidence indicates that bone-anchored implants for prosthesis fixation are cost-effective for those individuals who face significant challenges in using socket-suspension systems, although they may offer no additional advantage to those who are functioning well with their socket-suspended prostheses.

Assessment of the feasibility of a community-based mental health training programme for persons with disabilities by non-specialists from different stakeholders' perspectives in Bangladesh

INTRODUCTION

Bangladesh is a developing country where 11% of the population has at least one disability, but no community-level mental health service is available. There is limited evidence of the burden of mental health issues and health-seeking behaviour among this population. This study assessed the feasibility of a training intervention for persons with disabilities, where peer support providers provided community-based disability-inclusive mental health services.

METHODS

Four stakeholder groups participated in this qualitative study: peer responders (trained persons with disabilities), trainers, representatives of organisations of persons with disabilities and disability-specific organisations, and officials of international and national non-governmental organisations. Two types of qualitative interviews were used to collect data, and thematic analysis techniques were utilised.

RESULT

Stakeholders perceived the peer responder training programme as acceptable for persons with disabilities to develop themselves as peer support providers, with potential benefits including increased mental health literacy, ensuring accessible mental health services, and improving the well-being of persons with disabilities. Potential challenges included receiving training and delivering services. Increased training duration, more fieldwork, supervision opportunities, and refresher training were recommended to mitigate training challenges. Financial support and formal community recognition were deemed necessary for training delivery.

CONCLUSION

The peer responder training programme was feasible to ensure accessible mental health services for persons with disabilities, build a workforce to screen for mental health conditions, and provide appropriate referrals. A multi-sectoral collaboration of government and non-governmental institutions is recommended to policy advocates to expand the peer responder training programme in the mainstream mental healthcare system.

Effect of Adding Virtual Reality Training to Traditional Exercise Program on Pain, Mental Status and Psychological Status in Unilateral Traumatic Lower Limb Amputees: A Randomized Controlled Trial

Background: Lower limb amputation is an emotionally devastating condition that causes a complete change in the quality of life, may lead to phantom limb pain in most of the cases, and puts the individual in a high risk of developing psychological disorders. The objective of this study is to evaluate the consequence of adding virtual reality (VR) to a traditional exercise program on pain, mental status, and psychological status in traumatic unilateral lower limb amputees (LLAs). Methods: Thirty-two traumatic LLAs were randomly assigned into two equal groups in this randomized control trial. Participants did accomplish a postfitting exercise program at least 6 months before enrolment; the control group (CG) underwent a traditional rehabilitation program, and experimental group (EG) had the same program, in addition to VR training. Data were collected before and after 6 weeks of intervention using visual analog scale (VAS) for pain, Beck's depression inventory (BDI) for depression, and 12-item short form survey for mental health summary (MHS) and physical health summary (PHS). Results: Thirty-two amputees (29 males and 3 females) were included with mean age in CGs and EG (27.6 ± 4) and (27.6 ± 7.6) years, respectively. Postintervention, the VAS score was significantly reduced only in EG (P = 0.003). Both groups showed significant improvement in BDI, MHS, and PHS (P < 0.05). However, the EG showed a superior significance in BDI and MHS scores (P < 0.05). There was no significance between groups in PHS score. Conclusion: Adding VR to conventional training is beneficial in decreasing pain and in improving depression and MHS of traumatic unilateral LLAs.

Effects of Training and Calibration Data on Surface Electromyogram-Based Recognition for Upper Limb Amputees

Surface electromyogram (sEMG)-based gesture recognition has emerged as a promising avenue for developing intelligent prostheses for upper limb amputees. However, the temporal variations in sEMG have rendered recognition models less efficient than anticipated. By using cross-session calibration and increasing the amount of training data, it is possible to reduce these variations. The impact of varying the amount of calibration and training data on gesture recognition performance for amputees is still unknown. To assess these effects, we present four datasets for the evaluation of calibration data and examine the impact of the amount of training data on benchmark performance. Two amputees who had undergone amputations years prior were recruited, and seven sessions of data were collected for analysis from each of them. Ninapro DB6, a publicly available database containing data from ten healthy subjects across ten sessions, was also included in this study. The experimental results show that the calibration data improved the average accuracy by 3.03%, 6.16%, and 9.73% for the two subjects and Ninapro DB6, respectively, compared to the baseline results. Moreover, it was discovered that increasing the number of training sessions was more effective in improving accuracy than increasing the number of trials. Three potential strategies are proposed in light of these findings to enhance cross-session models further. We consider these findings to be of the utmost importance for the commercialization of intelligent prostheses, as they demonstrate the criticality of gathering calibration and cross-session training data, while also offering effective strategies to maximize the utilization of the entire dataset.

Primary Motor Area Activity in Phantom Limb Imagery of Traumatic Unilateral Lower Limb Amputees With Phantom Limb Pain

Introduction

Estimates of the worldwide increase in amputees raises the awareness to solve long-standing problems. Understanding the functional brain modifications after a lower limb amputation (LLA) is one of the first steps towards proposing new rehabilitation approaches. Functional modifications in the central nervous system due the amputation could be involved in prosthesis use failures and Phantom Limb Pain (PLP), increasing costs and overwhelming the health services.

Objective

This study analyses orphan primary motor area (M1-Orphan) hemodynamic and metabolic behaviour, which previously controlled the limb that was amputated, in comparison with the M1-Preserved, responsible for the intact limb (IL) during phantom limb imagery moving during Mirror Therapy (MT), compared to Isolated Intact Limb Movement Task (I-ILMT).

Methodology

A case-control study with unilateral traumatic LLA with moderate PLP who measured [oxy-Hb] and [deoxy-Hb] in the M1 area by Functional Near InfraredSpectroscopy (fNIRS) during the real (I-ILMT) and MT task.

Results

Sixty-five patients, with 67.69% of men, young (40.32 ± 12.91), 65.63% amputated due motorcycle accidents, 4.71 ± 7.38 years ago, predominantly above the knee (57.14%). The M1 activation in the orphan cortex did not differ from the activation in the intact cortex during MT (P > .05).

Conclusion

The perception of the Phantom limb moving or intact limb moving is metabolically equivalent in M1, even in the absence of a limb. In other words, the amputation does not alter the brain metabolism in control of phantom movement.

Design, Analysis, and Development of Low-Cost State-of-the-Art Magnetorheological-Based Microprocessor Prosthetic Knee

For amputees, amputation is a devastating experience. Transfemoral amputees require an artificial lower limb prosthesis as a replacement for regaining their gait functions after amputation. Microprocessor-based transfemoral prosthesis has gained significant importance in the last two decades for the rehabilitation of lower limb amputees by assisting them in performing activities of daily living. Commercially available microprocessor-based knee joints have the needed features but are costly, making them beyond the reach of most amputees. The excessive cost of these devices can be attributed to custom sensing and actuating mechanisms, which require significant development cost, making them beyond the reach of most amputees. This research contributes to developing a cost-effective microprocessor-based transfemoral prosthesis by integrating off-the-shelf sensing and actuating mechanisms. Accordingly, a three-level control architecture consisting of top, middle, and low-level controllers was developed for the proposed prosthesis. The top-level controller is responsible for identifying the amputee intent and mode of activity. The mid-level controller determines distinct phases in the activity mode, and the low-level controller was designed to modulate the damping across distinct phases. The developed prosthesis was evaluated on unilateral transfemoral amputees. Since off-the-shelf sensors and actuators are used in i-Inspire, various trials were conducted to evaluate the repeatability of the sensory data. Accordingly, the mean coefficients of correlation for knee angle, force, and inclination were computed at slow and medium walking speeds. The obtained values were, respectively, 0.982 and 0.946 for knee angle, 0.942 and 0.928 for knee force, and 0.825 and 0.758 for knee inclination. These results confirmed that the data are highly correlated with minimum covariance. Accordingly, the sensors provide reliable and repeatable data to the controller for mode detection and intent recognition. Furthermore, the knee angles at self-selected walking speeds were recorded, and it was observed that the i-Inspire Knee maintains a maximum flexion angle between 50° and 60°, which is in accordance with state-of-the-art microprocessor-based transfemoral prosthesis.

A Wearable Force Myography-Based Armband for Recognition of Upper Limb Gestures

Force myography (FMG) represents a promising alternative to surface electromyography (EMG) in the context of controlling bio-robotic hands. In this study, we built upon our prior research by introducing a novel wearable armband based on FMG technology, which integrates force-sensitive resistor (FSR) sensors housed in newly designed casings. We evaluated the sensors' characteristics, including their load-voltage relationship and signal stability during the execution of gestures over time. Two sensor arrangements were evaluated: arrangement A, featuring sensors spaced at 4.5 cm intervals, and arrangement B, with sensors distributed evenly along the forearm. The data collection involved six participants, including three individuals with trans-radial amputations, who performed nine upper limb gestures. The prediction performance was assessed using support vector machines (SVMs) and k-nearest neighbor (KNN) algorithms for both sensor arrangments. The results revealed that the developed sensor exhibited non-linear behavior, and its sensitivity varied with the applied force. Notably, arrangement B outperformed arrangement A in classifying the nine gestures, with an average accuracy of 95.4 ± 2.1% compared to arrangement A's 91.3 ± 2.3%. The utilization of the arrangement B armband led to a substantial increase in the average prediction accuracy, demonstrating an improvement of up to 4.5%.

Risk Factors Analysis of Phantom Limb Pain in Amputees with Malignant Tumors

Purpose

Postamputation neuropathic pain is a common disease in patients with malignant tumor amputation, seriously affecting amputees' quality of life and mental health. The objective of this study was to identify independent risk factors for phantom limb pain in patients with tumor amputation and to construct a risk prediction model.

Methods

Patients who underwent amputation due to malignant tumors from 2013 to 2023 were retrospectively analyzed and divided into phantom limb pain group and non-phantom limb pain group. To determine which preoperative factors would affect the occurrence of phantom limb pain, we searched for candidate factors by univariate analysis and used multivariate logistic regression analysis to identify independent factors and construct a predictive model. The receiver operating characteristic curve (ROC) was drawn to further evaluate the accuracy of the prediction model in evaluating the phantom limb pain after amputation of bone and soft tissue tumors.

Results

Multivariate analysis showed that age (OR, 1.054; 95% CI, 1.027 to 1.080), preoperative pain (OR, 5.773; 95% CI, 2.362 to 14.104), number of surgeries (OR, 3.425; 95% CI, 1.505 to 7.795), amputation site (OR, 5.848; 95% CI, 1.837 to 18.620), amputation level (OR, 8.031; 95% CI, 2.491 to 25.888) were independent risk factors for phantom limb pain for bone and soft tissue tumors. The the area under the curve (AUC) of this model was 0.834.

Conclusion

Risk factors for postoperative phantom limb pain were the site of amputation, proximal amputation, preoperative pain, multiple amputations, and older age. These factors will help surgeons to individualize and stratify phantom limb pain and help patients with risk counseling. In particular, an informed clinical decision targeting those modifiable factors can be considered when needed.

Prevalence of mental disorders in South Asia: A systematic review of reviews

Mental disorders are increasing in South Asia (SA), but their epidemiological burden is under-researched. We carried out a systematic umbrella review to estimate the prevalence of mental disorders and intentional self-harm in the region. Multiple databases were searched and systematic reviews reporting the prevalence of at least one mental disorder from countries in SA were included. Review data were narratively synthesised; primary studies of common mental disorders (CMDs) among adults were identified from a selected subset of reviews and pooled. We included 124 reviews. The majority (n = 65) reported on mood disorders, followed by anxiety disorders (n = 45). High prevalence of mental disorders and intentional self-harm was found in general adult and vulnerable populations. Two reviews met our pre-defined criteria for identifying primary studies of CMDs. Meta-analysis of 25 primary studies showed a pooled prevalence of 16.0% (95% CI = 11.0-22.0%, I 2 = 99.9%) for depression, 12.0% (5.0-21.0%, I 2 = 99.9%) for anxiety, and 14.0% (10.0-19.0, I 2 = 99.9%) for both among the general adult population; pooled estimates varied by country and assessment tool used. Overall, reviews suggest high prevalence for mental disorders in SA, but evidence is limited on conditions other than CMDs.

Predicting amputation using machine learning: A systematic review

Amputation is an irreversible, last-line treatment indicated for a multitude of medical problems. Delaying amputation in favor of limb-sparing treatment may lead to increased risk of morbidity and mortality. This systematic review aims to synthesize the literature on how ML is being applied to predict amputation as an outcome. OVID Embase, OVID Medline, ACM Digital Library, Scopus, Web of Science, and IEEE Xplore were searched from inception to March 5, 2023. 1376 studies were screened; 15 articles were included. In the diabetic population, models ranged from sub-optimal to excellent performance (AUC: 0.6-0.94). In trauma patients, models had strong to excellent performance (AUC: 0.88-0.95). In patients who received amputation secondary to other etiologies (e.g.: burns and peripheral vascular disease), models had similar performance (AUC: 0.81-1.0). Many studies were found to have a high PROBAST risk of bias, most often due to small sample sizes. In conclusion, multiple machine learning models have been successfully developed that have the potential to be superior to traditional modeling techniques and prospective clinical judgment in predicting amputation. Further research is needed to overcome the limitations of current studies and to bring applicability to a clinical setting.

A Comprehensive Review of the Vascular Consequences of Diabetes in the Lower Extremities: Current Approaches to Management and Evaluation of Clinical Outcomes

Diabetes mellitus is a global health concern characterized by chronic hyperglycemia, and its vascular consequences in the lower extremities pose significant challenges for individuals living with the condition. This comprehensive review delves into the multifaceted landscape of diabetes-related vascular complications in the lower limbs, with a primary focus on current strategies for management and the evaluation of clinical outcomes. This review achieves several critical objectives by synthesizing existing knowledge and research findings. It elucidates the intricate pathophysiological mechanisms underpinning these complications, shedding light on the cellular and molecular processes involved. Additionally, it outlines clinical assessment and diagnostic strategies used to identify and stratify risk, ranging from cutting-edge imaging techniques to clinical examinations. The review comprehensively examines current management strategies, encompassing lifestyle modifications, pharmacological interventions, surgical procedures, and wound care practices. Moreover, it assesses and analyzes clinical outcomes, including limb salvage rates, amputation rates, and overall quality of life for individuals undergoing treatment. In addressing the challenges faced in managing these complications, this review aims to contribute to improved patient care. It proposes future research directions to enhance the management and outcomes of diabetes-related vascular consequences in the lower extremities.

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.

Psychological adjustments among lower limb amputees in North Indian population: A cross-sectional study

Introduction

Limb amputation is an extremely stressful event for an individual, following which the amputee develops inferior body image, anxiety, and changes in self-concept and identity. For holistic rehabilitation, understanding the psychosocial status of the amputee and its' predictors is of utmost importance.

Objective

The aim of the article is to assess the psychological adjustments in patients with lower limb amputation and determine its clinical and sociodemographic correlates.

Material and Methods

A observational cross-sectional study was conducted from 2020 to 2022 among lower limb amputees of a tertiary care hospital in Lucknow which serves as the only rehabilitation and artificial limb center for the whole state of Uttar Pradesh. Baseline sociodemographic and clinical data were collected. The Hospital Anxiety and Depression Scale was used to determine underlying depression and anxiety, while the Trinity Amputation and Prosthesis Experience Scale was used for understanding the psychological adjustment.

Results

The mean age of the amputee was 39.47 ± 16.99 years. The mean general, social adjustment, and adjustment to limitation score was 16.3 ± 3.34, 15.19 ± 3.59, and 12.76 ± 3.15, respectively. Male amputees, aged >40 years, and pensioners had significantly higher scores for general adjustment (P < 0.05). Those aged >40 years were pensioners and had no underlying depression and anxiety and had better social adjustment (P < 0.05). Those with transfemoral amputation had a significantly lesser adjustment to limitation (P = 0.003).

Conclusion

Young age amputees had poor general and social adjustments and more activity restriction but high prosthesis satisfaction as compared to the elderly. Those with transfemoral amputation had a poor adjustment to limitation while those wearing above-knee prosthesis had more activity restriction.

What Is Hidden behind Amputation? Quanti-Qualitative Systematic Review on Psychological Adjustment and Quality of Life in Lower Limb Amputees for Non-Traumatic Reasons

OBJECTIVE

This systematic review aims to investigate Quality of Life (QoL)/Health Related Quality of Life (HRQoL) and psychological adjustment in non-traumatic lower limb amputees (LLA).

METHODS

PubMed, Scopus, and Web of Science databases were used for the literature search. Studies were read and analysed using the (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) PRISMA statement procedure.

RESULTS

The literature search retrieved 1268 studies, of which 52 were included in the systematic review. Overall, psychological adjustment, especially depression with or without anxiety symptoms, influences the QoL/HRQoL in this clinical population. Other factors influencing QoL/HRQoL include subjective characteristics, physical aspects, the cause and level of the amputation, relational aspects, social support, and the doctor-patient relationship. In addition, the patient's emotional-motivational status, depression and/or anxiety symptoms, and acceptance play a key role in the subsequent rehabilitation process.

CONCLUSIONS

In LLA patients, psychological adjustment is a complex and multifaceted process, and QoL/HRQoL may be influenced by various factors. Shedding light on these issues may provide useful suggestions for promoting clinical and rehabilitative interventions that may be tailored and effective in this clinical population.

Impact of Yoga Intervention in Lower Limb Amputees following Trauma in Relation to Behavior and Quality of Life: A Randomized Controlled Trial

Background

Yoga is an emerging intervention causing improvement in physical, mental, and spiritual well-being. Its role in improving outcomes in patients with amputation was investigated.

Methodology

Patients with traumatic lower limb amputation (n = 50) were enrolled and randomized to the Yoga group (n = 26) against control (n = 24). Sociodemographic details, quality of life (QOL) (World Health Organization QOL-BREF), Depression anxiety stress scale (DASS), Rosenberg self-esteem scale, and amputee body image score were applied at baseline, 6,-18 weeks of amputation.

Results

Sociodemographic and clinical variables were comparable between groups. At 18 weeks, the Yoga group had better QOL (P = 0.005) than the control group. Symptoms of depression (0.02) and anxiety (<0.001) reduced, and self-image (P = 0.015) improved significantly at 6 weeks, while stress (P = 0.003) reduced at 18 weeks in the yoga group. Despite comparable body image scores, the prosthesis usage (hours/day) was more (P = 0.005) in the Yoga (6.9 ± 3.2) group against the control (12 ± 2.7).

Conclusion

Yoga improves QOL and self-esteem and reduces depression, anxiety, and stress symptoms in patients with traumatic amputation.

Exercise Therapy in Nonspecific Low Back Pain among Individuals with Lower-Limb Amputation: A Systematic Review

Low back pain is very common condition that often becomes a long-lasting problem in prostheses users after lower limb amputation. The presented study aims to decide the potential benefits of exercise therapy on low back pain among lower limb amputees by using a systematic review. The PICO technique was used to answer the primary issue of this review: Does exercise treatment lessen the prevalence of low back pain in the population of lower limb amputees? Systematic review was conducted in the following databases: Medline-PubMed, EMBASE, Scopus, and Web of Science. Studies up to September 2010 published in English are included. Aim, target population, development and execution strategies, and treatment suggestions were among the data gathered. The primary outcomes of interest were exercise interventions as a therapy for low back pain but only two articles met including criteria. The search was broadened and 21 studies describing biomechanical changes in gait and pelvic-spine posture were analysed. This review indicates that movement therapy is a potential treatment strategy in low back pain among amputees. The major limitation of the study is the very heterogenous group of subjects in terms of amputation level, baseline activity level and comorbidities. We used a procedure that was registered in PROSPERO (CRD42022345556) to perform this systematic review of systematic reviews. There is a necessity of good quality research for concluding a consensus of exercise intervention.

Acute influence of an adaptive sporting event on quality of life in veterans with disabilities

Veterans with disabilities can experience poor quality of life following military service due to the associated negative physical and psychological ramifications. However, participation in physical activities has shown to induce both physical and mental benefits and improve the quality of life of this population. Adaptive sports, an innovative approach to address the unique physical and psychosocial needs of veterans with disabilities, are becoming more widely used as a rehabilitation tool to improve the quality of life for these veterans. This study aimed to determine the acute influence of participation in a single-day, veteran-based, adaptive kayaking and sailing event on the perceived overall health, quality of life, and quality of social life of veterans with varying disabilities. It was hypothesized that all three categories and the sum score of quality of life would reflect a positive acute response after participation in the community-based physical activity event. Veterans responded to three quality of life-related questions using a 5-point Likert scale before and directly after participating in the event. Findings indicated that an adaptive sporting event can have an acute positive influence on the quality of life of veteran participants, with improvements observed in all three categories of perceived quality of life. Therefore, it is advantageous for the whole-health rehabilitation of veterans with disabilities for the Department of Veterans Affairs to continue to provide opportunities for veterans to participate in non-traditional, community-based activities.

Knowledge, attitude and perception towards lower limb amputation amongst persons living with diabetes in rural South Africa: A qualitative study

Background

South Africa has a high prevalence of diabetes mellitus (DM), a leading risk factor for lower limb amputation (LLA). Lower limb amputation is associated with significant morbidity and mortality. Lower limb amputation incidence can be mitigated through prompt identification and treatment of individuals at risk and engagement in self-management practices. Also, when LLA is inevitable, outcomes or prognosis can be improved with timely surgery.

Aim

This study explored the knowledge, attitude and perception of persons living with diabetes towards LLA and its prevention.

Setting

Nqamakwe, a rural community in the Eastern Cape province of South Africa.

Method

This was a descriptive, qualitative study involving persons living with DM, with and without LLA, and community leaders. Fifteen participants were recruited purposively and conveniently from a rural community in the Eastern Cape, South Africa. Data collection took place through semistructured interviews, in English and a local language, Xhosa. Interviews were transcribed and translated, and an inductive approach was used for thematic analysis.

Results

A total of 15 individual interviews were conducted. Of those, 13 were persons with DM, five with LLA, including one with bilateral LLA. There was a gap in knowledge on foot self-examination as a measure of preventing LLA amongst persons with DM. The attitude of persons without LLA was mostly fearful and their fears centred around perioperative death, risk for contralateral amputation, loss of limb and independence. Consent to LLA procedure was a last resort and only when pain levels were unbearable. Family support and information on rehabilitation services and assistive devices also fostered consent to LLA surgery.

Conclusion

There is a need for awareness creation and adequate health education for persons living with DM on LLA and its prevention measures, especially foot care practices. Also, health education programmes for persons living with DM in rural areas should address the various misperceptions of LLA to reduce delays.

Contribution

The article revealed gaps in knowledge on LLA and its prevention among individuals living with diabetes as well as areas of concerns that may potentially delay acceptance when LLA is inevitable. Findings from our study may assist primary health care providers to determine important issues to be addressed during routine and pre-operative patient education.

Understanding and Measuring the Cognitive Load of Amputees for Rehabilitation and Prosthesis Development

Objective

To derive a definition of cognitive load that is applicable for amputation as well as analyze suitable research models for measuring cognitive load during prosthesis use. Defining cognitive load for amputation will improve rehabilitation methods and enable better prosthesis design.

Data Sources

Elsevier, Springer, PLoS, IEEE Xplore, and PubMed.

Study Selection

Studies on upper limb myoelectric prostheses and neuroprostheses were prioritized. For understanding measurement, lower limb amputations and studies with individuals without lower limb amputations were included.

Data Extraction

Queries including “cognitive load,” “neural fatigue,” “brain plasticity,” “neuroprosthetics,” “upper limb prosthetics,” and “amputation” were used with peer-reviewed journals or articles. Articles published within the last 6 years were prioritized. Articles on foundational principles were included regardless of date. A total of 69 articles were found: 12 on amputation, 15 on cognitive load, 8 on phantom limb, 22 on sensory feedback, and 12 on measurement methods.

Data Synthesis

The emotional, physiological, and neurologic aspects of amputation, prosthesis use, and rehabilitation aspects of cognitive load were analyzed in conjunction with measurement methods, including resolution, invasiveness, and sensitivity to user movement and environmental noise.

Conclusions

Use of “cognitive load” remains consistent with its original definition. For amputation, 2 additional elements are needed: “emotional fatigue,” defined as an amputee's emotional response, including mental concentration and emotions, and “neural fatigue,” defined as the physiological and neurologic effects of amputation on brain plasticity. Cognitive load is estimated via neuroimaging techniques, including electroencephalography, functional magnetic resonance imaging, and functional near-infrared spectroscopy (fNIRS). Because fNIRS measures cognitive load directly, has good temporal and spatial resolution, and is not as restricted by user movement, fNIRS is recommended for most cognitive load studies.

Lower limb amputations among individuals living with diabetes mellitus in low- and middle-income countries: A systematic review protocol

Background

The burden of diabetes mellitus (DM) and its associated complications continue to burgeon, particularly in low- and middle-income countries (LMICs). Lower limb amputation (LLA) is one of the most life-altering complications of DM, associated with significant morbidity, mortality and socio-economic impacts. High-income countries have reported a decreasing incidence of DM-associated LLA, but the situation in many LMICs is unknown. We aim to conduct a systematic review to determine the incidence and prevalence of DM-associated LLA in LMICs to better inform appropriate interventions and health system response.

Methods and analysis

A systematic search of the literature will be conducted on five databases: MEDLINE, Embase, Cumulative Index of Nursing and Allied Health Literature (CINAHL), Scopus and African Journal Online (AJOL). Only observational, quantitative studies reporting the incidence and/or prevalence of DM-related LLA will be considered. A validated study design-specific critical appraisal tool will be used to assess the risk of bias in individual studies. We will determine the incidence of LLA by examining the number of new cases of LLA among individuals with confirmed DM diagnosis during the specified period, while the prevalence will be based on the total number of all new and existing LLAs in a population. LLA will be considered as the resection of the lower limb from just above the knee to any point down to the toe. If heterogeneity is low to moderate, a random-effects meta-analysis will be conducted on extracted crude prevalence/incidence rates, with the median and interquartile range also reported. The systematic review will be performed in accordance with the JBI guideline for prevalence and incidence review. Study reporting will follow the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guideline.

Prospero registration number

CRD42021238656.

Can Bed-Side Grief Counseling Sessions Enhance Recovery in a Patient With Posttrauma Amputation: A Case Report

Amputation is the surgical removal of all or part of a body part. It demands an adjustment in almost every sphere of a person’s life in addition to physical disability. An amputee faces problems in almost every psychosocial sphere. 1 , 2 Along with physical pain in the stump, patients may experience phantom sensations. 3 – 5 Patients may also grieve, feel depressed, and anxious 3 , 6 , 4 , 7 or have posttraumatic stress disorder symptoms. 8 , 9 They may be apprehensive about their future plans and inconclusive regarding life challenges. Grief is one of the most common reactions to amputation, 10 , 1 , 7 but often gets neglected in intensive surgical units. 1 Many times, grief reactions are not resolved, turning into complicated grief or prolonged grief, leading to conditions like depression, anxiety, or even suicide. This article is about an attempt to help a patient initiate the grieving process for healthy outcomes.

An insight into Transfemoral Prostheses: Materials, modelling, simulation, fabrication, testing, clinical evaluation and performance perspectives

INTRODUCTION

A Transfemoral prosthesis restores any limb amputated above the knee. Designing and developing a transfemoral prosthesis that is consistent with human performance is a tough task. While prosthetic components are widely available in the market, ongoing research is being conducted to develop parts that would restore the lost capability, taking into account numerous social, economic and technological considerations.

AREAS COVERED

The present paper provides a comprehensive review about the mechanical aspects and performance of transfemoral prosthesis in recent years based on the research findings on materials, manufacturing methods and evaluations for suitability of the prostheses. The fundamental terminologies as well as technical advancements are covered in order to impart a better knowledge in the area of Lower Limb prostheses. This review also provides a concise description on the role of computers, advanced software packages, sensors and other hardware components for the design, fabrication and testing of transfemoral prosthetic devices in the current environment.

EXPERT OPINION

The current state of lower limb prostheses and future research opportunities are summarised to address upcoming challenges. Based on survey of various research works, adapting modern technology may aid in the development of functional and cost-efficient prosthetic components with superior safety, comfort and quality.

Trends of limb amputation considering type, level, sex and age in Saskatchewan, Canada 2006-2019: an in-depth assessment

BACKGROUND

Most epidemiologic reports focus on lower extremity amputation (LEA) caused specifically by diabetes mellitus. However, narrowing scope disregards the impact of other causes and types of limb amputation (LA) diminishing the true incidence and societal burden. We explored the rates of LEA and upper extremity amputation (UEA) by level of amputation, sex and age over 14 years in Saskatchewan, Canada.

METHODS

We calculated the differential impact of amputation type (LEA or UEA) and level (major or minor) of LA using retrospective linked hospital discharge data and demographic characteristics of all LA performed in Saskatchewan and resident population between 2006 and 2019. Rates were calculated from total yearly cases per yearly Saskatchewan resident population. Joinpoint regression was employed to quantify annual percentage change (APC) and average annual percent change (AAPC). Negative binomial regression was performed to determine if LA rates differed over time based on sex and age.

RESULTS

Incidence of LEA (31.86 ± 2.85 per 100,000) predominated over UEA (5.84 ± 0.49 per 100,000) over the 14-year study period. The overall LEA rate did not change over the study period (AAPC -0.5 [95% CI - 3.8 to 3.0]) but fluctuations were identified. From 2008 to 2017 LEA rates increased (APC 3.15 [95% CI 1.1 to 5.2]) countered by two statistically insignificant periods of decline (2006-2008 and 2017-2019). From 2006 to 2019 the rate of minor LEA steadily increased (AAPC 3.9 [95% CI 2.4 to 5.4]) while major LEA decreased (AAPC -0.6 [95% CI - 2.1 to 5.4]). Fluctuations in the overall LEA rate nearly corresponded with fluctuations in major LEA with one period of rising rates from 2010 to 2017 (APC 4.2 [95% CI 0.9 to 7.6]) countered by two periods of decline 2006-2010 (APC -11.14 [95% CI - 16.4 to - 5.6]) and 2017-2019 (APC -19.49 [95% CI - 33.5 to - 2.5]). Overall UEA and minor UEA rates remained stable from 2006 to 2019 with too few major UEA performed for in-depth analysis. Males were twice as likely to undergo LA than females (RR = 2.2 [95% CI 1.99-2.51]) with no change in rate over the study period. Persons aged 50-74 years and 75+ years were respectively 5.9 (RR = 5.92 [95% Cl 5.39-6.51]) and 10.6 (RR = 10.58 [95% Cl 9.26-12.08]) times more likely to undergo LA than those aged 0-49 years. LA rate increased with increasing age over the study period.

CONCLUSION

The rise in the rate of minor LEA with simultaneous decline in the rate of major LEA concomitant with the rise in age of patients experiencing LA may reflect a paradigm shift in the management of diseases that lead to LEA. Further, this shift may alter demand for orthotic versus prosthetic intervention. A more granular look into the data is warranted to determine if performing minor LA diminishes the need for major LA.

Comparison of health state utility measures and disabilities of arm, shoulder and hand questionnaire scores in bilateral hand amputees

Bilateral hand amputation (BHA) is a life-changing event that can result in a great degree of loss of function. Prosthetic limb replacement and composite tissue allotransplantation are the treatment options. Understanding the BHA in terms of economic utility will help direct future research and upgrading in healthcare delivery. This is a cross-sectional study in 32 BHA who have completed a minimum of six months after wound healing. The primary objective was to assess the convergent validity of three different health utility (HU) derivation methods, namely the time trade-off (TTO), EuroQol questionnaire (EQ-5D-5L), and EuroQol visual analog scale (EQ-VAS) among BHA. The secondary objective was to correlate the disabilities of arm, shoulder and hand (DASH) scores with the HU scores and see whether the DASH score predicts the HU scores derived by different methods. The mean (SD) HU scores for TTO, VAS, and EQ-5D-5L were 0.34 (0.25), 0.61 (0.25), and 0.46 (0.20), respectively. HU derived by the TTO method displayed a weak correlation with EuroQol-based derivatives (EQ-VAS & EQ-5D-5L). But there was a moderate correlation between values by EQ-VAS & EQ-5D-5L. Hence, the EuroQol HU derivative is preferable to TTO. The mean (SD) of the DASH score was 48.4 (22.9). There was a strong correlation between the DASH scores and HU derived by different methods. Also, the DASH score is seen to be a good predictor of HU scores. This study is the first to derive HU and correlate the DASH with HU scores in the BHA scenario .

"I Wish I Could Have My Leg": A Qualitative Study on the Experiences of Individuals With Lower Limb Amputation

Amputation is commonly regarded as a lifesaving procedure. However, the loss of a body part can lead to permanent disability that can impact patients physically, psychologically, and socially. The aim of this study was to describe and understand the perspectives of patients with lower limb amputation (LLA) about their condition. The study uses a descriptive phenomenological design. Data were collected from 12 patients. The researchers conducted interviews using semi-structured questions. MAXQDA was used for qualitative software support in managing the interview data. Data were transcribed. The participants were aged 61.3 ± 10.8 years. Three themes emerged from the qualitative data: (i) losing control over one's own life, (ii) dreams versus the realities of life, and (iii) future perceptions. Most of the participants emphasized that they face undesirable experiences in their post-amputation lives. The findings of the present study provide novel insight into how individuals subjectively experience life after LLA.

Secondary finger amputation after a work accident

INTRODUCTION

The main aim of the present study was to compare motives between patients requesting secondary finger amputation following or unrelated to a work accident. The secondary objective was to assess correlation between sick leave duration and motive for amputation following a work accident.

METHOD

A single-center retrospective study was conducted over an 11-year period in a hand clinic. Cases of secondary totalizing post-traumatic finger amputation at metacarpal base level were included. Exclusion criteria comprised non-traumatic amputation, age<16 years and thumb amputation. In all, 216 patients met the inclusion criteria. The main endpoints assessed motives in requests for secondary metacarpal base amputation: esthetic, functional or administrative. Secondary endpoints comprised accident-to-surgery interval, gender and age, amputated digit and dominant-side involvement.

RESULTS

Motive correlated significantly with gender (p<0.05). Administrative motives almost exclusively concerned males (21 males, 1 female) and predominantly concerned work accidents (19 vs. 3). Accident-to-surgery intervals were significantly longer in case of administrative motive (25.7 months, vs. 10.8 months for functional and 9 months for esthetic motives). Accident-to-surgery intervals were significantly longer in case of work accidents (15.2 vs. 9.5 months).

DISCUSSION

Age and gender influenced patients' attitudes in post-traumatic finger amputation. Work-accident status influenced attitudes in a quarter of cases; we consider it unlikely that this can be reduced to claims for compensation, but that it is rather a matter of undiagnosed pathological grief. These findings highlight the importance of early follow-up of victims of traumatic amputation and early screening for pathological grief.

Adherence rates of person-centered language in amputation research: A cross-sectional analysis

BACKGROUND

Person-centered language (PCL) is the recommended method of addressing patients by the American Medical Association Manual of Style in medical research, thus requiring published manuscripts to be free of non-PCL. Although individuals, communities, and organizations have the autonomy to use non-PCL, it is imperative for medical researchers to use PCL in an effort to reduce the transfer of stigmatization into clinical practice.

OBJECTIVE

To determine current adherence to PCL related to individuals with limb or digit amputations in scientific journals.

METHODS

A cross-sectional analysis was performed by systematically searching PubMed from May 1, 2018 to April 30, 2020 for publications focused on amputations. Journals with less than 20 articles were excluded, and remaining publications were randomized, with the first 500 articles selected. Articles were screened for inclusion criteria, and data were extracted in masked, duplicate fashion, for predetermined non-PCL terms. A chi-squared test and logistic regression were used to quantify PCL adherence study characteristics.

RESULTS

Of 500 articles, 81 were excluded, and 419 articles from 13 journals were examined-64.6% containing non-PCL. The most common non-PCL terms used were "amputee" in 148 articles and "limb loss" in 138 articles. PCL was significantly associated with article type, research funding, and journal requirements for PCL.

CONCLUSIONS

Results indicate that one-third of research articles were PCL-adherent, which we speculate may contribute to the stigma that individuals with amputations experience. Our findings suggest that PCL adherence is higher among surgery research and lower among engineering and prosthetic research.

Incidence and trends of limb amputation in first nations and general population in Saskatchewan, 2006-2019

BACKGROUND

There is conflicting evidence whether limb amputation (LA) disproportionately affects indigenous populations. To better understand this disparity, we compared the LA incidence rate between First Nations persons registered under the Indian Act of Canada (RI) and the general population (GP) in Saskatchewan.

METHODS

We used Saskatchewan's retrospective administrative data containing hospital discharge LA cases, demographic characteristics (age and sex), and residents population reported in the database stratified by RI and GP from 2006-2019. The LA cases for each stratified group were first disaggregated into three broad categories: overall LA (all reported LA), primary LA (first reported LA), and subsequent LA (revision or contralateral LA), with each category further split into the level of amputation defined as major amputation (through/above the ankle/wrist joint) and minor amputation (below the ankle/wrist joint). LA rates were calculated using LA cases as the numerator and resident population as the denominator. Joinpoint and negative binomial regressions were performed to explore the trends further.

RESULTS

Overall, there were 1347 RI and 4520 GP LA cases reported in Saskatchewan from 2006-2019. Primary LA made up approximately 64.5% (869) of RI and 74.5% (3369) of GP cases, while subsequent LA constituted 35.5% (478) of RI and 25.5% (1151) of GP cases. The average age-adjusted LA rate was 153.9 ± 17.3 per 100,000 in the RI cohort and 31.1 ± 2.3 per 100,000 in the GP cohort. Overall and primary LA rates for the GP Group declined 0.7% and 1.0%, while subsequent LA increased 0.1%. An increased LA rate for all categories (overall 4.9%, primary 5.1%, and subsequent 4.6%) was identified in the RI group. Overall, minor and major LA increased by 6.2% and 3.3%, respectively, in the RI group compared to a 0.8% rise in minor LA and a 6.3% decline in major LA in the GP group. RI females and males were 1.98-1.66 times higher risk of LA than their GP counterparts likewise, RI aged 0-49 years and 50+ years were 2.04-5.33 times higher risk of LA than their GP cohort. Diabetes mellitus (DM) was the most prevalent amputation predisposing factor in both groups with 81.5% of RI and 54.1% of GP diagnosed with DM. Also, the highest proportion of LA was found in the lowest income quintile for both groups (68.7% for RI and 45.3% for GP).

CONCLUSION

Saskatchewan's indigenous individuals, specifically First Nations persons registered under the Indian Act of Canada, experience LA at a higher rate than the general population. This disparity exists for all variables examined, including overall, primary, and subsequent LA rates, level of amputation, sex, and age. Amplification of the disparities will continue if the rates of change maintain their current trajectories. These results underscore the need for a better understanding of underlying causes to develop a targeted intervention in these groups.

Management of myxoid liposarcoma of the extremity

Myxoid liposarcoma (MLPS) is the second most common type of LPS after the well differentiated LPS. MLPS is primarily localized to the extremities. The incidence of LPS is ~2 per million worldwide. MLPS accounts for ~30% of all LPS cases. MLPS is usually encountered in adults, but can also occur in younger individuals more than other types of LPS. MLPS can be divided into low- and high-grade subtypes, which present with differences in patient prognosis and outcome. Methods of tumor management include surgery, radiotherapy and chemotherapy; however, there is no unified treatment based on tumor characteristics alone. The present manuscript reviews the surgical management, radiotherapeutic and chemotherapeutic approaches reported in the literature for different types of MLPS in the extremities, as well as the post-treatment outcomes. In addition, the present review provides an evidence-based management plan for MLPS in the form of an organogram based on specific tumor and patient parameters.

Estimation of Health Utility and Quality Adjusted Life Years in Bilateral Hand Transplantation: A Time Trade-off Study

BACKGROUND

Hand transplantation and advances in the field of prostheses have opened new frontiers in the restoration of hand function among bilateral hand amputees (BHA). There is only scarce literature evaluating the health utility (HU) and quality adjusted life years (QALY) gained by bilateral hand composite tissue allotransplantation (CTA) or prosthesis over amputation. The study was focused on BHA restored with prosthesis or CTA.

METHODS

The HU of three different health states (HS) namely, BHA, using prosthesis or with CTA and net QALYs gained by hand transplantation or prosthesis over amputation were computed by time trade-off (TTO) method among 236 study participants.

RESULTS

Among 236 study participants, medical professional (120), general public (89), BHA (23), and bilateral hand transplant recipients (4) were included. The mean HU by TTO method among the study participants (n = 232) as BHA, using prosthesis or CTA was 0.34 (±0.24), 0.50 (±0.26) and 0.69 (±0.26) respectively. Bilateral hand CTA imparted an expected gain of 12.57 (±11.43) mean QALYs over amputation among the study participants. The subgroup analysis displayed higher mean HU in hand CTA recipient HS along with maximum QALY gained by CTA over amputation.

CONCLUSIONS

Bilateral hand CTA HS stands above the other 2 HSs, namely BHA and prosthesis, in terms of the health utility. As demonstrated by QALY gain of 12.57, participants' valuation of health utility is notably higher for CTA with acceptance of lifelong immunosuppressant rather than for a state of uncompromised physical health with a bilateral hand amputation.

Interdisciplinary Care for Amputees Network: A Novel Approach to the Management of Amputee Patient Populations

Extremity amputation remains a common intervention for limb-threatening conditions. With advancement in surgical technique to address deleterious postoperative sequelae of limb removal, there is a salient need to develop and operationalize interdisciplinary care frameworks to provide more comprehensive care to an otherwise challenging patient population. Herein, we describe our interdisciplinary approach to the management of amputee patient populations at our institution, referred to as the Interdisciplinary Care for Amputees Network (ICAN). This novel framework focuses on 3 fundamental areas: combined preoperative patient evaluation, orthoplastic surgical intervention, and multi-specialty postoperative functional and psychosocial rehabilitation. Importantly, the successful implementation of a combined orthoplastic clinic requires establishing a working relationship among providers to leverage increased provider familiarity. This, coupled with sufficient clinic space, dedicated operating room time, and standardized patient workflow, serves to improve care and meet patient goals of pain minimization, return to desired functional status, and improvement in quality of life.

A low-cost transradial prosthesis controlled by the intention of muscular contraction

Persons with upper-limb amputations face severe problems due to a reduction in their ability to perform the activities of daily living. The prosthesis controlled by electromyography (EMG) or other signals from sensors, switches, accelerometers, etc., can somewhat regain the lost capability of such individuals. However, there are several issues with these prostheses, such as expensive cost, limited functionality, unnatural control, slow operating speed, complexity, heavyweight, large size, etc. This paper proposes an affordable transradial prosthesis, controlled by the muscular contractions from user intention. A surface EMG sensor was explicitly fabricated for capturing the muscle contraction information from the residual forearm of subjects with amputation. An under actuated 3D printed hand was developed with a prosthetic socket assembly to attach the remaining upper-limb of such subjects. The hand integrates an intuitive closed-loop control system that receives reference input from the designed sensor and feedback input from a force sensor installed at the thumb tip. The performance of the EMG sensor was compared with that of a traditional sensor in detecting muscle contractions from the subjects. The designed sensor showed a good correlation (r > 0.93) and a better signal-to-noise ratio (SNR) feature to the conventional sensor. Further, a successful trial of the developed hand prosthesis was made on five different subjects with transradial amputation. The users wearing the hand prototype were able to perform faster and delicate grasping of various objects. The implemented control system allowed the prosthesis users to control the grasp force of hand fingers with their intention of muscular contractions.

Limb Salvage Surgery in Fungating Giant Cell Tumors: A Report of Three Cases

Introduction:

The WHO defines giant cell tumor as a benign locally aggressive neoplasm with metastasizing capacity and aggressive behavior. Very rarely, these tumors are seen fungating, mostly when neglected. But when they do, the treatment option commonly conferred is amputation of the limb which is disabling and traumatizing.

Case Report:

We report three cases of fungating limb masses (proximal tibia, distal fibula, and distal radius) diagnosed with giant cell tumor histologically, undergoing limb saving surgeries with various reconstruction techniques to endorse a good quality of life and functioning limb.

Conclusion:

Our study is one of the earliest to report medium-term follow-up after such limb salvage procedure. We recommend that salvage procedures should be considered in giant cell tumors even in the presence of fungation if there is no neurovascular encasement.

Amputations of Lower Limb in Subjects with Diabetes Mellitus: Reasons and 30-Day Mortality

BACKGROUND

Diabetic foot is one of the leading causes of patient disability worldwide. Lower-extremity amputations (LEAs) resulting from this disease massively decrease quality of life, the function of the patient, and incur significant healthcare costs. The aim of this study was to assess trends in the number of amputations, the diagnosis at discharge, and diagnosis-related mortality after LEA procedures in a nationwide population.

METHODS

Datasets of the National Heath Fund containing information about all services within the public healthcare system in Poland, spanning the years 2010-2019, were analyzed. The source of data regarding mortality was the database of the Polish Ministry of Digital Affairs.

RESULTS

Between 2010 and 2019, the annual number of amputations in patients with diabetes increased significantly from 5,049 to 7,759 (p for trend < 0.000001). However, the number of amputations in patients with diabetes calculated as a number per 100,000 diabetics decreased significantly (p for trend < 0.0005) during this period. Amputations in patients with diabetes accounted for a majority of all amputations; the mean percentage of amputations in patients with diabetes was 68.6% of all amputations (from 61.1% in 2010 to 71.4% in 2019, p for trend < 0.0000001). The most common disease diagnosed at discharge after LEA in diabetic patients was diabetes itself. Vascular pathologies, such as soft-tissue/bone/joint infections and ulcerations, were the next most common. The 30-day mortality rate after LEA was rather high in patients with, as well as without, diabetes (depending on the cause for amputation 3.5-34% and 2.2-28.99%, respectively).

CONCLUSIONS

The number of LEA in patients with diabetes in Poland increased substantially between 2010 and 2019 along with an increasing number of diabetics. Vascular pathologies, infections, and ulcerations were the most common causes of LEA. The 30-day mortality rate after amputation was rather high and varied depending on the diagnoses at discharge.

Human Hand Anatomy-Based Prosthetic Hand

The present paper describes the development of a prosthetic hand based on human hand anatomy. The hand phalanges are printed with 3D printing with Polylactic Acid material. One of the main contributions is the investigation on the prosthetic hand joins; the proposed design enables one to create personalized joins that provide the prosthetic hand a high level of movement by increasing the degrees of freedom of the fingers. Moreover, the driven wire tendons show a progressive grasping movement, being the friction of the tendons with the phalanges very low. Another important point is the use of force sensitive resistors (FSR) for simulating the hand touch pressure. These are used for the grasping stop simulating touch pressure of the fingers. Surface Electromyogram (EMG) sensors allow the user to control the prosthetic hand-grasping start. Their use may provide the prosthetic hand the possibility of the classification of the hand movements. The practical results included in the paper prove the importance of the soft joins for the object manipulation and to get adapted to the object surface. Finally, the force sensitive sensors allow the prosthesis to actuate more naturally by adding conditions and classifications to the Electromyogram sensor.

Traumatic upper-limb amputation: The process toward acceptance

INTRODUCTION

After traumatic upper-limb amputation (TULA), one-third of patients develop traumatic pathological grief (PG). However, are the other two-thirds unscathed? The main aim of the present study was to assess the rate of TULA victims claiming to have dealt with the consequences and showing no PG. The secondary objective was to determine positive and negative factors enabling and preventing coping.

METHOD

A retrospective clinical study was conducted over an 11-year period in all adult TULA cases in our department. Assessment was on questionnaire. PG was assessed on the ICG (Inventory of Complicated Grief). Factors were assessed on physical, psychological, social, functional, esthetic and epidemiological criteria. Statistical analysis used StatView software, with the significance threshold set at p<0.05.

RESULTS

Functional and social impacts were significantly greater in case of PG. Thumb amputation was significantly associated with PG, while PG was significantly less frequent in case of amputation at the metacarpal base. Patients in PG had significantly more often undergone neuroma resection or stump revision surgery.

DISCUSSION

Fewer than a half of TULA victims achieved cure. Long-term prognosis depends on the patient's ability to accept the new situation, much more than on amputation level. Patients need support from the very first minutes, with follow-up extended well belong scar healing. Onset and healing of the narcissistic wound are inevitably delayed compared to skin healing.

Quality of life among Syrian patients with war-related lower limb amputation at the Military Hospital in Lattakia

Purpose

To describe the quality of life(QOL) of Syrian people with lower limb amputation after the war.

Methods

A cross-sectional study conducted at the Military Hospital in Lattakia, from May to August 2019. A convenience sample of 65 adult males who had previously undergone amputation of a lower limb was included in this study. Participants' data were collected including age, marital status, employment, time since amputation, level of amputation, type of amputation and the use of assistive devices. The QOL was measured using the World Health Organization Quality of Life Brief Version (WHO QOL-BREF). Data analysis was done by using SPSS version 20.

Results

Forty (61.5%) of subjects were between age of 40-60. Below knee and unilateral lower-limb amputees formed the highest number 52 (80.0%) and 51 (78.5%) respectively. The mean scores of environment, physical health, psychological, and social relationships domains of QOL were 15.86, 15.18, 14.66, and 6.64, respectively. There were statistically significant differences in various domains of QOL between groups with different status of employment, financial support, amputated lower limb, duration since amputation, and cause of amputation (P < 0.05).

Conclusion

There is a need to pay attention to experiences and the quality of life among Syrian patients with war-related amputation.

Sociodemographic Determinants for the Health-Related Quality of Life of Patients with Vascular Amputations as Determined with the Prosthesis Evaluation Questionnaire

Background: To identify the sociodemographic variables independently related to the different dimensions of the Prosthesis Evaluation Questionnaire (PEQ). Methods: An observational, cross-sectional study was conducted, with a sample of 61 Spanish vascular amputees (Valencia, Spain). Included in this study are the results of the PEQ and explanatory-sociodemographic variables, as well as a descriptive and analytic analysis. Results: Gender differences were observed in “appearance” and “perception of appearance” (significantly higher levels for men). Older patients tended to have worse scores in “utility”, “frustration”, “social burden” and “deambulation”. More favorable scores were obtained for those residing in rural areas in “social burden” and “deambulation”. Educational level had a positive correlation with scores. Conclusion: Gender, age, place of residence, and educational level could be considered determinants of the quality of health related to prosthesis adaptation in vascular amputees. Clinical relevance: Knowing the influential variables in the process of prosthetization will allow better adaptation and an improvement in the quality of life.

Psychiatric Disease after Isolated Traumatic Upper Extremity Amputation

Introduction  Psychiatric disease after traumatic limb loss impacts rehabilitation, prosthesis use, and quality of life. The purpose of this study was to evaluate the prevalence of psychiatric disease in civilians after isolated, traumatic upper extremity amputation and determine if any risk factors are associated with developing psychiatric disease.

Materials and Methods  Demographics, time since injury, mechanism of injury, amputation level, hand affected (dominant vs. nondominant), Bureau of Workers’ Compensation (BWC) status, and prosthesis use were retrospectively reviewed for all patients treated from 2012 to 2017. For patients with an International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10) diagnosed psychiatric disease, the diagnosis and length of treatment were recorded. Patients were grouped by presence or absence of psychiatric diagnosis and data analysis was performed using descriptive statistics, Fisher’s exact test, and relative risk.

Results  Forty-six patients met the inclusion criteria. Thirty-one patients (67.4%) had at least one diagnosed psychiatric condition. Major depressive disorder was the most common ( n = 14), followed by posttraumatic stress disorder ( n = 11), adjustment disorder ( n = 11), anxiety ( n = 6), and panic disorder ( n = 2). No statistically significant correlation was seen between psychiatric illness and gender, age at the time of injury, time since injury, current employment status, BWC status, hand injured (dominant vs. nondominant), prosthetic use, or level of amputation.

Conclusion  The rates of depression and anxiety after traumatic upper limb loss in the civilian population are similar to reported rates after combat injury. While we were unable to identify a statistically significant association with any of the studied variables, upper extremity surgeons should be aware of the high prevalence of psychiatric disease after traumatic upper extremity amputation.

Psychological effects of traumatic upper-limb amputations

INTRODUCTION

The main aim of the present study was to determine the existence of pathological grief in victims of traumatic upper-limb amputation. The secondary objective was to determine risk factors for onset of pathological grief.

METHOD

A retrospective clinical study was conducted for an 11-year period, including all cases of traumatic upper-limb amputation in adults. Patients were assessed on a questionnaire including an adaptation of the Inventory of Complicated Grief (ICG). Risk factors were assessed on surgical, personal occupational and subjective criteria. Statistical analysis on StatView software used matched Chi² tests for comparisons, with the significance threshold set at p<0.001.

RESULTS

With 1058 questionnaires sent out, the response rate was 52%; 3% of returned questionnaires were non-interpretable. Thirty-nine percent showed a state of pathological grief. Risk factors comprised lack of attempted replantation (p<0.001), isolated thumb amputation (p<0.001), and multi-digit or macro-amputation (p<0.001). Subjective esthetic blemish or the feeling of being mutilated was significantly associated with pathological grief (both p<0.001).

DISCUSSION

Traumatic upper-limb amputation victims incurred a risk of pathological grief (main endpoint), with identifiable risk factors (secondary endpoint). Victim accompaniment and screening for risk of pathological grief are essential to limit the psychological impact of trauma and promote social and occupational reintegration.

Health concerns of veterans with high-level lower extremity amputations

BACKGROUND

The aim of the study was to identify health concerns of veterans with high-level lower extremity amputations.

METHODS

Through a cross-sectional study, general practitioners, an orthopedic specialist, psychologists, psychiatrists, physiotherapist and prosthetists examined 100 veterans using a short-form health-related quality of life questionnaire (SF-36) that assessed their ability to perform activities of daily living (ADL), instrumental activities of daily living (IADL) and life satisfaction (SWLS) after hip disarticulation or hemi-pelvectomy amputations. The assessment tool was designed to gather statistically useful information about their health needs.

RESULTS

The means of the Physical Component Summary (PCS), Mental Component Summary (MCS), SWLS, ADL and IADL were 48.58 ± 29.6, 33.33 ± 22.0, 19.30 ± 7.7, 48.10 ± 10.5 and 5.08 ± 1.8, respectively. Somatization, depression, and anxiety were the most prevalent disorders; among the veterans who were visited by psychiatrists, 11.6% had a history of hospitalization in a psychiatry section, and 53.2% had a psychiatric visit. Regardless of their injury in battle, 34% of veterans were hospitalized. Hearing problems were common, and about four-fifths of the participants suffered from at least one orthopedic condition. Neuroma (49%) was the most common stump-related complication during orthopedic evaluations, though the prevalence of phantom pain was 81% during the pain assessment. A total of 87% of the participants had a history of wearing a prosthesis, but only 29% wore a prosthesis at the time of the present study. The Canadian-type of prosthesis was uncomfortable and not useful (27%) and excessively heavy (10%) according to the amputees.

CONCLUSIONS

Understanding veterans' characteristics and special needs are important to make sure that enough facilities and services are afforded to them. These findings emphasize the importance of paying close attention to different dimensions of health in veterans and can help health providers identify health needs and make regular assessments.

Chopart amputation with tibiotalocalcaneal arthrodesis and free flap reconstruction for severe foot crush injury

Aims

This study reports the outcomes of a technique of soft-tissue coverage and Chopart amputation for severe crush injuries of the forefoot.

Patients and Methods

Between January 2012 to December 2016, 12 patients (nine male; three female, mean age 38.58 years; 26 to 55) with severe foot crush injury underwent treatment in our institute. All patients were followed-up for at least one year. Their medical records, imaging, visual analogue scale score, walking ability, complications, and functional outcomes one year postoperatively based on the American Orthopedic Foot and Ankle Society (AOFAS) and 36-Item Short-Form Health Survey (SF-36) scores were reviewed.

Results

The mean length of follow-up was 18.6 months (13 to 28). Two patients had a local infection, flap necrosis was seen in one patient, and one patient experienced a skin graft wound healing delay. Of the 12 patients, one had persistent infection and eventually required below-knee amputation, but pain-free walking was achieved in all the other patients. The mean one-year postoperative AOFAS and SF-36 scores were 75.6 (68 to 80) and 82 (74 to 88), respectively.

Conclusion

Although our sample size was small, we believe that this treatment method may be a valuable alternative for treating severe foot crush injuries. Cite this article: Bone Joint J 2018;100-B:1359–63.

Evaluation of treatment of psychiatric morbidity among limb amputees

BACKGROUND

The sudden jolt of becoming an amputee brings with it the realization of loss of independence and self-built psychological and physical security. Advances in the field of prosthesis give the individual hope for better future, but the presence of psychological morbidity is a hurdle to be crossed in the road to satisfactory rehabilitation.

AIM

This study aimed to assess the psychiatric morbidity in amputees and the response to treatment.

MATERIALS AND METHODS

One hundred newly amputated soldiers were assessed by means of clinical interview, General Health Questionnaire, Impact of Event Scale, Hospital Anxiety Depression Scale, McGill Pain Questionnaire, and Dallas Pain Questionnaire. Individuals were treated with appropriate medications and psychotherapy, and response to treatment was assessed.

RESULTS

Psychiatric disorders were diagnosed in 66% including adjustment disorders (40%), depressive episode (20%), and posttraumatic stress disorder (6%). Phantom sensation and phantom pain were noted in 72% and 64% of participants, respectively. More psychiatric disorders and phantom sensation were found in the early months after amputation. Psychiatric morbidity was associated with negative body image, distressing pain, and restriction of activities of daily life. Treatment produced complete remission of symptoms in 65.15% of individuals suffering from psychiatric disorders and statistically significant reduction in the scores of psychiatric rating scales.

CONCLUSIONS

There is a high prevalence of psychiatric morbidity among amputees. Psychiatric treatment produces significant improvement in the psychological well-being of amputees and underlines the need to focus on the psychological rehabilitations of the amputee apart from physical rehabilitation.