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.

Epidemiology of Limb Amputations and Prosthetic Use During COVID-19 Pandemic in the Netherlands

OBJECTIVE

To evaluate the trends in the incidence of major limb amputations and the prevalence of Dutch prosthetic users at the national level in The Netherlands between 2012 and 2021 (during the COVID-19 pandemic). Local hospitals in The Netherlands reported a doubling of major lower limb amputations during COVID-19, information about a change in the incidence of major upper limb amputations was not reported. We could not confirm this remarkable increase in major lower limb amputations in our institution, nor did we observe a change in the incidence of major upper limb amputations. We hypothesize that the COVID-19 pandemic had no effect on the number of major limb amputations.

DESIGN

Observational retrospective study analyzing national open-access databases of health insurance claims.

SETTING

The Dutch national opensource database www.opendisdata.nl was used to retrieve the incidence of limb amputations in the period 2012-2021, stratified by the level of amputation and the cause of amputation. The results were verified using the www.gipdatabank.nl databank. This period included 4 intervals of nationwide COVID-19 lockdowns.

PARTICIPANTS

60,848 patients who underwent limb amputations at the upper or lower extremity in the Netherlands from 2012 to 2021 (N=60,848) were included in this study.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Upper- and lower-limb amputation and prosthetic use.

RESULTS

Data were retrieved for a total of 60,848 patients in the Netherlands, who underwent 68,180 amputations of the upper and lower extremities at any level from 2012 to 2021, including 22,095 major amputations of the lower extremities. The ongoing trend of stable numbers of major lower-limb amputations from 2012 to 2019 continued in 2020 and 2021. The verification of these data at the level of prosthetic users confirmed that the annual trends were unchanged.

CONCLUSION

The reported increased numbers of major lower-limb amputations during the COVID-19 pandemic in the Netherlands could not be confirmed using nationwide epidemiologic data.

Managing acute phantom limb pain with transcutaneous electrical nerve stimulation: a case report

INTRODUCTION

Phantom limb pain is characterized by painful sensations in the amputated limb. The clinical presentation of acute phantom limb pain may differ from that of patients with chronic phantom limb pain. The variation observed implies that acute phantom limb pain may be driven by peripheral mechanisms, indicating that therapies focused on the peripheral nervous system might be successful in reducing pain.

CASE PRESENTATION

A 36-year-old African male with acute phantom limb pain in the left lower limb, was treated with transcutaneous electrical nerve stimulation.

CONCLUSION

The assessment results of the presented case and the evidence on acute phantom limb pain mechanisms contribute to the current body of literature, indicating that acute phantom limb pain presents differently to chronic phantom limb pain. These findings emphasize the importance of testing treatments that target the peripheral mechanisms responsible for phantom limb pain in relevant individuals with acquired amputations.

Mesenchymal stem cells for critical limb ischemia: their function, mechanism, and therapeutic potential

Peripheral arterial disease is atherosclerotic occlusive disease of the lower extremity arteries and afflicts hundreds of millions of individuals worldwide. Its most severe manifestation is chronic limb-threatening ischemia (Petersen et al. (Science 300(5622):1140–2, 2003)), which is associated with severe pain at rest in the limbs, which progresses to necrosis, limb amputation, and/or death of the patient. Consequently, the care of these patients is considered a financial burden for both patients and health systems. Multidisciplinary endeavors are required to address this refractory disease and to find definitive solutions that lead to improved living conditions. Revascularization is the cornerstone of therapy for preventing limb amputation, and both open vascular surgery and endovascular therapy play a key role in the treatment of patients with CLI. Around one-third of these patients are not candidates for conventional surgical treatment, however, leading to higher amputation rates (approaching 20–25% at one year) with high morbidity and lower quality of life. Advances in regenerative medicine have enabled the development of cell-based therapies that promote the formation of new blood vessels. Particularly, mesenchymal stem cells (MSCs) have emerged as an attractive therapeutic agent in various diseases, including CLI, due to their role in tissue regeneration and immunomodulation. This review discusses the characteristics of MSCs, as well as their regenerative properties and their action mechanisms on CLI.

Upper and lower limb amputations in vehicle-related fatalities

Traumatic limb amputation is rare in occupants following a motor vehicle collision (MVC). A retrospective analysis of autopsy reports at Forensic Science South Australia (FSSA) over a 19 year period from January 2000 to December 2018 was performed to determine the incidence of limb amputation in lethal collisions and to identify predisposing factors. Only 18 cases (1.54%) of occupant fatalities had a traumatic limb amputation with an age range of 18-78 years (mean 44.2 years), male to female ratio 13:5, and an average body mass index (BMI) of 28.5 (overweight). There were nine cases of upper limb amputation and nine cases of lower limb amputation (one case had both upper and lower limb amputations). Head on impacts without subsequent rollover were the most common collision type in both upper and lower amputation. The likely cause of limb amputation in vehicle crashes is, therefore, speed on impact rather than rollovers as has been previously suggested.

Long term outcomes after incident diabetic foot ulcer: Multicenter large cohort prospective study (EDI-FOCUS investigators) epidemiology of diabetic foot complications study: Epidemiology of diabetic foot complications study

AIMS

This long-term prospective study evaluated limb amputation and mortality after the first neuropathic diabetic foot ulcer (DFU).

METHODS

A total of 2880 patients with neuropathic DFU (DFU group) and a similar number of patients of diabetes without DFU (nDFU) matched for age and diabetes duration were prospectively assessed at five referral-centers over 14 years. Pre-defined outcome was death during follow-up. Various diabetic co-morbidities and amputation were assessed as mortality predictors.

RESULTS

Overall, 501 (17.4%) patients in DFU group died compared to 89 (3.1%) (p < 0.01) in nDFU group during a median follow-up of 7(1-14) years. The 5- and 10-year mortality was 22% and 71% in the DFU group with a median survival of 7.72 (7.37-8.08) years compared to 3% (p < 0.01) and 5% (p < 0.01) and survival of 12.6 (10.5-12.7) years (p < 0.001) in nDFU group. 29.3% patients had limb amputations. The mortality risk was independent of glycemic control [OR 1.03 (0.80-1.32; p = 0.83)]. However, diabetes duration > 10 years [OR 1.31(1.02-1.70, p = 0.035)], nephropathy [OR 1.47 (1.04-2.09, p < 0.030)], minor 1.85 (1.40-2.44; p < 0.001) or major amputation 2.96 (2.01-4.34, p < 0.001)] predicted mortality.

CONCLUSIONS

Every one-in-three individual with neuropathic DFU has amputation and every sixth individual has an early demise. Prevalent nephropathy and incident amputation following DFU predicts mortality.

Presence of pyrroloquinazoline alkaloid in Adhatoda vasica attenuates inflammatory response through the downregulation of pro-inflammatory mediators in LPS stimulated RAW 264.7 macrophages

Introduction: Inflammation is the primary response caused due to harmful stimuli which are followed by the increased draining of plasma and immune cells from the body into the site of the injured tissue. A signaling cascade of growth factors and cytokines propagates and eventually matures in the inflammatory site involving the blood vessels and immune markers within the injured tissue in order to promote the renewal of the degenerated tissue. During a chronic disorder like diabetic foot ulcer, there is an obstinate inflammation which may act as a prime factor for limb amputation and upon persistent prevalence may even lead to death.

Methods: This study focuses on the mode of action of ALK-F (alkaloid fraction) isolated from Adhatoda vasica in attenuating the nitric oxide production which was estimated by Griess assay, tumor necrosis factor-α (TNF-α), and interleukin-6 (IL-6) expression was analyzed by ELISA and expression of COX-2 and iNOS by RT-PCR and western blotting in LPS stimulated RAW 264.7 macrophages. Total intracellular ROS was analyzed by DCFH-DA probing and the presence of quinazoline alkaloid (vasicine) in the ALK-F was evidenced by high performance liquid chromatography (HPLC).

Results: The ALK-F of A. vasica exhibited a significant inhibitory effect on LPS elicited nitrite production (13.2 ± 1.06 µM), iNOS, and COX-2 (2.6 and 3.3 fold) in a dose-dependent manner. There was a significant decrease in the generation of these pro-inflammatory cytokines TNF-α (1102 ± 1.02 pg/mL) and IL-6 (18 ± 0.87 ng/mL) and total intracellular ROS in the highest tested concentrations (1 µg and 10 µg) of ALK-F of A. vasica. HPLC analysis by the gradient elution method revealed the presence of 12% of quinazoline alkaloid vasicine in the crude alkaloid fraction.

Conclusion: Thus this study communally suggests that attenuation of nitric oxide and the dysregulation of genes responsible for inflammation which deliberates A. vasica to conflict against inflammation and provide remedial benefits in diabetic wound care.

Prehospital amputation: An experimental comparison of techniques

OBJECTIVE

Prehospital limb amputation is a rare but potentially life-saving intervention. When patients cannot be extricated due to limb entrapment or have hemodynamic compromise that precludes a prolonged extrication, they may benefit from an emergent prehospital amputation. The objective was to experimentally compare three prehospital amputation techniques on porcine legs.

METHODS

The three techniques studied were a scalpel with a Gigli saw, a hacksaw, and a reciprocating saw. For the first technique, a scalpel was used to make a circumferential incision in the soft tissue and a Gigli wire saw to cut through the bone. The second and third techniques only used a saw and did not require soft tissue incision with a scalpel. Three providers including an emergency medicine physician, a paramedic, and a medical student performed three amputations of each technique, resulting in twenty-seven total amputations. The primary outcome was amputation time. Secondary outcomes were rate of instrument malfunction and cleanliness of cut.

RESULTS

The primary outcome of amputation time was different between techniques. The Gigli saw technique took 32.86 ± 16.53 s (mean ± SD), hacksaw technique 6.28 ± 0.76 s, and reciprocating saw technique 2.84 ± 0.40 s. There were no differences in amputation time between participants for a given amputation technique. The Gigli saw technique had an instrument malfunction on 3/9 trials which was distinct from the other techniques. Differences in cleanliness of cut were nonsignificant.

CONCLUSIONS

Prehospital limb amputation with a hacksaw or reciprocating saw may result in faster completion of the time-sensitive procedure with fewer instrument malfunctions.

A Pre-clinical Study of the Response Threshold of Intact and Transected Nerves to Stimulation by Transcutaneous Intense Focused Ultrasound

We used diagnostic ultrasound imaging to guide individual bursts (0.1 s) of 2 MHz intense focused ultrasound (iFU) to determine the sensitivity of intact and transected nerves. We found that all nerves had greater sensitivity to iFU stimulation than surrounding muscle. Intact nerves from healthy volunteers had less sensitivity to iFU stimulation (272 ± 35 W/cm² [median ± standard error]) than transected nerves (19 ± 37 W/cm²). Intact, contralateral nerves of amputees dichotomized naturally into two groups-one very sensitive to iFU stimulation (6 ± 2 W/cm²) and one relatively insensitive (539 ± 19 W/cm²), compared with the intact nerves of healthy volunteers. Our study demonstrates the ability of iFU under ultrasound image guidance to stimulate deep, intact and transected peripheral nerves. It also highlights differences in the receptivity to ultrasound stimulation of the peripheral nerves of amputees versus healthy volunteers.

Clinical spectrum and short-term outcome of adult patients with purpura fulminans: a French multicenter retrospective cohort study

PURPOSE

Data on purpura fulminans (PF) in adult patients are scarce and mainly limited to meningococcal infections. Our aim has been to report the clinical features and outcomes of adult patients admitted in the intensive care unit (ICU) for an infectious PF, as well as the predictive factors for limb amputation and mortality.

METHODS

A 17-year national multicenter retrospective cohort study in 55 ICUs in France from 2000 to 2016, including adult patients admitted for an infectious PF defined by a sudden and extensive purpura, together with the need for vasopressor support. Primary outcome variables included hospital mortality and amputation during the follow-up period (time between ICU admission and amputation, death or end of follow-up).

RESULTS

Among the 306 included patients, 126 (41.2%; 95% CI 35.6-46.9) died and 180 (58.8%; 95% CI 53.3-64.3) survived during the follow-up period [13 (3-24) days], including 51/180 patients (28.3%, 95% CI 21.9-35.5) who eventually required limb amputations, with a median number of 3 (1-4) limbs amputated. The two predominantly identified microorganisms were Neisseria meningitidis (63.7%) and Streptococcus pneumoniae (21.9%). By multivariable Cox model, SAPS II [hazard-ratio (HR) = 1.03 (1.02-1.04); p < 0.001], lower leucocytes [HR 0.83 (0.69-0.99); p = 0.034] and platelet counts [HR 0.77 (0.60-0.91); p = 0.007], and arterial blood lactate levels [HR 2.71 (1.68-4.38); p < 0.001] were independently associated with hospital death, while a neck stiffness [HR 0.51 (0.28-0.92); p = 0.026] was a protective factor. Infection with Streptococcus pneumoniae [sub-hazard ratio 1.89 (1.06-3.38); p = 0.032], together with arterial lactate levels and ICU admission temperature, was independently associated with amputation by a competing risks analysis.

CONCLUSION

Purpura fulminans carries a high mortality and morbidity. Pneumococcal PF leads to a higher risk of amputation.

TRIALS REGISTRATION

NCT03216577.

[The endo-exo prosthesis treatment concept : Improvement in quality of life after limb amputation]

Osseointegrated, percutaneous implants as the force bearer for exoprosthetics after limb amputation have been used in individual cases for clinical rehabilitation of amputees during the past years. Most experience in this field in Germany has been accumulated at the Sana Klinik in Lübeck with the so-called endo-exo prosthesis (EEP) system. The two-step implantation procedure can now be considered as reliable. Following a well-documented learning curve initial soft tissue problems concerning the cutaneous stoma can now be regarded as exceptions. The retrospective examination of the results concerning by now more than 100 patients provided with an endo-exo femoral prosthesis (EEFP) showed a very satisfying outcome concerning objective as well as subjective values, such as duration of daily use and wearing comfort of the exoprosthesis. Regaining the ability of osseoperception due to the intraosseous fixation is described by the patients as a great advantage. The step from a socket prosthesis to an EEP is felt to be a big increase in quality of life by nearly all patients included into the follow-up. Nearly all of the patients questioned would choose an endo-exo prosthesis again. Meanwhile, the success of the EEP resulted in the broadening of indications from above-knee amputations to transtibial as well as transhumeral amputations. The results are likewise encouraging. The use of EEP for the upper limbs leads to substantial improvement in the range of motion of the shoulder joint with the intramedullary anchored percutaneous implant. Furthermore, new pathbreaking possibilities in the fixation of myoelectrically controlled arm prostheses may arise from the EEP technique.

Three cases of feet and hand amputation from Medieval Estremoz, Portugal

Peri-mortem limb amputations are rarely reported in the paleopathological literature. The cases reported here concern severing of both hands and feet observed in three adult male skeletons, exhumed from the medieval Portuguese necropolis of Rossio do Marquês de Pombal, Estremoz, Portugal. The fact that they were found in the same site, in graves placed side by side, that all are young males, and that the three skeletons show similar perimortem injuries, make this a unique case meriting detailed analysis. Considering the lesions' location and pattern, as well as historical data, we hypothesize that this is a case of amputation as a consequence of judicial punishment. Estremoz was an important city in sustaining the Royal power at a regional scale during the medieval period.

Necrotising soft-tissue infections of the upper limb: risk factors for amputation and death

Necrotising soft-tissue infections (NSTIs) of the upper limb are uncommon, but potentially life-threatening. We used a national database to investigate the risk factors for amputation of the limb and death. We extracted data from the Japanese Diagnosis Procedure Combination database on 116 patients (79 men and 37 women) who had a NSTI of the upper extremity between 2007 and 2010. The overall in-hospital mortality was 15.5%. Univariate analysis of in-hospital mortality showed that the significant variables were age (p = 0.015), liver dysfunction (p = 0.005), renal dysfunction (P < 0.001), altered consciousness (p = 0.049), and sepsis (p = 0.021). Logistic regression analysis showed that the factors associated with death in hospital were age over 70 years (Odds Ratio (OR) 6.6; 95% confidence interval (CI) 1.5 to 28.2; p = 0.011) and renal dysfunction (OR 15.4; 95% CI 3.8 to 62.8; p < 0.001). Univariate analysis of limb amputation showed that the significant variables were diabetes (p = 0.017) mellitus and sepsis (p = 0.001). Multivariable logistic regression analysis showed that the factors related to limb amputation were sepsis (OR 1.8; 95% CI 1.5 to 24.0; p = 0.013) and diabetes mellitus (OR 1.6; 95% CI 1.1 to 21.1; p = 0.038). For NSTIs of the upper extremity, advanced age and renal dysfunction are both associated with a higher rate of in-hospital mortality. Sepsis and diabetes mellitus are both associated with a higher rate of amputation.

Comparison of carboplatin and doxorubicin-based chemotherapy protocols in 470 dogs after amputation for treatment of appendicular osteosarcoma

Background

Many chemotherapy protocols have been reported for treatment of canine appendicular osteosarcoma (OSA), but outcome comparisons in a single population are lacking.

Objective

To evaluate the effects of protocol and dose intensity (DI) on treatment outcomes for carboplatin and doxorubicin‐based chemotherapy protocols.

Animals

Four hundred and seventy dogs with appendicular OSA.

Methods

A retrospective cohort study was performed comprising consecutive dogs treated (1997–2012) with amputation followed by 1 of 5 chemotherapy protocols: carboplatin 300 mg/m²IV q21d for 4 or 6 cycles (CARBO6), doxorubicin 30 mg/m²IV q14d or q21d for 5 cycles, and alternating carboplatin 300 mg/m²IV and doxorubicin 30 mg/m²IV q21d for 3 cycles. Adverse events (AE) and DI were evaluated. Kaplan–Meier survival curves and Cox proportional hazards regression were used to compare disease‐free interval (DFI) and survival time (ST) among protocols.

Results

The overall median DFI and ST were 291 days and 284 days, respectively. A lower proportion of dogs prescribed CARBO6 experienced AEs compared to other protocols (48.4% versus 60.8–75.8%; P = .001). DI was not associated with development of metastases or death. After adjustment for baseline characteristics and prognostic factors, none of the protocols provided a significant reduction in risk of development of metastases or death.

Conclusions and Clinical Importance

Although choice of protocol did not result in significant differences in DFI or ST, the CARBO6 protocol resulted in a lower proportion of dogs experiencing AEs, which could be advantageous in maintaining high quality of life during treatment. DI was not a prognostic indicator in this study.

Limb amputation and prosthesis

Limb amputation is an alternative to euthanasia when catastrophic injury prevents successful restoration of the limb or when cost is an issue. Proximal limb disarticulation for amputation is preferred if a prosthesis is not considered. Distal amputations are needed to accommodate exoskeletal prosthesis. This article reviews the considerations and describes techniques for this surgery.

The association between depressive mood and pain amongst individuals with limb amputations

INTRODUCTION

The purpose of this study was to evaluate the relationship between pain and depressive mood amongst persons with limb amputations, and to examine the relationship between the etiology (work-related trauma or other types) and depressive mood.

METHODS

Mailed questionnaires were used to collect personal information from 69 limb amputees living in the community. The severity of limb amputation-related pain was rated using the Chronic Pain Grade scale. Eighteen (26.1%) of the participants referred their pain as Grade 0 (no pain) and 25 (36.2%) referred as Grade I (mild pain). Depressive mood was classified using the Zung Self-Rating Depression Scale.

RESULTS

Eighteen (26.1%) of the participants were classified as having mild depression, 16 (23.2%) as having moderate depression, and 7 (10.1%) as having severe depressive mood. A significant proportion of participants with moderate or severe depression were amputees with work-related etiology for their loss of limbs. In addition, amputees with more severe depressive mood tended to experience a higher level of amputation-related pain than amputees with less severe depressive mood.

CONCLUSIONS

The results of this study revealed the validity of optional approaches such as prescription of antidepressants or psychological counseling to improve mental health of individuals with limb amputations.