Above-knee Amputation Research Articles

The Effect of Socioeconomic Status On Amputation Outcomes And Limb Salvage Interventions

INTRODUCTION AND OBJECTIVES Disadvantaged patients have historically undergone higher level amputations without prior limb salvage interventions when compared with other populations. We sought to determine if racial and socioeconomic status is associated with decreased access to vascular care, less attempts of primary revascularization and higher level amputations. METHODS The Vascular Quality Initiative was queried from 2012-2020 for patients with below-knee and above-knee amputations (AKA). Outcomes based on race and distressed community index (DCI) as a marker of socioeconomic status were investigated. Baseline characteristics, prior revascularization on the ipsilateral limb and amputation outcomes were compared between races and the five DCI groups (prosperous, comfortable, mid-tier, at-risk, distressed) using Pearson chi and student t-test. RESULTS The cohort consisted of 14,816 cases of amputations. As seen in table I, when comparing DCI groups, the AKA rate was highest in the distressed group while prior revascularization was lowest (p<0.001). Thirty-day and one-year mortality were equal among the groups as well as the postoperative complication rate. Ambulation at long term follow up progressively decreased through the groups from 60.5% in the prosperous group to 49.6% in the distressed group (p<0.001). When comparing races (table II) the black group had a higher rate of AKA and a lower rate of primary revascularization when compared to the white group. The black group also had the lowest rate of ambulation at follow up. CONCLUSIONS Lower socioeconomic status and minority race is associated with a higher rate of AKA, a lower rate of primary revascularization and a low chance at future ambulation nationwide. Disadvantaged patients have historically undergone higher level amputations without prior limb salvage interventions when compared with other populations. We sought to determine if racial and socioeconomic status is associated with decreased access to vascular care, less attempts of primary revascularization and higher level amputations. The Vascular Quality Initiative was queried from 2012-2020 for patients with below-knee and above-knee amputations (AKA). Outcomes based on race and distressed community index (DCI) as a marker of socioeconomic status were investigated. Baseline characteristics, prior revascularization on the ipsilateral limb and amputation outcomes were compared between races and the five DCI groups (prosperous, comfortable, mid-tier, at-risk, distressed) using Pearson chi and student t-test. The cohort consisted of 14,816 cases of amputations. As seen in table I, when comparing DCI groups, the AKA rate was highest in the distressed group while prior revascularization was lowest (p<0.001). Thirty-day and one-year mortality were equal among the groups as well as the postoperative complication rate. Ambulation at long term follow up progressively decreased through the groups from 60.5% in the prosperous group to 49.6% in the distressed group (p<0.001). When comparing races (table II) the black group had a higher rate of AKA and a lower rate of primary revascularization when compared to the white group. The black group also had the lowest rate of ambulation at follow up. Lower socioeconomic status and minority race is associated with a higher rate of AKA, a lower rate of primary revascularization and a low chance at future ambulation nationwide.

Synovial mast cells from knee and hip osteoarthritis: histological study and clinical correlations

PurposeThe aim of this study was to investigate the presence of synovial mast cells (MCs) in hip and knee tissue from osteoarthritis (OA) patients and to correlate them with clinical and radiological data.MethodsSynovial tissue was obtained during arthroplasty from 60 patients, 30 with knee OA and 30 with hip OA. Control synovial tissue was obtained from 30 patients without OA, 15 undergoing above-knee amputation and 15 receiving a hip replacement for fracture. Before surgery, the radiographic findings were graded according to the Kellgren-Lawrence system and clinical data including pain (VAS) and functional information (KOOS and HOOS) was collected. The tissue was stained with hematoxylin–eosin and toluidine blue for histochemistry and incubated with CD117 and CD31 antibodies for immunohistochemistry. MC and vessel number and synovitis score were determined in all samples.ResultsMean MC number, synovitis score and vessel number were significantly higher in the OA samples (p < 0.05) than in control tissue. MC number correlated with the synovitis score and disease severity in both patient groups.ConclusionsThe prevalence of MCs in synovium from OA patients and their association with synovial inflammation and pain suggest a role for them in OA pathophysiology.

Effect Of Use Of Flexible Transfemoral Prosthesis On Level Of Independence In Performing Daily Activities Of Transfemoral Amputee

Background: Transfemoral amputees experience many difficulties in carrying out daily activities. One of the devices that can be used in above-knee amputation patients is transfemoral prosthesis. The use of transfemoral prostheses in post-amputation patients can help with activities, one of which is independence in self-care, mobility, and locomotion.&#x0D; Methods: The study was conducted at PT Kuspito Orthotic Prosthetics and the time of the study was carried out in 2021. The population of this study was users of flexible prostheses at PT Kuspito Ortotik Prosthetic. The samples of this study were flexible prostheses users at PT. Kuspito prosthetic orthotic that meets the criteria as many as 30 users. The sampling technique was purposive sampling, inclusion criteria: subjects aged 17-35 years, subjects in good health, subjects using a flexible unilateral prosthesis, at least using an artificial leg for 1 month, having a strength value of 4, having normal Range Of Motion. Exclusion criteria: the subject had advanced disease, bilateral prosthesis user. The measuring instrument used was the Functional Independence Measure (FIM) questionnaire that is valid and reliable. &#x0D; Results: The value of Sig. is 0.000, there is a significant difference in the level of independence between the results of the pre-test and post-test. there is a significant difference in the results that using a flexible prosthesis can increase the level of independence in above-knee amputees in carrying out daily activities. &#x0D; Conclusion: The functional independence of above-knee amputation patients is strongly influenced by the use of a flexible prosthesis. It is recommended that above-knee amputation patients can use a flexible prosthesis to increase the level of independence.

Prediction of wound complications after major amputation for patients with critical limb ischemia

Background/aim Management of patients with critical limb ischemia from peripheral vascular disease is still a big issue for vascular and endovascular surgeons. For patients who are not candidates for revascularization, 20–40% will undergo major amputation within 6–12 months. Mortality following major amputation of the lower extremity in these patients has been high. This study aims at identifying important factors that lead to wound complications following major amputation in patients with end-stage critical ischemia. Patients and methods This study enrolled 120 in patients who underwent major lower extremity amputations affected by critical limb ischemia, since January 2017 and till March 2020, in the Vascular Surgery Departments at Al-Azhar University Hospitals, Cairo, Egypt. A total of 67 patients underwent transfemoral above-knee amputations (AKA) and 53 underwent transtibial below-knee amputations (BKA). The follow-up was done at first week and first, third, and sixth months postoperatively, and 1-year mortality was assessed as well. The various risk factors were analyzed in this study, including age, coronary artery disease, chronic heart failure, cerebrovascular disease, hypertension, diabetes mellitus, hemodialysis, white blood cell (WBC) count, C-reactive protein-quantitative (CRP), lactate dehydrogenase, and serum albumin level. Results The present study exhibited that most cases were men (75%) and former smokers (64.2%). A total of 91 patients (75.8%) had a history of hypertension. Univariate analysis exhibited that there were defiantly more wound occurrences (P&lt;0.05) for those patients who underwent BKA in the greater than or equal to 55-year-old age group, smokers, patients with high WBCs, patients with low serum albumin level and with positive CRP, and dialysis-dependent patients. However, the patients who underwent an AKA, the multivariate analysis determined positive CRP and dialysis dependent as significant predictors (P&lt;0.05) of a wound occurrence. Conclusion Predictors that significantly increased the risks of delayed recovery for those who underwent BKAs are greater than or equal to 55-year-old group, smokers, patients with elevated WBCs, and patients on dialysis proved to be predictive, and for AKA the predictive factors were low serum albumin level, patients with high WBCs, and patients with dialysis dependence.

Analyzing Risk Factors for Sequential Above Knee Amputation after Below Knee Amputation in Surgical Treatment of Ischemic and/or Infectious Foot Disease

Category:DiabetesIntroduction/Purpose:Some patients with below knee (BK) amputation for treatment of ischemic and/or infectious foot disease eventually further progress to above knee (AK) amputation. We aimed to analyze predictors for sequential AK amputation after BK amputation.Methods:We retrospectively reviewed medical records and find 55 patients with BK amputation for surgical treatment of ischemic and/or infectious foot from 2013 to 2018. Twelve patients with sequential AK amputation after BK amputation were designated as group I, and 43 patients successfully treated with BK amputation only were designated as group II. Two groups were compared for various demographic, laboratory and physical state. Then, multivariate logistic regression analysis was done to find predictors for sequential AK amputation after BK amputation.Results:In univariate analysis between two groups, only 'knee contracture' showed significant difference between two groups (p= 0.003). In multivariate logistic regression analysis performed with variables showing p <0.1 during univariate comparison, knee contracture was found to be predictor for sequential AK amputation after BK amputation (odds ratio= 34.740, p= 0.041).Conclusion:Patients with intractable ischemic and/or infectious foot disease with knee contracture, optimal level of amputation may be above knee level. Careful decision on amputation level can reduce surgical burden for intractable ischemic and/or infectious foot patients.

Osteosynthesis of acute femoral neck fracture in a young adult with ipsilateral transfemoral amputation

Management of fracture neck of the femur in young adults with above-knee amputation is a challenging scenario for even the most experienced orthopedic surgeon owing to the short lever arm possessed by the residual limb to perform a closed reduction. We report a unique case of fracture neck of the right femur successfully managed by closed reduction and percutaneous screw fixation in a 43-year-old male who had undergone an ipsilateral transfemoral amputation 15 years back.

Machine learning analysis of multispectral imaging and clinical risk factors to predict amputation wound healing.

Prediction of amputation wound healing is challenging due to the multifactorial nature of critical limb ischemia and lack of objective assessment tools. Up to one-third of amputations require revision to a more proximal level within 1year. We tested a novel wound imaging system to predict amputation wound healing at initial evaluation. Patients planned to undergo amputation due to critical limb ischemia were prospectively enrolled. Clinicians evaluated the patients in traditional fashion, and all clinical decisions for amputation level were determined by the clinician's judgement. Multispectral images of the lower extremity were obtained preoperatively using a novel wound imaging system. Clinicians were blinded to the machine analysis. A standardized wound healing assessment was performed on postoperative day 30 by physical exam to determine whether the amputation site achieved complete healing. If operative revision or higher level of amputation was required, this was undertaken based solely upon the provider's clinical judgement. A machine learning algorithm combining the multispectral imaging data with patient clinical risk factors was trained and tested using cross-validation to measure the wound imaging system's accuracy of predicting amputation wound healing. A total of 22 patients undergoing 25 amputations (10 toe, five transmetatarsal, eight below-knee, and two above-knee amputations) were enrolled. Eleven amputations (44%) were non-healing after 30days. The machine learning algorithm had 91% sensitivity and 86% specificity for prediction of non-healing amputation sites (area under curve, 0.89). This pilot study suggests that a machine learning algorithm combining multispectral wound imaging with patient clinical risk factors may improve prediction of amputation wound healing and therefore decrease the need for reoperation and incidence of delayed healing. We propose that this, in turn, may offer significant cost savings to the patient and health system in addition to decreasing length of stay for patients.

Biarticular energy-recovering transfemoral prosthesis for trip prevention and sit-to-stand assistance

The invention is a prosthetic leg for above-knee amputees that helps prevent tripping and provides support for strenuous movments. The design harvests energy from walking to further lift the foot and decrease the risk of tripping. The invention also harvests energy during the sitting motion and uses it to power the leg when the user stands up.The prosthesis is unpowered and lightweight, with polycentric joints and a single pneumatic actuator. The actuator harvests, stores, and releases energy in both tension and in compression and is biarticular, allowing it to power both the knee and the ankle. The invention's unique geometry allows it to exert forces at the joints that can mimic the muscle forces produced in a healthy leg during specific movments. The technology is currently designed to mimic leg forces during sitting and standing, but could also be tuned to mimic leg forces of other movements. While walking, the invention harvests energy from the leg's momentum and uses it to lift the foot higher off the ground during swing, increasing toe clearance. This decreases the chance of tripping and greatly increases walking safety, especially among the elderly and impaired who fall more frequently and can sustain serious injureies from a fall. The combination of these two functions makes the invention ideal for low-mobility prosthetic users.The invention is currently at TLR 3, and the authors are seeking commercial partners who are interested in continuing the invention's development and bringing it to market, or who would wish to implement this technology under a license.

A Holistic Physiotherapeutic Approach to Manage a Patient of Hemangiopericytoma Followed by Amputation

Hemangiopericytomas are atypical malignancies that arise from the pericytes that surround blood arteries. Mechanical injuries, severe traumatic injuries, infective illnesses, vascular diseases, peripheral neuropathy, cancers, and hereditary diseases are all major reasons for amputation. It is also used to get rid of ulcerated, ischaemic, or necrotic tissue. In amputation certain body parts tends to be removed to save individuals’ life. This was the case of a 35-year-old male who presented with the history of oedema in the posterior portion of his right knee. He was eventually diagnosed with a tumour following diagnostic tests, and the patient under went an above-knee amputation of the right-side. The outcome measures were used to evaluate patients’ recovery before and after rehabilitation. A robust therapeutic regimen was planned which included appropriate stump caring, enhanced strength and flexibility, quality enhancement, equilibrium, balance, co-ordination, and optimal locomotor training. Gait rehabilitation benefited the patient in maintaining a normal gait cycle, and weight transfer. Upper limb strength is vital for crutch walking, which allowed him to participate in every day activities and enhance overall well-being.

Early evaluation of a powered transfemoral prosthesis with force-modulated impedance control and energy regeneration

Individuals with an above-knee (AK) amputation typically use passive prostheses, whether reactive (microprocessor) or purely mechanical. Though sufficient for walking, these solutions lack the positive power generation observed in able-bodied individuals. Active (powered) prostheses can provide positive power but suffer complex control and limited energy storage capacities. These shortcomings motivate the development of an active prosthesis implementing a novel impedance controller design with energy regeneration. The controller requires only five tuning parameters that are intuitive to adjust in contrast to the current standard—finite state machine impedance scheduling of up to 45 gains. This simplification is uniquely achieved by modulating knee joint impedance by axial shank force. Furthermore, the proposed control approach introduces analytical guidance for impedance tuning to purposely integrate energy regeneration; specifically, a precise amount of negative damping is injected into the joint. A pilot study conducted with a volunteer with an AK amputation walking at three distinct speeds and at continually self-selected varying speeds demonstrated the adaptability of the controller to changes in speed. Self-powered operation was attained for all trials despite low mechanical component efficiencies. These early results suggest the efficacy of simplifying impedance control tuning and fusing control and energy regeneration in transfemoral prostheses.

Health-related quality of life in patients with lower limb amputation – an assessment of the measurement properties of EQ-5D-3L and EQ-5D-5L using data from the Swedish Amputation and Prosthetics Registry

Purpose To assess the measurement properties of EQ-5D-3L and EQ-5D-5L in patients with a major lower limb amputation (LLA). Methods This was a retrospective register-based study using data from the Swedish Amputation and Prosthetics Registry (SwedeAmp). Patients with a six-months follow-up (including either EQ-5D-3L or EQ-5D-5L) after a major unilateral LLA were included. The measurement properties of EQ-5D-3L and EQ-5D-5L were compared in terms of feasibility, response patterns, informativity, and convergent and known-group validity. Results The sample included 700 patients with below-knee amputation (76%), above-knee amputation (18%), or knee disarticulation (7%). Responses to EQ-5D-3L and −5L were similar regarding feasibility (98% completion rate) and the proportion reporting no problems (7% and 6%). Compared to EQ-5D-3L, EQ-5D-5L showed higher absolute and relative informativity in all dimensions, with the largest improvement in the mobility dimension. In the analyses of convergent validity, the EQ-5D-5L generally showed stronger correlations with disease-specific measures. Only EQ-5D-5L was able to discriminate between subgroups with different amputation levels. Conclusion The findings support the use of EQ-5D-5L over EQ-5D-3L in patients with an LLA, mainly due to improved informativity and improved convergent and known-group validity. Implications for rehabilitation The measurement properties of two EQ-5D versions, EQ-5D-3L and EQ-5D-5L, has so far not been evaluated in patients with a lower limb amputation (LLA) The results support the use of EQ-5D-5L over the use of EQ-5D-3L, mainly due to improved informativity and stronger correlations with disease-specific patient-reported outcome measures The five-level version of EQ-5D is recommended for future applications of EQ-5D in clinical outcome studies, health economic evaluations, and in the routine follow-up of patients with a major LLA In the early rehabilitation process six months after an LLA, the majority of patients reported problems with mobility, pain/discomfort, and usual activities

Through-knee versus above-knee amputation for vascular and non-vascular major lower limb amputations.

Diabetes and vascular disease are the leading causes of lower limb amputation. Currently, 463 million adults are living with diabetes, and 202 million with peripheral vascular disease, worldwide. When a lower limb amputation is considered, preservation of the knee in a below-knee amputation allows for superior functional recovery when compared with amputation at a higher level. When a below-knee amputation is not feasible, the most common alternative performed is an above-knee amputation. Another possible option, which is less commonly performed, is a through-knee amputation which may offer some potential functional benefits over an above-knee amputation. To assess the effects of through-knee amputation compared to above-knee amputation on clinical and rehabilitation outcomes and complication rates for all patients undergoing vascular and non-vascular major lower limb amputation. The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL databases; the World Health Organization International Clinical Trials Registry Platform; and the ClinicalTrials.govtrials register to 17 February 2021. We undertook reference checking, citation searching, and contact with study authors to identify additional studies. Published and unpublished randomised controlled trials (RCTs) comparing through-knee amputation and above-knee amputation were eligible for inclusion in this study. Primary outcomes were uncomplicated primary wound healing and prosthetic limb fitting. Secondary outcomes included time taken to achieve independent mobility with a prosthesis, health-related quality of life, walking speed, pain, and 30-day survival. Two review authors independently reviewed all records identified by the search. Data collection and extraction were planned in line with recommendations outlined in the Cochrane Handbook for Systematic Reviews of Interventions. We planned to assess the certainty of evidence using the GRADE approach. We did not identify RCTs that met the inclusion criteria for this review. No RCTs have been conducted to determine comparative clinical or rehabilitation outcomes of through-knee amputation and above-knee amputation, or complication rates. It is unknown whether either of these approaches offers improved outcomes for patients. RCTs are needed to guide practice and to ensure the best outcomes for this patient group.

Characterisation of Phantom Limb Pain in Traumatic Lower-Limb Amputees

Introduction There is no diagnosis for phantom limb pain (PLP), and its investigation is based on anamnesis, which is subject to several biases. Therefore, it is important to describe and standardize the diagnostic methodology for PLP. Objective To characterise PLP and, secondarily, to determine predictors for its diagnosis. Methodology. This is a cross-sectional study involving patients with unilateral traumatic lower-limb amputation aged over 18 years. Those with clinical decompensation or evidence of disease, trauma, or surgery in the central or peripheral nervous system were excluded. Sociodemographic and rehabilitative data were collected; PLP was characterised using the visual analogue scale (VAS), pain descriptors, and weekly frequency. Results A total of 55 eligible patients participated in the study; most were male, young, above-knee amputees in the preprosthetic phase of the rehabilitation. The median PLP VAS was 60 (50–79.3) mm characterised by 13 (6–20) different descriptors in the same patient, which coexist, alternate, and add up to a frequency of 3.94 (2.5–4.38) times per week. The most frequent descriptor was movement of the phantom limb (70.91%). Tingling, numbness, flushing, itchiness, spasm, tremor, and throbbing are statistically significant PLP descriptor numbers per patient predicted by above-knee amputation, prosthetic phase, higher education level, and greater PLP intensity by VAS (p < 0.05). Conclusion PLP is not a single symptom, but a set with different sensations and perceptions that need directed and guided anamnesis for proper diagnosis.

Design of a Four-Bar Latch Mechanism and a Shear-Based Rotary Viscous Damper for Single-Axis Prosthetic Knees

Abstract With over 30 million people worldwide requiring assistive devices, there is a great need for low-cost and high-performance prosthetic technologies that can enable kinematics close to able-bodied gait. Low-income users of prosthetic knees in the developing world repeatedly report the need for n inconspicuous gait to mitigate the severe socioeconomic discrimination associated with disability. However, passive prosthetic knees designed for these users have primarily focused on stability and affordability, often at the cost of the high biomechanical performance that is required to replicate able-bodied kinematics. In this study, we present the design and preliminary testing of two distinct mechanism modules that are novel for passive prosthetic knee applications: the stability module and the damping module. These mechanisms are designed to enable users of single-axis, passive prosthetic knees to walk with close to able-bodied kinematics on level-ground, specifically during the transition from the stance phase to the swing phase of the gait cycle. The stability module was implemented with a latch mounted on a virtual axis of a four-bar linkage, which can be engaged during early stance for stability and disengaged during late stance to initiate knee flexion. The damping module was implemented with a concentric stack of stationary and rotating pairs of plates that shear thin films of high-viscosity silicone oil. The goal of the resulting first-order damping torque was to achieve smooth flexion of the prosthetic knee within the able-bodied gait range (64 ± 6 deg). For preliminary user-centric validation, a prototype prosthetic knee with the stability module and two different dampers (with varying damping coefficients) was tested on a single subject with above-knee amputation in India. The stability module enabled smooth transition from stance to swing with timely initiation of knee flexion. The dampers also performed satisfactorily, as the increase in the damping coefficient was found to decrease the peak knee flexion angle during swing. The applications of the mechanisms presented in this article could significantly improve the kinematic performance of low-cost, passive prosthetic knees.

Research on Joint-Angle Prediction Based on Artificial Neural Network for Above-Knee Amputees.

In the current study, our research group proposed an asymmetric lower extremity exoskeleton to enable above-knee amputees to walk with a load. Due to the absence of shank and foot, the knee and ankle joint at the amputation side of the exoskeleton lack tracking targets, so it is difficult to realize the function of assisted walking when going up and downstairs. Currently, the use of lower-limb electromyography to predict the angles of lower limb joints has achieved remarkable results. However, the prediction effect was poor when only using electromyography from the thigh. Therefore, this paper introduces hip-angle and plantar pressure signals for improving prediction effect and puts forward a joint prediction method of knee- and ankle-joint angles by electromyography of the thigh, hip-joint angle, and plantar pressure signals. The generalized regression neural network optimized by the golden section method is used to predict the joint angles. Finally, the parameters (the maximum error, the Root-Mean-Square error (RMSE), and correlation coefficient ()) were calculated to verify the feasibility of the prediction method.

Distribution of joint work during walking on slopes among persons with transfemoral amputation

Persons with above-knee amputation have increased energy consumption and greater difficulty in negotiating uphill and downhill slopes. Walking on slopes requires an adaptation of the positive and negative work performed by the joints of the lower limb to propel the center of mass. Modern prosthetic feet and knees can only partially adapt to changes in inclination, and the redistribution of joint work among persons with above-knee amputation is not described in the literature.Level, upslope and downslope walking (at 5% and 12% inclinations) were investigated for twelve subjects with transfemoral amputation fitted with an Energy Storing And Return foot (ESAR) and a Microprocessor controlled Prosthetic Knee (MPK) versus a control group of seventeen asymptomatic subjects. Lower limb joint and individual limb power and work were compared between prosthetic, contralateral and control limbs.The prosthesis dissipates less energy than the joints of the lower limb of the control group when descending the slope, but the demand on the contralateral limb is limited by a lower speed and step length. The huge deficit of positive work produced by the prosthetic ankle cannot be compensated by the residual hip during level and slope ascent which transfers the demand for energy production to the contralateral limb up to 40% on a 12% slope.This study highlights that prosthetic devices (ESAR foot and MPK) for persons with above-knee amputation present some limitations during slope walking that cannot be compensated by the residual hip and increase the work performed by the contralateral limb.

Stump-plasty: An Operation Born of Necessity in Gaza

Aim and objectiveThe most recent wave of lower limb amputees in Gaza arises from ballistic injuries sustained during protests. This study evaluates the requirement for surgical revision of these mature stumps to allow prosthetic fit and mobility.Materials and methodsA multidisciplinary team (MDT) comprising a prosthetist, orthopaedic and plastic surgeons and a physiotherapist screened 104 amputee stumps (103 cases). The 27 cases selected for surgical revision (stump-plasty) are the subject of this study.The MDT prescriptions of care issued at screening were compared to surgical procedures performed at stump-plasty and the findings. Compliance with the MDT prescription was recorded. Stump issues are identified to propose modifications of primary amputation technique to mitigate future revisions.Patients’ healthcare status was assessed by questionnaire (EQ-5D-L5) at screening, then subsequently post-stump-plasty.ResultsMore below-knee amputees (BKAs) than above-knee amputees (AKAs) required stump-plasty. Revisions varied according to the quality of tissue present at the amputation level. AKA revisions addressed bulk and contour issues whereas BKA revisions related to bone prominence, neuroma formation and lack of soft tissue cover. Despite many variations in tissue-targeted procedures being possible, the MDT prescription was followed accurately at surgery.Suggested modifications at primary amputation to decrease revisions include improved bone tip bevelling at BKA and greater soft tissue reduction at AKA. Severed nerve management needs to be rationalised to reduce primary neuroma formation and neuroma revision at stump-plasty requires consideration to attempt to reduce the recurrent risk. Removal of the fibular remnant in short BKA stumps at primary amputation could mitigate common peroneal nerve hypersensitivity later.Following stump-plasty, amputees recorded a significantly improved score in three of five dimensions of the EQ-5D-L5 questionnaire: activities, anxiety levels and pain.Conclusion and clinical significancePrimary ballistic injury dictates the level of amputation and the resultant stump quality. Issues arising in these complex amputee stumps benefited from measured decisions and specialist care delivered by the MDT. Stump-plasty aims to improve the amputees’ prosthetic fit, mobility and health.How to cite this articleGodwin Y, Almaqadma A, Abukhoussa H, et al. Stump-plasty: An Operation Born of Necessity in Gaza. Strategies Trauma Limb Reconstr 2021;16(2):102–109.

Risk factor analysis for above-knee amputation in patients with periprosthetic joint infection of the knee: a case-control study

BackgroundPeriprosthetic joint infection (PJI) is a severe complication following knee arthroplasty. Therapeutic strategies comprise a combination of surgical and antibiotic treatment modalities and aim to eradicate the infection. Sometimes control of the disease can only be attained by above-knee amputation (AKA). While a vast amount of literature exists illuminating predisposing factors for PJI, risk factors favoring the endpoint AKA in this context are sparsely known.MethodsThe purpose of this investigation was to delineate whether patients with PJI of the knee present specific risk factors for AKA. In a retrospective case-control study 11 cases of PJI treated with AKA were compared to 57 cases treated with limb salvage (LS). The minimum follow-up was 2 years. Comorbidities, signs and symptoms of the current infection, factors related to previous surgeries and the implant, microbiology, as well as therapy related factors were recorded. Comparative analysis was performed using student’s t-test, chi-square test or Fisher’s exact test. Binary differences were calculated using odds ratio (OR). Reoperation frequency was compared using Mann-Whitney U test. In-depth descriptive analysis of 11 amputees was carried out.ResultsA total of 68 cases aged 71 ± 11.2 years were examined, 11 of which underwent AKA and 57 had LS. Severe comorbidities (p = 0.009), alcohol abuse (p = 0.015), and preoperative anemia (p = 0.022) were more frequently associated with AKA. Preoperative anemia was found in all 11 amputees (100%) and in 33 of 57 LS patients (58%) with an average preoperative hemoglobin of 99.9 ± 15.1 g/dl compared to 118.2 ± 19.9 g/dl (p = 0.011). No other parameters differed significantly. AKA patients underwent a median of eight (range 2–24) reoperations, LS patients a median of five (range 2–15).ConclusionFactors potentially influencing the outcome of knee PJI are diverse. The indication of AKA in this context remains a rarity and a case-by-case decision. Patient-intrinsic systemic factors such as alcohol abuse, severe comorbidities and preoperative anemia may elevate the individual risk for AKA in the setting of PJI. We recommend that anemia, being a condition well amenable to therapeutic measures, should be given special consideration in management of PJI patients.Trial registrationThis study was registered with Kantonale Ethikkommission Zürich, (BASEC-No. 2016–01048).

396 A 6-Month Audit of Initial Diabetic Foot Assessment and Documentation for Patients Undergoing Major Lower Limb Amputations in An Orthopaedics Ward

Abstract Aim To determine if adequate diabetic foot assessment and documentation were done at the Orthopaedics ward for patients undergoing a below-knee amputation (BKA) or above-knee amputation (AKA). Method Retrospective data from August 2019 to January 2020 were taken from paper documentation and e-records from the Orthopaedics ward and operation theatre. Diabetic foot assessments were based on the ASEANPlus guidelines for diabetic foot wounds which included foot inspection (for dermatological or musculoskeletal abnormalities), vascular (palpation of dorsalis pedis and posterior tibial pulses, ABSI measurement) and neurological assessments (testing of sensation and ankle reflexes). The assessments were deemed “adequate” or “inadequate” based on the information found on documentation. Results Only 67/81 data pieces were available for analysis (AKA=26, BKA=41), with an average age of 60 years. Inspection of the foot was most adequately assessed and documented (100%), followed by vascular and neurological assessment. For vascular assessment, palpation of pulses was done in 94% cases, and ABSI was performed in 76%. For neurological assessment, assessment of sensation was performed in 55%, while ankle reflexes were only assessed and documented in 25% cases. Conclusions Overall, the local practice had poor documentation of diabetic foot assessment, especially in vascular and neurological assessments. Possible reasons for poor practice include lack of guidance for incoming junior doctors starting their Orthopaedics rotation, and subsequently, the lack of skills and confidence in performing said assessments. Measures that could be done to improve the quality of practice include teaching key examinations to junior staff and having closer monitoring of notes documentation during ward rounds.

The Benefits of a Muscle-Sparing Below Knee Amputation in the Elderly Population.

It is well accepted that good muscle coverage of the bones at the end of a below knee amputation (BKA) stump is preferable, for both weight bearing and protection against prosthesis failure. Elderly patients often have atrophy of the leg musculature secondary to age-related physiological changes and decreased use. These patients often have poor coverage and bulk in their stumps after the standard BKA. We propose a selective muscle-sparing approach to these patients, utilizing selective removal of muscle bundles with regard to their blood supply and fascial planes. The surgical method technique along with outcomes of patients undergoing the procedure is presented here. A retrospective chart review was performed to identify patients who had undergone a muscle-sparing BKA from March 2008 to October 2017 by a single surgeon. Estimated blood loss, operative time, and perioperative and postoperative complications were assessed. Forty-six patients greater than 60years of age underwent muscle-sparing BKA procedures. Complete healing was seen in 30 (65%) patients, while 7 (15%) were lost to follow-up and 9 (20%) required conversion to an above knee amputation (AKA). Intraoperative outcomes in our series were notable for an average estimated blood loss (EBL) of 84.3ml, lower than the traditional BKA (average EBL 150-500ml), with comparable operative times averaging 131 minutes and as short as 85 minutes (skin incision to dressing). No patients in the cohort required postoperative blood transfusions (day 0-4), significantly less than the reported 3-7ml/kg body weight blood requirements in similar patient populations. The muscle-sparing BKA technique should be considered in elderly patients, where the normally bulky posterior calf muscle mass is lacking. The selective removal of muscle bundles with regard to their blood supply leaves maximum coverage of the bone with decreased potential hematoma formation and blood loss.