Divergent redox states define regenerative outcomes between salamanders and Xenopus.

In the United States, approximately 2.3 million people live with limb loss, of whom about 91% have undergone lower extremity amputation. Despite these numbers, relatively few studies have evaluated outcomes after elective transtibial amputation. In particular, we do not know whether the outcomes after amputation for intractable neurogenic pain such as complex regional pain syndrome (CRPS) are comparable to outcomes after late amputations (6 weeks or more after limb salvage) performed for other reasons such as recurrent infection, soft tissue problems, recalcitrant nonunion, poor function, and chronic nonneurogenic pain. (1) Did patients who underwent late amputation for CRPS or neuropathic pain have inferior Patient-Reported Outcomes Measurement Information System (PROMIS) scores at follow-up compared with patients who had nonneurogenic elective amputation? (2) Did patients who underwent late amputation for CRPS or neuropathic pain have more pain, use more pain medication, or wear prosthetics less often than patients who have undergone nonneurogenic elective amputation? (3) Were patients who underwent late amputation for CRPS or neuropathic pain more likely to be revised to a higher level of amputation or express decision regret than patients undergoing nonneurogenic elective amputation? This retrospective comparative study examined 70% (50 of 71) of patients who underwent elective (that is, scheduled, nonurgent) transtibial amputation between July 2006 and September 2019 at least 6 weeks after lower extremity trauma (median [range] 2 years [6 weeks to 15 years]). Most patients were men (94% [47 of 50]) and active duty service members who sustained combat-related trauma (74% [37 of 50]). Patients with CRPS (defined using the Budapest criteria diagnostic guidelines, which requires ongoing disproportionate pain plus signs in four categories: sensory, vasomotor, sudomotor/edema, and motor/trophic changes, n = 10) and other forms of neuropathic pain (n = 10) were compared with a control group of patients who had nonneurogenic elective amputation (n = 30). Demographic characteristics among cohorts were not different given the numbers available. The median (range) follow-up was 9 years (3 to 16) after amputation. The primary outcome was the PROMIS pain interference score. Secondary outcomes included other PROMIS metrics, VAS pain, and patient-reported medication and prosthetic use as well as revision to a higher level of amputation and decision regret. With the numbers available, we found no difference in PROMIS pain interference scores for patients with transtibial amputations performed for neurogenic pain compared with other causes of late amputation (median [range] 57 [45 to 64] versus 56 [39 to 72]; p = 0.81). There were likewise no differences with the numbers available in PROMIS physical function, mobility, life satisfaction, and severity of substance use. Amputations performed for neurogenic pain resulted in more pain reduction than late amputations for other causes (median ΔVAS -5 [-9 to -1] versus median Δ VAS -3 [-8 to 7]; p = 0.02). Both groups reported a reduction in opioid use (100% reduction in median frequency of opioid administrations for both groups; p < 0.001). Prosthetic use was not different with the numbers available among all cohorts. No patients in the CRPS plus neuropathic pain cohort were revised to a higher level of amputation compared with 2 patients in the nonneurogenic elective amputation cohort. No patients expressed definitive decision regret. Patients undergoing elective transtibial amputations for intractable neurogenic pain experienced clinically meaningful improvement in pain. Our findings support the use of transtibial amputation for treatment-resistant neurogenic pain, and they provide reasonable, but generally favorable, expectations for patients considering this irreversible procedure that are generally comparable to outcomes from patients undergoing late amputations for other indications. Level III, therapeutic study.

Enhancing skin-implant integration in lower-limb transcutaneous prostheses: From interface biology to bioactive, antimicrobial and cell-based strategies.

Chronic Lower Extremity Wounds: Updates on Lower Extremity Reconstruction in Clinics in Plastic Surgery.

Infected aortic fields are among the most complex surgical challenges, often requiring urgent intervention and associated with a high risk of morbidity and mortality. Bovine pericardium offers a customisable, off-the-shelf option for in situ reconstruction using biological material. We evaluate long-term outcomes following emergency bovine pericardium neo-aorta reconstruction in infected aortic fields. Prospectively collected data for all patients treated with bovine pericardium neo-aorta reconstructions from 2018 to date were analysed. The surgical approach included resection of the infected aortic segment, explantation of previous grafts and/or stents, and reconstruction of the neo-aorta using a bovine pericardium sheet. Data collected included patient demographics, comorbidities, clinical presentation, previous interventions, blood tests, complications, length of antibiotic treatment and long-term survival. All neo-aortas were enrolled in an annual ultrasound surveillance programme to monitor for aneurysmal degeneration. Fifteen aortic reconstructions were performed. The most common indication was aorto-enteric fistulas (n = 7), followed by infected aortic grafts (n = 4), mycotic aneurysms (n = 3) and one contaminated field due to emergency colectomy. Median follow-up was 34 months (range 9-84). Thirty-day mortality was 7%, with another 7% at 10 weeks. Antibiotic-free survival rate was 86%. One patient (7%) required long-term antibiotics post-partial endovascular aneurysm repair explant. Complications included one graft occlusion with limb loss and one case of end-stage renal failure. No aneurysmal degeneration was identified during follow-up. Bovine pericardial neo-aorta reconstructions have shown excellent long-term resistance to infections and very good durability. Our data add to growing evidence supporting off-the-shelf use of bovine pericardium in emergency aortic reconstruction. Larger numbers through multicentre studies or special registries would help support more regular use.

Limited data are available regarding partial foot amputation (amputation of two adjacent digits, excluding the first digit) in cats. Three domestic shorthair cats with a median age of 4.2 yr were presented for partial foot amputation between 2010 and 2022. Neoplasia was the indication for partial foot amputation in two cats; one cat underwent partial foot amputation for treatment of a chronic wound. All cats underwent lateral partial foot amputation (excision of digits 4-5) of a thoracic limb. One cat had excisions at the level of the metacarpal-phalangeal joint, and two cats had excision at the level of the distal metacarpal bone. No cats experienced surgical complications intraoperatively. All cats achieved resolution of lameness postoperatively at a median duration of 28 days, although one cat experienced a long-term grade 1 complication associated with a wound that developed where weight bearing occurred. Lateral partial foot amputation of a thoracic limb was overall well tolerated in these three cats, with favorable long-term functional outcomes and manageable complications. Results support the role of partial foot amputation as a viable limb-sparing option in cats, although additional data are needed to assess outcomes for other partial foot amputation locations (medial, central, and pelvic limb) in cats.

The purpose of this article is to introduce the angiosome concept in the lower legs and its consideration in severe soft tissue injuries in open tibial fractures. The main aim is to focus on the vascularity and perforators in the crura and to emphasise step-by-step time management and proper debridement for securing the maximal viability of the soft tissue before the reconstruction phase. So far, many publications have presented optimal traumatological protocols and timing in lower leg injuries and many reviews have compared fracture stabilisation and flap reconstruction options; however, no consensus exists. Radical and immediate debridement is crucial for minimising infection complications, revision surgeries and total healthcare costs, early definitive reconstruction, limb salvage success, decreased hospitalisation stay and better long-term quality-of-life outcome for the patients. The fundamental orthoplastic approach has been an indisputably accepted strategy since its introduction in the 1990s by Levin. Unfortunately, not all centres are staffed with a plastic surgeon 24/7. Furthermore, transportation to the tertiary specialist centre is often delayed; hence, we believe that a correct primary soft tissue and antibiotics administration protocol can be provided in all medical centres by orthopaedists. So, the basic knowledge of the principles of lower leg vascularity is, therefore, essential. In the difficult cases of the Anderson-Gustilo IIIC fractures, we provide some of the latest recommendations for soft tissue viability verification and blood perfusion improvement, when considering limb salvage versus amputation. This narrative review was developed in accordance with PRISMA 2020 recommendations for transparency in study selection and reporting.

Art has historically reflected prevailing medical conditions and societal responses to disability. Hieronymus Bosch's The Procession of Cripples depicts numerous individuals with visible musculoskeletal deformities, providing a unique historical perspective on disability in late medieval Europe. A visual and historical analysis of Bosch's ink-on-paper illustration was performed. Each depicted figure was evaluated for observable limb deformities, gait abnormalities, amputations, and use of assistive devices. Findings were interpreted using contemporary pediatric orthopaedic diagnostic principles. Thirty-one individuals demonstrate a spectrum of abnormalities consistent with congenital limb deficiencies, posttraumatic deformities, postinfectious sequelae, and neuromuscular conditions. Multiple figures rely on primitive mobility aids, including crutches, limb boards, and early prosthetic constructs. These devices reflect foundational orthotic and prosthetic principles that parallel modern pediatric orthopaedic interventions aimed at restoring function and ambulation. The Procession of Cripples provides a detailed visual record of musculoskeletal pathology and early assistive technology in the medieval period. The work illustrates historical continuity in the goals of pediatric orthopaedics: restoring mobility, alignment, and independence in children with limb deformities and neuromuscular conditions. Level V-expert opinion/historical analysis.

A preliminary technique development for quantitative analysis of transhumeral bone, post-amputation, using a computed tomography BMD phantom

The use of vasopressors during microsurgical reconstruction is debated. Their effect on the comorbid lower extremity (LE) wound population is unstudied. This study characterizes the impact of intraoperative vasopressor use in LE free tissue transfer (FTT) for limb salvage. A review of LE FTT from February 2017 to June 2024 was conducted. Flap outcomes within 7 and 42 days were evaluated, as well as long-term limb salvage. Of 258 LE FTT performed, vasopressors were used in 177 cases (68.6%). Most vasopressors were administered via intermittent bolus only (75.7%) or combined with continuous infusion (23.7%). American Society of Anesthesiologists Class was significantly higher in the vasopressor group compared with controls (p = 0.001). The vasopressor group trended to have higher median Charlson Comorbidity Indices (4, interquartile range [IQR]: 3 vs. 3, IQR: 3; p = 0.055), and rates of diabetes (65.0% vs. 54.3%, p = 0.103), peripheral vascular disease (63.8% vs. 51.9%, p = 0.068), and chronic kidney disease (14.7% vs. 6.2%, p = 0.063). The rate of reoperation, microvascular thrombosis, or flap success at 7 and 42 days did not differ between groups. By a median long-term follow-up of 24.5 (IQR: 39.2) months, rates of major limb amputation (vasopressor: 10.7% vs. control: 7.4%, p = 0.402) and mortality (6.8% vs. 2.5%, p = 0.237) were similar between groups. In this complex population, intraoperative use of vasopressors does not appear to negatively impact flap viability or limb salvage.

Associations between physical activity, psychosocial adjustment and prosthesis satisfaction in people with lower limb amputation.

The role of profundoplasty is well-established as central for patients affected by chronic limb-threatening ischemia (CLTI) and, in selected cases, for patients with disabling intermittent claudication. The most largely adopted technique involves endarterectomy of the common femoral artery (CFA) and of the profunda femoris artery (PFA) followed by surgical reconstruction through the interposition of a patch, which can be synthetic or biological. Although widely used, this technique is not without pitfalls related to the use of synthetic material, the primary concern being the risk of infection associated with it. The aim of this study is to describe the outcomes of our alternative approach to traditional profundoplasty, which represents the standard of care at our institution and may offer relevant advantages in comparison to the usual approach. From July 2017 to February 2025, 69 consecutive patients (mean age 69.2 years, range 61-86 years) underwent an alternative approach to profundoplasty requiring superficial femoral artery (SFA) transection, medial longitudinal PFA incision, retrograde CFA endarterectomy, and standard PFA endarterectomy with optimal management of the distal endpoint). Proximal SFA is always reattached to reconstruct the PFA. In particular, depending on clinical factors, such as the presence of CLTI, or anatomical factors, such as the presence of a nonrevascularizable occlusive disease of the SFA, it can be either used as autologous patch (terminalized SFA) or sutured back, effectively "lowering" the femoral bifurcation. Clinical outcomes were assessed at 6, 12, 24, and 36 months. The primary endpoint included technical success, primary patency, and secondary patency. Secondary endpoint considered major limb amputation, primary-assisted patency, and all-cause mortality. Of 69 patients, 28 (40.5%) were Rutherford 3 (severe claudication), 33 (47.8%) Rutherford 4 (CLTI, with rest pain), and 8 (11.7%) Rutherford 5 (CLTI with presence of trophic lesions). The CFA was involved in 95.6% and the PFA in 92.7% of cases. Concomitant iliac disease was present in 20.2% and significant external iliac artery or SFA pathology in 52.1% and 49.2%, respectively. Multilevel disease predominated (75.4%). Technical success was 100%. After endarterectomy, the SFA was either sutured back and lowered (56.5%) or terminalized for patching (43.5%). Concomitant inflow procedures were performed in 55% and outflow procedures in 17.3% patients. Mean ankle-brachial index improved from 0.45 to 0.68. Thirty-day mortality and major amputation were 0%; local and systemic complications were 5.8% and 1.4%, respectively. At mean follow-up of 53.4 months, primary, primary-assisted, and secondary patency at 2 years were 93.8%, 96.9%, and 100%, with 96.7% limb salvage and 83.1% survival. In our experience, this technique is a valid alternative to the typical profundoplasty, with the potential advantages being a suture-free CFA, leaving an intact potential site of puncture for future endovascular approach, and the absence of synthetic material in the groin, with consequent reduced risk of infective sequelae and costs.

In December 2024, the US Department of Veterans Affairs (VA) and the US Department of Defense (DoD) released a joint update of their 2017 clinical practice guideline (CPG) for the rehabilitation of individuals with lower limb amputation (LLA). This synopsis highlights the key aspects of the guideline development process and describes the CPG recommendations. The VA/DoD Evidence-Based Practice Work Group convened a joint VA/DoD guideline development work group (WG) that included clinical stakeholders and conformed to the Institute of Medicine's tenets for trustworthy clinical practice guidelines. The guideline WG conducted a patient focus group, developed key questions, and systematically searched and evaluated the literature from a 8 year time frame (English-language publications from July 6, 2016 to March 15, 2024). The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system was utilized to evaluate the evidence and formulate recommendations. The WG developed 26 recommendations along with algorithms and supplemental materials to guide providers in providing evidence-based, interdisciplinary, patient-centered care through all phases of LLA rehabilitation. The CPG was reviewed by stakeholders outside the WG before approval by the VA/DoD Evidence-Based Practice WG. This article summarizes key features of the guideline to help clinicians utilize the CPG to support patient-centered care.

Glucagon-like peptide 1 receptor agonists (GLP-1 RAs) are well-known medications commonly prescribed for type 2 diabetes management and pharmacologic management of obesity. While GLP-1 RAs have many positive effects on glycemic control and cardiovascular health, the secondary effect of weight loss can present a challenge in maintaining optimal prosthesis fitting and functionality among individuals with prosthetic limbs. More specifically, weight loss can lead to decreased muscle mass and volume of the residual limb, resulting in loosening of the prosthesis. In turn, individuals often require more frequent prosthetic adjustments to ensure their safety and comfort while using the prosthetic device. Herein, we describe 3 cases of semaglutide use in patients with prosthetic limbs who subsequently presented with a variety of complications, including skin breakdown, disproportionate residual limb volume loss, decreased prosthetic use, and increased residual limb pain. Such "Ozempic limbs" have not yet been reported in the literature. These observations suggest that further research in GLP-1 RA selection is required for persons with amputation, as well as increased patient education regarding the unique complications.

Predictors of Prosthetic Eligibility after Major Lower Limb Amputation: A Retrospective Cohort Study.

Dynamic balance adaptations in response to bound arm walking.

Several studies have demonstrated the efficacy of paclitaxel drug-coated balloons (DCBs) for the treatment of femoropopliteal (FP) lesions in patients with peripheral artery disease (PAD). Despite the available evidence, long-term real-world efficacy data are limited. To report the 3-year outcomes of the prospective, multicenter, single-arm real-world registry conducted in the United States, assessing the clinical use of the Lutonix 035 DCB in arteries of the superficial femoral artery (SFA) and popliteal artery (PA). In the SAFE-DCB US Registry, a total of 1005 subjects at 74 investigational sites were treated with the Lutonix 035 DCB and were followed up to 36 months. The per protocol included 966 patients (mean age 69.1 years; 56.7% male). A total of 1237 target lesions were treated, in which 93.3% were de novo, 85.2% were located in the SFA, and 88% had mild-to-severe calcification. Forty-five percent of the patients were Rutherford 3, and 35.1% had critical limb-threatening ischemia. The primary efficacy endpoint is target lesion revascularization (TLR) at 12 months. Secondary endpoints included rate of primary patency at 12 months and freedom from TLR and freedom from target vessel revascularization (TVR) evaluated through 36 months. The safety endpoints evaluated through 36 months were freedom from the composite of device- and/or procedure-related perioperative (≤30 day) death, TVR, and freedom from major amputation of the target limb. Primary patency at 12 months post-index procedure by Kaplan-Meier estimates was 83.7%. Freedom from TLR at 12 months was 88.6%, 75.7% at 24 months, and 74.4% at 36 months. At 36 months, freedom from TVR post-index procedure by Kaplan-Meier estimates was 69.5%. Freedom from primary safety events at 30 days was 98.2%. Freedom from composite of all-cause perioperative (≤30 day) death and from the following: index limb amputation, index limb reintervention, and index-limb-related death by Kaplan-Meier estimates at 12 months was 80.8%, at 24 months 67.4% and 58.4% at 36 months. Freedom from major amputation of the target limb at 36 months was 95.6%. The results from the SAFE-DCB US Registry for femoral popliteal (FP) disease demonstrated sustained safety and efficacy over 3 years following the Lutonix 035 DCB intervention.Clinical ImpactThis prospective real-world population study supports long-term clinical outcomes of Lutonix and provides meaningful insights into the sustained efficacy of drug-coated balloon (DCB) therapy in real-world femoropopliteal population. The low-bailout stenting rate (1.7%), and the 36-month sustained Freedom from target lesion revascularization rate (74.4%) supporting DCB usage when a "leave nothing behind" approach is favored. Furthermore, these results reinforce the effectiveness of DCBs in the endovascular treatment peripheral artery disease.

When one part feels, the whole belongs: associations between local touch referral and illusory full-limb ownership in individuals with leg amputation.

Phantom limb pain (PLP) presents a significant challenge in pediatric patients following limb amputation, with traditional management strategies often falling short of providing effective relief. This clinical vignette describes the successful utilization of topical ketamine cream as an adjunctive therapy in the multimodal pain management of a 12-year-old female patient who underwent left above-knee amputation (AKA) following traumatic injuries. Despite receiving standard analgesic therapy postsurgery, the patient reported persistent pain at the surgical site and phantom limb sensations, prompting consultation for pain management. Subsequent initiation of topical ketamine cream resulted in marked improvement in pain control and reduction in opioid requirements. The patient's pain continued to decrease over the course of treatment, facilitating the discontinuation of opioids and demonstrating sustained pain relief. This case highlights the unique challenges of managing PLP in pediatric patients and the potential of nonopioid alternatives, such as topical ketamine, in improving pain management outcomes. This case suggests the feasibility and efficacy of topical ketamine cream in pediatric PLP management, emphasizing the need for further research to establish optimal dosing regimens and long-term safety profiles. By expanding our understanding of alternative analgesic modalities, we can enhance pain management outcomes and improve the quality of life for pediatric patients living with PLP.

Results of ankle replantation procedure: a case series and review of the literature