Ankle Amputation Research Articles

A Review of Antithrombotic Treatment in Critical Limb Ischemia After Endovascular Intervention.

Endovascular intervention is often used to treat critical limb ischemia (CLI). Post-intervention treatment with antiplatelet and/or anticoagulant therapy has reduced morbidity and mortality due to cardiovascular complications. The purpose of this review is to shed light on the various pharmacologic treatment protocols for treating CLI following endovascular procedures. We reviewed the literature comparing outcomes after antithrombotic treatment for patients with CLI. We characterized antithrombotic therapies into three categories: (1) mono-antiplatelet therapy (MAPT) vs. dual antiplatelet therapy (DAPT), (2) MAPT vs. antiplatelet (AP) + anticoagulant (AC) therapy, and (3) AC vs. AP + AC therapy. Relevant results and statistics were extracted to determine differences in the rates of the following outcomes: (1) re-stenosis, (2) occlusion, (3) target limb revascularization (TLR), (4) major amputation, (5) major adverse cardiac events, (6) all-cause death, and (7) bleeding. Studies suggest that DAPT reduces post-surgical restenosis, TLR, and amputation for diabetic patients, without increasing major bleeding incidences, compared to MAPT. Also, AP + AC therapy provides overall superior efficacy, with no difference in bleeding incidences, compared to antiplatelet alone. Additionally, the effects were significant for restenosis, limb salvage, survival rates, and cumulative rate of above ankle amputation or death. These results suggest that treatment with DAPT and AP + AC might provide better outcomes than MAPT following the endovascular intervention for CLI, and that the ideal treatment may be related to the condition of the individual patient. However, the studies were few and heterogenous with small patient populations. Therefore, further large controlled studies are warranted to confirm these outcomes.

645-P: QTc Prolongation as a Risk Factor for Five-Year Survival after Above-Ankle Amputation in Patients with Type 2 Diabetes

Patients with diabetic foot ulcers (DFU) are considered high-risk individuals for increased cardiovascular disease and mortality. After a major amputation the mortality risk is even higher, with five-year mortality rates exceeding 70%. QTc interval prolongation is a potential indicator of increased cardiovascular risk in the general population as well as in patients with diabetes. The aim of this study was to evaluate the impact of QTc prolongation on 5-years survival after above ankle amputation in patients with type 2 diabetes. We retrospectively enrolled all patients (n=97) with type 2 diabetes, not older than 85 years without a pacemaker, who underwent a major amputation at two hospitals with multidisciplinary DFU teams. Patients were grouped according to QTc time ≤ or >440 ms. Mortality data after 5 years was obtained from the Swedish National Death Registry. Non-parametric statistics were used when assessing differences and survival was analyzed with Kaplan-Meier estimates with log-rank test. As shown in the Figure, QTc prolongation was significantly associated with worse survival (82 vs. 57% 5-year mortality). Presence of ischemic heart disease, age and diabetes duration did not differ between groups. In conclusion, we have demonstrated that routinely ECG screening with QT interval analysis in a DFU-population, provides important information regarding long-term survival. Disclosure S. Puvaneswaralingam: None. K. Fagher: Speaker's Bureau; Self; AstraZeneca, Boehringer Ingelheim Pharmaceuticals, Inc., Merck Sharp & Dohme Corp., Novo Nordisk A/S, Sanofi. M. Londahl: Advisory Panel; Self; AstraZeneca, Boehringer Ingelheim International GmbH, Novo Nordisk A/S, Sanofi. Speaker's Bureau; Self; AstraZeneca, Boehringer Ingelheim International GmbH, Novo Nordisk A/S, Sanofi. Funding Craaford Foundation; Krapperyp Foundation; County of Skåne Foundation; Diabetes Foundation

Preoperative hemoglobin A1c levels and increased risk of adverse limb events in diabetic patients undergoing infrainguinal lower extremity bypass surgery in the Vascular Quality Initiative

BackgroundThe impact of preoperative glycemic control on the risk of adverse perioperative outcomes in diabetic patients undergoing lower extremity bypass (LEB) surgery is not well-understood. We determined whether higher preoperative hemoglobin A1c (HbA1c) levels are associated with an increased risk of major adverse limb events, major adverse cardiovascular events, and mortality in diabetic patients undergoing infrainguinal LEB. MethodsA retrospective review of all infrainguinal LEB surgeries in the Vascular Quality Initiative registry from January 2012 to February 2017 was performed. Only surgeries performed on diabetic patients with complete demographic and clinical data, including HbA1c value at the time of LEB, were included for analysis (n = 7727). Entries were stratified according to the following HbA1c levels: 6 or less (n = 1087), greater than 6 to 7 or less (n = 2137), greater than 7 to 8 or less (n = 1657), and greater than 8 (n = 2846). Multivariate logistic regression was used to determine the association of preoperative HbA1c levels on the risk of in-hospital major adverse limb events (above ankle amputation, loss of primary graft patency), major adverse cardiovascular events (myocardial infarction, stroke, congestive heart failure, cardiac arrhythmia), and mortality. ResultsThe number of surgeries complicated by adverse limb and cardiovascular events were 356 (4.6%) and 1314 (17.0%), respectively. There were 72 in-hospital deaths (0.9%). After adjustment for clinical and demographic variables, patients with high HbA1c values (≥8%) were at an increased risk of adverse limb events (odds ratio [OR], 1.37; 95% confidence interval [CI], 1.01-1.86) compared with those with a normal HbA1c (>6% to ≤7%). High HbA1c values were not associated with an increased risk of cardiovascular events (OR, 1.07; 95% CI, 0.81-1.43) or mortality (OR, 1.57; 95% CI, 0.83-3.03). Patients with low HbA1c values (≤6%) did not experience a significantly higher risk for any of the three outcomes. In a stratified analysis, the association of high HbA1c values with adverse limb events was only present in those presenting without critical limb ischemia (OR 1.82; 95% CI, 1.05-3.16). ConclusionsPoor preoperative glycemic control in diabetic individuals undergoing infrainguinal LEB, particularly in those without critical limb ischemia, is associated with an increased risk of in-hospital limb events. Further study should evaluate whether improved efforts to identify individuals with poorly controlled diabetes and subsequent interventions to better optimize glycemic control during the preoperative period improve limb outcomes after LEB.

Aspirin for primary prevention of cardiovascular disease in diabetes.

Aspirin for primary prevention of cardiovascular disease in diabetes.

Ozone Therapy in a Patient with Diabetic Foot Ulcerations and a Decision for Amputation

Background: Diabetic foot together with open wounds in distal type peripheral arterial disease constitutes a challenge in therapeutic planning. Ozone therapy may unveil new horizons in management. Case Report: A 67-year-old woman with diabetes mellitus was applied with open wounds at the bottom of her foot with purulent discharge, with a decision for above ankle amputation. She had had numerous interventions for her wounds including metatarsal amputations due to osteomyelitis and had been on an intense treatment including antibiotics, insulin, antihypertensives and antiaggregants. Angiogram revealed diffuse peripheral arterial disease in lower extremities. All medication but antihypertensives was stopped. She received major medical ozone application as 2000 gamma/session i.v. for 2 weeks, external ozone sac application starting from 60 and dropping to 30 gamma/session for 3 weeks and ozone insuflation 40 gamma/session for 10 sessions. Her purulent discharge ceased after the third session and the atonic debris of the wounds exfoliated, the wounds healed from the base towards the surface of the skin. She was then put on cilostazol and clopidogrel therapy. Conclusion: By being one of the known strongest bactericide, virucide, and fungicide elements, medical ozone therapy stimulates and upregulates the antioxidant system of the body with its hormesis effects. After the cessation of all circulatory system supporting medication (as their interaction with ozone is not clear yet), appropriate ozone therapy may bring new horizons for patients when all classically known methods of treatment have been completed, before assigning the patients for amputation.

Influence of Heel Ulceration on Limb Salvage After Open and Endovascular Intervention for Limb-Threatening Critical Ischemia

Infrapopliteal disease is documented in 50% of patients presenting with tissue loss. The implications of heel ulceration on index limb outcomes is still unclear. The aim of this study was to impact the outcomes of heel ulceration after endovascular and open intervention for limb-threatening critical ischemia A database of patients undergoing lower extremity open and endovascular interventions between 2001 and 2017 was retrospectively queried. We identified 608 patients with isolated infrapopliteal disease and heel ulceration. Heel ulceration was further stratified as less than 5 cm, 5 to 10 cm, and greater than 10 cm in diameter. An intention-to-treat analysis by patient was performed. Amputation-free survival (survival without major amputation) and freedom from major adverse limb events (above ankle amputation of the index limb) or major reintervention (new bypass graft, jump/interposition graft revision) were evaluated. There were 384 patients (58% male; average age, 65 years; 2898 vessels) who underwent endovascular tibial intervention and 124 patients (45% male; average age, 59 years) underwent superficial femoral artery or popliteal tibial bypass for limb-threatening critical ischemia (Table). There was no difference in 30-day outcomes (Table). Outcomes of amputation-free survival and freedom from major adverse limb event were superior in the open group. Patients with heel ulcers of less than 5 cm and 5 to 10 cm had similar outcomes. Heel ulcers greater than 10 cm diameter were associated with worse 30-day and 5-year outcomes (Table). The presence of end-stage renal disease, osteomyelitis, and uncontrolled diabetes (glycosylated hemoglobin of >10) were associated with poor 30-day and 5-year outcomes. The combination of one or more of these variables with a heel ulcer greater than 10 cm in diameter was associated with a higher 30-day amputation rate (50% endo vs 45% open; P < .02). Heel ulceration of greater than 10 cm is associated with early major adverse limb event and early amputation in both open and endovascular interventions. The presence of end-stage renal disease, osteomyelitis, and uncontrolled diabetes (glycosylated hemoglobin of >10) in combination with a large heel ulcer is predictive of early major amputation.TableOutcomesEndovascularOpenP valueNo. of limbs at risk384124–High-risk PIII score, %41%43%NSWIfI stage 3/443%41%NSTASC I C/D, %79%85%.1230-day MACE, %2%3%.1530-day MALE, %11%10%.2330-day amputation, %27%26%.255-year amputation-free survival, mean ± SEM %27 ± 937 ± 8.055-year freedom from MALE, mean ± SEM %21 ± 835 ± 7.05MACE, Major adverse cardiac events; MALE, major adverse limb events; PIII, PREVENT III; SEM, standard error of the mean; TASC, TransAtlantic Inter-Society Consensus; WIfI, Society for Vascular Surgery Wound, Ischemia, foot Infection. Open table in a new tab

Audit of acute pain management post-major amputation in South Mersey ARTerial (SMART) Centre

Good pain management is essential post amputation. Patients experience a mixed nature of pain including nociceptive pain, wound pain and neuropathic/phantom limb pain. There often a mixed picture. Good pain management aids early mobilisation. National guidelines recommend 100% compliance with a pain management protocol. Aim is to assess current compliance with the local pain management protocol, review how pain is assessed and treated, and find if patients are discharged with unnecessary medication. All patients following lower limb major amputation (above ankle amputation) in 2016 were identified, data collected retrospectively from electronic case notes. Forty patients included. Twenty above knee, 18 below knee and 2 through knee amputations. Length of stay ranged from 6 to 121 days. Thirty-two percent (13/40) of patients had chronic pain and already on analgesia. Fifteen had significant nociceptive stump pain, 6 only neuropathic pain and 5 mixed pain. Nine reported no pain on day 1. Six had no assessment of pain in medical notes. Following surgery, 22.5% (9/40) were not given zomorph (or alternative opiate), 20% (8/40) were not given gabapentin with no reason or alternative (according to local protocol). Twenty percent (8/40) had problematic pain and discharged on multiple medications. Two waited over 10 days before mobilisation, these patients had uncontrolled pain. Four mobilised on day 1 with good pain control. Two discharged on zomorph despite having no pain. Eighteen discharged on gabapentin; however 5 on a small dose. A uniform pain assessment as part of the major amputation pathway is required to be used by all clinicians involved in patient care. This would provide an accurate assessment of pain and used as a tool to monitor response to medication changes. An assessment of pain on admission and discharge with medication review is essential. Multicentre audits are recommended to establish corresponding guidelines for pain management for these patients.

Influence of micro- and macro-vascular disease and Tumor Necrosis Factor Receptor 1 on the level of lower-extremity amputation in patients with type 2 diabetes

BackgroundPatients with type 2 diabetes (T2D) face a high amputation rate. We investigated the relationship between the level of amputation and the presence of micro or macro-vascular disease and related circulating biomarkers, Tumor Necrosis Factor Receptor 1 (TNFR1) and Angiopoietin like-2 protein (ANGPTL2).MethodsWe have analyzed data from 1468 T2D participants in a single center prospective cohort (the SURDIAGENE cohort). Our outcome was the occurrence of lower limb amputation categorized in minor (below-ankle) or major (above ankle) amputation. Microvascular disease was defined as a history of albuminuria [microalbuminuria: uACR (urinary albumine-to-creatinine ratio) 30–299 mg/g or macroalbuminuria: uACR ≥ 300 mg/g] and/or severe diabetic retinopathy or macular edema. Macrovascular disease at baseline was divided into peripheral arterial disease (PAD): peripheral artery revascularization and/or major amputation and in non-peripheral macrovascular disease: coronary artery revascularization, myocardial infarction, carotid artery revascularization, stroke. We used a proportional hazard model considering survival without minor or major amputation.ResultsDuring a median follow-up period of 7 (0.5) years, 79 patients (5.5%) underwent amputation including 29 minor and 50 major amputations. History of PAD (HR 4.37 95% CI [2.11–9.07]; p < 0.001), severe diabetic retinopathy (2.69 [1.31–5.57]; p = 0.0073), male gender (10.12 [2.41–42.56]; p = 0.0016) and serum ANGPTL2 concentrations (1.25 [1.08–1.45]; p = 0.0025) were associated with minor amputation outcome. History of PAD (6.91 [3.75–12.72]; p < 0.0001), systolic blood pressure (1.02 [1.00–1.03]; p = 0.004), male gender (3.81 [1.67–8.71]; p = 0.002), and serum TNFR1 concentrations (HR 13.68 [5.57–33.59]; p < 0.0001) were associated with major amputation outcome. Urinary albumin excretion was not significantly associated with the risk of minor and major amputation.ConclusionsThis study suggests that the risk factors associated with the minor vs. major amputation including biomarkers such as TNFR1 should be considered differently in patients with T2D.

The Impact of Perioperative Ankle-Brachial Index and Clinical Status on Outcomes following Lower Extremity Bypass

Ankle-brachial index (ABI) is a common method of graft surveillance after infrainguinal lower extremity bypass (LEB) surgery and is recommended by the Society for Vascular Surgery. Several studies failed to show the benefit of ABI surveillance but were limited by sample size, and the practice remains variable. We identified all patients who underwent LEB for occlusive disease from the Vascular Study Group of New England Registry (VSGNE) between 2003 and 2016. Postoperative changes were defined as follows: improvement for ABI >0.15 at discharge or clinical status improved (i.e., symptoms improved from rest pain to asymptomatic, and so forth), no change if ABI was within 0.15 or no change in clinical status, or worsened if ABI decreased >0.15 or clinical status deteriorated. We determined the independent effect of these changes on rates of mortality, reintervention, patency loss, amputation, and Major Adverse Limb Events (MALE-above ankle amputation, revision, thrombectomy, or lysis). In addition, we compared the practice of perioperative ABI to follow-up without ABI using propensity scores with inverse probability weights. We identified 7,994 patients undergoing their first intervention in the VSGNE, 2,251 of whom (29%) had both preoperative and discharge ABIs. Overall, 5,369 (67%) of the bypasses used vein, and 4,539 (57%) were femoropopliteal, with no difference in the rate of vein use or bypass type between those who had discharge ABIs and those who did not (P>0.05). Most bypasses were performed for chronic limb-threatening ischemia (59% in the ABI group, 65% in those without ABI data, P<0.01 for difference). At discharge, ABI remained stable in 22%, improved in 69%, and worsened in 9%, whereas clinical status remained stable in 12%, improved in 77%, and worsened in 12%. In univariate analysis, clinical status was associated with mortality, amputation, and MALE, but ABI change was only associated with mortality (all P<0.01). After multivariable adjustment, ABI change was no longer associated with mortality and remained unassociated with amputation and MALE (P>0.05), and the addition of ABI change to the models did not improve the fit of the model (likelihood ratio P>0.05). Forgoing perioperative ABI was associated with higher rates of patency loss (P=0.02), but not reinterventions (P=0.57), or untreated patency loss (P=0.17). A change in clinical status, but not a change in ABI, was associated with adverse outcomes after LEB. In this group of VSGNE patients with follow-up, perioperative ABI did not add incremental value to clinical status alone as a method of graft surveillance.

Various forms of anterolateral thigh flap for lower extremity and ankle amputation with extensive skin and soft tissue defect reconstruction

Objective To explore the application of various forms of anterolateral thigh flap in lower extremity and ankle amputation with extensive skin and soft tissue defect reconstruction. Methods From September 2011 to December 2015, 26 cases of lower extremity and ankle amputation with extensive skin and soft tissue defect reconstruction (included 20 male patients and 6 female patients) were admitted, the age ranged from 22 to 61 years old (38.6±4.5). Among these cases, 10 cases received flow-through anterolateral thigh flap, 16 cases used chimeric anterolateral thigh flap with vastus lateralis thigh muscle flap, 15 flaps were thinned in one-staged, 5 flaps were harvested in double-paddled form. The flap size ranged from 10 cm×6 cm to 28 cm×12 cm. The donor site was closed directly in all cases. Results All flaps and replanted extremities survived uneventfully. All patients were followed up for 8 to 30 months with satisfied esthetic and functional results in reconstructed foot and ankle, the texture of flaps was good, no bulky was noted and no second revision was needed. No local ulcer happened and regained protective sensation. Only linear scar left in the donor sites, no hernia occurred. Conclusions Various forms of anterolateral thigh flap is the effective choice in lower extremity and ankle amputation with extensive skin and soft tissue defect reconstruction. Key words: Thigh/SU; Surgical flaps; Ankle injuries/SU; Soft tissue injuries/SU

Lutonix® 014 DCB global Below the Knee Registry Study: interim 6-month outcomes.

The most common clinical presentation of peripheral artery disease (PAD) comprises intermittent claudication (IC), but about one third of patients will progress to critical limb ischemia (CLI), characterized by rest pain and/or tissue loss, which is the most severe limb manifestation of PAD. Paclitaxel-coated balloons are well established for the endovascular treatment of femoropopliteal lesions in patients with IC and CLI. This ongoing multicenter registry study is exploring the role of the Lutonix® 014 drug-coated balloon (DCB) in the treatment of below-the-knee (BTK) arteries and CLI. Three hundred fourteen (314) patients were enrolled from 26 sites and 12 countries. The real-world patients represent those undergoing intervention for BTK arteries with the Lutonix® 014 DCB. The study had both, primary safety and primary efficacy endpoints. The primary safety endpoint was freedom at 30 days from BTK major adverse limb event (MALE) + perioperative death (POD). Primary efficacy was freedom from clinically driven target lesion reintervention (fTLR) at 6 months. Additional secondary endpoints related to safety were reported. The interim 6 months' results showed freedom from MALE and POD at 30 days of 98.6% and at 6 months (180 days) of 96.0%. Primary efficacy of fTLR at 6 months (180 days) was 87.9%. Safety related secondary endpoints at 6 months (180 days) showed freedom from all of the following: all cause death of 91.2%, above ankle amputation 97.1%, reintervention for thrombosis 95.2%, reintervention for distal embolization 100.0%, and target vessel revascularization of 88.0%. There were no unexpected device or drug related events reported. The interim 6-month outcomes demonstrate the safety and efficacy of the Lutonix® 014 DCB for the treatment of BTK arteries.

National audit shows diabetic foot care suffers from variation between services in ulcer outcomes

National audit shows diabetic foot care suffers from variation between services in ulcer outcomes

Abstract 21100: Long-Term Clinical Outcomes of Patients With Chronic Kidney Disease and Critical Limb Ischemia Underwent Percutaneous Transluminal Angioplasty

Background: Critical limb ischemia (CLI) and chronic kidney disease (CKD) are associated with poor outcomes. We assessed the 5-year clinical outcomes of CKD versus non-CKD patients (pts) with CLI who underwent peripheral transluminal angioplasty (PTA). Methods: A total 765 consecutive CLI pts underwent PTA were analyzed. CKD is defined as either kidney damage or estimating glomerular filtration rate (GFR) &lt; 90 mL/min/m 2 . Kidney damage is defined as pathologic abnormalities or markers of damage, including abnormalities in blood or urine tests or imaging studies. Patients (pts) were divided into two groups according to the presence of CKD (CKD group: 465 pts, non-CKD group: 300 pts). To adjust for any potential confounders that could cause bias, propensity score matching (PSM) analysis was performed. Five-year clinical outcomes were assessed by Kaplan-Meier curved analysis and log rank test. Results: The CKD stage of study populations showed that 42% had mild, 21% moderate, 3% severe, and 32% kidney failure or dialysis. After PSM analysis, two matched groups (226 pairs, n= 452 pts) were generated and their baseline characteristics were balanced. During the 5-year clinical follow-up, there were no differences in the incidence of myocardial infarction, strokes and coronary or peripheral revascularization between the two groups. However, the incidence of total death and the above the ankle amputation were higher in the CKD group than the non-CKD group [Table]. Conclusion: CKD pts with CLI had higher incidence of mortality and amputation rate at 5 years following standard PTA compared with non-CKD pts. Improved therapies and special care are needed for this high-risk group of patients.

Dismounted complex blast injuries

Category: Trauma Introduction/Purpose: The United States Medical Corps has continued to evaluate and define the injury patterns of our service members in an effort to prevent injury and improve combat casualty care. The pattern of injury can be predicted by the mechanism of injury. One of the more recently described and studied mechanisms has been coined the ‘dismounted complex blast injury. This injury pattern involves traumatic amputation of at least one leg with a second injury involving another extremity in addition to an injury to either the pelvis, the abdomen, or the urogenital region. The purpose of this study was to better define and describe the injuries occurring to the non amputated extremity. Methods: This is a retrospectively review of data from the US and UK Joint Theater Trauma Registries (JTTR) of consecutive patients admitted to the UK Role 3 hospital at Camp Bastion, Afghanistan, from January 1, 2009, to February 29, 2012. Data was obtained from the US JTTR (Joint Theatre Trauma Registry). Each patient was assigned an Injury Severity Score (ISS) and an Abbreviated Injury Scale (AIS) score. Only those patients with an AIS of 3 or greater (a serious injury) were included. All xrays and CT scans were evaluated by two board certified orthopaedic surgeons and one board certified musculoskeletal radiologist. Fisher’s exact test was used to compare categorical data and binomial logistic regression was be used to compare proportions of types of injuries by traumatic amputation level observed. Results: There were 295 patients with lower extremity injuries identified. 201 had traumatic lower extremity amputations, 140 with bilateral lower extremity amputations, 61 with single leg amputations. The mean age was 23.38 +/-3.77 years. All were male. Below the knee amputation was the most frequent amputation type observed, representing 55.7% of the amputations (29/52), the next most frequent was the through knee amputation representing 25%. The least frequent was the through ankle amputation. The presence of a symes level amputation was associated with an 8.1% increase in the odds of the presence of a skeletal foot injury in the rear lower extremity. There was also an association found between AKA level amputation and skeletal injury in the contralateral upper extremity . Conclusion: This is among the first studies to correlate level of injury and associated musculoskeletal injury for the Afghanistan theater of operations. The results of this data set demonstrate that proximal lower extremity amputation levels are significantly associated with distal upper extremity skeletal injury. In addition, the Symes level of amputation is significantly associated with contralateral foot fractures. Amputation levels proximal to the ankle often present with associated Genitourinary injuries. Unique to this study is the demonstration of a significant association of upper extremity injury with a more proximal lower extremity amputation level .

Application of shortened replantation combined with limb lengthening in treatment of severe amputation of middle and distal lower leg

To investigate the effectiveness and technical points of shortened replantation combined with limb lengthening in the treatment of severe amputation of middle and distal lower leg. Twelve cases of severe amputation of middle and distal lower leg were treated with shortened replantation at the 1st stage and limb lengthening at the 2nd stage between April 2009 and May 2016. There were 9 males and 3 females with an average age of 28 years (range, 16-32 years). The injury causes included traffic accident injury in 4 cases, heavy pound injury in 6 cases, and machine crush injury in 2 cases. The interval from injuries to treatment ranged from 30 minuts to 6 hours (mean, 3 hours and 12 minutes). All of 12 cases, 6 cases were completely amputated in the right middle and distal lower leg, 4 were not completely amputated in the left middle and distal lower leg, and 2 were ankle amputations. The limbs were 4.0-12.5 cm shorter than the contralateral sides, with an average of 7.3 cm. Limb lengthening was performed at 1.5-8.0 months after replantation and the time of extension was 1.7-5.3 months (mean, 3.1 months). All 12 patients recovered the same lengths of both lower extremities after shortened replantation and limb lengthening. The lengthened segments gained good bone mineralization, bony union was achieved at lengthened segments and broken end of fracture at 7-16 months (mean, 11.3 months). All patients were followed up 6 months to 5 years (mean, 2 years and 5 months). The range of motion of the knee joint were 0-5° (mean, 3°) in hyperextension and 110-140° (mean, 120°) in flexion. Except for 2 cases of ankle arthrodesis, plantar flexion angles were 15-45° (mean, 26°) and dorsiflexion angles were 10-25° (mean, 15°) in the other cases. The plantar sensation was restored to the S 3 + level in 4 cases, S 3 level in 6 cases, and S 2 level in 2 cases. At last follow-up, the affected limb function were excellent in 7 cases, good in 3 cases, fair in 2 cases according to Kofoed functional evaluation criteria. It expanded indications for replantation of lower limb amputation, reduced the operation difficulty and trauma with shortened replantation combined with limb lengthening in the treatment of severe amputation of middle and distal lower leg.

Outcomes of Isolated Tibial Endovascular Intervention for Rest Pain in Patients on Dialysis

Tibial interventions for critical limb ischemia are frequent in patients with end-stage renal disease (ESRD) presenting with critical ischemia. The aim of this study was to examine impact of ESRD on the patient-centered outcomes following tibial endovascular Intervention for rest pain. A database of patients undergoing lower extremity endovascular interventions between 2006 and 2016 was retrospectively queried. Patients with rest pain (Rutherford 4) were identified. Patients with claudication (Rutherford 1 to 3) and tissue loss (Rutherford 5 and 6) were excluded. Patients were categorized by the presence or absence of ESRD. Patient-orientated outcomes of clinical efficacy (CE; absence of recurrent symptoms, maintenance of ambulation, and absence of major amputation), amputation-free survival (AFS; survival without major amputation), and freedom from major adverse limb events (MALEs; above ankle amputation of the index limb or major reintervention new bypass graft, jump/interposition graft revision) were evaluated. A total of 829 patients (56% male, average age 59years; 658 nonhemodialysis [non-HD] and 171 HD) underwent isolated tibial intervention in one leg for rest pain. Technical success was 99% with a median of 2 vessels treated per patient. There was no difference in the distribution of Trans-Atlantic Inter-Society Consensus I lesions, but both the modified Society for Vascular Surgery (SVS) runoff score and the pedal runoff score were worse in the HD group. The 30-day major adverse cardiac events and 30-day MALEs were equivalent in both groups. CE was 38±9% and 19±8% at 5years for the non-HD and HD groups, respectively (P<0.01). Overall, AFS was 45±8% and 18±9% at 5years for the non-HD and HD groups, respectively (P<0.01). Freedom from MALE was 41±9% and 21±8% at 5years for the non-HD and HD groups, respectively (P<0.01). Patients with ESRD who present with rest pain have equivalent short-term outcomes to those not on dialysis but do not achieve long-term satisfactory CE and AFS after isolated tibial intervention for rest pain.

Association between phantom limb complex and the level of amputation in lower limb amputee

ObjectiveThe aim of this study was to evaluate the natural course of phantom limb complex without any treatment after lower limb amputation. MethodsThe study design was consisted of a combination of retrospective review and cross-sectional interview. 101 patients with lower limb amputation were included into the study. Patients were divided into three groups according to the amputation level: i) from hip disarticulation to knee disarticulation (including knee disarticulation) (25 patients, mean age: 55.9, 19 males, 6 females) ii) transtibial amputation (below knee to ankle including ankle disarticulation) (41 patients, mean age: 58.6, 33 males, 8 females) iii) below ankle to toe amputation (35 patients, mean age: 58.7, 26 males, 9 females). The patients were evaluated on both early postoperative period (EPP) and sixth months after the surgery (ASM). The data related amputation including amputation date, level, cause, stump pain (SP), phantom limb pain (PLP), components of PLP, phantom sensation (PS) were recorded based on the information obtained from patients' and hospital files. ResultsStatistically significant differences were found for pain intensity (VAS) between groups for SP and PLP at EPP (p < 0.001, p = 0.036; respectively). The mean VAS score in Group I for SP and PLP was higher than other groups. This differences for SP and PLP did not continue at ASM assessment (p = 0.242, p = 0.580; respectively). ConclusionVAS scores for SP in above knee amputations and VAS scores for PLP in above knee amputations and below ankle amputations were higher at EPP. But these high scores had disappeared over time. Management strategies have to be considered particularly in the early postoperative period in patients who had undergone above knee amputation. Level of EvidenceLevel III Prognostic study.

Evaluating Blood Loss and the Effect of Antiplatelet Treatment inFootand Ankle Amputations.

The interrelationship between diabetes mellitus and cardiovascular disease is well-documented, and, secondary to the latter, is the use of antiplatelet therapy. Although diabetes and the associated vascular manifestations are driving forces behind lower extremity amputations, few data are available on the risks of perioperative antiplatelet therapy with foot and ankle amputations. The goal of the present study was to address the surgical effect of continuing or discontinuing antiplatelet therapy before foot and/or ankle amputation. The following data were retrospectively collected: blood loss, pre- and postoperative hematocrit and hemoglobin, operative time, amputation type, age, diabetic status, antiplatelet treatment, and number of transfusions during the perioperative period. Perioperative antiplatelet therapy was defined as exposure to aspirin or clopidogrel within 3days before surgery. To compare the outcomes between groups, the following factors were analyzed using bivariate analyses and then multivariate regression models: (1) the need for transfusions, (2) high blood loss (>20mL), (3) volume of blood loss, and (4) operative time. The noninferiority of continued antiplatelet use was assessed in terms of operative time and blood loss, using a noninferiority margin of 10minutes or 10mL, respectively. Antiplatelet therapy was not a statistically significant risk factor for any of the studied outcomes on multivariate analysis. Equivalence testing revealed that continuing antiplatelet therapy is not inferior to discontinuing perioperative therapy in terms of blood loss and operative time. Multivariate analysis of the data suggested that antiplatelet therapy has no statistically significant impact on blood loss, transfusion rate, or operative time.

Predicting prosthetic prescription after major lower-limb amputation.

We describe prosthetic limb prescription in the first year following lower-limb amputation and examine the relationship between amputation level, geographic region, and prosthetic prescription. We analyzed 2005 to 2010 Department of Veterans Affairs (VA) Inpatient and Medical Encounters SAS data sets, Vital Status death data, and National Prosthetic Patient Database data for 9,994 Veterans who underwent lower-limb amputation at a VA hospital. Descriptive statistics and bivariates were examined. Cox proportional hazard models identified factors associated with prosthetic prescription. Analyses showed that amputation level was associated with prosthetic prescription. The hazard ratios (HRs) were 1.41 for ankle amputation and 0.46 for transfemoral amputation compared with transtibial amputation. HRs for geographic region were Northeast = 1.49, Upper Midwest = 1.26, and West = 1.39 compared with the South (p < 0.001). African American race, longer length of hospital stay, older age, congestive heart failure, paralysis, other neurological disease, renal failure, and admission from a nursing facility were negatively associated with prosthetic prescription. Being married was positively associated. After adjusting for patient characteristics, people with ankle amputation were most likely to be prescribed a prosthesis and people with transfemoral amputation were least likely. Geographic variation in prosthetic prescription exists in the VA and further research is needed to explain why.

Macrovascular complications in diabetics in the Centre for Diabetes Bjelovar during the period from January 2003 to April 2014

Cardiologia CROATICA The goal: To present the incidence of macrovascular diabetic complications in outpatients in the Centre for Diabetes in the Bjelovar-Bilogora County during the period from January 2003 to April 2014. Patients and Methods: Data were collected by using the database of the computer software CroDiab NET as a part of the national registry for diabetes. Risk factors prevalence and glycemic regulation data in diabetics of the Centre for Diabetes in Bjelovar Bilogora county have been already published. This study included 4,631 electronic health records processed during the follow-up period, considering the history of myocardial infarction, stroke, below ankle amputations, above ankle amputations and claudications. Results: The most common macrovascular complication in this patient group is myocardial infarction (about 10% of patients). The second most common macrovascular complication was stroke (9%), followed by claudications (4.58%), below ankle amputations (2.46%) and above ankle amputations (2.06%). The lowest value of myocardial infarction was 7.4% in 2010. The prevalence of patients with stroke also showed a downward trend from 14.9% in 2007 to 7.4% in 2012. Amputations below the ankle show the highest rate of 3.83 % in 2007, but with a clear downward trend to 1.56% in 2013, and with further decline to 0.86% in the first four months of 2014. The frequency of amputations above the ankle shows even greater fall from 6.82% in 2003 to 0.88 % in 2013, followed by a further downward trend. Frequency of patients with claudications shows downward trend from 7.39% in 2003 to 3.45% in April 2014. Conclusions: The most common macrovascular complication was myocardial infarction, followed by stroke, and peripheral arterial insufficiency (claudications and amputations). The registered downward trend of macrovascular complications can be explained by good and even better glycemic control and management of cardiovascular risk factors. Good disease control pays off!