Below-knee Amputation Research Articles

Outcomes of Tibiocalcaneal Arthrodesis in High Risk Patients: An Institutional Cohort of 18 Patients

Category:HindfootIntroduction/Purpose:Tibiocalcaneal (TC) arthrodesis is commonly performed in patients with severe hindfoot disease. These include severe Charcot deformities, ankle malformations, chronic osteomyelitis (COM), and avascular necrosis (AVN). The talar vasculature becomes disrupted to the point that the bone can no longer be salvaged. The procedure involves performing a talectomy and fusing the tibia to the calcaneus. This helps in preserving the remaining hindfoot anatomy while allowing the patient to regain function and mobility. Our study highlights certain risk factors that influence the rate of postoperative complication after tibiocalcaneal surgery.Methods:We retrospectively reviewed the charts of 18 patients from a single institution who underwent tibiocalcaneal arthrodesis between the years of 2011 and 2019. Preoperative diagnoses, comorbidities, post-operative outcomes were noted among all patients. Then, the rates of non-union, below-knee amputations, revision surgeries, postoperative infections, and hardware failure were recorded. This data was then analyzed to determine which preoperative and perioperative factors affected postoperative outcomes for patients after tibiocalcaneal arthrodesis surgery.Results:Nonunion was the most commonly reported complication in this series. Eight of the eighteen patients were documented to have nonunion including three patients with stable pseudarthrosis. Diabetic patients had a slightly higher incidence of nonunion (4 of 7 patients) compared to those without diabetes (4 of 11 patients). Of the 9 patients diagnosed with Charcot arthropathy, 5 had nonunion. Three of five individuals with a BMI ranging from 25-30, and four of six individuals with a BMI of greater than 30 had a nonunion. Infection was a post-operative complication for four of the eighteen patients. Two of the four patients had multiple comorbidities in addition to chronic infections in the joint which were recurrent after surgery.Conclusion:In conclusion, TC arthrodesis provides a viable option for high risk patients with complicated ankle pathology who have not had successful outcomes from previous treatment. It is not without complications considering the comorbidities the patients present with before requiring this procedure. Further studies are necessary in order to validate the trends of outcomes and comorbidities of patients with TC arthrodesis.

Intra-surgical Site Vancomycin Powder Application in Infected Diabetic Heel Ulcers with Calcaneal Osteomyelitis

Category:Diabetes; HindfootIntroduction/Purpose:The treatment of diabetic heel ulcers (DHU) with osteomyelitis is challenging, and dismal clinical results have been reported after calcanectomy, with reported revision rates of 0-63.5%. The topical application of vancomycin powder has reported to be beneficial in foot and ankle surgery amongst diabetic patients. However, no studies have examined the efficacy of intra-surgical site vancomycin powder application in DHU surgery. There are potential risks of intra-surgical site vancomycin powder application, such as the selection of gram-negative and multi-drug resistant bacteria, and increased wound complications. Thus, we aimed to 1) assess the clinical outcomes of calcanectomy for DHU and 2) investigate the clinical efficacy of intra-surgical site vancomycin powder application in patients who underwent partial- or total calcanectomies performed to treat infected DHU with osteomyelitis.Methods:This study was approved by our institution’s Research Subjects Review Board. Subjects were identified utilizing current procedural terminology code 28120 (Partial excision bone; talus or calcaneus) for partial or total calcanectomies performed at our academic institution. Thirty-eight calcanectomies performed secondary to DHU with osteomyelitis were identified. Patient demographics (age, sex, gender, body mass index), preoperative labs (hemoglobin A1c, blood glucose, white blood cell, erythrocyte sedimentation rate, C-reactive protein, serum creatinine, hemoglobin), ASA Class, peripheral arterial disease assessed by ankle-brachial index, Charleston Comorbidity Index, and intra-surgical site application of vancomycin powder were recorded. Duration of follow-up, type and quantity of systemic antibiotics administered during surgery, surgical complications, and return to the operating room (RTOR) were also recorded. There were two cohorts: those whose surgical wound was closed without vancomycin powder (initial 25 patients; ‘novancomycin’ group) versus those whose surgical site was closed with vancomycin powder (later 13 patients; ‘vancomycin’ group).Results:The average follow-up was 26.1 +- 15.0 months. Surgical pathology confirmed negative bone resection margins for all patients. Nineteen patients required an unplanned RTOR (50.0%). A revision amputation was performed in fifteen extremities (39.5%). Thirteen patients received intrawound vancomycin at closure, and 25 did not. Nine of thirteen (69.2%) patients who received vancomycin powder required RTOR. This includedTwo below-knee amputations (BKA), two irrigation and debridements (I&D), and six revision or total calcanectomies. There was a significantly higher rate of RTOR in the vancomycin cohort relative to the no-vancomycin cohort (76.9% vs 36.0%, p=0.038). Of the 25 no-vancomycin group, 17 did not return to the OR, 4 underwent BKA, 1 had I&D, and 2 required revision or total calcanectomy.Conclusion:In our cohort, calcanectomy performed for the surgical management of DHU with osteomyelitis yielded a high rate (50%) of unplanned follow-up procedures. Intra-surgical site vancomycin powder application during wound closure after calcanectomy did not result in clinical benefit and is likely unnecessary. The risk and benefit profile of intra-surgical site vancomycin powder application for diabetic foot infection surgery needs to be further investigated.

Arthroscopic Tibiotalar Arthrodesis versus Open Arthrodesis with Anterior Locking Plate: A Retrospective Case Series

Category:Ankle; Ankle Arthritis; ArthroscopyIntroduction/Purpose:Tibiotalar arthrodesis is a common procedure for the treatment of ankle arthritis. Arthroscopic arthrodesis with screw fixation has become increasingly popular with reported shorter hospital stays, shorter time to fusion, and equivalent patient reported outcomes to open arthrodesis with screw fixation. However, there is limited research comparing arthroscopic arthrodesis to open arthrodesis with a modern anterior locking plate. The aim of this study was to determine if the use of a modern anterior locking plate in primary ankle arthrodesis would have a similar time to fusion versus arthroscopic arthrodesis with screw fixation.Methods:We performed a retrospective case review of primary ankle arthrodesis cases from 2009 to 2018 that utilized either an open approach with an anterior locking plate or an arthroscopic approach with screw fixation. All open cases were performed by a single surgeon using an anterior locking plate; all arthroscopic cases were performed by another surgeon using cannulated screw fixation. Post-operative protocol was similar for both patient groups, with at least 6 weeks of casting and protected weight- bearing followed by a transition to removable cast-boot and progressive weight-bearing. Exclusion criteria included combined tibiotalar/subtalar arthrodesis, hindfoot arthrodesis, cases where infection was suspected pre-operatively, and revision arthrodesis for any reason (IE, infection, failed total ankle arthroplasty, prior nonunion). Time to fusion was based on evaluation of post- operative radiographs performed at six and ten weeks.Results:28 open and 25 arthroscopic arthrodesis cases met inclusion criteria. The fusion rate at six weeks was 82.1% (open) versus 72% (arthroscopic). At ten weeks the fusion rate was 100% (open) versus 91% (arthroscopic). 4/28 open arthrodesis cases experienced continued pain versus 8/25 arthroscopic. For the open procedure, one patient required reoperation for skin grafting away from the incision due to a poor-fitting workboot. Two patients had removal of painful hardware; one of these patients required a second reoperation for symptomatic neuroma resection. For arthroscopic cases, two patients had removal of hardware and one patient had an elective below-knee amputation for intractable pain. Average patient age was 53.3 years (open) versus 48.4 (arthroscopic). Average length of hospital admission was 2.3 days (open) versus 0.9 (arthroscopic).Conclusion:Open tibiotalar arthrodesis with a modern anterior locking plate resulted in faster time to radiographic fusion and a lower incidence of continued pain compared to arthroscopic arthrodesis in this study. The faster time to fusion may be due to the superior biomechanical stability of a locking construct. Arthroscopic arthrodesis resulted in shorter hospital admissions, and neither group had any incision-related complications. In this case series, open and arthroscopic fusion had comparable outcomes.

Comparing preference of ankle\u2013foot stiffness in below-knee amputees and prosthetists

When fitting prosthetic feet, prosthetists fuse information from their visual assessment of patient gait with the patient’s communicated perceptions and preferences. In this study, we sought to simultaneously and independently assess patient and prosthetist preference for prosthetic foot stiffness using a custom variable-stiffness prosthesis. In the first part of the experiment, seven subjects with below-knee amputation walked on the variable-stiffness prosthetic foot set to a randomized stiffness, while several prosthetist subjects simultaneously observed their gait. After each trial, the amputee subjects and prosthetist subjects indicated the change to stiffness that they would prefer (increase or decrease). This paradigm allowed us to simultaneously measure amputee subject and prosthetist subject preferences, and provided a reliability index indicating the consistency of their preferences. In the second part of the experiment, amputee subjects were instructed to communicate verbally with one prosthetist subject to arrive at a mutually preferred stiffness. On average, prosthetist subjects preferred a 26% higher stiffness than amputee subjects (p < 0.001), though this depended on the amputee subject (p < 0.001). Prosthetist subjects were also considerably less consistent than amputee subjects in their preferences (CV of 5.6% for amputee subjects, CV of 23% for prosthetist subjects; p = 0.014). Mutual preference seemed to be dictated by the specific patient-prosthetist dynamic, and no clear trends emerged.

Targeted muscle reinnervation at the time of amputation in the management of complex regional pain syndrome of the lower extremity.

Complex regional pain syndrome (CRPS) is a chronic, posttraumatic condition defined by severe pain and sensorimotor dysfunction. In cases of severe CRPS, patients request amputation, which may cause phantom limb pain (PLP) and residual limb pain (RLP). Targeted muscle reinnervation (TMR) reduces the risk of PLP and RLP. This report describes the use of TMR at the time of amputation in a series of patients with CRPS. Four patients (ages 38-71 years) underwent TMR at the time of amputation for CRPS between April 2018 and January 2019. Three patients had a history of trauma and surgery to the affected limb. All patients attempted pharmacologic and interventional treatments for 1-7 years before requesting amputation. Three patients underwent below-knee amputations (BKA) and one had an above-knee amputation (AKA). Target muscles included the soleus, gastrocnemius, and flexor hallucis longus (BKA), and semitendinosus, biceps femoris, and vastus medialis (AKA). Postoperative phantom and residual limb pain symptoms were collected via a telephone survey adapted from the Patient-Reported Outcomes Measurement Information System (PROMIS). There were no complications related to the TMR procedure. Average follow-up time was 12.75 months. Patients reported varied outcomes: two had RLP and PLP, one had RLP only, and one had PLP only. All patients reported successful prosthetic use. TMR may be performed at the time of amputation for CRPS. Further study is necessary to determine the effect of TMR on pain, pain medication use, prosthesis use, and other domains of function.

Inhibitors of SGLT2 and DPP-4 have similar risk of below-knee amputation

Inhibitors of SGLT2 and DPP-4 have similar risk of below-knee amputation

A Novel Approach to Limb Salvage: Healing Transmetatarsal Amputations without a Viable Plantar Flap

The lack of a viable plantar flap in patients undergoing transmetatarsal amputation has been considered an indication for below-knee amputation (BKA). In an effort to reduce limb loss in this patient population, we sought to review our experience with transmetatarsal amputation salvage in patients with an open, guillotine transmetatarsal amputation. We hypothesized that performing a transmetatarsal amputation without a viable flap would extend time of independent ambulation and improve limb salvage. This is a retrospective review of 27 consecutive patients who did not have a viable plantar flap and who underwent an open, guillotine transmetatarsal amputation. Patients presented with a nonviable plantar flap due to either extensive tissue loss on initial presentation, or secondary transmetatarsal amputation (TMA) flap necrosis. Patients initially underwent an open, guillotine TMA for control of infection and debridement of nonviable tissue. To achieve best results, during procedure, the metatarsals were resected to be as flush with soft tissue as possible. Once infection was resolved and all nonviable tissue debrided, negative pressure wound therapy (NPWT) was applied to the open wound. NPWT was continued until a base of granulation tissue covered the previously exposed bone. Wound closure was obtained by either the application of a split-thickness skin graft (STSG) or through continued NPWT allowing the wound to heal by secondary intention. Between January 2016 and December 2018, there were 27 open TMAs performed in 27 patients. Two patients did not granulate sufficiently and underwent BKA. Fourteen patients underwent STSG for closure, whereas 11 patients continued with NPWT. In the STSG group, 12 (86%) of the patients are healed, with a median time to complete healing of 75days (range 28-330days); the remaining 2 are ambulatory and undergoing continued wound care. In the 11 patients who did not receive STSG, 7 (64%) are healed with a median time to heal of 165days. Of the remaining 4 patients in this group, 3 are ambulatory and still undergoing wound care, one was lost to follow-up. Overall, 19 patients (70%) have completely healed with a median time to heal of 82days. Limb salvage in patients with a nonviable plantar flap for TMA is possible and should be a considered procedure. This technique has the potential to improve functional outcomes and limb salvage in patients who might otherwise undergo BKA.

Contemporary Outcomes of Peripheral Bypass Compared with Amputation in Octogenarians

Chronic limb threatening ischemia in octogenarians presents unique treatment challenges in patients with multiple comorbidities and variable functional status. Endovascular interventions offer a better risk profile; however, this is not always a feasible option for anatomic or disease-specific reasons. This study compares outcomes of peripheral bypass versus amputation in octogenarians. The American College of Surgeon's National Surgical Quality Improvement Program database was queried from 2013 to 2016 for patients >80 years undergoing femoral-popliteal bypass (FPB), femoral-tibial bypass, or popliteal-tibial bypass with vein or prosthetic graft versus above-knee amputation (AKA) or below-knee amputation. Patients presenting with systemic inflammatory response syndrome, sepsis, septic shock, or a leukocytosis >11,000 were excluded. Patient demographics, risk factors, and 30-day unadjusted outcomes were analyzed. Multivariate regression analysis was then performed to compare risk adjusted 30-day morbidity and mortality. The bypass group contained 2226 patients compared with 1253 patients in the amputation group. AKA represented 59.9% of the amputation group. The largest portion of bypasses were FPBs at 58.6%. Total preoperative functional dependence was 1.3% for bypass versus 18.2% for amputation (P-value, <0.01). Risk factors for amputation over bypass included age, minority race, American Society of Anesthesiologists class IV-V, diabetes, congestive heart failure, dialysis, preoperative open wound, facility of origin, and functional dependence. Unadjusted 30-day mortality was 3.6% for bypasses and 7.7% for amputations (P-value, <0.01), with an in-hospital mortality of 2.0% vs. 3.2% and a mortality after discharge of 1.6% vs. 4.5%, respectively (P-value <0.01). Unadjusted morbidity was not significantly different between the 2 groups (18.7% bypass vs. 17.8% amputation, P-value, 0.52). After multivariate risk adjustment, there was no statistically significant difference in mortality or morbidity between the groups. Contemporary risk-adjusted 30-day morbidity and mortality for bypass versus amputation in octogenarians show no significant difference. These data demonstrate that aggressive surgical limb salvage can be safe in well-selected patients in this age group.

Interventions for motor rehabilitation in patients with below-knee amputation due to peripheral arterial disease or diabetes

Interventions for motor rehabilitation in patients with below-knee amputation due to peripheral arterial disease or diabetes

Feasibility of Bent-Knee Prosthesis for Early Ambulation After Below-Knee Amputation

Feasibility of Bent-Knee Prosthesis for Early Ambulation After Below-Knee Amputation

Extensive Deep Tissue Involvement in Nicolau Syndrome and Below-Knee Amputation: A Case Report and Literature Review.

Nicolau syndrome (NS) is a rare cutaneous drug reaction in response to injections administered via any route. Based on the available studies in the medical literature, NS presents as skin and subcutaneous fat necrosis, and typically, it does not cause severe complications such as acute limb ischemia or death. In this study, we report the case of a 6-year-old boy who received an intramuscular injection of benzathine penicillin G for the treatment of bacterial pharyngitis, and subsequently developed a severe case of NS, which eventually led to below-knee amputation of the right lower limb. Although a few approaches have been suggested for the management of NS, they might not be effective under certain circumstances. Early detection, close monitoring, and consistent interventions, such as surgical fasciotomy and debridement procedures, might be necessary in severe cases of NS.

In-Hospital Morbidity and Mortality of Traumatic Lower-Extremity Amputations.

Traumatic lower-extremity amputations often result in complications and surgical revisions. The authors report the in-hospital morbidity and mortality of traumatic lower-extremity amputations at a metropolitan level I trauma center for a large rural region and compare below-knee (BK) vs higher-level amputation complications. They retrospectively reviewed 168 adult patients during a 10-year period (2005 to 2015) who had a traumatic injury to the lower extremity that required an amputation. Main outcome measurements included amputation level, complication rates, intensive care unit (ICU) admission rates, length of stay, total trips to the operating room (OR), and Injury Severity Score (ISS). A total of 95 patients had through-knee/above-knee (TK/AK) amputations, and 73 patients had BK amputations. The majority of injuries occurred in the non-urban setting. The TK/AK group had higher ICU admission rates (76% vs 35%, P<.0001), longer overall hospital length of stay (22.0 vs 15.5 days, P=.01), more total OR trips (6.5 vs 5.0, P=.04), and higher ISS (17.0 vs 11.5, P<.0001). A complication was experienced by 64% of all patients during the initial hospitalization. The TK/AK group had higher complication rates than the BK group, including wound infection, pulmonary embolus, rhabdomyolysis, compartment syndrome, and death. Patients with TK/AK traumatic amputations have a greater burden of injury with higher complication rates, increased ICU admissions, increased length of stay, and increased ISS and require more return trips to the OR compared with patients with BK amputations. [Orthopedics. 2020;43(6):e561-e566.].

Sodium-Glucose Cotransporter 2 Inhibitors and the Risk of Below-Knee Amputation: A Multicenter Observational Study.

Reports of amputations associated with sodium-glucose cotransporter 2 (SGLT2) inhibitors have been inconsistent. We aimed to compare the risk of below-knee amputation with SGLT2 inhibitors versus dipeptidyl peptidase 4 (DPP-4) inhibitors among patients with type 2 diabetes. This multicenter observational study used administrative health care databases from seven Canadian provinces and the U.K. Incident SGLT2 inhibitor users were matched to DPP-4 inhibitor users using a prevalent new-user design and time-conditional propensity scores. Cox proportional hazards models were used to estimate site-specific adjusted hazard ratios (HR) and corresponding 95% CIs of incident below-knee amputation for SGLT2 inhibitor versus DPP-4 inhibitor users. Random effects meta-analyses were used to pool the site-specific results. The study cohort included 207,817 incident SGLT2 inhibitor users matched to 207,817 DPP-4 inhibitor users. During a mean exposed follow-up time of 11 months, the amputation rate was 1.3 per 1,000 person-years among SGLT2 inhibitor users and 1.5 per 1,000 person-years among DPP-4 inhibitor users. The adjusted HR of below-knee amputations associated with SGLT2 inhibitor use compared with DPP-4 inhibitor use was 0.88 (95% CI 0.71-1.09). Similar results were obtained in stratified analyses by specific SGLT2 inhibitor molecule. In this large multicenter observational study, there was no association between SGLT2 inhibitor use and incident below-knee amputations among patients with type 2 diabetes compared with DPP-4 inhibitor use. While these findings provide some reassurance, studies with a longer duration of follow-up are needed to assess potential long-term effects.

Natural History After Below-knee Amputation: Analysis of Survival and Prosthetic Fitting Over 2 Decades

IntroductionThis study sought to evaluate the natural history of patients undergoing below-knee amputation (BKA) and compare their evolution over 2 decades, as well as survival predictors, prosthetic fitting, and contralateral amputation. MethodsRetrospective study of 209 consecutive patients (mean age 72.9 years; 68% males) who underwent BKA in 2 periods: 1996–2005 and 2006–2015. The fitting of prostheses, risk of contralateral amputation and survival, as well as their predictive factors, were assessed by survival analysis. Results133 BKA were performed from 1996 to 2005 and 106 from 2006 to 2015. The etiology that motivated the BKA was acute ischemia (4.3%), chronic ischemia (34.0%), infection (9.1%) or mixed (chronic+infection, 52.6%), with no differences found between periods. Survival: mortality within one month=9.2%, one year=31.9%, 2 years=43.8% and 5 years=63.9%, with no significant differences between the 2 periods. Prosthetic: the fitting rate was 44.5% throughout the follow-up, with no significant differences between the two periods. 41.1% patients managed to walk. Contralateral amputation: 20.1% of the patients later required a major contralateral amputation, with no significant differences between the two periods. ConclusionsIn the last decade, fewer BKA have been performed probably, due to higher previous interventional revascularization. Despite this, the results of fitting, contralateral amputation or survival was not modified. In any case, the number of patients who are able to achieve ambulation is modest, so it emphasizes the need for an optimal selection of patients with BKA with the goal of prosthetic fitting.

Child of steel

Allergic reactions to metal implants have been on the rise reaching an incidence of 10-17% in the general population. In Asia, nickel ranks among the top five most common source of metal sensitivity. We present a case of nickel allergic contact dermatitis secondary to an orthopaedic implant. 12/M with chronic osteomyelitis of the left tibia presented with non-union of the bones necessitating an Ilizarov fixator implant using conventional SAE 16 stainless steel plate and bone graft. After 9 months, there was paucity of the bone allograft necessitating adjustment of the Ilizarov fixator and repeat bone allograft. 2 weeks after the second revision of the metal implant, the child manifested with pruritic wheals on both his flanks lasting for a week. Months later, the wheals developed along the pin tracts with serous exudate. Orthopaedics entertained a possible hypersensitivity to the metal implant and the fixator was removed. For further work-up, the child was referred to dermatology and allegro-immunology service whereupon further history revealed that he has a prior undocumented allergy to metal accessories when he was 6 years old. A patch test was later performed revealing +1 reaction to nickel. Failure of the union of the left tibia and decreasing function of the left leg necessitated a below-knee amputation and subsequent application of a prosthetic limb. This is a rarely reported case of metal implant allergy in a pediatric patient presenting as failure in wound healing and non-union of tibial fracture. This case further emphasizes the importance of a complete medical history in assessing a patient with possible metal allergy and its proper diagnosis and management. This case also highlights the possible role of metal exposure and the patient’s chronic infection in the pathogenesis of bone non-union.

Present-day analysis of early failure after forefoot amputation

BackgroundForefoot transmetatarsal amputation is performed commonly to achieve limb salvage, but transmetatarsal amputations have a high rate of failure, requiring more proximal amputations. Few contemporary studies have examined the incidence of major amputation (transtibial or transfemoral) after transmetatarsal amputation. The goal of this study is to determine risk factors and outcomes for a more proximal amputation after forefoot amputation. MethodsWe queried the 2012 to 2016 database of the American College of Surgeons National Quality Improvement Program for patients undergoing a complete transmetatarsal amputation with wound closure by Current Procedural Terminology code. Patients requiring early (within 30 days) more proximal amputation after transmetatarsal amputation were compared with those who did not need further amputation. Characteristics of patients requiring more proximal amputation were examined, and a multivariable logistic regression model was created to identity risk factors for early more proximal amputation. ResultsIn the study, 1,582 transmetatarsal amputation were identified. Most patients were male (70%), white (59%), and diabetic (74%), with a median age of 63 years. More proximal amputation occurred in 4.2% of patients within the first 30 days postoperatively. This early failure was associated with greater hospital stays postoperatively (10 days vs 7 days), more wound complications (29% vs 11%), pneumonia (8% vs 2%), stroke (3% vs 0.1%), and overall complications (50% vs 28%; P ≤ .025 each). Although there was no difference in 30-day mortality (P = .27), there was a marked increase in unplanned readmission (59% vs 14%; P < .0001) for those undergoing reamputation. On multivariable analysis, preoperative systemic inflammatory response, sepsis, or septic shock (odds ratio 2.1; 95% confidence interval, 1.2–3.6) were independent predictors of more proximal amputation. ConclusionEarly below-knee or above-knee amputation early after transmetatarsal amputation leads to increased morbidity. Because patients with preoperative sepsis may be at increased risk of failure after transmetatarsal amputation, the level of amputation should be considered carefully in these patients.

MYXOID PLEOMORPHIC SARCOMA IN A NON-HEALING ULCER POST-BURN OF THE LEFT FOOT: A RARE CASE REPORT

Myxoid pleomorphic sarcoma is categorized as a soft-tissue sarcoma that most commonly appears in the lower extremities during adulthood, but rarely in the feet. We present a rare case of a primary myxoid pleomorphic sarcoma in the foot of a 45-year-old female which was rare in females. On examination, a ulceroproliferative growth of around 10 cm × 12 cm size was seen over the posterior aspect of foot involving the whole ankle region, with a thickened scar over the plantar and medial aspect of the right foot. Magnetic resonance imaging of the mass revealed a high signal intensity on T1-weighted images and heterogeneously high signal intensity on T2-weighted images without fat suppression. Histology showed variable cellularity, myxoid granular to the filamentous background, and round to spindled tumor cells. The immunohistochemistry showed positive for vimentin, acid mucins, CD34, and negative for S100. Hence, these findings were consistent with myxoid pleomorphic sarcoma. The patient was treated with below-knee amputation.

A five years retrospective study of factors influencing outcome of major lower limb amputations

Background: The word amputation is derived from Latin -Amputare - to cut away. The amputation is indicated when the limb is considered as dead limb/ deadly limb/ dead loss limb. Often cases are referred to tertiary centre late, resulting in complications which requires surgical management. Aim of the study was to compare the outcomes of major lower limb amputations and to identify risk factors associated with mortality and morbidity following major lower limb amputations.Methods: A retrospective observational study was done for 5 years between January 2014 to November 2019, comprising 276 patients undergoing major lower extremity amputations. Adult patients undergoing lower extremity amputations for ischemic, infected or gangrenous lower limb were included and patients who underwent amputations for trauma or tumours were excluded. The data regarding comorbidities, postoperative complications, outcome of major lower limb amputations were evaluated.Results: 276 patients underwent lower limb amputations (above knee amputations (AKA)-127, below knee amputations (BKA)-134, forefoot amputations-15). Male patients outnumbered females (6.7:1) and most of them were of elderly age group (mean age 60.56 years). The most common indications for amputations in our study were peripheral vascular disease (120), diabetes (87), necrotizing fasciitis (37). The 1 year mortality rates following lower limb amputations in our study were 14% (BKA) and 34% (AKA).Conclusions: Lower limb amputations are associated with high mortality rates. Mortality can be expected in both the early and the late postoperative periods and is most probably related to serious comorbidities, such as renal and heart disease, rather than the level of amputation.

Clinico-microbiological profile and outcome of diabetic foot ulcers

Background: Diabetic foot ulcers (DFU) are debilitating to the patients and significantly impair their quality of life. DFU associated with infection have the worst outcomes and may lead to amputations if timely intervention is not done. In the present study, aim was to identify the association between the type of organism isolated and the rates of amputations in diabetic foot ulcers.Methods: We retrospectively studied 50 diabetic foot ulcers from January 2017 to June 2017, who were in-patients in a single unit of surgery department in King George Hospital, Visakhapatnam. Baseline clinical examination was done. Parameters such as age, sex, duration, diabetic status and its treatment, organisms isolated, various treatment options for ulcers and the outcomes were studies.Results: Males were the predominant study subjects (M: F=32:18). The age of presentation was 18-65 years with an average of 46 years. Gram negative organisms were the frequent microbial isolates, all being mono-microbial infections. It was dominated by E. coli (17), Pseudomonas (12) and Klebsiella (11). Above-knee amputation was done in one patient and below-knee amputations in three patients. Total mortality in our study was 5. After applying the chi-square test, it was found that there is no significant association between the type of organism and the rate of amputations in our study.Conclusions: Diabetes is a significant risk factor for ulceration in the extremities, which possesses considerable mortality and morbidity. Early intervention, control of diabetes and compliance of the patient treatment are all necessary to reduce the rates of amputations and mortality in patients with diabetic foot ulcers.

Closed incision negative pressure wound therapy may decrease wound complications in major lower extremity amputations

ObjectiveWound complications after major lower extremity amputations (LEAs) are a cause of significant morbidity in vascular surgery patients. Recent publications have demonstrated the efficacy of the closed incision negative pressure dressing at preventing surgical site infections (SSIs); however, there are few data on its use in major LEAs. This study sought to assess if closed incision negative pressure wound therapy (NPWT) would decrease the risk of complications as compared with a standard dressing in patients with peripheral vascular disease undergoing major LEA. MethodsFifty-four consecutive patient limbs with a history of peripheral arterial disease underwent below-knee or above-knee amputations. This was a retrospective review of a prospectively maintained database from January 2018 to December 2019, and it included 23 amputations in the NPWT group and 31 amputations in the standard dressing group. NPWT using the PREVENA system was applied intraoperatively at the discretion of the operating surgeon and removed 5 to 7 days postoperatively. The standard group received a nonadherent dressing with an overlying compression dressing. Amputation incisions were assessed and wound complications were recorded. Student's t-test and two-sample proportion z-test were used for statistical analysis. A P value of less than .05 was considered statistically significant. ResultsFor comorbidities, there was a higher incidence of tobacco use in the NPWT as compared with the standard group (44% vs 13%; P = .011), as well as trends toward increased prior amputations, anemia, hyperlipidemia, and chronic obstructive pulmonary disorder in the NPWT group. For risk factors, there were more dirty wounds in the NPWT as compared with the standard group (52% vs 26%; P = .046). For outcomes, there were fewer wound complications in the NPWT as compared with the standard group (13% vs 39%; P = .037). The types of wound-related complications in the NPWT group included one wound dehiscence with a deep SSI, one superficial SSI, and one incision line necrosis. In the standard group, there were four wound dehiscences with deep SSI, three superficial SSIs, four incision line necroses, and one stump hematoma. The rates of perioperative mortality and amputation revision did not differ significantly between the NPWT and the standard groups (3% vs 4% and 4.3% vs 10%, respectively). ConclusionsClosed incision NPWT may decrease the incidence of wound complications in vascular patients undergoing major LEA. This held true even among a population that was potentially at higher risk. This therapy may be considered for use in lower extremity major amputations.