Below-knee Amputation Research Articles

The Utility of Advanced Lower-Extremity Duplex Using Pedal Acceleration Time in the Management of the Threatened Diabetic Foot.

Patients with diabetes and diffuse infrageniculate arterial disease who present with chronic limb-threatening ischemia require an exact anatomical plan for revascularization. Advanced pedal duplex can be used to define possible routes for revascularization. In addition, pedal acceleration time (PAT) can predict the success or failure of both medical and surgical interventions. A retrospective review of patients who were referred to our group for unilateral limb-threatening ischemia with isolated infrageniculate disease was conducted. Pedal duplex and PAT at the base of the wound was performed before and 1 week after intervention. The primary endpoint was limb salvage at 1 year. Revascularization was defined as direct or indirect based on the angiosome concept. Fifty-four patients meeting inclusion criteria presented over a 5-year period (toe wound, n = 42; heel wound, n = 8; both, n = 4). At 1 year, 10 (18.5%) had required below-knee amputation, whereas the remainder had healed/improved. Limb salvage was predicted by absence of ongoing smoking, absence of dialysis, and postprocedural PAT (class I/II). Limb salvage did not correlate with direct versus indirect revascularization. Advanced lower-extremity duplex in conjunction with determining PAT at the area of concern is a useful technique for mapping the vasculature and identifying targets for revascularization in patients with diffuse infrageniculate disease. Target artery revascularization to the wound bed resulting in a PAT less than 180 msec is predictive of limb salvage, regardless of whether perfusion is direct or indirect.

Effectiveness of Aerobic Training with Strengthening Exercise on Endurance in Patients with Below Knee Amputation: Experimental study

Background: Below-knee amputation (BKA) is a condition in which the limb is amputated in the transtibial levelin which the distal tibia, fibula, whole of the ankle joint, and associated musculature and other components areremoved.Purpose: To determine the effect of aerobic training with strengthening exercise to increase endurance in patientswith below knee amputation.Materials and Methods: Total of 30 subjects with below knee amputation were selected based on the selectioncriteria. All the subjects were well elucidated about the objective of the study and the intervention and informedconsent was obtained before participating in this study. The subjects received strengthening exercise and aerobictraining for 4 weeks. The pretest values are taken with 6MWT and Borg scale; the same were recorded for post-testafter 4 weeks of intervention. The entire process was performed from November 2022 to March 2023.Result: Using a paired t-test to compare the pre and post-test results, the experiment revealed a significant differencein 6MWT and Borg scale. Independent sample t-test outcome at four weeks showed significant improvement inendurance.Conclusion: The results and the data obtained from this research was statically classified and can be concluded thatthere was a definite and positive effect of aerobic training with strengthening exercise and increased endurance inpatients with below knee amputation.

PERBEDAAN KECEPATAN BERJALAN PADA PENGGUNA TRANSTIBIAL PROSTHESIS TIPE SACH FOOT DAN SINGLE AXIS FOOT

Background: Below-knee amputations are the most common amputations in amputation patients. One of the mobility devices that can be used by amputation patients is a prosthesis. The main function of the prosthesis is to help its users be able to walk again and carry out activities normally . The appropriate type of prosthesis is a key factor in rehabilitation. The choice of foot prosthesis type is one of the factors that affect the gait parameter where in the gait parameter there is a walking speed factor. In most cases, the limb wearing the prosthesis does not compensate the amputated limb well, this can affect the speed of walking Method and Subject: This type of research uses analytical observational methods, with a cross-sectional research design. The subjects of this study were users of transtibial prosthesis type SACH foot and single-axis foot. The sample from this study was 16 respondents with purposive sampling techniques. The measuring instruments used in this study were meters and 10 MWT (Meter Walk Test). Results: Based on statistical tests using Mann Whitney, the results were found that there was a difference in walking speed in transtibial prosthesis users of SACH foot and single-axis foot types. Where the p-value (sig) < 0.05 is 0.001 with an effect size (large effect difference) of 0.83 which means it has a high or strong difference effect. Conclusion: there is a difference in walking speed in users of SACH foot and single-axis foot type prosthesis transtibials.

Prophylactic Posterior Targeted Muscle Reinnervation (TMR) Approach in Below Knee (BKA) Amputation Settings

Background/Objective: Targeted muscle reinnervation (TMR) is a nerve reconstruction technique focused on improving phantom limb pain (PLP), residual limb pain (RLP), prosthesis function, and limiting neuroma formation. In below-knee-amputations (BKA), TMR performed "through-the-wound" is heavily documented. Alternatively, the "posterior approach" was developed to help increase visibility of peripheral nerves from the posterior fossa. This study focuses on the surgical efficiency and patient outcomes of the posterior approach compared to the through-the-wound approach. We hypothesize the posterior approach will be comparable toor improve time-to-prosthesis fitting, OR time, and pain scores.
 Methods: 157 patients underwent TMR at two hospitals in Indianapolis, IN, and were identified using CPT 64890. 39 patients underwent posterior approach TMR post-BKA. Data on demographics, follow-up/rehabilitation visits, post-operative complications, prosthesis fitting, and total OR time were collected. Additionally, 32 patients received TMR "through-the-wound", and total OR time, post-operative complications, and time-to-prosthesis fitting were tracked. Patient-reported outcome (PRO) surveys are being sent to patients pending IRB approval.
 Results: Of the 39 who received the posterior approach between 1/10/2020 and 4/6/2023, 25 received TMR in the right leg and 14 in the left. Following BKA, average time to TMR was 144 days. However, 18 patients received TMR directly after undergoing BKA (46.2%). Average OR time for acute and delayed posterior TMR patients was 208.06 minutes and 199.47 minutes, respectively. 10 patients reported post-operative complications (25.6%): dehiscence (12.8%) or infection (7.7%). 23 patients received prosthesis fitting on average 3 months post-op. Average OR time and time-to-prosthesis fitting for "through-the-wound" TMR surgeries were 192.84minutes and 5.81 months, respectively.
 Potential Impact: Posterior approach TMR had no significant impact on OR time, but time-to-prosthesis fitting significantly decreased. Once PRO surveys return, average long-term PLP and RLP can be determined. Preliminarily, posterior approach TMR improves aspects of patient outcomes while not compromising surgical efficiency.

A digital process to replicate the socket-foot alignment in below-knee running specific prostheses

A well-fitting socket and a fine-tuned foot alignment are crucial elements in a running-specific prosthesis to allow Paralympic athletes with below-knee amputation to express their full competitive potential. For this reason, once a satisfactory socket-foot configuration is established after dynamic alignment, it is fundamental to reproduce the same conditions when constructing the definitive carbon fiber socket, and when renewing or constructing a back-up prosthesis, without dismantling the original. In addition, to cope with emerging needs of the athlete, it would be beneficial to implement fine-tuning adjustments of the alignment in a very controlled manner. At present, this requires elaborate bench procedures, which tend to be expensive, time consuming, prone to manual errors, cumbersome in use and most often require damaging or disposing of the current socket. In this study, we propose an original CAD/CAM workflow that allows replicating the desired socket-foot configuration for below-knee sprinting prostheses, as well as performing socket adaptations and introducing fine-tuning adjustments to the alignments. The workflow is exemplified with reference to two case studies involving elite Paralympic runners with transtibial and partial foot amputations, respectively.

Tibiotalocalcaneal arthrodesis with an intramedullary nail: The functional and clinical outcome of a challenging patient group and its comparison to a below knee amputation

BackgroundTibiotalocalcaneal arthrodesis (TTCA) is a salvage procedure to fuse the ankle and subtalar joints to treat severe ankle and hindfoot disease. Patients often have multiple operations before a TTCA. A below knee amputation (BKA) has major physical and psychological impacts. Our aim is to investigate the outcomes of these treatments in salvage situations, with a focus on objective functional measurements and patient reported outcome measures (PROMs). Methods52 patients underwent TTCA with a retrograde intramedullary nail and contacted for clinical and functional assessments and compared to patients who underwent traumatic BKA. PROMS such as AOFAS score, SF-36 and foot function index (FFI), and objective functional outcome measures were used. ResultsOf the 52 TTCA patients, 28 patients were recruited for follow-up. 35.7% of patients had postoperative complications. Mean postoperative AOFAS score was 63.9 ± 8.4 (range, 47–81), FFI 48.8 ± 15.8 (range, 22.2–75.2). 11 BKA patients (mean age 46.4 years) were included as control group. BKA patients scored higher than the TTCA patients on SF-36 physical functioning (p < 0.01) and SF-36 mental health (p < 0.05) subscales. The flat-surface functional tests (timed up and go test, 2-minute walk test, 10-meter walk test) showed significantly (p < 0.05) better outcomes for the BKA compared to TTCA. ConclusionsA TTCA is a salvage procedure with high complication rates. Functional and psychometric results are reduced compared to the normal population. Patients after a BKA had significantly better scores on SF-36 functional and mental health subscales and better functional outcomes for flat ground activities compared to TTCA. Heterogeneity of the TTCA and BKA patient cohorts is a limitation of this study. With these results in mind, the outlook of a BKA is not necessarily a grim one. They may be used by surgeons to counsel patients preoperatively when managing complex ankle and hindfoot disease. Level of evidenceLevel III, retrospective cohort study

Single Center Outcomes of Percutaneous Deep Vein Arterialization in Patients with End-Stage Peripheral Artery Disease.

Background: Peripheral artery disease (PAD) can present as chronic limb threatening ischemia (CLTI) with ischemic pain and tissue loss. Progression of distal disease can lead to a "no option" or end-stage disease without traditional open or endovascular revascularization due to lack of pedal targets. Innovations in endovascular technology allow for the use of percutaneous deep vein arterialization (pDVA) to treat patients with CLTI. Purpose: We describe our experience and technique for treating four patients with end-stage PAD with pDVA. Research Design: Four patients with end-stage PAD were followed during and after pDVA creation. Technical success, complications, wound healing, and freedom from major amputation were analyzed. Data Collection and Analysis: Patient data and outcomes were collected via chart review and at time of follow up appointments in vascular surgery clinic. Results: Technical success was 100%, without post-procedural complications, and patients were continued on antiplatelet and anticoagulation. Three patients (75%) had successful wound healing, with 2 patients healing after transmetatarsal amputation (TMA), and 1 healing a distal foot ulceration that did not require surgery. One patient had worsening ischemic breakdown of a TMA, despite re-intervention on the pDVA, which required a below knee amputation (BKA). Freedom from major amputation was 75% overall, with an average follow-up time of 410 days post-procedure (Range: 113-563 days). Conclusions: Percutaneous deep vein arterialization attempts to provide blood flow to the preserved venous bed in patients with end-stage PAD. Exploration and utilization of this technique continues to expand in the modern vascular era. This case series highlights 4 patients with end-stage PVD who underwent pDVA, with 100% procedural success, and 75% limb salvage rate.

Early versus delayed lower extremity amputations caused by firearm injury: A minimum 2-year follow-up.

High-energy casualties such as firearm injuries may result in extensive loss of soft tissue and bone in the lower extremities. Although the primary aim in these types of injuries is the preservation of the extremity, repeated surgical procedures for extremity salvage and subsequent restoration of function could have detrimental effects on the patient both physically and psychologically. The main aim of this study is to evaluate the physical and psychological outcomes of patients who underwent lower extremity amputation in the early period after a firearm injury compared with the results of patients who underwent amputation in the late period. We also evaluated the factors affecting the prognosis in patients undergoing late below-knee amputation (BKA). This retrospective study included patients who underwent BKA following a lower extremity injury caused by firearms between March 2016 and March 2022. Patients who underwent emergency BKA at the first center they were taken to immediately after the injury constituted the early amputation (EA) group. Patients who were transferred to our tertiary-level referral center for continuation of treatment after the first intervention at another center and later underwent BKA constituted the late amputation (LA) group. The patients were evaluated regarding age, gender, amputation side, presence of phantom limb pain (PLP), and post-traumatic stress disorder (PTSD). Information was available from hospital records for a total of 35 patients; 16 in the EA group and 19 in the LA group. All patients were male. The mean age at the time of injury was 25.5±5.3 years (range, 20-45 years), and the mean follow-up period was 37±17 months (range, 25-84 months). In the comparison of PLP experienced, the difference between the groups was statistically significant, with PLP experienced by 1 (10%) patient in the EA group and by 9 (90%) in the LA group (p=0.010). PTSD was diagnosed in 3 (23%) patients in the EA group and 10 (77%) patients in the LA group (p=0.039). Patients who underwent late BKA were found to be affected by PLP and PTSD at a higher rate. When deciding on extremity-preserving surgery for patients with severe open injuries to the lower extremity, it is crucial to consider the poor outcomes associated with late BKA. Patients should be thoroughly informed about these negative outcomes.

Feasibility of Freedom of Information Requests for Amputee Epidemiology in the United Kingdom.

While each of the 44 National Health Service commissioned artificial limb clinics in the United Kingdom record information about their own prosthetic limb users, these are not collated to give a national picture of amputee epidemiology. The requirement to respond to Freedom of Information (FoI) requests within 20 working days offers another way of extracting data from all centres, and this study describes a first attempt to use this method to update national epidemiological data. Questions were sent to the FoI email addresses of all 44 centres, requesting numbers of adult unilateral below-knee amputees, adult unilateral above or through-knee amputees and child unilateral above or through-knee amputees (all of K2 level mobility), numbers of people consistently using a prosthesis with a single axis myoelectric hand, and access to an occupational therapist with skills to teach someone to use a myoelectric hand. A FoI request was sent to NHS England seeking release of data that they collect every month from all the prosthetic services which they commission in England. All but one of the UK centres responded, the great majority within 31 days. Incomplete results were generally due to centres finding the questions ambiguous and many did not record mobility levels consistently. While 33 centres had access to skilled occupational therapy, only 4 reported more than 10 patients who constantly used a single axis myoelectric hand. Eighteen centres were unable to provide complete data, and the remainder reported a ranges of 5 to 992 below-knee amputees, 7 to 574 adult above-knee amputees and 0 to 137 child above-knee amputees, suggesting different approaches to managing missing mobility level data. Freedom of Information requests are an inexpensive way of gathering data from NHS prosthetic clinics, which can identify age, sex, level of amputation but not activity levels or use of a prosthesis and hence only gives limited demographic information of the amputee cohort.

Long-term outcomes of major and minor lower limb amputation: eight-year retrospective analysis from a single tertiary referral centre

Objective: Lower limb amputation is increasingly common yet outcomes are historically poor, with high rates of short-term mortality, revisions and poor quality of life. This observational study evaluates outcomes from a high-volume tertiary vascular referral centre. Methods: Retrospective electronic case note review was performed to elicit all major and minor amputations performed between 03/11/2014 and 31/05/2022 for peripheral arterial disease and diabetic foot sepsis. Cases of amputation for trauma or chronic pain were not included. Results: A total of 1,566 amputations (865 major, 701 minor) were carried out in 1,237 patients during the study period. Mortality was significantly higher for patients undergoing major amputation compared with minor amputation at 30 days (7.9%, n=61/773 vs 1.0%, n=6/575; p&lt;0.0001) and at 1 year post-procedure (23.7%, n=183/773 vs 13.6%, n=78/575, p&lt;0.0001). Revision rates were significantly lower for major amputations than for minor amputations at 30 days (2.4%, n=19/799 vs 13.2%, n=91/691; p&lt;0.0001) and at 1 year post-procedure (10.0%, n=68/677 vs 26.3%, n=163/619, p&lt;0.0001). Of the patients with major amputation fitted with a prosthesis, there was no significant difference in the numbers of patients ambulating (p=0.19) or the mean ambulatory level (p=0.08) between above-knee and below-knee amputation at 6 months post-procedure. Conclusions: Both major and minor lower limb amputations are associated with a high risk of revision and mortality within 1 year which should be discussed explicitly as part of the informed consent process.

Dilute Povidone-Iodine Solution Soaking Is Ineffective in Improving Outcomes of Necrotizing Fasciitis Caused by Diabetic Foot.

Wound soaking is a physical debridement method that helps reduce bacterial colonization and consequently promotes wound healing. Although soaking in povidone-iodine solution was ineffective in reducing bacterial colonization in acute trauma wounds, there is still a lack of evidence supporting the efficacy of this method in treating severe soft tissue infection. This study aimed to explore the effects of wound soaking in 1% dilute povidone-iodine solution on necrotizing fasciitis caused by diabetic foot ulcers. We retrospectively reviewed and finally included 153 patients who were admitted because of diabetic foot ulcers after undergoing fasciotomy for necrotizing infection from January 2018 to December 2021. Results showed no statistical difference in the outcomes between patients in the soaking and nonsoaking groups. End-stage renal disease (P = 0.029) and high serum C-reactive protein level (P = 0.007) were the only independent factors for below-knee amputation in the univariate and multivariate logistic regression analyses. Therefore, soaking diabetic wounds with severe infection in 1% dilute povidone-iodine solution may not reduce the hospital length of stay, risk of below-knee amputation, and readmission rate.

Spinal Anesthesia in a Patient with reduced Ejection Fraction undergoing Below-Knee Amputation

The ejection fraction is calculated by dividing the stroke volume by the end diastolic volume. It is literally the fraction of the end diastolic ventricular volume that is ejected with each beat. This measurement is important to know how well the heart is pumping out blood and decide in diagnosing heart failure (HF). Normally the percentage of EF is above 50%. A decrease in EF will make it difficult to perform anesthesia during surgery due to life-threatening arrhythmia, leading to sudden cardiac arrest and death. Patients with reduced ejection fraction need identification of risk factors, preoperative evaluation and optimization, correct medical therapy, adequate monitoring, and appropriate anesthetic technique and drugs. In this report, we present a 46-year-old man with reduced ejection fraction 30% and coronary artery disease who underwent below knee amputation surgery under spinal anesthesia. Spinal anesthesia was performed on the patient using low dose bupivacaine and fentanyl as adjuvant. Management of patients is aimed at maintaining adequate preload, avoiding tachycardia and arrhythmia along with maintaining afterload by maintaining a balance between oxygen supply and demand. Thus in patients with reduced ejection fraction, who are posted for noncardiac surgeries, the more preferable and safer alternative is regional anesthesia as it reduces the sympathetic stress response

Major Lower Limb Amputation for Chronic Limb-Threatening Ischemia Is Associated with Poor Long-Term Survival: 4-Year Follow-Up of a Single-Center Experience.

Objective: Despite advances in medicine, 30% of patients with chronic limb-threatening ischemia (CLTI) require major lower limb amputation (MLLA). The long-term outcome of this cohort is poorly described. Methods: In all, 154 patients undergoing MLLA for CLTI during 2018-2020 were analyzed for short-term and long-term outcomes and prosthesis use. Results: In total, 106 below-knee amputations and 48 above-knee amputations were followed up for a mean duration of 50 months (37-78). The mean age of the cohort was 63 years. The majority were male (60%) with multiple comorbidities, including diabetes (83.8%), hypertension (49.4%), ischemic heart disease (20%), and smoking (32.5%). An equal proportion underwent MLLA as primary (45%) or secondary (55%). 30-day mortality was 6%. The mean length of in-hospital stay was 18 days (3-56). Overall survival rates at 1st, 2nd, and 4th year were 73%, 64%, and 35%, respectively. On a multivariate regression analysis, a higher level of amputation had a significant impact on mortality (p = 0.015). 54% of amputees had a prosthetic limb. However, the primary use of prosthesis was for cosmesis, with only 12% mobile independently. Conclusions: MLLA for CLTI is associated with poor early and long-term survival. Prosthesis use and mobility are extremely poor in the Sri Lankan context.

Takayasu Arteritis Presenting with Gangrene: A Case Report

Takayasu Arteritis (TA) is a chronic inflammatory disease affecting large blood vessels, particularly the aorta and its branches, making it a type of vasculitis. It is reported to be highly prevalent in Southeast Asian countries. Clinical presentations may vary, including headache, weight loss, malaise, fever, hypertension, visual disturbances, and musculoskeletal symptoms. Gangrene is a rare manifestation of TA, with relatively few cases reported globally. If gangrene is present, it is commonly noted in the lower limbs. Inflammation of the blood vessels caused by TA might lead to stenosis of the affected vessels. The underlying pathophysiology of gangrene development in TA is poorly understood but is mainly attributed to the occlusion of blood vessels. It is associated with inflammatory markers produced by lymphocytes and macrophages. Immunosuppressive drugs are recommended for symptomatic relief. Early diagnosis and intervention can be useful in managing TA, preventing adverse outcomes, and reducing its financial, social, and psychological consequences. This is a case report of a 32-year-old female, presented with gangrene and a history of rheumatoid arthritis. Further examination revealed a presentation of TA. The patient was managed by below-knee amputation for gangrene of the left leg and medical management for TA. Therefore, authors aim to draw attention to the diagnosis of TA and the rare associated morbidity, ‘gangrene,’ and the importance of timely intervention.

Design and Manufacturing of a Low-Cost Prosthetic Foot

Below-knee prosthetics are used to restore the functional activity and appearance of persons with lower limb amputation. This work attempted to design and manufacture a low-cost, novel, comfortable, lightweight, durable, and flexible smart below-knee foot prosthesis prototype. This prosthesis foot was designed according to the natural leg measurement of an adult male patient. The foot is composed of rigid PVC layers interspersed with elastic strips of PTFE, and the axis of the ankle joint is flexible and consists of metal layers and a composite of polymeric damping strips with different mechanical properties, making it flexible and allowing it to absorb shocks and store and release energy. The design, modeling, and simulation of the manufactured prosthetic foot were performed via the ANSYS 18.0 software and the finite element method (FEM), where a large number of parallel and oblique planes and sketches were created. This work included four adult patients weighing 50, 75, 90, and 120 kg with different walking cycles. The results show that the highest equivalent von Mises stress and total deformations for the prosthetic limb occur at the beginning of the walking step, while the highest equivalent elastic strains and strain energy release rates are observed at the end of the walking step, regardless of the weight. This prototype can satisfactorily perform the biomechanical functions of a natural human foot, and it can be produced in attractive sizes, models, and shapes to suit different levels of below-knee amputations for different ages and weights, especially for patients with limited income.

The impact of comorbidities on mortality in patients with non-traumatic major lower extremity amputation

Objective: Major lower limb amputation is generally associated with a high risk of early and late-term mortality. In this study, 30-day, one-year and three-year mortality of non-traumatic major lower extremity amputations and comorbidities affecting the mortality rate were investigated. Method: Patients who underwent a major lower limb amputation secondary to diabetes or peripheral artery disease between the years 2010–2015 were retrospectively evaluated. Additional to patient demographic data and comorbidities, amputation level, survival and mortality time were extracted. Mortality rates after 30 days, one year and three years were analysed. The associations of the survival to different parameters were evaluated with Kaplan–Meier analysis and log rank test, while the impact of the risk factors on mortality was evaluated with the Cox regression test. Results: A total of 193 patients were enrolled in the study. Approximately 60% of patients were aged ≥65 years, and 65.8% were male. Below-knee amputation was performed in 64.8% of patients and above-knee amputation in 35.2% of patients. The mean follow-up of patients was 29.48 months (range: 0–101 months). After non-traumatic major lower extremity amputation, 30-day, one-year and three-year mortality were 16.6%, 38.3% and 60.1%, respectively. On Cox regression analysis, age ≥65 years was the only variable that had significant impact on the 30-day mortality (hazard ratio (HR): 3.4; p=0.012), while age ≥65 years (HR: 2.5, p=0.000), diabetes (HR: 2, p=0.006) and renal failure (HR: 2, p=0.001) were found to have significant impacts on three-year mortality. Conclusion: The findings of this study showed that &gt;50% of patients with non-traumatic major lower limb amputations died within three years. Advanced age, diabetes and renal failure were the risk factors that increased the mortality. The high mortality rates revealed the importance of employing all hard-to-heal wound treatment options before making an amputation decision. Further, prospective studies are needed to determine the effects of primary disease status and timing of amputation on mortality.

Exploring the Indications, Levels, and Outcomes of Lower Extremity Amputation at a Tertiary Care Hospital in Pakistan.

Lower extremity amputation (LEA) is a surgical procedure performed to remove either a part or the entire lower limb due to medical conditions such as trauma, infection, peripheral vascular disease, or malignancy. The procedure is becoming increasingly common in Pakistan, with a bulk of patients presenting from rural areas in tertiary care centers. Understanding the indications, levels, and outcomes of LEA is essential for improving patient care and adopting preventive strategies, especially in developing countries. This study was conducted at Dow University Hospital in Karachi, Pakistan. Retrospective data of 384 patients who underwent non-traumatic lower extremity amputations between January 2016 and December 2020 was collected to include relevant history and characteristics, amputation indication and level, type of anesthesia used, and outcome within hospital stay. The data was analyzed using descriptive statistics. The data is composed of a wide age range (18 to 91 years) of patients, including a male majority (76.3%, n = 293). The employment status of the patients was taken into consideration, with a reported high number of unemployed individuals (60.4%, n = 232). Diabetes mellitus (84.4%, n = 324) was a commonly reported past medical condition, followed by hypertension (4.4%, n = 17). Indications for amputation exceedingly recorded were diabetic foot ulcers (84.4%, n = 324), followed by infections (9.4%, n = 36) and peripheral arterial disease (3.6%, n = 14). The anesthetic approach that was observed most in these patients was regional anesthesia (74.7%, n = 287). Right-sided amputations (52.9%, n = 203) were dominant, with below-knee amputations leading by the level of amputation performed (42.5%, n = 163). Many patients delayed seeking treatment (71.6%, n = 275) and indicated denial of severity (18%, n = 69) as a reason for the delay. Regarding outcome, many patients were successfully discharged following treatment (85.9%, n = 330). Overall, LEAs are being frequently performed in developing countries, such as Pakistan, especially with a large population living with diabetes mellitus. The implications of this disease are reflected in this study population, with the majority of patients reporting delays in treatment due to reasons such as the unknown severity of the disease or financial burdens. The challenges faced by these individuals, especially in this country, can be tackled with widespread affordability and availability of care and education on early management.

Cutaneous hydrophilic polymer embolism in a patient with acute kidney injury post endovascular procedure

Background: Hydrophilic polymer gel coatings are used on different intravascular devices to prevent vasospasm and thrombosis. However, it may become dislodged from these devices, leading to ischaemic complications in various organs including the skin, kidneys, brain, heart or lungs. Hydrophilic polymer embolisation (HPE) is a rare complication following endovascular procedures that is currently not fully recognised. The current knowledge of this phenomenon is based on reports consisting of histologic evidence of foreign polymers in the affected organ. Case description: A 76-year-old male with a history of hypertension, type 2 diabetes, renal cell carcinoma and chronic kidney disease underwent endovascular stenting of the superficial femoral artery due to critical limb ischaemia of the right foot. The patient had an acute kidney injury following the procedure. Upon examining the legs, there were tender non-blanching macular lesions on the right lower limb. A skin biopsy of the lesion was performed and showed hydrophilic polymer embolisation. Unfortunately, a few weeks later the patient was readmitted due to a worsening of the right foot wound situation, which required below-knee amputation. Conclusion: HPE is a rarely reported complication after endovascular interventions, with the potential to embolise to multiple organs. By observing skin manifestations, it is possible to aid the early detection of ischaemic events in other organs and identify their underlying causes. Generally speaking, the course is benign and self-limiting when the skin is involved, but may be more sinister especially when other organs (e.g. brain) are involved.

Design and Manufacturing Ankle Foot Prosthetics for Patients with Transtibial Amputation

Rapid Prototyping (RP) is a technology used to incrementally shape products or add material using 3D printing equipment. 3D printing is extensively utilized throughout several industries, particularly in the medical sector. This study aims to make a valuable contribution to the field by specifically focusing on the manufacturing of foot prosthetics for patients who have undergone below-knee amputations. The design step on Solidwork software is initiated, followed by the realization of the chosen design utilizing a 3D printing machine, which utilizes PLA as the preferred material. The main focus of this study is to optimize the manufacturing process in order to determine the parameters that result in the most effective production of foot prosthesis, while minimizing the time required for machining. Optimization analysis revealed that the most effective parameters for producing PLA foot prosthesis using a 3D printing machine are a layer height of 0.1 mm, infill density of 100%, print speed of 100 mm/s, and nozzle temperature of 210°C. These adjusted parameters are essential benchmarks for the production sector of foot prostheses.

Management and Outcomes of Invasive Procedures in Individuals with Hemophilia A on Emicizumab Prophylaxis: A Single Center Experience.

Prophylactic treatment with emicizumab has become an important and effective bleeding prevention for people with hemophilia A (PwHA). Perioperative management of PwHA using emicizumab prophylaxis is still challenging due to a lack of experience. Medical records of perioperative management and outcomes were reviewed, and data were collected for adult PwHA receiving emicizumab and undergoing surgical procedures between August 2019 and July 2022 at the University Medical Center Ljubljana. Twelve surgical procedures were performed in eight PwHA (one with FVIII inhibitors) while on emicizumab prophylaxis. Three minor procedures included cataract surgery, cystoscopic lithotripsy, and percutaneous coronary intervention. Nine major surgeries included four osteosyntheses, necrectomy of chronic osteomyelitis with new ankle arthrodesis, two below-knee amputations, total knee replacement, and placement of ventriculostomy after a spontaneous intraventricular hemorrhage. No major bleeds, thrombotic events or deaths, or new inhibitors appeared. Our real-world experience demonstrates that minor and major surgeries can be performed safely in PwHA on emicizumab prophylaxis. Additional data are needed to optimize dosing/duration of additional hemostatic agents in diverse invasive procedures and complex clinical situations.