Bilateral Lower Limb Amputation Research Articles

Frequency of Low Back Pain and its Effect on Function and HealthRelated Quality of Life across Three Levels of Lower Limb Amputation: A Cross-Sectional Study

Background: Amputation is a profoundly life-altering event that can have both physical and psychological impacts on individuals. Objective: This study aimed to investigate the frequency of low back pain and its effect on function and health-related quality of life in individuals with various levels of lower limb amputation. Methods: It was a cross-sectional study at the Pakistan Institute of Prosthetic and Orthotics Peshawar (PIPOS) from May to September 2020, 264 participants were purposively selected. Inclusion criteria: males and females aged 18-65 with unilateral transfemoral, knee disarticulation, or transtibial amputations. Exclusion criteria: hearing/speech impairments, hip pathology, or bilateral lower limb amputation. Data collected via selfadministered questionnaires, including the Roland Morris Disability Questionnaire (RMDQ) and the Short Form 36 Health Survey (SF-36). Data analyzed using SPSS v.25. Results: Of the 264 participants, 219 were males (83%), and 45 were females (17%). There was significant connection between before and after amputation back pain (P < 0.05). However, no notable link was observed between low back pain and the three amputation levels (P > 0.05). Moreover, there was no statistical disparity in disability based on the level of amputation (P > 0.05). Significantly, low back pain differed across all quality of life domains (P < 0.05), except for mental and physical health. In contrast, no statistical variation was noted in the quality of life among the three amputation levels (P > 0.05). Conclusion: This study underscores the prevalence of low back pain in lower limb amputees. However, we did not find a clear association between low back pain and specific amputation levels (unilateral transfemoral, knee disarticulation, or transtibial amputation). Additionally, low back pain appears to impact disability and select aspects of quality of life, such as physical function, social function, and general health in individuals with lower limb amputation.

A rare case of a dog bite leading to bilateral lower limb amputations

Capnocytophaga canimorsus is a rare cause of bacteraemia, occurring usually after dog bites, and can have devastating consequences for patients. This report describes the case of a 65-year-old woman who presented acutely unwell 6 days after being bitten on the hand by a dog. She suffered consequences of overwhelming sepsis, disseminated intravascular coagulation and bilateral acute limb ischaemia requiring bilateral major lower limb amputations. C. canimorsus-associated sepsis is extremely rare, but early (prophylactic) antibiotic treatment after a dog or cat bite could prevent serious complications associated with this bacterium.

Weight Changes in Young Service Members After Lower Limb Amputation: Insights From Group-Based Trajectory Modeling.

Weight gain can contribute to osteoarthritis, cardiovascular disease, low back pain, and poor health-related quality of life. Weight trajectory patterns have been described in older veterans with limb loss; however, there is limited evidence of changes in weight in younger veterans with limb loss. Service members with unilateral or bilateral lower limb amputations (LLAs) (and without an upper limb amputation) were included in this retrospective cohort analysis (n = 931). The mean postamputation baseline weight was 78.0 ± 14.1 kg. Bodyweight and sociodemographic data were extracted from clinical encounters within electronic health records. Group-based trajectory modeling assessed weight change patterns 2 years postamputation. Three weight change trajectory groups were identified: 58% (542 of 931) of the cohort had stable weight, 38% (352 of 931) had weight gain (mean gain = 19.1 kg), and 4% (31 of 931) had weight loss (mean loss = 14.5 kg). Individuals with bilateral amputations were more frequently noted in the weight loss group compared with those with unilateral amputations. Individuals with LLAs because of trauma other than blasts were more frequently found in the stable weight group compared with those with amputations because of disease or a blast. Younger individuals (<20 years old) with amputations were more likely to be in the weight gain group compared with older individuals. More than half the cohort maintained a stable weight for two years after amputation, and more than a third experienced weight gain during the same time frame. Knowledge of underlying factors that were associated with weight gain could inform preventative strategies for young individuals with LLAs.

A Nomogram for Predicting the Risk of Critical Limb Ischemia in Adults with Hypertension: A Retrospective Study.

Peripheral arterial disease (PAD) presenting with underlying hypertension (HTN) poses a higher risk of bilateral lower limb amputation than PAD patients without HTN. While the role of HTN management of PAD patients has received limited attention. We analyzed the clinical characteristics of PAD in adults with HTN and explored risk factors for PAD to construct a nomogram for evaluating critical limb ischemia (CLI) and lesion severity. Between January 2014 and December 2019, we retrospectively evaluated 1886 patients with peripheral artery disease with coexisting HTN. Patients were randomly divided into training (n = 1320, 70%) and validation cohorts (n = 566, 30%), and according to the subjective experience of PAD [Fontaine classification (I-II vs III-IV)], patients were further classified into intermittent claudication (IC) and CLI groups. LASSO regression and multivariate Cox proportional hazard analyses were used to construct a nomogram using variables defined in the training cohort, which was validated in the validation cohort. The evaluation of the predictive discriminative, accuracy and clinical application are further analyzed. In the training cohort, optimal independent factors included age, male sex, body mass index, diabetes mellitus, heart rate, triglyceride, and uric acid (AM-BDHTU), which were included in the nomogram predicting the CLI risk (all P < 0.05). The C-index values for CLI risk in PAD with HTN patients were 0.729 (95% CI: 0.704-0.807) and 0.728 (95% CI: 0.652-0.744) in the training and validation sets, respectively. Calibration curves indicated good consistency between predicted and actual outcomes. DCA confirmed the clinical utility of the diagnostic model. The AM-BDHTU nomogram, constructed and validated using simple to obtain clinical variables, when combined with the Fontaine classification, effectively predicts the risk of CLI among PAD patients with HTN.

Knowledge, attitude and perception towards lower limb amputation amongst persons living with diabetes in rural South Africa: A qualitative study.

South Africa has a high prevalence of diabetes mellitus (DM), a leading risk factor for lower limb amputation (LLA). Lower limb amputation is associated with significant morbidity and mortality. Lower limb amputation incidence can be mitigated through prompt identification and treatment of individuals at risk and engagement in self-management practices. Also, when LLA is inevitable, outcomes or prognosis can be improved with timely surgery. This study explored the knowledge, attitude and perception of persons living with diabetes towards LLA and its prevention. Nqamakwe, a rural community in the Eastern Cape province of South Africa. This was a descriptive, qualitative study involving persons living with DM, with and without LLA, and community leaders. Fifteen participants were recruited purposively and conveniently from a rural community in the Eastern Cape, South Africa. Data collection took place through semistructured interviews, in English and a local language, Xhosa. Interviews were transcribed and translated, and an inductive approach was used for thematic analysis. A total of 15 individual interviews were conducted. Of those, 13 were persons with DM, five with LLA, including one with bilateral LLA. There was a gap in knowledge on foot self-examination as a measure of preventing LLA amongst persons with DM. The attitude of persons without LLA was mostly fearful and their fears centred around perioperative death, risk for contralateral amputation, loss of limb and independence. Consent to LLA procedure was a last resort and only when pain levels were unbearable. Family support and information on rehabilitation services and assistive devices also fostered consent to LLA surgery. There is a need for awareness creation and adequate health education for persons living with DM on LLA and its prevention measures, especially foot care practices. Also, health education programmes for persons living with DM in rural areas should address the various misperceptions of LLA to reduce delays.Contribution: The article revealed gaps in knowledge on LLA and its prevention among individuals living with diabetes as well as areas of concerns that may potentially delay acceptance when LLA is inevitable. Findings from our study may assist primary health care providers to determine important issues to be addressed during routine and pre-operative patient education.

A Comparison of the Two-Minute Walk Test (2MWT) and Comprehensive High-level Activity Mobility Predictor (CHAMP) in People with a Leg Prosthesis

Objective To determine if the two-minute walk test (2MWT) could serve as an alternative measure of high-level mobility in lower limb prosthesis users when circumstances preclude administration of the Comprehensive High-level Activity Mobility Predictor (CHAMP). Design Cross-sectional study. Setting Indoor recreational athletic field and gymnasium Subjects Fifty-eight adult lower limb prosthesis users with unilateral or bilateral lower limb amputation who participate in recreational athletic activities. Intervention N/A Main Measures The 2MWT and CHAMP while using their preferred prosthesis(es) on an indoor artificial athletic field or hardwood gymnasium floor. Results Thirty-nine men and nineteen women with a median age of 38.3 years participated in the study. Most participants experienced amputation(s) due to trauma (62%) or tumor (10%) and were generally higher functioning (K4 (91.4%) and K3 (8.6%)). The median (range) score for the CHAMP was 23.0 points (1.5–33.5) and the mean ± standard deviation (range) 2MWT distance walked was 188.6 ± 33.9 m (100.2–254.3 m). The CHAMP demonstrated a strong positive relationship with 2MWT (r = 0.83, p < 0.001). The 2MWT distance predicted 70% of the variance in CHAMP score. Conclusions Although the 2MWT does not test multi-directional agility like the CHAMP, they were found to be highly correlated. If space is limited, the two-minute walk test can serve as an alternative measure for assessing high-level mobility capabilities in lower limb prosthesis users.

The effect of dual-task testing on the balance and gait of people with lower limb amputations: A systematic review.

To systematically review the literature on the effect of dual-task testing on the balance and gait of people with lower limb amputations (PLLA). Databases MEDLINE, EMBASE, CINAHL, PsycINFO, Web of Science, and Scopus were searched in duplicate (inception to December 1, 2020). Inclusion criteria: participants were adults with transtibial, knee-disarticulation, transfemoral, or bilateral lower limb amputations; balance or gait was paired with a secondary task; and studies were peer-reviewed and published in English. Two authors independently reviewed articles and consensus was required. A standardized data extraction sheet was used to gather study relevant information in duplicate. Methodological quality of reporting was examined using the Downs and Black Scale. A meta-analysis was unable to be performed owing to substantial participant and protocol heterogeneity among the studies included. Of 3950 articles screened, 22 met inclusion criteria. Four assessed dual-task balance and 18 dual-task gait. During single-task standing, PLLA demonstrated higher sway distance and sway velocity than controls (CN); however, a greater dual-task effect was observed only for sway velocity. Gait pace, rhythm, variability, asymmetry, and postural control were observed to be worse in PLLA relative to CN during single-task. Dual-task gait testing resulted in a disproportionally reduced pace and rhythm and increased asymmetry in PLLA compared to CN. People with lower limb amputations have impaired balance and gait, which is affected by dual-task to a greater degree compared to healthy adults. An examination of how PLLA-specific factors such as level of amputation, reason for amputation, and experience with a prosthesis affect dual-task performance has not yet been thoroughly explored. Future research should continue to characterize the cognitive-mobility link to better understand the challenges associated with the use of a prosthesis.

Satisfaction with Prostheses and Services in Cyclists with a Lower Limb Amputation

Objective: To investigate the prosthetic and service satisfaction in cycling and non-cycling adults with a lower limb amputation in Thailand and to analyze factors associated with satisfaction. Materials and Methods: Orthotics and Prosthetics Users’ Survey questionnaire was given to 424 adults with uni or bilateral lower limb amputation in five public hospitals and mobile units. Associated variables in univariate analysis were entered into a multiple linear regression. Results: Forty-five percent of participants were from the Veterans General Hospital, Bangkok. Cyclists were slightly more satisfied with the prostheses than non-cyclists, but no differences were reported for service satisfaction. In general, all participants were satisfied with the service received. Factors associated with higher prosthetic satisfaction were not using gait aids, being employed or retired, being amputated below the knee, no or basic education, and hospital delivering the prosthesis. The factor associated with higher service satisfaction was not using gait aids. Conclusion: The results suggested that mobility independence, use of the prosthesis, and socioeconomic status may influence prosthetic and service satisfaction. Communication between people with a lower limb amputation and prosthetists, as well as follow-up after delivery may improve the prosthetic and service satisfaction. Satisfactory prostheses may increase activity participation, as seen in cyclists. Keywords: Satisfaction, Prosthesis, Service, Cycling, Amputation, Lower limb, Transfemoral amputation, Transtibial amputation

An Emerging Infection: Streptococcal Toxic Shock-Like Syndrome Caused By Group B Streptococcus (GBS), Streptococcus Agalactiae

Abstract Introduction/Objective Streptococcus agalactiae, Group B Streptococcus (GBS), is a major cause of neonatal sepsis and infections in pregnant women. However, incidence of invasive GBS infections has more than doubled in the last two decades with highest risk in adults 65 years or older. Other risk factors are diabetes, malignancy, and immunocompromised state. Bacteremia and skin soft tissue infections are the most common invasive infections in nonpregnant adults. Rarely GBS infection has a fulminating pyrogenic exotoxin-mediated course characterized by acute onset, multiorgan failure, shock, and sometimes death, referred to as toxic shock-like syndrome. Methods A 77-year-old hypertensive female with uncontrolled type 2 diabetes mellitus and a history of bilateral foot ulcers presented to the hospital in probable septic shock. Clinical diagnosis of necrotizing fasciitis was made and she underwent bilateral lower limb amputations. Results Grossly soft tissue appeared gray. Microscopically fascia was necrotic without neutrophils present and Gram stain revealed sheets of Gram positive cocci. These findings reflected histopathologic Stage III necrotizing fasciitis, which is associated with 47% mortality. Autopsy showed a similar histology of Stage III necrotizing fasciitis involving the surgical stump. Erythema and desquamation of the upper limbs bilaterally and multi-organ failure met the clinical picture of Streptococcal Toxic Shock Syndrome (STSS) and fulfilled the criteria for TSS due to Group A Streptococcus (GAS), defined by The Working Group on Severe Streptococcal Infections. Conclusion Group B Streptococcal Toxic Shock-Like Syndrome may have a similar outcome to STSS caused by GAS and other pathogens and, in limited studies, mortality has been 30% or greater.

Primary prophylaxis for venous thromboembolism in people undergoing major amputation of the lower extremity

People undergoing major amputation of the lower limb are at increased risk of venous thromboembolism (VTE). Risk factors for VTE in amputees include advanced age, sedentary lifestyle, longstanding arterial disease and an identifiable hypercoagulable condition. Evidence suggests that pharmacological prophylaxis (e.g. heparin, factor Xa inhibitors, vitamin K antagonists, direct thrombin inhibitors, antiplatelets) is effective in preventing deep vein thrombosis (DVT), but is associated with an increased risk of bleeding. Mechanical prophylaxis (e.g. antiembolism stockings, intermittent pneumatic compression and foot impulse devices), on the other hand, is non-invasive and has minimal side effects. However, mechanical prophylaxis is not always appropriate for people with contraindications such as peripheral arterial disease (PAD), arteriosclerosis or bilateral lower limb amputations. It is important to determine the most effective thromboprophylaxis for people undergoing major amputation and whether this is one treatment alone or in combination with another. This is an update of the review first published in 2013. To determine the effectiveness of thromboprophylaxis in preventing VTE in people undergoing major amputation of the lower extremity. The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, Cochrane Central Register of Controlled Trials, MEDLINE, Embase and Cumulative Index to Nursing and Allied Health Literature databases, the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 5 November 2019. We planned to undertake reference checking of identified trials to identify additional studies. We did not apply any language restrictions. We included randomised controlled trials and quasi-randomised controlled trials which allocated people undergoing a major unilateral or bilateral amputation (e.g. hip disarticulation, transfemoral, knee disarticulation and transtibial) of the lower extremity to different types or regimens of thromboprophylaxis (including pharmacological or mechanical prophylaxis) or placebo. Two review authors independently selected studies, extracted data and assessed risk of bias. We resolved any disagreements by discussion. Outcomes of interest were VTE (DVT and pulmonary embolism (PE)), mortality, adverse events and bleeding. We used GRADE criteria to assess the certainty of the evidence. The two included studies compared different treatments, so we could not pool the data in a meta-analysis. We did not identify any eligible new studies for this update. Two studies with a combined total of 288 participants met the inclusion criteria for this review. Unfractionated heparin compared to low molecular weight heparin One study compared unfractionated heparin with low molecular weight heparin and found no evidence of a difference between the treatments in the prevention of DVT (odds ratio (OR) 1.23, 95% confidence interval (CI) 0.28 to 5.35; 75 participants; very low-certainty evidence). No bleeding events occurred in either group. Deaths and adverse events were not reported. This study was open-label and therefore at a high risk of performance bias. Additionally, the study did not report the method of randomisation, so the risk of selection bias was unclear. Heparin compared to placebo In the second study, there was no evidence of a benefit from heparin use in preventing PE when compared to placebo (OR 0.84, 95% CI 0.35 to 2.01; 134 participants; low-certainty evidence). Similarly, no evidence of improvement was detected when the level of amputation was considered, with a similar incidence of PE between the two treatment groups: above knee amputation (OR 0.79, 95% CI 0.31 to 1.97; 94 participants; low-certainty evidence); and below knee amputation (OR 1.53, 95% CI 0.09 to 26.43; 40 participants; low-certainty evidence). Ten participants died during the study; five underwent a post-mortem and three were found to have had a recent PE, all of whom had been on placebo (low-certainty evidence). Bleeding events were reported in less than 10% of participants in both treatment groups, but the study did not present specific data (low-certainty evidence). There were no reports of other adverse events. This study did not report the methods used to conceal allocation of treatment, so it was unclear whether selection bias occurred. However, this study appeared to be free from all other sources of bias. No study looked at mechanical prophylaxis. We did not identify any eligible new studies for this update. As we only included two studies in this review, each comparing different interventions, there is insufficient evidence to make any conclusions regarding the most effective thromboprophylaxis regimen in people undergoing lower limb amputation. Further large-scale studies of good quality are required.

Retrospective study of cardiovascular disease risk factors among a cohort of combat veterans with lower limb amputation.

IntroductionPrevious studies have shown that veterans with lower limb amputation have a higher risk for cardiovascular disease (CVD) compared with population-based controls. American veterans who have served in Iraq and Afghanistan with lower limb amputation may be at a similarly higher risk.Patients and methodsThe Navel Health Research Center (NHRC) maintains the Expeditionary Medical Encounter Database (EMED) of military personnel who have sustained combat limb amputation or serious limb injury during the conflicts in Iraq and Afghanistan. Department of Veterans Affairs data from 2003 to April 2015 was used to analyze CVD risk factors in this cohort. Veterans with either unilateral (n=442) or bilateral (n=146) lower limb amputation were compared to those with serious lower limb trauma without amputation (n=184). Multivariate regression was used to measure associations between lower limb amputation and CVD risk factors over an average of 8 years of follow-up. Outcomes included mean arterial pressure (MAP), low-density lipoprotein, high-density lipoprotein (HDL), and serum triglycerides (TG).ResultsCompared with the limb injury group, those with unilateral lower limb amputation had significantly lower HDL (p<0.05) and higher TG (p<0.05). Those with bilateral lower limb amputation had significantly higher MAP (p<0.05), lower HDL (p<0.01), and higher TG (p<0.001). The prevalence of metabolic syndrome, defined as type 2 diabetes or a constellation of blood pressure and lipid changes consistent with metabolic syndrome, was 8.7%, 14.9%, and 21.9% for limb injury, unilateral amputation, and bilateral amputation groups, respectively. Veterans with bilateral lower limb amputation had a 2.25-increased odds ratio (95% confidence interval 1.19–5.05) of type 2 diabetes or blood pressure and lipid changes consistent with metabolic syndrome compared to those with limb injury.ConclusionsResults suggest that veterans with lower limb amputation have a higher risk for metabolic syndrome. Primary care interventions to manage weight, blood pressure, and lipid levels are fundamental in order to reduce cardiac risk in this relatively young cohort.

Avaliação da porcentagem de gordura corporal em um indivíduo com amputação transfemoral bilateral por diferentes métodos

A amputação predispõe a um risco de alterações na composição corporal, condição que interfere no equilíbrio no uso da prótese, aumenta o cansaço físico e tem como consequência menor rendimento nas terapias físicas. Nesse sentido, é fundamental eleger o método mais apropriado para avaliar a composição corporal. Objetivo: Avaliar a porcentagem de gordura corporal em um indivíduo com amputação transfemoral por diferentes métodos. Método: Trata-se de um estudo de caso de caráter clínico retrospectivo com um participante do sexo masculino, idade 67 anos com amputação transfemoral bilateral por insuficiência vascular, atendido pelo Serviço de Nutrição do Instituto de Medicina Física e Reabilitação do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - IMREA HCFMUSP. Utilizou-se o somatório das dobras cutâneas, absorciometria de raio-X de dupla energia (DXA) e análise de impedância bioelétrica (IB). Resultados: Os dados antropométricos apontaram porcentagem de gordura corporal de 34,3%, a IB 33% e o DXA revelou 37%. Conclusão: Para este caso, sugere-se que na inviabilidade de avaliar a porcentagem de gordura corporal em indivíduos com amputação com o DXA, o somatório das dobras é o método elegível. Estudos futuros são imprescindíveis a fim de estabelecer o método adequado para avaliação da composição corporal de pessoas com amputações bilaterais de membros inferiores, tendo em vista que este resultado contribui para o melhor desfecho clínico de pacientes em processo de reabilitação.

Clinical and demographic characteristics of patients with lower limb amputation

Aim: Lower limb loss affects an individual’s ability to stand, transfer, and ambulate. The aim of this study is to assess clinical and demographic characteristics of patients with lower limb amputation.Materials and Methods: Our study is a retrospective cohort study. 836 patients with lower limb amputation applied to our hospital between January 2012 and May 2013 were included in this study. Demographic and clinical characteristics of patients were reviewed and saved from patient’s folder. Descriptive variables were shown as mean±standard deviation(min–max). And categorical variables were shown as the number of cases (n%).SPSS software Version 15.0 was used in the evaluation of the data.Results: The mean age of total 836 lower limb amputees was 36.12±11.69 years (9-78). The percentage of unilateral amputation was 770(92.3%) and bilateral lower limb amputation was 59(7.1%). According to the level of amputation, 456(54.5%) of the patients had unilateral above-knee, 236(28.3%) had unilateral below-knee amputation. For etiology, we found that 373(44.6%) of them were traffic accidents, 103(12.5%) occupational accidents. The majority of patients 456(54.5%) were ambulated microprocessor-controlled above-knee prosthesis and then below-knee prosthesis with active vacuum system 224(26.7%).Conclusion: Although trauma is recognized to be the most common cause of amputation among applying amputees, we think that those amputees do not reflect the general profile in our country but that it is instructive with regard to the features of amputees. This data is important for the community rehabilitation of amputees and the development of new prosthetics.

Pain and loss of income after traumatic limb loss in Palestinian war casualties: a retrospective, cross-sectional study

BackgroundDuring four separate Israeli military attacks on the Gaza Strip (in 2006, 2009, 2012, and 2014), about 4000 Palestinians were killed and more than 17 000 Palestinians were injured (412 killed and 1264 injured in 2006; 1383 killed and more than 5300 injured in 2009; 130 killed and 1399 injured in 2012; and 2251 killed and 11 231 injured in 2014). An unknown number of people had traumatic amputation of one or more extremities. In addition to loss of body parts, loss of work and income further complicated patients' lives after trauma. In 2015, we reported preliminary data on the somatic consequences, showing that eight of ten amputees had unilateral or bilateral lower limb amputations, most often because of attacks by drone-carried weapons. A third of cases had amputations during ceasefire periods. A high number of debilitating extremity injuries were in the young civilian population, where needs of rehabilitation were difficult to meet because of limited local resources during the long-lasting siege of the Gaza Strip. Here we report long-term functional and psychosocial consequences of traumatic amputations in Gaza War casualties. MethodsThis cross-sectional study was done at The Artificial Limb and Polio Center, a local rehabilitation centre in Gaza City. We studied Palestinians living in the Gaza Strip who had sustained traumatic amputations during Israeli military attacks between 2006 and 2014. We explored the amputees' self-assessed health, socioeconomic status, anatomical location and level of amputation, comorbidity, and date and mechanism of injury. We used two validated and self-administered screening questionnaires (36-Item Short Form Survey and General Health Questionnaire 12 [GHQ12]) combined with a detailed clinical examination of each amputee. We used standardised records and questionnaires in Arabic. Data were analysed with SPSS. The study was approved by the Palestinian Ministry of Health in the Gaza Strip, Al-Shifa Hospital's board, and the director of the Artificial Limb and Polio Center in the Gaza Strip. All participants included in the study completed a written consent form. FindingsWe included 165 Palestinians in this study. Pain was reported by more patients who were unable to continue work because of the traumatic amputation than by patients who were unemployed for other reasons, even when adjusting for time passed since amputation (p=0·039). We found a correlation between reported pain and poverty (income <800 shekels per month; χ2=0·034) but no correlation between GHQ12 scores indicating psychological distress and the extent of the initial trauma. Use of prosthetics decreased GHQ12 scores, suggesting a lower level of psychological distress in users of artificial limbs. InterpretationSelf-reported pain after loss of one or more limbs correlated with deteriorated occupational and financial life situation after the amputation. Use of prosthesis seemed to ease the psychological distress. Poverty and unemployment caused by amputations and disability might be a more important trauma than the physical amputation itself. FundingNone.

Indications and Pattern of Limb Amputation: A Tertiary Hospital Experience, South-South, Nigeria

The aim of this paper was to study the indications and patterns of limb amputations in the University of Calabar Teaching Hospital, a retrospective study of 142 limb amputations performed in patients admitted to the University of Calabar Teaching Hospital, South-South, Nigeria. Data was obtained from theater records and the medical record department of the hospital after due ethical approval. The data spanned a period of 10 years (from January 2004 to December 2014). A total of 142 patients were seen. The age ranged from 8 to 87 years with a mean age of 46 years ± SD 17.9 years and a male to female ratio of 2.3:1. Adults accounted for 95.8% while 4.2% were children. Emergency procedures accounted for 47.9% of the amputations. Diabetic foot gangrene was the major cause of lower limb amputation 91 (64.1%), trauma accounted for 27 (19%) of these, 15.5% were due to road traffic accidents, and 3.5% were cases of gunshot injuries. Tumors and limb ischemia accounted for 9.2 and 2.8%, respectively. Electrical injury, industrial accidents, and ischemic limbs from tight tourniquet splints by traditional bonesetters were the common causes of upper limb amputations. Most of the amputations were on the lower limb (83.7%) with the left lower limb accounting for 47.8% and the right lower limb accounting for 35.9% .Upper limb amputations accounted for 15.4% with right and left upper limbs being 8.4 and 7.0%, respectively .Only one patient had bilateral lower limb amputation(0.7%). For the levels of amputation, the majority were below knee 54 (38%) followed by above elbow 38 (26.8%) amputations (Figure 1); others were ray amputation of the foot and hand as 28 (19.7%) and 8 (5.6%), respectively. The least was below elbow amputation 6 (4.2%). The study showed that 96% of the causes were potentially preventable, and that establishment of a prosthetic-orthotic center is needed in this part of the country.

Health-related quality of life and the ability to perform activities of daily living: a cross-sectional study on 1079 war veterans with ankle-foot disorders

BackgroundThe ankle-foot injuries are among the war-related injuries that cause many serious secondary problems for a lifetime. This nationwide study aimed to assess health-related quality of life and the ability to perform activities of daily living in veterans with ankle-foot injuries due to the Iran-Iraq war.MethodsA total of 1079 veterans with ankle-foot injuries were enrolled in a cross-sectional study from 2014 to 2016. Demographic characteristics, including age, gender, marital status, disability percent, educational level, employment and additional injuries, were collected. The ability to perform daily activities was assessed using the Barthel activities of daily living (ADL) and Lawton instrumental activities of daily living (IADL) Indexes. Physical and mental health-related quality of life (HRQOL) data were measured via the SF-36 subscales. The data were compared with those of bilateral lower limb amputees (BLLAs) and of the general Iranian population. Statistical analyses, including Pearson’s correlation coefficient, one-sample t-test and analysis of variance (ANOVA), were performed using SPSS16.0. A multiple linear regression model was used to determine the contribution of independent variables to the Physical Component Summary (PCS) and Mental Component Summary (MCS).ResultsThe highest and lowest scores were observed for mental health (48.93 ± 20.69) and bodily pain (28.16 ± 21.74), respectively. The mean scores of veterans with ankle-foot injuries on the SF-36 were significantly lower on all eight measures than those of the general Iranian male population and of the bilateral lower limb amputees (P < 0.001). The mean scores of ADLs and IADLs were 83.9 ± 16.3 and 5.3 ± 2.0, respectively. The higher dependency in ADLs (P < 0.001) and IADLs (P < 0.001), the higher disability rate (P < 0.001) and additional injury (P < 0.001) were significant determinants of the PCS. ADL (P < 0.001) and IADL (P < 0.001) limitations, additional injury (P < 0.001), history of hospitalization in the year preceding the study (P = 0.007) and employment (P = 0.001) were reported as determinants of the MCS.ConclusionThe results strongly suggest that veterans with ankle-foot injuries suffer from critically poor health-related quality of life. The main predicting factors of HRQOL were the disability to perform ADLs/IADLs, suffering two or more injuries, a history of hospitalization in the year preceding the study and unemployment.

Incidence of Overuse Musculoskeletal Injuries in Military Service Members With Traumatic Lower Limb Amputation

ObjectiveTo describe the incidence of overuse musculoskeletal injuries in service members with combat-related lower limb amputation. DesignRetrospective cohort study. SettingMilitary treatment facilities. ParticipantsService members with deployment-related lower limb injury (N=791): 496 with a major lower limb amputation and 295 with a mild lower limb injury. InterventionsNot applicable. Main Outcome MeasuresThe outcomes of interest were clinical diagnosis codes (International Classification of Diseases–9th Revision) associated with musculoskeletal overuse injuries of the lumbar spine, upper limb, and lower limb regions 1 year before and 1 year after injury. ResultsThe overall incidence of developing at least 1 musculoskeletal overuse injury within the first year after lower limb amputation was between 59% and 68%. Service members with unilateral lower limb amputation were almost twice as likely to develop an overuse lower or upper limb injury than those with mild combat-related injury. Additionally, service members with bilateral lower limb amputation were more than twice as likely to develop a lumbar spine injury and 4 times more likely to develop an upper limb overuse injury within the first year after amputation than those with mild combat-related injury. ConclusionsIncidence of secondary overuse musculoskeletal injury is elevated in service members with lower limb amputation and warrants focused research efforts toward developing preventive interventions.

Correlation of ambulation potential with quality of life in lower limb amputees

Background: To identify the effect of walking ability on quality of life in lower limb amputees and draw a correlation between prosthesis use, socio economic status and quality of life. It was an Observational Cross sectional study.Methods: Lower limb amputees excluding hip disarticulation and bilateral lower limb amputation, individuals above eighteen years of age who attended rehabilitation research centre outpatient door were interviewed. Structured questionnaire including patient background, amputation characteristics and details regarding prosthesis, was administered along with detailed musculoskeletal examination. Outcome variables: Locomotor capability index (LCI) and timed up and go test (TUG) were used for ambulation potential and Short form 36 (SF 36) for quality of life.Results: Significant correlation was observed between mental health short form 36 score and locomotor capability index (basic and advanced). Poor negative correlation of SF 36 score was observed with age (r=-0.125, p=0.006S). Significant correlation was observed between Physical Health Short Form 36 score and locomotor capability index (basic and advanced), and this correlation was higher and more significant. Poor negative correlation of SF 36 score was observed with age (r=-0.203, p&lt;0.001S).Conclusions: Ability to ambulate is an independent factor that has a positive correlation with quality of life.

Ciąża, poród i połóg u kobiety po przebytym w dzieciństwie rozległym urazie miednicy oraz obustronnej wysokiej amputacji kończyn dolnych – opis przypadku

Wstęp: Celem pracy było przedstawienie przebiegu ciąż, porodów i połogu u 42-letniej pacjentki, która w dzieciństwie przebyła obustronną wysoką amputację kończyn dolnych, złamanie kości miednicy oraz uszkodzenie układu moczowo-płciowego.Opis przypadku: Pacjentka w 4. r.ż. uległa wypadkowi tramwajowemu, doznając zmiażdżenia obu kończyn dolnych oraz rozległego urazu krocza. Dokonano wówczas obustronnej amputacji ud w stawach biodrowych. Rozerwaną pochwę i odbytnicę zaopatrzono chirurgiczne, wytworzono sztuczny odbyt naokrężnicy esowatej. Po licznych operacjach rekonstrukcyjnych pacjentka mogła samoistnie oddawać mocz i stolec, kontrolując potrzeby fizjologiczne.Pierwsza ciąża powikłana była nadczynnością tarczycy. Ciążę ukończono drogą cięcia cesarskiego w 31. tyg. z powodu przedwczesnego pęknięcia błon płodowych po przeprowadzeniu sterydoterapii. Kolejna ciąża pacjentki powikłana była także nadczynnością tarczycy, okresową tachykardią oraz cukrzycą ciężarnych. W 32. tyg. zastosowano sterydoterapię. Ciążę zakończono w 36. tyg. drogą cięcia cesarskiego z powodu rozpoczynającego się porodu.U pacjentki nie stwierdzano zaburzeń neurologicznych, była w stanie prawidłowo ocenić aktywność ruchową płodu i ewentualną czynność skurczową macicy, co pozwoliło na ambulatoryjne prowadzenie obu ciąż. Przebyte operacje naprawcze w obrębie układu moczowego oraz dolnego odcinka przewodu pokarmowego stanowiły nie tylko istotny czynnik ryzyka powikłań porodu operacyjnego drogą cięcia cesarskiego, ale również, z uwagi na zmienioną anatomię i możliwą obecność rozległych zrostów, mogły wpłynąć na przebieg ciąży.

Severe amputation injuries after Israeli military operations in Gaza: a retrospective, clinical follow-up study

BackgroundFour major attacks on Gaza since 2006 have killed around 4000 and injured more than 17 000 Palestinians. An unknown number of the wounded suffered extremity injuries with amputations. The long-term functional, somatic, and psychosocial consequences of traumatic amputations in Gaza have not been reported. We describe the demography, anatomical distribution, and causative factors of a sample of traumatic amputations in Gaza in this ongoing study. MethodsWe studied 147 randomly selected Palestinian surviving casualties in Gaza who had suffered traumatic amputations following Israeli military operations during the period 2006–2014. All participants were aged over of 16 years when included. One additional patient was invited to participate but declined. We organised the study at a key rehabilitation centre, the Artificial Limb and Polio Centre (ALPC) in Gaza City. Data were collected from June to October, 2014. We recorded date and mechanism of injury as well as results of in-depth clinical examinations in each survivor. Records and self-administrated questionnaires in Arabic were translated into English and data analysed with SPSS common version 21·0. The Palestinian Ministry of Health, the board and directors at Al-Shifa Hospital, and ALPC approved the protocol. We obtained written informed consent from each patient. Findings11 women (7·5 %) and 136 men (92·5 %) with traumatic amputations participated. The mean age was 30·6 years (range 16–64). 85 patients (57·8 %) had unilateral lower extremity amputations, 31 (21·1%) bilateral lower extremity amputations, and 31 (21·1%) other amputations. Attacks from drones were reported by the survivors as the reason for explosions that caused amputation injury in 85 of the cases (57·8%). 52 (61.2 %) of such drone attacks had occured during declared military operations. 24 (31·6 %) had occurred during periods of ceasefire. Nine (11·8%) participants reported only the month and year of attack, not the exact day. InterpretationMilitary operations in Gaza have caused a large, unknown number of traumatic amputations. In our study, most participants had unilateral or bilateral lower limb amputations and the majority of injuries followed attacks with drone-carried weapons. Several participants were wounded during ceasefire periods. The need for rehabilitation is difficult to meet because of limited local resources. FundingNone.