Decision For Amputation Research Articles

'Leaving the Door Open': Perspectives on Decision-Making for Non-Emergency Diabetes-Related Amputation.

Having a lower extremity amputation is a life-changing decision for people living with a diabetes-related foot ulcer. Although previous research has described both positive and negative lifestyle and function outcomes of diabetes-related amputations, limited research has been conducted on the decision-making processes leading up to the amputation. This study aimed to explore the perspectives of persons, healthcare practitioners and experts (including academics and specialists) on decision-making for people with a diabetes-related foot ulcer who may require a non-emergency amputation. A qualitative descriptive study using semi-structured interviews enabled people to share their thought processes when making decisions for amputation. Twenty-six participants were interviewed, including nine people with a diabetes-related foot ulcer or amputation, nine health practitioners and eight experts located across five countries. There were 13 female and 13 male participants. Thematic analysis was used for data analysis. Four themes described the decision-making considerations for amputation: 'Balancing the evidence in decision-making', 'Trust, respect and timing of conversations inform decision-making', 'Tailoring decisions for individual circumstance' and 'Reaching the tipping point in decisions for the future'. Work commitments, functional and lifestyle impacts of amputation, the presence of support networks and clinical wound features formed the evidence for a decision for amputation. Understanding quality of life needs ensured that decisions for amputation addressed expectations and lifestyle needs. Living with a diabetes-related foot ulcer presented daily challenges that pushed people to a tipping point, at which amputation was considered to overcome these hardships and enable them to move on to the next chapter of their life. Further research is required to understand how person-centred factors can be better incorporated alongside objective clinical assessments in decisions for amputation. People with diabetes-related foot ulcers, health practitioners and experts shared their perspectives on the decision-making process for amputation through one-to-one interviews. Consideration of the person in the context of their life, environment and personal needs alongside the pathological factors is warranted.

Replantation dilemma: lessons learned from managing a dog bite forearm amputation in a sixteen-year-old girl.

Bite injuries, particularly those involving the hands, present a significant medico-legal challenge, often leading to complications and frequent emergency department visits. Dog and cat bites, especially among children, are major contributors to infections due to the complex anatomy of the hand, which predisposes it to severe infections even from minor bites. Capnocytophaga canimorsus, found in the oral cavity of dogs and cats, is particularly concerning due to its potential to cause severe infections. Prompt and appropriate treatment is essential to mitigate these risks. Managing such injuries poses significant challenges, necessitating clear guidelines for reporting and safety measures. This article highlights the urgent need for additional research, support, and education, particularly focusing on children, along with the development of international guidelines to improve outcomes for patients. A case study of a sixteen-year-old girl who had her left forearm amputated due to a rottweiler bite is presented. Despite initial attempts at replantation, complications led to the decision for amputation. This case underscores the challenges in managing severe dog bite injuries, emphasizing the importance of prompt assessment, thorough debridement, and proper wound management to minimize complications. Additionally, psychological evaluation and treatment are crucial for patients and parents following such traumatic events. From a medical standpoint, this case highlights the importance of monitoring inflammatory markers, appropriate surgical priorities, and the need for psychological support. Prevention of dog bites is crucial, requiring increased awareness among public authorities and dog owners. Clear guidelines for reporting dog bites are essential, but further research is needed to improve their comprehensiveness and effectiveness.

Dıabetic Foot: Wound Healing, Amputation Decision, and Innovative Developments

Aim: To review the effects of diabetes-related diseases on the healing process and amputation decision in diabetic foot ulcers (DFU), negative pressure wound therapy (NPWT) results, and current treatment approaches.
 Materials and Methods: The study was planned as retrospective and cross-sectional. Data of patients who were admitted to our clinic due to DFU and were treated were examined. A total of 38 patients were included in the study. The results of patients (n=19) who underwent periodic debridement and classic dressing were compared with the results of patients (n=19) who underwent NPWT. Healing in patients was achieved by amputation (n=8), repair with partial thickness grafts or flaps (n=10), and secondary epithelialization development (n=10). The effect of diabetes-related peripheral arterial disease (PAD), cardiovascular disease (CVD), chronic kidney disease (CKD), diabetic retinopathy (DRP), and previous amputation history (AH) on recovery time was examined. The predictive importance of diabetes-related diseases for amputation was investigated.
 Results: It was determined that diabetes-related diseases caused a delay in wound healing. [PAD (p

Associations Between Systolic Pressure, Vascular Waveform, and Volume Flow with Debridement or Amputation Treatment Decisions in Diabetic Foot Ulcer Patients.

Diabetic foot ulcer disease, affecting 6.3% of the global population, necessitates crucial decisions regarding debridement and amputation, with substantial cost, morbidity, and mortality implications. This study's primary goal is to determine effective vascular examination modalities, including systolic blood pressure, vascular waveforms, and blood volume flow to guide optimal treatments for diabetic foot patients. This cross-sectional study at Cipto Mangunkusumo General Hospital aimed to identify effective vascular examination modalities, such as systolic blood pressure, vascular waveforms, and blood volume flow, to guide treatment choices for diabetic foot patients. The study included 38 subjects, equally split between debridement and amputation groups. Notably, the presence of a biphasic pattern in popliteal artery vascular examinations was associated with the decision for amputation in diabetic foot patients (p < 0.05). The Chi-square test revealed that a biphasic ultrasound pattern served as a predictive factor for amputation among diabetic foot patients, with three times more biphasic patients choosing amputation over debridement. Conversely, assessments of popliteal artery systolic pressure, common femoral artery waveform, popliteal artery volume flow, and common femoral artery volume flow showed no significant correlations with the choice of debridement or amputation treatment for diabetic foot patients. In summary, ultrasound assessment of vascular waveform in the popliteal artery emerges as a predictive factor for amputation or debridement in diabetic foot patients.

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.

Hyperbaric oxygen therapy does not change the amputation level in patients with fasciotomy after an earthquake: Our single-center experience after 2023 Kahramanmaras earthquake.

This study aims to evaluate the effect of hyperbaric oxygen therapy (HBOT) on the amputation level in patients undergoing fasciotomy with a Mangled Extremity Severity Score (MESS) score of ≥7 after 2023 Kahramanmaras earthquake. Between February 6th, 2023 and March 10th, 2023, a total of 23 patients (14 males, 9 females; mean age: 36.8±13.2 years; range, 17 to 64 years) who needed amputation with a MESS score of ≥7 and refused amputation were included in the study. All fasciotomies were performed in an external center, and five of them was incomplete. First, incomplete fasciotomies were completed with debridement due to deep muscle necrosis. Daily two HBOT sessions were performed for the first three days. In the following days, daily one HBOT session was performed. The HBOT was terminated for the patients who were decided by the council that they did not benefit from HBOT treatment. Six (26.08%) of the patients had a bone fracture (n=2 forearm, n=1 femur, n=2 tibia, and n=1 ankle fracture). The mean number of HBOT session was 13.24±5.4 (range, 7 to 30) and the mean duration of HBOT was 26.5±10.8 (range, 14 to 60) h. The mean MESS score was 9.96±1.36 (range, 7 to 12). All of the patients were trapped under the rubble with a mean time of 12.3±5.4 (range, 6 to 23) h. All fasciotomies were performed within the first 30 h. Twenty-two of the patients were amputated at the level previously determined by the experienced trauma surgeons. The amputation level changed in only one patient. After 38 h of HBOT, transradial amputation was performed to the patient in whom transhumeral amputation level was determined previously. None of the patients had any adverse event related to HBOT. Our study results suggest that the MESS is a useful scoring system for amputation decision after a high-energy trauma, such as an earthquake, with a high accuracy rate. The outcomes of HBOT are not satisfactory for high-energy traumas, such as earthquakes, in those requiring fasciotomy having more muscle necrosis and a MESS score of ≥7.

Lower Extremity Malformations.

Lower Extremity Malformations.

Comparison of the Efficiency of Epidermal Growth Factor and Negative Pressure Wound Therapy in Diabetic Foot Patients.

Advanced modalities are used for wounds where conventional treatment is insufficient in diabetic foot patients. In this study, we investigated the effects of using Epidermal growth factor (EGF) and NPWTmodalities alone or in combination on the frequency and level of amputation. In the retrospective study, which included 286 patients in total, 76 patients were referred with the decision of amputation or amputation was planned during hospitalization. After the treatments, amputation and distalization of amputation were found 73.3% and 33.3% in the conventional treatment patients. While 86.4% amp and 18.2% amp distalization were found in negative pressure wound therapy (NPWT) only patients, this rate was 52.4% and 90.5% in EGF + NPWT patients, 50% and 83.3% in EGF only patients. While amp and distalization rates were found to be significantly better in those receiving only EGF or EGF + NPWT (P = .015, P = .017 respectively for amputation and P = .000 for distalization), no difference was found in those receiving EGF and EGF + NPWT. As a result of our study, although npwt contributed positively to the number and level of amputations compared to conventional treatment, a significant improvement was found in the number and level of amps when EGF was used alone or combined with NPWT. With this result, EGF was thought to be an important treatment modality that should be evaluated in diabetic foot ulcers (DFUs) without amputation decision.

Diyabetik Ayak Komplikasyonlarının Farklı Görüntüleme Yöntemlerinin Kan Akımı Bulguları ile İlişkisinin Karşılaştırılması

Background: The aim of this study was to determine the relationship of soft tissue and bone lesions with vascular flow according to different imaging methods in patients with diabetic foot.Materials and Methods: This retrospective, cross-sectional, descriptive study was conducted in the Radiodiagnostic Department of a university hospital.Results: The most commonly seen finding was cellulitis (n:57, 72.2%) and the least seen was subchond-ral cyst (n:14, 17.7%). According to the CDUS findings, arterial blood flow was absent in 24.1%, and was monophasic in 27.8%. Vascular blood flow on CDUS was accepted as insufficient in 41 (51.9%) patients. On the CTA images, complete obstruction was determined in 21.5% of patients and &amp;gt;70% narrowing in 20.3%. Vascular blood flow was accepted as insufficient in 46 (58.2%) patients according to the CTA findings. In the interpretation of the CDUS findings, insufficient blood flow was determined in 63% of the patients determined with osteomyelitis, in 61% with cellulitis, in 34% with abscess, in 34% with tenosy-novitis, in 29% with joint effusion, and in 17%with subchondral cyst. A statistically significant difference was determined in the blood flow determined with CDUS only in the patients determined with cellulitis (p=0.021). Conclusions: In the diagnosis of complications developing secondary to diabetes, and in the decision for amputation, both CDUS and CTA imaging methods are of value.

The integrity or deficiency of the soft tissue envelope predicates the 10 decisions for reconstruction of the mangled hand

Combined upper extremity injuries involving both bone and soft tissue destruction are commonly referred to as “mangled hands”. These injuries often involve a twisting or crushing mechanism or are the result of a high energy trauma, and their reconstruction requires a knowledge of both advanced orthopedic and plastic surgery techniques – the epitome of an orthoplastic approach. In this review, we outline 10 decisions and technical steps to optimize the outcomes in these complex injuries. Specifically, we discuss why the integrity of the soft tissue envelope, or lack thereof, predicates our algorithm with regard to limb salvage and reconstruction. • Initial evaluation of the mangling hand injury should focus on cataloguing injuries and identifying ischemia. • Projecting the likely function of the hand in 2 years can assist with the decision for amputation or reconstruction. • A quality, systematic debridement under tourniquet sets the stage for successful future reconstruction. • In treatment, orthoplastic principles should be followed in a stepwise manner. • The integrity of the soft tissue envelope dictates the timing of reconstruction of nerve, tendon and bone injuries.

A review of the first wave of lower limb amputees from the Great March of Return in Gaza: Taking stock and preparing for the task ahead

AimBallistic injuries during the Great March of Return (GMR) protests in Gaza have resulted in young, civilian amputees. This article defines this unique population, their injuries and clinical variables that impacted on amputation. MethodA multidisciplinary team (MDT) assessed 103 lower limb amputees (104 stumps). Individualized prescriptions of care were formulated and applied for both stump and prosthesis management.The cohort's health state was assessed at screening by applying the EQ-5D-L5 questionnaire. The EQ-5D-L5 will be repeated on completion of the prescription of care. ResultsThe population is predominantly young, male, suffering unilateral amputation with an equal ratio of above knee (AKA) to below knee (BKA) amputations. 18% were amputated immediately and 82% with delay. Most amputations occur within 15 days of gunshot wound (GSW).All tissue elements were affected by the severe, ballistic injury. Division, gapping and tissue loss consolidated the decision for amputation rather than limb salvage. Knee zone injury was common, influencing the high numbers AKAs.Primary injury ramified beyond the amputated leg: 38% have contralateral leg injuries. 20% had physiological challenges requiring Intensive care unit (ICU) admissions. Infection was reported in 49% of amputees with 12% reporting acute sepsis. Psychologically, 49% reported severe, or extreme, anxiety and depression.AKAs were associated with greater morbidity: amputees are significantly younger, have more proximal vascular injuries, receive delayed amputations and experience longer time intervals to stump healing. ICU care and contralateral leg injuries were more frequent.One third of amputees used their prostheses’, one third did not and one third do not have a prosthesis yet. The limiting factor for repair was supply of materials. 11% of amputees needed no adjustment to stump or prosthesis. Surgical stump revision was recommended in 26% of stumps and prosthetic management in 41%. A further 22%, subject to the success or failure of prescribed prosthetic adjustment, could require stump revision. ConclusionYouth, proximal injury, high numbers of AKA, psychosocial issues and the need for stump and prosthetic support define this group of amputees. Unifying expertise within a National MDT will promote continuity of care necessary for decades to come.The ultimate aim is an evidence-based amputee care system in Gaza, with lower limb specialists promoting best outcomes, judicious allocation of funds and maximising amputee quality of life.

Complications, mobility, and quality of life in ankle sarcoma patients.

The aims of the study were to analyze differences in surgical and oncological outcomes, as well as quality of life (QoL) and function in patients with ankle sarcomas undergoing three forms of surgical treatment, minor or major limb salvage surgery (LSS), or amputation. A total of 69 patients with ankle sarcomas, treated between 1981 and 2017 at two tumour centres, were retrospectively reviewed (mean age at surgery: 46.3 years (SD 22.0); 31 females (45%)). Among these 69 patients 25 were analyzed prospectively (mean age at latest follow-up: 61.2 years (SD 20.7); 11 females (44%)), and assessed for mobility using the Prosthetic Limb Users Survey of Mobility (PLUS-M; for amputees only), the Toronto Extremity Salvage Score (TESS), and the University of California, Los Angeles (UCLA) Activity Score. Individual QoL was evaluated in these 25 patients using the five-level EuroQol five-dimension (EQ-5D-5L) and Fragebogen zur Lebenszufriedenheit/Questions on Life Satisfaction (FLZ). Of the total number of patients in the study, 22 (32%) underwent minor LSS and 22 (32%) underwent major LSS; 25 underwent primary amputation (36%). Complications developed in 26 (38%) patients, and were more common in those with major or minor LSS in comparison to amputation (59% vs 36% vs 20%; p = 0.022). A time-dependent trend towards higher complication risk following any LSS was present (relative risk: 0.204; 95% confidence interval (CI) 0.026 to 1.614; p = 0.095). In the prospective cohort, mean TESS was higher following minor LSS in comparison to amputation (91.0 vs 67.3; p = 0.006), while there was no statistically significant difference between major LSS and amputation (81.6 vs 67.3; p = 0.099). There was no difference in mean UCLA (p = 0.334) between the three groups (p = 0.334). None of the items in FLZ or EQ-5D-5L were different between the three groups (all p > 0.05), except for FLZ item "self-relation", being lower in amputees. Complications are common following LSS for ankle sarcomas. QoL is comparable between patients with LSS or amputation, despite better mobility scores for patients following minor LSS. We conclude that these results allow a decision for amputation to be made more easily in patients particularly where the principles of oncological surgery would otherwise be at risk. Cite this article: Bone Joint J2021;103-B(3):553-561.

How important are mean platelet volume and neutrophil values in diabetic foot amputation decision?

Previous studies have shown mean platelet volume (MPV) levels to be an important biomarker in the formation of foot ulcers in diabetic patients. The aim here was to show whether MPV, monocyte, platelet, and neutrophil levels could guide diabetic foot amputation. Two groups of patients diagnosed with type 2 diabetes and homogeneous in terms of age, sex, diabetes duration, body mass index (BMI), and hemoglobulinA1C (HbA1C) levels were included. The first group consisted of 36 patients with amputation, and the second group consisted of 30 patients with ulceration but no indication for amputation. Besides overall demographic characteristics, preoperative HbA1C, MPV, platelet, monocyte, and neutrophil levels were determined in both groups. The amputated group had higher MPV and neutrophil levels than the non-amputated control group (p = 0.028 and p < 0.001, respectively). Neutrophil levels could differentiate amputations at a rate of 69.44% and non-amputations at 76.67%. Platelet levels were not statistically significant in differentiating between amputated and non-amputated patients (p = 0.064). Neutrophil levels were 1.207 times higher, and platelet levels were 1.005 higher in the amputation group (p < 0.05). The atherosclerotic process that occurs during the course of diabetes is thought to be associated with high MPV levels in patients with diabetic foot ulcers. However, the findings obtained here support the use of neutrophil and platelet levels as a marker to predict amputation in diabetic foot monitoring. Further prospective studies with larger numbers of patients are needed to determine the role of MPV levels in the follow-up of diabetic foot ulcers. Level III, risk/prognostic study.

Prospective observational study evaluating the predictive value of ankle branchial pressure index on the outcomes of diabetic foot ulcers

Background: The study was conducted to determine the diagnostic accuracy of ankle branchial pressure index (ABPI) in predicting major amputation and duration of wound healing in diabetic foot ulcers.Methods: 105 participants (30-85 years) admitted in general surgery inpatient with diabetic foot ulcers during 18 months were enrolled in the present prospective observational study. Institutional ethics committee approved the study and written informed consent was obtained from all study participants. Data was analyzed using R and the tests of significance were chi square test and ANOVA. Area under curve (AUC) of receiver operator characteristic (ROC) was used to describe the diagnostic accuracy of ABPI. P&lt;0.05 was considered statistically significant.Results: The mean ABPI of study participants was 0.7 with 23.8% participants having normal ABPI. Lower ABPI was associated with longer duration of ulcer healing (p=0.003). All participants with ABPI &lt;0.3 required more than 120 days for wound healing (p&lt;0.001) and required above knee amputation (p&lt;0.001). AUC ROC of ABPI and major amputation is 0.987 with 92.9% sensitivity and 98.9% specificity. Significantly higher proportion of participants with ABPI ≤0.48 underwent major amputation. The AUC of ROC of ABPI on duration of wound healing was 0.953 with 84.9% sensitivity and 98.1% specificity. Conclusions: ABPI can be used as a routine tool in all patients with diabetic foot ulcers for screening peripheral arterial disease so that the decision for amputation can be made early during diabetic foot ulcers.

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

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

Patients’ clinical charecteristics and predictors for diabetic foot amputation

IntroductionMedical and surgical treatment options are available for patients with diabetic foot ulcers. In more severe cases, amputation decisions are determined by patient comorbidities, performance, imaging studies, and clinical examination results. However, an objective indicator that predicts how this amputation process will end has not yet been clarified. This study identifiies clinical characteristics that can be predictors of the need for diabetic foot amputation among patients. MethodsIn this retrospective observational study, a total of 400 patients with type 2 diabetes who were over the age of 18 and possessed diabetic foot ulcers were examined. The clinical, radiological, and scintigraphic profiles of these patients including age, gender, duration of diabetes, smoking history, previous diabetic foot amputation, presence of hypertension (HT), coronary artery disease (CAD), peripheral artery disease (PAD), cerebrovascular disease, cardiovascular disease, retinopathy, neuropathy and nephropathy were analyzed. ResultsOf the 400 patients with diabetic foot ulcers, 143 (35.75%) underwent foot amputation. Moreover, the frequency of proteinuria in amputees was significantly higher than in non-amputees (p<0,05). Amputees also exhibited significantly longer smoking histories (p<0,001), and the frequency of reamputation was significantly higher in those who possesed histories of previous amputation (p=0.038). After multivariate analysis PAD presence and previous diabetic ulcer history were the significant factors to determine the amputation decision. ConclusionThe following patient characteristics were determined as being effective for predicting the need for amputation: male sex, CAD, PAD, HT, proteinuria, ulcers with Wagner Stages 4–5, smoking histories, previous diabetic ulcer histories, and previous amputation histories. The specificity of the model with these variables was determined as 86% in the patients who did not need amputation. Significant determinants were peripheral artery disease presence and diabetic foot ulcer history. Still, further and more extensive research with higher numbers of patients is necessary for determining more precisely the need for amputation.

The patient's experience of amputation due to peripheral arterial disease

It is not uncommon that patients with peripheral arterial disease (PAD) need to undergo a lower limb amputation, with or without previous revascularization attempts. Despite that, the patient's experience of the amputation has been scarcely studied. The aim of this qualitative study was to describe the patient's experience of amputation due to PAD. Thirteen interviews were conducted with vascular patients who had undergone a lower limb amputation at tibia, knee, or femoral level. Data were analyzed with content analysis. Our findings of the patient's experiences during the amputation process resulted in three themes with additional time sequences: the decision phase "From irreversible problem to amputation decision", the surgical phase "A feeling of being in a vacuum," and the rehabilitation phase "Adaptation to the new life". One main finding was that the patients felt abandoned during the surgical period. Despite that, most of the participants were satisfied with the decision, some of them even regretted that they had not undergone an amputation earlier in the process. It is important for the patient's well-being to develop a partnership with the surgeon to increase a feeling of being participating in the care. Vascular patients need better information on lower limb amputation, and its consequences so as to be better prepared for the whole process. To increase the patient's quality of life and reduce unnecessary suffering, amputation may be presented earlier in the process as a valuable treatment option.

IP183. Patient Experience of Early and Late Recovery After Major Leg Amputation for Arterial Disease

Lower extremity amputation often represents the culmination of an extended management pathway for those with arterial occlusive disease. To date, studies of vascular amputees primarily aim to develop quantitative models based on retrospective data that predict functional outcomes following limb loss. However, little is known about the physical and psychological adjustment and recovery process following major amputation. This study used formal qualitative methodology to define the postamputation adjustment and recovery period and to elicit patient factors that enhance this process. Purposive sampling was used to identify vascular amputees representing a spectrum of functional mobility and independence levels. Structured one-on-one interviews were conducted with 20 participants (median age, 65 years; range, 45-88 years; 85% male; below-knee amputation, n = 14; above-knee-amputation, n = 6). The median time from amputation to interview was 16 months (range, 4-48 months). Interview questions were based on previously identified postamputation quality of life domains. Key findings from the interviews were validated via an independent focus group with five vascular amputees. Data were coded, analyzed, and interpreted by two independent reviewers. Participants uniformly expressed the desire to have an active role in the decision process to undergo amputation, even while acknowledging other options had been exhausted. Following amputation, participants described a 6-month adjustment and recovery period during which they learned how to adapt daily activities to comply with their new functional and psychological needs (Fig, A). Uncontrolled pain, financial worries, feeling unprepared to live with an amputation, and questions about prosthetics were the most commonly mentioned needs that amputees felt were poorly addressed. Typical adaptive coping strategies, including social/emotional support and maintaining a sense of humor/positive outlook, had a positive impact on recovery (Fig, B). Participants defined recovery as when they had regained their functional independence, which was most commonly described as a level of mobility that allowed them to perform activities of daily living with minimal assistance. A preference for amputation earlier in the limb ischemia treatment course was expressed by two of five focus group participants. The postamputation adjustment process has both an early (up to 6 months) and late phase (>6 months) and concludes when amputees regain what they perceive as functional independence. Patients desire to actively participate in amputation decision making, and at times will preferentially opt for earlier amputation. Education regarding the domains that impact quality of life and a balanced shared decision-making process, constitute opportunities for surgeons to enhance postamputation recovery.

Does the benefit of salvage amputation always outweigh disability in drug-failure mycetoma?: a tale of two cases.

It is popularly believed that eumycetoma cases should be dealt with using surgical amputation for a better chance of cure especially when chemotherapy has failed. However, amputation leads to disability on one hand and on the other it may also fail to be curative. We present two cases with contrasting treatment options and outcome. In the eumycetoma case reported here, a 40-year-old male presented with right foot swelling for 16 years, from which Scedosporium apiospermum was isolated. He responded poorly to antifungal therapy and refused below-knee amputation 12 years ago. With counseling and wound care his condition improved, and Foot and Ankle Ability Measure (FAAM) score remained almost stable at 90% for 16 years, which is much better than the average functional outcome after amputation. Another 46-year-old female underwent below-knee amputation after receiving incomplete courses of antibiotics and antifungals for mycetoma of unknown etiology. She presented to us after recurrence of mycetoma on an amputated stump and was successfully treated by proper courses of antibiotics after detecting the causal agent, Actinomadura madurae. Her post-amputation disability and depression could have been avoided if the hasty decision of amputation had not been taken. In our opinion, living with drug-non-responsive mycetoma, supported by symptomatic management, may be a better option than amputation and its associated morbidities. So before taking the path of salvage amputation, we must consider many aspects, including patient's livelihood, psychological aspects and chances of recurrence even after the procedure.

Amputation in Diabetic Foot Ulcer and Infection

Amputation of diabetic foot ulcer and infection is a critical modality for saving a patient’s life from life threatening infections or ischemic limbs. However, it can cause serious handicaps or complications, such as lifetime shortening and re-amputation of the other limb. The minimal amputation is the main goal of amputation in diabetic patients. However, insufficient amputation can have a harmful effect on patients. The decision of amputation is very difficult and should be made using multidisciplinary approaches. All aspects of the patient’s situation, including vascular status, degree of infection, and medical conditions should be considered. The foot surgeon should keep in mind the notion that proper amputation can lead to a new life for diabetic foot patients.