Amputation Etiology Research Articles

Frequency and Localization of Neuromas in Transtibial Residual Limbs

ObjectiveTo describe the frequency and localization of neuromas in residual limbs of individuals with transtibial amputation using ultrasound imaging. DesignCross-sectional study. SettingRehabilitation center research laboratory. ParticipantsAdults who have lived with a transtibial amputation for >12 months were recruited for this study. Participants were included regardless of the presence or absence of residual limb neuropathic pain. Twenty-three participants (24 transtibial residual limbs) with and without residual limb neuropathic pain were enrolled. The etiology of amputation of most participants was peripheral vascular disease and diabetes. InterventionA comprehensive history was collected and a musculoskeletal ultrasound assessment for the presence and location of neuromas in their residual limb was conducted. During the ultrasound evaluation, a sonopalpation Tinel test was performed by applying pressure on each neuroma with the probe. Main Outcome MeasuresNumber of neuromas and their localization in each residual limb examined. ResultsA total of 31 neuromas in the 24 transtibial residual limbs were identified by ultrasound imaging. The average number of neuromas per residual limb was 1.3. All the major peripheral nerves studied could present neuromas, with a predominance of the superficial fibular nerve within our sample. Thirty-five percent of all the neuromas were described as painful. ConclusionsThe presence of terminal neuromas on surgically sectioned nerves in transtibial residual limbs is frequent. Seventy-nine percent of participants had at least one neuroma. Ultrasound imaging is clinically useful to identify neuromas. The evaluator can easily communicate with the patient to diagnose symptomatic neuromas.

Cardiorespiratory fitness in persons with lower limb amputation.

The aim of this study is to gain insight in the cardiorespiratory fitness of persons with lower limb amputation (LLA) during rehabilitation, and in potential factors influencing their cardiorespiratory fitness. We performed a retrospective cohort study using data from cardiopulmonary exercise tests. Included participants were adults with LLA. Main outcome was cardiorespiratory fitness expressed as O 2 peak (ml/min/kg) and was directly determined using breath-by-breath gas analysis. O 2 peak was compared to reference values for able-bodied controls. Multivariate regression analysis was performed to investigate potential factors related to O 2 peak in persons with LLA. Potential factors were age, BMI adjusted, gender, level of amputation, aetiology of amputation, unilateral/bilateral, type of ergometry and use of beta blockers. Data of 74 participants with LLA are presented; 84% male (n = 62), mean age 58.9 (SD 11.6), mean BMI 26.7 (SD 5.6), 44 participants have a LLA above the knee, 30 below the knee. Overall O 2 peak was lower in persons with LLA compared to reference values for able-bodied controls, with mean O 2 peak for the total LLA group of 14.6 ± 4.1 ml/kg/min. In the multivariate regression analysis, only age was a significant predictor for lower O 2 peak (regression coefficient: -0.15, 95% CI [0.23-0.069], r 2 = 0.166). These results indicate that the cardiorespiratory fitness in persons with LLA is low, while they actually need more energy to walk and perform other daily activities. Cardiorespiratory fitness is not closely associated with the analysed demographic or clinical factors and will have to be determined on an individual basis for use in daily practice.

Kvalitet života bolesnika nakon transtibijalne amputacije i različiti periodi nošenja proteze

Introduction. Research into patients with lower limb amputation (LLA) puts strong emphasis on quality of life (QoL) and importance of the research in that regard as a measure for the rehabilitation outcomes. The aim of this study was to show which aspects of QoL are related to the duration of wearing a prosthesis in patients with transtibial amputation (TTA). Methods. The study sample comprised 40 patients who used prosthesis for 1 - 3 years (group A), 4 - 7 years (group B) and > 8 years (group C). All patients completed Trinity Amputation and Prosthesis Experience Scale-Revised (TAPES-R). Results. Prosthesis wearing history was significantly different between the groups: group A (2.2 ± 0.7 years), group B (5.5 ± 1.3 years) and group C (22.9 ± 13.6 years), p<0.001. Patients in group B were significantly (p < 0.05) older compared to patients in group C, displayed a significantly (p < 0.05) lower rate of employment and significantly (p < 0.05) longer duration of diabetes mellitus. Patients in group C displayed a significantly (p = 0.005) lower rate of diabetes mellitus. TAPES-R showed that social adjustment was significantly lower (p < 0.05) in patients in group C compared to patients in group A (3.14 ± 0.46 vs. 3.55 ± 0.41). Conclusion. Although patients with TTA showed good QoL, the group with a long history of wearing a prosthesis differed significantly in social adjustment compared to patients with a short period of wearing a prosthesis. The age and etiology of amputation differed significantly between the groups.

Characterization of initial ankle-foot prosthesis prescription patterns in U.S. Service members following unilateral transtibial amputation.

The purpose of this study was to explore relationships between patient-specific characteristics and initial ankle-foot prosthesis prescription patterns among U.S. Service members with unilateral transtibial limb loss. A retrospective review of health records identified 174 individuals with unilateral transtibial limb loss who received care at Walter Reed National Military Medical Center between 2001 and 2019. We examined patient-specific factors such as demographics, participant duty status at injury and amputation, amputation etiology, and timing between injury, amputation, and initial prescription. The type of first prescribed ankle-foot prosthesis was categorized as energy storing and return - nonarticulating, energy storing and return - articulating, or computer controlled. Sex, amputation etiology, time from injury to initial prescription, and time from amputation to initial prescription differed by type of initial ankle-foot prosthesis prescription. Service members with shorter intervals between injury-initial prescription and amputation-initial prescription, and those injured by combat blast, were more likely to receive a non-articulating device. Incorporating sex, time from injury-initial prescription, time from amputation-initial prescription, and amputation etiology as predictors of prosthesis type, we were able to correctly classify 72% of all first prostheses prescribed. Patient-specific characteristics such as sex, the time between injury-initial prescription, time from amputation-initial prescription and amputation etiology are essential characteristics that influence initial ankle-foot prosthesis prescription patterns in U.S. Service members.

Secondary amputation after lower extremity free-flap reconstruction

BackgroundMicrosurgical free-tissue transfer is often the definitive reconstructive option for lower extremity limb salvage. Despite an initial successful free-flap reconstruction, some patients ultimately undergo lower extremity amputation. The indications for secondary amputation include non- or malunion, infection, hardware failure, or chronic pain. This study aimed to identify the etiology and outcome of secondary amputation after lower extremity free-flap reconstruction. MethodsA retrospective cohort study was performed including patients who underwent lower extremity free-flap reconstruction from January 2002 to December 2020. Patients who underwent secondary amputation were identified. A survey based on the PROMIS® Pain Interference Scale and activities of daily living (ADLs) was then conducted to assess patient-reported outcomes. Fifteen (52%) patients who underwent amputation responded to the survey, with a median follow-up time of 4.4 years. ResultsOf 410 patients who underwent lower extremity free-flap reconstruction, 40 (9.8%) patients underwent subsequent amputation. Of these, 10 patients had failed free-flap reconstruction and 30 patients had secondary amputation after an initially successful soft tissue coverage. The most common etiology for secondary amputation was infection (68%, n = 27). Eighty percent (n = 12) of survey respondents were able to use a prosthetic limb and ambulate. ConclusionsThe most common etiology of secondary amputation was infection. Most patients who ultimately underwent amputation were able to ambulate with a prosthetic, but the majority of patients reported chronic pain. This study could be used to guide potential free-flap candidates regarding the risks and outcomes of lower extremity free-flap reconstruction.

Factors affecting successful prosthetic use after hemipelvectomy and hip disarticulation amputations: Five-year experience from a tertiary prosthetic rehabilitation center.

Rehabilitation after hip disarticulation and hemipelvectomy amputations can be challenging, and many opt to forego prosthetic limb use. There is limited evidence on characteristics that result in successful prosthetic use; therefore, our study aimed to identify these to help guide patient expectations. A retrospective review was performed on patients seen at a UK tertiary prosthetic center in the past 5 years with hip disarticulation or hemipelvectomy amputations. Details and etiology of amputation, length between assessment and delivery of prosthesis, goals, reasons for abandonment, and outcomes were recorded. Successful prosthetic use was defined as the use of a prosthesis at least 3 times a week. Characteristics were compared using odds ratios and Fisher exact test. Twenty-seven patient notes were analyzed: 42% female, 58% male, and age range 14-90. Thirty percent had a hemipelvectomy, and 70% had a hip disarticulation. Neoplasia accounted for 78% of etiologies followed by trauma 15% and infected endoprosthesis 7%. Sixty-seven percent trialed a walking prosthesis; 33% of these stopped eventually. There were no statistically significant findings of factors increasing odds of successful prosthetic use. However, age significantly increased the odds of being given a trial of a prosthesis. Although younger patients are more likely to be given the opportunity to trial a walking prosthesis, age does not seem to affect the overall outcome alone. In cases of neoplasia, there is often a delayed start to rehabilitation and prosthetic use, which may affect eventual success. Further studies are required to define the optimum characteristics for successful prosthetic use at higher amputation levels.

Modifying the five-time sit-to-stand test to allow use of the upper limbs: Assessing initial evidence of construct validity among lower limb prosthesis users.

The Five-time Sit-to-Stand (5xSTS) Test is a performance-based measure used by clinicians and researchers to assess the body functions needed to accomplish sit-to-stand transitions (e.g., lower limb strength, balance, and trunk control). The current requirements for performance of the 5xSTS Test (i.e., crossing arms over the chest) may not be appropriate for many, if not most lower limb prosthesis (LLP) users. The study aims were to (1) develop a modified five-time sit-to-stand (m5xSTS) Test protocol; (2) to examine initial evidence of known-groups construct validity among LLP users by comparing differences in performance by amputation level, amputation etiology, and functional level; and (3) to assess initial evidence of convergent construct validity by examining the correlations between m5xSTS performance with self-reported mobility (Prosthetic Limb Users Survey of Mobility (PLUS-M)), self-reported balance confidence (Activities-balance Confidence Scale (ABC)) and functional capability (comfortable walking speed). Three-hundred sixty-one LLP users participated in this cross-sectional study. The investigators developed a m5xSTS Test protocol that allows tested individuals to use different assistance strategies (i.e., use of upper limbs to push off thighs, push up from the armrests, or use a walker) when needed to perform the test. The investigators recorded m5xSTS Test times and assistance strategies. Significant differences in m5xSTS Test times were found between those who did and did not use an assistance strategy, as well as between participants grouped by different amputation level, etiology, and functional level. Significant moderate negative correlations were found between m5xSTS Test times and PLUS-M T-score (ρ = -0.42, p<0.001), ABC score (ρ = -0.42, p<0.001), and comfortable walking speed (ρ = -0.64, p<0.001), respectively. The m5xSTS Test allows LLP users to perform sit-to-stand transitions in a manner that accounts for their functional impairments, is consistent with post-amputation training, and is safe for the tested individual. Results from this study provide preliminary evidence of known groups and convergent construct validity for the m5xSTS Test with a large national sample of LLP users.

Osseointegration for Lower Limb Amputation: Understanding the Risk Factors and Time Courses of Soft Tissue Complications.

Lower-limb osseointegrated prostheses are a novel alternative to traditional socket-suspended prostheses, which are often associated with poor fit, soft tissue damage, and pain. Osseointegration eliminates the socket-skin interface and allows for weight-bearing directly on the skeletal system. However, these prostheses can also be complicated by postoperative issues that can negatively impact mobility and quality of life. Little is known about the incidence of or risk factors for these complications as few centers currently perform the procedure. A retrospective analysis was performed on all patients who underwent single-stage lower limb osseointegration at our institution between 2017 and 2021. Patient demographics, medical history, operative data, and outcomes were collected. Fisher exact test and unpaired t tests were performed to identify risk factors for each adverse outcome, and time-to-event survival curves were generated. Sixty patients met our study criteria: 42 males and 18 females with 35 transfemoral and 25 transtibial amputations. The cohort had an average age of 48 years (range, 25-70 years) and follow-up period of 22 months (range, 6-47 months). Indications for amputation were trauma (50), prior surgical complication (5), cancer (4), and infection (1). Postoperatively, 25 patients developed soft tissue infections, 5 developed osteomyelitis, 6 had symptomatic neuromas, and 7 required soft tissue revisions. Soft tissue infections were positively correlated with obesity and female sex. Neuroma development was associated with increased age at osseointegration. Neuromas and osteomyelitis were both associated with decreased center experience. Subgroup analysis by amputation etiology and anatomic location did not show significant differences in outcomes. Notably, hypertension (15), tobacco use (27), and prior site infection (23) did not correlate with worse outcomes. Forty-seven percent of soft tissue infections occurred in the 1 month after implantation, and 76% occurred in the first 4 months. These data provide preliminary insights into risk factors for postoperative complications arising from lower limb osseointegration. These factors are both modifiable (body mass index, center experience), and unmodifiable (sex, age). As this procedure continues to expand in popularity, such results are necessary to inform best practice guidelines and optimize outcomes. Further prospective studies are needed to confirm the above trends.

Changing Trends in Aetiology of Amputations: A 12-year Retrospective Cross-sectional Study

Introduction: The Kashmir valley, which has experienced political instability since 1989, has witnessed a rise in amputations and a different aetiology compared to other parts of India. Limited data exists on the changing patterns of various causes of amputations before and after 1989 in the Kashmir valley, India. Aim: To analyse the demographic characteristics, amputation patterns, and different causes among amputees. Materials and Methods: A retrospective cross-sectional study was conducted at the Artificial Limb Centre (ALC) of Bone and Joint Hospital Barzulla, Srinagar, India. The study included 504 patients whose medical records were reviewed from 2006 to 2018 to identify the aetiology, geographical distribution, and level of amputation. Descriptive analysis was performed to determine the frequencies of various causes and levels of amputation. Results: The study found that the most common traumatic causes of amputation were Road Traffic Accidents (RTAs), firearm injuries, and blasts. Non traumatic amputations (vascular disease and malignancies) accounted for 30% of cases. Lower limb amputations (91.5%) were more prevalent than upper limb amputations (8.5%). Conclusion: Prior to 1989, RTA accidents were the major cause of amputations, but there was a surge in amputations caused by firearm injuries and blasts. Additionally, there has been increase in amputations caused by malignancies and dysvascular ischaemia in non traumatic causes.

Walking asymmetry and its relation to patient-reported and performance-based outcome measures in individuals with unilateral lower limb loss

ABSTRACT Gait asymmetry persists for most people after lower limb amputation and is associated with slower walking speeds. However, the relationship between gait asymmetry and patient-reported function remains unclear because they are not commonly assessed together. The purpose of this study was to determine relationships between gait asymmetries in people with lower limb loss and (1) patient-reported outcomes and (2) performance-based prosthetic functional measures. This cross-sectional analysis included nine people with unilateral limb loss aged 48.2 ± 13.1 years of mixed amputation etiology. Patient-reported outcomes included the Prosthetic Evaluation Questionnaire mobility subscale and Activities-specific Balance Confidence scale. Performance outcomes included the Berg Balance Scale and the 30-second sit-to-stand test. Walking performance measures included the 2-Minute Walk Test, during which APDM Opal sensors recorded spatiotemporal gait parameters, and daily step-counts from StepWatch4 activity monitors. The study found that the most asymmetric gait symmetry ratios (prosthetic-limb divided by intact-limb) could be attributed to prosthetic foot dorsiflexion-plantarflexion and rotation motion limitations: prosthetic-limb trailing double support (0.789 ± 0.052), toe-off (0.760 ± 0.068) and toe-out angle (0.653 ± 0.256). Single limb stance, and stance and swing phase durations were most strongly associated with balance and walking performance measures. Notably, no symmetry ratio was significantly associated with patient-reported prosthetic function (unadjusted Pearson correlation coefficients r < 0.50, P > 0.05). More gait symmetry was associated with better balance and walking performance but had no significant relationship with patient-reported function. Although achieving gait symmetry after lower limb loss is a common walking goal, symmetry was unrelated to the perception of functional mobility for people with lower limb loss.

Association Between Osseointegration of Lower Extremity Amputation and Mortality Among Adults

Transcutaneous osseointegration post amputation (TOPA) creates a direct linkage between residual bone and an external prosthetic limb, providing superior mobility and quality of life compared with a socket prosthesis. The causes and potential risks of mortality after TOPA have not been investigated. To investigate the association between TOPA and mortality and assess the potential risk factors. This observational cohort study included all patients with amputation of a lower extremity who underwent TOPA between November 1, 2010, and October 31, 2021, at a specialty orthopedic practice and tertiary referral hospital in a major urban center. Patients lived on several continents and were followed up as long as 10 years. Transcutaneous osseointegration post amputation, consisting of a permanent intramedullary implant passed transcutaneously through a stoma and connected to an external prosthetic limb. Death due to any cause. The hypotheses tested-that patient variables (sex, age, level of amputation, postosseointegration infection, and amputation etiology) may be associated with subsequent mortality-were formulated after initial data collection identifying which patients had died. A total of 485 patients were included in the analysis (345 men [71.1%] and 140 women [28.9%]), with a mean (SD) age at osseointegration of 49.1 (14.6) years among living patients or 61.2 (12.4) years among patients who had died. Nineteen patients (3.9%) died a mean (SD) of 2.2 (1.7) years (range, 58 days to 5 years) after osseointegration, including 17 (3.5%) who died of causes unrelated to osseointegration (most commonly cardiac issues) and 2 (0.4%) who died of direct osseointegration-related complications (infectious complications), of which 1 (0.2%) was coclassified as a preexisting health problem exacerbated by osseointegration (myocardial infarction after subsequent surgery to manage infection). No deaths occurred intraoperatively or during inpatient recuperation or acute recovery after index osseointegration (eg, cardiopulmonary events). Kaplan-Meier survival analysis with log-rank comparison and Cox proportional hazards regression modeling identified increased age (hazard ratio, 1.06 [95% CI, 1.02-1.09]) and vascular (odds ratio [OR], 4.73 [95% CI, 1.35-16.56]) or infectious (OR, 3.87 [95% CI, 1.31-11.40]) amputation etiology as risk factors. Notable factors not associated with mortality risk included postosseointegration infection and male sex. These findings suggest that patients who have undergone TOPA rarely die of problems associated with the procedure but instead usually die of unrelated causes.

Factors influencing physical activity among individuals with lower limb amputations: a qualitative study

Purpose The purpose of this study was to explore the barriers and facilitators to physical activity from multiple stakeholder perspectives including individuals with LLA and health professionals. Materials and methods A qualitative descriptive study situated within an interpretive research paradigm was conducted. Semi-structured interviews were held with individuals with LLA recruited from rehabilitation hospitals in a metropolitan city in Canada. Health professionals with experience in amputation care were recruited from across Canada. Data were analysed using codebook thematic analysis. Results Thirty-three individuals with LLA and eighteen health professionals participated. Six themes were generated which represent the perceived barriers and facilitators to physical activity. Themes including Informal and Formal Supports, Availability of and Access to Community Resources, and Fit and Function of the Prosthesis were perceived by many individuals as facilitators, while acting as a barrier for others depending on an individual’s circumstances. Conclusions These findings provide us with a basis of understanding from which we can begin addressing barriers to physical activity for individuals with LLA, in support of developing patient-centred interventions and physical activity programs for this population. IMPLICATIONS FOR REHABILITATION Irrespective of amputation etiology, individuals who have lower limb amputation experience several barriers to engaging in physical activity. Many system-level barriers to physical activity exist for people with lower limb amputation, which include lack of availability and access to community resources and specialised prostheses conducive to physical activity participation. A participatory approach engaging both patients and rehabilitation professionals can address the patient-provider discordance with respect to a patient’s motivation and attitude towards physical activity participation by creating a supportive environment conducive to behaviour change. The development of future, patient-centered interventions, and physical activity programs for individuals with lower limb amputation must consider fear of falling as a prominent barrier to physical activity and devise potential strategies to address this barrier, by setting realistic and actionable goals.

Descriptive Study of Patients With Upper Limb Amputation As Possible Candidates for a Hand Transplant in Medellín, Colombia

IntroductionThe amputation of the upper limb, especially of the hand, is a serious trauma with significant functional and psychological impact. Treatment options include adaptation to the stump, use of prostheses, and composite tissue transplantation. Unfortunately, in Colombia, to date, there are no epidemiological data that characterize the sociodemographic and clinical variables of patients with upper limb amputation.ObjectiveTo describe the clinical and epidemiological characteristics of patients with upper limb amputation in two hospital institutions in the city of Medellín during the period 2018-2019 as a basis for developing a hand transplant program in Colombia.MethodsA descriptive cross-sectional study was carried out where a total of 443 medical records were reviewed, of which eight records that met the inclusion criteria were identified. Variables such as age, etiology of amputation, level of amputation, comorbidities, complications, and rehabilitation process were analyzed. The information was collected in the REDCap program, and a descriptive analysis was carried out with the data obtained.ResultsFrom a sample of 443 amputee patients, eight were selected that met the inclusion criteria. There were 7/8 men (87%) aged 43 years. A total of 75% came from rural areas. In 3/8 patients, there was amputation of the dominant limb. The most common mechanisms were shear trauma and crushing in the context of an occupational accident. A total of 50% had a complete extra-hospital amputation, and reimplantation was not attempted in any of the cases. The most frequent levels of amputation were the proximal and distal third of the forearm. The longest follow-up time was 12 months. Only two patients mentioned the possibility of using a prosthesis during rehabilitation.ConclusionsThree young patients were identified, without comorbidities, with amputation of the dominant limb in the context of an occupational accident and without the possibility of rehabilitation with prostheses who benefit from a possible future hand transplant. However, it is necessary to implement a composite tissue transplantation program and public health policies that allow this procedure to be performed in Colombia.

The role of Rehabilitation in pediatric amputation – A 10-year retrospective study in a Portuguese population

Introduction: Limb amputation in pediatric population, whether congenital or acquired, has a set of attributes that require a different medical approach and rehabilitation management. Objectives: To characterize the pediatric population referred to the Amputee Rehabilitation consultation and evaluate amputation type and segment relationship with prosthesis usage. Material and methods: We conducted a retrospective study based on the clinical information from patients referred to the Pediatric Rehabilitation consultation between January 2011 and March 2021. The variables analyzed included gender, type, and etiology of amputation, amputation level, age of prosthesis, time to the first prosthesis, pre-prosthetic training, number of components prescribed, waiting time per component, and prosthesis use. Results: The study included 50 patients, 68% of congenital etiology. Within the group of acquired amputations, 62.5% had neoplastic causes. The initial use of a prosthesis occurred in 91.7% of the population with upper limb amputations. However, the final adhesion of the upper limb prosthesis was only 50%. There was a statistically significant dependence and a moderate association between the amputated segment and the final use of the prosthesis. The abandonment risk of upper limb prosthesis was seven times higher than lower limb prosthesis. The remaining variables did not demonstrate any other type of significant association. Conclusion: In pediatric age, congenital amputations are more frequent than acquired causes. However, contrary to other data, malignancy was the most frequent etiology in this study within acquired amputations. Regardless of the type of amputation, the use of a prosthesis is related to the affected segment. The abandonment risk of upper limb prostheses is significant, given the development of compensatory strategies that allow the functional use of the limb. Physical and Rehabilitation Medicine plays an essential role in the assessment and management of pediatric amputation. Prescribing at the right time, carrying out an adequate program, with the child and family, is the key to their functional independence.

Does re-amputation following lower extremity amputation in diabetic or dysvascular patients negatively affect survival?

Objective: We aimed to investigate the characteristics of patients who underwent unilateral amputation due to diabetes and peripheral artery disease, as well as the risk factors that cause re-amputation, and to determine these patients' survival status and the risk factors for mortality. Patients and Methods: This retrospective study included 133 patients who underwent amputation due to diabetes and peripheral arterial disease between 2012 and 2018. The etiology of amputation, the re-operation rate and time to re-operation following initial amputation, survival status and follow up results were accessed from hospital records. Results: Twenty-eight patients underwent amputation due to peripheral arterial disease, whereas 105 patients had peripheral vasculopathy due to diabetes mellitus. The re-operation rate was 33.8%, and the median period from initial surgery to the second surgery was six-weeks. Sixty-six deceased patients survived with a median of 6 months following initial operation. Conclusion: The most crucial factor causing re-amputation was the non-healing wound problems. Patients with amputation should be followed up carefully for wound problems in the six weeks after surgery. Advanced age, American Society of Anesthesiologist grade 4 patients, associating neurological disease, low albumin level, low lymphocyte count and postoperative intensive care unit requirement were all poor prognostic factors for survival. Re-amputation had no negative effect on survival.

Impact of Civilian Patient Care on Major Amputation Case Volume in the Military Health System.

Sustaining critical wartime skills (CWS) during interwar periods is a recurrent and ongoing challenge for military surgeons. Amputation surgery for major extremity trauma is exceptionally common in wartime, so maintenance of surgical skills is necessary. This study was designed to examine the volume and distribution of amputation surgery performed in the military health system (MHS). All major amputations performed in military treatment facilities (MTF) for calendar years 2017-2019 were identified by current procedural terminology (CPT) codes. The date of surgery, operating surgeon National Provider Identifier, CPT code(s), amputation etiology (traumatic versus nontraumatic), and beneficiary status (military or civilian) were recorded for each surgical case. One thousand one hundred and eighty-four major amputations at 16 of the 49 military's inpatient facilities were identified, with two MTFs accounting for 46% (548/1,184) of the total. Six MTFs performed 120 major amputations for the treatment of acute traumatic injuries. Seventy-three percent (87/120) of traumatic amputations were performed at MTF1, with the majority of patients (86%; 75/87) being civilians emergently transported there after injury. Orthopedic and vascular surgeons performed 78% of major amputations, but only 9.7% (152/1,570) of all military surgeons performed any major amputation, with only 3% (52) involved in amputations for trauma. Nearly all (87%; 26/30) of the orthopedic surgeons at MTF1 performed major amputations, including those for trauma. This study highlights the importance of civilian patient care to increase major amputation surgical case volume and complexity to sustain critical wartime skills. The preservation and strategic expansion of effective military-civilian partnerships is essential for sustaining the knowledge and skills for optimal combat casualty care.

Is there a changing trend in the Etiology of major lower limb amputation in the developing nations?

Background: Amputation is the removal of part or the whole of a limb and when done on the lower limb proximal to or at the ankle is called major lower limb amputation. Specific indications include trauma, peripheral vascular disease, tumor, infection and congenital anomalies and others. The mortality rate is especially high in those with peripheral vascular disease, also high are complications concerning stump healing, and difficulty in rehabilitation. There seem to be some changing trend in the etiology of lower limb amputation in the developing nations which if reported at all is under. The study sets to determine if there is a changing trend in the indications of lower limb amputation to enable planning by the hospital towards improving services and to influence government policy in Terms of instituting preventive measures. Multi disciplinary team approach to rehabilitation offers the most effective means for successful re-integration of the patient with an amputated limb to their previous life styleMethods: Folders of patients perused for information as regards their bio-data, indications, clinic-pathological variables and early outcome of managements. Data was analyzed using Statistical Package for Social Sciences (SPSS) version 16.0 for windows. Frequency distribution tables of variables were generated and chats formed. Measure of central tendency and dispersion of quantitative variables as well as proportion for qualitative variables were determined.Results: Age ranged was 18-82years with a mean age of 52.61±19.03. Majority were of the working age group 18-60yrs (94.4%). There were 53(67.1%) males with a male: female ratio of 2.04:1 Peripheral vascular disease accounted for 70.5% of the patients followed by trauma (19.2 %). Thirty seven (46.8%) had below knee amputations.Seventy one (89.9%) of them were discharged home, 3(3.8%) signed against medical advice and left while 5(6.3%) died.Conclusion: The etiology of major lower limb amputation is really changing towards what we normally see in the developed nations with peripheral vascular disease taking over from trauma as the major cause of amputation and not only is it changing it comes with its documented unwanted consequences such as high morbidity and mortality.

Survey of transfemoral amputee experience and priorities for the user-centered design of powered robotic transfemoral prostheses

BackgroundTransfemoral amputees experience a complex host of physical, psychological, and social challenges, compounded by the functional limitations of current transfemoral prostheses. However, the specific relationships between human factors and prosthesis design and performance characteristics have not yet been adequately investigated. The present study aims to address this knowledge gap.MethodsA comprehensive single-cohort survey of 114 unilateral transfemoral amputees addressed a broad range of demographic and clinical characteristics, functional autonomy, satisfaction and attitudes towards their current prostheses, and design priorities for an ideal transfemoral prosthesis, including the possibility of active assistance from a robotic knee unit. The survey was custom-developed based on several standard questionnaires used to assess motor abilities and autonomy in activities of daily living, prosthesis satisfaction, and quality of life in lower-limb amputees. Survey data were analyzed to compare the experience (including autonomy and satisfaction) and design priorities of users of transfemoral prostheses with versus without microprocessor-controlled knee units (MPKs and NMPKs, respectively), with a subsequent analyses of cross-category correlation, principal component analysis (PCA), cost-sensitivity segmentation, and unsupervised K-means clustering applied within the most cost-sensitive participants, to identify functional groupings of users with respect to their design priorities.ResultsThe cohort featured predominantly younger (< 50 years) traumatic male amputees with respect to the general transfemoral amputee population, with pronounced differences in age distribution and amputation etiology (traumatic vs. non-traumatic) between MPK and NMPK groups. These differences were further reflected in user experience, with MPK users reporting significantly greater overall functional autonomy, satisfaction, and sense of prosthesis ownership than those with NMPKs, in conjunction with a decreased incidence of instability and falls. Across all participants, the leading functional priorities for an ideal transfemoral prosthesis were overall stability, adaptability to variable walking velocity, and lifestyle-related functionality, while the highest-prioritized general characteristics were reliability, comfort, and weight, with highly variable prioritization of cost according to reimbursement status. PCA and user clustering analyses revealed the possibility for functionally relevant groupings of prosthesis features and users, based on their differential prioritization of these features—with implications towards prosthesis design tradeoffs.ConclusionsThis study’s findings support the understanding that when appropriately prescribed according to patient characteristics and needs in the context of a proactive rehabilitation program, advanced transfemoral prostheses promote patient mobility, autonomy, and overall health. Survey data indicate overall stability, modularity, and versatility as key design priorities for the continued development of transfemoral prosthesis technology. Finally, observed associations between prosthesis type, user experience, and attitudes concerning prosthesis ownership suggest both that prosthesis characteristics influence device acceptance and functional outcomes, and that psychosocial factors should be specifically and proactively addressed during the rehabilitation process.

Etiology and outcomes of amputation in patients with peripheral artery disease in the EUCLID trial

ObjectiveAmputation remains a frequent and feared outcome in patients with peripheral artery disease (PAD). Although typically characterized as major or minor on the extent of tissue loss, the etiologies and outcomes after amputation by extent are not well-understood. In addition, emerging data suggest that the drivers and outcomes of amputation in patients with PAD may differ in those with and without diabetes mellitus (DM). MethodsThe EUCLID trial randomized 13,885 patients with symptomatic PAD, including 5345 with concomitant diabetes, to ticagrelor or clopidogrel and followed them for long-term outcomes. Amputations were prospectively reported by trial investigators. Their primary and contributing drivers were adjudicated using safety data, including infection, ischemia, or multifactorial etiologies. Outcomes following major and minor amputations were analyzed, including recurrent amputation, major adverse limb events, adverse cardiovascular events, and mortality. Multivariable logistic regression models were used to identify independent predictors of minor amputations. Analyses were performed overall and stratified by the presence or absence of DM at baseline. ResultsOf the patients randomized, 398 (2.9%) underwent at least one lower extremity nontraumatic amputation, for a total of 511 amputations (255 major and 256 minor) over a median of 30 months. A history of minor amputation was the strongest independent predictor for a subsequent minor amputation (odds ratio, 7.29; 95% confidence interval, 5.17-10.30; P < .001) followed by comorbid DM (odds ratio, 4.60; 95% confidence interval, 3.16-6.69; P < .001). Compared with patients who had a major amputation, those with a minor amputation had similar rates of subsequent major amputation (12.2% vs 13.6%), major adverse limb events (15.1% vs 14.9%), and major adverse cardiovascular events (17.6% vs 16.3%). Ischemia alone was the primary driver of amputation (51%), followed by infection alone (27%), and multifactorial etiologies (22%); however, infection was the most frequent driver in those with DM (58%) but not in those without DM (15%). ConclusionsOutcomes after amputation remain poor regardless of whether they are categorized as major or minor. The pattern of amputation drivers in PAD differs by history of DM, with infection being the dominant etiology in those with DM and ischemia in those without DM. Greater focus is needed on the prognostic importance of minor amputation and of the multifactorial etiologies of amputation in PAD. Nomenclature with anatomical description of amputations and eliminating terms “major” or “minor” would seem appropriate.

Impact of Level of Pediatric Amputation on Selection of Prosthetic Component Options

ABSTRACT Introduction Amputation is one of the oldest surgeries known to the human race. The principles of amputation in children are different than in adults. Common indications for amputation include congenital, traumatic, infection, malignancy, vascular, and other pathology. Improper prosthetic fitting or inability to use the most modern available prosthesis can lead to dissatisfaction and compromised high-level function. The aim of this study was to assess residual limbs for compatibility to fit the most modern prosthetic components. Methods This study is a retrospective review of medical records of patients who underwent amputation between the pelvis and midfoot before 18 years of age. Age, sex, etiology, and level of amputation were recorded. A senior certified prosthetist graded the limbs based on limitations the residual limb imposed on options for the highest functioning modern prosthetic components. Results Sixty-one patients were identified (35 male, 26 female) with a mean age at assessment of 17.35 years (range, 1.86–35.35 years). Congenital causes and tumors were the most common etiology. Amputations around the ankle were most common (25), followed by transtibial (20). There were 59% grade 1 limbs with no restrictions to component options, 28% grade 2 with moderate restrictions, and 13% grade 3 or severely limited component options due to the residual limb. Most grade 1 residual limbs were transtibial or proximal. Amputations distal to transtibial were of all grades. Conclusions The choices for optimal high-level prosthetic components are much less limited for transtibial amputation than more distal amputations leading to potentially less high-level prosthetic function. Managing the residual limb length and prosthetic fitting ability is an important element in pediatric amputations if the goal is to fit mature young adults with the highest functioning level prosthetic components.