Higher Level Of Amputation Research Articles

Treatment of Charcot Neuroarthropathy and osteomyelitis of the same foot: a retrospective cohort study

BackgroundWe evaluated treatment of osteomyelitis in the foot in the presence of Charcot neuroarthropathy, a devastating condition with progressive degeneration and joint destruction. We hypothesized that there was a difference in (1) amputation rate, (2) amputation level, (3) duration of antibiotic therapy, and (4) duration of immobilization for treatment of osteomyelitis within versus outside the Charcot zone.MethodsForty patients (43 ft) diagnosed with Charcot neuroarthropathy and osteomyelitis of the same foot were retrospectively analyzed. Some patients were successfully treated for osteomyelitis at different sites on the same foot at different times, thus 60 cases of osteomyelitis were identified in 40 treated patients. Cases were divided according to osteomyelitis localization: Group 1 had osteomyelitis outside the active Charcot region; Group 2 had osteomyelitis within the active Charcot region.ResultsMale patients (n = 29; mean age 58.2, range 40.1 to 77.5 years) were younger than female patients (n = 11; mean age 70.4, range 51.4 to 87.5, p = 0.02 years). Amputation rate was 52% overall (26/40 patients; 26/43 ft): 63% of 30 Group 1 cases and 40% of 30 Group 2 cases (p = 0.09). Amputation level (p = 0.009), duration of antibiotic treatment (p = 0.045) and duration of immobilization (p = 0.01) differed significantly between the groups.ConclusionsOsteomyelitis within the Charcot region is associated with a higher level of amputation and longer durations of antibiotic therapy and immobilization. Osteomyelitis outside and within the Charcot affected region should be considered separately. If osteomyelitis occurs outside the active Charcot region, primary amputation may be preferred to internal resection.Level of EvidenceRetrospective cohort chart review study.

The Use of Rifampin Therapy to Treat Diabetic Patients with Osteomyelitis of the Foot in the Veterans Health Administration: Patient Characteristics and Clinical Outcomes

Background Nearly 25% of Veterans Health Administration (VHA) patients are diagnosed with diabetes mellitus (DM). Among DM patients, the lifetime incidence of foot ulcers is 15%. Infection is a common complication of foot ulcers and 20–60% of infections result in diabetic foot osteomyelitis (DFO). Current treatment guidelines do not endorse any specific antibiotic agent for DFO, but small clinical trials suggest the addition of rifampin to antimicrobial regimens results in improved cure rates for osteomyelitis.Methods Using VHA databases, we identified index DFO cases from 2009 to 2013 and extracted patient and infection characteristics including demographics, comorbidities, chronic medications, antibiotic regimens, and microbiology data when present. We analyzed the subset of patients alive, without high-level amputation, and treated with antibiotics at 90 days after diagnosis. We summarized patient characteristics and compared a composite endpoint of amputation or death within 2 years of DFO diagnosis among those treated with rifampin to those not treated with rifampin.ResultsIn total, 10,736 DFO cases met our criteria (Figure). Of these, 151 were considered treated with rifampin, based on 14 or more days of rifampin initiated within 90 days of diagnosis; 10,551 were unexposed to rifampin; and 34 were excluded for late or short treatment with rifampin. We observed significant differences between patients treated with and without rifampin (Table) and 44% of rifampin-treated patients were seen in 14 facilities.Amputation or death at 2 years was observed in 44 (29%) of patients treated with rifampin and 4,007 (38%) of patients not treated with rifampin (P = 0.03).Conclusion Rifampin was rarely used in the treatment of DFO in the VHA and a few facilities accounted for a large proportion of rifampin-treated cases. We observed higher rates of amputation-free survival in patients treated with rifampin, but in the presence of notable confounders including age, comorbidities, and organism.Not treated with rifampin N = 10,551Treated with rifampin N = 151 P-valueAge (mean)6562<0.01Charlson comorbidity (mean)4.03.5<0.01Warfarin (prior 6 months) (%)9.76.60.25 S. aureus identified (%)33.945.7<0.01Complex VA Medical Center (%)39.445.00.19Disclosures E. Saade, Steris: Grant Investigator, Grant recipient. Janssen: Grant Investigator, Research grant. Sequiris: Grant Investigator, Research grant. Pfizer: Grant Investigator, Research grant. R. A. Bonomo, Entasis: Grant Investigator, Research grant. Allecra: Grant Investigator, Research grant. Wockhardt: Grant Investigator, Research grant. Merck: Grant Investigator, Research grant. Roche: Grant Investigator, Research grant. GSK: Grant Investigator, Research grant. Allergan: Grant Investigator, Research grant. Shionogi: Grant Investigator, Research grant

Surgical and medical morbidity following failed non-traumatic partial foot amputation in diabetic patients

Category: Ankle, Diabetes, Lesser Toes, Midfoot/Forefoot Introduction/Purpose: Maximal limb preservation is often the goal in choosing partial foot amputation (PFA) as a treat-ment for diabetic foot infections. Some of these patients will go on to experience multiple hospital admissions, IV antibiotic courses, surgical debridements, re-amputations and other medical compli-cations. This study describes the treatment course of these patients starting at second partial foot amputation and ending at 5 year follow-up. Methods: A retrospective cohort was built from a database of all amputation procedures performed on diabet-ic patients at the University of Iowa Department of Orthopedics from 2000 – 2015. The cohort was evaluated over time frame starting at second PFA (index procedure) and ending at 5 years after in-dex procedure. Of 264 patients who underwent partial foot amputation, 49 experienced two lower extremities PFA between January 2000 and December 2011 (cut-off used to allow minimum of 5 years post-PFA). Demographic data was recorded at index PFA and included surgical dates, laterali-ty, surgery type, diagnoses at time of initial surgery, and death date. A chart review collected in-formation on 5 year post-index PFA incidence of: non-surgical hospitalizations, antibiotic admin-istrations, total contact cast applications, and complications (such as osteomyelitis and acute renal failure). Results: Thirty-two (65%) of the second partial foot amputations (index) were ipsilateral and 17 were con-tralateral to first partial foot amputation (pre-index procedure). Eighteen (37%) of the partial foot amputation patients eventually experienced transtibial / transfemoral amputations in the 5 years fol-lowing index PFA. Eleven (22%) had at least a third partial foot amputation (and as many as 7) dur-ing study period. Sixteen (32%) patients had 17 transtibial / transfemoral amputations within 5 year time frame. 11 of the 17 (65%) TT / TF procedures were ipsilateral to index (second) PFA. Seven (17%) of the patients died. Conclusion: Maximal limb preservation may not be beneficial in all cases, particularly in the case of repeat PFAs. This cohort of repeat PFA patients demonstrated a complicated medical course with long pe-riods of hospitalization, leg immobilization in cast, and home-going antibiotics (requiring PICC). This study suggested that over a 5 year period following second PFA, patients on average experi-enced at least 31 days in TCC, 17 days hospitalized and underwent one additional amputation pro-cedure. These are likely underestimates due to follow-up or outside hospital cares. A large number of patients (18 or 37%) ultimately required higher-level amputation. There is a potential morbidity with PFA that may not be communicated to patients when making these decisions. In this cohort, the average days to second PFA was 360 days. 18 of 49 repeat PFA patients underwent tran-stibial or transfemoral amputation within 5 years of their initial PFA. The morbidity of the interim medical course over 5 years added to the poor quality of life after PFA.

Characterization of interfacial socket pressure in transhumeral prostheses: A case series.

One of the most important factors in successful upper limb prostheses is the socket design. Sockets must be individually fabricated to arrive at a geometry that suits the user’s morphology and appropriately distributes the pressures associated with prosthetic use across the residual limb. In higher levels of amputation, such as transhumeral, this challenge is amplified as prosthetic weight and the physical demands placed on the residual limb are heightened. Yet, in the upper limb, socket fabrication is largely driven by heuristic practices. An analytical understanding of the interactions between the socket and residual limb is absent in literature. This work describes techniques, adapted from lower limb prosthetic research, to empirically characterize the pressure distribution occurring between the residual limb and well-fit transhumeral prosthetic sockets. A case series analyzing the result of four participants with transhumeral amputation is presented. A Tekscan VersaTek pressure measurement system and FaroArm Edge coordinate measurement machine were employed to capture socket-residual limb interface pressures and geometrically register these values to the anatomy of participants. Participants performed two static poses with their prosthesis under two separate loading conditions. Surface pressure maps were constructed from the data, highlighting pressure distribution patterns, anatomical locations bearing maximum pressure, and the relative pressure magnitudes. Pressure distribution patterns demonstrated unique characteristics across the four participants that could be traced to individual socket design considerations. This work presents a technique that implements commercially available tools to quantitatively characterize upper limb socket-residual limb interactions. This is a fundamental first step toward improved socket designs developed through informed, analytically-based design tools.

Resolving the effect of wrist position on myoelectric pattern recognition control

BackgroundThe use of pattern recognition-based methods to control myoelectric upper-limb prostheses has been well studied in individuals with high-level amputations but few studies have demonstrated that it is suitable for partial-hand amputees, who often possess a functional wrist. This study’s objective was to evaluate strategies that allow partial-hand amputees to control a prosthetic hand while allowing retain wrist function.MethodsEMG data was recorded from the extrinsic and intrinsic hand muscles of six non-amputees and two partial-hand amputees while they performed 4 hand motions in 13 different wrist positions. The performance of 4 classification schemes using EMG data alone and EMG data combined with wrist positional information was evaluated. Using recorded wrist positional data, the relationship between EMG features and wrist position was modeled and used to develop a wrist position-independent classification scheme.ResultsA multi-layer perceptron artificial neural network classifier was better able to discriminate four hand motion classes in 13 wrist positions than a linear discriminant analysis classifier (p = 0.006), quadratic discriminant analysis classifier (p < 0.0001) and a linear perceptron artificial neural network classifier (p = 0.04). The addition of wrist position data to EMG data significantly improved performance (p < 0.001). Training the classifier with the combination of extrinsic and intrinsic muscle EMG data performed significantly better than using intrinsic (p < 0.0001) or extrinsic muscle EMG data alone (p < 0.0001), and training with intrinsic muscle EMG data performed significantly better than extrinsic muscle EMG data alone (p < 0.001). The same trends were observed for amputees, except training with intrinsic muscle EMG data, on average, performed worse than the extrinsic muscle EMG data. We propose a wrist position–independent controller that simulates data from multiple wrist positions and is able to significantly improve performance by 48–74% (p < 0.05) for non-amputees and by 45–66% for partial-hand amputees, compared to a classifier trained only with data from a neutral wrist position and tested with data from multiple positions.ConclusionsSensor fusion (using EMG and wrist position information), non-linear artificial neural networks, combining EMG data across multiple muscle sources, and simulating data from different wrist positions are effective strategies for mitigating the wrist position effect and improving classification performance.

Association of risk factors with a major re-amputation in Malaysian diabetic patients: a retrospective cohort analysis of patient registry

This study aimed to determine the association of risk factors with a major re-amputation in Malaysian diabetes patients. This is a retrospective review and analysis of a patient cohort obtained from National Orthopedic Registry Malaysia (NORM) between June 2008 and December 2009. Re-amputation is defined as the removal of bones to advance to a higher level of amputation. An amputation can be regarded as a re-amputation if it is performed on the same limb within the same admission period and is also considered to be the final level of amputation. The plausible risk factors that are reported as importantly associated with the risk of re-amputation include patients’ baseline socio-demographic factors, clinical characteristics, and treatment outcomes, and these are analyzed both separately and together. A total of 137 patients were eligible for inclusion into the study. Only 23.4% of the total 137 patients were actually re-amputated. Baseline clinical characteristics such as the presence of neuropathy (p = 0.004), nephropathy (p = 0.005), and the topical application of emollient (p = 0.003) are found to be associated with requirement for a major re-amputation. Almost a quarter of patients who had an initial amputation will require a re-amputation. The patients who were at a particularly high risk of the need for re-amputation were those experiencing complications of diabetes such as nephropathy. Topical application of emollient is necessary to delay the need for re-amputation and if possible, avoid it altogether.

Free-Flap Transfer for Coverage of Transmetatarsal Amputation Stump to Preserve Residual Foot Length.

Surgical management of soft-tissue defects of the forefoot and midfoot caused by trauma or diabetic complications can be challenging because locoregional tissue is insufficient to provide adequate flap. This deficiency necessitates higher-level amputations, such as Chopart or even transtibial amputation, resulting in far more debilitating functional outcomes than are seen with partial foot amputation. The purpose of this study was to examine the surgical outcomes after transmetatarsal amputation and a free-flap transfer to preserve foot length. This prospective case series was conducted from January 2011 to December 2015 at the Department of Plastic and Reconstructive Surgery at our institute. A total of 16 patients (11 men and 5 women) were enrolled in this study, all of whom were candidates for higher-level amputation because of inadequate soft-tissue coverage after debridement. Each patient underwent transmetatarsal amputation and reconstruction of the amputation stump using free-flap transfers to preserve foot length. Preoperative and postoperative data were collected to evaluate the postoperative outcomes. All 16 free-flap transfers were successful, with no major complications. In 2 cases, partial flap necrosis required additional skin grafting. The mean follow-up period was 24.3 months (range = 7-55 months). Flap coverage was stable, and all the patients were comfortable with their prostheses at long-term follow-up. Use of a free flap to reconstruct a transmetatarsal amputation stump provided stable coverage, preserved maximal foot length, and resulted in good functional outcomes.

Evaluating EMG Feature and Classifier Selection for Application to Partial-Hand Prosthesis Control.

Pattern recognition-based myoelectric control of upper-limb prostheses has the potential to restore control of multiple degrees of freedom. Though this control method has been extensively studied in individuals with higher-level amputations, few studies have investigated its effectiveness for individuals with partial-hand amputations. Most partial-hand amputees retain a functional wrist and the ability of pattern recognition-based methods to correctly classify hand motions from different wrist positions is not well studied. In this study, focusing on partial-hand amputees, we evaluate (1) the performance of non-linear and linear pattern recognition algorithms and (2) the performance of optimal EMG feature subsets for classification of four hand motion classes in different wrist positions for 16 non-amputees and 4 amputees. Our results show that linear discriminant analysis and linear and non-linear artificial neural networks perform significantly better than the quadratic discriminant analysis for both non-amputees and partial-hand amputees. For amputees, including information from multiple wrist positions significantly decreased error (p < 0.001) but no further significant decrease in error occurred when more than 4, 2, or 3 positions were included for the extrinsic (p = 0.07), intrinsic (p = 0.06), or combined extrinsic and intrinsic muscle EMG (p = 0.08), respectively. Finally, we found that a feature set determined by selecting optimal features from each channel outperformed the commonly used time domain (p < 0.001) and time domain/autoregressive feature sets (p < 0.01). This method can be used as a screening filter to select the features from each channel that provide the best classification of hand postures across different wrist positions.

The problem of classification and organization of medical care for diabetic patients with different forms of ulcerative-necrotic lesions of lower extremities

Patients with diabetes mellitus (DM) are at risk of development of both diabetic foot syndrome and ulcers on the lower legs due to chronic venous insufficiency and other factors. The main group in this study was comprised of diabetic patients with ulcers of different etiology (venous, post-traumatic, mixed) treated at the Diabetic Foot Cabinet during 5 years (n=101). The group of comparison included simultaneously treated patients with diabetic foot syndrome (n=721). Patients of the main group was dominated by women (71%) and patients with type 2 DM. Ulcer healing due to the treatment, persistent non-healing ulcers, and high-level amputations occurred equally often in the two groups: 60 and 58%, 18 and 15%, 4 and 5% respectively (р>0,05). Lower leg ulcers in DM are very persistent and constitute a serious medico-social problem to be addresses based at Diabetic Foot cabinets. The frequency of such ulcers and related amputations must be taken into consideration in epidemiological surveys.

Complexity Analysis of Surface EMG for Overcoming ECG Interference toward Proportional Myoelectric Control

Electromyographic (EMG) signals from muscles in the body torso are often contaminated by electrocardiography (ECG) interferences, which consequently compromise EMG intensity estimation. The ECG interference has become a barrier to proportional control of myoelectric prosthesis using a neural machine interface called targeted muscle reinnervation (TMR), which involves transferring the residual amputated nerves to nonfunctional muscles (typically pectoralis muscles for high level amputations). This study investigates a novel approach toward implementation of proportional myoelectric control by applying sample entropy (SampEn) analysis of surface EMG signals for robust intensity estimation in the presence of significant ECG interference. Surface EMG data from able-bodied and TMR amputee subjects with different degrees of ECG interference were used for performance evaluation. The results showed that the SampEn analysis had high correlation with surface EMG amplitude measurement but low sensitivity to different degrees of ECG interference. Taking this advantage, SampEn analysis of surface EMG signal can be used to facilitate implementation of proportional myoelectric control against ECG interference. This is particularly important for TMR prosthesis users.

The Timed Up and Go and Two-Minute Walk Test: Exploration of a method for establishing normative values for established lower limb prosthetic users

The Timed Up and Go (TUG) and Two-Minute Walk Test (2MWT) are clinically appropriate mobility measures in amputee rehabilitation. Despite the tests being routinely performed, reference values for amputees have yet to be established. This study aimed to establish and trial a method for estimating normative values of the TUG and 2MWT for transtibial and transfemoral amputees. Thirty-seven established prosthetic users aged 40–69 years (28 unilateral transtibial amputees and nine unilateral transfemoral) performed two recorded trials of the TUG and 2MWT. Participant characteristics were collected using the Trinity Amputation and Prosthesis Experience Scale. Preliminary normative data for the TUG and 2MWT were produced for three age cohorts and the two amputee subpopulations. Poorer mobility performance with transfemoral amputation was evident for both mobility measures. Multivariate analysis displayed relationships between age, length of time with a prosthesis and performance of both tests. In conclusion, normative values for the TUG and 2MWT for transtibial and transfemoral amputees may be calculated. Preliminary results indicate that higher levels of amputation relate to poorer performance on both the TUG and 2MWT. Studies with larger samples are required to further develop these values for use in rehabilitation.

Biomedical Technologies in the Treatment of Skin and Soft Tissue Defects in Patients with Diabetic Foot Syndrome

The aim of our study was to investigate the effectiveness of collagen implants in the closure of tissue defects. We offer a method that enables us to avoid the drawbacks of autodermoplasty based on the free split-thickness skin graft. Materials and Methods: This paper describes all steps of treatment of skin and soft tissue defects in patients with diabetic foot syndrome (DFS), including ultrasonic cavitation with hydrosurgical debridement to remove necrotic debris, purulent pellicle and bacterial biofilm, and an alternative technique for wound defect closure using high-tech biomaterials based on type I collagen (“Collost”, “Salvecoll”). Results: Use of type I collagen (“Collost”, “Salvecoll”) as a component of combination treatment of tissue defects in DFS allowed us to increase the relative rate of wound healing, reduce the incidence of high-level amputations, and significantly reduce inpatient surgical coverage around the clock and speed up a patient’s transfer to outpatient care. Conclusion: Ultrasonic cavitation with hydrosurgical debridement is the most effective procedure for wound preparation for closure. The use of bioplastic collagen materials in patients with DFS is the most effective solution in the management of wound defects.(Int J Biomed. 2016; 6(1):41-45.).

Results of in situ femoropopliteal (tibial) bypass in patients with extended lower limbs arterial bed lesion and critical ischemia

Aim. To specify the indications for in situ femoropopliteal (tibial) bypass, to study complications rate immediately after, within 1 and 2 years of the surgery.&#x0D; Methods. The study group included 33 patients with symptoms of critical lower limb ischemia, who underwent femoral-popliteal or femoral-tibial bypass. 4 (12.1%) cases of type C and 29 (87.9%) cases of type D arterial bed lesions according to TASC II classification were revealed after investigation. Patients were followed up for 2 years period. Shunt thrombosis rate, condition of the trophic ulcers, chronic arterial ischemia stage before and after the surgery, mortality, lower limb amputation were measured outcomes.&#x0D; Results. Repeated reconstructions rate for primary shunt thrombosis immediately after surgery was 30.3±8.0%. Shunt thrombosis (secondary) occurred in only three (9.1±5.0%) patients. The main causes which led to the shunt thrombosis during or at the 1st day after the surgery, were absence of intraoperative valvulotomy quality control and presence of unligated great saphenous vein tributaries. Trophic defects healing was observed in 3 (30.0±14.5%) of 10 patients with ulcers immediately after surgery and in all cases (100.0%) by the end of 1 year follow-up. The total number of high-level amputations within 2 years was 25.8±7.9%, the overall mortality rate within 2 years was 6.1±4.2%. Femoral-popliteal or femoral-tibial bypass surgery allowed to preserve the limb in 74.2% of patients within 2 years of follow-up. Bypass patency was preserved in 41.7% of patients out of 24 in situ bypass surgeries for the follow-up time. In our opinion critical limb ischemia with significant and extended arterial bed lesions of D and C types (according to TASC II score) is one of the indications for in situ femoropopliteal (tibial) bypass as for the surgery of the first choice. Endovascular treatment is also impossible for this type of lesion, as alternative surgeries using reversed autovein and synthetic explant do not meet all the requirements for an extended bypass.&#x0D; Conclusion. The lack of adequate intraoperative valvulotomy quality control and presence of unligated great saphenous vein tributaries may be the causes of early postoperative shunt thrombosis; despite the low femoropopliteal (tibial) bypass patency rate in patients with critical ischemia, the surgery was recognized as efficient as it allowed to preserve the limbs in 74.2% of patients.

Phantom movements from physiologically inappropriate muscles: A case study with a high transhumeral amputee.

Individuals with high-level amputation have a great need for functional prostheses because of their vast functional deficits. Conventional techniques are considered inappropriate for high-level amputees due to the lack of physiologically appropriate muscles. This study investigates how accurate phantom movements (PMs) can be classified from physiologically inappropriate muscles. The study involves a case study of a 42-year-old transhumeral amputee. Suitable PMs and best electrode configuration were identified using the sequential forward selection method and brute-force technique. Using linear discriminant analysis, the best PMs (elbow extension/flexion, wrist supination/pronation) and rest were classified with error ranging from 3% to 0.18% when using 3 to 8 EMG channels respectively. A completion rate of 93 % was obtained during a targeted achievement control test in a virtual reality environment. This case indicates that a proximal transhumeral amputee can generate muscle activation patterns related to distinct PMs; and these PMs can be decoded from physiologically inappropriate muscles.

FEASIBILITY STUDY FOR ANFIS AND EMG UTILIZATION IN MODELING PROSTHESIS FOR TRANS-FEMORAL CUT REHABILITATION AND GAIT CYCLE RESTORATION

Rehabilitation of lower limbs with high-level amputation (Trans-femoral Cut) requires an alternative method of inverse and forward dynamics to be employed. Inverse and forward dynamics are capable of solving the problem of redundancy of muscles in human lower limbs. Furthermore, inverse and forward dynamics can be used for estimating joints moments, predicting body segment kinematics, and estimating the distribution of forces between the agonist/antagonist muscle group with reasonable accuracy [Riener R, Lünenburger L, Colombo G, Human-Centered robotics applied to gait training and assessment robert, J Rehabil Res Dev43:679, 2006; Keller T, Perry JC, Rehabilitation robotics for outpatient clinical and domestic use, WC IFMBE Proc25:291, 2009; Crespo LM, Reinkensmeyer DJ, Review of control strategies for robotic movement training after neurologic injury, J Neuroeng Rehabil6:20, 2009; Hillman MI, Rehabilitation robotics from past to present — A historical prespective, Adv Rehabil Robotics, Lect Notes Contr Inf306:25, 2004.]. However, the application of these methods, in rehabilitation, is still limited due to their dependence on multiple input data that cannot be measured using conventional measurement tools. This study is aimed at verifying and validating new models which are capable of predicting body segment kinematics accurately using features obtained from electromyography (EMG) and adaptive neuro fuzzy inference system (ANFIS). These features are used to model a set of (input\output) dynamic data. EMG signals obtained from full gait cycle trials of a subject are used to calculate joint moments. Kinematics of the body segments are obtained by applying Euler numerical integration. The relative percentage root mean square (RMS) error between predicted kinematics from ANFIS and measured values for hip, knee, and ankle were 2.23%, 0.98%, and 0.69%, respectively. However, the achieved minimal reasonable accuracy for minimum number of measured inputs depends on the characteristics of the gait parameters such as cyclic nature and delayed symmetric activities between right and left leg about mid sagittal plane. Results of the combined model show that higher prediction accuracy of the gait cycle is achieved and so rehabilitation of lower limbs is feasible.

Clinical relevance of mold culture positivity with and without recurrent wound necrosis following combat-related injuries.

Invasive fungal wound infections (IFIs) are a recognized threat for personnel who sustain combat-related blast trauma in Afghanistan. Blast trauma, particularly when dismounted, has wounds contaminated with organic debris and potential for mold infection. Trauma-associated IFI is characterized by recurrent wound necrosis on serial debridement with histologic evidence of invasive molds and/or fungal culture growth. Wounds with mold growth but lacking corresponding recurrent necrosis present a clinical dilemma of whether to initiate antifungal treatment. Our objective was to assess the clinical significance of fungal culture growth without recurrent wound necrosis. US military personnel wounded during combat in Afghanistan (June 2009 to August 2011) were assessed for growth of mold from wound cultures and/or histopathologic evidence of IFI. Identified patients were stratified based on clinical wound appearance (with/without recurrent necrosis), and the resultant groups were compared for injury characteristics, clinical management, and outcomes. A total of 96 patients were identified: 77 with fungal elements on histopathology and/or fungal growth plus recurrent wound necrosis and 19 with fungal growth on culture but no wound necrosis after initial debridements. Injury patterns and severity were similar between the groups. Patients with recurrent necrosis had more frequent fevers and leukocytosis during the first 2 weeks after injury, and the majority received antifungal therapy compared with only three patients (16%) without recurrently necrotic wounds. Overall, patients without recurrent wound necrosis had significantly less operative procedures (p = 0.02), shorter stay in the intensive care unit (p < 0.01), and lower rates of high-level amputations (5% vs. 20%) and deaths (none vs. 8%) despite no or infrequent antifungal use. The finding of molds on wound culture among patients with blast trauma in the absence of recurrently necrotic wounds on serial debridement does not require systemic antifungal chemotherapy. Therapeutic study, level IV. Prognosti/epidemiologic study, level III.

Hemipelvectomy

The hemipelvectomy, most commonly performed for pelvic tumor resection, is one of the most technically demanding and invasive surgical procedures performed today. Adequate soft tissue coverage and wound complications after hemipelvectomy are important considerations. Rehabilitation after hemipelvectomy is optimally managed by a multidisciplinary integrated team. Understanding the functional outcomes for this population assists the rehabilitation team to counsel patients, plan goals, and determine discharge needs. The most important rehabilitation goal is the optimal restoration of the patient's functional independence. Factors such as age, sex, etiology, level of amputation, and general health play important roles in determining prosthetic use. The three main criteria for successful prosthetic rehabilitation of patients with high-level amputation are comfort, function, and cosmesis. Recent advances in hip and knee joints have contributed to increased function. Prosthetic use after hemipelvectomy improves balance and decreases the need for a gait aid. Using a prosthesis helps maintain muscle strength and tone, cardiovascular health, and functional mobility. With new advances in prosthetic components, patients are choosing to use their prostheses for primary mobility.

Primary closure of elective toe amputations in the diabetic foot--is it safe?

Toe amputation is the most common partial foot amputation. Controversy exists regarding whether to primarily close toe amputations or to leave them open for secondary healing. The purpose of this study was to evaluate the results of closed toe amputations in diabetic patients, with respect to wound healing, complications, and the need for further higher level amputation. We retrospectively reviewed the results of 40 elective or semi-elective toe amputations with primary closure performed in 35 patients treated in a specialized diabetic foot unit. Patients with abscesses or necrotizing fasciitis were treated emergently and were excluded. Patients in whom clean margins could not be achieved due to extensive cellulitis or tenosynovitis and patients requiring vascular intervention were excluded as well. Outcome endpoints included wound healing at 3 weeks, delayed wound healing, or subsequent higher level amputation. Out of 40 amputations, 38 healed well. Thirty amputations healed by the time of stitch removal at 3 weeks and eight had delayed healing. In two patients the wounds did not heal and subsequent higher level amputation was eventually required. In carefully selected diabetic foot patients, primary closure of toe amputations is a safe surgical option. We do not recommend primary closure when infection control is not achieved or in patients requiring vascular reconstruction. Careful patient selection, skillful assessment of debridement margins and meticulous technique are required and may be offered by experienced designated surgeons in a specialized diabetic foot unit.

Perioperative management of diabetic foot.

Perioperative management of diabetic foot.

Impact of amputation level and comorbidities on functional status of nursing home residents after lower extremity amputation

The ability of nursing home residents to function independently is associated with their quality of life. The impact of amputations on functional status in this population remains unclear. This analysis evaluated the effect of amputations-transmetatarsal (TM), below-knee (BK), and above-knee (AK)--on the ability of residents to perform self-care activities. Medicare inpatient claims were linked with nursing home assessment data to identify admissions for amputation. The Minimum Data Set Activities of Daily Living Long Form Score (0-28; higher numbers indicating greater impairment), based on seven activities of daily living, was calculated before and after amputation. Hierarchical modeling determined the effect of the surgery on postamputation function of residents. Controlling for comorbidity, cognition, and prehospital function allowed for evaluation of Activities of Daily Living trajectories over time. In total, 4965 residents underwent amputation: 490 TM, 1596 BK, and 2879 AK. Mean age was 81 years, and 54% of the patients were women. Most were white (67%) or black (26.5%). Comorbidities before amputation included diabetes mellitus (70.7%), coronary heart disease (57.1%), chronic kidney disease (53.6%), and/or congestive heart failure (52.1%). Mortality within 30 days of hospital discharge was 9.0%, and hospital readmission was 27.7%. Stroke, end-stage renal disease, and poor baseline cognitive function were associated with the poorest functional outcome after amputation. Compared with residents who received TM amputation, those who had BK or AK amputation recovered more slowly and failed to return to baseline function by 6 months. BK was found to have a superior functional trajectory compared with AK. Elderly nursing home residents undergoing BK or AK amputation failed to return to their functional baseline within 6 months. Among frail elderly nursing home residents, higher amputation level, stroke, end-stage renal disease, poor baseline cognitive scores, and female sex were associated with inferior functional status after amputation. These factors should be strongly assessed to maintain activities of daily living and quality of life in the nursing home population.