Late Amputation Research Articles

Deap-seated infection and nonunion following internal fixation for Charcot foot deformity correction. A proportional meta-analysis of level 4 evidence

BackgroundGiven the paucity of literature on the management of infected metalwork and nonunion in neuropathic diabetic patients, a meta-analysis was designed to investigate the two major complications following Charcot reconstruction performed by means of internal fixation methods. MethodsWe searched PubMed, Scopus and CENTRAL until the 17th of May 2022 for completed studies investigating outcomes following midfoot and/or hindfoot and/or ankle diabetic Charcot reconstruction. For a paper to qualify for inclusion, an internal fixation element should have been considered. Random effects meta-analysis of proportion was performed to calculate the rate of post-operative deep-seated infections with the associated amputation rate and nonunions by using Open Meta-analyst software. Sub-analysis linked to anatomical location of reconstruction was performed and the quality of the included studies was appraised using the Moga tool. ResultsThirty studies with 492 eligible reconstructions were considered. Of those, deep-seated infections were diagnosed in 46 cases (Estimated proportion was 6.7%, 95% CI [4.2%–9.2%]). Debridement and antibiotic administration with or without metalwork removal were considered in the majority of the participants with successful clinical outcomes. Amputation was performed in 15 patients due to unmanageable post-operative infection and nonunion was reported in 17 studies (Estimated rates were 36.6%, 95% CI [18.4%–56.3%]; and 11.9%, 95%CI [6.6%–18.1%]; respectively). ConclusionsMeta-analysis showed that although the overall risk of infection development is less than 10%, just below one third of the infected cases undergo late amputation. Moreover, internal fixation reconstructions carry a nonunion risk of just above 10%.

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

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

Mono-Focal Distraction Osteogenesis in Management of Traumatic Bone Loss (Systematic Review of Literature)

Background Traumatic bone loss poses a serious problem for orthopedic surgeons added to the long standing risk of infection implied by open type fractures. Aim of the Work This study aims to assess the efficacy of distraction osteogenesis in compensating bone defects using the Paley score for functional and radiological outcomes. Methodology We searched the literature through PubMed database with publication date restricted to 10 years range from 2009-2019 English literature of prospective studies only were selected with strict inclusion criteria where repeated articles were excluded unless they presented follow up with functional outcome data about cases. Seven studies were included satisfying the predetermined inclusion criteria with total of 242 cases. Patients’ data were collected and analyzed with only: 176 cases mentioned demographic data with average age of ‘37’ and no comorbidities to decrease the risk of bias in our results. 125 patients had fractures in tibia without soft tissue loss and 51 patients needed skin grafting, 3.4% of total cases underwent late amputation, 14.2% experienced pin tract infection. Results Our results appear to demonstrate the efficacy of mono-focal distraction osteogenesis technique in compensating long bone defects of the lower limbs in traumatic events. We isolated studies reporting exclusively on either proximal tibia or distal tibia bone defects compared the respective outcomes of interest in the absence of statistical heterogeneity. The only significant difference that could be established was a four-fold decrease of the likelihood of fair functional results in the ‘distal tibia’ subgroup compared with the ‘proximal tibia’ subgroup. In distal tibial defects, we explored the impact of the size of a bone defect and duration of external fixation on outcomes of interest. We noticed a 3.7-times increase in the odds of re-fracture when the size of the distal tibial defect exceeded 8 cm Conclusion Mono-focal distraction osteogenesis (Ilizarov method) is effective in managing bone defects larger than 3 cm² however for defects larger than 8cm² there’s increased risk of re-fracture.

A Longitudinal Perspective on Conversion to Amputation for Combat-Related Extremity Injuries Treated with Flap-Based Limb Salvage.

To define the rate and primary drivers behind early and late amputation following flap-based limb salvage in the setting of combat extremity trauma. Retrospective review. Level II trauma center. Three hundred seven (303 men, 4 women) patients who underwent flap-based limb salvage treatment between 2003-2014. We reviewed patient medical records, radiographs, and clinical photographs. Early and late amputation rates, time to amputation, reason for amputation. Three hundred seven patients accounted for 323 limbs that underwent flap-based limb salvage treatment (187 lower extremities, 136 upper extremities). A total of 58 extremities (18%) initially treated with flap-based limb salvage ultimately underwent amputation at a median of 480 days (IQR, 285-715 days) from injury. Periarticular fractures and lower extremity injuries were risk factors for both early and late amputation. Other independent risk factors for early amputation were flap complications and vascular injuries, whereas risk factors for late amputation were fractures that went on to nonunion. This study highlights that a subset of patients ultimately require major limb amputation despite having achieved what is initially considered "successful" limb salvage. Flap-related complications, vascular injury, and lower extremity site of injury were associated with early amputation after successful expeditionary efforts at limb preservation. Conversion to late amputation was associated with lower extremity periarticular fractures and fracture nonunion. Chronic pain and persistent limb dysfunction were the most common reasons for late amputation. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Oncology

The December 2022 Oncology Roundup360 looks at: Is high-dose radiation therapy associated with early revision with a cemented endoprosthesis?; Neoadjuvant chemotherapy and endoprosthetic reconstruction for lower extremity sarcomas: does timing impact complication rates?; Late amputation after treatment for lower extremity sarcoma; Osteosarcoma prediagnosed as another tumour: a report from the Cooperative Osteosarcoma Study Group; The influence of site on the incidence and diagnosis of solitary central cartilage tumours of the femur: a 21st century perspective.

What's New in Musculoskeletal Tumor Surgery.

What's New in Musculoskeletal Tumor Surgery.

CORR Insights®: What Are Risk Factors for and Outcomes of Late Amputation After Treatment for Lower Extremity Sarcoma: A Childhood Cancer Survivor Study Report.

SELECTED PROCEEDINGS FROM THE 2021 MUSCULOSKELETAL TUMOR SOCIETY MEETING GUEST EDITOR H. THOMAS TEMPLE MD

What Are Risk Factors for and Outcomes of Late Amputation After Treatment for Lower Extremity Sarcoma: A Childhood Cancer Survivor Study Report.

What Are Risk Factors for and Outcomes of Late Amputation After Treatment for Lower Extremity Sarcoma: A Childhood Cancer Survivor Study Report.

CORR Insights®: Military Service Members with Major Lower Extremity Fractures Return to Running with a Passive-dynamic Ankle-foot Orthosis: Comparison with a Normative Population.

CORR Insights®: Military Service Members with Major Lower Extremity Fractures Return to Running with a Passive-dynamic Ankle-foot Orthosis: Comparison with a Normative Population.

CORR Insights®: Institutional Experience and Orthoplastic Collaboration Associated with Improved Flap-based Limb Salvage Outcomes.

CORR Insights®: Institutional Experience and Orthoplastic Collaboration Associated with Improved Flap-based Limb Salvage Outcomes.

IDEO energy-storing orthosis: Effects on lower extremity function and preservation

IntroductionThe Intrepid Dynamic Exoskeletal Orthosis (IDEO) brace is a custom energy-storing orthosis design meant to improve gait, stability, and function after lower extremity injury or limb salvage. Early studies demonstrated the potential for the IDEO to improve functional performance, in conjunction with its paired return to run (RTR) rehabilitation program, compared to other brace types, and an impressively decreased rate of late amputation. The current study aimed to investigate these functional and revision outcomes from our institution to determine which patients may benefit most from IDEO bracing and what factors of the IDEO design and rehabilitation program are most important for improved outcomes after lower extremity trauma and/or loss of function. MethodsWe performed a retrospective review of all patients treated with a IDEO style brace at a single military lower extremity trauma referral center between May 2003 and November 2017. We reviewed the medical records for initial diagnosis, post-orthotic rehabilitation program, IDEO use characteristics, pain, change in desire for amputation, and whether patient underwent eventual amputation. ResultsWe identified 213 patients with 222 lower extremities treated with IDEO brace. Of these, 76 limbs were treated for combat-related injuries. At one year follow-up, use status could not be determined for 37 extremities (16.7%). Of the 185 limbs with use data available, 116 (61.1%) continued regular brace use, and 37 (15.7%) reported intermittent use. Patients diagnosed with footdrop or weakness were more likely to continue use (OR 2.33, p=0.04), while patients with a previous fusion were less likely to continue use (OR 0.45, p=0.049). Undergoing any dedicated therapy increased chances of continued use (OR 3.37, p<0.001). At final follow-up, 16 patients (7.5%) underwent delayed lower extremity amputations following IDEO treatment. Overall, 27.2% of patients who initially desired amputation eventually underwent amputation despite IDEO brace use. Patients who underwent amputation reported higher pain levels (2 versus 5, p<0.001). DiscussionIn select patients, the IDEO may decrease the desire for delayed amputation and permit higher levels of activity; however, its efficacy appears tied to the rehabilitative regimen, pain levels, and initial diagnosis. These findings should guide post-surgical extremity bracing prescriptions and expectations.

Combined Orthopaedic and Vascular Injuries With Ischemia: A Multicenter Analysis.

To review a large, multicenter experience to identify the current salvage and amputation rates of these combined injuries and, where possible, the variables that predict amputation. Retrospective. Nine trauma centers. This study involved 199 patients presenting to 9 trauma centers with orthopaedic and vascular injuries resulting in ischemic limbs for whom the orthopaedic service was involved with the decision for salvage versus amputation. We reviewed 199 patients, 17-85 years of age. One hundred seventy-two of the injuries were open. Thirty-eight patients (19%) were treated with amputation upon admission as they were deemed to be unsalvageable. Of the remaining 161 patients who had attempted salvage, 36 (30%) required late amputation. Closed injuries were successfully salvaged in 25 of 27 cases (93%). The highest rate of amputation was in tibia fractures with a combined amputation rate of 62%. In those attempted to be salvaged, 21 of 48 (44%) required amputation. The ischemia time for successful salvage was significantly less, P = 0.03. One hundred twenty-four patients had their definitive vascular repair before the bony reconstruction. There were 15 vascular complications, of which 13 (86%) had the definitive vascular repair performed before the definitive osseous repair, although this was not statistically significant. In this series of combined orthopaedic and vascular injuries, we found a high rate of acute and late amputations. It is possible that other protocols, such as shunting and stabilizing the osseous injury, before vascular repair may benefit limb salvage, although this needs more study. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Patency of arterial repairs from wartime extremity vascular injuries

BackgroundExtremity vascular injury (EVI) causes significant disability in Veterans of the Afghanistan/Iraq conflicts. Advancements in acute trauma care improved survival and decreased amputations. The study of wartime EVI has relied...

Myelination of Callosal Axons Is Hampered by Early and Late Forelimb Amputation in Rats.

Deafferentation is an important determinant of plastic changes in the CNS, which consists of a loss of inputs from the body periphery or from the CNS itself. Although cortical reorganization has been well documented, white matter plasticity was less explored. Our goal was to investigate microstructural interhemispheric connectivity changes in early and late amputated rats. For that purpose, we employed diffusion-weighted magnetic resonance imaging, as well as Western blotting, immunohistochemistry, and electron microscopy of sections of the white matter tracts to analyze the microstructural changes in the corticospinal tract and in the corpus callosum (CC) sector that contains somatosensory fibers integrating cortical areas representing the forelimbs and compare differences in rats undergoing forelimb amputation as neonates, with those amputated as adults. Results showed that early amputation induced decreased fractional anisotropy values and reduction of total myelin amount in the cerebral peduncle contralateral to the amputation. Both early and late forelimb amputations induced decreased myelination of callosal fibers. While early amputation affected myelination of thinner axons, late amputation disrupted axons of all calibers. Since the CC provides a modulation of inhibition and excitation between the hemispheres, we suggest that the demyelination observed among callosal fibers may misbalance this modulation.

Hindfoot blast injuries caused by improvised explosive devices: long-term functional assessment in French military personnel.

The chosen treatment and long-term evaluation of hindfoot blast injuries are not well-represented in the literature. The first objective of this retrospective study was to evaluate functional outcomes in French service personnel who had sustained such injuries caused by improvised explosive devices. The second objective was to compare the results for patients who had amputations with those who did not. The hypothesis was that amputee recovered better function. Long-term functional evaluations were carried out using the American Orthopaedic Foot and Ankle Society scale (AOFAS), the Foot and Ankle Ability Measure (FAAM), and the Short Form 12 health survey (SF-12). Eight servicemen with ten hindfoot blast injuries were reviewed at a mean follow-up time of seven years. Primary management was always conservative although half of the patients required late amputation for chronic pain. The patients who underwent amputation reported significantly lower levels of pain than those who did not have an amputation, with higher FAAM and SF-12 scores. In this series, long-term functional results appear better in the amputated group.

Bone reconstruction by the induced membrane technique. What differences between conventional and ballistic trauma?

BackgroundThe induced membrane technique (IMT) has been widely evaluated for reconstruction of post-traumatic bone defects. However, no specific evaluation was conducted in ballistic injuries. The objective of the present study was to compare IMT in conventional trauma (CT) versus ballistic trauma (BT) managed in a military trauma center. MethodsA retrospective study was conducted between 2009 and 2018 in patients treated by IMT for post-traumatic bone defects, whatever the defect location. Endpoints comprised bone union, residual infection, additional bone grafting and lower-limb amputation. ResultsThirty-six patients were included: 24 in the CT and 12 in the BT group. Demographics and injury pattern were similar in both groups, with open fracture and infected lesions predominating. The only significant difference was that tibial bone defects were larger in the BT group. Operative parameters and results were also similar. At a mean 24 months’ follow-up, bone union rate was 83% in both groups, without significant differences in residual infection, complementary grafting or late amputation. ConclusionIMT is appropriate to bone reconstruction in the aftermath of ballistic trauma, with similar results to those obtained in conventional trauma. Level of evidenceIV, retrospective study.

Cryopreserved Arterial and Venous Allograft for Infrainguinal Bypass in Chronic Critical Limb Ischemia

Introduction: In critical limb ischemia the first choice for open revascularization procedure is infrainguinal surgery with autologous vein. However, due to lack of adequate veins, in 20-30 percent of patients an alternative conduit is required for limb salvage surgery. Synthetic prosthesis implantation is an option, but long term results are poor. Cryopreserved human arteries and veins have been used in infected cases, but there is a lack of data regarding allografts in non-infected cases. Our objective was to analyse the results of infrainguinal bypass surgery using allografts for critical lower limb ischemia. Methods: We performed retrospective analyses of patients with critical limb ischemia, who underwent infrainguinal bypass surgery with allografts in a tertiary care university center between 2007 and 2017. Mann-Whitney U-test and Kaplan-Meier analysis with log-rank test were performed for statistical analysis. Results: During an 11-year period, infrainguinal allograft implantations were performed in 134 cases for critical limb ischaemia [91 males (67.9%)]. The mean age of patients was 66.4 ± 9.9 years. Great saphenous veins were implanted in 100 cases and superficial femoral arteries in 34 cases. The average postoperative hospital stay was 13.6 ± 5.6 days. Thirty-day mortality was 2.98%. Early postoperative complications occurred in 17.1% of patients. Thirty-day reoperation rate was 10.44% and late intervention was necessary in 15.67% of cases. After allograft implantation, graft infection was confirmed in 2 cases (1.49%). Five-year occlusion rate of implanted superficial femoral arteries was significantly lower as compared with saphenous vein (p=0.002). Major amputation rates at 1, 3 and 5 years after surgery were 26%, 35% and 37%, respectively. The long-term survival rate was 47% at 5 years. Conclusion: In critical limb ischemia, allograft implantation is a reasonable option for limb salvage. Late amputation rate and long term mortality remain high. The ideal choice of allograft for revascularization is superficial femoral artery since the long term patency is better when compared to saphenous veins. Disclosure: Nothing to disclose

Megaprosthesis in distal femur nonunions in elderly patients—experience from twenty four cases

Purpose of the studyTo evaluate the outcomes and complications using cemented megaprosthesis in elderly patients with distal femur nonunions (DFN).Materials and methodsBetween 2012 and 2016, 24 patients of DFN with an average age of 71.8 years (66–83) and an average 1.9(1–3) prior surgery was managed with distal femur replacement using cemented modular endoprosthesis. Outcomes were analysed on the following criteria: implant status, complications, knee range of motion, Knee Society Score (KSS) and Musculoskeletal Tumor Society (MSTS) score.ResultsAll patients were extremely satisfied with their outcomes. At an average 22.1 months (10–43) follow-up, patients had an average 69.5° (40°-110°) knee flexion, an average KSS of 75.7 (63–88) and an average MSTS score of 19.3 (17–25). Four patients died at an average 21.3 months after surgery due to causes unrelated to the fracture. One patient (4.1%) had implant-related complication; deep infection which required debridement and intravenous antibiotics. There were no late amputations or peri-operative deaths and no patient had aseptic loosening of components.ConclusionBy permitting immediate full weight-bearing ambulation and with most patients returning to an acceptable functional status, cemented megaprosthesis is a viable and useful single-stage management option in elderly patients with DFN.

Clinic Use at the Departments of Defense and Veterans Affairs Following Combat Related Amputations.

Little population-based research has described the transition from Department of Defense (DoD) to Department of Veterans Affairs (VA) healthcare following combat related amputations. The objectives were to describe (1) to what extent patients used either DoD only facilities, both DoD and VA facilities, or VA only facilities during the first 5 years postinjury, (2) which specific clinics were used and (3) clinic use among patients with different levels of amputation (upper versus lower), and among patients with early or late amputation. This was a retrospective analysis of health data extracted from the expeditionary medical encounter database (EMED) and national DoD and VA databases. Patients were 649 US service members who sustained a single major limb amputation following injuries in the Iraq and Afghanistan conflicts, 2001-2008. We compared yearly DoD and VA clinic use by patient groups with different levels of amputation (upper limb: above versus below elbow or lower limb: above versus below knee), different timing of amputation (early: within 90 days postinjury versus late: more than 90 days postinjury), military component (Active Duty versus National Guard/Reserve) and race (White versus Black). For all groups, we calculated the percentage of patients using: (1) DoD only, (2) both DoD and VA or 3) VA only clinics during each of postinjury years 1 through 5. We also calculated the percentage of patients who used specific clinics (e.g., social work, prosthetics, mental health) during each postinjury year. During postinjury year 1, over 98% of patients used DoD only or both DoD and VA clinics. Most individuals (70% to 78%) used both DoD and VA clinics during postinjury year 1. Use of VA only clinics increased gradually between postinjury year 2 (15% to 30% of patient groups) and year 5 (75% to 88%). This gradual transition to use of VA only clinics was seen consistently across patient groups with different anatomical levels or timing of amputation, military component or race. Patients with lower levels of amputation (versus higher levels) and individuals with early amputations (versus late) transitioned earlier to VA only care. Overall, clinic use was high as 91% to 100% of all patient groups used one or more clinics (DoD or VA) during each of the first 5 years. For specific clinics, most patients used DoD facilities related to rehabilitation (physical therapy, prosthetics) or transitional care (social work) particularly during postinjury year 1. Use of most VA clinics studied (social work, primary care, prosthetics, mental health) showed a modest increase primarily after postinjury year 1 and remained stable through postinjury year 5. The results indicated apparent underuse of psychiatric/mental health and prosthetics between postinjury year 1 and 2. The present study indicated a gradual transition from DoD to VA only healthcare which extended across 5 years following combat related amputations. Patients with lower levels of amputation or early amputation generally transitioned earlier to VA only healthcare. These results can inform medical planning to support a timely and clinically effective transition from DoD to VA healthcare.

Analysis of Limb Outcomes by Management of Concomitant Vein Injury in Military Popliteal Artery Trauma

Despite aggressive limb salvage attempts, military popliteal artery injuries are associated with high amputation rates. Combined arterial and venous injuries present a management dilemma for military surgeons in austere settings, and the impact of vein injury management strategy on limb outcomes is not clear. Military casualties sustaining combined ipsilateral popliteal artery and vein injuries from 2003 to 2016 were identified from a military vascular injury database. Limbs were grouped based on whether venous ligation or repair was initially performed. The primary outcome was secondary amputation; the secondary outcomes included limb and vascular/graft complications. Fifty-six limbs were included; of which, 27 (48%) were managed with vein ligation and 29 (52%) with repair. Veins were repaired primarily in 13 (45%) cases with the remainder being treated with interposition grafts. Median injury severity score was higher in the ligation group (19 vs 15, P=0.09), but vascular and concomitant limb injury characteristics were similar. Amputation rates did not differ by vein treatment (45% repair vs. 41% ligation, P=0.76), and this held with injuries above and below the knee considered independently. Most (71%) amputations were performed <30days from injury. Amputation was indicated more frequently for vascular repair failure in the ligated group (55% vs 15%, P=0.04). Four graft infections were all in the repair group (P=0.07 vs ligation). Arterial graft complications were more frequent with vein repair (45%) than ligation (30%), but this did not reach significance (P=0.24). Only one deep vein thrombosis was diagnosed in each group (P=0.96). Type of management of concomitant popliteal vein injury was not associated with early or late amputation in this series of military popliteal artery injuries. Vein injury management may have had implications for the development of arterial graft and limb complications, however. Surgical decision-making regarding popliteal vein treatment should balance short-term contingencies with long-term limb salvage issues.