Leg Amputation Research Articles

Characterizing the Prevalence of Pelvic Floor Disorders in Males and Females With Lower Limb Amputation: Initial Study Findings

Purpose: Investigate the prevalence of pelvic floor disorder symptoms in males and females with unilateral lower limb amputation. Methods: This was a cross-sectional survey-based study. Study surveys were administered online through a study-specific Qualtrics site and participants accessed surveys from the privacy of their own environment. The Pelvic Floor Distress Inventory-20 was utilized to determine the presence and severity of pelvic floor disorder symptoms. Both traditional and contemporary methods of scoring were utilized in reporting results, with the newer scoring method offering a severity of distress classification. Results: Respondents were 135 individuals with unilateral lower limb amputation who utilize a prosthetic limb for daily mobility. Preliminary results indicate that 98% of participants are experiencing some level of distress from pelvic floor disorder symptoms. Additionally, 71.9% of participants reported previous medical treatment for low back pain and 59.3% reported falling in the past year. Correlation between traditional and contemporary scoring techniques was strong (rs = 0.97, P < .001). Female participants, and those with previous low back pain or falls presented with significantly higher scores (P < .01). Discussion: This is the first study to explore the magnitude of pelvic floor disorders in males and females with lower limb amputation. Results indicate that a high percentage of individuals with unilateral major leg amputations are experiencing some level of distress due to pelvic floor symptoms, with concomitant reports of low back pain and falls. Continued investigation is warranted to further identify the effects of pelvic floor symptoms on functioning and quality of life.

Living with chronic structural vulnerability: A biopsychosocial-structural formulation of a patient exhibiting "medical noncompliance" in the setting of historical trauma and social suffering.

Living with chronic structural vulnerability: A biopsychosocial-structural formulation of a patient exhibiting "medical noncompliance" in the setting of historical trauma and social suffering.

Morphological and Biomechanical Consequences of Leg Amputation in a Warring States Individual (2200 BP) From the Frontier of Northern China

ABSTRACTLeg amputation leads to irreversible limb loss and physical impairments, which requires local and systemic skeletal adaptations. The functional morphology of amputees in antiquity has not been systematically investigated. In this study, an individual with signs of lower limb amputation who lived 2200 years ago during the Warring States Period of the Eastern Zhou Dynasty was assessed using functional morphological approaches. The skeleton demonstrated functional morphological adaptations both locally and systematically. Bone thickness and enthesis changes of the amputated leg had signs of atrophy, indicating functional decline and prolonged disuse after the amputation. After amputation, the individual relied on his upper limbs for balance and support. Besides, the individual experienced considerable lumbar strain attributable to his postamputation lifestyle and compensatory movement patterns. The reason for amputation might be penal in a military setting. These findings reveal adaptive mechanisms of limb function and the challenges faced by amputees, offering insights into the consequences of such procedures.

Facility-Level Variation in Major Leg Amputation Among Patients With Newly Diagnosed Diabetic Foot Ulcer.

The prevalence of diabetes is increasing over time, fueling an epidemic of diabetic foot ulcers (DFUs) and subsequent risk of leg amputation. However, little is known about the variation in outcomes for patients with DFUs according to the health care facilities treating them. To examine facility-level variation in major leg amputation among veterans with incident DFUs using the Veterans Health Administration (VHA) cohort. A retrospective cohort study was conducted from January 1, 2016, to December 31, 2021, of all veterans with a new diagnosis of DFU at 140 VHA facilities across the US. Patients were followed up to 1 year from DFU diagnosis. Analyses were conducted between March 22, 2024, and January 13, 2025. A facility was assigned to each patient corresponding to the health care site where the initial DFU diagnosis was made. The primary outcome was major leg amputation during the follow-up period. A multivariable mixed-effects regression model with random facility intercepts was applied to assess variation in major leg amputation rates across facilities, adjusting for social drivers of health, comorbidities, and complicated DFU at initial diagnosis. The median odds ratio (MOR) was calculated to quantify facility-level variation in outcomes. A total of 86 094 veterans (98.3% male; mean [SD] age, 73.0 [8.1] years; age range, 55-102 years) were included. Major leg amputation was performed for 3279 veterans (3.8%) within a year of DFU diagnosis. The MOR for facility-level variation in major leg amputation was 1.85, indicating that the odds of major leg amputation were 1.85 times higher between 2 randomly selected facilities for an average patient (P < .001). In contrast, the MOR for facility-level variation in 1-year mortality was 1.16 (P < .001). This cohort study of veterans with newly diagnosed DFU found significant facility-level variation in major leg amputation rates within 1 year of DFU diagnosis. Facility-level variation in 1-year mortality rates was much smaller, suggesting variation in leg amputation was likely to stem from variation in DFU-specific care. The VHA should strive to minimize the odds of major leg amputation and interfacility variation.

Mechanisms of Impaired Wound Healing in Type 2 Diabetes: The Role of Epigenetic Factors.

Despite decades of research, impaired extremity wound healing in type 2 diabetes remains a significant driver of patient morbidity, mortality, and health care costs. Advances in surgical and medical therapies, including the advent of endovascular interventions for peripheral artery disease and topical therapies developed to promote wound healing, have not reduced the frequency of lower leg amputations for nonhealing wounds in type 2 diabetes. This brief report is aimed at reviewing the roles of various cell types in tissue repair and summarizing the known dysfunctions of these cell types in diabetic foot ulcers. Recent advances in our understanding of the epigenetic regulation in immune cells identified to be altered in type 2 diabetes are summarized, and particular attention is paid to the developing research defining the epigenetic regulation of structural cells, including keratinocytes, fibroblasts, and endothelial cells. Gaps in knowledge are highlighted, and potential future directions are suggested based on the current state of the field.

Innovative e-learning tool for amputees in Ukraine and Germany : Digital assistance for self-help in interdisciplinary rehabilitative care

Following the Russian war of aggression the number of people in Ukraine with amputated arms and legs rose sharply, overwhelming afledgling rehabilitation system. This article describes the development and implementation of an e‑learning tool aimed at medical professionals, amputees and their relatives, which contains awide range of information on rehabilitation after limb amputation and is easily accessible. It is designed to provide practical support for the rehabilitation process of affected individuals and is available free of charge in the Ukrainian and German languages. An interdisciplinary team of doctors, therapists, orthopedic technicians and ascientist developed the structure and outline of the learning module in aconsensus process. The content was developed in small teams and, after an internal content review by two team members, linguistically synchronized and implemented on the open-source learning platform Integrated Learning, Information and Work Cooperation System (Integriertes Lern‑, Informations- und Arbeitskooperations-System, ILIAS). The e‑learning tool was fully developed and implemented within 10months. It is available free of charge in two languages at https://digitale-lehre-mhh.de . It distinguishes between rehabilitation after arm or leg amputation, after which three consecutive rehabilitation phases (postacute, intermediate and maintenance phases) can be selected. The next level gives access to the specific content, which consists of apathway, explanatory texts, images, video sequences and audio files on treatment, self-exercises and practical tips.

Rationale and Design of the DEFIANCE Study: A Randomized Controlled Trial of Mechanical Thrombectomy Versus Anticoagulation Alone for Iliofemoral Deep Vein Thrombosis

Rationale and Design of the DEFIANCE Study: A Randomized Controlled Trial of Mechanical Thrombectomy Versus Anticoagulation Alone for Iliofemoral Deep Vein Thrombosis

Overview of current prosthesis socket technologies for transfemoral amputees

When exploring innovations in amputation medicine and the technical aids required for care, the thought of prosthetic socket technologies might not immediately come to mind. Yet, these attachment systems, commonly referred to as quivers or similar in everyday language, that connect prostheses to the user's body, are an essential component of prosthetic care for individuals with leg amputations. Based on the principles of modern amputation surgery, where surgeons aim to create the best possible fit between prosthesis and residual limb stump, this approach requires prosthetic technology to provide treatment that aligns with current technical standards. When the patient and stump conditions are compatible, a full contact must be created in which the stump surface is in full contact with the complete inner surface of the shaft. This ensures the best possible distribution of pressure and strain loading during the standing and momentum phases. The challenge for orthopedic technicians lies in creating asecure and reliable interface for the individual user's everyday prosthesis, one that supports the daily activities as effectively as possible and ideally for 365 days ayear and for many hours each day. Therefore, the socket is acrucial link between the wearer and the prosthesis. If the socket does not properly fit or hold, the wearer cannot utilize the prosthesis functions or stand and walk safely. In light of these problems, evolving user requirements, scientific advances, technological progress and the overarching goal of further improving the mobility and quality of life of patients, have driven the development of various new socket systems over the past decades.

“A Leg Lamp Story”

Abstract I cannot see the leg lamp from the film A Christmas Story (directed by Bob Clark, 1983) without going back to the night my dad walked into our home with a nail in his foot. His injury eventually led to a partial leg amputation. This piece of reflective writing interweaves research on the leg lamp—an understudied icon of twentieth-century decorative arts in the United States—through recollections of my dad’s life.

Limb-specific blood flow regulation during cycling exercise in traumatic single lower limb amputees.

To investigate the limb-specific blood flow regulation during dynamic bilateral cycling exercise in individuals with traumatic single lower-limb amputation compared to a control group. Seven individuals with single lower leg amputation (AMP) (37 ± 11years, 11 ± 8years since amputation) and 7 age-matched controls (Ctrl) (36 ± 10years) were tested during three 5min constant workload exercise at 60W, 100W, and 80% of peak power output (PPO), on a reclined cycling ergometer. In AMP, femoral blood flow (FBF) and leg vascular conductance (LVC) were measured in the amputated leg (AL) and whole leg (WL), while in Ctrl, the same measurements were obtained in the right and left legs. Interlimb balance was measured with a power meter, and bilateral asymmetry index was calculated for FBF and interlimb balance. Oxygen consumption ( O2), ventilation ( ), mean arterial pressure (MAP), heart rate (HR), and cardiac output (CO) were also quantified. AMP exhibited lower FBF in AL compared to WL (60W, - 61%; 100W, -69%; 80% PPO, - 64%; p < 0.001). LVC increased as expected in WL but did not increase significantly throughout workloads in AL. Interlimb balance exhibited a much higher contribution of the WL (60W, 76% of the work; 100W, 68%; 80% PPO,65%) than AL (60W, 26%; 100W, 34%; 80% PPO, 35%). No differences were found in FBF (p = 0.187), LVC (p = 0.871), and interlimb balance (p = 0.829) in CTRLs. No difference between AMP and CTRL in O2 (p = 0.241), (p = 0.124), MAP (p = 0.186), HR (p = 0.360), and CO (p = 0.144) at any workload was detected. Individuals with amputation present considerable limb-specific blood flow regulation during bilateral cycling exercise. Understanding the mechanisms for this interlimb difference may provide important information to improve rehabilitation and training in this population.

Clopidogrel and Aspirin Resistance and Its Interaction with Peripheral Arterial Disease Outcomes in the Indian Population

Objectives: The objective of the study was to ascertain adverse events (major adverse cardiac and limb events) events in patients of established peripheral arterial disease (PAD), on clopidogrel and aspirin antiplatelet therapy. Patients and Methods: Patients aged 18 years or over, with PAD were screened for participation in the study. Patients were considered to have symptomatic PAD if they met either of two criteria: a history of intermittent claudication, rest pain, or tissue loss of presumed atherosclerotic origin, with either ankle–brachial index &lt;0.85, previous leg amputation, peripheral vascular surgery, or percutaneous intervention; or angiographic or computed tomographic imaging of significant lower-extremity occlusive atherosclerotic disease. The patients took clopidogrel and aspirin at a dose ≥75 mg/day for at least 4 weeks before enrolment. Those with contraindications to antiplatelet usage were excluded from the study. Blood was used as genotyping material. Patient samples were genotyped for clopidogrel resistance (CR)-associated single-nucleotide polymorphism (SNPs) using Illumina Global Screening Array Ver 3 Bead Chip. Illumina Infinium Genotyping Assay protocol was implemented. Intensities of the beads’ fluorescence were detected using iScan Reader (Illumina Inc). Aspirin resistance (AR) was determined with the whole blood, point of care, turbidimetric cartridge-based method, platelet aggregation, and VerifyNow P2Y12 assay, and results were reported in platelet reactivity units (PRU), at a cutoff of 550 PRU. Results: The mean age was 58.4 (12.6) years with 90% males. The mean body mass index was 22.57 (3.54) kg/m2. The cohort comprised 58.9% smokers, 42% alcoholics, 33.5% diabetics, and 63% hypertensives. Limited efficacy of clopidogrel was observed in 52.38% of patients with loss of function (LOF) variations in the CYP2C19 gene. The mean duration of follow-up was 13.4 (4.7) months. Subjects with CYP2C19 LOF alleles showed more complications (39%) and the relationship between the LOF variation in the CYP2C19 gene and the adverse clinical outcomes (major adverse cardiac events [MACE] and major adverse limb events [MALE]) was found to be statistically significant (P = 0.11). CR and AR were found in 147 (50.3%) and 69 (23%) patients, respectively. Resistance to both the antiplatelets was found in 41 (14%) patients. Conclusion: In this largest observational study, the use of dual antiplatelet therapy in the Indian population with PAD on the MACE and MALE events was higher in the patients with CYP2C19 LOF alleles. The study found a statistically significant relationship between genetic testing results and clinical outcomes.

Burden of diabetic peripheral neuropathy in a rural demography of India is revealed by biothesiometry: a reliable screening tool

Background: Diabetes mellitus (DM) is the most prevalent non-communicable disease in the world estimated to be 4.4% in 2030 globally. Among its complications, diabetic peripheral neuropathy (DPN) is the common disorder manifested as ‘glove and stocking sensation’ in the lower extremities. Aim to study the prevalence and to grade DPN in patients attending OPD. Methods: Patients coming to the general surgery and plastic surgery outpatient department were selected. A total of 331 patients will be asked history by a simple questionnaire and symptoms are graded by modified neuropathy symptom score (MNSS) and clinical examination are done and graded by diabetic neuropathy examination (DNE) and vibration perception threshold (VPT) is measured by biothesiometry. Results: Among the DPN patients, 57.40% are asymptomatic and 12.08% are having severe symptoms by MNDS score and about 27.49% having increased risk for pronation for foot ulcer by DNE score and about 43.2% having risk for foot ulcer by biothesiometry average from the most common site for loss of sensation involving over 1st, 3rd, 5th metatarsal head to the least involved site as midfoot. Conclusions: This study reveals the impact of DPN in a rural area, so by implementing this type of screening method reduces the development of foot ulcers by about 60% in asymptomatic patients and leg amputations by 85% in patients with severe stage of DPN with proper foot care.

MODERN APPROACHES TO THE DEVELOPMENT AND USE OF BIOCOMPATIBLE IMPLANTS: MATERIALS, TECHNOLOGIES AND PROSPECTS

Objective: This study aims to evaluate the osseointegration potential of stainless steel implants manufactured using additive technologies for tibial prosthetics in rabbits, focusing on mechanical stability and bone-implant integration. Method: The experimental study was conducted on six chinchilla rabbits aged 6–8 months. Under general anesthesia, each rabbit underwent leg amputation followed by the implantation of a screw-type stainless steel implant produced through additive manufacturing. The implants were stabilized using the Ilizarov apparatus for six weeks. Clinical assessments, radiological imaging, and histological analyses were performed to evaluate the extent of osseointegration. Results: The findings demonstrate that the screw-type implant structure successfully osseointegrated into the tubular bone, with significant new bone tissue formation observed on the implant surface after 12 weeks. This bone-implant integration formed a stable bone-implant block capable of withstanding mechanical stress, confirming the implant's mechanical stability within the bone. Novelty: This study highlights the promising potential of additive manufacturing technologies in producing biocompatible implants with enhanced osseointegration capabilities, paving the way for more effective and durable orthopedic prosthetics.

ОЦЕНКА МОРФОФУНКЦИОНАЛЬНОГО СОСТОЯНИЯ ВОЕННОСЛУЖАЩИХ С АМПУТАЦИЕЙ ГОЛЕНИ НА ЭТАПАХ ФИЗИЧЕСКОЙ РЕАБИЛИТАЦИИ

The article presents studies of morphofunctional indicators of 15 military men 34,9±2,1 years old with amputation of the lower leg of one of the lower extremities, obtained as a result of mine-explosive wounds. Studies were carried out after surgical treatment before discharge from the hospital and a course of physical rehabilitation at the stage of preparation for prosthetics in the conditions of spa treatment. Rehabilitation measures were aimed at developing muscle-joint feeling, mobility in the joints of the amputated limb, strengthening the extensors of the knee joint, strength and endurance of the muscles of the stump. At the stages after surgical treatment and the period of physical rehabilitation, anthropometric and cardiorespiratory parameters were recorded. After rehabilitation measures, the body mass index corresponding to the norm was found in 40 % of military personnel, and the number of overweight men increased to 60 %. The results of studies of the cardiorespiratory system revealed compliance with the normative values of heart rate, systolic and minute blood volume in military personnel at both stages of research. After physical rehabilitation, a statistically significant decrease in respiratory rate by 11 %, heart rate by 12 % and an increase in stroke volume by 9 % were found. Naturally, there were no changes in the minute blood volume. A satisfactory result of the capabilities of the heart muscle and arterial system factors showed a decrease in systolic blood pressure parameters by 5 %, and diastolic by 9 %, average dynamic by 7 %. Increased cardiac activity in some of the subjects contributed to the development of a compensatory reaction at the level of peripheral vessels, manifested in a decrease in vascular resistance. Thus, the physical rehabilitation of disabled servicemen who underwent lower limb amputations contributed to unidirectional changes in morphofunctional indicators. Motor load contributed to the strengthening of weakened muscle groups and unidirectional positive adaptive rearrangements of regulatory mechanisms from the circulatory system. Information on changes in morphofunctional indicators allows determining rehabilitation strategies aimed at restoring motor capabilities and compensating for lost functions of military personnel with lower limb amputation at the stage of preparation for prosthetics.

Predictive Factors of Amputation in Diabetic Foot.

Background: Diabetic foot ulcers are a common complication of diabetes mellitus, often leading to progressive sensory deficits, impaired vascularization, and a predisposition to ulceration and gangrene. Untreated ulcers may cause recurrent infections that endanger a patient's life. Amputation of part of the limb up to a well-vascularized level is one of the treatments employed for untreated ulcers. Objectives: Laboratory data were analyzed with the aim of identifying risk factors related to surgical amputation treatment of diabetic foot. We believe it is useful to identify risk factors that can be altered from a reversible condition in the clinical decision-making of treatment, thus manifesting themselves in a timely manner to provide the patient with an alternative to surgical amputation of the lower limb. Methods: Our retrospective study was conducted by the Department of Orthopedics and Traumatology at the Fondazione Policlinico Universitario Agostino Gemelli IRCCS in Rome. We recruited 200 patients who underwent lower limb amputation for diabetic foot between 2017 and 2021 and had blood tests both 30 days and within 5 days before the first surgery. Results: This case-control study revealed a significant negative correlation between hemoglobin (Hb) levels and the occurrence of leg amputations. In contrast, C-reactive protein (CRP) levels, the neutrophil-to-lymphocyte ratio (NLR), and the platelet-to-lymphocyte ratio (PLR) showed significant positive correlations with leg amputations. A 3-year follow-up of the cases also revealed a significative positive correlation between age, white blood cells (WBC) count, NLR, PLR, and death at 3 years. Conclusions: Our findings suggested that lower Hb levels and elevated CRP, NLR, and PLR levels in patients with diabetic foot disease may be associated with a higher risk of lower-limb amputation. Unexpectedly, this study also demonstrated that elderly age, WBC, CRP, NLR and PLR levels may be associated with a negative prognosis for these patients. These findings highlighted the importance of monitoring these laboratory values in diabetic patients to identify individuals at higher risk of leg amputations and implement appropriate interventions to prevent or minimize the occurrence of this severe complication.

Ultrasound-Guided Nerve Blocks for Leg Amputation in High-risk Patients under Antithrombotic Therapy: A Report of Two Cases and Review of Literature

Patients with complex comorbidities under antithrombotic therapy are a real challenge for anesthesiologists because of general and neuraxial anesthesia high risks. Perineural anesthesia allows high quality intraoperative conditions for fragile patients and provides excellent postoperative results. Ultrasound guided superficial nerve blocks were defined to be with low risk of bleeding and seems to be a safe anesthetic option for patients under antithrombotic therapy. Through two cases of leg amputation performed under ultrasound-guided femoral and sciatic nerve blocks we discuss the interest and the practicability of this anesthetic technique in such patients.

Strength profiles in patients with knee osteoarthritis with and without unilateral transfemoral amputation

Background: Individuals with lower limb amputation have increased risk of developing knee osteoarthritis (KOA) in the intact limb, however there is little information regarding strength profiles in individuals with KOA with and without amputation. Objective: To compare lower extremity strength in individuals with KOA with and without unilateral transfemoral (TF) amputation. Study Design: Descriptive laboratory study. Methods: Seven participants with unilateral TF amputation (3F/4M, 58.0 ± 11.0 years, 172.7 ± 12.8 cm, 90.8 ± 19.1 kg, 38.8 ± 14.4 years after amputation) and symptomatic KOA in the intact limb and 9 participants with unilateral KOA (control (CON)) without leg amputation (4F/5M, 66.0 ± 9.9 years, 170.5 ± 10.7 cm, 86.8 ± 18.1 kg) participated in this study. Both groups completed strength testing on the involved limb with KOA and the Knee Injury and Osteoarthritis Outcome Score (KOOS) questionnaire to meaure subjective function. Strength variables were mass-normalized. Results: There were no significant differences between groups in age, mass, or height. The CON group reported significantly reduced subjective function on the KOOS total score (P = 0.049; d = 1.03) and KOOS symptoms scores (P = 0.047, d = 0.95) compared with the TF amputation group. A lower subjective function score indicates worse function. There were no other significant differences between groups on KOOS subcategories. The TF amputation group had significantly greater average isokinetic quadriceps torque (P = 0.05; d = 1.10), peak isokinetic quadriceps torque (P = 0.02; d = 1.36), and average isokinetic quadriceps power (P = 0.02; d = 1.38) compared with the CON group. There were no differences between groups in isometric knee extensor strength or any differences in knee flexor isokinetic or isometric strength. Conclusions: The TF amputation group demonstrated greater isokinetic knee extensor strength in their intact limb with KOA compared with the CON group osteoarthritic limb; however, there were no differences in isometric strength. Furthermore, the differences in isokinetic strength may suggest that those with a history of leg amputation may require more strength and power in the intact limb to maintain daily activity and, therefore, may require greater thresholds of strength to protect the knee joint from cartilage degradation.

Colostomy formation in a peritoneal dialysis patient.

This case report discusses the complex management of a 46-year-old man with poorly controlled type 1 diabetes mellitus, stage 5 chronic kidney disease, and severe neuropathic complications, which led to bilateral leg amputations. The patient experienced persistent diarrhea due to diabetic neuropathy, significantly impairing his daily functioning. Despite transitioning from hemodialysis to peritoneal dialysis, the diarrhea persisted. A colostomy was subsequently performed, which, although it did not completely resolve the diarrhea, allowed for better control, improving the patient's self-care and independence. Notably, the catheter exit site was maintained on the opposite side of the abdomen. Despite initial concerns about the feasibility of peritoneal dialysis (PD) in patients with stomas, including the challenges of creating a stoma in patients with an existing PD catheter, this case demonstrates the successful continuation of PD following a colostomy. Traditionally, intestinal stomas have been viewed as a relative contraindication to PD due to risks such as leakage and infection. However, current guidelines recommend using extended catheters with a presternal exit site to minimize these risks. The patient's quality of life improved significantly after the colostomy, with no major complications observed during follow-up. This report underscores the importance of tailoring treatment to individual patient needs, balancing risks with potential well-being benefits, and highlights the necessity of interdisciplinary collaboration and adherence to best practices. Given the limited literature on PD in patients with intestinal stomas, this case contributes valuable clinical insights for future management.

Multidisciplinary Amputation Prevention at the DeBakey VA Hospital: Our First Decade.

In 2011, the Veterans Health Administration (VHA) undertook multidisciplinary efforts to improve care for patients with nonhealing foot ulcers and reduce leg amputation rates. This article examines the impact of interdisciplinary care for amputation prevention in the VHA. The VHA patient population was characterized using internal registries. Texas hospital admission data were used to identify sex and zip-code matched cohorts. VHA provided data on national and local frequencies of various amputations and the number of patients with diabetes. Compared to matched nonveteran patients, veterans treated at VHA hospitals were older and more often self-identified as Black. They also had significantly higher rates of diabetes, chronic kidney disease, and systolic heart failure. A decrease from 160 to 66 amputations per 100,000 was seen from 2012 to 2017 (a 60% reduction) after implementing interdisciplinary care. Several evidence-directed practices were implemented during the study period. The proportion of angiograms for foot ulcers or gangrene increased from 28.9% to 90.9%. Interdisciplinary care can significantly reduce leg amputation rates. This reduction does not seem dependent on a particular model for providing inpatient care.

Microvascular blood flow disturbances predict poor outcome of revascularization in CLTI patients

Abstract Background We have recently established hypoxic microvascular remodelling as a critical pathomechanistic factor that limits oxygen diffusion to muscle in chronic limb threatening ischaemia (CLTI). Using animal models of experimental hind limb ischaemia we have also displayed the biological relevance of post-ischaemic microvascular remodelling in skeletal muscle. Our results indicate that differential microvascular changes associate to muscle damage and repair. The natural microvascular dynamics that inherently promote muscle recovery are defected in CLTI patients. Particularly, a progressive arterialization of capillaries in CLTI muscle differentiates the dynamics of the microvasculature from initially assisting muscle regeneration to aggravating ischaemic damage. Methods To establish the clinical relevance of the post-ischaemic microvascular changes in CLTI, we now have studied the effect of microvascular remodelling on the outcome of CLTI patients undergoing surgical or endovascular revascularization. Contrast enhanced ultrasound was used preoperatively to determine the microvascular status of CLTI patients (n=36) scheduled for immediate revascularization. Outcome events such as: hospitalization; reoperation; leg amputation; or death, were postoperatively followed from medical records up to 6 months after revascularization. Patients were grouped according to muscle capillary transit time (Tct) being either similar (n=18) or shorter (n=18) to that in the contralateral legs of the patients, and treatment outcomes were compared between groups. Results The results display consistent increases in postoperative event rates in all measured outcomes in the ShortTct group as compared to controls (at 1 month 8 vs. 2 events (rate ratio 4.00 (95%CI: 0.85-18.84, p=0.080)); at 3 months 13 vs. 4 events (rate ratio 3.25 (95%CI: 1.06-9.97, p=0.039)); at 6 months 17 vs. 9 events (rate ratio 1.89 (95%CI: 0.84-4.24, p=0.123))). For example, 5 vs. 0; 7 vs. 1; and 7 vs. 4 reoperations were detected in the ShortTct group as compared to controls at 1, 3 and 6 months, respectively. By 6 months after initial revascularization also 2 deaths were recorded in the ShortTct group as compared to no deaths in the controls. Conclusions Despite still small samples size in this study, these results suggest that microvascular blood flow disturbances, such as short preoperative muscle capillary transit time, can predict poor outcome of CLTI patients after revascularization. Importantly, the results also identify patients with microvascular blood flow disturbances a subgroup of CLTI patients that should likely receive more specialized care to improve outcomes. The results also call for immediate actions from the scientific community to improve clinical detection of microvascular alterations and to develop strategies to normalize microvascular function in CLTI patients.