Multiple Amputations Research Articles

Rehabilitation of a quadruple amputee with leukemia: A challenging endeavor

Making a person with quadruple amputation walk again is a challenging task for the rehabilitation team. Quadruple amputation secondary to symmetrical peripheral gangrene is a rare clinical scenario posing challenges in rehabilitation. Literature regarding rehabilitation of persons with multiple amputations is limited. This case describes the rehabilitation of a 57-year-old lady suffering from acute myeloid leukaemia who underwent quadruple amputation. She had undergone bilateral transtibial and bilateral transradial amputation after vasopressor-induced symmetrical peripheral gangrene. In view of expected guarded level of functional independence, ambulatory independence was the primary goal at admission to Department of PMR. The various steps taken in rehabilitation and modifications made to assistive devices are described in this article. Challenges faced during various phases of training, and subsequent ambulation are detailed in this article. Overcoming limitations, the client was made to be an indoor ambulator with appropriate prostheses and mobility aids. She was partially independent for activities of daily life after in-patient rehabilitation. The background of leukaemia and subsequent chemotherapy also affected the rehabilitation of this patient. Although various studies have described cases of quadruple amputation rehabilitation achieving functional independence and ambulation, the absence of specific guidelines and protocols make rehabilitation of persons with multiple amputations inefficient. This case study also shows the need for personalized goal setting for persons with multiple amputations. Realistic goal setting, psychological counselling, and an interdisciplinary approach are imperative in rehabilitation of persons with quadruple amputation. Flexible functional scales specific to persons with multiple amputations are necessary to evaluate such persons objectively. Studies with larger sample size, longer follow-ups, and comprehensive review of existing literature are needed to standardize rehabilitation of quadruple amputation and evaluate the various factors that may affect rehabilitation outcome.

The Use of Antibiotic-Impregnated Cement for Infection or Mechanical Support in Diabetic Foot Osteomyelitis A Systematic Review and Meta-Analysis

Background Diabetic foot infections are difficult to eradicate and could lead to serious complications such as multiple surgeries, amputation and mortality. Culture-based IV antibiotics and particularly amputation are usually the available options. Only few studies articles reported the use of cement impregnated with antibiotics to fill temporarily or permanently a bone defect, but with no evidence synthesis yet. Therefore, this study aims at assessing the outcomes of the use of antibiotic-impregnated cement for infection or mechanical support in diabetic foot osteomyelitis. Methods A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis. We searched multiple electronic databases using the terms “osteomyelitis AND cement AND diabetic AND foot.” The quality of the included studies was evaluated using the Joanna Briggs Institute Appraisal Tool. Results Six studies met the inclusion criteria combining 82 patients with 85 procedures. With a mean follow-up period of 22 ±14.6 months, the meta-analytical results were as follows: (1) the weighted healing rate was 85.2%, (2) 63.6% of cement were kept in place, (3) 8.2% of cement had to be exchanged, (4) 24.4% of placed cement had to be removed, (5) minor amputation following cement placement was 13.4%, and (6) the rate of secondary surgery was 18.7%, with arthrodesis being the most common (94%). Conclusion There are limited studies available detailing the outcomes of cement use in diabetic foot osteomyelitis. In the case of the difficult-to-heal osteomyelitis of the diabetic foot and whenever a peripheral bone rim could be preserved, filling the void within to deliver local infection control and to assure mechanical resistance for ambulation could be a non-radical limb preserving option. Level of Evidence Level IV

Multiple Free Flaps and Second Toe Transfer to Salvage Grasp Function in Bilateral Complete Degloved Hands

AbstractA 21-year-old male laborer sustained bilateral degloving injury of the hands with multiple digital amputations and devascularized digits. After X-rays, preliminary debridement was done, when digital amputations were completed, including index ray amputation on both sides. The next day, two anterolateral thigh (ALT) flaps and one second toe transfer were done to restore coverage in the palm and the web and reconstruct the lost thumb. This ensured both coverage and thumb length on the right side, but on the left side the procedure was terminated with flap transfer only. After 3 months, the other second toe was harvested with a dorsalis pedis flap for reconstruction of the left thumb, and a free gracilis flap was done for optimal donor site coverage in the donor left foot. Evaluation after 2 years showed functional hands with reasonable power grasp, pinch grip, and dexterity to manipulate small and large objects that permitted an independent living.

Nonbacterial thrombotic endocarditis of mitral valve associated with a lymphoproliferative malignancy: case report and literature review

BackgroundNon-bacterial thrombotic endocarditis (NBTE) is a rare condition marked by sterile vegetations on cardiac valves, often linked to rheumatologic diseases, autoimmune disorders, and advanced solid malignancies. An early diagnosis and treatment of the associated clinical condition are mandatory, although they do not usually eliminate valvular vegetations, making anticoagulation essential to prevent embolic events. Despite variability, the prognosis of NBTE is usually unfavorable due to recurrent embolic events and the severity of the primary condition, typically advanced cancer.Case presentationWe present a case of a 57 years-old male who presented to the emergency department with a 5-day history of painful bilateral digital edema and color change episodes (from pallor to cyanosis). Physical examination revealed erythrocyanosis in the distal extremities, prompting consideration of secondary Raynaud syndrome.Despite medical therapy, progressive digital ischemia led to multiple finger amputations. During etiological investigation, anticoagulation tests and autoimmune analysis yielded negative results. A transesophageal echocardiogram was performed, revealing an irregular hyperechogenic mass on the anterior leaflet of the mitral valve without valve dysfunction, and a thoracic computed tomography scan with contrast showed an enlarged right paratracheal lymph node. Histopathological analysis from a transthoracic needle biopsy of the paratracheal lymph node revealed diffuse large B-cell lymphoma. The patient underwent aggressive R-CHOP chemotherapy, achieving a favorable complete response.ConclusionThis is a particular case involving the occurrence of NBTE and Raynaud phenomenon as the initial paraneoplastic manifestations in a previously healthy young man. Reports of NBTE associated with lymphoproliferative conditions are quite rare, with fewer than ten cases described in the literature. To our knowledge, this is the first case of NBTE specifically associated with diffuse large B-cell lymphoma.

Success Rates of Finger Revascularization and Replantation.

Revascularization surgery has been reported to have a higher success rate than replantation due to sufficient venous return. However, in complex cases, success depends on a wide range of indications. This study aimed to investigate success rates in cohorts that included severe cases. This single-center, noninterventional, retrospective cohort study included 292 patients (349 digits) who underwent revascularization or replantation at our institution between January 2000 and December 2022. Sex, age, smoking history, comorbidities, affected digit, amputation level, complete or incomplete amputation, type of fracture and mechanism, artery diameter, needle, vein anastomosis in the revascularization subgroup, vein grafting, warm ischemic time, and outcomes were investigated and compared between the revascularization and replantation subgroups of the distal and proximal amputation groups. In the distal amputation group, the arterial diameter in the revascularization subgroup was larger than that in the replantation subgroup (P < 0.05). In the proximal amputation group, the revascularization subgroup had a lower frequency of multiple amputations than the replantation subgroup (P < 0.05). Vein grafts were more frequently used in both revascularization subgroups than in the replantation subgroups (P < 0.05). However, the other injury severity indices were similar, and the success rates were not significantly different between the subgroups. The revascularization success rate was similar to that of replantation. Vein anastomosis or vein grafting to the veins should be advocated for revascularization in severe cases where skin bridges may not have sufficient venous return.

Association of Demographic Characteristics and Laboratory Values in Diabetic Foot Infections Leading to Lower-Extremity Amputation.

Lower-extremity amputations are a common complication of poorly controlled diabetes and contribute to significant morbidity and mortality in diabetic patients. We sought to determine whether objective data points obtained on presentation or hospital admission, including white blood cell (WBC) count, hemoglobin A1c (HbA1c), C-reactive protein (CRP), and descriptive patient demographics allow for the ability to predict optimal amputation levels and outcomes of lower-extremity amputation in the diabetic population. A retrospective analysis of 162 patients was performed evaluating laboratory and descriptive values on hospital presentation for lower-extremity infection during a 16-year period. Occurrence of multiple amputations and level of amputation were assessed against laboratory values to determine whether these objective values would provide clinicians with a better understanding of amputations in the diabetic patient. The mean patient age was 60.6 years. A significantly higher percentage of patients who underwent amputations through the tibia and fibula or of the foot midtarsal were male compared with patients who underwent amputations of the thigh through femur. Patients who had amputations through the tibia and fibula had a significantly higher WBC count compared with patients who had a transmetatarsal amputation (P = .03). There was no significant difference in type or quantity of amputations when analyzing HbA1c and CRP levels. An admission WBC count may be used as a predictor of lower-extremity amputation level and outcomes in diabetic infections. Although a statistically significant difference was not found for CRP or HbA1c levels between amputation procedures and number of procedures performed, these values remain useful in managing lower-extremity infections in diabetic patients.

Vasculitis-panniculitis mimicking unresolved diabetic foot ulcer.

Diabetes foot ulcer (DFU) is a common long-term complication of diabetes. Intractable chronic wounds to standard care of diabetic foot raise the question of whether other factors intervene in disease development. We report a case of a 54-year-old male patient who came to Sardjito General Hospital with leg pain and previous history of multiple debridement and amputation for DFU referred from a remote hospital yet no improvement was evident in the surrounding lesion following treatment. Consequently, a histopathological examination was carried out proving the presence of other aetiologic factors, vasculitis and panniculitis existing in the lesion. In this case, we report a rare type of causative factor of foot ulcers among diabetic patients. Vasculitis suspected for polyarteritis nodosa accompanied by panniculitis is considered in this patient. The treatment of choice is corticosteroids or immunosuppressants based on the clinical condition, contrary to usual wound care in DFU. Based on the evidence, clinicians need to consider other causes than only macrovascular complications in a diabetic patient with DFU that is intractable to standard wound care. In this patient, vasculitis may be considered in forming diabetic foot ulcers alongside macrovascular complications. A thorough examination is essential to rule out other processes in intractable DFU patients. Prompt management based on proper diagnosis is crucial to prevent peripheral arterial disease complications. Vasculitis and macrovascular complication are inseparable processes forming DFU in this patient.

Impact of diabetes on medical costs in the pre- and postoperative year of lower extremity amputations in Belgium

AimsTo compare the medical costs of individuals undergoing lower extremity amputation (LEA) in Belgium with those of amputation-free individuals. MethodsBelgian citizens undergoing LEAs in 2014 were identified. The median costs per capita in euros for the 12 months preceding and following minor and major LEAs were compared with those of matched amputation-free individuals. ResultsA total of 3324 Belgian citizens underwent LEAs (2295 minor, 1029 major), 2130 of them had diabetes. The comparison group included 31,716 individuals. Amputation was associated with high medical costs (individuals with diabetes: major LEA €49,735, minor LEA €24,243, no LEA €2,877 in the year preceding amputation; €45,740, €21,445 and €2,284, respectively, in the post-amputation year). Significantly higher costs were observed in the individuals with (versus without) diabetes in all groups. This difference diminished with higher amputation levels. Individuals undergoing multiple LEAs generated higher costs (individuals with diabetes: €39,313–€89,563 when LEAs preceded index amputation; €46,629–€92,877 when LEAs followed index amputation). Individuals dying in the year after a major LEA generated remarkably lower costs. ConclusionsLEA-related medical costs were high. Diabetes significantly impacted costs, but differences in costs diminished with higher amputation levels. Individuals with multiple amputations generated the highest costs.

Successful reproduction of female loggerhead sea turtles with severe limb amputations

AbstractWe evaluate the frequency of flipper amputation and its impact on reproduction in the threatened loggerhead turtle (Caretta caretta) population of the Eastern Atlantic, through a long‐term study on several high‐density nesting beaches of Cabo Verde. 5982 adult females were individually identified, tagged and measured, and the presence of limb amputations was recorded. 918 of them had one or multiple amputations of the rear or front flippers. Most of these turtles (n = 778) had partial rather than complete flipper amputations. However, we found no difference in body condition indices (1.2 vs. 1.1), clutch size (82 vs. 83 eggs), or hatching success (79 vs. 80%) between amputated and non‐amputated females. While amputations may cause individual mortality or reduced fitness, our results indicate that some amputated turtles successfully nest and survive across multiple nesting seasons. Moreover, the amputations do not appear to be impacting the strong recovery of this population. This study provides evidence of the successful reproductive capacity of amputated loggerhead sea turtles and, by extension, the potential reproductive success of amputees released from recovery centers.

Risk Factors Analysis of Phantom Limb Pain in Amputees with Malignant Tumors.

Postamputation neuropathic pain is a common disease in patients with malignant tumor amputation, seriously affecting amputees' quality of life and mental health. The objective of this study was to identify independent risk factors for phantom limb pain in patients with tumor amputation and to construct a risk prediction model. Patients who underwent amputation due to malignant tumors from 2013 to 2023 were retrospectively analyzed and divided into phantom limb pain group and non-phantom limb pain group. To determine which preoperative factors would affect the occurrence of phantom limb pain, we searched for candidate factors by univariate analysis and used multivariate logistic regression analysis to identify independent factors and construct a predictive model. The receiver operating characteristic curve (ROC) was drawn to further evaluate the accuracy of the prediction model in evaluating the phantom limb pain after amputation of bone and soft tissue tumors. Multivariate analysis showed that age (OR, 1.054; 95% CI, 1.027 to 1.080), preoperative pain (OR, 5.773; 95% CI, 2.362 to 14.104), number of surgeries (OR, 3.425; 95% CI, 1.505 to 7.795), amputation site (OR, 5.848; 95% CI, 1.837 to 18.620), amputation level (OR, 8.031; 95% CI, 2.491 to 25.888) were independent risk factors for phantom limb pain for bone and soft tissue tumors. The the area under the curve (AUC) of this model was 0.834. Risk factors for postoperative phantom limb pain were the site of amputation, proximal amputation, preoperative pain, multiple amputations, and older age. These factors will help surgeons to individualize and stratify phantom limb pain and help patients with risk counseling. In particular, an informed clinical decision targeting those modifiable factors can be considered when needed.

An Atypical Case of Hepatitis B-Associated Vasculitis

One of the many extra-hepatic manifestations of hepatitis B virus (HBV) infections is vasculitis. While the classic HBV-associated vasculitis is polyarteritis nodosa, other vasculitides have been reported. The authors present an atypical case of acute HBV-associated vasculitis in a 57-year-old male with tobacco use disorder, characterised by extremity ischaemia, gangrene, splenic infarction, and positive proteinase-3 antibodies without sinopulmonary, gastrointestinal, or renal disease. The aggressiveness of the patient’s disease necessitated pulse-dose corticosteroids, cyclophosphamide, and two courses of plasmapheresis, and ultimately required multiple amputations of fingers and toes.

Usefulness of the lateral arm free flap for hand defect reconstruction

Purpose: Although various surgical reconstruction methods are available for multidigit defects or soft tissue defects of the hand, they often require a thin flap due to the hand’s unique physical characteristics. We performed a total of 13 cases of lateral arm free flap surgery at our hospital. The purpose of this study was to report the usefulness of this technique. Methods: This study included the following cases: four cases of multiple digit amputations, seven cases of hand dorsum skin defects, one case of first web reconstruction due to web contracture, and one case of an index finger bone and soft tissue defect with only the ulnar-side neuro-vascular bundle remaining. After emergency simple debridement, subsequent reconstruction was performed using a lateral arm free flap. Results: All 13 cases healed without necrosis. Patients who underwent finger amputation were able to preserve the length of their fingers without any additional amputation. Patients who initially had hand dorsum defects were able to maintain grasping function after flap stabilization. The patient with web contracture was able to recover the lost pinching function, and the patient with a combined loss of osteoarticular and soft tissue of the index finger maintained the shape and length of the finger despite the absence of joint function. Conclusion: The lateral arm free flap is a useful reconstruction method that can be easily performed with a single session of regional anesthesia. Since the flap is thin, it is suitable for hand defect reconstruction. If necessary, vascularized bone grafting is possible.

The relationship between combat-related traumatic amputation and subclinical cardiovascular risk

BackgroundThe relationship between acute combat-related traumatic injury (CRTI) to coronary flow reserve (CFR) and subclinical cardiovascular risk have not been examined and was the primary aim of this study. Methods and resultsUK combat veterans from the ADVANCE cohort study (UK-Afghanistan War 2003–14) with traumatic limb amputations were compared to injured non-amputees and to a group of uninjured veterans from the same conflict. Subclinical cardiovascular risk measures included fasted blood atherogenic index of plasma (AIP), triglyceride-glucose index (TyG; insulin resistance), the neutrophil-lymphocyte ratio (NLR) and high-sensitivity C-reactive protein (hs-CRP; vascular inflammation), body mass index (BMI) and visceral fat volume (dual-energy X-ray absorptiometry) and 6-min walk distance (6MWD; physical performance). The subendocardial viability ratio (SEVR), to estimate CFR, was calculated using arterial pulse waveform analysis (Vicorder device). In total 1144 adult male combat veterans were investigated, comprising 579 injured (161 amputees, 418 non-amputees) and 565 uninjured men. AIP, TyG, NLR, hs-CRP, BMI, total body fat and visceral fat volume were significantly higher and the SEVR and 6MWD significantly lower in the amputees versus the injured-non-amputees and uninjured groups. The SEVR was lowest in those with above knee and multiple limb amputations. CRTI (ExpB 0.96; 95% CI 0.94–0.98: p < 0.0001) and amputation (ExpB 0.94: 95% CI 0.91–0.97: p < 0.0001) were independently associated with lower SEVR after adjusting for age, rank, ethnicity and time from injury. ConclusionCRTI, traumatic amputation and its worsening physical deficit are associated with lower coronary flow reserve and heightened subclinical cardiovascular risk.

Successful Multiple Finger Replantation; Procedure and Considerations

Multiple finger amputations require challenging surgeries and special approach. At least, the thumb and middle finger should be replanted to maintain minimal hand functions. Technically, multiple amputations are more difficult than single finger amputation and distal amputations are more difficult than proximal ones. Herein, we present a case of four finger amputation. All fingers were successfully replanted. The patient required a long period of physical rehabilitation. The patient underwent another operation because of the extensor lag of the four fingers. In the second operation a four-tail FDS transfer to the lateral bands was performed. The rehabilitation process is still ongoing.

Developing a Program forAdvanced Physical Therapist Practice inAmputation Care.

Over the past 20 years, military medicine made greatstrides in the medical management of traumatically injured patients. Significant advancements were made in the treatment and rehabilitation after limb loss. These advancements can be attributed to the large number of complex patients presenting to military treatment facilities and the demand for medical professionals to provide care to patients with complex injuries and multiple traumatic amputations. The concern now is to maintain the skills needed to be prepared for the next conflict. To meet this demand, the Extremity Trauma and Amputation Center of Excellence (EACE) initiated the documentation of knowledge, skills, and abilities (KSAs) to ensure that the skill sets needed to treat this unique population are not lost. The EACE developed KSAs to sustain advanced clinical practice for physical therapists, occupational therapists, and prosthetists and is in the process of developing KSAs for orthotists and physical medicine physicians. The learning objectives [terminal and enabling learning objectives (TLOs and ELOs)] derived from each set of KSAs will drive curricula development for enduring education, residencies, and fellowships. This article describes the KSAs and learning objectives for advanced physical therapist competencies in amputation care. Clinical subject matter experts (SMEs) convened from the Department of Defense (DoD) Advanced Rehabilitation Centers (ARCs) to draft the initial KSAs. All experts had specific expertise in treating individuals with highly complex lower and upper limb amputation. In a quasi-Delphi methodology, the initial draft KSAs underwent five cycles of review and comment by an additional 15 DoD, Veterans Affairs, and civilian institution experts from clinical practice, education, and research. The consensus KSAs were then transcribed into learning objectives with collaboration between clinical subject matter experts and doctoral-level educators. The final program document has 21 instructional modules with 30 TLOs and 157 ELOs. The KSAs and the learning objectives describe the skills expected of an advanced practice physical therapist treating patients with traumatic limb loss. Weaknesses of this document include the focus on traumatic amputation and military specific needs. However, many of the central advanced practices are universal to all physical therapists working in amputation. Thus, this document should serve as a starting point and can evolve to include dysvascular, oncology, and other etiologies. To our knowledge, this is the first paper to describe the KSAs for the advanced practice physical therapist working with traumatic limb loss population. This work will form the framework for physical therapist advanced practice training programs.

1369-P: The Natural Trends in Incidence of Lower Extremity Amputations in South Korea, 2003–2021

Introduction: National data in incidence of lower extremity amputations in the population of South Korea is lacking. Diabetes mellitus is a major risk factor for lower extremity amputations. The prevalence of diabetes mellitus is increasing faster than previously estimated in South Korea. Therefore, we investigated the trend of lower extremity amputations not only in people with diabetes, but also in the total (medically documented) population. Method: We gathered and analyzed the data of the medically documented population, aged 20 years or older, from the Korean Health Insurance Service claims database between 2003 and 2021. Results: Since 2003, incidence of lower extremity amputations among the total population has steadily increased, more than doubling by 2021 (6.8 to 14.5 amputations per 100,000 of population). The contribution of diabetes mellitus on lower extremity amputation has also elevated from 47% in 2003 to 70% in 2021. During the study period, the incidence of lower extremity amputations was consistently higher by more than three times in men (21.6) than in women (7.3), amputations per 100,000 of population in 2021. When foot amputations were classified by lower extremity parts, the proportion of major amputations (above ankle) has decreased slightly. In the last 10 years, the frequency and proportion of three or more repeated foot amputations has reduced (431 (9.2%) to 207 (4.1%)). Conclusion: We reported the increasing trend of lower extremity amputation between 2003 and 2021 according to the increase in the prevalence of diabetes mellitus in South Korea. Among all lower extremity amputations, the major amputations and multiple amputations, 3 or more times, are decreasing. Disclosure J.Jeon: None. K.Lee: None. N.Kim: None. J.Back: None. N.Lee: None. S.Han: None. H.Kim: None. D.Kim: None. T.Kim: None. S.An: None.

AN OBSERVATIONAL STUDY TO ASSESS THE CLINICAL PROFILE AND OUTCOMES OF DIABETIC FOOT ULCER AT A TERTIARY CARE HOSPITAL IN JAIPUR

Background: Diabetes mellitus (DM) is one of the main problems in health systems and a global public health threat that has increased dramatically over the past 2 decades [2, 3]. According to epidemiological studies, the number of patients with DM is estimated to be more than 360 million people by 2030 [4, 5]. DFU is considered as a major source of morbidity and a leading cause of hospitalization in patients with diabetes. In view of this, the present study was undertaken to address the demographics, clinical prole, and outcomes of diabetic foot ulcer at a tertiary care hospital in Jaipur. A hospital based prospective observational study The mea Methods: Observations: n age of the study participants was found to be 56.33 + 12.637. 61.8% of the study participants were found to have pure neuropathic type of ulcer with 24.3% having neuro-ischemic type of ulcer. 13.9% of the study participants had pure ischemic type of ulcer. 37.5% of the study participants underwent wound debridement. 3.5% of the study participants underwent SSG,59% of the study participants underwent amputations. The mean HbA1c of the study participants was found to be 8.951 + 1.6008. The mean duration of stay at hospital of the study participants was found to be 5.73 + 2.025. Mortality of the study population was 3.5%. Majority of the patients underwent multiple toe amputations, there w Conclusion: as a signicant statistical association between the Wagner's grade and the mode of intervention performed, . Adequate glycaemic control, periodic screening for diabetic foot neuropathy, preventive foot care and education programs should be made available, particularly in primary and secondary health care settings to tackle the DFU disease which is a contributor to signicant morbidity among diabetics

Electrical Burn and Associated Factors That Prolong In-patient Stay in a Level Three Burn Unit.

Electrical trauma is associated with significant morbidity and mortality, which have been reduced by improved medical care, as measured by the length of stay (LOS) as a marker for this population's quality of care. This paper will review the clinical and demographic characteristics, LOS in the hospital, and variables related to patients with electrical burns. A retrospective cohort study was conducted at a specialized burn unit in Southwest Colombia. Five hundred seventy-five electrical burn-related admissions from 2000 to 2016 were reviewed for the LOS and variables including patient-related (age, gender, marital status, education, and occupation), location of the accident (domestic vs labor-related), voltage, direct contact, arc, flash, flame, clinical presentation (burn surface area, depth, single or multiple organ injury, secondary infection, and abnormal labs), and treatment (surgical procedures and intensive care unit [ICU] admission). Univariate and bivariate analysis, with its 95% CI (confidence interval). We also performed a multiple logistic regression. LOS was correlated to males, age greater than 20 years, construction workers, high voltage injuries, severe burns by area and depth, infection, ICU admission, and multiple surgical procedures or extremity amputation. LOS due to electrical injury was observed to be significantly associated with the following variables, carpal tunnel release (OR [odds ratio]= 4.25, 95% CI [confidence interval] 1.70-5.20); amputation (OR = 2.81, 95% CI 1.60-5.10); infection (OR = 2.60, 95% CI 1.30-5.20); site of infection, mainly wound (OR = 1.30, 95% CI 1.10-1.44); associated injury (OR = 1.72, 95% CI 1.00-3.24); work or domestic accident (OR = 1.83, 95% CI 1.00-3.32); aged 20-40 years (OR = 1.41, 95% CI 1.00-2.10); CPK (OR = 1.40, 95% CI 1.00-2.00); and third-degree burns (OR = 1.55, 95% CI 1.00-2.80). Risk factors for LOS secondary to electrical injury should be appropriately addressed. Prevention at high-risk workplaces is imperative. Mitigating the injury with appropriate management of infection and timely surgical interventions play an essential role in the successful treatment of these patients.

Iatrogenic-induced Peripheral Gangrene: From Multiple Limb Amputations to Prosthetic Restoration

Objectives: Multiple limb amputations are an uncommon complication from inotrope-induced peripheral gangrene. Case Presentation: A 20-year-old lady with valvular heart disease had septic shock secondary to infective endocarditis and required prolonged cardiopulmonary resuscitation. Despite aggressive fluid resuscitation, the patient had triple strength intravenous noradrenaline to maintain hemodynamic stability. On day 5 of post-shock, dry gangrene occurred in distal parts of all limbs, and inotrope was stopped. Although the gangrenous changes were non-progressive, she required a significant degree of assistance with mobility and daily function performance. The patient was counseled for multiple limb amputations to promote walking and hand function through prosthetic restoration. Five months after the event, she had a right transtibial amputation, left Chopart amputation, left wrist disarticulation, and right second, third, fourth, and fifth fingers amputation. Three specific goals for inpatient rehabilitation were independent short-distance ambulation with prostheses, performing basic activities of daily living with adaptive devices, and independent wheelchair propulsion for long-distance mobility using a right-sided transtibial prosthesis, left-sided Syme's prosthesis with Kingsley's foot, right-sided silicone-based cosmetic glove and left-sided body-powered transradial prosthesis. Discussion: Although an uncommon complication, inotrope may lead to multiple limb amputations secondary to peripheral gangrene. Following amputation, the ultimate rehabilitative goal is to restore the mobility and capacity to perform daily functions through prosthetic restoration, whether walking for lower amputees or functioning hand for upper limb amputees. Prescribing prosthesis in a single limb loss is relatively straightforward, but restoring multiple limb amputations bears many challenges toward successful recovery of walking and functions.

Waterhouse-Friderichsen syndrome following a dog bite in an asplenic patient: case report and review of the literature

The Waterhouse-Friderichsen syndrome represents a critical condition characterized by a septic shock associated with a disseminated intravascular coagulation causing the plugging of the microvascular network virtually all organs and systems, including the skin, the kidneys, the liver, and adrenal glands; the mortality rate is elevated, and survivors often must undergo multiple limb amputations. Here, we describe the uncommon case of an asplenic patient who developed this syndrome after a superficial wound caused by a dog bite causing an initial infection due to Capnocytophaga canimorsus that is part of the normal oral microbiome of pets. The clinical and pathological findings and the current and future therapeutic options are reviewed and discussed.