Prevention Of Amputation Research Articles

Hyperbaric oxygenation in prevention of amputations of diabetic foot

Background/Aim. Diabetic foot is the term for the pathological changes on foot in patients with diabetes. It is caused by diabetic angiopathy, polyneuropathy and osteoarthropathy. The treatment is complex and long-term and often leads to the loss of the extremity. The appliance of hyperbaric oxygen therapy (HBOT) has a lot more important place in adjuvant treatment of this disease. The aim of this study was to determine the influence of HBOT on the wound healing in comparison with the conventional treatment, the possibility of shortening the time of the treatment in patients with diabetic foot. Methods. In a fiveyear period a retrospective-prospective multicentric study, involving 60 patients with diabetic foot divided into two groups, was performed. The first group (group A) consisted of 30 patients treated by combined therapy (with medications, surgical therapy and HBOT). All the patients were receiving HBOT in the Special Hospital for Hyperbaric Medicine, CHM Hollywell-Neopren in Belgrade. The control group (group B) also consisted of 30 patients treated with medications and surgical therapy, but without HBOT. Results. The demographic data, the types of diabetes, as well as the Wagner classification stage of diabetic ulcers and radiography scans of changes in bones were equal in both groups. The median healing time of the Wagner grade III ulcer in the group A was 37.36 days [mean ? standard deviation (SD) = 65.6 ? 45.8 days], and in the group B 99.78 days (mean ? SD = 134.8 ? 105.96 days) and it was statistically significant (p = 0.074). The median time of recovery in patients of the group A with the Wagner grade IV was 48.18 days (mean ? SD = 49.7 ? 33.8 days), and in the group B 85.05 days (mean ? SD = 86.7 ? 71.6 days) and that was statistically significant (p = 0.121). The foot amputations were performed in both groups in 3 (10%) patients. In the group A there were no high amputations, whereas in the group B there were 4 (13.33%) below-knee amputations and 4 (13.33%) above-knee amputations which was highly statistically significant (p < 0.0001). Conclusion. In this study, HBOT definitely showed positive adjuvant role in the treatment of diabetic foot. For the good treatment result it is essential the timely and successful surgical treatment of the ulcer and the use of bandage with the healing dressings. In case of the clear signs of local infection, the antibiotic therapy according to the antibiogram is necessary.

Predictive factors for amputations: knowing the problem to seek prevention strategies

Objective: To investigate the predictive factors for amputations in southern Brazil. Methods: This was a review of medical records from amputated patients in a tertiary hospital in southern Brazil. Results: One hundred and fifteen medical reports regarding to admissions of 51 amputated patients (31.37% women and 68.62% men) were analyzed. The main cause of amputation in diabetics was the neuropathy and its complications. Among nondiabetics, the main causes of amputation were polydactyly (31.58%) and traumatism (traffic accidents, home accidents, and work accidents). This data showed that the investigated amputations are predominantly in male, aging approximately sixty years old, presenting comorbidities like diabetes and arterial hypertension. Moreover, the most amputations were performed as the minor type. Conclusion: These data can contribute for implementation of targeted health education strategies and interventions, improving the prevention of amputations in persons with diabetes.

Diabetic Foot Risk Classification using Decision Tree and Bio-Inspired Evolutionary Algorithms

Diabetic foot complications are a burden to the Indian population which affects both financially and physically. The complications could be prevented if the risk of diabetic foot are detected well in advance before the peripheral nerves are damaged leading to amputation and limb loss. The quantification of severity plays an important role in timely intervention, delivery of appropriate treatment and prevention of amputation. This can be modeled as a classification problem where the risk category is stratified into different levels of severity. This paper is an approach to build such a system, capable of classifying the risk category of diabetic patients for suitable follow-up and care. Decision trees are used for the same with features selected using bio-inspired evolutionary algorithms like Particle Swarm Optimization (PSO), Genetic Algorithm (GA), Cuckoo Search (CS), FireFly (FF), Dragon Fly (DF) and Gravitational Search Algorithm (GSA). The overall accuracy is 77% but it identifies the low risk and high risk cases effectively with 97% and 89% respectively.

Efficacy of Recombinant Human Epidermal Growth Factor (Regen-D 150) in Healing Diabetic Foot Ulcers: A Hospital-Based Randomized Controlled Trial.

To validate the efficacy of recombinant human epidermal growth factor (hEGH) in healing diabetic foot ulcers (DFUs) at biochemical and molecular levels. A total of 50 noninfected DFU subjects were recruited for the study and divided into 2 groups based on the treatment application on the subjects. Group 1: DFU subjects treated with hEGH gel-based product called Regen-D 150 (n = 27) and group 2: DFU subjects treated with alternative placebo as the control group (n = 23). Patients were observed for 30 days and punch biopsy was taken at days 0 and 14. Histologic analysis was done to study the matrix alignment, cellular infiltration, and differentiation of epithelial layers. Biochemical analysis was done to quantitatively estimate the amount of collagen and proteoglycans regenerated in the wound area. Complete healing of ulcers was observed in 21 (78%) subjects in group 1, whereas only 12 (52%) subjects among group 2 reported of complete healing of ulcer after completion of the study period of 30 days. Collagen and fibroblasts were significantly developed in group 1 when observed in the follow-up samples. Healing time of the wound among the group 1 subjects was significantly less than the group 2 subjects (45 ± 12 vs 72 ± 18 days, P < .0001) and even showed a better blood glucose level. Early and regular application of the hEGH on DFUs will lead to prevention of leg amputations and would serve to act as a major treatment therapy for healing of chronic wounds.

Lower Limb Amputations and Revascularisation Procedures in the Hungarian Population: A 14 Year Retrospective Cohort Study

The aim of this study was to assess the long term trends of lower limb amputation and revascularisation in Hungary over 14 years. This was a retrospective cohort study that included all patients who underwent lower limb amputation or revascularisation over a 14 year period (2004-2017) in Hungary. Inpatient administrative data claims covering the entire beneficiary population were incorporated. Lower limb amputations (both minor and major) and revascularisation procedures (both open and endovascular) were identified in the claims files. Incidence rates were calculated and time trends were assessed via a generalised additive model. From 2004 to 2017, a total of 121351 lower limb amputations (61154 minor; 60197 major) and 149355 revascularisation procedures (89243 open; 60112 endovascular) were detected in 140581 patients. The number of minor amputations decreased moderately in the last few years of the study period, while major amputations showed a slight decline (15%) beginning after 2013, which was more marked (22%) following adjustment forage. While the crude incidence of open vascular surgery procedures decreased by 31% (from 74.5/105 to51.4/105), endovascular procedures showed growth by 79% (from 33.7/105 to 60.4/105) over the whole observation period. Observed amputation and revascularisation trends in Hungary are similar to the international experience. The major difference is a more than one decade lag in the starting point of the decline of amputations and in the move towards endovascular procedures. The number of amputations is more than twofold higher and the number of revascularisations is close to half that reported internationally. This comprehensive report of two vascular care performance indicators reveals an east/west vascular health divide in Europe and indicates the need to improve amputation prevention.

Transplantation of Autologous Bone Marrow Derived Mononuclear Cells and Bone Marrow Aspirate in Patients with Nonreconstructable Peripheral Arterial Disease

Introduction - The patients with critical limb ischemia (CLI) (nonreconstructable peripheral arterial disease) due to multifocal occlusion especially below-knee-lesion with the non-healing ulcers is a disaster that leads to amputation of extremities. Limb amputations are often the inevitable treatment of non-healing ulcers in patients with infrainguinal arterial occlusive disease. Only induction of angiogenesis may be an option in treatment such of patients. One method of induction is the use of aspirate of bone marrow (ABM) or/with bone marrow derived mononuclear cells (BMMCs). Methods - From 2009 till 2013 we have treated 65 patients. Indication: CLI stage III-15, stage IV-40 (PAOD-48, thromboangiitis obliterans-17: mean Rutherford classification 5 [4-6]) with infrainguinal arterial occlusive disease and weren’t suitable for or had previously failed revascularization treatment. To patients CLI III – were administered the ABM in ischemic muscle (leg and foot), to patients CLI IV – were administered ABM and injected Ficoll-isolated BMMCs locally (foot-fingers-wounds). To 8 patient procedure where done twice in 1-1,5 year. These procedures were combined with debridements of ulcers or with minor amputation. Some of them required dermotransplantation. Patients were followed-up by walking distance, resting pain, ABI, wound conditions, but primary outcome was defined as prevention of major limb amputation. Results - Mean follow-up duration was 3 years. No procedure-related complications were encountered. Due to exacerbation and disease progression major amputation in 30 days after procedure required 4 patients, in term of 4-6 month 3 patients below-knee-amputation, in 36 month were done 5 below-knee-amputations. Size of the ulcers were decreased, and healed by dermotransplantation in 15, in 10 was succeeded by minor amputation (fingers or forefoot). Walking distance improved from 65+/–10 meters to 185+/–45 meters. Rest pain improved markedly in 37, mildly in 16 patients. Mean ABI was increased from 0,28+/–0,05 to 0,35+/–0,40. Limb salvage was 89,2% at baseline to 6 month and in term of 36 month was 81,3%. Also using laser Doppler flowmetry and angiography there is an increase of blood flow recovery and collateral formation. Conclusion - This study shows that locally administered autologous BMMCs and ABM transplantation represent a safe and effective option of treatment in patients with CLI due to non-reconstructable peripheral arterial disease.

Multidisciplinary approach achieves limb salvage without revascularization in patients with mild to moderate ischemia and tissue loss

ObjectiveThe Society for Vascular Surgery Wound, Ischemia, and foot Infection (WIfI) classification system has been validated to predict wound healing and limb salvage of patients with peripheral artery disease (PAD). Our goal was to evaluate the association between WIfI stage and wound healing, limb salvage, and survival in a select cohort of patients with PAD and tissue loss undergoing an attempt of wound healing without immediate revascularization (conservative approach) in a multidisciplinary wound program. MethodsVeterans with PAD and tissue loss were prospectively enrolled in our Prevention of Amputation in Veterans Everywhere (PAVE) program. Limbs were stratified to a conservative, revascularization, primary amputation, and palliative limb care approach based on the patient's fitness, ambulatory status, perfusion evaluation, and validated pathway of care. Rates of wound healing, wound recurrence, limb salvage, and survival were retrospectively analyzed by WIfI clinical stages (stage 1-4) in the conservative group. Cox regression modeling was used to estimate clinical outcomes by WIfI stage. ResultsBetween January 2006 and October 2017, there were 961 limbs prospectively enrolled in our PAVE program. A total of 233 limbs with 277 wounds were stratified to the conservative approach. WIfI staging distribution included 19.7% stage 1, 20.2% stage 2, 38.6% stage 3, and 21.5% stage 4. All ischemia scores were classified as 1 or 2. Advanced wound interventions and minor amputations were performed on 40 limbs (16.6%) and 57 limbs (23.7%), respectively. Average long-term follow-up was 41.4 ± 29.0 months. Complete wound healing without revascularization was achieved in 179 limbs (76.8%) during 4.4 ± 4.1 months. Thirty-four limbs (14%) underwent deferred revascularization because of a lack of complete wound healing. At long-term follow-up, wound recurrence per limb was 39%. Overall limb salvage at long-term follow-up was 89.3%. Stratified by WIfI stage, there was no statistically significant difference between groups for wound healing (P = .64), wound recurrence (P = .55), or limb salvage (P = .66) after adjustment for significant patient, limb, and wound characteristics. ConclusionsIn select patients with mild to moderate ischemia and tissue loss, a stratified approach can achieve acceptable rates of wound healing and limb salvage, with limited need for deferred revascularization. WIfI clinical staging did not predict wound healing, limb salvage, or survival in this cohort.

Patient Health Literacy and Diabetic Foot Amputations

Patient health literacy is associated with self-care and management of chronic diseases, including diabetes. Interventions that address health literacy and aim to improve clinical outcomes have been focused mostly in primary care. The purpose of this study was to explore the association between patient health literacy and diabetic foot amputations in a retrospective cohort analysis in a large orthopaedic practice at an academic medical center. Using data extraction from clinical records, orthopaedic patients who had a diabetic foot amputation or re-amputation in the last 2 years were compared with the general orthopaedic patient population, with patient health literacy screening results as the dependent variable. Results revealed a statistically significant difference in health literacy between the foot amputee group (N = 177) and the general orthopaedic patient group (N = 14,683) (p < .0001). Patients in the foot amputee group were 8.07 times more likely to have inadequate health literacy than patients in the general orthopaedic patient group. Because diabetic amputations are frequently associated with poorly controlled diabetes, these results provide a strong rationale to develop health literacy-based interventions that address diabetes self-management and foot exams in orthopaedic practices to improve clinical outcomes, including amputation prevention.

Diyabetik Ayak Ülseri Hastalarında Major Amputasyonun Önlenmesi icin Bir Yöntem: Negatif Basınclı Yara Tedavisi ile Kombine İntralezyonel Epidermal Growth Faktör Kullanılması

Background:Diabetic foot ulcer (DFU) is a serious health problem affecting 15% of patients with diabetes mellitus. Diabetic foot ulcers cause a decrease in the quality of life of patients like job loss, long-term hospital stay, financial burden and also lower extremity amputation. Many methods have been applied to treat patients with DFU, but amputations have not been prevented. In this study, we presented patients who had been referred to us from various hospitals with a decision for major amputation, but treated by us using intralesional epidermal growth factor therapy (EGF) combined with negative-pressure wound therapy (NPWT) to prevent below-knee amputation. Methods:Patients who had been referred to us from various hospitals with a decision for major amputation, but treated by us using combined therapy to prevent below-knee amputation. The efficacy of treatment was assessed according to wound closure and amputation prevention. Results:According to Wagner's classification, 17 (51.6%) out of 33 patients were the grade 3, and 16 (48.4%) were the grade 4 patients. Major amputation was performed in one patient. Infection was present in 24 (75%) of the patients. Necrosis was present in 12 (37.5%) of these patients. The average wound size was 18 cm (10-25 cm). Complete skin closure was achieved in 27 patients (84.3%), and closure with 100% granulation was achieved in 5 patients (15.6%). None of the patients underwent major amputation. EGF+NPWT treatment were administered for 45 days on average. Infections were developed in three patients during one-year of follow-up approximately, and medical treatment was administered.Conclusions: Our patients were in the high risk group for major amputation, which were referred from various hospitals with the recommendation of major amputation. We believe that the regular application of NPWT combined with EGF can prevent major amputations.

Global Vascular Guidelines on the Management of Chronic Limb-Threatening Ischemia

Chronic limb-threatening ischemia (CLTI) is associated with mortality, amputation, and impaired quality of life. These Global Vascular Guidelines (GVG) are focused on definition, evaluation, and management of CLTI with the goals of improving evidence-based care and highlighting critical research needs. The term CLTI is preferred over critical limb ischemia, as the latter implies threshold values of impaired perfusion rather than a continuum. CLTI is a clinical syndrome defined by the presence of peripheral artery disease (PAD) in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration. Venous, traumatic, embolic, and nonatherosclerotic etiologies are excluded. All patients with suspected CLTI should be referred urgently to a vascular specialist. Accurately staging the severity of limb threat is fundamental, and the Society for Vascular Surgery Threatened Limb Classification system, based on grading of Wounds, Ischemia, and foot Infection (WIfI) is endorsed. Objective hemodynamic testing, including toe pressures as the preferred measure, is required to assess CLTI. Evidence-based revascularization (EBR) hinges on three independent axes: Patient risk, Limb severity, and ANatomic complexity (PLAN). Average-risk and high-risk patients are defined by estimated procedural and 2-year all-cause mortality. The GVG proposes a new Global Anatomic Staging System (GLASS), which involves defining a preferred target artery path (TAP) and then estimating limb-based patency (LBP), resulting in three stages of complexity for intervention. The optimal revascularization strategy is also influenced by the availability of autogenous vein for open bypass surgery. Recommendations for EBR are based on best available data, pending level 1 evidence from ongoing trials. Vein bypass may be preferred for average-risk patients with advanced limb threat and high complexity disease, while those with less complex anatomy, intermediate severity limb threat, or high patient risk may be favored for endovascular intervention. All patients with CLTI should be afforded best medical therapy including the use of antithrombotic, lipid-lowering, antihypertensive, and glycemic control agents, as well as counseling on smoking cessation, diet, exercise, and preventive foot care. Following EBR, long-term limb surveillance is advised. The effectiveness of nonrevascularization therapies (eg, spinal stimulation, pneumatic compression, prostanoids, and hyperbaric oxygen) has not been established. Regenerative medicine approaches (eg, cell, gene therapies) for CLTI should be restricted to rigorously conducted randomizsed clinical trials. The GVG promotes standardization of study designs and end points for clinical trials in CLTI. The importance of multidisciplinary teams and centers of excellence for amputation prevention is stressed as a key health system initiative.

PC082. High-Granularity Geographic Information System Analysis of Amputation Trends in West Virginia Identifies Specific Geographic Areas to Target for Improved Diabetes and Peripheral Artery Disease Care

Amputation is a devastating but preventable complication of diabetes and peripheral artery disease (PAD). Multiple studies have focused on disparities in amputation rates based on race/ethnicity and socioeconomic status, but few focus on amputation trends in rural populations. This study’s objective was to identify the prevalence of major and minor amputation among those with documented disease in a rural Appalachian state and to use advanced spatial epidemiology methods to identify high-risk areas for amputation. This study used 2011 to 2016 hospital discharge data from the West Virginia State Inpatient Database to identify all adults (>18 years) with recorded diagnoses of diabetes or PAD. Major and minor amputations in this population were identified using International Classification of Diseases, Ninth Revision and Tenth Revision codes. Amputation rate was defined as the number of amputations among admissions with diabetes or PAD. To identify high-risk areas for amputation, Bayesian spatial hierarchical modeling was conducted to obtain model-fitted relative risk estimates at both the county and ZIP code level (of patient residence), and the deviance information criterion was used to investigate model performance. In 2011 to 2016, there were 519,990 admissions that met the criteria of diabetes or PAD. Among them, 2584 major and 3829 minor amputations were performed, with 6279 amputations performed overall, corresponding to a rate of 12.1/1000. This number is significantly higher than the national average of 2.4/1000 reported in other studies. On geographic analysis, we found significant variation in risk for both major and minor amputation across the state, even after adjusting for the prevalence of risk factors. Specifically, we found that ZIP codes in central and northeastern West Virginia had relative risks of amputation >1.5 times higher than the rest of the state (Figs 1 and 2). In addition, we found significant differences in estimates between standard crude risk estimation for this disease and our method, which was able to illustrate amputation risk at a much higher level of granularity by producing ZIP code-level data on amputation risk while controlling for associated comorbidities. We found a significantly higher prevalence of amputation in West Virginia compared with the national prevalence reported in other studies. In addition, we found significant geographic variation in amputation risk across the state and identified highly specific areas where, even after adjusting for covariates, the risk of amputation among those with diabetes or PAD was higher than expected. These findings allow the targeted allocation of resources for amputation prevention efforts and also direct further research to gain a greater understanding of the cause of this issue.Fig 2Geographic variation in model-fitted estimates of ZIP code-level relative risk of minor amputation in West Virginia, 2011 to 2016.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Meta-analysis of risk factors for amputation in diabetic foot infections.

Knowledge of risk factors is crucial to develop management and treatment protocols for the prevention of lower extremity amputation for patients with diabetic foot infections (DFIs). We searched the research literature for studies reporting risk factors for lower extremity amputation in patients with DFI. The main outcome variables included both minor and major amputations. This study was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, and the protocol was registered in PROSPERO (CRD42018118543). A total of 2471 potential articles from the database search met the inclusion criteria. After reviewing the titles, abstracts, and full texts, remaining 25 articles were included in the final analysis. We identified 6132 patients with DFI in the 25 included articles. Of these, 1873 patients who underwent amputation were investigated. Male gender (odds ratio [OR]: 1.31), smoking (OR: 1.38), history of amputation (OR: 1.47), history of osteomyelitis (OR: 1.94), peripheral arterial disease (OR: 2.35), retinopathy (OR: 1.32), International Working Group on the Diabetic Foot (IWGDF) grades 3 and 4 (OR: 1.7 and 2.5), Wagner grades 4 and 5 (OR: 4.3 and 6.4), gangrene/necrosis (OR: 9.9), osteomyelitis (OR: 4.5), neuroischaemic DFI (OR: 3.06), severe infection (OR: 3.12), length of hospitalization (standardized mean difference [SMD]: 0.7), leukocytosis (OR: 1.76), mean erythrocyte sedimentation rate (ESR) (SMD: 0.5), mean C-reactive protein (CRP) (SMD: 0.8), tissue culture positivity (OR: 1.61), and isolation of Gram-negative bacteria from tissue culture (OR: 1.5) were found as predictors of amputation in DFI. The present study highlighted some differences in diabetic foot ulcers and DFIs in terms of risk factors for lower extremity amputation. These data provide detailed information about risk factors for amputations among patients with DFI, thus contributing to the creation of new classification systems for assessment of high-risk patients.

An Academic-Practice Partnership: Fostering Collaboration and Improving Care Across Settings.

Through the Veterans Affairs Nursing Academic Partnership (VANAP), baccalaureate nursing students and faculty participated in practice innovations in a Veterans Affairs Health Care System. Nationally, VANAP has attempted to bridge gaps between theory and practice and across care settings. In a population health course, nursing students were placed in both inpatient and outpatient settings. Through activities such as postconferences and population-based projects, students joined forces with Veterans Affairs staff on issues that affected veterans' health care. Two student groups worked on amputation prevention from opposite ends of the spectrum. Their projects, with the continuation of these by faculty and staff, resulted in 47% decrease in vascular-related hospital readmissions. Student placements in settings across the care continuum improved communication between the settings. The enhanced partnership between the 2 organizations addressed a relevant, meaningful patient care issue.

Risk Factors Associated With Major Lower Extremity Amputation After Osseous Diabetic Charcot Reconstruction

Patients with diabetic Charcot neuroarthropathy (CN) are at high risk for ulcerations and major lower extremity amputations (LEAs). Osseous reconstruction is an important component in ulcer healing and prevention; however, despite such efforts, major LEAs remain a serious postreconstruction concern. The aim of this study was to identify risk factors for major LEA in patients who underwent osseous Charcot reconstruction. A retrospective review was performed on 331 patients with the diagnosis of CN in the foot and ankle treated over a 16-year period. Two hundred eighty-five patients were included after exclusion of those without diabetes. Demographic data, anatomic wound location, surgical interventions, wound healing status, and the level of eventual amputation were recorded. Multivariate logistic regression and Fisher's exact test were used for analysis. All patients had diabetes, neuropathy, or CN and required osseous reconstruction. Risk factors and their respective odds ratios (ORs) are as follows: postoperative nonunion (OR 8.5, 95% confidence interval [CI] 2.2 to 33.5, 0.0023), development of new site of CN (OR 8.2; 95% CI 1.1 to 62.9; p = .0440), peripheral arterial disease (OR 4.3; 95% CI 1.7 to 11.0; p = .0020), renal disease (OR 3.7; 95% CI 1.6 to 8.8; p = .0025), postoperative delayed healing (OR 2.6; 95% CI 1.1 to 6.5; p = .0371), postoperative osteomyelitis (OR 2.4; 95% CI 1.0 to 5.9; p = .0473), or elevated glycated hemoglobin (OR 1.2; 95% CI 1.0 to 1.4; p = .0053). Independent risk factors found to be statistically significant for major LEA in diabetic CN in the setting of osseous reconstruction must be mitigated for long-term prevention of major amputations.

A Depiction of Rehabilitation Patients 65 Years and Younger With Dysvascular Lower Extremity Amputation.

The majority of lower limb amputations (LLA) in Canada are dysvascular due to complications of diabetes and/or vascular disease. Traditionally dysvascular amputations have occurred in the elderly. With younger onset of adult diabetes, amputations are now occurring in non-geriatric populations. An understanding of younger patients with dysvascular LLA is needed to determine their risk factors, and unique health and psychosocial challenges. To obtain a depiction of the key demographic and impairment characteristics of adults 65 years and younger with dysvascular LLA undergoing inpatient rehabilitation. A retrospective chart review was completed on inpatient adult amputation rehabilitation patients over a five year period. Data extracted included socio-demographics, Functional Independence Measure (FIM) scores, comorbidities, and discharge outcomes. One hundred and forty-three patients who were 65 years and younger were included, which represented almost a quarter of all admissions. Most patients were male (79%) with an average age of 55 years old (SD=8). The majority (72%) were unemployed. The mean number of co-morbidities was 5.2 (SD=8.2). Individuals discharged home (n=122) had higher (p<0.05) FIM scores than those readmitted to acute care or discharged to long-term care (n=20). Similar to the literature on older dysvascular LLA patients, our study found high rates of disability and co-morbidities in younger patients with dysvascular LLA, which might impact their ability to work. Given these challenges, better amputation prevention strategies and targeted rehabilitation programming for this population are needed.

An Application for Skin Macules Characterization Based on a 3-Stage Image-Processing Algorithm for Patients with Diabetes.

Diabetic skin manifestations, previous to ulcers and wounds, are not highly accounted as part of diagnosis even when they represent the first symptom of vascular damage and are present in up to 70% of patients with diabetes mellitus type II. Here, an application for skin macules characterization based on a three-stage segmentation and characterization algorithm used to classify vascular, petechiae, trophic changes, and trauma macules from digital photographs of the lower limbs is presented. First, in order to find the skin region, a logical multiplication is performed on two skin masks obtained from color space transformations; dynamic thresholds are stabilised to self-adjust to a variety of skin tones. Then, in order to locate the lesion region, illumination enhancement is performed using a chromatic model color space, followed by a principal component analysis gray-scale transformation. Finally, characteristics of each type of macule are considered and classified; morphologic properties (area, axes, perimeter, and solidity), intensity properties, and a set of shade indices (red, green, blue, and brown) are proposed as a measure to obviate skin color differences among subjects. The values calculated show differences between macules with a statistical significance, which agree with the physician's diagnosis. Later, macule properties are fed to an artificial neural network classifier, which proved a 97.5% accuracy, to differentiate between them. Characterization is useful in order to track macule changes and development along time, provides meaningful information to provide early treatments, and offers support in the prevention of amputations due to diabetic feet. A graphical user interface was designed to show the properties of the macules; this application could be the background of a future Diagnosis Assistance Tool for educational (i.e., untrained physicians) and preventive assistance technology purposes.

Evaluation of Superficial and Deep Specimens for Isolation and Identifi-cation of Bacterial Isolates from Diabetic Foot Infections.

Worldwide, Diabetic foot infections (DFIs) are a major medical, social, and economic problem reaching epidemic proportions carrying the increased risk of complications.[1,2] About 25% of the diabetics have the risk of developing foot ulceration which is one of the leading cause of mortality and morbidity in developing coun-tries.2,3,4The most feared complication of in-fected diabetic foot ulcers is gangrene which results in amputations and occurs 10-30 times more often in diabetics. About one major am-putation in 30 seconds worldwide in diabetics and the elevated mortality at follow up, rang-ing from 13% to 40% at 1 year to 39% – 80% at 5 years requires urgent strategies towards prevention of foot ulceration and amputations.[3,5] Once the protective layer of skin is bro-ken, the deep tissues are exposed to bacterial infection that progresses rapidly.

LEA 11. Implementation of a Multidisciplinary Team Approach in Lower Extremity Amputation Prevention Program for Diabetic Foot Ulcer Referral from Primary Health Care to a Tertiary Center Vascular Surgery Clinic: Initial Experience in an Asian Population

LEA 11. Implementation of a Multidisciplinary Team Approach in Lower Extremity Amputation Prevention Program for Diabetic Foot Ulcer Referral from Primary Health Care to a Tertiary Center Vascular Surgery Clinic: Initial Experience in an Asian Population

Lower Extremity Revascularization With Transmetatarsal Amputation Improves Healing and Reduces Major Amputation

A transmetatarsal amputation (TMA) allows patients with forefoot wounds to maintain ambulatory function and preserves a sensate heel and ankle. However, healing after TMA is often compromised in older patients by peripheral artery disease (PAD). The aim of this study was to investigate the effect of lower extremity revascularization (LER) on TMA healing and prevention of major amputation. A retrospective review was conducted of all patients who had a TMA at three centers of a multicenter vascular practice from January 1, 2008, to December 31, 2016. In January 2012, a multidisciplinary limb salvage team consisting of vascular surgeons and podiatrists was established. Data on demographics, procedural details, and outcomes were collected. A total of 124 patients had 134 TMAs with a median follow-up of 1221 days (interquartile range [IQR], 730-1757 days). The mean age was 60.9 ± 11.5 years; 81% were men, 87% had diabetes, 56% had PAD, and 31% had coronary artery disease (CAD). Of 134 TMAs, 68% (91) healed, 10% (14) had recurrent wounds, and 22% (29) failed, requiring above- or below-knee amputation (AKA/BKA). Patients with PAD/CAD had a significantly lower healing rate (51/84 [61%] vs 40/50 [80%]; P = .021) and significantly higher AKA/BKA rate (24/84 [29%] vs 5/50 [10%]; P = .012). LER was associated with significantly improved TMA healing rates (36/52 [69%] vs 15/32 [47%]; P = .042). Open LER had a significantly higher healing rate (16/31 [52%] vs 4/20 [20%]; P = .024) and lower AKA/BKA rate (2/31 [6%] vs 9/22 [41%]; P = .002) than endovascular LER. By Kaplan-Meier analysis, the median time to healing was 295 days (IQR, 99-754 days). The median time to AKA/BKA was 1062 days (IQR, 471-1595 days). In a multivariable Cox model, LER was associated with a lower risk (hazard ratio, 0.43; P = .039) of AKA/BKA, and PAD/CAD was associated with a higher risk (hazard ratio, 5.41; P = .001); 70% (94/134) of the TMAs were performed by the multidisciplinary limb salvage team, and there was an increase in TMA for Wound, Ischemia, and foot Infection (WIfI) stage 3/4 wounds (84/94 [89%] vs 28/40 [70%]; P = .006). In a multivariable Cox model, there was no change in TMA healing or AKA/BKA rates despite the higher WIfI category. TMA is a successful and durable procedure for patients with advanced foot wounds. Whereas TMA healing is time and labor intensive, aggressive use of LER can achieve TMA healing and avoid major amputation in older patients with PAD.

Preventing Major Amputations in Patients with Critical Limb Ischemia.

This review summarizes the risks of lower extremity amputation associated with critical limb ischemia (CLI) and discusses current therapies that can prevent amputation in CLI. CLI remains an under-recognized condition associated with high rates of major amputation and disparities in care. Optimal medical therapy can reduce the risk of major adverse cardiovascular and limb events, but revascularization combined with close wound care remains the cornerstone of amputation prevention. Endovascular revascularization has become more common over time and has been associated with a reduction in amputation rates. Ongoing clinical trials will help inform best practices for revascularization strategies and techniques. Vascular care is inconsistent across the USA, with significant variation in access to care revascularization rates and rates of major amputation. Major amputation can be prevented in patients with CLI when optimal medical therapy, lifestyle modification, and revascularization are provided in a multidisciplinary setting.