Previous Amputation Research Articles

Descripción del perfil clínico, aislamientos microbiológicos y complicaciones en una población de pacientes con amputación de miembros inferiores secundaria a pie diabético infectado. Estudio de Cohorte Longitudinal

Background85% of amputations in diabetic patients are preceded by the appearance of an ulcer. Reamputation rates of up to 60.7% at 5 years has been described, as well as mortality of up to 69.7% at one year for major amputations. Aim of the study is to characterize a population of diabetic patients, amputees due to infections associated with diabetic foot in a university hospital. Material and methodsInclusion and exclusion criteria and a sociodemographic, clinical and microbiological data collection format were applied to all amputations related to infections associated with diabetic foot between 2014 and 2016. Means and standard deviations and / or medians and percentiles were used. ResultsThe average age was 61.6 years. Male sex and poor glycemic control and a high number of comorbidities such as hypertension and chronic kidney disease predominated. 24.4% of previous ulcers and 18.1% previous amputations. Major amputations were 39%. Stump infection was 23.6% and reamputations 24.5%. Mortality was 4.54% DiscussionPoor metabolic control was identified, as well as a high percentage of comorbidities and complications. Insufficient nutritional follow-up and staging of vascular status with underreporting of relevant data such as neuropathy, deformities and status of the contralateral foot. The number of ulcers and previous amputations was high. There was good clinical / laboratory correlation. Initial major amputations were more frequent in women. There is a high percentage of surgical site infections and reamputations.Evidence Level: III

Development of a Diabetic Foot Ulceration Prediction Model and Nomogram

This study aimed to identify the risk factors for diabetic foot ulceration (DFU) to develop and evaluate the performance of a DFU prediction model and nomogram among people with diabetes mellitus (DM). This unmatched case-control study was conducted with 379 adult patients (118 patients with DM and 261 controls) from four general hospitals in South Korea. Data were collected through a structured questionnaire, foot examination, and review of patients' electronic health records. Multiple logistic regression analysis was performed to build the DFU prediction model and nomogram. Further, their performance was analyzed using the Lemeshow-Hosmer test, concordance statistic (C-statistic), and sensitivity/specificity analyses in training and test samples. The prediction model was based on risk factors including previous foot ulcer or amputation, peripheral vascular disease, peripheral neuropathy, current smoking, and chronic kidney disease. The calibration of the DFU nomogram was appropriate (χ² = 5.85, p = .321). The C-statistic of the DFU nomogram was .95 (95% confidence interval .93~.97) for both the training and test samples. For clinical usefulness, the sensitivity and specificity obtained were 88.5% and 85.7%, respectively at 110 points in the training sample. The performance of the nomogram was better in male patients or those having DM for more than 10 years. The nomogram of the DFU prediction model shows good performance, and is thereby recommended for monitoring the risk of DFU and preventing the occurrence of DFU in people with DM.

Risk factors for foot ulceration among adult patients with diabetes on chronic hemodialysis in Dakahlia Governorate, Egypt

Background Although risk factors for diabetic foot ulceration have been extensively studied in patients with diabetes in Egypt, there is surprisingly limited evidence among those on chronic hemodialysis (CHD). The study aimed to scrutinize the risk factors for foot ulceration in adult patients with diabetes with end-stage renal disease on hemodialysis in Dakahlia Governorate central hemodialysis units. Patients and methods This cross-sectional study included all diabetic patients under CHD aged more than or equal to 18 years (n=98), recruited over 7 months from the largest seven central hemodialysis units in Dakahlia Governorate, Egypt. Data collection consisted of a participant interview, medical record review, and noninvasive comprehensive foot examination. The assessment included peripheral neuropathy, peripheral arterial disease, other foot pathologies, footwear, and foot health care behavior. Results The study included 57 males and 41 females. The median duration of diabetes was 15 (2–33) years. Overall, 61 (62.2%) patients were on insulin therapy. The median duration of hemodialysis was 3 years. Insensate neuropathy and peripheral arterial disease were detected in 65.3 and 15.3% of patients, respectively. The prevalence of foot deformities was 18.36%. Plantar calluses and dry skin were diagnosed in 27.6 and 62.2% of patients, respectively. A total of two (2.04%) patients had active foot ulcers and nine (9.18%) patients had ulcers in remission; therefore, the overall diabetic foot ulceration prevalence was 11.22%. In addition, 10 (10.2%) patients had previous minor amputations, with no reported major amputations. Overall, 95.92% had poor foot health care behaviors, and 81.63% were using inappropriate footwear. None of the included patients previously used custom-made insoles. Conclusions The key finding of this article suggests a high prevalence of risk factors for foot ulceration among diabetic patients receiving hemodialysis. Diabetic foot screening should be included in the management strategy of those on CHD.

Study the susceptibility pattern of bacteria isolated from infected wounds and determine various risk factors associated with foot ulcer

Studying of bacteria prevalence and antimicrobial susceptibility in samples from foot ulcer patients with chronic wounds will provide the epidemiological information on chronic wound infections, representing support for diagnosis, treatment and management of this pathology, thus preventing further complications of foot infection. There are many risk factors associated with a foot ulcer, so identifying those risk factors and preventing them will help in reducing the incidence of the disease to a certain extend. Identifying the type of organisms causing the chronic wound infection, antibiotic sensitivity and resistance representing support for diagnosis, treatment and management thus preventing further complications of foot infection, and to understand the significant risk factors associated with the development of foot ulcers. An interventional study was conducted among the 80 patients with foot ulcers admitted in General surgery ward of a medical college teaching hospital from Dec 2018 to May 2019. Antimicrobial susceptibility results showed that gram-negative organism was more prevalent and among the species, the isolated majority was found to be Staphylococcus aureus 28 (0.35%) followed by Klebsiella 16(20%) and E.coli15(18.75%). The most sensitive antibiotic found was Meropenam70 (87.5%) followed by Imipenam 67(83.75%) and Linezolid 65(81.25%) The most resistant antibiotic was Cotrimoxazole 66(82.5%). This study concludes that high proportion of foot ulcers were found amongst diabetic patients than non-diabetic patients, and were often associated with trauma, cellulitis, gangrene. Some of the critical risk factors for foot ulcers included low educational status, previous history of foot ulcer, previous amputation was done, duration of ulcers, smoking, peripheral neuropathy, infection and HbA1c levels of patients.

Clinical-surgical treatment of diabetic foot ulcers in a colombian hospital

This study elucidates the clinical-surgical features of and treatments for patients with diabetic foot ulcers (DFU). Through an observational descriptive cross-sectional study, 44 clinical records of patients with type 2 diabetes mellitus between 2012 and 2017 were analyzed. The sociodemographic features, risk factors, related pathologies, diagnostic methods, and infections were compared for patients who received amputation or debridement as treatment. Patients with previous amputations, Wagner grade 4 DFUs, and infections are more likely to amputation, while individuals with alcoholism, previous ulcers, and diabetic neuropathy are more likely to receive debridement as treatment. Patients older than 60 years, women, smokers, and alcoholics are more likely to develop either ischemia or infection. Plain radiography detected complications and pathologies such as soft tissue density increase, bone density decrease, and osteolytic and osteoarthritic injuries. The analysis of clinical records is a useful method for characterizing and identifying the main risk factors that affect a specific population. Accordingly, health professionals may use the information provided in this study to carry out appropriate systemic metabolic management, prevent unnecessary surgical interventions, and educate patients to adopt safe self-care practices. • Clinical records allow to identify risk factors affecting patients with diabetes. • Patients with Wagner grade 4 and infections are more likely to suffer an amputation. • Women, smokers and alcoholics are more likely to develop ischemia and infection. • Patients presented an increase of density in soft tissues. • Radiography images evidenced osteolytic lesions and osteoarthritic signs.

Microvascular disease, peripheral artery disease, and the risk of lower limb amputation

Abstract Background Peripheral artery disease (PAD) is the leading cause of non-traumatic lower limb amputation. Microvascular disease (peripheral neuropathy, nephropathy, or retinopathy) increases the risk of lower limb amputation in patients with established PAD. Purpose We estimated risk of lower limb amputation associated with microvascular disease and PAD in a Danish cohort. Methods We conducted a population-based cohort study of every person living in Western Denmark aged 50–75 years on January 1, 2012 and followed them for 7 years. People with previous lower limb amputation were excluded. People were stratified by the presence of microvascular disease (peripheral neuropathy, nephropathy, or retinopathy) and PAD (peripheral atherosclerosis including intermittent claudication, or previous lower limb revascularization). We estimated the 7-year cumulative incidence and hazard ratio (HR) of lower limb amputation using individuals with neither microvascular disease nor PAD as reference. We also provide a sex-specific analyses and estimated the population attributable fraction of amputation associated with male sex. Results We included 933,597 individuals, of whom 16,007 had microvascular disease, 18,400 had PAD, and 1,789 had both microvascular disease and PAD. Patients with either microvascular disease (3.7%) or PAD (3.9%) had similar unadjusted 7-year risks of lower limb amputation (Figure). Microvascular disease (adjusted HR 3.21, 95% CI 2.86–3.59) and PAD (adjusted HR 7.37, 95% CI 6.68–8.14) increased the risk of lower limb amputation separately in adjusted analysis. Individuals with both microvascular disease and PAD had the highest risk of amputation (adjusted HR 11.82, 95% CI 10.11–13.80). While the relative impact of microvascular disease and PAD were similar in men and women, men had increased risk of amputation compared to women, in absolute terms. The population attributable fraction of amputations associated with male sex was 31%. Conclusion Microvascular disease and PAD are independently associated with a 3-fold and 7-fold increase of amputation rate, respectively. Combined, microvascular disease and PAD had an additive effect constituting a 12-fold amputation risk. Amputation risk was higher in men than in women, with 3 in 10 lower limb amputations in Western Denmark attributable to male sex. Figure 1 Funding Acknowledgement Type of funding source: Public hospital(s). Main funding source(s): Department of Cardiology, Aarhus University Hospital

Risk of lower limb amputation in diabetes patients with and without coronary artery disease – a cohort study from Western Denmark

Abstract Background Diabetes patients are at greater risk of lower limb amputation due to a higher risk of peripheral artery disease (PAD) and peripheral neuropathy. The effect of concomitant coronary artery disease (CAD) is less explored. Purpose We examined the risk of PAD, lower limb revascularization, and lower limb amputation in diabetes and non-diabetes patients with and without CAD examined by coronary angiography. Methods We included all patients who underwent coronary angiography between 2003–2016 in Western Denmark. Patients with a history of PAD or previous lower limb revascularization or amputation were excluded. Patients were stratified by diabetes and CAD status and followed in prospective registries for a maximum of 10 years. Outcomes were PAD, lower limb revascularization, and lower limb amputation. We estimated 10-year cumulative incidence and adjusted hazard ratios (aHR) using patients with neither diabetes nor CAD as reference. We also examined the effect of CAD extent, insulin treatment, and duration of diabetes in the diabetes group. Results A total of 118,787 coronary angiography patients were included of whom 17,482 (14.7%) had diabetes. Median follow-up was 6.8 years. Patients with both diabetes and CAD had the highest risk of PAD (aHR 3.90, 95% CI 3.55–4.28), lower limb revascularization (aHR 4.61, 95% CI 3.85–5.52), and lower limb amputation (aHR 9.49, 95% CI 7.27–12.39), compared with patients with neither diabetes nor CAD. Extent of CAD, insulin treatment, and duration of diabetes were all associated with increased risks of PAD and amputation in the diabetes group. CAD only patients had higher 10-year risk of PAD compared to diabetes only patients (7.9% versus 6.9%), but had lower risk of amputation (0.6% versus 2.4%, Figure). CAD only patients were most often amputated at hip/femur level, while diabetes only patients most often were amputated at ankle/foot/toe level. Conclusions Presence of CAD in patients with diabetes was an indicator of high risk of PAD and lower limb amputation, and the risk depended on severity of both CAD and diabetes. Figure 1 Funding Acknowledgement Type of funding source: Public hospital(s). Main funding source(s): Department of Cardiology, Aarhus University Hospital

Correlation Between The History of Previous Lower Extremity Amputation as a Risk Factor for the Subsequent Lower Extremity Amputation in Diabetic Patients Among RSUD Dr. Soetomo Patients in 2018

Diabetes mellitus is a group of metabolic diseases characterized by hyperglycemia. Complications are common among patients with this condition, such as diabetic foot syndrome, which is the presence of foot ulcer associated with neuropathy, PAD, and infection, and is a major cause of LEA. Aim of this research is to analyze the correlation between previous LEA as a risk factor for the subsequent LEA in patients with Diabetic Foot among patients in RSUD Dr. Soetomo, Surabaya from January-December 2018. This is descriptive cross-sectional study. Data was analyzed using descriptive statistic and correlation test with Microsoft Excel 2007 and SPSS 20. Statistical testing was performed using Spearman’s rank correlation and Cohen J criteria with significance level of P55 years old (62.9%). Mostly have undergone LEA (74.3%) while the remaining have undergone LEA twice (17.1%). There is a significant correlation between initial LEA and the subsequent LEA (p0.01). 
 Keywords: diabetes mellitus; lower extremity amputation; risk factors; RSUD Dr. Soetomo

Comparison of open- and closed-cell stent design outcomes after carotid artery stenting in the Vascular Quality Initiative

BackgroundThe association between stent design and outcomes after carotid artery stenting (CAS) has remained controversial. The available data are conflicting regarding the superiority of any specific stent design. The present study investigated the association between cell design and outcomes after carotid artery stenting (CAS) in a real world setting. MethodsPatients who had undergone CAS with distal embolic protection in the Society for Vascular Surgery Vascular Quality Initiative (VQI) database from 2016 to 2018 were included in the present study. Patients undergoing CAS for trauma or dissection or more than two treated lesions were excluded. We also excluded lesions for which more than two carotid stents had been used and lesions confined to the common or external carotid artery. Univariable and multivariable logistic regression analyses were used to compare the outcomes after CAS between the open- and closed-cell stent designs. ResultsOf the 2671 CAS procedures included in the present analysis, 1384 (51.8%) had used closed-cell stents and 1287 (48.2%) had used open-cell stents. On univariable analysis, no significant differences were noted between the closed- and open-cell stents in in-hospital mortality (1.8% vs 1.4%; P = .40), stroke (1.8% vs 2.4%; P = .28), and stroke/death (3.3% vs 3.5%; P = .81). After adjusting for potential confounders (ie, age, symptomatic status, previous major amputation, statin and antiplatelet use, American Society of Anesthesiologists class, elective procedures, approach, and post-stent dilatation), no difference was noted in in-hospital stroke/death between the two stent designs (odds ratio [OR], 1.08; 95% confidence interval [CI], 0.68-1.74; P = .74). However, the interaction between stent design (open vs closed) and lesion location (bifurcation vs internal carotid artery [ICA]) was statistically significant (P = .02). Closed-cell stents were associated with five times the odds of in-hospital stroke/death when used in carotid artery bifurcation (OR, 5.5; 95% CI, 1.3-22.2; P = .02). However, when the stent was limited to the ICA, no differences were noted (OR, 0.87; 95% CI, 0.51-1.45; P = .62). One-year follow-up data were available for 19% of patients. No differences in ipsilateral stroke or death at 1 year were noted between the open- and closed-cell stents, except when the lesion was located in the carotid bifurcation (hazard ratio, 6.7; 95% CI, 1.4-31.4; P = .02). ConclusionsClosed-cell stents were associated with an increased odds of in-hospital stroke/death for carotid bifurcation lesions, which might be related to the relatively lower conformability of closed-cell stents in the tortuous and diameter-mismatched bifurcation anatomy vs the relatively linear uniform diameter of the ICA. Improved follow-up and in-depth analysis of lesion-specific characteristics that might influence the outcomes of these two designs are needed to validate these results.

Midfoot Charcot Neuro-arthropathy Precipitated by First or Fifth ray Amputation

Charcot Neuro-arthropathy (CN) can occur spontaneously in a neuropathic foot but is often precipitated by an insult to the foot, such as trauma. We noted an association between 1st and 5th ray amputations and the development of midfoot CN in our clinics. We therefore set out to analyse our data over a 6-year period to evaluate and improve our practice. Our project encompassed all diabetic adults with peripheral neuropathy undergoing an amputation of the first or fifth ray between January 2013 and January 2019. Patient demographics, stump length, progression to CN, imaging reports, the need for further operative management, length of stay and operating specialty were collected. Cases that developed CN after 1st or 5th ray amputation ("CN group") were compared with a cohort composed of patients that did not ("non-CN group"). We identified 92 patients (98 surgical episodes) who had previous 1st or 5th ray amputations [77 males (83.7%), 15 females (16.3%), mean age 61.5 ± 13.5]. Midfoot CN developed in 16 cases (17.4%; nine following 1st ray and seven following 5th ray amputation). This represented 30.9% of all our new CN cases. CN was diagnosed within six months in six cases and up to three years in the remaining 12. Five of the 1st ray amputations were conducted with a stump length of ≤10 mm from the tarsometatarsal joint and a further one had resorbed down to it before the Charcot process. Three of the 5th ray amputations were carried out leaving a stump length ≤25 mm. Receiver Operator Curve (ROC) analysis showed no obvious diagnostic value of stump length in predicting CN (area under the curve 0.42 (95% CI 0.26 - 0.59)). Following a logistic regression analysis into effect of age, gender and peripheral vascular disease, only age was found to significantly affect the risk of developing CN (Nagelkerke R2 = 0.122, p = 0.013). This is the first report of midfoot CN developing after 1st or 5th ray amputations. The foot could be destabilised following these procedures, leading to increased pressures across the midfoot. Our small sample was unable to demonstrate a significant correlation between stump length and CN risk. However, more work is needed to ascertain this. Meanwhile, we believe this translates clinically into a need for enhanced foot protection following 1st and 5th ray amputations in our practice.

Characteristics and outcomes of hip fractures in lower limb amputees.

Lower limb amputees, regardless of age are at an increased risk of developing fragility fractures of the neck of femur. The characteristics and outcomes of the fractures of the neck of femur in lower limb amputees have not been studied in detail. We undertook a retrospective review of a prospectively collected single centre and single surgeon database between March 1996 and January 2017, using a standard proforma to identify patients who required surgical intervention for fracture neck of femur and had sustained a previous lower limb amputation and compared them with a cohort of standard hip fracture patients. Twenty-seven patients, sustaining 28 fractures of the neck of femurs were identified of which 16 were females with mean age of 78 years (50-89). Nineteen fractures were sustained on the ipsilateral side of the amputation. Results showed that seventy percent of amputees returned to their previous level of mobility and prior residence. Mortality in this group is higher as compared to a standard hip fracture patient but pain and mobility were comparable in both groups. The incidence of both hip fractures and amputations in increasing worldwide but no study has compared outcomes of hip fractures in amputees and compared them to a standard hip fracture patient. Amputees exhibit reduced bone density both at the hip and stump end which increases risk for osteoporosis and fragility fractures in the hip. The management of our patients followed orthopaedic principles, well established surgical interventions and rehabilitation. This study reveals that hip fractures in amputees can have comparable results to a standard hip fracture cohort if preoperative optimisation, planning and postoperative rehabilitation is carried out.

Total hip replacement in dogs with contralateral pelvic limb amputation: A retrospective evaluation of 13 cases.

To report the clinical characteristics, surgical management, and medium-term outcomes of total hip replacement (THR) performed in dogs with previous contralateral pelvic limb amputation. Thirteen client-owned dogs. Multi-institutional retrospective clinical study. Data recorded from medical records included signalment, indication for amputation and THR, and surgical complications. Implant positioning and complications were assessed on radiographs. Clinical outcomes were evaluated during follow-up examinations by one of the authors and through a mobility- and lifestyle-based questionnaire completed by owners. All 13 dogs had satisfactory clinical results at follow-up a median of 3 months (range, 2-36) after THR. No postoperative luxation was recorded. Four dogs had minor complications that did not require additional treatment. The only major complication was one failure of osseointegration of a cementless acetabular cup, and it was successfully revised. Total hip replacement resulted in satisfactory clinical results and acceptable morbidity in this population. Total hip replacement should be considered in dogs with severe coxofemoral joint disease and contralateral pelvic limb amputation.

Risk factors for foot ulceration among adult patients with diabetes on chronic hemodialysis in Dakahlia governorate, egypt

Background Although risk factors for diabetic foot ulceration have been extensively studied in patients with diabetes in Egypt, there is surprisingly limited evidence among those on chronic hemodialysis (CHD). The study aimed to scrutinize the risk factors for foot ulceration in adult patients with diabetes with end-stage renal disease on hemodialysis in Dakahlia Governorate central hemodialysis units. Patients and methods This cross-sectional study included all diabetic patients under CHD aged more than or equal to 18 years (n=98), recruited over 7 months from the largest seven central hemodialysis units in Dakahlia Governorate, Egypt. Data collection consisted of a participant interview, medical record review, and noninvasive comprehensive foot examination. The assessment included peripheral neuropathy, peripheral arterial disease, other foot pathologies, footwear, and foot health care behavior. Results The study included 57 males and 41 females. The median duration of diabetes was 15 (2–33) years. Overall, 61 (62.2%) patients were on insulin therapy. The median duration of hemodialysis was 3 years. Insensate neuropathy and peripheral arterial disease were detected in 65.3 and 15.3% of patients, respectively. The prevalence of foot deformities was 18.36%. Plantar calluses and dry skin were diagnosed in 27.6 and 62.2% of patients, respectively. A total of two (2.04%) patients had active foot ulcers and nine (9.18%) patients had ulcers in remission; therefore, the overall diabetic foot ulceration prevalence was 11.22%. In addition, 10 (10.2%) patients had previous minor amputations, with no reported major amputations. Overall, 95.92% had poor foot health care behaviors, and 81.63% were using inappropriate footwear. None of the included patients previously used custom-made insoles. Conclusions The key finding of this article suggests a high prevalence of risk factors for foot ulceration among diabetic patients receiving hemodialysis. Diabetic foot screening should be included in the management strategy of those on CHD.

What happens to our amputees? The Darling Downs experience.

Major lower limb amputation is occasionally required in the management of end-stage pathology where other treatment options have failed. The primary aim of this study was to determine the 30-day and 1-year mortality rates of patients undergoing nontraumatic major lower limb amputation. Secondary aims were to investigate risk factors for poor outcomes, incidence of previous minor amputation, and the rate of subsequent major amputation. All nontraumatic, major lower limb amputations performed at Toowoomba Hospital during an 18-year period were retrospectively reviewed. Mortality data were obtained from the Queensland Registry of Births, Deaths and Marriages. Kaplan-Meier analysis was performed to determine survival after amputation. A total of 147 patients were included in the study, with 104 undergoing below knee and 43 undergoing above knee amputations. Ten patients identified as having an Aboriginal and Torres Strait Islander background. For all patients, the 30-day mortality was 4.1% and 1-year mortality was 21.1%. For Indigenous patients, 30-day mortality was 10%. Previous minor amputation had occurred in 40 patients. Twenty-nine patients underwent further minor surgery after their initial major amputation, with thirteen requiring subsequent major amputation. Factors that increased mortality risk were the presence of peripheral vascular disease, an American Society of Anesthesiologists score of four and age greater than 65 years. The morbidity and mortality following major lower limb amputation is significant. The findings of this study highlight the importance of preventative measures to minimize the incidence of lower limb amputations in the future.

Secondary Prevention for Atherosclerotic Cardiovascular Disease: Comparing Recent US and European Guidelines on Dyslipidemia.

Secondary Prevention for Atherosclerotic Cardiovascular Disease: Comparing Recent US and European Guidelines on Dyslipidemia.

Multidisciplinary Management of Diabetic Foot Ulcers in Primary Cares in Quebec: Can We Do Better?

A growing body of evidence supports the presence of integrated foot care based on multidisciplinary and interdisciplinary teams in the management and prevention of diabetic foot ulcer (DFU) worldwide. This model of care is however rare in the clinical setting in Quebec, Canada. Many best practice gaps are identified as well as probable causal hypothesis are listed in this commentary. We support our opinions with a pilot audit conducted as part of a continuous quality improvement process in managing patients with DFU in our area and on Canadian facts and data. Our pilot study (n = 27 hospitalized patients) included a typical DFU population with neuropathy, peripheral arterial disease and previous amputation. It highlights underachievement of best practice recommendations implementation such as multidisciplinary DFU management and offloading interventions in our establishment. Due the high morbidity and mortality associated with DFU patients, four died during the studied hospitalization episode. Several barriers were encountered in the pilot audit justifying that no robust conclusion can be raised. However, our observations are concerning. Even though data accessibility was limited, our observations are sadly coherent with what is found in the literature. Economic data of what this means for our health system is put forward in the overall discussion. We are preoccupied by the trends outlined by some facts and observations, and this commentary was written with this in mind. In the face of the diabetes crisis that is arising, a plea is made to reassess care pathway for this vulnerable population as we emphasize the importance of teamwork in managing DFU.

Improvement in Bone Mineral Density after a Distal Weight-Bearing Implant in a Series of 13 Cases

ABSTRACT Introduction The amputation of lower limbs and the subsequent use of a prosthesis require the adoption of new biomechanical patterns of load and gait by the patient, which may favor the onset of local or generalized bone mineral density loss. Osseo-anchored implants that allow distal weight bearing of the residuum may be able to mitigate bone mineral density loss related to amputation. The objective of this study is to determine the effect of the use of a distal weight-bearing implant on the bone mineral density of the amputated limb in relation to the nonamputated limb. Materials and Methods An interrupted time series clinical trial carried out in the Outpatient Department of Rehabilitation of the five participant hospitals. Thirteen patients with previous transfemoral amputations of traumatic, oncologic, and vascular etiology were enrolled. These patients underwent surgical implantation of an osseo-anchored implant with a distal spacer that allows a direct load on the residuum over the distal surface of the socket. Patients were followed for a 14-month period and assessed presurgically and postsurgically using dual-energy x-ray absorptiometry of the femur neck. Results The mean increase in bone mineral density for the amputated limb was 0.020 g/cm2, which represented a mean percentage increase of 3.0%. For the nonamputated limb, the mean increase in bone mineral density was 0.005 g/cm2 and the mean percentage increase was 0.5%, with eight patients showing improvements in bone mineral density. The mean percentage of bone mineral density of the amputated limb in comparison with the nonamputated limb was 70.6% preimplantation and 73.2% postimplantation, with an average increase of 2.6%. Conclusions The results of this study show an improvement in bone mineral density in individuals with transfemoral amputation 14 months after having received a distal weight-bearing implant.

Arterial Reconstruction for Patients with Chronic Limb Ischemia Improves Ambulatory Function and Health-related Quality of Life

Arterial reconstruction (AR) for limb ischemia may improve ambulatory function (AF) and health-related quality of life (HR-QoL). However, the efficacy of AR in terms of HR-QoL varies in studies, probably because of cohort differences in disease severity, hemodynamic outcomes, and observation duration. We assessed HR-QoL for patients with various severities of ischemia in a 3-year observational study. We conducted a single-center 3-year observational study using Short Form 36 in patients with chronic limb ischemia. Between 2001 and 2009, 515 consecutive patients had AR, and 330 who underwent elective AR consented to the study. Of the 330 patients (claudicants 49%, critical limb ischemia [CLI] 51%), 307 underwent bypass and 23 endovascular therapy. Postal questionnaires were sent after AR, and 8 domains, the physical and mental component summary (PCS and MCS) scores, and the patient-reported AF were compared, and negative predictors were identified. Overall, the MCS was minimally affected, but AF and the PCS were impaired. After AR, these measures were significantly improved, and maximum recovery was attained at 6months. In subgroup analysis, significant predictors of a negative impact on postoperative PCS included age ≥80, CLI, physical aftereffects of stroke (PAS), and previous major amputation (PMA). Of these, PMA was associated with the lowest PCS score, followed by PAS; for these patients, AR contributed minimally to HR-QoL recovery. PCS scores of claudicants attained a maximum value at 6months; however, PCS scores of CLI patients were significantly lower than intermittent claudication patients (P<0.0001), and patients with major tissue loss required 2years to attain maximum PCS recovery. This 3-year observational study verified the efficacy of AR in improving AF and HR-QoL. Age ≥80, CLI, PAS, and PMA were definitive predictors, and for patients with the latter 2, AR contributed minimally to improving HR-QoL.

Demographic and socioeconomic profiles of patients admitted with diabetic foot complications in a tertiary hospital in Belem - Para.

to assess the socioeconomic and demographic profiles of patients hospitalized with a diagnosis of diabetic foot in a tertiary hospital in Belem-PA, Brazil, as well as to evaluate risk factors for lower limb amputations in such patients, classifying them according to the Wagner and PEDIS classifications. we conducted a descriptive, cross-sectional, unicentric, and analytical study carried out through a structured questionnaire. the study consisted of 57 patients, aged between 48 and 84 years old, 66.7% being male. The average income ranged between one and three (61.4%) minimum wages and below one minimum wage (31.6%). Type II Diabetes Mellitus was predominant (86.0%). Concerning comorbidities, arterial hypertension displayed the highest proportion (62.3%), followed by dyslipidemia (52.8%). Smokers comprised 35.1% of the sample. Infectious diabetic foot (50.9%) and mixed diabetic foot (49.1%) were the most common. Of the 20 patients with previous amputation, 90% had undergone minor amputation, and 10%, major ones. Callosity (92.6%) was the most prevalent deformity. Fifty-four (94.7%) patients underwent surgery, those being debridement (24.1%), minor amputation (37.0%) and major amputation (38.9%). During hospitalization, 78.9% of individuals did not require ICU stay. Hospitalization time varied between three and 59 days, and 78.9% of hospitalized patients did not progress to death, but 43.1% of patients submitted to major amputations died. patients with diabetic foot followed-up have a low socioeconomic profile; most of them underwent surgical procedures, whether major or minor, due to the higher prevalence of infectious diabetic foot and/or non-adherence to non-operative treatment.

Limb Preservation Using Edetate Disodium-based Chelation in Patients with Diabetes and Critical Limb Ischemia: An Open-label Pilot Study.

BackgroundIn 2015, there were 30.3 million patients with diabetes in the US, including 25.2% of people ages 65 or older and 108,000 hospitalizations for non-traumatic amputations. Severe diabetic limb disease includes critical limb ischemia (CLI ) due to an infrapopliteal disease with foot pain and ischemic ulcerations including gangrene. Environmentally acquired toxic metals, such as lead and cadmium, have been associated with cardiovascular disease. Thus, we designed the present unblinded pilot study to determine whether there was a signal of benefit for edetate disodium-based infusions in patients with critical limb ischemia.MethodsThis was an open-label pilot study in 10 patients with diabetes and critical limb ischemia. Each patient received up to 50 edetate disodium-based infusions and was assessed for safety, clinical efficacy, metal excretion, and quality of life. The primary endpoint was to assess the effect of edetate disodium-based therapy plus vitamins in patients with diabetes and infra-popliteal peripheral artery disease presenting with severe CLI and determine if there were improvements in vascular flow parameters.ResultsWe enrolled 10 (60% male) predominantly Caucasian (90%) subjects. The mean age was 75.3 (8.0) years. Smoking was reported by 30%. There were 70% with coronary artery disease (30% had prior coronary artery bypass grafting) and 50% had a prior lower-extremity amputation, three having previous minor amputations and two major amputations. There were no major adverse cardiovascular events during the infusion phase through the one-year follow-up. Patients completing 40 infusions demonstrated complete wound healing and improvement in the quality of life.ConclusionPatients with diabetes and CLI treated with a regimen of edetate disodium-based infusions demonstrated a potential signal of benefit and preliminary evidence of safety. The Trial to Assess Chelation Therapy in Critical Limb Ischemia (TACT3a), a randomized double-blind, placebo-controlled clinical trial now in progress, will further test these findings.