Revision Amputation Research Articles

Current Trends in the Management of Lower Limb Amputations

Background: Lower limb amputation is a major but preventable public health problem in a developing nation such as India. It is a burden for the patients as well as their families not only economically but also socially and psychologically. The duration of treatment lasts from a few days to several months and depends on the extent of disease, level of amputation and patient’s comorbid status. The purpose of this study is to outline the demographics, various indications and the complications of lower limb amputations, the newer interventions in the management of lower limb amputations and to evaluate our experience in managing such patients presenting at a tertiary care hospital in South India. Methodology: This is a prospective study done between the period of December 2019 and December 2020 at Sapthagiri Medical College and Research Centre, Bengaluru, Karnataka, India. All patients undergoing lower limb amputation during this time period were included in the study. Results: A total of 50 patients were included into the study. Majority of the patients were males (72%). The most common indication for major limb amputation is peripheral arterial occlusive disease (PAOD) 50% and Diabetic foot in 36.96%. Below knee amputation was the most common procedure performed in 52.17%. The most common additional procedures performed were wound debridement in 23.91%, secondary suturing in 19.57%. Revision amputation rate was 8.7%. Post-operative complication rate was 39.13% and surgical site infection was the most common complication accounting for 17.39%. 8% of the patients underwent vascular interventions which prevented major limb loss. Conclusion: Diabetic foot and PAOD of lower limbs that progressed to gangrene are the most common indications for lower limb amputations, majority of which can be prevented by health education and early presentation. Appropriate management by applying newer trends such as vascular intervention can help in reducing morbidity.

A Look at the Course and Management of Non-Traumatic Upper Extremity Amputation

Objectives Amputation is a major source of morbidity and mortality. Non-traumatic amputations of the upper extremity are less common, and less well-characterized, than the lower extremity. We hypothesize that upper extremity amputations are often associated with multiple returns to the operating room. Methods Twenty-five patients were identified that underwent primary or revision ray or phalangeal amputations for vascular/infectious indications. Chart review was utilized to gather information on additional amputations and demographic information. These groups were compared via chi-squared analysis assuming equal distributions of operations would be present between groups. Results Of the patients with infectious and/or vascular amputations, 56% had a subsequent amputation. Additionally, 23 irrigation and debridement\’s (I and D) were performed before resorting to amputation with 6 patients requiring multiple I and Ds. Post-amputation, 3 patients required I and D, 7 revision amputations at higher levels, 8 amputations of additional ipsilateral digits, and 4 amputations of contralateral digits were performed. After initial amputation, there is a 76% chance of undergoing an additional operation and/or amputation of the upper extremity. A subgroup of these patients with diabetes showed statistically significant increases in ipsilateral amputations following initial amputation. Conclusions Our study shows that patients undergoing digit amputation for nontraumatic indications may require additional upper extremity operations following initial amputation. Subsequent revision amputation at a higher level is common and suggests that more aggressive early amputation may be warranted in these patients. Specifically, diabetic patients are at significantly increased risk of requiring additional digit amputations and may benefit from more aggressive initial surgery at time of presentation.

Contribution of revision amputation vs replantation for certain digits to functional outcomes after traumatic digit amputations: A comparative study based on multicenter prospective cohort

BackgroundTraumatic digit amputations can result in significant impairment. Optimal surgical treatment is unclear for certain digits in various amputation patterns. Our aim was to compare the contribution of revision amputation vs replantation for each particular digit to functional outcomes. Materials and methodsProspective cohort study at three tertiary hospitals was conducted in China. Eligible participants were 3192 patients with traumatic digit amputations enrolled from January 1, 2014, to January 1, 2018. The primary outcome was Michigan Hand Outcomes Questionnaire (MHQ) scores 2 years after initial surgery. Secondary outcome was score on the Disabilities of the Arm, Shoulder, and Hand (DASH). ResultsOf 3192 enrolled patients, 2890 completed the study. Main-effect linear regression showed that participants with replantation of thumb, index, long, and ring (proximal to the proximal interphalangeal [PIP] joint) fingers had significantly better MHQ scores compared to participants with the corresponding finger revision amputation. DASH results were comparable. Finger-finger interaction analyses conducted with multifactor dimensionality reduction (MDR) revealed that the small finger and ring finger had the smallest and greatest interactions with other fingers, respectively. After stratification by amputation level of thumb, index finger, or long finger, linear regression showed that replantation of the ring finger distal to the PIP joint resulted in better MHQ and DASH when the thumb or long finger was also traumatically amputated proximal to the IP/PIP joint. ConclusionsReplantation of the thumb, index, long, and ring (proximal to PIP joint) fingers is preferable to revision amputation, regardless of amputation pattern. Replantation of the ring finger amputated distal to PIP was beneficial only when the thumb or long finger was amputated proximal to IP/PIP joint. Replantation or revision amputation of the small finger was indistinguishable in terms of functional outcome. Future investigations and clinical decisions should take into account the role of finger-finger interactions.

Evaluation of Fingertip Injuries and Modalities of Flap Coverage in the Emergency Settings: A Retrospective Study

Abstract Background Fingertip comprises the nail complex and glabrous pulp, which is richly vascularized and innervated, built around the distal phalanx. The fingertip is commonly affected because it is the most distal part of the hand so it's easily to be injured during athletic participation, occupational activities or in accidents. Various fingertip reconstruction methods are reported as healing by secondary intention, shortening and primary closure, skin grafts and flaps. Flaps are considered when there's a big soft tissue loss or an exposed bone. Complications of fingertip reconstructions are common such as flexion deformity and neuroma. Objective In this study, we assessed and compared the outcomes of different modalities of soft tissue covemge using different flap techniques in cases of fingertip injuries as regalding the incidence of neuroma, necrosis, donor site morbidity, joint stiffness and sensory impairment, together with the patient satisfaction. Patients and Methods We analyzed a retrospective cohort study of 90 patients with 96 fingertip injuries who underwent coverage by various flap techniques at Ain Shams University Hospitals in the period between July 2017 and July 2019. Results The V-Y Advancement flap and the Cross-finger flap were the commonest flaps done in 26 cases (27.1%) and 25 cases (26.0%) respectively. There's a highly statistically significance in the incidence of necrosis in abdominal flap (100%) followed by Moberg flap (46.2%). In addition, there is a statistically significance in the incidence of neuroma in Moberg flap (53.8%). Most of patients who underwent coverage by flap technique were very satisfied by the results (60.4%). Conclusion Many techniques have been described for reconstruction of fingertip trauma including revision amputation, skin grafting, local flaps, distant flaps and free flaps. The treatment choice depends on many factors such as patient preference, culture, resources available and surgeon skills. The goals of reconstruction in fingertip amputations are to cover the defect with a satisfactory cosmetic appearance, establish maximum function and preservation of sensation.

Considerations When Performing Arthrodesis in the Scleroderma Hand.

Hand deformities secondary to scleroderma can limit activities of daily living and be associated with substantial disability. This study aimed to evaluate the outcomes following arthrodesis performed to treat digital contractures secondary to scleroderma. We performed a retrospective review of all patients with scleroderma who underwent arthrodesis by a single surgeon from 2015 to 2020. We collected demographic information, operative variables, and outcomes variables. Our primary outcome was occurrence of any postoperative complication, which we defined to include wound dehiscence, digital ischemia, malunion, nonunion, cellulitis, and osteomyelitis. We calculated descriptive statistics and performed all analyses at the joint level. We identified 9 patients who underwent arthrodesis of 19 joints. All patients were women with a mean age of 55.3 years. At the time of surgery, most patients were taking disease-modifying antirheumatic drugs (DMARDs). Kirschner wires (K-wires) were used in most cases (n = 18), 15 of which were removed uneventfully at an average of 4.8 months after surgery. With a mean follow-up time of 15.4 months, the overall complication rate was 5.3% (n = 1). This patient developed digital ischemia in 1 of 4 operative digits, which became gangrenous and required amputation. Our study suggests that arthrodesis can be performed safely in the scleroderma hand, even when patients are taking DMARDs. Given the uneventful K-wire removal in all joints and the high risk of exposure of buried hardware in this population, we recommend nonpermanent placement of K-wires. Hand surgeons may consider arthrodesis in the scleroderma hand before proceeding to revision amputation.

Single Digit Index Finger Amputation-To Replant or Not?

Background: Single index finger replantation is often listed as a contraindication due to its hindrance of hand function when replanted. Recent studies demonstrate comparable subjective and global functional outcomes for index flexor zone II finger replants versus revision amputations. We therefore sought to identify current opinions of plastic surgery trainees and staff treating single index finger zone II amputations including influential patient and injury characteristics. Methods: With the approval of the Canadian Society of Plastic Surgery, a 17-question survey was sent via email to all listed members on 3 separate occasions. Participation was voluntary and survey responses were compiled and analyzed using SPSS statistical software. Results: Survey response rate was 38.5%. When asked whether the surgeon would replant a single index digit, flexor zone II, sharp amputation, 55.3% of respondents chose "yes," while 44.7% responded "no." Staff (51.5%) were less likely to replant a single index digit amputation. Likelihood of replant dropped substantially in crush (12.4%) and avulsion (17.1%) injury. Smoking was the most likely patient characteristic to change a surgeon's decision (61.9%). Poor range of motion (77.5%) and patient satisfaction (72.5%) were the most frequently listed reasons not to replant. Conclusion: Among Canadian plastic surgeons, there exists disagreement in how single index flexor zone II amputations should be managed. In review of the literature, these notions and previous teaching around replants highlight many inherent surgeon biases with regard to the merit and value of single digit replantation.

QS4: Fat Grafting for the Dysesthetic Digit: A Discussion of Technique And Pilot Data

Purpose:Digital amputation represents a common injury requiring acute hand surgery intervention. These injuries are often complicated by pain, hypersensitivity, dysesthesia, cold intolerance, and contour deficits/pulp atrophy. Many secondary procedures exist to address these concerns; however, they are often limited by undesirable donor site morbidity and/or complex rehabilitation. There is currently no single gold standard for treatment of the dysesthetic digit. Free adipose transfer via lipofilling offers to correct these defects by providing soft, healthy bulk to the amputated site with minimal comorbidity. Here we describe a protocol and preliminary data for providers considering adipose transfer to the dysesthetic digit.Methods:We examined 113 patients who sustained digit amputations between 2010 and 2019. Patients sustained an average of 1.6+/-0.9 amputations per trauma. 13 patients were identified with chronic pain, dysethesia, cold intolerance, or hypersensitivity that persisted after therapy. Controlling for reversible nail bed pathology, 10 patients demonstrated primary chronic dysesthesia.Results:4 of 10 patients presenting for chronic amputation stump dysesthesia elected for fat grafting to the fingertip. All patients reported improved pain and reduced dysesthesia/hypersensitivity post-intervention. 3 patients required no further intervention after one round of grafting; 1 patient underwent repeat grafting. Of the non-grafted group, 66.7% (4/6) progressed to revision amputation. There were no operative revision amputations after grafting.Conclusions:Fat grafting to the fingertip offers a simple, safe, and easily accessible technique to augment soft tissue bulk at the digital stump. Our preliminary data suggests that this may be an effective option to manage digital dysesthesia/hyperesthesia.

Multidisciplinary Team-based Amputee Care: Level Sparing Surgical Techniques and Treatment of Chronic Pain

Careful consideration of a multitude of factors including vascular status, soft tissue envelope, functional status, and goals are integral in determining optimal amputation technique. For patients undergoing a secondary or revision amputation, those same factors, in addition to frequently encountered issues such as poor prosthetic fit, unstable soft tissues, neuromatous pain, and poor overall function should be evaluated. A multidisciplinary team including orthopedics, musculoskeletal radiology, plastic and reconstructive surgery, vascular interventionists, infectious disease, physical medicine and rehabilitation specialists, wound care, physical therapy, and prosthetists are integral to the optimal care of amputees and the potential for level sparing amputation surgery. Ample social support including social work and an amputee support group is fundamental in helping patients navigate primary amputation issues as well as the transitions over time as an amputee learns to live their life optimally.

Study of clinical pattern of limb loss in electrical burn injuries

Introduction: Electrical burn injuries are devastating and cause not only loss of life but also severe disabilities in the form of limb loss. Increase in urbanization, industrialization and overcrowding has led to an increase in electric injuries. Material and methods: The study was prospective in nature evaluating electric burns and studied the pattern of limb loss for a duration of 18 months from October 2016 to March 2018. Parameters recorded were demographic data, clinical data regarding the electrical injuries, complications, and outcomes. Results: Male patients made up 85.3% of cases. Mean TBSA was 24.76 ± 19.18%. Mean age was 27.59 ± 13.73 years. Pediatric patients made up 17%. High voltage burns constituted 68.2 %. Electric contact burn was the most common type making up 49.5% of cases. The most common cause was occupational (38.9%). A fasciotomy was required in 22% of cases with an amputation rate of 38% (209 out of 550). There were 190 major amputations and 106 minor amputations. Overall, the right upper limb amputations were twice as common as the left. The ratio of upper limb: lower limb amputation was 4:1. Fifty patients (23.9%) required revision amputation. The age group 11 to 30 years made up 55.5% of amputations. There was no statistical difference in amputation rates between males (31.31%) and females (41.97%). In patients with TBSA less than 25% amputation rate was 47.77% as compared to patients with more than 25% TBSA, 19.47% (p<0.001). Most amputations occurred due to electric contact burns (74.16%). In the high voltage group, 46.1% underwent amputation vs low voltage group -20.6% (p<0.001). Overall mortality rate was 12.7%. Three hundred patients (55%) had low level of awareness regarding consequences of electric injury. Thirty one percent had medium level of awareness and only 14 % had high level of awareness. There was a significant correlation between education level and awareness in adult patients (p<0.001). Seventy percent of persons with occupational injuries used only footwear and no other protective equipment. Conclusion: Increasing public awareness, safety measures at workplaces are measures that will help reducing electrical burns which reduce limb and life loss.

Comparing digital replantation versus revision amputation patient reported outcomes for traumatic digital amputations of the hand: A systematic review and meta-analysis.

Adults with traumatic digital amputation (TDA) of the hand may be managed with replantation or revision amputation. To date, there is no systematic review evaluating patient reported outcomes (PROs) comparing replantation versus revision amputation. Three databases (MEDLINE, EMBASE, and PubMed) were systematically searched in duplicate from inception until June 13, 2019 using Covidence software. Studies comparing replantation versus revision amputation outcomes were considered for inclusion. Methodological quality was assessed using Methodologic Index for Nonrandomized Studies (MINORS) criteria. Data were pooled in a random-effects meta-analysis model using Revman software. Certainty of evidence was evaluated using Grading of Recommendations, Assessment, Development, and Evaluations (GRADE). Of 4350 studies identified, 12 retrospective cohort studies met inclusion criteria and compared TDA outcomes for replantation (n = 717; 82.9% male; mean age 40.3) versus revision amputation (n = 1046; 79.8% male; mean age 41.7). The overall replantation survival rate was 85.3%. The average MINORS score was 57% (13.75/24). Replantation of the thumb had a superior Michigan Hand Questionnaire (MHQ) score (+11.88, 95% CI [7.78-15.99], I2 = 21%) compared with revision amputation. Replantation of single non-thumb digits had a superior MHQ score (+5.31, 95% CI [3.10-7.51], I2 = 67%) and Disability of Arm, Shoulder, and Hand (DASH) score (-5.16, 95% CI [-8.27 to -2.06], I2 = 0%) compared with revision amputation. Most patients in the meta-analysis were from Asian populations (87.9%). There is low-quality evidence that thumb replantation achieves superior PROs compared with revision amputation, which may be clinically important. Replantation of single non-thumb digits also yielded superior PROs, which is likely not clinically important and based on very low-quality evidence. Future studies with populations outside Asia are required to determine if PROs vary based on cultural differences toward digital amputation.

Replantation

The advent of microsurgery has profoundly impacted the field of hand surgery, providing a means for precise coaptation of vessel and nerve, consequently allowing salvage of amputated parts. Despite these technical advances, the overall goal of management following amputation remains the same – provide the most functional outcome for each patient’s individual occupational and vocational needs. Therefore, it is not only the surgeon’s task to competently perform a replantation when necessary, but also understand in which patients and injuries a revision amputation may ultimately provide a superior outcome. Candidacy for replantation should be resolved by way of a focused history, physical examination, radiographic imaging, and a thorough discussion regarding the need for rehabilitation and potential for secondary procedures. Ultimately, there are very few absolute indications or contraindications for replantation, and each case must be considered on an individual basis. This review contains 3 figures, 4 tables, and 28 references. Key words: amputation, upper extremity, hand, digit, salvage, replant, replantation, revascularization, surgery of the hand

Amputation Revision Surgery – Refining the surgical approach. Ten years of experience and 250 cases, impressions, outcomes, and thoughts for the future

Introduction: The decision for revision amputation surgery requires a multi-disciplinary approach and the evidence on outcome data available in the current literature is limited. The aim of this observational, retrospective study was to investigate in patients undergoing stump revision, whether factors such as pathology and reason for the revision surgery affect surgical ‘success’ rates as primary outcomes. Secondary outcomes of interest include rehabilitation outcomes and complication rates.Methods: From December 2008 to November 2018, 250 amputation revision procedures were performed at our centre. Surgical and rehabilitation outcomes and indication for revision surgery were measured for each patient.Results: There was an overall surgical success rate of 81% and an overall rehabilitation success rate of 63%, with variable outcomes related to the indication for surgery. Revisions for bony pathology had excellent results from a surgical perspective (100%) and good results from a rehabilitation perspective (71%). Revisions for soft tissue pathology and neuroma had satisfactory results from a surgical perspective (81% and 74% respectively) and rehabilitation perspective (56% and 71% respectively). Surgical success rates for those undergoing revision surgery due to non-neuroma pain were poor.Conclusions: We found that revision surgery for defined anatomical abnormalities, such as bone pathology or neuromata are associated with good outcomes. Surgical techniques, specifically related to the management of neuromas are continuing to develop, with promising results from the application of targeted muscle reinnervation (TMR) in the treatment of neuromata. The primary amputation surgeon should exercise caution when considering compromising bone length for soft tissue or skin coverage, as revision surgery can address the excision of skin graft or refashioning of the soft tissue envelope at a later stage. Careful patient selection is key to ensure we advocate offering our patients the right operation at the right time, for the right pathology.

Association of Interfacility Transfer and Patient and Hospital Characteristics With Thumb Replantation After Traumatic Amputation

Given that 40% of hand function is achieved with the thumb, replantation of traumatic thumb injuries is associated with substantial quality-of-life benefits. However, fewer replantations are being performed annually in the US, which has been associated with less surgical expertise and increased risk of future replantation failures. Thus, understanding how interfacility transfers and hospital characteristics are associated with outcomes warrants further investigation. To assess the association of interfacility transfer, patient characteristics, and hospital factors with thumb replantation attempts and success. This cross-sectional study used data from the US National Trauma Data Bank from 2009 to 2016 for adult patients with isolated traumatic thumb amputation injury who underwent revision amputation or replantation. Data analysis was performed from May 4, 2020, to July 20, 2020. Interfacility transfer, defined as transfer of a patient from 1 hospital to another to obtain care for traumatic thumb amputation. Replantation attempt and replantation success, defined as having undergone a replantation without a subsequent revision amputation during the same hospitalization. Multilevel logistic regression models were used to assess the associations of interfacility transfer, patient characteristics, and hospital factors with replantation outcomes. Of 3670 patients included in this analysis, 3307 (90.1%) were male and 2713 (73.9%) were White; the mean (SD) age was 45.8 (16.5) years. A total of 1881 patients (51.2%) were transferred to another hospital; most of these patients were male (1720 [91.4%]) and White (1420 [75.5%]). After controlling for patient and hospital characteristics, uninsured patients were less likely to have thumb replantation attempted (odds ratio [OR], 0.61; 95% CI, 0.47-0.78) or a successful replantation (OR, 0.64; 95% CI, 0.49-0.84). Interfacility transfer was associated with increased odds of replantation attempt (OR, 1.34; 95% CI, 1.13-1.59), with 13% of the variation at the hospital level. Interfacility transfer was also associated with increased replantation success (OR, 1.23; 95% CI, 1.03-1.47), with 14% of variation at the hospital level. In this cross-sectional study, interfacility transfer and particularly hospital-level variation were associated with increased thumb replantation attempts and successes. These findings suggest a need for creating policies that incentivize hospitals with replantation expertise to provide treatment for traumatic thumb amputations, including promotion of centralization of replantation care.

Türkiye’de ampütasyonların endikasyonları, komplikasyonları ve revizyonları

Aim: The objective of this study is to determine the incidence of indications for amputations, major amputation related complications and revision numbers in Level I trauma center; which consists burn care unit, hyperbaric oxygen unit and hand surgery department in Turkey.&#x0D; Materials and Methods: Amputation procedures were retrospectively reviewed and evaluated according to the amputation levels, etiology, and demographic data. Major complications that require surgical intervention, type of surgical intervention for these complications and interval between index surgery and first complication related surgery were recorded. Re-amputations were evaluated according to interval between index and revision surgery, revision indication, and revised level.&#x0D; Results: A total of 558 amputations were performed for 476 patients (367 male, 109 female) in five-year period. The most common indication of amputation was diabetic complications, 250 amputations for 215 diabetic patients (44.8%) were performed. Peripheral arterial disease and trauma were the second and third common indications. The most common indication for upper extremity amputation was trauma. The most common amputation levels were hand amputations in the upper extremity, and below-knee amputation in the lower extremity. Fifty-seven of the surgical procedures were re-amputations and the interval between index surgery and revision amputation was 5.0±15.8 months. The most common indication for revision amputation was diabetic complications. Complications that required surgical intervention were infection in 46 patients, local soft tissue necrosis in 28 patients, and wound dehiscence in 2 patients.&#x0D; Conclusions: This is the first study investigating amputation etiology from high capacity hospital in capital city of Turkey that can demonstrate the whole country. The most common indications in this study were diabetic foot, PAD, and trauma as it is in developed countries. The results of this study can be the first step of multicenter epidemiological studies about amputations.

Modified Oblique Triangular Neurovascular Island Flap Technique to Prevent the Development of Hooked Nail Deformity.

Hooked fingernail deformity can develop after any type of fingertip amputation. A more proximal amputation is associated with a higher probability of developing hooked fingernails. Proximal fingertip amputations with very short remaining nail beds are recommended for revision amputation with nail bed ablation. This procedure eliminates the possibility that the patient may have a functional nail. When the nail matrix is still retained, an oblique triangular neurovascular island flap may preserve the nail and digit length. At our institution, the modified oblique triangular neurovascular island flap is routinely used for patients who underwent fingertip amputation with a retained nail bed. These modifications may aid in preventing the development of hooked nail deformity and creating a round pulp contour without the need for fixation, composite grafts, or distant soft tissue transfer.

Intraoperative Site Vancomycin Powder Application in Infected Diabetic Heel Ulcers With Calcaneal Osteomyelitis.

Intraoperative site application of vancomycin powder has been found to be beneficial in foot and ankle surgery among diabetic patients undergoing elective procedures. However, there are concerns for risks such as selection of multidrug-resistant bacteria, local tissue irritation, and increased wound complications. The clinical utility of intraoperative site vancomycin powder application in infected diabetic foot ulcer surgery is unknown. We aimed to report the clinical outcomes of partial or total calcanectomy for diabetic heel ulcer (DHU) and determine if intraoperative site application of vancomycin powder placement at the time of wound closure leads to improved clinical outcomes. A current procedural terminology query (CPT 28120: partial excision bone; talus or calcaneus) was run that identified 35 patients representing 38 calcanectomies performed secondary to infected DHU with calcaneal osteomyelitis. An initial group of 25 patients did not receive intraoperative site vancomycin powder, whereas the following 13 cases received intraoperative site vancomycin powder. Demographics, clinical characteristics, comorbidities, operative complications, unexpected return to the operating room (RTOR), and revision amputations were recorded for each patient. Average follow-up was 26.1 (6.5-51.6) months. There was a significantly higher rate of RTOR among the vancomycin powder cohort (VANC) relative to the no-vancomycin cohort (No-VANC) (84.6% vs 36.0%, P = .038). Of the 13 VANC patients, 3 healed the wound and did not require RTOR, 2 underwent below-knee amputation (BKA), 2 received irrigation and debridement (I&D), and 6 underwent revision or total calcanectomies. Of the 25 No-VANC patients, 17 healed the wound, 4 underwent BKAs, 1 received an I&D, and 2 required revision or total calcanectomy. There was a trend toward increased rates of revision calcanectomy and BKA among the VANC cohort, but this was not statistically significant (61.5% vs 28.0%, P = .079). Partial or total calcanectomies for the management of infected DHU resulted in an overall healing rate of 50.0%, unplanned RTOR and revision calcanectomy rate of 39.5%, and a limb salvage rate of 82.6%. We found no clinical benefit with the intraoperative site application of vancomycin powder. Level III, retrospective case control study.

Patient profiles of below knee-amputation following road traffic accidents – An observational study from a level 1 trauma centre in India

BackgroundPrimary amputation below the level of the knee joint is the most frequently performed amputation following trauma; however, data about incidence, patient profiling, and causative factors are seldom available in India. ObjectiveTo evaluate the profile and incidence of trauma-related amputations below the level of the knee joint at a level 1 trauma center. MethodsAn observational study over six months was conducted at a level 1 trauma center of north India. Epidemiological data such as age, sex, occupation, socioeconomic status, mechanism of injury, time of surgery, single or staged procedure, and complications were recorded from the admission files. Observations125/3047 (4.1%) trauma patients underwent amputation, of which 32.8% (41 of 125) had amputation below the level of the knee joint. Unilateral transtibial amputation was the most common (85.3%) involving 40/41 males with a mean age of 37.2 years of low socioeconomic status. Road traffic accidents were the most common cause (85.36% of cases). 39 of 41 cases presented within 24 h of injury and underwent surgery within 24 h of presentation. Secondary surgery was needed in 24.4% of the patients and revision amputation was done in only 2.4% (n = 1/41). No patient developed medical complications, and the average hospital stay was 8.7 days with a range from 2 to 14 days. ConclusionWe have documented a significant amputation rate in trauma cases (4.1%) reflecting on the seriousness of patients seen at our center. Most patients are young males at the peak of their productive lives, and from low socioeconomic status. Road Safety is essential, and specialized services for the amputees may be the need of the hour.

Comparing Digital Replantation Versus Revision Amputation Patient-reported Outcomes for Traumatic Digital Amputations of the Hand: A Systematic Review and Meta-analysis

Purpose Adults with traumatic digital amputation (TDA) of the hand may be managed with replantation or revision amputation. To date, there is no systematic review evaluating patient reported outcomes (PROs) comparing replantation versus revision amputation. Methods Three databases (MEDLINE, EMBASE, and PubMed) were systematically searched in duplicate from inception until June 13, 2019 using Covidence software. Studies comparing replantation versus revision amputation outcomes were considered for inclusion. Methodological quality was assessed using Methodologic Index for Nonrandomized Studies (MINORS) criteria. Data were pooled in a random-effects meta-analysis model using Revman software. Certainty of evidence was evaluated using Grading of Recommendations, Assessment, Development, and Evaluations (GRADE). Results Of 4350 studies identified, 12 retrospective cohort studies met inclusion criteria and compared TDA outcomes for replantation (n = 717; 82.9% male; mean age 40.3) versus revision amputation (n = 1046; 79.8% male; mean age 41.7). The overall replantation survival rate was 85.3%. The average MINORS score was 57% (13.75/24). Replantation of the thumb had a superior Michigan Hand Questionnaire (MHQ) score (+11.88, 95% CI [7.78-15.99], I2 = 21%) compared with revision amputation. Replantation of single non-thumb digits had a superior MHQ score (+5.31, 95% CI [3.10-7.51], I2 = 67%) and Disability of Arm, Shoulder, and Hand (DASH) score (-5.16, 95% CI [-8.27 to -2.06], I2 = 0%) compared with revision amputation. Most patients in the meta-analysis were from Asian populations (87.9%). Conclusion There is low-quality evidence that thumb replantation achieves superior PROs compared with revision amputation, which may be clinically important. Replantation of single non-thumb digits also yielded superior PROs, which is likely not clinically important and based on very low-quality evidence. Future studies with populations outside Asia are required to determine if PROs vary based on cultural differences toward digital amputation.

Intra-surgical Site Vancomycin Powder Application in Infected Diabetic Heel Ulcers with Calcaneal Osteomyelitis

Category:Diabetes; HindfootIntroduction/Purpose:The treatment of diabetic heel ulcers (DHU) with osteomyelitis is challenging, and dismal clinical results have been reported after calcanectomy, with reported revision rates of 0-63.5%. The topical application of vancomycin powder has reported to be beneficial in foot and ankle surgery amongst diabetic patients. However, no studies have examined the efficacy of intra-surgical site vancomycin powder application in DHU surgery. There are potential risks of intra-surgical site vancomycin powder application, such as the selection of gram-negative and multi-drug resistant bacteria, and increased wound complications. Thus, we aimed to 1) assess the clinical outcomes of calcanectomy for DHU and 2) investigate the clinical efficacy of intra-surgical site vancomycin powder application in patients who underwent partial- or total calcanectomies performed to treat infected DHU with osteomyelitis.Methods:This study was approved by our institution’s Research Subjects Review Board. Subjects were identified utilizing current procedural terminology code 28120 (Partial excision bone; talus or calcaneus) for partial or total calcanectomies performed at our academic institution. Thirty-eight calcanectomies performed secondary to DHU with osteomyelitis were identified. Patient demographics (age, sex, gender, body mass index), preoperative labs (hemoglobin A1c, blood glucose, white blood cell, erythrocyte sedimentation rate, C-reactive protein, serum creatinine, hemoglobin), ASA Class, peripheral arterial disease assessed by ankle-brachial index, Charleston Comorbidity Index, and intra-surgical site application of vancomycin powder were recorded. Duration of follow-up, type and quantity of systemic antibiotics administered during surgery, surgical complications, and return to the operating room (RTOR) were also recorded. There were two cohorts: those whose surgical wound was closed without vancomycin powder (initial 25 patients; ‘novancomycin’ group) versus those whose surgical site was closed with vancomycin powder (later 13 patients; ‘vancomycin’ group).Results:The average follow-up was 26.1 +- 15.0 months. Surgical pathology confirmed negative bone resection margins for all patients. Nineteen patients required an unplanned RTOR (50.0%). A revision amputation was performed in fifteen extremities (39.5%). Thirteen patients received intrawound vancomycin at closure, and 25 did not. Nine of thirteen (69.2%) patients who received vancomycin powder required RTOR. This includedTwo below-knee amputations (BKA), two irrigation and debridements (I&D), and six revision or total calcanectomies. There was a significantly higher rate of RTOR in the vancomycin cohort relative to the no-vancomycin cohort (76.9% vs 36.0%, p=0.038). Of the 25 no-vancomycin group, 17 did not return to the OR, 4 underwent BKA, 1 had I&D, and 2 required revision or total calcanectomy.Conclusion:In our cohort, calcanectomy performed for the surgical management of DHU with osteomyelitis yielded a high rate (50%) of unplanned follow-up procedures. Intra-surgical site vancomycin powder application during wound closure after calcanectomy did not result in clinical benefit and is likely unnecessary. The risk and benefit profile of intra-surgical site vancomycin powder application for diabetic foot infection surgery needs to be further investigated.

The Impact of a Limb Preservation Service on the Incidence of Major Amputations for All Indications at a Level I Trauma Center

Multidisciplinary limb preservation services (LPS) have improved the care of patients with limb-threatening vascular disease. However, the impact of an LPS on major amputations for nonvascular etiologies is unknown. We sought to characterize the trends in major amputations performed at a level I trauma center following the institution of an LPS. A retrospective review of all patients undergoing amputation at a level I trauma center from January 2009 to December 2018 was performed. Patients were divided into 2 cohorts: those undergoing amputation pre-LPS (2009-2013) and post-LPS (2014-2018). Major amputations were defined as any amputation at or proximal to the below-knee level. Indications for amputation included chronic limb-threatening ischemia (CLTI), acute limb ischemia (ALI), trauma, infection, and revision amputations. During the study period, 609 major amputations were performed, 490 pre-LPS and 119 post-LPS, representing a 76% reduction. Reductions were seen for every indication, including trauma (95%), ALI (90%), chronic infection (83%), revision (79%), CLTI (68%), and acute infection (62%). Although previous work has validated the role of an LPS in advanced vascular disease, its value extends beyond vascular disease alone. The drastic reductions seen in the number of amputations performed for a variety of indications, including trauma and diabetic foot infections, further validate the use of a multidisciplinary LPS.