Toe Amputation Research Articles

THU375 A Case Of Right Eye VI Nerve Palsy In A Patient With Uncontrolled Type 2 Diabetes Mellitus

Abstract Disclosure: C. Musurakis: None. A. Havrylyan: None. J.L. Gilden: None. Background: Uncontrolled type 2 diabetes is one of the most common etiologies of acquired VI nerve palsy. Clinical Case: A 40-year-old Mexican female with uncontrolled type 2 diabetes mellitus (DM), diabetic retinopathy and hypertension was admitted to the hospital due to the new onset of diplopia, headache, and right eye pain. Her symptoms started 2 weeks before seeking medical care and had worsened when she looked towards the right. Duration of DM was more than 10 years, with long-standing history of diet and medication non-compliance. She had never taken the prescribed metformin and insulin, nor did she monitor her blood glucose levels at home. Four years previously, she had received laser therapy to both eyes for diabetic retinopathy. Although she denied numbness or tingling of her extremities, she had a left 4th toe amputation in the past, due to infection, which was complicated by chronic osteomyelitis. There was no prior history of cerebrovascular or cardiac disease. Family history was positive for type 2 DM in both parents. Upon hospital admission, HbA1c was 13.2% (n<5.7). BMI 23.7. Vitals: BP 184/104, HR 110. Labs: blood glucose was 439 mg/dL (n=70-99), CO2 23 mEq/L (n=21-31), AG 12 mmol/L (n=4-11), Beta-Hydroxybutyrate/Acetate 2.0 mmol/L (n=0.1-0.3), venous pH 7.36 (n=7.35-7.45). Physical exam: no conjunctival redness, discharge or swelling around the eye, but inability to abduct the right eye laterally. CT head wo contrast: significant atherosclerotic calcifications within the intracranial segment of right vertebral artery and no acute intracranial abnormality. CTA brain w/wo contrast: no obvious mass effect on 6th cranial nerve territories. MRI of brain and orbit w/wo contrast showed no macroscopic anatomic abnormality or impingement on right abducens nerve but showed minimal white matter changes on the centrum bilaterally. She was diagnosed with an isolated VI facial nerve palsy in the setting of longstanding uncontrolled diabetes mellitus and hypertension. She was started with basal-bolus insulin and antihypertensive therapies and recommended to continue this medication regimen after discharge. She was also advised that gradual recovery of vision may be achieved with glycemic control of DM and hypertension. Conclusion: Although the etiology of acquired VI nerve palsy may be idiopathic, or result from hypertension, trauma, multiple sclerosis, neoplasm, CVA, postsurgical complication, or aneurysm, it is also caused by uncontrolled diabetes mellitus combined with hypertension. It is to be noted that when neoplasm or aneurysm is the cause, the history and examination often reveals the presence of other neurologic symptoms or signs. Reference: Patel SV, Holmes JM, Hodge DO, Burke JP. Diabetes and hypertension in isolated sixth nerve palsy: a population-based study. Ophthalmology. 2005 May;112(5):760-3. doi: 10.1016/j.ophtha.2004.11.057. PMID: 15878054. Presentation: Thursday, June 15, 2023

A Step in the Right Direction: Analyzing Differences in Demographics and Mortality in Operative Management of Charcot Neuroarthropathy

Category: Midfoot/Forefoot; Diabetes Introduction/Purpose: Charcot neuroarthropathy (CN) of the foot is a debilitating condition associated with diabetic neuropathy that involves progressive bone and joint destruction. Previous literature suggests the prevalence of CN is between 0.8%-8% in diabetic patients; however, CN diagnosis relies on skilled physician judgment, ultimately making management difficult. Physicians must account for the location, deformity, stage, and presence or absence of infection to appropriately treat CN. Correct diagnosis and treatment is essential to improving patients’ quality of life, but treatment varies with no definitive best-practice guidelines. Here, we provide demographic and all-cause mortality data for patients who underwent arthrodesis, exostectomy, minor amputations, and below-the-knee amputation (BKA), to evaluate the outcomes and characterize the populations managed with surgery for Charcot neuroarthropathy of the foot. Methods: Institutional review board approval was obtained. A database of all patients from 1/1/2000 to 1/31/2022 with CPT and ICD codes indicating a diagnosis of Charcot neuroarthropathy who underwent exostectomy, arthrodesis, and/or amputation was created from the electronic medical record. Demographic and mortality data was collected for the study sample, including date-of- birth, sex, race, and all-cause mortality. Procedure data was also collected, which included date, code, and description. Amputation patients were separated into major and minor; major include transtibial and trans-metatarsal, whereas minor include toe and metatarsal amputations. Descriptive statistics were conducted and single-factor ANOVA and Chi squared tests were used for analysis. Results: Of the 2,066 patients; 557 had arthrodesis, 493 had exostectomy, 681 had minor amputation, and 335 had major amputation. Average age was 58.17 ± 13.8 overall, and 54.8 ± 13.6, 55.0 ± 13.0, 61.6 ± 13.6, and 61.5 ± 13.4 years for arthrodesis, exostectomy, minor amputation, and major amputation, respectively. Females accounted for 56.6% of arthrodeses, 56.8% of exostectomies, 34.5% of minor amputations, and 28.4% of major amputations performed (p < 0.001). Patients were predominantly white in each group and overall, 2.1% were tobacco smokers. Mortality was 10.6%, 11.4%, 33.8%, and 31.9% in the arthrodesis, exostectomy, minor amputation, and major amputation groups, respectively (Figure 1). Conclusion: This is the first report of significant sample size (>2,000 patients) comparing both demographic and mortality between common surgical procedures for Charcot neuroarthropathy. Patients undergoing both minor and major amputations were more likely to be older and male compared to those undergoing less intensive operations. Most importantly, this data demonstrates that patients undergoing amputation have significantly worse mortality (33.8% and 31.9%) than those who undergo arthrodesis (10.6%) and exostectomy (11.4%). Future studies may include an analysis of cause-specific mortality for patients diagnosed with CN to evolve clinical and surgical management.

The Opportunity for Impactful Integration of Vascular and Podiatric Care.

The importance of collaboration between vascular and podiatric surgeons has been well-established. High-level partnerships are integral to the development of multidisciplinary programs and wound care centers, ultimately resulting in improved patient outcomes. This vascular-podiatric integration is not universal, however, and podiatric surgery may not be aligned within a vascular surgery division at many institutions. As one such institution, we reviewed our single-center experience in order to identify opportunities for the impactful integration of vascular-podiatric patient care. Institutional electronic medical records were retrospectively reviewed for all procedures performed by vascular surgeons at a high volume, safety-net academic medical center. Data were collected on all primary and additional procedures, current procedural terminology (CPT) codes, case type (elective, urgent, emergent), surgeon specialty, and date/time of the procedures performed. CPT codes were linked to the Centers for Medicare & Medicaid Services' Physician Fee Schedule to estimate the work relative value unit (wRVU) per procedure. From 2018 to 2022, vascular surgeons performed a total of 12,206 operations, of which 1102 (9.9%) involved podiatric procedures. The most common vascular-performed podiatry procedures performed were toe amputations (38.1%, n = 420), transmetatarsal foot amputations (20.1%, n = 222), and ankle/foot debridement (16.2%, n = 178). Foot/ankle-specific procedures were identified as the primary procedure in 726 (65.9%) cases and as the adjunct procedure in 376 (34.1%) cases. A substantial proportion of podiatric procedures occurred on an urgent (n = 278, 25.2%) or emergent (n = 28, 2.5%) basis. A total of 163 (14.8%) cases occurred after hours (either before 0600 or after 1800), and 133 (12.1%) cases were performed on a holiday or weekend. Procedure-specific revenue included 4243.39 wRVU for primary procedures and 2108.08 wRVU for additional procedures performed. We report our single-center experience in which vascular surgeons provide a significant proportion of podiatric procedures. Our study underscores the potential for integrating podiatric surgeons within a vascular surgical division and presents opportunities for collaboration and enhanced patient care.

Analysis of Lower Extremity Amputations from the SerbVasc Registry.

Peripheral arterial disease (PAD) and diabetes are the major causes of lower extremity amputations (LEAs) worldwide. Morbidity and mortality in patients with LEAs are high with an associated significant burden on the global health system. The aim of this article is to report the overall morbidity and mortality rates after major and minor LEAs from the Serbian Vascular Registry (SerbVasc), with an analysis of predictive factors that influenced adverse outcomes. SerbVasc was created in 2019 as a part of the Vascunet collaboration that is aiming to include all vascular procedures from 21 hospitals in Serbia. Prevalence of diabetes among patients with LEAs, previous revascularization procedures, the degree and the type of foot infection and tissue loss, and overall morbidity and mortality rates were analyzed, with a special reference to mortality predictors. In the period from January 2020 to December 2022, data on 702 patients with LEAs were extracted from the SerbVasc registry, mean age of 69.06±10.63 years. Major LEAs were performed in 59%, while minor LEAs in 41% of patients. Diabetes was seen in 65.1% of the patients, with 44% of them being on insulin therapy. Before LEA, only 20.3% of patients had previous peripheral revascularization. Soft tissue infection, irreversible acute ischemia, and Fontaine III and IV grade ischemia were the most common causes of above-the-knee amputations while diabetic foot was the most common cause of transphalangeal and toe amputations. The infection rate was 3.7%, the re-amputation rate was 5.7%, and the overall mortality rate was 6.9%, with intrahospital mortality in patients with above-the-knee amputation of 11.1%. The most significant intrahospital mortality predictors were age >65 years (p<0.001), chronic kidney disease (CKD) (p<0.001), ischemic heart disease (IHD) (p=0.001), previous myocardial revascularization (p=0.017), emergency type of admission (p<0.001), not using aspirin (p=0.041), using previous anticoagulation therapy (p=0.003), and postoperative complications (p<0.001). The main predictors of increased mortality after LEAs from the SerbVasc registry are age >65 years, CKD, IHD, previous myocardial revascularization, emergency type of admission, not using aspirin, using previous anticoagulation therapy, and postoperative complications. Taking into account high mortality rates after LEAs and a small proportion of previous peripheral revascularization, the work should be done on early diagnosis and timely treatment of PAD hopefully leading to decreased number of LEAs and overall mortality. Mortality after lower limb amputation from the SerbVasc register is high. A small number of previously revascularized patients is of particular clinical importance, bearing in mind that the main reasons for above-the-knee amputations were irreversible ischemia, Fontaine III and Fontaine IV grade ischemia. Lack of diagnostics procedures and late recognition of patients with PAD, led to subsequent threating limb ischemia and increased amputation rates. The work should be done on early diagnosis and timely treatment of PAD in Serbia, hopefully leading to an increased number of PAD procedures, decreased number of LEAs, and lower overall mortality.

An Integrated Management (Ayurveda and Modern Medicine) of Peripheral Vascular Disease with Non-Healing Wound -A Case Study

&#x0D; Peripheral vascular disease (PVD) includes peripheral arterial disease (PAD) and venous disease. PAD is a chronic progressive atherosclerotic disease leading to partial or total peripheral vascular occlusion. In ayurveda it is compared with Vatarakta, classified as a Mahavatavyadhi and as a separate disease in the literature has evoked attention of the Ayurvedic physicians and scholars because of its versatility in symptoms.In this case study, A Case of 54 years old male patient came to OPD of shalyatantra department Parul institute of Ayurveda with complains of wound over right foot, Throbbing pain and discoloration, Swelling over foot, Pus discharge, Fever on /off, unable to walk. with past history Amputation of left 3rd toe- in 2019 and Injury with thorn before 25 days ago. with addiction of tea, alcohol and Tobacco. In general examination patient was k/c/o HTN and DM since 20-25 years.Treatment protocol for this patient given was - 1. Blood sugar management 2. Wound care 3. Saman chikitsa (symptomatic management) 4. Jalokaavacharan 5. Debridement over sole of foot 6. Compartment syndrome (fasciotomy) over sole with 1 vertical line and above 2 vertical line incision 7. Amputation. which provided significant relief in the chief complaints and ultimately prevented major deformity in the form of amputation.Conclusion: Life style of patient improved remarkable. Patient could be able to walk after treatment . Pain and Discoloration decreased.&#x0D;

A CASE STUDY ON DUSTAVRANA

Background: Dusta vrana is the severe complication of untreated ulcers caused by varicose vein, Thromboangiitis Obliterans, atherosclerosis, trauma, etc. vrana with poothi gandha, vivarnata, bahu srava, maha ruja is known as dusta vrana. Such ulcers can be managed with Panchakarma chikitsa by following the bahya and abhyantara shodhana management line. Brief case report: A 75 years old male patient came with pain, swelling and ulcer over the left foot for six months with a history of trauma; he was a known case of Thromboangiitis Obliterans, having undergone amputation of 1st, 2nd, and 4th and 5th toes of left lower limb. The patient had a 60-70 % block of distal Anterior tibial artery and dorsalis pedis artery. Bahya shodhana was done by dhara with gomutra, sphatika jala panchavalkala kwatha and abhyantara shodhana by Manjistadi kshara basti in yoga basti pattern. Conclusion: Significant reduction was seen in slough and pain. The appearance of granulation tissue was observed. Sthanika dhara with gomutra, which has ushna, teekshna, and lekhana properties, removes slough and improves local circulation. Sphatika jala does lekhana and shodhana. Panchavalkala kwatha has vrana ropana property. Manjistadi kshara basti does srotoshodhana and enhances circulation by virtue of its kshareeya guna and acts as rakta prasadaka and vrana ropaka.

Design of a 3D prosthesis of the big toe for amputees due to diabetes mellitus type II and finite element analysis.

At present the percentage of people suffering from type II diabetes mellitus continues to increase. One of the consequences of this disease is the reduction of blood flow in the feet and legs, which could hinder the healing of a sore, in such a way that if a patient with this condition is not treated in time, gangrene can be generated, which could cause the amputation of the first toe, this would affect the gait process, which will not be carried out properly. There are foot prostheses focused on the functionality of the first toe; however, there are no prostheses focused on the specific design of the big toe. Therefore, this work aims to design a prosthesis for the first toe capable of improving gait, likewise a finite element analysis was carried out to ensure that the proposed design is capable of resisting up to a certain body weight. After carrying out the finite element analysis, the maximum and minimum values of displacement and equivalent force are observed with respect to the external forces to which the designed part is subjected.

Should we resect more proximally? Outcomes of toe amputation versus ray resection in patients with infected diabetic ulcers and osteomyelitis. A preliminary study and new treatment algorithm

BackgroundThe treatment of severe diabetic toe infection complicated with osteomyelitis is often surgical. The decision on the level of amputation, when required, is difficult. Very few articles reported comparative outcomes between toe amputation and ray resection, and only in relation to the hallux. The aim of this preliminary report is to record the results of these procedures when performed on all toes. MethodsThis is a comparative retrospective study where the charts of a continuous series of 44 patients (48 procedures) with diabetic forefoot infection were analyzed. Only cases of severe infection with confirmed osteomyelitis were included. Two groups were compared based on the level of amputation: the toe amputation group (at and distal to the metatarsophalangeal joint) and the ray resection group (distal to tarsometatarsal joint). The primary outcomes were defined as osteomyelitis recurrence and re-amputation. ResultsOutcome comparison between toe amputation and ray resection; 47.3 % vs. 51.7 % had a recurrence of their osteomyelitis (p = 0.8), 36.8 % vs. 34.5 % had a re-amputation (p = 0.02). Re-amputation was needed in 25 % of cases following hallux/first ray index procedure while the same was required in 39 % of cases following lateral toes/rays index procedures (p = 0.4). Both primary outcomes were correlated to CDK, smoking and creatinine level. ConclusionsBone infection recurrence and re-amputation are highly prevalent in patients undergoing initial amputation for severe diabetic toe infection. A more aggressive approach in the form of a more proximal level of index amputation might be needed when treating severe toe infections with osteomyelitis in patients with diabetes.

Articular Cartilage After Toe Amputation-Protective Barrier or Source of Infection?: A Retrospective Chart Review.

Digital and ray amputations are common surgical treatments for infected bone and traumatic injuries in the foot. When disarticulated, the exposed articular cartilage can be addressed by either leaving the cartilage cap as a "protective barrier" to infection or by remodeling the exposed bone, removing the cartilage to bleeding bone to better fight infection. Our objective is to provide the first study in the foot to determine whether leaving exposed articular cartilage after toe amputation results in more returns to surgery and delayed healing. We performed a review of the electronic database of patients who had undergone toe amputation and/or metatarsal head amputation with the inclusion criteria of Current Procedural Terminology codes 28825, 28820, and 28810. Excluded patients were those who had multiple osteomyelitic bones or more than one-digit amputations because of the difficulty of controlling the extent of infection. Sixty-three procedures were included in the study (group 1, n = 47; group, n = 216). The time to healing between group 1 (44.0 ± 40.6 days) and group 2 (51.7 ± 48.0 days) was not statistically significant (t test, 0.54392), with reinfection rate being low in both group 1 (8.51%) and group 2 (6.25%). Our study showed a low reinfection rate in both groups (8.51% vs 6.25%). Age, A1C, and BMI were also similar between both groups. The PAD difference (55.3% vs 81.3%) could have contributed to the time to heal (44.0 vs 51.7 days) but not to infection rate between both groups. Tobacco use did not seem to affect time to heal or infection rate between both groups. From our results, there doesn't seem to be a difference in infection rates between each group.

A Subungual Nevoid Melanoma of the Right Hallux from a 65-Year-Old Man: A Case Report.

Nevoid melanoma (NeM) is a rare variant of malignant melanoma characterized by slight cellular atypia, polymorphism, and incomplete maturation. It most frequently occurs on the trunk and arms but rarely on the foot. Here, we report a subungual NeM of the right hallux. A 65-year-old man presented with severe pain of 6 months' duration to his right great toe following self-treatment for an ingrown nail. He was evaluated and treated with debridement of the toenail at an urgent medical center 3 months prior. However, this had not relieved his pain. The patient also noticed discoloration of his distal great toe over the past 3 months. Removal of part of the ingrown nail revealed a pigmented mass extending distally from the matrix. Surgical excision of the mass was performed because of the concern for malignancy. The diagnosis of NeM was based on histologic analysis along with enhanced diagnostic modalities. The patient was further treated with surgical amputation of the great toe and anti-programmed cell death-1 therapy. The patient had no relapse at 1-year follow-up. Nevoid melanoma is a rare variant of malignant melanoma on the toes, which needs to be differentiated from a nevus with atypia, with a variety of modalities including cellular and molecular profiling. The optimal treatment is amputation.

Opioid-Prescribing Approaches-One-Size-Fits-All versus Patient-Centric and Procedure-Focused-Among Podiatric Physicians: A Cross-Sectional Study.

More than half of opioid misusers last obtained opioids from a friend or relative, a problematic reflection of the commonly known opioid reservoir maintained by variable prescription rates and, notably, excessive postoperative prescription. We examined the postoperative opioid-prescribing approaches among podiatric physicians. We administered a scenario-based, anonymous, online questionnaire via an online survey platform. The questionnaire consisted of five patient-foot surgery scenarios aimed at discerning opioid-prescribing approaches. Respondents were asked how many opioid "pills" (dosage units) that they would prescribe at the time of surgery. We divided respondents into two opioid-prescribing approach groups: one-size-fits-all (prescribed the same dosage units regardless of the scenario) and patient-centric and procedure-focused (prescribed varied amounts of opioid dosage units based on the patient's opioid history and the procedure provided in each scenario). We used the Mann-Whitney U test to determine the difference between the opioid dosage units prescribed at the time of surgery by the two groups. Approximately half of the respondents used a one-size-fits-all postoperative opioid-prescribing approach. Podiatric physicians who used a patient-centric and procedure-focused approach reported prescribing significantly fewer opioid dosage units in scenarios 1 (partial toe amputation; -9.1; P = .0087) and 2 (incision and drainage with partial fifth-ray resection; -12.3; P = .0024), which represented minor procedures with opioid-naive patients. Podiatric physicians who used a one-size-fits-all opioid-prescribing approach prescribed more postoperative opioid dosage units regardless of the scenario. Given that the patient population requiring foot surgery is diverse and may have multiple comorbidities, the management of postoperative pain, likewise, should be diverse and nuanced. The patient-centric and procedure-focused approach is suited to limit excess prescribing while defending the physician-patient relationship.

A 15-year follow-up report of an elderly diabetic foot with multiple recurrences leading to toe amputation and thoughts on the model of care for diabetic foot ulcer.

Diabetic foot ulcer (DFU) is one of the most serious complications of diabetes. Elderly diabetic patients are a high prevalence of diabetic foot ulcers, and their high recurrence, disability, and mortality rates impose a heavy economic burden on families and society. This paper reports a case of an elderly patient with a diabetic foot ulcer who was admitted in April 2007 and discharged after recovery from comprehensive diabetic foot treatment. Due to intermittent foot care and lack of home care, the patient's foot ulcers recurred after repeated healing during home rehabilitation, eventually resulting in the amputation of the right bunion. After the patient was discharged from the hospital with an amputated toe, the whole-process seamless management model of "hospital - community - family" was implemented. The hospital provides specialized foot support and guidance, and the community is responsible for daily disease management and referrals. The family is responsible for the implementation of home rehabilitation programs, and family caregivers need to identify and provide feedback on foot abnormalities promptly. As of May 2022, the patient had not experienced ulcer recurrence. This paper reports the whole process of "ulcer development → ulcer healing → ulcer recurrence healing → toe amputation → continuous care management" experienced by the patient in 15 years, aiming to reflect on the significance of the whole-process seamless foot care management model of "hospital-community-family" for diabetic foot ulcer rehabilitation through the case.

Purtscher-like retinopathy in a 19-year-old with maturity-onset diabetes of the young: a case report

BackgroundWe report the first case of Purtscher-like retinopathy in a patient with 17q12 deletion-associated maturity-onset diabetes of the young.Case presentationA 19-year-old diabetic Hispanic male with history of cataracts and toe amputations presented with sudden onset of painless bilateral vision loss for 1 week with no associated trauma. Visual acuity was counting fingers at six feet in both eyes. Dilated retinal examination revealed bilateral peripapillary cotton wool spots and intraretinal hemorrhages, and significant subretinal and intraretinal fluid on optical coherence tomography. Fluorescein angiography revealed arteriolar staining and leakage around the disc with areas of capillary nonperfusion, supporting the diagnosis of Purtscher-like retinopathy. Systemic workup revealed multiple diabetic complications including chronic osteomyelitis of multiple toes, nonhealing diabetic foot ulcers, neurogenic bladder and bowel, and bilateral lower-extremity muscular neuropathies. Genetic evaluation revealed a 17q12 deletion, which is associated with maturity-onset diabetes of the young 5. On follow-up examination, he received a single intravitreal antivascular endothelial growth factor injection in the left eye (off label) for persistent macular edema. Although his retinal edema improved, his visual acuity remained poor.ConclusionsThe presentation of our patient’s multiple diabetic complications along visual symptoms suggests Purtscher-like retinopathy can be a sequela of uncontrolled diabetes. Purtscher-like retinopathy is a rare but possible consideration in diabetic patients who present with acute-onset vision loss.

Percutaneous Partial Bone Excision in the Management of Diabetic Toe Osteomyelitis.

Diabetic foot osteomyelitis affecting the toes is associated with several complications including amputation. Management is variable and include medical therapy alone or coupled with surgery. Removal of infected tissues is a common therapeutic option. However, limited source data are available. This study determines the outcome and complications of percutaneous partial bone excision (PPBE) of infected bone among diabetic patients with toe osteomyelitis. This is an uncontrolled experimental prospective study in diabetic patients who underwent PPBE of infected pieces of bone for toe osteomyelitis in the outpatient setting at a single foot clinic. All participants were followed up until the occurrence of wound healing or amputation. Forty-seven patients (mean ± SD age was 62.8 ± 11.6 years) participated. Forty-four patients (93.6%) had complete healing and 3 (6.4%) required toe amputation. The mean (±SD) wound healing time was 11 (±4.6) (range, 7-22) weeks. Diabetes mellitus type 1 and younger age were significantly associated with increased risk for amputation. PPBE of infected toes in diabetic patients can be performed successfully and safely in the outpatient clinic. It can also improve healing and avoids inpatient stay. Level II, prospective cohort study.

#4893 THE INCIDENCE, RISK FACTORS AND OUTCOMES OF ACUTE KIDNEY INJURY AFTER MINOR LOWER LIMB AMPUTATIONS

Abstract Background and Aims Minor lower limb amputations (toe amputations and/or amputations distal to or through the tarsometatarsal joint), are limb and potentially lifesaving procedures. However, they are associated with serious adverse events including acute kidney injury (AKI). The aim of this study was to determine the incidence of AKI after such interventions, identify potential risk factors and assess impact on patient survival. Method This was a single centre retrospective study involving patients who underwent minor lower limb amputations at Mater Dei Hospital Malta between January and December 2019. Patient and procedure details were obtained from hospital records. Estimated glomerular filtration rate (eGFR) was calculated using the Modification of Diet in Renal Disease formula. Chronic kidney disease (CKD) was defined as per Kidney Disease: Improving Global Outcomes (KDIGO) criteria. AKI was defined using Acute Kidney Injury Network (AKIN) criteria or KDIGO criteria if day 7 serum creatinine was available. Statistical analysis was performed using SPSS Statistics for Windows v21.0 (IBM Corp.). Results A total of 201 patients were included; males 69.7%, mean age 70.4 ±11.5 years, 87.1% had diabetes mellitus, 71.1% hypertension and 26.4% had ischemic heart disease. Pre-existing CKD was identified in 35.8%; 16.4% CKD stage 3a, 13.4% CKD stage 3b, 5.5% CKD 4 and 1 patient CKD 5. The majority (76.1%) underwent single toe amputations. Surgery was performed under loco-regional anaesthesia in 90% of patients, mostly in view of lower limb ulcers (64.7%) or gangrene (29.4%). A cohort of 54 (26.9%) patients received iodine based contrast within 7 days of procedure, including those who underwent bypass surgery (8%) and endarterectomy (4%). The incidence of AKI after minor lower limb amputations using AKIN criteria was 18.9%. An additional 12 patients were identified using KDIGO criteria (24.9%), however KDIGO criteria could only be applied for 123 patients as the rest did not have a day 7 serum creatinine. Most developed stage 1 AKI (18.4%), one patient developed stage 2 AKI and none developed stage 3 AKI using AKIN criteria. Only 1 patient needed temporary haemodialysis having developed AKI after day 3 post-operatively fulfilling KDIGO but not AKIN criteria. Recovery of kidney function occurred in all patients. All-cause mortality at 30 days, 60 days and 18 months (end of follow-up) was 2.0%, 5.5% and 19.9% respectively. None of the deaths were directly related to the AKI-amputation event. Patients who developed AKI, compared to those who did not, were more likely to have an eGFR &amp;lt;45ml/min/1.73 m2 at the time of procedure (39.5% vs. 14.7%, p = 0.001). They were significantly older (73.0 ±10.4 vs. 68.5 ±11.8 years, p = 0.033), and more likely to have underlying chronic obstructive pulmonary disease (COPD) (28.9% vs. 13.5% p = 0.028). Use of loop and/or thiazide diuretics (68.4% vs. 49.1%, p = 0.049), fluoroquinolones (71.1% vs. 52.8% p = 0.047) and/or carbapenems (10.5% vs. 2.5%, p = 0.043) was also more frequent in this group. Use of iodine based contrast within 7 days of procedure did not effect incidence of AKI. Hospital length of stay and all-cause mortality were not significantly higher in patients with AKI. An eGFR &amp;lt;45ml/min/1.73 m2 was established as a strong independent predictor for the development of AKI (odds ratio [OR] 3.24, confidence interval [CI]: 1.40–7.52, p = 0.006), as were use of fluoroquinolones (OR: 3.19, CI: 1.30–7.82, p = 0.012) and day 1 C-reactive protein (CRP) (OR: 1.01, CI: 1.00–1.01, p = 0.009). Cumulative survival censored at the end of follow-up was not significantly lower in patients who developed AKI (log rank: 0.45, p = 0.50). Conclusion In our study, 18.9% of patients developed AKI after minor lower limb amputations using AKIN criteria. One patient required acute haemodialysis. Age, COPD, diuretics, fluoroquinolones and carbapenems were associated with increased incidence of AKI. An eGFR &amp;lt;45ml/min/1.73 m2, day 1 CRP and fluoroquinolone use were independent risk factors for the development of AKI. In this small patient cohort, AKI was not associated with higher all-cause mortality, and none of the deaths were directly related to the AKI-amputation event.

Endovascular Approach to Complex CTO Lesion in a Poor Surgical Candidate

Despite the various uses of endovascular and surgical techniques in management of patients with critical limb ischemia (CLI), traditional open bypass surgery with vein graft was shown to be more durable in the long term in long segment and heavily calcified lesions per the Best-CLI trial. However, patients with extensive cardiovascular risk factors and poor surgical candidates benefit from an endovascular approach. Endovascular revascularization of long segment lesions is complex and often requires the use of multiple unique techniques. Here, we present a case of a 76-year-old male with complex cardiovascular history with history of partial amputation of the right great toe and fifth toe who presented with non-healing ulcers overlying the right first and fifth distal metatarsals. A 76-year-old man with complex cardiovascular history presented with limited mobility, rest pain, and non-healing ulcers overlying the right first and fifth distal metatarsals. Bilateral common femoral artery (CFA) endarterectomy and lower left extremity angioplasty with stenting was done in the past. Doppler studies demonstrated dampened and flat pulses throughout the right lower extremity. Current computed tomography angiography (CTA) showed occlusion of the right superficial femoral artery (SFA) from the ostium to the P3 segment of the popliteal artery with significant calcification. Through ultrasound-guided left CFA access, a .035 guidewire and sheath were advanced into right distal CFA/proximal SFA and with angiogram confirming CTA results. Through the ultrasound-guided right PTA access and double flossing technique, retrograde V-18 guidewire was advanced into the antegrade Navicross catheter positioned within the right CFA. Subsequently, over the guidewire orbital atherectomy and balloon angioplasty were performed from the distal CFA to the proximal ATA region. With use of intravascular ultrasound for vessel diameter measurement, self-expanding stents were placed from the proximal SFA to the distal popliteal region. Final angiogram demonstrated an improvement of luminal diameter with less than 30% stenosis through the right lower extremity. Patient was started on Xarelto and aspirin. Multimodal endovascular technical approaches such as double-crossing flossing technique, controlled antegrade and retrograde tracking (CART) and reverse CART technique, and synapse rendezvous technique help with management of complex long segment occlusions. The case above demonstrates the use of double-crossing flossing technique in successful revascularization of a patient with end-stage CLI.Fig 2View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Outcomes after minor lower limb amputation for peripheral arterial disease and diabetes: population-based cohort study.

Patients with diabetes and peripheral arterial disease are at increased risk of minor amputation. The aim of study was to assess the rate of re-amputations and death after an initial minor amputation, and to identify associated risk factors. Data on all patients aged 40 years and over with diabetes and/or peripheral arterial disease, who underwent minor amputation between January 2014 and December 2018, were extracted from Hospital Episode Statistics. Patients who had bilateral index procedures or an amputation in the 3 years before the study were excluded. Primary outcomes were ipsilateral major amputation and death after the index minor amputation. Secondary outcomes were ipsilateral minor re-amputations, and contralateral minor and major amputations. In this study of 22 118 patients, 16 808 (76.0 per cent) were men and 18 473 (83.5 per cent) had diabetes. At 1 year after minor amputation, the estimated ipsilateral major amputation rate was 10.7 (95 per cent c.i. 10.3 to 11.1) per cent. Factors associated with a higher risk of ipsilateral major amputation included male sex, severe frailty, diagnosis of gangrene, emergency admission, foot amputation (compared with toe amputation), and previous or concurrent revascularization. The estimated mortality rate was 17.2 (16.7 to 17.7) per cent at 1 year and 49.4 (48.6 to 50.1) per cent at 5 years after minor amputation. Older age, severe frailty, comorbidity, gangrene, and emergency admission were associated with a significantly higher mortality risk. Minor amputations were associated with a high risk of major amputation and death. One in 10 patients had an ipsilateral major amputation within the first year after minor amputation and half had died by 5 years.

Highly Differentiated Plantar Verrucous Carcinoma Secondary to Neuropathy Leprosy Ulcer: Case Report and Literature Review

Malignant transformation of chronic trophic ulcers in leprosy is not rare as it had been considered to be in the past. We described a case of a 77-year-old man diagnosed with lepromatous leprosy (LL) fiftyeight years ago, and skin ulcer initially occurred on the sole of his right foot because of neurovascular dystrophic and had been existing during the last five decades, which had gradually grown into a “cauliflower-like” tumor with mild pain and spontaneous bleeding over last 3 years. No improvement was achieved after oral antibiotic and topical treatment. The patient underwent tumor excision and four toes amputation after the diagnosis of verrucous carcinoma based on lesion histopathologic examination. After 1year follow-up, no metastasis was found.

Single Center Experience of RETREG1-related Hereditary Sensory Autonomic Neuropathy in Turkey (P11-8.009)

<h3>Objective:</h3> To describe the clinical characteristics of patients with <i>RETREG1</i> mutations. <h3>Background:</h3> Homozygous loss-of-function mutations in <i>RETREG1</i> result in Hereditary Sensory Autonomic Neuropathy (HSAN) Type 2. Clinical features include variable autonomic disturbances and upper motor neuron features such as brisk tendon reflexes, spasticity, and Babinski sign. <h3>Design/Methods:</h3> Herein, we evaluated the clinical and genetic features of 6 patients from 3 unrelated families with <i>RETREG1</i> mutation at the Neuromuscular Unit of the Istanbul Faculty of Medicine, Istanbul University. <h3>Results:</h3> Four patients were male. The median age of onset was 7.0 ± 2.5 (between 2 and 9 years). Foot ulcerations were the presenting symptom in four patients and walking difficulties in two. All patients were born to consanguineous marriages. In a median disease duration of 23.0 ± 14.4 years, four patients had osteomyelitis, and two had toe amputations. Five patients had a history of painless fractures in different lower extremity bones. Four patients had autonomic nervous system symptoms such as excessive sweating, constipation and orthostatism. Neurological examination of all patients showed spasticity, and brisk tendon reflexes. Muscle weakness in the lower extremities was noted in five patients. Sensory examination showed stocking type hypoesthesia and diminished vibration sensation in all patients. Five patients had pes planus deformity. Nerve conduction studies showed axonal sensory neuropathy in four patients and sensory-motor in two. Two families had homozygous c.433C&gt;T (p.Gln145*), and one had c.826delA (p.S276VfsX8) pathogenic variants in the <i>RETREG1</i> gene. <h3>Conclusions:</h3> In our study, all patients showed signs and symptoms consistent with pain insensitivity. Although shadowed by marked sensory symptoms, motor signs, such as spasticity, and muscle weakness, were also noted in our patients. Considering the autosomal recessive inheritance, new cases with <i>RETREG1</i> mutation are likely to be reported from Turkey, a country with a high rate of consanguineous marriages. <b>Disclosure:</b> Arman Cakar has nothing to disclose. Ms. BAGIROVA has nothing to disclose. Dr. Durmus has nothing to disclose. Prof. UYGUNER has nothing to disclose. Dr. Parman has nothing to disclose.

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

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