Traumatic Lower Limb Amputation Research Articles

Evaluation of short-term functional mobility outcomes in patients with traumatic lower limb amputations: A prospective cohort study in India

BackgroundTraumatic amputation of the lower limb is a significant life-changing event. It is associated with substantial functional disability. ObjectiveTo assess the serial improvement in functional mobility outcomes after the rehabilitation provided to traumatic unilateral lower limb amputee (TULLA) over 6 months of follow-up. MethodsIt is a prospective observational cohort study including 106 TULLA performed in a tertiary care trauma center in North India from January 2021 to December 2021. Patients were followed up at 2 weeks, 3 months and 6 months post-surgery in the focused amputee clinic, where functional mobility care was provided by physical rehabilitation and prosthesis application and patients were evaluated using the Locomotors Capabilities Index (LCI-5) and L-Test of functional mobility. ResultsThere was a significant improvement in LCI-5 and L-Test from discharge to follow-up. The mean overall LCI-5 scores were 14.68 ± 6.56, 28.29 ± 9.04 and 42.77 ± 8.94 at 2 weeks, 3 months and 6 months respectively. The mean L-test for overall individuals with limb loss (N = 100) at discharge, 2 weeks, 3 months and 6 months were 178.41 ± 49.62, 126.98 ± 37.76, 98.39 ± 30.09 and 72.82 ± 21.03 respectively. Further, a subgroup analysis showed a significant improvement in LCI-5 and L-test in individuals with above-knee and below-knee limb loss with prostheses compared to those without prostheses. ConclusionOur multidisciplinary approach helps to improve functional mobility outcomes among TULLA. Focused amputee clinics are the need of the hour to achieve successful functional mobility following amputation.

Developing an exercise intervention to minimise hip bone mineral density loss following traumatic lower limb amputation: a Delphi study

ObjectiveTo elicit expert opinion and gain consensus on specific exercise intervention parameters to minimise hip bone mineral density (BMD) loss following traumatic lower limb amputation.MethodsIn three Delphi rounds, statements were...

What Are the Factors Associated With Revision Surgery on the Residual Limb and Functional Results in Patients With Posttraumatic Lower Limb Amputations?

Lower limb amputations performed after trauma are associated with a high risk of revision surgery. While the factors influencing revision surgery in the upper limbs have been studied, no studies have analyzed these factors in the lower limbs. Existing explanations for these revision surgeries are unclear, often leaving patients uninformed. Surgeons also lack the tools to explain the factors that influence repeat operations to patients. Therefore, the aim of this study was to provide surgeons with some answers so they can inform their patients undergoing posttraumatic lower limb amputation, whether military or civilian. (1) What was the survivorship of the initial amputation free from any revision surgery? (2) What patient- and injury-related factors were associated with revision amputation? (3) Do these factors influence functional outcomes in these patients? A single-center, retrospective study was conducted between January 2010 and February 2020 on patients who had undergone traumatic lower limb amputation. Between January 2010 and February 2020, 322 patients underwent amputation or were followed up at Percy Military University Hospital. Thirty-one patients had undergone amputation at another center, 178 had undergone amputation for nontraumatic reasons, and 27 patients had only upper limb amputations. Of those remaining, 1 died before 6 months, and 6% (5 of 86) were not fitted with a prosthesis, leaving 99% (85 of 86) for survivorship free from revision analysis and 93% (80 of 86) for functional endpoints analysis in this retrospective study at a median of 6.5 years (IQR 5 to 9) following the index amputation. The median age at the time of amputation was 31 years (IQR 26 to 52), 85% (72 of 85) of patients were men, and 31% (26 of 85) were military personnel. Revision surgery was defined as surgery performed at or after 6 months to ensure that the residual limb was healed and fitted with a prosthesis. Revision procedures performed before 6 months (median 2 [IQR 0 to 7]) were considered as part of the initial residual limb formation surgery. We performed Kaplan-Meier survivorship analysis for the time free from revision amputation from 6 months after amputation. We considered the competitive risk of death using a Fine-Gray model by an ascending stepwise procedure. To answer our third research question, we performed a chart review and assessed patients' use of prostheses and assistive devices and the percentage of patients who returned to work. An ordinal logistic regression was used to analyze the factors influencing functional outcome using an ascending stepwise procedure. A total of 85 patients (94 limbs) were included, of whom 25 (27 limbs) underwent a revision surgery on the residual limb > 6 months after amputation. Kaplan-Meier survival estimates indicated that 5 years after the initial amputation 64% (95% confidence interval 53% to 77%) of the patients remained free from revision surgery on their residual limb. Factors associated with increased odds of revision amputation were smoking (subdistribution HR 2.6 [95% CI 1.2 to 5.8]; p = 0.02) and an age of > 50 years (subdistribution HR 0.3 [95% CI 0.1 to 0.8]; p = 0.01). Ninety-four percent (80 of 85) of patients were fitted with prostheses, and 40% (32 of 80) of patients used material or human assistance for simple activities of daily living. Seventy-one percent of patients (57 of 80) had returned to work. Ordinal logistic regression revealed an association between preinjury sports activity and the absence of need for assistance in daily activities (OR 9 [95% CI 2.9 to 31.8]; p < 0.001). Smoking appeared to be an associated risk factor for residual limb revision surgery in posttraumatic lower limb amputations and is potentially modifiable. Being at least 50 years of age seemed to be associated with a lower incidence of revision surgery, which is probably linked to lower functional demands made on limbs beyond this age. Our study showed a remarkable rate of fitting with a prosthetic device, with an improved functional result if the patient was athletic before the trauma. These results provide more precise information on the care pathway to be considered for each patient. A study with a much larger sample would make it possible to assess the risk factors for the occurrence of each complication involving revision surgery. Level III, therapeutic study.

Clinical Characteristics Associated with the PLP-PLS Index, a New Potential Metric to Phenotype Phantom Limb Pain.

Phantom limb pain (PLP) is highly prevalent after amputation. However, the influence of non-painful sensations (PLS) remains unclear. This study examines the PLP-PLS index as a novel tool to differentiate PLP from PLS and explores the association of clinical factors with the index. We conducted a cross-sectional analysis of baseline data from 112 participants in a previous factorial trial in patients with unilateral traumatic lower limb amputation. Linear regression models were used to examine the associations between the index and various demographic, psychological and clinical factors. Logistic and Poisson regression, and e-value calculation were utilized for sensitivity analyses. Adjusted multivariable linear regression models demonstrated significant associations of phantom movement sensation (β: -1.532; 95% CI: -2.615 to -0.449; p = 0.006) and time since amputation (β: 0.005; 95% CI: 0.0006 to 0.0101; p = 0.026) with the PLP-PLS index. These findings were confirmed by multivariable logistic regression (phantom movement sensation OR: 0.469; 95% CI: 0.200 to 1.099, p = 0.082; time since amputation OR: 1.003; 95% CI: 1.00003 to 1.007; p = 0.048) and sensitivity analyses. Time since amputation and phantom movement sensation likely reflect distinct phenotypes and potential mechanisms for PLP and PLS. The PLP-PLS index is a promising clinical tool for selecting therapies to prevent/treat PLP and for measuring treatment effects to modulate phantom pain. These findings emphasize the importance of understanding the mechanisms underlying PLP and PLS for improving clinical management and guiding future research.

Long-term health-related physical fitness following traumatic lower limb amputation: Experience from low-resource military community settlements

Long-term health-related physical fitness following traumatic lower limb amputation: Experience from low-resource military community settlements

An Evaluation of Phantom Pain among Traumatic Lower Limb Amputees in Lahore

Background: Amputation is the surgical removal of all or part of an irreparably damaged limb due to injury or disease. Trauma is the leading cause of lower limb amputation in Pakistan. Phantom limb pain (PLP) is a common and distressing complication following amputation, affecting the quality of life and functional outcomes. Objective: The primary objective of this study was to assess the occurrence and intensity of phantom limb pain in patients who had undergone lower limb amputation due to traumatic causes in Pakistan. Methods: A descriptive cross-sectional study was conducted over six months, involving 73 patients who had undergone lower limb amputation due to trauma. The study was carried out in Ghurki Trust Teaching Hospital, Sheikh Zayed Hospital, and Mayo Hospital. Patients aged 20-45 years, with amputations performed within one year, were included. Exclusion criteria were non-traumatic amputations and amputations older than one year. Non-probability convenience sampling was used. Participants were divided into three groups based on the level of amputation: hip disarticulation (n=12), transfemoral (n=28), and transtibial (n=33). Phantom limb pain was assessed using the Numeric Pain Rating Scale (NRPS), an 11-item scale ranging from 0 (no pain) to 10 (severe pain). Data were analyzed using SPSS version 25, and descriptive statistics were presented in tables and graphs. Ethical approval was obtained from the Ethics Committee of Lahore College of Physical Therapy (ERC-LCPT/298/2019). Written informed consent was obtained from all participants. Results: The study found that 83.6% of the participants experienced phantom limb pain. Among the hip disarticulation group, 91.7% reported PLP, with a mean NRPS score of 7.3. In the transfemoral group, 89.3% experienced PLP, with a mean NRPS score of 6.8. In the transtibial group, 75.8% reported PLP, with a mean NRPS score of 5.4. The association between the level of amputation and the presence of PLP was significant, with p-values of 0.003 for hip disarticulation, 0.000 for transfemoral, and 0.001 for transtibial amputations. Conclusion: Phantom limb pain is a prevalent and significant issue among patients with traumatic lower limb amputations in Pakistan, with varying intensity across different levels of amputation. These findings underscore the need for targeted pain management strategies and comprehensive rehabilitation programs to address PLP and improve the quality of life for amputees.

Effect of Adding Virtual Reality Training to Traditional Exercise Program on Pain, Mental Status and Psychological Status in Unilateral Traumatic Lower Limb Amputees: A Randomized Controlled Trial.

Background: Lower limb amputation is an emotionally devastating condition that causes a complete change in the quality of life, may lead to phantom limb pain in most of the cases, and puts the individual in a high risk of developing psychological disorders. The objective of this study is to evaluate the consequence of adding virtual reality (VR) to a traditional exercise program on pain, mental status, and psychological status in traumatic unilateral lower limb amputees (LLAs). Methods: Thirty-two traumatic LLAs were randomly assigned into two equal groups in this randomized control trial. Participants did accomplish a postfitting exercise program at least 6 months before enrolment; the control group (CG) underwent a traditional rehabilitation program, and experimental group (EG) had the same program, in addition to VR training. Data were collected before and after 6 weeks of intervention using visual analog scale (VAS) for pain, Beck's depression inventory (BDI) for depression, and 12-item short form survey for mental health summary (MHS) and physical health summary (PHS). Results: Thirty-two amputees (29 males and 3 females) were included with mean age in CGs and EG (27.6 ± 4) and (27.6 ± 7.6) years, respectively. Postintervention, the VAS score was significantly reduced only in EG (P = 0.003). Both groups showed significant improvement in BDI, MHS, and PHS (P < 0.05). However, the EG showed a superior significance in BDI and MHS scores (P < 0.05). There was no significance between groups in PHS score. Conclusion: Adding VR to conventional training is beneficial in decreasing pain and in improving depression and MHS of traumatic unilateral LLAs.

Primary Motor Area Activity in Phantom Limb Imagery of Traumatic Unilateral Lower Limb Amputees With Phantom Limb Pain.

Estimates of the worldwide increase in amputees raises the awareness to solve long-standing problems. Understanding the functional brain modifications after a lower limb amputation (LLA) is one of the first steps towards proposing new rehabilitation approaches. Functional modifications in the central nervous system due the amputation could be involved in prosthesis use failures and Phantom Limb Pain (PLP), increasing costs and overwhelming the health services. This study analyses orphan primary motor area (M1-Orphan) hemodynamic and metabolic behaviour, which previously controlled the limb that was amputated, in comparison with the M1-Preserved, responsible for the intact limb (IL) during phantom limb imagery moving during Mirror Therapy (MT), compared to Isolated Intact Limb Movement Task (I-ILMT). A case-control study with unilateral traumatic LLA with moderate PLP who measured [oxy-Hb] and [deoxy-Hb] in the M1 area by Functional Near InfraredSpectroscopy (fNIRS) during the real (I-ILMT) and MT task. Sixty-five patients, with 67.69% of men, young (40.32 ± 12.91), 65.63% amputated due motorcycle accidents, 4.71 ± 7.38 years ago, predominantly above the knee (57.14%). The M1 activation in the orphan cortex did not differ from the activation in the intact cortex during MT (P > .05). The perception of the Phantom limb moving or intact limb moving is metabolically equivalent in M1, even in the absence of a limb. In other words, the amputation does not alter the brain metabolism in control of phantom movement.

653 Evaluating the Effectiveness of Osseointegration for Traumatic Lower Limb Amputations: A Narrative Review

Abstract Aim Major trauma to the limbs often results in amputation and can have a debilitating effect on an individual’s physical and psychological health. Currently, the conventional management to remediate the consequences of limb amputation is a Traditional Socket-mounted Prosthesis (TSP) for the affected limbs. However, its use is associated with various complications, such as skin ulcers, increased fracture risk, nerve pain, and heterotopic ossification. To address this, a novel approach known as osseointegration; a procedure in which an artificial implant is surgically integrated and anchored into residual bone, has been developed. This narrative review aims to primarily evaluate the efficacy and functional outcomes of lower limb osseointegration compared to TSP. Method A literature review was performed to identify and analyse studies addressing the efficacy, functional outcomes, and complications of lower limb osseointegration prosthesis compared to TSP. Studies were summarised according to type of osseointegration prosthesis, number of surgeries required, and amputation location. Data on efficacy, functional outcomes, and complications of patients with osseointegrated prosthesis was extracted. Results Six studies were chosen for critical analysis of the primary and secondary aims. All studies reported osseointegration conferred significant improvements in mobility, walking capability, walking speed, quality of life, prosthesis comfortability, prosthetic control, and prosthetic use. Complications reported were mild infection, phantom limb pain and periprosthetic fractures although incidences were rare. Conclusions Osseointegration has been shown to increase prosthetic use, improve confidence, walking ability, and mobility. Complications are mild and easily treated. Overall, there is sufficient evidence to suggest osseointegration could become standard management for lower-limb amputations.

Impact of Yoga Intervention in Lower Limb Amputees following Trauma in Relation to Behavior and Quality of Life: A Randomized Controlled Trial.

Yoga is an emerging intervention causing improvement in physical, mental, and spiritual well-being. Its role in improving outcomes in patients with amputation was investigated. Patients with traumatic lower limb amputation (n = 50) were enrolled and randomized to the Yoga group (n = 26) against control (n = 24). Sociodemographic details, quality of life (QOL) (World Health Organization QOL-BREF), Depression anxiety stress scale (DASS), Rosenberg self-esteem scale, and amputee body image score were applied at baseline, 6,-18 weeks of amputation. Sociodemographic and clinical variables were comparable between groups. At 18 weeks, the Yoga group had better QOL (P = 0.005) than the control group. Symptoms of depression (0.02) and anxiety (<0.001) reduced, and self-image (P = 0.015) improved significantly at 6 weeks, while stress (P = 0.003) reduced at 18 weeks in the yoga group. Despite comparable body image scores, the prosthesis usage (hours/day) was more (P = 0.005) in the Yoga (6.9 ± 3.2) group against the control (12 ± 2.7). Yoga improves QOL and self-esteem and reduces depression, anxiety, and stress symptoms in patients with traumatic amputation.

Functional outcomes and associated factors of individuals with unilateral traumatic lower limb amputation in Sri Lanka: An observational study.

Rehabilitation is important after an amputation surgery. This study was conducted to find the level of functional outcomes of individuals with unilateral traumatic lower limb amputation and the impact of sociodemographic, amputation, and rehabilitation characteristics on functional outcomes. An observational cross-sectional study was conducted with 48 participants (aged 20-60 years) who visited the Center for Handicapped from across the country. Functional outcomes were measured using the Locomotor Capabilities Index, Amputee Mobility Predictor with Prosthesis, 6-minute walk distance, and spirometry test and sociodemographic, amputation, and rehabilitation characteristics using a self-constructed questionnaire. Amputee Mobility Predictor with Prosthesis K levels showed 65% had the ability to ambulate in the community and could master environmental barriers. Locomotor Capabilities Index scores showed 96% could independently perform basic daily activities with or without using assistive devices and 83% could perform advanced daily activities. None of the individuals had achieved their predicted 6-minute walk distance, but 52% had "good and above" level of maximum oxygen consumption; restrictive respiratory pattern was indicated among 31%. Amputee Mobility Predictor with Prosthesis and Locomotor Capabilities Index scores were significantly ( p < 0.005) affected by mobility hours/day, amputation level, prosthesis usage, and satisfaction. Six-minute walk distance was significantly ( p < 0.005) related to income, time since amputation, duration of rehabilitation, mobility hours/day, sex, job engagement, previous job, amputation level, K levels, and satisfaction with prosthesis. Rehabilitation in Sri Lanka mainly focuses on basic walking training, not on long-term survival, distance walking, and cardiorespiratory endurance, which can lead to future comorbidities. Raising awareness in the society about rehabilitation services and more effective rehabilitation programs are recommended.

Social and community participation following traumatic lower limb amputation: an exploratory qualitative study

Purpose To explore barriers and facilitators to social and community participation experienced by people following traumatic lower limb amputation (LLA). Methods An exploratory qualitative study was conducted with nine adults with traumatic LLA in Victoria, Australia. Participants were a minimum of 18 months post amputation. Interview data was analysed using thematic analysis. Results Participants referenced the inaccessibility of the built environment and physical challenges associated with prosthetic mobility as barriers to participation. Chronic and complex health concerns due to their injuries resulted in physical and emotional distress for some, further limiting their social and community engagement. Participants highlighted the benefit of peer-support networks and the value of supportive community groups in assisting the transition to their pre-amputation family, work and social roles. Participants also felt that a strong, positive attitude and being self-motivated were important to aid in their return to social and community participation. Conclusion People following traumatic LLA experience a number of physical, psychological and environmental challenges to participation. The role of peer-support networks, community groups and personal attitudes are important facilitators to assist a return to family, work and life roles. The findings of this study have informed the development of recommendations to guide clinical practice. IMPLICATIONS FOR REHABILITATION Peer-support groups for people following traumatic lower limb amputation (LLA) may assist to improve their long-term adjustment to disability and community participation Retraining skills in an individual’s own community should be considered when planning community-based therapy services for people following traumatic LLA. Ongoing psychosocial support including strategies to develop self-efficacy and positive mindset may improve social and community participation Regular medical and allied health reviews can be beneficial to promote early intervention for any complications that arise to minimise time off prosthesis.

Kinesiophobia and associated factors in patients with traumatic lower extremity amputation.

The study aimed to demonstrate the level of kinesiophobia in patients with traumatic lower limb amputation (LLA) and to investigate the correlation between kinesiophobia and associated factors. This cross-sectional study included 52 male patients (mean age: 37.8±8.7 years; range, 18 to 65 years) with traumatic LLA between March 2021 and July 2021. Kinesiophobia level was measured with the Tampa Scale for Kinesiophobia. Pain intensity and prosthesis satisfaction were evaluated with the Visual Analog Scale. The Falls Efficacy Scale-International was used for the assessment of fear of falling. The Nottingham Health Profile was used to evaluate the quality of life. The percentage of the patients with a high level of kinesiophobia was 40.4%. Kinesiophobia was significantly correlated with residual limp pain intensity (r=0.317, p=0.022), the number of falls (r=0.284, p=0.041), fear of falling (r=0.495, p=0.001), and quality of life (r=0.512, p=0.001). No significant correlations between kinesiophobia and intact limb pain intensity, low back pain intensity, or prosthesis satisfaction were detected. Regression analysis showed that the physical activity subscale score of the Nottingham Health Profile was a statistically significant predictor of high kinesiophobia scores. The findings suggest that limitations in physical activity were independently associated with kinesiophobia in patients with traumatic LLA. Fear and avoidance behaviors, which may limit physical activity, should be considered in the evaluation of individuals with LLA.

Effect of perioperative sciatic nerve block on chronic pain in patients undergoing below-knee amputation: A randomised controlled trial

Many pain syndromes such as chronic phantom limb pain (PLP) and stump pain (SP), involving nociceptive and neuropathic pain, develop after amputation. Recent literature suggests that the use of regional blocks reduces repeated stimulation of transected nerve roots and thus prevents central sensitisation. This randomised, double-blind study was conducted to evaluate the effect of pre-emptive ultrasound-guided single-shot lateral sciatic nerve block on the occurrence of chronic pain at six months after traumatic below-knee amputation. Thirty patients undergoing traumatic lower limb amputation under general anaesthesia were randomised into two groups: Group B received sciatic nerve block pre-emptively using ultrasound with 20 ml of 0.75% ropivacaine, whereas group C received 20 ml of normal saline. Follow-up of patients was done till six months post-amputation. The primary objective was to assess the occurrence of chronic pain at six months. Pain at 15 days and one month after surgery, post-operative morphine consumption and post-operative nausea and vomiting (PONV) were the secondary outcomes assessed. The occurrence of PLP at six months was comparable in the two groups, group B (46.7%) and C (66.7%). None of the patients developed SP at six months. Median intensities of phantom pain were 1.0 (range, 1-2.0) versus 1.0 (range, 1-2.0) (P = 0.36), and median intensities of SP 2 (range, 2-3.0) versus 3 (range, 2-3.0) (P = 0.39) at 1 month. Pre-emptive sciatic nerve block did not decrease the occurrence or severity of chronic pain after traumatic below-knee amputation.

Satisfaction of lower limb amputees with their prostheses and with the clinical services - a cross-sectional survey.

To evaluate the amputees' satisfaction with their prostheses and with the clinical services. The cross-sectional study was conducted at the Medical Rehabilitation Hospital, Madinah, Saudi Arabia, from August 2018 to November 2019, and comprised unilateral, traumatic lower limb amputees. Data was collected using the client satisfaction with the device, and the client satisfaction with service modules of the Orthotics and Prosthetics User's Survey instrument. Data was analysed using SPSS 23. Of the 220 subjects, 43(19.54%) were transfemoral amputees; 37(86%) males with a mean age of 51.9±12.7 years, and 6(14%) females with mean age 51.9±12.7 years. There were 168(76.36%) transtibial amputees; 146(87%) males with mean age 51.7±12.9 years, and 22(13%) females with mean age 54.1±12.7 years. Besides, there were 9(4.09%) female partial-foot amputees with a mean age of 36.0± 6.5 years. Overall, 165(75%) subjects were satisfied with the durability of their prostheses, and 213(97%) were satisfied with the service standard. Most of the participants were generally satisfied with their prostheses, and almost all of them were generally satisfied with the clinical services.

Characterisation of Phantom Limb Pain in Traumatic Lower-Limb Amputees

Introduction There is no diagnosis for phantom limb pain (PLP), and its investigation is based on anamnesis, which is subject to several biases. Therefore, it is important to describe and standardize the diagnostic methodology for PLP. Objective To characterise PLP and, secondarily, to determine predictors for its diagnosis. Methodology. This is a cross-sectional study involving patients with unilateral traumatic lower-limb amputation aged over 18 years. Those with clinical decompensation or evidence of disease, trauma, or surgery in the central or peripheral nervous system were excluded. Sociodemographic and rehabilitative data were collected; PLP was characterised using the visual analogue scale (VAS), pain descriptors, and weekly frequency. Results A total of 55 eligible patients participated in the study; most were male, young, above-knee amputees in the preprosthetic phase of the rehabilitation. The median PLP VAS was 60 (50–79.3) mm characterised by 13 (6–20) different descriptors in the same patient, which coexist, alternate, and add up to a frequency of 3.94 (2.5–4.38) times per week. The most frequent descriptor was movement of the phantom limb (70.91%). Tingling, numbness, flushing, itchiness, spasm, tremor, and throbbing are statistically significant PLP descriptor numbers per patient predicted by above-knee amputation, prosthetic phase, higher education level, and greater PLP intensity by VAS (p < 0.05). Conclusion PLP is not a single symptom, but a set with different sensations and perceptions that need directed and guided anamnesis for proper diagnosis.

Assessment of lower limb peripheral nerves with ultrasound in patients with traumatic amputation.

Objectives This study aims to assess the sciatic nerve (SN), common peroneal nerve (CPN), and tibial nerve (TN) by ultrasound in patients with traumatic lower limb amputation (LLA) and to examine the possible relationship between ultrasonographic and clinical findings. Patients and methods This cross-sectional study included a total of 33 male patients (mean age: 36.6±8.7 years; range, 21 to 48 years) who had LLA due to traumatic injury between May 2019 and April 2020. Amputation and prosthesis use and functional K level of activity were recorded. Ultrasound examinations were performed to measure the cross-sectional areas (CSAs) of the SN, CPN, and TN bilaterally at the same levels. The values from the normal sides were accepted as controls. Results The CSA values were greater on the amputated sides than the non-amputated sides for SN (p=0.001), TN (p=0.001), and CPN (p=0.015), regardless of the activity level. The amputated side SN (p=0.001), TN (p=0.001), and CPN (p=0.016) were thicker in patients with level of K4 activity than the non-amputated side. For the patients with K3 activity level, larger TN CSA values were determined on the amputated side, compared to those at the K4 level (p=0.035). The SN was found to be greater in patients using microprocessor-controlled knee prosthesis (p=0.032) and TN was larger in hypobaric sealing membrane users on the amputated sides (p=0.041). Conclusion The SN, CPN, and TN were found to be larger in all patients on the amputated sides and in patients with K4 activity level. Based on these findings, the K3 activity level and the use of hypobaric sealing membrane seems to affect the CSA values of TN. Additionally, the use of microprocessor knee prosthesis affects the CSA values of SN. We believe that these results may be essential for the analysis or prediction of lower extremity nerve involvement according to the K activity level and the use of prosthesis in patients with traumatic LLA.

Effects of Combined and Alone Transcranial Motor Cortex Stimulation and Mirror Therapy in Phantom Limb Pain: A Randomized Factorial Trial

Phantom limb pain (PLP) is a frequent complication in amputees, which is often refractory to treatments. We aim to assess in a factorial trial the effects of transcranial direct current stimulation (tDCS) and mirror therapy (MT) in patients with traumatic lower limb amputation; and whether the motor cortex plasticity changes drive these results. In this large randomized, blinded, 2-site, sham-controlled, 2 × 2 factorial trial, 112 participants with traumatic lower limb amputation were randomized into treatment groups. The interventions were active or covered MT for 4 weeks (20 sessions, 15 minutes each) combined with 2 weeks of either active or sham tDCS (10 sessions, 20 minutes each) applied to the contralateral primary motor cortex. The primary outcome was PLP changes on the visual analogue scale at the end of interventions (4 weeks). Motor cortex excitability and cortical mapping were assessed by transcranial magnetic stimulation (TMS). We found no interaction between tDCS and MT groups (F = 1.90, P = .13). In the adjusted models, there was a main effect of active tDCS compared to sham tDCS (beta coefficient = −0.99, P = .04) on phantom pain. The overall effect size was 1.19 (95% confidence interval: 0.90, 1.47). No changes in depression and anxiety were found. TDCS intervention was associated with increased intracortical inhibition (coefficient = 0.96, P = .02) and facilitation (coefficient = 2.03, P = .03) as well as a posterolateral shift of the center of gravity in the affected hemisphere. MT induced no motor cortex plasticity changes assessed by TMS. These findings indicate that transcranial motor cortex stimulation might be an affordable and beneficial PLP treatment modality.

The Effect of Adding Virtual Reality Training on Traditional Exercise Program on Balance and Gait in Unilateral, Traumatic Lower Limb Amputee.

Objective: Lower limb amputation is common in war combat and armed conflict as well as in traumatic settings and presents a challenge for health care providers. The incorporation of advanced technologies, particularly virtual reality, presents an opportunity to address the main consequences of amputation, principally balance and gait. The aim of this study was to investigate the additional effect of virtual reality with a traditional rehabilitation exercise program on balance and gait in unilateral, traumatic lower limb amputees. Materials and Methods: Thirty-two traumatic lower limb amputees, fulfilling a postfitting rehabilitation program at least 6 months ago, were recruited and randomly assigned into two identically sized groups; group C (control group) experiencing the traditional exercise program and group VR (virtual reality group) experiencing an addition of a virtual reality training. The intervention was conducted over 6 weeks at a rate of three sessions per week. Outcome measures assessed before and after 6 weeks were the Berg Balance Scale (BBS), Timed Up and Go (TUG) test, Dynamic Gait Index (DGI), and 6-minute walk test (6 MWT). Results: Both interventions induced improvement in all measured parameters (P < 0.05); however, virtual reality demonstrated significant superior effects only on the balance markers, TUG test, DGI, and BBS (P < 0.05), but not on the 6 MWT (P > 0.05). Conclusion: Virtual reality is a promising, amusing, and safe intervention for addressing balance and gait in unilateral, traumatic lower limb amputees.

Study on Microbiome of Chronic Non Healing Diabetic Ulcers with Special Reference to Biofilm and Multidrug Resistant Strains

Introduction: Diabetic Foot Ulcers (DFU) represent a silent epidemic and are the leading cause of 80% of non traumatic lower-limb amputations. Anaemia in diabetes may have adverse effects on systemic diseases and predict the progression of diabetes complications. Biofilms act as a mechanical barrier to antimicrobials and immune system cells and contribute to Multidrug Resistance (MDR). Aim: To determine the bacteriome and mycobiome of diabetic ulcers and the associated biofilm formation and anti-microbial resistance profile of the pathogens. Also, to determine the molecular characterisation of biofilm-forming resistant isolates by Polymerase Chain Reaction (PCR). Materials and Methods: This cross-sectional study was done on 150 diabetic patients with non healing ulcers and was chosen and studied from January-December 2019. Pus and tissue bit samples were processed as per standard microbiological procedures. Antimicrobial susceptibility test was performed as per Clinical and Laboratory Standards Institute (CLSI) guidelines. Biofilm formation was detected by the tissue culture plate method. Molecular characterisation of resistant pathogens was done by PCR. Variables were expressed as proportions or percentages. Results: Out of 150 diabetic patients, 17.3% of patients underwent amputation. A 90% of patients were associated with anaemia. Most ulcers were polymicrobial in nature. Predominantly isolated pathogens were Pseudomonas aeruginosa 37 (17.1%) and Staphylococcus aureus 33 (15.2%) among aerobic bacteria, Peptostreptococcus 10 (4.6%) among the anaerobes and Candida albicans 20 (9.2%) in fungus. Gram negative bacteria showed high sensitivity to piperacillin-tazobactam, meropenem, and gram positive cocci to vancomycin and linezolid. A 82% of bacterial isolates and 50% of fungal isolates were biofilm producers. Staphylococcus aureus was a strong biofilm producer. On molecular characterisation, blaCTX-M, blaTEM, blaNDM-1, blaOXA-23, mecA genes were present in resistant biofilm-forming isolates. Conclusion: Polymicrobial wound infection and biofilm formation in DFU confers antibiotic resistance and contributes to Multidrug Resistant Organisms (MDRO’s). However, proper antibiotic surveillance and antibiotic policy, and preventive strategies can curtail the spread of resistant strains.