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Abstract. Chronic critical lower limb ischemia (CLI) has been defined as ischemia that endangers the leg. An attempt was made to give a precise definition of CLI, based on clinical and hemodynamic data (Second European Consensus). CLI may be easily defined from a clinical point of view as rest pain of the distal foot or gangrene or ulceration. It is probably useful to add leg ulcers of other origin which do not heal because of severe ischemia, and to consider the impact of frailty on adverse outcome. From a hemodynamic viewpoint there is no consensus and most of the existing classifications are not based upon evidence. We should thus propose a definition and then validate it in a prospective cohort in order to define the patients at major risk of amputation, and also to define the categories of patients whose prognosis is improved by revascularisation. From today’s available data, it seems clear that the patients with a systolic toe pressure (STP) below 30 mmHg must be revascularised whenever possible. However other patients with clinically suspected CLI and STP above 30 mmHg must be evaluated and treated in specialised vascular units and revascularisation has to be discussed on a case by case basis, taking into account other data such as the WiFi classification for ulcers.In conclusion, many useful but at times contradictory definitions of CLI have been suggested. Only a few have taken into account evidence, and none have been validated prospectively. This paper aims to address this and to give notice that a CLI registry within Europe will be set up to prospectively validate, or not, the previous and suggested definitions of CLI.

Gait analysis is recognized as a useful assessment tool in the field of human movement research. However, doubts remain on its real effectiveness as a clinical tool, i.e. on its capability to change the diagnostic-therapeutic practice. In particular, the conditions in which evidence of a favorable cost-benefit ratio is found and the methodology for properly conducting and interpreting the exam are not identified clearly. To provide guidelines for the use of Gait Analysis in the context of rehabilitation medicine, SIAMOC (the Italian Society of Clinical Movement Analysis) promoted a National Consensus Conference which was held in Bologna on September 14th, 2013. The resulting recommendations were the result of a three-stage process entailing i) the preparation of working documents on specific open issues, ii) the holding of the consensus meeting, and iii) the drafting of consensus statements by an external Jury. The statements were formulated based on scientific evidence or experts’ opinion, when the quality/quantity of the relevant literature was deemed insufficient. The aim of this work is to disseminate the consensus statements. These are divided into 13 questions grouped in three areas of interest: 1) General requirements and management, 2) Methodological and instrumental issues, and 3) Scientific evidence and clinical appropriateness. SIAMOC hopes that this document will contribute to improve clinical practice and help promoting further research in the field.

Capturing the variability that exists among patients attending an amputee clinic using standardized paper-based questionnaires is time-consuming and may not be practical for routine clinical use. Electronic questionnaires are a potential solution; however, the benefits are dependent on the feasibility and acceptance of this mode of data collection among patients.To determine the feasibility and patient preference/comfort in using a tablet-based questionnaire for data collection in an outpatient amputee rehabilitation clinic compared to a traditional paper-based questionnaire.Observational study.In all, 48 patients with major extremity amputations completed both tablet and paper questionnaires related to their amputation and prosthetic use. Both trials were timed; patients then completed a semi-structured questionnaire about their experience.In all, 20.5% of patients needed hands-on assistance completing the paper questionnaire compared to 20.8% for the tablet. The majority of participants (52.1%) indicated a preference for the tablet questionnaire; 64.6% of patients felt the tablet collected a more complete and accurate representation of their status and needs. In all, 70.8% of participants described themselves as comfortable using the tablet.Despite comorbidities, patients with amputations demonstrated excellent acceptance of the electronic tablet-based questionnaire. Tablet questionnaires have significant potential advantages over paper questionnaires and should be further explored. Clinical relevance A custom electronic questionnaire was found to be beneficial for routine clinic use and was well received by patients in an amputee rehabilitation clinic. Development of such questionnaires can provide an efficient mechanism to collect meaningful data that can be used for individual patient care and program quality improvement initiatives.

Breast cancer is the most common malignancy occurring in women. The treatment of breast cancer is a complex, multistep process involving surgical treatment, chemotherapy, radiotherapy, hormone therapy, targeted therapy, and very often rehabilitation. After the treatment of the underlying disease, or still in its course, there remains a problem of deformation of the chest. Although the number of women opting for breast reconstructive surgery increases every year, the number of such procedures in Poland is low.was to investigate the reasons why women after amputation of the breast due to cancer are not likely to undergo breast reconstructive surgery.The study comprised 73 women, residents of the province of Silesia, aged between 37 and 79 years, who had undergone mastectomy for malignancy in the years 1987-2013.From all of the reasons given by women for refraining from breast reconstruction, the most frequently pointed was the fear of being subjected to further surgery (38.3%). 23 women (31.5%) admitted that they were also afraid of postoperative pain. Similarly, a common response (35.6%) was that it is not essential for their mental state, and 30% of respondents fully accepted their appearance after mastectomy. Concern about the effect of failed reconstruction was reported by 24.6% of the women, and the fear that the surgery could negatively affect the process of cancer treatment by 27.4% of respondents. Lack of information about the capabilities and knowledge of breast reconstruction methods was not an important factor in decision-making.Most of the surveyed women who abandon breast reconstruction surgery, make this decision on the basis of more than one reasons. Fear of undergoing a second surgical procedure and pain related to it were the most important reasons for the refusal of breast reconstruction. An important factor in the decision to desist from breast reconstruction is the age of the patients.

Introduction The population of patients with lower limb atherosclerosis includes a considerable proportion of individuals with long superficial femoral artery (SFA) lesions. Chronic total occlusions (CTOs) represent the "last frontier" of percutaneous interventions. While open strategies are considered earlier as standard management for these lesions, the results of a number of trials indicate that endovascular management might become an effective alternative to surgery. Material and methods This paper presents 5-year outcomes of a first-in-man (FIM) study (before CE mark) and the registry of OCT Guided Ocelot Catheter (Avinger) for chronic total occlusions of the superficial femoral artery. The study group comprised 10 patients with Rutherford 3 lower limb ischemia including nine men and one woman. Results The efficacy of the primary intervention was 90%. Angiography performed at 6 months of the procedure, according to the study protocol, revealed 3 and 1 cases of restenosis and reocclusion, respectively, repaired using PTA and open common and deep femoral artery patch plasty. Doppler ultrasound performed at 1, 2 and 5 years after the primary intervention did not reveal significant target vessel restenosis. The primary and primary-assisted patency was 89%. During a 5-year follow-up, four peripheral percutaneous interventions and one femoropopliteal bypass surgery were performed in non-target limbs. There were no cardiovascular deaths, myocardial infarction or stroke and no amputation was required. Conclusions This is a first-in-man study reporting long-term follow-up after SFA CTO revascularization using the Ocelot catheter. The catheter proved to have a satisfactory safety profile and a high proportion of CTO crossings. A 5-year follow-up revealed high primary and primary-assisted patency rates.

In post-amputation rehabilitation, a common goal is to return to ambulation using a prosthetic limb, suspended by a customised socket. Prosthetic socket design aims to optimise load transfer between the residual limb and mechanical limb, by customisation to the user. This is a time-consuming process, and with the increase in people requiring these prosthetics, it is vital that these personalised devices can be produced rapidly while maintaining excellent fit, to maximise function and comfort. Prosthetic sockets are designed by capturing the residual limb’s shape and applying a series of geometrical modifications, called rectifications. Expert knowledge is required to achieve a comfortable fit in this iterative process. A variety of rectifications can be made, grouped into established strategies [e.g. in transtibial sockets: patellar tendon bearing (PTB) and total surface bearing (TSB)], creating a complex design space. To date, adoption of advanced engineering solutions to support fitting has been limited. One method is numerical optimisation, which allows the designer a number of likely candidate solutions to start the design process. Numerical optimisation is commonly used in many industries but not prevalent in the design of prosthetic sockets. This paper therefore presents candidate shape optimisation methods which might benefit the prosthetist and the limb user, by blending the state of the art from prosthetic mechanical design, surrogate modelling and evolutionary computation. The result of the analysis is a series of prosthetic socket designs that preferentially load and unload the pressure tolerant and intolerant regions of the residual limb. This spectrum is bounded by the general forms of the PTB and TSB designs, with a series of variations in between that represent a compromise between these accepted approaches. This results in a difference in pressure of up to 31 kPa over the fibula head and 14 kPa over the residuum tip. The presented methods would allow a trained prosthetist to rapidly assess these likely candidates and then to make final detailed modifications and fine-tuning. Importantly, insights gained about the design should be seen as a compliment, not a replacement, for the prosthetist’s skill and experience. We propose instead that this method might reduce the time spent on the early stages of socket design and allow prosthetists to focus on the most skilled and creative tasks of fine-tuning the design, in face-to-face consultation with their client.

Study objective Necrotizing fasciitis (NF) is an uncommon life-threatening necrotizing skin and soft tissue infection. Bullae are special skin manifestations of NF. This study was conducted to analyze the differences between different types of bullae of limbs with NF for providing the information to emergency treatment. Methods From April 2015 to August 2018, patients were initially enrolled based on surgical confirmation of limbs with NF. According to the presence of different bullae types, patients were divided into no bullae group (Group N), serous-filled bullae group (Group S), and hemorrhagic bullae group (Group H). Data such as demographics, clinical outcomes, microbiological results, presenting symptoms/signs, and laboratory findings were compared among these groups. Results In total, 187 patients were collected, with 111 (59.4%) patients in Group N, 35 (18.7%) in Group S, and 41 (21.9%) in Group H. Group H had the highest incidence of amputation, required intensive care unit care, and most patients infected with Vibrio species. In Group N, more patients were infected with Staphylococcus spp. than Group H. In Group S, more patients were infected with β-hemolytic Streptococcus than Group H. Patients with bacteremia, shock, skin necrosis, anemia, and longer prothrombin time constituted higher proportions in Group H and S than in Group N. Conclusions In southern Taiwan, patients with NF accompanied by hemorrhagic bullae appear to have more bacteremia, Vibrio infection, septic shock, and risk for amputation. If the physicians at the emergency department can detect for the early signs of NF as soon as possible, and more patient’s life and limbs may be saved.

Supplemental Digital Content is Available in the Text. A 6-day ambulatory continuous peripheral nerve block reduces phantom limb pain and pain-induced physical and emotional dysfunction for at least 4 weeks after treatment., Phantom limb pain is thought to be sustained by reentrant neural pathways, which provoke dysfunctional reorganization in the somatosensory cortex. We hypothesized that disrupting reentrant pathways with a 6-day-long continuous peripheral nerve block reduces phantom pain 4 weeks after treatment. We enrolled patients who had an upper- or lower-limb amputation and established phantom pain. Each was randomized to receive a 6-day perineural infusion of either ropivacaine or normal saline. The primary outcome was the average phantom pain severity as measured with a Numeric Rating Scale (0-10) at 4 weeks, after which an optional crossover treatment was offered within the following 0 to 12 weeks. Pretreatment pain scores were similar in both groups, with a median (interquartile range) of 5.0 (4.0, 7.0) for each. After 4 weeks, average phantom limb pain intensity was a mean (SD) of 3.0 (2.9) in patients given local anesthetic vs 4.5 (2.6) in those given placebo (difference [95% confidence interval] 1.3 [0.4, 2.2], P = 0.003). Patients given local anesthetic had improved global impression of change and less pain-induced physical and emotional dysfunction, but did not differ on depression scores. For subjects who received only the first infusion (no self-selected crossover), the median decrease in phantom limb pain at 6 months for treated subjects was 3.0 (0, 5.0) vs 1.5 (0, 5.0) for the placebo group; there seemed to be little residual benefit at 12 months. We conclude that a 6-day continuous peripheral nerve block reduces phantom limb pain as well as physical and emotional dysfunction for at least 1 month.

Purpose The aim of the study was to identify solution strategies from a non-governmental (NGO) hospital in a war region for violence-related injuries and to show how high-income countries (HIC) might benefit from this expertise. Methods NGO trauma hospital in Lashkar Gah, Afghanistan. Four hundred eighty-four war victims admitted in a three month period (February 2016–May 2016) were included. Patients´ characteristics were analyzed. Results The mean age was 23.5 years. Four hundred thirty-four (89.9%) were male, and 50 (10.1%) were female. The most common cause of injury was bullet injuries, shell injuries, and mine injuries. The most common injured body region was the lower extremity, upper extremity, and the chest or the face. Apart from surgical wound care and debridements, which were performed on every wound in the operation theatre, laparotomy was the most common surgical procedure, followed by installation of a chest drainage and amputation. Conclusion The surgical expertise and clear pathways outweigh modern infrastructure. In case of a mass casualty incident, fast decision-making with basic diagnostic means in order to take rapid measurements for life-saving therapies could make the difference.

Aim of the study The goal of our study was to assess the sexual functioning of patients undergoing mastectomy, five years after surgery, compared to a control group. Material and methods A cross-sectional study included 170 patients five years post mastectomy (group A1) and 149 healthy women (group A2) who had never been diagnosed with breast cancer. The study was conducted at the Oncology Centre in Bydgoszcz, at the Amazon Clubs, and at the University of the Third Age by the University of Economy in Bydgoszcz. Standardised questionnaires: the Female Sexual Function Index (FSFI) and Rosenberg's SES (self-esteem scale) were used. Results Our study results show significantly worse sexual functioning in the domains pertaining to desire (p = 0.0015), arousal (p = 0.0052), lubrication (p = 0.0026), ability to reach orgasm (p = 0.0417), sexual satisfaction (p = 0.0142), and the presence of clinically significant sexual dysfunction (p = 0.0028) among patients after amputation of the mammary gland. On the scale of pain relating to sexuality, there were no significant differences between the two groups (p> 0.05). The overall score in the FSFI questionnaire was also lower (p = 0.0066) among women after mastectomy. Highly statistically significant (p < 0.0001) differences in self-esteem were also noted between the two groups, with worse results observed in patients after mastectomy. Conclusions Diagnosis of sexual dysfunction in patients treated for breast cancer allows timely implementation of counselling and interventional therapy depending on the causal factors and individual preferences of patients.

Aims In peripheral artery disease (PAD), endovascular treatment success of heavily calcified lesions is often compromised by a number of vascular complications, such as recoils, dissections and need for target vessel re-interventions. The increasing use of scoring balloon techniques has raised the hope for better periprocedural outcomes; however, the knowledge regarding the actual benefits of the scoring balloon technique in comparison to standard therapy is still limited. Thus, the aim of the current study was to determine the safety and effectiveness of scoring balloon angioplasty in a real-life patients’ collective with PAD. Methods and Results A total of 425 patients with moderate to severely calcified femoropopliteal lesions received interventional treatment between 2011 and 2018 at the single center; 230 received a treatment with a scoring balloon (AngioSculpt™), and 195 received a plain procedure without AngioSculpt™. Key questions of this analysis were: (1) whether AngioSculpt™ can be used as a safe and effective stand-alone treatment in heavily calcified lesions in a 24-month follow-up, as well as (2) whether target lesion preparation with scoring balloon bears additional benefits to standard treatment (PTA ± stent implantation). In terms of freedom from target lesion revascularization there were no significant differences between AngioSculpt™ and standard procedure (82.3% vs. 78.1%, P > 0.05). Vessel preparation with balloon angioplasty had no additional effects on survival and amputation rates in comparison to standard treatment without AngioSculpt™ (P > 0.05). The deployment of a scoring balloon did not reduce the subsequent need for additional stent implantations (32.6%, and 32.3%, P > 0.05). Conclusion Lesion preparation with AngioSculpt™ scoring balloon represents a safe and effective tool in the treatment of complex femoropopliteal lesions. In this retrospective analysis, AngioSculpt™ scoring balloon angioplasty did not significantly improve vessel patency- both when used as an adjunctive in preparation for stenting and as stand-alone treatment. A prospective study is needed to further investigate the scoring balloon treatment options. Graphic abstract

Introduction The rate of atherectomy utilization in peripheral artery diseases (PAD) is growing. The two atherectomy devices available on the market and used most frequently are the directional and rotational ones. Nonetheless, there is a lack of direct comparison between these two types of atherectomy in PAD. Aim To compare the long-term outcomes after PAD endovascular revascularization with two types of atherectomies: rotational (AR) (Phoenix Philips) and directional (AD) (SilverHawk Medtronic). Material and methods This was a single-center, retrospective study of obstructive and symptomatic PAD patients who underwent revascularization with atherectomy. The endpoints were considered as target lesion revascularization (TLR), death, amputations and bailout stenting (BS). Results The AR group consisted of 97 patients, while the AD group consisted of 85 individuals. There were no significant differences between the groups in terms of baseline characteristics except for an increased critical limb ischemia (CLI) prevalence in the AR group. The mean follow-up for AD and AR was 282.6 ±147.4 and 255.7 ±186.1 days, respectively (p = 0.44). There were no significant differences in the death rate (AD: 1 (1.7%) vs. AR: 5 (5.7%); p = 0.54), amputations (AD: 2 (2.3%) vs. AR: 5 (5.7%); p = 0.45) or bailout stenting (AD: 2 (2.3%) vs. AR: 3 (3.2%); p = 0.74), whereas TLR was more frequent in the AD group (AD: 25 (29%) vs. AR: 15 (15.9%; p = 0.03). The Kaplan-Meier analysis showed no significant differences between the groups in time to TLR, amputation or death. Conclusions In this hypothesis-generating study the AR had a lower rate of TLR when compared to the AD. Nevertheless, this should be confirmed in further controlled randomized trials.

The purpose of the study was to determine the effect of tricalcium silicate cement on the protective process of pulp in the treatment of reversible pulpitis. There was carried out an experiment on 3-month-old male rabbits to study morphofunctional changes in the pulp tissue with modeling of reversible pulpitis followed by vital amputation with coating of the pulp with tricalcium silicate (8 animals, study group) and mineral trioxide aggregate (MTA) (8 animals, comparison group). In 2 and 6 weeks dental tissues were fixed by 10% formalin solution and after decalcification and done routine procedures, histological sections were made, stained with hematoxylin and eosin. After the application of tricalcium silicate cement in 2 weeks, the odontoblast density changed to 3.92±1.03×103/mm2from 8.3±1.02×103/mm2of cell density in the intact group. The number of neutrophils also plays a big role in the regeneration of inflamed pulp. Thus, in 2 weeks the number of neutrophils made up 6.39±2.61x102per 1mm2, which is 3 times less than after mineral trioxide aggregate usage – 19.49±2.85x102per 1mm2. It was established that the processes of rheological disorders with impaired lymph circulation are replaced by the restoration of the cellular component. In such a way the proposed vital amputation was examined for reversible pulpitis and it revealed similar clinical and pathological effectiveness with a positive regenerative process with formation of a sufficient number of odontoblasts (7.98±1.51×103/mm2) for the subsequent formation of a hard tissue bridge, which consists of collagen fibers in the form of a frame. The main goal of vital amputation procedure is regeneration (proliferation) of the pulp with a short-term signs of alteration and exudation, which is provided by the choice of material for the pulp covering. Thus, after the vital amputation of the pulp, followed by the use of tricalcium silicate cement 6 weeks after, the number of neutrophils was 1.39±0.72x102per 1mm2, which is 5 times less than after using mineral trioxide aggregate.

Introduction Osteosarcoma is the most common primary malignant bone tumor in adults and is usually located in long bones. Standard treatment consists of perioperative chemotherapy and radical surgical resection. In the case of the extremity location, the gold standard is limb-sparing surgery (LSS) using a variety of reconstructive techniques. Aim of the study To assess long-term results of adults patients treated for limb osteosarcoma in our referral center depending on the method of surgical treatment. Material and methods In our study, we analyzed 175 adult patients with localized disease (American Joint Committee on Cancer [AJCC] stage I-III) treated for extremity osteosarcoma at our institution between 2000 and 2017. The median observation time was 41 months (3-225 months). 111 patients were treated with LSS (80 patients had tumor resection followed by endoprosthetic reconstruction, 31 patients had local resection without reconstruction) and 64 patients underwent amputation. Results 5-year overall survival (OS) and progression-free survival (PFS) in the study group were 62% and 52% and the life expectancy was on average 136 months. In the group of patients treated with LSS, 5-year OS and PFS were 66% and 59%, respectively, and life expectancy was 147 months, while in the group of patients undergoing amputation 5-year OS, PFS and life expectancy were 55%, 42% and 117 months. Conclusions The best results in the treatment of extremity osteosarcoma were achieved in a group of patients without distant metastases at the time of diagnosis, treated with perioperative chemotherapy and radical resection followed by endoprosthetic reconstruction.

Background: Patients with thromboangiitis obliterans (TAO) can develop critical limb-threatening ischemia (CLTI) and require limb amputation. Smoking cessation and exercise therapy are recommended as standard treatments, and revascularization by bypass surgery or endovascular therapy (EVT) is required for patients with CLTI. However, there are many cases in which revascularization is difficult because of vascular characteristics, and the patency rate after revascularization remains unsatisfactory. Therapeutic angiogenesis using bone marrow-derived mononuclear cell (BM-MNC) implantation is used clinically, with many trials demonstrating long-term efficacy and safety of the technique in patients with CLTI, especially that caused by TAO. To expand the use of BM-MNCs implantation in clinical practice, further evidence is required in patients with CLTI caused by TAO. Methods and Results: This trial is a multicenter, prospective, non-randomized interventional trial of an Advanced Medicine B treatment approach. We aim to enroll 25 patients aged 20-80 years with Fontaine classification Stage III or IV, who will undergo BM-MNC implantation. The primary endpoint is the improvement in skin perfusion pressure of the target limb 180 days after BM-MNC implantation, whereas secondary endpoints are improvements in rest pain or ulcer size. We will also investigate rates of major or minor amputation, survival, and adverse events during follow-up. Conclusions: BM-MNC implantation is expected to be an efficacious and feasible treatment for patients with CLTI caused by TAO.

Highlights • This is the first study about suicide and accident death in patients with bone tumors. • Patients had higher risk of suicide and accident death than all residents. • Amputation increased suicidal risk but did not increase the risk of accident death. • Clinicians should pay more attention to the psychological status in these survivors., Background It has been recognized that cancer is associated with a higher risk of suicide or accidental death. Earlier studies have evidenced that patients with malignant bone tumors usually experience psychological dysfunction and physical disability following surgery, which are shared risk factors between suicidal and accidental deaths. To our knowledge, there is no large population-based study on the risk of suicide or accidental death among patients with malignant bone tumors. Questions/purposes This study aimed to determine whether patients with primary malignant bone tumors are at a higher risk of suicide and accidental death than the general population and to identify the demographic and tumour-related characteristics and type of surgery associated with a higher risk of suicide and accidental death among these patients. Methods Overall, 50,817 patients diagnosed with primary malignant bone tumors between 1973 and 1975 were identified from the Surveillance, Epidemiology, and End Results database. The standardised mortality ratio (SMR) was calculated based on the general population’s mortality data, gathered by the National Center for Health Statistics. The Cox regression model was developed to determine risk factors associated with a higher risk of suicide and accidental death. Results Patients with primary malignant bone tumors had a higher risk of suicide and accidental death than the general population in the United States (US) (SMR = 2.17; 95% confidence interval (CI) [1.80–2.62] and SMR = 1.73; 95% CI [1.54–1.95]). Compared with limb salvage, amputation significantly increased the risk of suicide (SMR = 3.99; 95% CI [2.52–6.34], hazard ratio (HR) = 2.32; 95% CI [1.31–4.09]; P

It has been proposed that finite element analysis can complement clinical decision making for the appropriate design and manufacture of prosthetic sockets for amputees. However, clinical translation has not been achieved, in part due to lengthy solver times and the complexity involved in model development. In this study, a parametric model was created, informed by variation in (i) population-driven residuum shape morphology, (ii) soft tissue compliance and (iii) prosthetic socket design. A Kriging surrogate model was fitted to the response of the analyses across the design space enabling prediction for new residual limb morphologies and socket designs. It was predicted that morphological variability and prosthetic socket design had a substantial effect on socket-limb interfacial pressure and shear conditions as well as sub-dermal soft tissue strains. These relationships were investigated with a higher resolution of anatomical, surgical and design variability than previously reported, with a reduction in computational expense of six orders of magnitude. This enabled real-time predictions (1.6 ms) with error vs the analytical solutions of

Objective: To evaluate the association between peripheral artery disease (PAD) and major adverse cardiovascular events (MACE) in patients with acute coronary syndrome (ACS) in the Arabian Gulf. Methods: Data from 4,044 consecutive patients diagnosed with ACS admitted to 29 hospitals in four Arabian Gulf countries from January 2012 to January 2013 were analyzed. PAD was defined as any of the following: claudication, amputation for arterial vascular insufficiency, vascular reconstruction, bypass surgery, or percutaneous intervention in the extremities, documented aortic aneurysm or an ankle brachial index of Results: The overall mean age of the cohort was 60 ± 13 years and 66% (n = 2,686) were males. A total of 3.3% (n = 132) of the patients had PAD. Patients with PAD were more likely to be associated with smoking, prior MI, hypertension, diabetes mellitus, and stroke/TIA. At the 1-year follow-up, patients with PAD were significantly more likely to have MACE (adjusted OR [aOR], 2.07; 95% confidence interval [CI]: 1.41–3.06; p< 0.001). The higher rates of events were also observed across all MACE components; stroke/TIA (aOR, 3.22; 95% CI: 1.80–5.75; p< 0.001), MI (aOR, 2.15; 95% CI: 1.29–3.59; p =0.003), all-cause mortality (aOR, 2.21; 95% CI: 1.33–3.69; p =0.002), and readmissions for cardiac reasons (aOR, 1.83; 95% CI: 1.24–2.70; p =0.003). Conclusions: PAD was significantly associated with MACE in ACS patients in the Arabian Gulf.

Background Major lower limb amputation remains a common treatment for patients with peripheral vascular disease (PVD) in whom other measures have failed. It has been associated with high morbidity and mortality, including risks from venous thromboembolism (VTE). Methods A two-year retrospective cohort study was conducted involving 79 patients who underwent major lower limb amputation (below- or above-knee amputation) between January 2014 and December 2015 in a single tertiary referral centre. Amputation procedures were performed for reasons relating to complications of PVD and/or diabetes mellitus. Patients were followed-up to investigate all-cause mortality rates and VTE events using the Northern Ireland Electronic Care Record database (mean follow-up time 17 months). Results Of the 79 patients, there were 52 male and 27 female. Mean age at time of surgery was 72 years (range 34-99 years). Forty-six patients (58%) suffered from diabetes mellitus, 29 (35%) heart failure, 31 (39%) chronic kidney disease (CKD) and 10 (13%) chronic obstructive pulmonary disease (COPD). Twenty patients (25%) were on anticoagulant therapy, and 53 (67%) were on antiplatelet therapy. Thirty-five patients (44%) died during follow-up; mean age at death was 74 years. No statistically significant association was found between mortality rate and the level of amputation (p=0.3702), gender (p=0.3507), or comorbid diabetic mellitus (p=0.1127), heart failure (p=0.1028), CKD (p=0.0643) or COPD (p=0.4987). Two patients experienced radiologically-confirmed non-fatal pulmonary emboli and two patients developed radiologically-confirmed deep vein thrombosis. Conclusions The results are in agreement with current literature that amputation is associated with significant mortality, with almost half of the study population dying during follow-up. Further work should explore measures by which mortality rates may be reduced.

Introduction: To confirm the success of our limb salvage treatment protocol and determine what factors are predictive of success versus failure in limb salvage techniques for patients with chronic osteomyelitis of the tibia and ankle.Methods: Retrospective case series analyzing factors and outcomes in patients who underwent limb salvage techniques for chronic osteomyelitis of tibia or ankle. Main outcome measurements included infection controlled without the need for amputation or chronic antibiotic suppression and union of infected non-unions.Results: Mean follow-up was 3.9 years. Out of the sixty-seven patients (mean age: 51.4 years) treated for chronic osteomyelitis, fifty-four had an associated non-union. Sixty-one patients (91.0%) had their infection controlled by limb salvage. Five ultimately required amputation and one remained on daily chronic antibiotics. Diabetics complicated with neuropathy and increasing numbers of limb salvage surgeries were associated with a significantly higher failure rate. Forty-eight out of fifty-four patients (88.9%) also had successful healing of their infected non-union. Diabetes and need for more limb salvage surgeries were also found to have a significantly higher failure rate.Conclusions: Limb salvage is a reliable and successful treatment for patients with chronic osteomyelitis and infected non-unions of the lower extremities. Diabetic neuropathy is a risk factor that impedes success.Level of Evidence: Prognostic Level IV.

Peripheral artery disease (PAD), when present with diabetes, is associated with significant morbidity and mortality. The spectrum of PAD in diabetes includes atherosclerosis with stenotic disease; and diffuse medial calcification with non-compliant arteries, as reflected by high ankle brachial index. The clinical characteristics of a high ABI are less well characterized than that of low ABI.The aim of this study was to determine the unique clinical phenotype of patients with diabetes who have high ankle brachial index (ABI) reading. We performed a cross sectional observational study including 360 patients. Subjects were grouped according to normal (≥ 0.8 ≤ 1.3), low (1.3) result. Subjects with high ABI were characterised by higher BMI, higher waist/height ratio (WHtR), and lower serum lower vitamin D. Although reduced renal function and neuropathy was present more frequently in those with high ABI, this was also the case in those with low ABI. Similarly to those with low ABI result, a high ABI result was associated with increased risk of diabetic foot complications including amputation. When adjusted for known risk factors for PAD, higher WHtR and lower vitamin D were significant predictors of high ABI. These results suggest an association between increased WHtR and low vitamin D with high ABI; whether there is a causal relationship requires further exploration. Keywords: Diabetes, Peripheral arterial disease, ABI, Obesity, 25-hydroxyvitamin D

Background: We hypothesized that polymicrobial posttraumatic osteomyelitis (PTO) may be associated with worse outcomes when compared to monomicrobial PTO. We therefore attempted to show the outcomes and predisposing factors associated with polymicrobial PTO.Methods: A single-center case-control study was carried out from 2007 to 2012. The outcome variables analyzed were: the need for additional surgical and antibiotic treatments, rates of amputation, and mortality associated with the infection. Univariate and multivariable analyses using multiple logistic regression were performed to identify risk factors associated with polymicrobial PTO, and p < 0.05 was considered significant.Results: Among the 193 patients identified, polymicrobial PTO was diagnosed in 37.8%, and was significantly associated with supplementary surgical debridement (56.1% vs. 31%; p < 0.01), a higher consumption of antibiotics, and more amputations (6.5% vs 1.3%; p < 0.01). Factors associated with polymicrobial PTO in the multivariable analysis were older age (odds ratio [OR] = 1.02, 95% confidence interval [CI] = 1.01 to 1.03, p = 0.04), working in agriculture (OR = 2.86, 95% CI = 1.05 to 7.79, p = 0.04), open fracture Gustilo type III (OR = 2.38, 95% CI = 1.02 to 5.56, p = 0.04), need for blood transfusion (OR = 2.15, 95% CI = 1.07 to 4.32, p = 0.03), and need for supplementary debridement (OR = 2.58, 95% CI = 1.29 to 5.16, p = 0.01).Conclusions: PTO is polymicrobial in more than one-third of patients, associated with extra surgical and clinical treatment, and worse outcomes including higher rates of amputation.

Objective: The aim of this study was to analyze the patient demographics, etiology of limb loss as well as reporting SF-36 scores for microprocessor prosthesis users in Turkish population. Methods: We reviewed 72 patients (61 male and 11 female; mean age: 37.7 ± 10.7) with uni-lateral, above knee amputation and a history of regular and microprocessor prosthesis use. All patients were called back for a last follow-up and they were asked to fill a self-administered general health status questionnaire (SF-36). Results: According to the SF-36 results; physical component score (PCS) score was 46 ± 7.3 and mental components summary (MCS) score was 46.5 ± 9.1. These scores have statistical similarity with Turkish healthy controls, except SF (social functioning) sub-dimension. PCS score for women microprocessor users were significantly lower than men (43.3 vs. 48.7, p = 0.03), but MCS scores were similar in between genders (46 vs. 48.2, p = 0.13). Conventional prostheses usage time was positively correlated with physical function (PF) scores (r = 0.322, p = 0.010). Microprocessor prosthesis usage time was negatively correlated with role limitations due to emotional problem (RE) scores (r = −0,313, p = 0.009). Conclusion: The quality of life surveys were showed that the loss of an extremity have higher physical and psychological impact on women's physical scores. Overall, SF-36 results were similar in microprocessor using amputee's and Turkish normal controls. Level of evidence: Level IV, therapeutic study. Keywords: Trans-femoral amputees, Microprocessor controlled prosthesis, Quality of life analysis, Physical component summary score

Introduction: Untreatable foot problems in diabetics may require lower extremity amputation, which has a high level of patient mortality. This high mortality rate is worse than most malignancies. The present study aimed to identify parameters that can be used to estimate survival in DM patients undergoing below-knee amputations for diabetic foot problems. Materials and methods: A total of 470 patients (299 males, 171 females) with a mean age of 64.32 years who underwent below-knee amputation for diabetic foot problems between 2004 and 2014 were enrolled in the study. The length of time from the operation to time of death was recorded in days. Patient details were obtained, including age during surgery, BMI, oral antidiabetic and insulin usage, dialysis therapy history, lower extremity endovascular intervention, previous amputation at the same extremity, the need for stump revision surgery during follow-up, and above-knee amputation at the same site. Biochemical test results of pre-operative HbAl c, ESR, and levels of CRP, BUN, and creatinine were also obtained. Results: A total of 333 patients (70.9%) died and 137 (29.1%) survived post-surgery. Survival rates were 90% in the first 7 days, 84% in the first 30 days, and 64% after the first year. Patient median life expectancy post-surgery was 930 106 days. Hemodialysis treatment (p = 0.001), endovascular intervention (p = 0.04), sex (p = 0.004), age (p = 0.001), BUN level (p = 0.001), and duration of insulin use (p = 0.003) were shown to be effective predictors of mortality. Conclusions: Life expectancy is low (