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A mangled extremity is the most devastating limb injury and presents a challenge for the orthopedic surgeon. There are two main treatment options, reconstruction or amputation, but sometimes indications for either are not clear. There are many pro and contra arguments for both options. To make the decision easier numerous score systems have been introduced, but the final decision is based on the judgment and experience of the treating surgeon. Early extremity reconstruction appears to give better results than delayed or late reconstruction and should be the treatment of choice where possible. The goal in reconstruction of a lower extremity is to restore and maintain balance and ambulation, while restoration of an upper extremity's numerous functions is more demanding. In this paper the authors describe and suggest treatment approaches in patients with a severely mangled extremity, including assessment and treatment of all injured tissues, using defined protocols, with special attention to bone stabilization, revascularization, soft-tissue coverage and nerve reconstruction. These have a great impact on the outcome and function of the injured extremity. Rehabilitation and return to the preinjury level is slow and sometimes uncertain. [ABSTRACT FROM AUTHOR]

Major amputations of the lower extremity may be required after trauma and a variety of underlying diseases such as peripheral vascular disease, diabetes, and malignancies. The goal of any major amputation is an optimal functional result with a maximum limb length in combination with optimal wound healing. The preservation of the knee joint is essential for successful rehabilitation, and this is best achieved by the Burgess below-knee amputation (BKA). Whenever a BKA is not possible, the Gritti–Stokes amputation is our first choice. This technique mainly consists of a through-knee amputation with the creation of a pedicled patella flap consisting of the patella, patellar ligament, and overlying soft tissue. After osteotomy of the distal femur and resection of the articular surface of the patella, the anterior flap is rotated in order to cover the femur defect while performing a patellofemoral arthrodesis. The aim of this paper is to describe our surgical technique and experience with GSA and to point out the important steps of this procedure. In conclusion, GSA is an excellent surgical option for patients requiring major lower limb amputations where BKA cannot be considered. Particular attention must be paid to careful preoperative evaluation and optimization of comorbidities. A meticulous surgical technique is warranted, including atraumatic tissue handling and an optimal patellofemoral arthrodesis technique.

Cranial cruciate ligament disease (CCLD) is one of the most frequent causes of hindlimb lameness in dogs. Tibial tuberosity advancement (TTA) is a common surgery performed for CCLD. A modified, simplified technique (TTA Rapid) is also reported to have very good clinical outcomes. In this paper, we report a modified TTA Rapid technique to treat a CCLD in a dog with an amputated contralateral hindlimb. A 5-year-old mixed breed dog presented with amputated right hindlimb and difficulty walking. Pain and positive drawer sign were present at manipulation of left stifle joint. Radiographic findings of the stifle joint confirmed the presence of moderate osteoarthritis associated with CCLD, and modified TTA Rapid procedure was performed. Recovery from surgery was uneventful, and the dog was able to stand by his own by the second day postoperative. At three months follow-up evaluation, the dog was free of lameness and the osteotomy site was completely healed. This paper describes the first modified TTA rapid osteotomy technique performed in a dog with a contralateral amputated hindlimb.

Background: The therapeutic benefits of motor imagery (MI) are now well-established in different populations of persons suffering from central nervous system impairments. However, research on similar efficacy of MI interventions after amputation remains scarce, and experimental studies were primarily designed to explore the effects of MI after upper-limb amputations. Objectives: The present comparative study therefore aimed to assess the effects of MI on locomotion recovery following unilateral lower-limb amputation. Methods: Nineteen participants were assigned either to a MI group (n = 9) or a control group (n = 10). In addition to the course of physical therapy, they respectively performed 10 min per day of locomotor MI training or neutral cognitive exercises, five days per week. Participants' locomotion functions were assessed through two functional tasks: 10 m walking and the Timed Up and Go Test. Force of the amputated limb and functional level score reflecting the required assistance for walking were also measured. Evaluations were scheduled at the arrival at the rehabilitation center (right after amputation), after prosthesis fitting (three weeks later), and at the end of the rehabilitation program. A retention test was also programed after 6 weeks. Results: While there was no additional effect of MI on pain management, data revealed an early positive impact of MI for the 10 m walking task during the pre-prosthetic phase, and greater performance during the Timed Up and Go Test during the prosthetic phase. Also, a lower proportion of participants still needed a walking aid after MI training. Finally, the force of the amputated limb was greater at the end of rehabilitation for the MI group. Conclusion: Taken together, these data support the integration of MI within the course of physical therapy in persons suffering from lower-limb amputations. [ABSTRACT FROM AUTHOR]

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Key Clinical Message: In select cases of body integrity identity disorder or body integrity dysphoria where noninvasive treatments prove ineffective and the patient's distress is substantial, elective amputation may serve as a viable and highly satisfying intervention, aligning the individual's physical self with their perceived identity. This case report presents an illustration of body integrity identity disorder (BIID), wherein a 20 years old ambidextrous male experiencing profound distress over his left hand's fourth and fifth fingers sought elective amputation after noninvasive treatments proved unsuccessful. Despite ethical concerns and limited literature on BIID, the decision to proceed with elective surgery was based on the patient's sustained desire, potential risks of self‐harm, and the distinct presentation involving two fingers rather than a complete limb. Following amputation, the patient experienced immediate relief, with nightmares ceasing, emotional distress subsiding, and improved functionality. This case highlights the potential efficacy and patient satisfaction associated with elective amputation in specific BIID presentations, shedding light on the unique challenges faced by affected individuals and emphasizing the importance of understanding, support, and inclusive healthcare practices. [ABSTRACT FROM AUTHOR]

The prognostic nutritional index (PNI) is a new marker used to assess a patient's nutritional and immune status. It is calculated using serum albumin levels and total lymphocyte count. The aim of this study was to investigate the relationship between PNI and amputation in patients with diabetic foot ulcer (DFU). Patients with DFU were enrolled in this retrospective study. In our study, a total of 386 patient data, of 110 (28.5%) amputated and 276 (71.5%) non-amputated patients, were statistically analyzed. PNI values were significantly lower in the amputated patient group than in the non-amputee patient group (p < 0.001). According to the ROC analysis results, PNI was significant in the prediction of amputation at an excellent level (AUC = 0.937 (0.911–0.963), p < 0.001). The optimal cut-off point for PNI was found to be 39,005. There was classification success for this cut-off point: sensitivity was calculated as 82.7% (74.1–89) and specificity as 93.1% (89.3–95.7). In the multivariate model, the odds ratio (OR) (95% CI) was calculated as 81.8 (38.5–173.7) for PNI. The PNI was associated with an increase in amputation rate in patients with DFU. By using PNI, patients can be directed to advanced centers and have access to early and appropriate interventions. [ABSTRACT FROM AUTHOR]

We evaluated the outcomes of the Krukenberg procedure conducted for the loss of a hand secondary to an electrical burn injury in six patients (10 hands). Patient demographics, indications for surgery, surgical strategy, complications, clinical measurements and Disabilities of the Arm, Shoulder and Hand (DASH) score were recorded, in addition to subjective outcome measures, including self-perception of social acceptance and employment status. The median DASH score at follow-up was 22 (range 4–50, interquartile range 25). Patients reported recovery of useful function in operated limbs. We recommend this procedure in low-resource settings when other reconstruction is impossible. Level evidence: IV [ABSTRACT FROM AUTHOR]

Background: Diabetic foot infection (DFI) leads to poor prognosis and polymicrobial infections are usually the main cause. The study is to explore the microbiological distribution, antimicrobial drug susceptibility, and risk factors of polymicrobial infections in hospitalized patients with DFI. Methods: This retrospective study included 160 patients with DFI in Wagner's grades 2, 3, and 4. Deep necrotic tissue was used to acquire specimens for microbiological culture. VITEK-2 system and MALDI-TOF mass spectrometry were used to identify the bacterial isolates. The Kirby Bauer method was used for drug susceptibility tests. Results: A total of 202 pathogens were isolated. The proportion of gram-negative bacilli (GNB, 62.4%, 126 of 202) was higher than that of gram-positive cocci (GPC, 37.6%, 76 of 202). The most prevalent GPC was Staphylococcus aureus in every Wagner grade, while the most common GNB varied in different Wagner grades. Linezolid was the most effective antibiotic for GPC in different Wagner grades. Imipenem was the most effective antibiotic for GNB in Wagner grade 2. Amikacin was the most effective antibiotic for GNB in Wagner grades 3 and 4. Polymicrobial infections existed only in Wagner grades 3 and 4 and increased the risk of amputation (p < 0.01). History of antibiotics, duration of diabetic foot, CRP, and lower extremity arterial disease were the independent risk factors of polymicrobial infections (p < 0.05). Conclusions: Clinicians should adjust the antibiotic as needed based on the results of drug susceptibility and clinical treatment effect among different Wagner grades. Particular attention should be given to the treatment of polymicrobial infections. [ABSTRACT FROM AUTHOR]

Negative pressure injury is one of the auxiliary methods of treating diabetes foot ulcers. It has been shown to be superior to conventional techniques in randomized controlled trials (RCTs). Nevertheless, the results of observational research are still scarce. A systematic review of RCTs and observations was carried out to evaluate the effectiveness and security of negative pressure wound therapy (NPWT) treatment for diabetes foot ulcers. Three English e‐databases have been found for NPWT research. The meta‐analyses of the comparative studies provided point estimates of results. Intermediate results were given as median and binary values were given in the form of odds ratios (OR). Seventeen trials, 13 RCTs and four randomized, controlled trials were found in the survey. Of these, 831 were treated with NPWT, 834 were treated with standard therapy. A total of 14 studies have been conducted to investigate the influence of NPWT on the healing of diabetic foot ulcers(DFU). In the study, NPWT was shown to speed up the healing of the wound in DFU patients(OR, 2.57; 95% CI, 1.72, 3.85 p < 0.0001). A subgroup analysis showed that NPWT was associated with an acceleration of the wound healing rate in 10 RCT trials (OR, 2.48; 95% CI, 1.58, 3.89 p < 0.001). In the four nRCT trials, NPWT was also shown to speed up the healing of the wound(OR, 2.95; 95% CI, 1.03, 8.42 p = 0.04). In 11 studies, the influence of NPWT on amputations of diabetes mellitus (DM) foot ulcers was investigated. The results showed that NPWT was associated with a reduction in amputations (OR, 0.53; 95% CI, 0.37, 0.74 p = 0.0002).In a subgroup of RCT trials, nine RCT trials showed a reduction in amputations(OR, 0.61; 95% CI, 0.43, 0.87 p = 0.007). In both nRCT trials, NPWT also showed a reduction in amputations (OR, 0.03; 95% CI, 0.00, 0.24 p = 0.001). Generally speaking, NPWT can help to heal the wound and lower the risk of amputations in people with diabetes. The subgroup analysis showed similar results for the RCT and non‐RCT trials. NPWT can be used to treat diabetes foot ulcers caused by diabetes. [ABSTRACT FROM AUTHOR]

The assessment for safety and effectiveness of surgical interventions in the management of diabetic foot ulcers (DFUs) in comparison to non‐surgical approaches was performed. A comprehensive search was performed across PubMed, MEDLINE, Cochrane Library and EMBASE in order to identify case–control studies, randomized controlled trials (RCTs), observational studies, cohort studies and observational studies pertaining to DFU treatments. Studies conducted in English language and focusing on wound healing rates, recurrence rates, time to healing and complication management met the inclusion criteria. There were six studies included in this meta‐analysis. Surgical procedures, such as debridement, revascularization and skin transplantation, demonstrated significantly superior efficacy in promoting wound healing (84%) and shorter duration of healing (6 weeks) in comparison to non‐surgical approaches, including off‐loading, wound dressings and pharmacological therapies. Surgical interventions for DFUs resulted in a wound recovery rate of 84%, a significantly higher mean rate than non‐surgical approaches (60%) that was observed. In addition, it was observed that the surgical group experienced considerably reduced average healing period of 9 weeks, in contrast to the non‐surgical group's mean healing period of 12 weeks. Nevertheless, it is imperative to acknowledge that surgical procedures were notably correlated with a heightened occurrence of complications, such as amputations, which transpired in 19% of instances. Surgical interventions for DFUs may provide superior short‐term results with regard to healing rates and recovery time, as indicated by this meta‐analysis. However, they are additionally correlated with the heightened likelihood of complications. Although non‐surgical techniques offered comparatively secure option, they were also less reliable. Individualized treatment modalities should be chosen in consideration of patient‐specific factors and comparative advantages and disadvantages. [ABSTRACT FROM AUTHOR]

This review article aims to provide an updated and comprehensive overview of the latest trends in adult upper limb prostheses, specifically targeting various amputation levels such as transradial, transmetacarpal, transcarpal, and transhumeral. A systematic search was conducted across multiple databases, including IEEE Xplore, MDPI, Scopus, Frontiers, and Espacenet, covering from 2018 to 2023. After applying exclusion criteria, 49 scientific articles (33 patents and 16 commercial prostheses) were meticulously selected for review. The article offers an in-depth analysis of several critical aspects of upper limb prostheses. It discusses the evolution and current state of input control mechanisms, the number of degrees of freedom, and the variety of grips available in prostheses, all tailored according to the level of amputation. Additionally, the review delves into the selection of materials used in developing these prostheses and examines the progression of technology readiness levels. A significant focus is also placed on the evolution of prosthesis weight over the years for different amputation levels. Moreover, the review identifies and explores critical technological challenges and prospects in upper limb prostheses. Finally, the article culminates with a conclusion that encapsulates the key findings and insights on the advancements and ongoing developments in this field. [ABSTRACT FROM AUTHOR]

Tongue injuries in children vary from slight lacerations to complete amputation. It could be due to falls, self-mutilation, epilepsy, child abuse, or sports injuries. The anterior dorsum is the most common site, followed by the mid dorsum and anterior ventral part. These injuries may cause dysfunction of the tongue, hemorrhage, and disfigurement. Management of injuries of the tongue in young children is challenging. There are no established guidelines for managing tongue lacerations. This is a case report of a 3-year-old girl with a laceration on the anterolateral part of the tongue with nonapproximating wound edges. The laceration extended from the dorsal to the ventral part. The parents were apprehensive for the surgical management of the injury due to the age of their daughter. Hence, healing of the injury with conservative management without suturing was achieved. The management of traumatic injuries of the tongue in children is difficult due to their age and cooperation. The pediatrician has to decide whether to heal the tongue by primary or secondary intention. Our decision to allow the healing by secondary intention was successful. The tongue healed without any complications, barring a small scar, with satisfactory esthetic and functional outcome. Both the parents and the child were satisfied with the management of the injury. [ABSTRACT FROM AUTHOR]

Since the inception of the SARS-CoV-2 pandemic, healthcare systems around the world observed an increased rate of Acute Limb Ischemia (ALI) in patients with a COVID-19 infection. Despite several pieces of evidence suggesting that COVID-19 infection may also worsen the prognosis associated with ALI, only a small number of published studies include a direct comparison regarding the outcomes of both COVID-19 and non-COVID-19 ALI patients. Based on the above, a systematic review and a meta-analysis of the literature were conducted, evaluating differences in the incidence of two major outcomes (amputation and mortality rate) between patients concurrently affected by COVID-19 and negative ALI subjects. PubMed (MEDLINE), Web of Science, and Embase (OVID) databases were scrutinized from January 2020 up to 31 December 2023, and 7906 total articles were recovered. In total, 11 studies (n: 15,803 subjects) were included in the systematic review, and 10 of them (15,305 patients) were also included in the meta-analysis. Across all the studies, COVID-19-positive ALI patients experienced worse outcomes (mortality rates ranging from 6.7% to 47.2%; amputation rates ranging from 7.0% to 39.1%) compared to non-infected ALI patients (mortality rates ranging from 3.1% to 16.7%; amputation rates ranging from 2.7% to 18%). Similarly, our meta-analysis shows that both the amputation rate (OR: 2.31; 95% CI: 1.68–3.17; p < 0.00001) and mortality (OR: 3.64; 95% CI: 3.02–4.39; p < 0.00001) is significantly higher in COVID-19 ALI patients compared to ALI patients. [ABSTRACT FROM AUTHOR]

Facing above-knee amputation poses a significant hurdle due to its profound impact on walking ability. To overcome this challenge, a complex adaptation strategy is necessary at the neuromuscular level to facilitate safe movement with a prosthesis. Prior research conducted on lower-limb amputees has shown a comparable amount of intricacy exhibited by the neurological system, regardless of the level of amputation and state of walking. This research investigated the differences in muscle synergies among individuals with unilateral transfemoral amputations during walking at three different speeds of transient-state gait. Surface electromyography was recorded from eleven male transfemoral amputees' intact limbs (TFA), and the concatenated non-negative matrix factorization technique was used to identify muscle synergy components, synergy vectors (S), and activation coefficient profiles (C). Results showed varying levels of correlation across paired-speed comparisons in TFA, categorized as poor (S1), moderate (S3 and S4), and strong (S2). Statistically significant differences were observed in all activation coefficients except C3, particularly during the stance phase. This study can assist therapists in understanding muscle coordination in TFA during unsteady gait, contributing to rehabilitation programs for balance and mobility improvement, and designing myoelectric prosthetic systems to enhance their responsiveness to trips or falls. [ABSTRACT FROM AUTHOR]

The study aims to construct an inertial measuring system for the application of amputee subjects wearing a prosthesis. A new computation scheme to process inertial data by installing seven wireless inertial sensors on the lower limbs was implemented and validated by comparing it with an optical motion capture system. We applied this system to amputees to verify its performance for gait analysis. The gait parameters are evaluated to objectively assess the amputees' prosthesis-wearing status. The Madgwick algorithm was used in the study to correct the angular velocity deviation using acceleration data and convert it to quaternion. Further, the zero-velocity update method was applied to reconstruct patients' walking trajectories. The combination of computed walking trajectory with pelvic and lower limb joint motion enables sketching the details of motion via a stickman that helps visualize and animate the walk and gait of a test subject. Five participants with above-knee (n = 2) and below-knee (n = 3) amputations were recruited for gait analysis. Kinematic parameters were evaluated during a walking test to assess joint alignment and overall gait characteristics. Our findings support the feasibility of employing simple algorithms to achieve accurate and precise joint angle estimation and gait parameters based on wireless inertial sensor data. [ABSTRACT FROM AUTHOR]

Peripheral artery disease (PAD) is associated with high rates of readmission following endovascular interventions and contributes to a significant hospital readmission burden. Quality metrics like hospital readmissions affect hospital performance, but must adjust to local trends. Our primary goal was to evaluate risk factors and readmission rates post-percutaneous peripheral intervention in a US-Mexico border city, at a single tertiary university hospital. We performed a retrospective review of patients with PAD undergoing first time peripheral intervention from July 2015 to June 2020. Among 212 patients, 58% were readmitted with median 235-day follow-up (inter-quartile range (IQR) 42–924); 35.3% of readmissions occurred within 30 days, and 30.2% of those were within 7 days. Median time to readmission was 62 days. Active smokers had 84% higher risk of readmission (hazard ratio (HR) 1.84, 95% CI 1.23–2.74, P <.01). Other significant factors noted were insurance status—Medicaid or uninsured (HR 1.94, 95% CI 1.22–3.09), prior amputation (HR 1.69, 95% CI 1.13–2.54), heart failure, both preserved (HR 4.35, 95% CI 2.07–9.16) and reduced ejection fraction (HR 1.88, 95% CI 1.14–3.10). Below the knee, interventions were less likely to be readmitted (adjusted HR.64, 95% CI 0.42–.96). Readmission rates were unrelated to medication adherence. [ABSTRACT FROM AUTHOR]

Background: Targeted muscle reinnervation (TMR) has been shown to play an important role in managing neuromas. However, the impact of the timing of TMR on pain visual analogue scale (VAS) scores or patient opioid use has not been thoroughly explored. We hypothesized that TMR performed acutely would lead to lower VAS scores and decreased opioid intake. Methods: Prospectively collected data from an amputation registry at a single institution were utilized to identify patients who underwent TMR. Acute TMR was defined as TMR performed within 1 month of the major limb amputation. Primary outcomes included VAS pain scores and patient-reported opioid consumption. Results: In all, 25 patients (26 limbs) were identified in the acute group, and 18 patients (18 limbs) were identified in the delayed group. At intermediate follow-up (between 4 and 8 months postoperatively) and at final follow-up, the average pain VAS score in the delayed TMR group was significantly higher than that in the acute group (5.2 vs. 1.9 at intermediate P =.01 and 6.2 vs. 1.9 at final P =.002). In all, 84% of the amputees overall were not consuming opioid medications at the time of final follow-up (79% acute, 88% delayed, P =.72). There were no statistically significant differences in opioid consumption between the acute and delayed group at intermediate follow-up (P =.35) or at final follow-up (P =.68). Conclusions: TMR is an effective procedure to reduce pain following major limb amputation. Patients with TMR performed acutely had significantly lower VAS pain scores at both intermediate and final follow-up than patients with TMR performed in a delayed setting. Type of Study/Level of Evidence: Therapeutic II. [ABSTRACT FROM AUTHOR]

Precariousness dominates the lives of patients with recent diabetic lower extremity amputations. Wound healing is not guaranteed, post-amputation mortality is high and personal and social identities are destabilised. This study explores the experiences of nine post-amputation diabetic patients in the context of Singapore’s primary health and social care and diversified cultural setting. The loss of physical integrity leads to the self being rendered precarious in multiple ways: emotional-existential precariousness results from uncertainty about survival; agentic precariousness, from restrictions to the individual’s autonomy; the social self is rendered precarious as social relations and identities are changed; and financial precarity, which arises from job insecurity and treatment cost. Patients act to overcome precariousness and regain agency in various ways. Supporting patients’ agency should be integral to all healthcare interventions, at whatever stage of the patient’s journey, and needs to take into account cultural roles and values. [ABSTRACT FROM AUTHOR]

Chronic pain resulting from peripheral nerve injury remains a common issue in the United States and affects 7 to 10% of the population. Regenerative Peripheral Nerve Interface (RPNI) surgery is an innovative surgical procedure designed to treat posttraumatic neuropathic pain, particularly when a symptomatic neuroma is present on clinical exam. RPNI surgery involves implantation of a transected peripheral nerve into an autologous free muscle graft to provide denervated targets to regenerating axons. RPNI surgery has been found in animal and human studies to be highly effective in addressing postamputation pain. While most studies have reported its uses in the amputation patient population for the treatment of neuroma and phantom limb pain, RPNI surgery has recently been used to address refractory headache, postmastectomy pain, and painful donor sites from the harvest of neurotized flaps. This review summarizes the current understanding of RPNI surgery for the treatment of chronic neuropathic pain. [ABSTRACT FROM AUTHOR]

This retrospective cohort study aims to assess whether the implementation of a multidisciplinary approach in the Gosford Hospital High‐Risk Foot Clinic improved outcomes of diabetic foot ulcers. Ulceration is a common foot complication of diabetes mellitus and greatly increases patient morbidity and mortality. Patients who attended at least one appointment at the Gosford Hospital High‐Risk Foot Clinic in 2017 or 2019 were identified through the Gosford Hospital Podiatry department's records. The 2017 and 2019 cohorts were compared on measures of ulcer healing, incidence of amputation, incidence of vascular intervention and surgical debridement, percentage of patients admitted to hospital due to complications and use of systemic antibiotic therapy. Sixty‐one patients in 2017 and 59 patients in 2019 met inclusion criteria, and from them, 207 ulcers were included. Between 2017 and 2019, there was a 6.2‐week reduction in time to 100% ulcer healing in 2019 (p = 0.021), and 10.1% more ulcers healed within 52 weeks (p = 0.22, 95% confidence interval [CI] [−5.9%, 25.5%]). Whilst there was no significant difference in incidence of patients receiving amputation, there was an increased absolute number of amputations in 2019. Implementation of a multidisciplinary approach at the Gosford Hospital High‐Risk Foot Clinic led to improvements in diabetic foot ulcer healing. [ABSTRACT FROM AUTHOR]

Peripheral artery disease (PAD) continues to increase in prevalence worldwide due to risk factors such as advanced age, diabetes mellitus, and obesity. Critical limb ischemia (CLTI) is the advanced form of PAD that can result in a lack of healing and limb loss as the most devastating consequence. Patients with PAD, especially CLTI, benefit from multidisciplinary care to optimize outcomes by reducing cardiovascular morbidity and mortality and preventing lower extremity amputation. Collaboration between various specialties allows a focus on problems involved in treating the patient with PAD including prevention, screening, medical care, wound care, infection, and revascularization when needed. Although there is no clear definition or consensus on the structure of the PAD team, certain guidelines are applicable to most clinical scenarios emphasizing “provider champions” in leading a clinical program. A vascular specialist (vascular surgery, interventional radiology, interventional cardiology) and a soft tissue specialist (podiatry, plastic surgery) are the typical “champions,” often involving orthopedics, general surgery, vascular medicine, diabetology/endocrinology, infectious disease, nephrology, and rehabilitation medicine. The team should also include wound nurses, nutritionists, occupational therapists, orthotists, pharmacists, physical therapists, prosthetists, and social workers. This paper presents a brief overview of the structure of the multidisciplinary team with key components and functions of such a team to optimize treatment outcomes for PAD and CLTI.

Background: Diabetic foot ulcer and potential subsequent lower extremity amputation are major complications of diabetes mellitus and are also prominent morbidity factors that could affect patients' quality of life. Objectives: This study aimed to assess the prevalence of diabetic foot amputation and explore correlates of amputation cause and type among subjects with diabetes mellitus in Tehran, Iran. Methods: A descriptive cross-sectional study was conducted to assess the demographic, sociological, and clinical characteristics of subjects who had undergone lower extremity amputation due to diabetic foot ulcers, from 2011 to 2020, in two educational medical centers in Tehran, Iran. We examined the medical records of 4676 individuals who were admitted to Shariati and Sina hospitals due to diabetic foot issues. Information related to patient demographics (age, gender, marital status), social factors (education level, insurance), and clinical data (medical history, laboratory results, and characteristics of diabetic foot ulcers) was collected for subjects who had undergone lower extremity amputation due to diabetic foot ulcer. The collected data was reported using average values, standard deviations and proportions and analyzed using statistical tests. Results: During one decade, 882 out of 4676 (18.8%) patients with diabetic foot ulcers underwent lower extremity amputations of various types in Sina and Shariati hospitals in Tehran, Iran. Of these, 692 (14.5%) were included for further analysis in the study and the rest were excluded due to lack of sufficient recorded data. About 75.9% of the study population was male, and the average age including both sexes was 60 years. About 92.7% were married, and on average, subjects had been afflicted with diabetes mellitus for 15.1 years. Statistical analysis using Pearson's chi-square test showed there was a significant association between the treatment regimen for diabetes mellitus and the type of amputation (P =.01), as well as between the duration of the disease and the cause of amputation (P =.01) and its type (P =.04). Conclusion: diabetes mellitus related treatment regimen and duration of disease are significantly associated with amputation cause and type. Plain Language Summary: Understanding Why and How Diabetic Patients Lose Their Feet: A Study from Tehran, Iran This study explored patients with diabetes in Tehran, Iran, experience foot problems leading to amputation. We looked at the records of 4676 patients over a decade, finding that 18.8% had lower limb amputations. Key factors included treatment methods for diabetes and the duration of the disease, significantly impacting the cause and type of amputation. These insights can guide better care to prevent such serious complications in patients with diabetes. [ABSTRACT FROM AUTHOR]

Purpose: Limb salvage surgery and amputation are two commonly performed procedures for lower extremity tumors. When comparing these procedures in tumor patients, it is important to consider their impact on quality of life (QOL) and functional mobility. These patients often experience physical, emotional, and psychological challenges, making these factors crucial in determining the most suitable treatment approach. Method: The outcomes of lower extremity tumors patients for QOL were collected from PubMed, MEDLINE, EMBASE, Cochrane, and Google Scholar until 28 February 2023. The physical function, mental health, role function, social function, emotional function, Toronto Extremity Salvage Score, and Musculoskeletal Tumor Society Score outcomes were analyzed to determine the differences between the two procedures. Results: Five articles were included according to the selection criteria with a total of 245 patients. The standard mean difference (SMD) values of each parameter were slightly higher in limb salvage surgery patients but not higher enough to produce statistically significant results; the SMD values for physical function and mental health were 0.72 and 0.04, respectively. This study did not report any heterogeneity or publication bias. Conclusions: QOL is a large and enhanced term, which carries its importance and is challenging to compare between any procedures. The minimal rise in SMD of different QOL parameters highlighted only a slight advantage of limb salvage surgery over amputation. Therefore, further research is required to explore the impact of this crucial topic. [ABSTRACT FROM AUTHOR]

Despite the increasing incidence and prevalence of amputation across the globe, individuals with acquired limb loss continue to struggle with functional recovery and chronic pain. A more complete understanding of the motor and sensory remodeling of the peripheral and central nervous system that occurs postamputation may help advance clinical interventions to improve the quality of life for individuals with acquired limb loss. The purpose of this article is to first provide background clinical context on individuals with acquired limb loss and then to provide a comprehensive review of the known motor and sensory neural adaptations from both animal models and human clinical trials. Finally, the article bridges the gap between basic science researchers and clinicians that treat individuals with limb loss by explaining how current clinical treatments may restore function and modulate phantom limb pain using the underlying neural adaptations described above. This review should encourage the further development of novel treatments with known neurological targets to improve the recovery of individuals postamputation. [ABSTRACT FROM AUTHOR]

Background. Diabetes mellitus (DM) is a major global health problem, and its incidence is growing. Depending on this increase, the number of diabetes-related complications will also rise. Objectives. This study aimed to determine the risk factors associated with major and minor amputations resulting from diabetes. Materials and methods. Patients diagnosed with diabetic foot complications (n = 371) and hospitalized between January 2019 and March 2020 were retrospectively evaluated using information obtained from the database of Diabetic Foot Wound Clinic. Examination of the data identified 165 patients for inclusion in the study, who were stratified into major amputation (group 1, n = 32), minor amputation (group 2, n = 66) and non-amputation (group 3, n = 67) groups. Results. Of the 32 patients who underwent major amputations, 84% had a below-knee amputation, 13% had an above-knee amputation and 3% had knee disarticulation. At the same time, 73% of 66 patients who underwent minor amputation had a single-finger amputation, 17% had a multiple-finger amputation, 8% had a transmetatarsal amputation, and 2% had Lisfranc amputation. Laboratory results showed high acute phase protein and low albumin (ALB) levels in patients from group 1 (p < 0.05). Although Staphylococcus aureus was found to be the most common infectious agent, Gram-negative pathogens were dominant (p < 0.05). Also, there was a significant cost difference between the groups (p < 0.05). Furthermore, those aged over 65 had a high Wagner score, high Charlson Comorbidity Index (CCI), long diabetic foot ulcer (DFU) duration, and high white blood cell (WBC) count, all of which were risk factors for major amputation (p < 0.05). Conclusions. This study demonstrated an increased Wagner staging and incidence of peripheral neuropathy (PN) and peripheral arterial disease (PAD) in major amputation patients. In addition, the rate of distal vessel involvement was high in major amputation patients, with elevated acute phase proteins and low ALB levels crucial in laboratory findings. [ABSTRACT FROM AUTHOR]

The purpose of the present study aims to describe 16 clinical cases of pet lizards with hemipenile prolapse - 11 leopard geckos (Eublepharis macularius), 3 chameleons (2 Chamaeleo calyptratus and 1 Furcifer pardalis), and 2 bearded dragons (Pogona vitticeps). After an unsuccessful attempt of manual repositioning of the everted hemipenes, unilateral or bilateral surgical amputation was performed to avoid future complications. All patients were anesthetized with a combination of medetomidine hydrochloride and ketamine hydrochloride. In the bearded dragons, a local block with lidocaine hydrochloride was additionally used. The authors' clinical experience with this surgical procedure confirmed the view that the hemipenectomy is an appropriate attempt in hemipenile prolapse in pet lizards from the Eublepharidae, Chamaeleonidae, and Agamidae families. [ABSTRACT FROM AUTHOR]

Background: Depression is increasingly diagnosed in the general population today. The loss of a limb through amputation, which can result in disfigurement, may also contribute to the development of depression despite pre-operative counselling. Understanding the factors associated with depression in individuals with limb amputation is important to effectively identify and manage this psychological condition. The objective of this study was to identify the factors associated with depression in individuals who have undergone limb amputation. Methods: A descriptive crosssectional study was conducted in Quetta City from May to July 2018. Data were collected using a structured, respondent-cantered questionnaire based on the Hospital Anxiety and Depression Scale (HADS). Results: Females were more affected as 5 out of 7 (71.42%) were depressed compared to 32 out of 47 (68%) males. The study found a statistically significant association between depression and marital status (p-value of 0.047) as well as amputation (p-value of 0.039). These results suggest that both sociodemographic factors, such as marital status, and the experience of amputation are associated with the development of depression in individuals with limb amputation. Conclusion: Amputation is significantly associated with the level of depression among amputees, and sociodemographic factors, such as marital status, also play a role in the development of depression. Therefore, it is recommended to conduct yearly screenings for depression following an amputation to effectively identify and manage this psychological condition. Further research and interventions are needed to address the mental health needs of individuals with limb amputation and implement strategies for depression prevention and management in this population. [ABSTRACT FROM AUTHOR]

Earthworms are affected by physical stress, like injury, and by exposure to xenobiotics, such as the toxic metal cadmium (Cd), which enters the environment mainly through industry and agriculture. The stress response to the single and the combination of both stressors was examined in regenerative and unharmed tissue of Lumbricus terrestris to reveal if the stress response to a natural insult like injury (amputation) interferes with Cd detoxification mechanisms. We characterized the roles of metallothionein 1 (MT1) and MT2 isoforms, heat shock protein 70 as well as immune biomarkers such as the tolllike receptors (TLR) single cysteine cluster TLR and multiple cysteine cluster TLR. The role of the activated transcription factors (ATFs) ATF2, ATF7, and the cAMP responsive element binding protein as putative regulatory intersection as well as a stress-dependent change of the essential trace elements zinc and calcium was analyzed. Phosphorylated AMP activated protein kinase, the cellular energy sensor, was measured to explore the energy demand, while the energy status was determined by detecting carbohydrate and protein levels. Taken together, we were able to show that injury rather than Cd is the driving force that separates the four treatment groups - Control, Cd exposure, Injury, Cd exposure and injury. Interestingly, we found that gene expression differed regarding the tissue section that was analyzed and we hypothesize that this is due to the migration of coelomocytes, earthworm immune cells, that take over a key role in protecting the organism from a variety of environmental challenges. Surprisingly, we discovered a role for MT1 in the response to multiple stressors and an isoform-specific function for the two newly characterized TLRs. In conclusion, we gathered novel information on the relation of innate immunity, wound healing, and Cd detoxification mechanisms in earthworms. [ABSTRACT FROM AUTHOR]

Several reports have demonstrated the effectiveness of neurorehabilitation, such as mirror therapy or virtual reality, in treating phantom limb pain (PLP). This case study describes the effect of virtual reality training (VRT) on severe, long-term PLP and upper limb activity on the amputated side in a patient who underwent digit amputation 9 years prior. A woman in her 40 s underwent amputation of 2-5 fingers 9 years prior due to a workplace accident. She experienced persistent pain in the palms of her hand near the amputation sites. A single case design (ABA'B') was applied. Periods A and A' were set as periods without VRT intervention, and Periods B and B' were set as periods with VRT intervention. Periods A, B, A', and B' lasted 4, 10, 8, and 10 weeks, respectively. VRT was a task during which visual stimulation and upper limb movements were linked. The task consisted of catching a rolling ball in the display with a virtual hand, operated with both hands using a controller. VRT was performed once every 2-4 weeks for 30 min. Pain intensity was assessed using the short-form McGill Pain Questionnaire-2. Bilateral upper limb activity was measured continuously for 24 h using a triaxial accelerometer attached to the right and left wrist joints. The pain intensity was 147/220 points during Period A, 128 points during Period B, 93 points during Period A', and 100 points during Period B', showing a gradual decrease. Upper limb activity occurred mainly on the intact side during Periods A and B, whereas the activity on the amputated side increased 2-fold after Period A', and both upper extremities were used equally. Virtual reality training resulted in reduced pain intensity and increased activity in the upper limb. VRT may have induced reintegration of the sensory-motor loop, leading to a decrease in the PLP intensity. The upper limb activity on the amputated side may have also increased with the pain reduction. These results suggest that VRT may be valuable in reducing severe, long-term PLP. [ABSTRACT FROM AUTHOR]

Diabetic foot ulcer (DFU), a common intractable chronic complication of diabetes mellitus (DM), has a prevalence of up to 25%, with more than 17% of the affected patients at risk of amputation or even death. Vascular risk factors, including vascular stenosis or occlusion, dyslipidemia, impaired neurosensory and motor function, and skin infection caused by trauma, all increase the risk of DFU in patients with diabetes. Therefore, diabetic foot is not a single pathogenesis. Preclinical studies have contributed greatly to the pathogenesis determination and efficacy evaluation of DFU. Many therapeutic tools are currently being investigated using DFU animal models for effective clinical translation. However, preclinical animal models that completely mimic the pathogenesis of DFU remain unexplored. Therefore, in this review, the preparation methods and evaluation criteria of DFU animal models with three major pathological mechanisms: neuropathy, angiopathy and DFU infection were discussed in detail. And the advantages and disadvantages of various DFU animal models for clinical sign simulation. Furthermore, the current status of vitro models of DFU and some preclinical studies have been transformed into clinical treatment programs, such as medical dressings, growth factor therapy, 3D bioprinting and pre‐vascularization, Traditional Chinese Medicine treatment. However, because of the complexity of the pathological mechanism of DFU, the clinical transformation of DFU model still faces many challenges. We need to further optimize the existing preclinical studies of DFU to provide an effective animal platform for the future study of pathophysiology and clinical treatment of DFU. [ABSTRACT FROM AUTHOR]

We performed a scoping review to identify the extent of the literature describing the use of iloprost in the treatment of frostbite. Iloprost is a stable synthetic analog of prostaglandin I2. As a potent inhibitor of platelet aggregation and vasodilator, it has been used to address the post-rewarming reperfusion injury in frostbite. The search using iloprost and frostbite as key words and MeSH terms yielded 200 articles. We included in our review the literature examining iloprost for the treatment of frostbite in humans in the form of primary research, conference proceedings and abstracts. Twenty studies published from 1994 to 2022 were selected for analysis. The majority were retrospective case series consisting of a homogeneous population of mountain sport enthusiasts. A total of 254 patients and over 1000 frostbitten digits were included among the 20 studies. The larger case series demonstrated a decrease in amputation rates relative to untreated patients. Primary gaps in the literature include a paucity of randomised trials and relatively limited study populations to date. While the case evidence is promising, a multi-centre collaboration would be crucial to adequately power prospective randomised studies to definitively determine if iloprost has a role in the treatment of frostbite. [ABSTRACT FROM AUTHOR]

As the number of patients with amputations increases, research on assistive devices such as prosthetic limbs is actively being conducted. However, the development of assistive devices for patients with partial amputations is insufficient. In this study, we developed a finger prosthesis for patients with partial amputations. The design and mathematical modeling of the prosthesis are briefly presented. A pneumatic actuator, based on the McKibben muscle design, was employed to drive the finger prosthesis. We characterized the relationship between the actuator's force and axial length changes with varying pressure. An empirical model derived from conventional mathematical modeling of force and axis length changes was proposed and compared with experimental data, and the error was measured to be between about 3% and 13%. In order to control the actuator using an electromyography (EMG) signal, an electrode was attached to the user's finger flexors. The EMG signal was measured in relation to the actual gripping force and was provided with visual feedback, and the magnitude of the signal was evaluated using root mean square (RMS). Depending on the evaluated EMG signal magnitude, the pressure of the actuator was continuously adjusted. The pneumatic pressure was adjusted between 100 kPa and 250 kPa, and the gripping force of the finger prosthesis ranged from about 0.7 N to 6.5 N. The stiffness of the prosthesis can be varied using the SMA spring. The SMA spring is switched to a fully austenite state at 50 °C through PID control, and when the finger prosthesis is bent to a 90° angle, it can provide approximately 1.2 N of assistance force. Finally, the functional evaluation of the finger prosthesis was performed through a pinch grip test of eight movements. [ABSTRACT FROM AUTHOR]

Objectives: This study aims to determine the prevalence of knee osteoarthritis (OA) and associated risk factors in the contralateral limb after lower limb amputation. Methods: This cross-sectional survey included 500 lower limb amputees using prostheses for at least 1 year using convenience sampling from the Pakistan Institute of Prosthetic and Orthotic Sciences (PIPOS), Peshawar City, Pakistan rehabilitation services program (PRSP) and its satellite centers across Khyber Pakhtunkhwa. A sample included either gender aged 20 to 80 years. A basic demographic sheet and risk factors questionnaire and American College of Rheumatology (ACR) guidelines diagnostic knee OA criteria, such as using history, physical examination, and radiographic findings were used to collect data. Data were analyzed using SPSS software, version 21. T-test and analysis of variance (ANOVA) statistics were utilized to observe any relationship with P<0.05 as significant. Results: The current study revealed the prevalence of OA in 131 people (26.2%) with a higher prevalence in 86 married men (65.5%) aged 51-80 years (99[75.6%] and 99[75.6%]) with the predominance of 87 trans-tibial amputees (TTA) (66.4%). Sustained knee bending was the most prevalent risk factor in 127 people (96.9%, 31.07), followed by the history of a painful knee injury in 117 people (89.3%, 12.00), sitting on the floor for home activities in 106 people (80.9%, 8.00) and occupation with knee use in 129 people (98.5%, 7.25). Discussion: The high prevalence of 26.2% of OA in the sound limb in lower limb amputees is more common in married men aged 51-80 years with trans-tibial amputation on the contralateral side. Common risk factors include sustained knee bending, a history of a painful knee injury, sitting on the floor for home activities, and occupations with knee use. [ABSTRACT FROM AUTHOR]

Introduction: Nepal is a developing country where diabetes is becoming a major health challenge due to its high prevalence of 8.5% affecting around 2 million people. Due to limited resources, there are many barriers to providing affordable and convenient diabetes care or regular screening for complications. There is no reliable data on incidence, prevalence, and complications of diabetic foot problems in Nepal. Methods: We conducted an online survey amongst senior physicians, who were members of 'Diabetes & Endocrine Association of Nepal' to assess their perception of diabetic foot problems in Nepal. Results: Thirty-Eight physicians responded to the survey who saw a total of 17597 patients in the preceding month. They recalled seeing 647 with 'Diabetic Foot Ulcers', giving a crude Diabetic Foot Ulcer prevalence rate of 3.7%. They recalled seeing 2522 patients with painful neuropathy that required medical treatment, giving a crude painful neuropathy prevalence rate of 14.3%. A history of foot ulcer was present in an additional 578 patients. Previous minor amputation had been performed in 215 patients (1.2%) and major amputation in 135 patients (0.8%). Discussion: Despite having expertise in various fields there is no dedicated multidisciplinary diabetic foot clinic in Nepal. This survey shows that diabetic foot problems are abundant in Nepal and there is a need for structured multidisciplinary approach for screening and treatment. [ABSTRACT FROM AUTHOR]

A meta‐analysis investigation was executed to measure the outcome of endovascular surgery (ES) and open surgery (OS) for the management of peripheral artery diseases (PADs) on amputation and limb salvage (LS). A comprehensive literature inspection till February 2023 was applied and 3451 interrelated investigations were reviewed. The 31 chosen investigations enclosed 19 948 individuals with PADs were in the chosen investigations' starting point, 8861 of them were utilising ES, and 11 087 were utilising OS. Odds ratio (OR) in addition to 95% confidence intervals (CIs) were utilised to compute the value of the effect of ES and OS for the management of PADs on amputation and LS by the dichotomous approaches and a fixed or random model. ES had significantly lower amputation (OR, 0.80; 95% CI, 0.68‐0.93, P = 0.005) compared with those with OS in individuals with PADs. No significant difference was found between ES and OS in 30‐day LS (OR, 0.95; 95% CI, 0.64‐1.42, P = 0.81), 1‐year LS (OR, 1.06; 95% CI, 0.81‐1.39, P = 0.68), and 3‐year LS (OR, 0.86; 95% CI, 0.61‐1.19, P = 0.36) in individuals with PADs. ES had significantly lower amputation, 30‐day LS, 1‐year LS, and 3‐year LS compared with those with OS in individuals with PADs. However, care must be exercised when dealing with its values because of the low sample size of some of the nominated investigations for the meta‐analysis. [ABSTRACT FROM AUTHOR]

Introduction: This retrospective study describes the demographics and injury characteristics of a recently identified cohort of US Service members with combat-related lower extremity limb salvage (LS). Methods: US Service members with combat trauma were identified from the Expeditionary Medical Encounter Database and Military Health System Data Repository and stratified into primary amputation (PA), LS, and non-threatened limb trauma (NTLT) cohorts based on ICD-9 codes. Disparities in demographic factors and injury characteristics were investigated across cohorts and within the LS cohort based on limb retention outcome. Results: Cohort demographics varied by age but not by sex, branch, or rank. The mechanism of injury and injury characteristics were found to be different between the cohorts, with the LS cohort exhibiting more blast injuries and greater injury burden than their peers with NTLT. A sub-analysis of the LS population revealed more blast injuries and fewer gunshot wounds in those that underwent secondary amputation. Neither demographic factors nor total injury burden varied with limb retention outcome, despite slight disparities in AIS distribution within the LS cohort. Conclusions: In accordance with historic dogma, the LS population presents high injury severity. Demographics and injury characteristics are largely invariant with respect to limb retention outcomes, despite secondary amputation being moderately more prevalent in LS patients with blast-induced injuries. Further study of this population is necessary to better understand the factors that impact the outcomes of LS in the Military Health System. [ABSTRACT FROM AUTHOR]

The diabetic peripheral neuropathy pain model was constructed after 95 Sprague Dawley rats had been randomly divided among blank reference and model groups. Aescin low-dose group (0.5 mg/kg), aescin medium-dose group (1.0 mg/kg), aescin high-dose group (1.5 mg/kg), and positive control group (0.25 mg/ kg mecobalamin) were then randomly assigned to the simulation group following successful modeling. At the conclusion of the study, the mean sciatic nerve conduction velocity was determined, blood glucose in addition to the amount of inflammatory factors tumor necrosis factor-alpha, interleukin-6, and interleukin-1 were determined, and sciatic nerve cells from mice in all groups were collected for Western blot to identify the protein levels of high mobility group box 1 and receptor for advanced glycation end products. The mean sciatic nerve conduction velocity of the medium and high-dose groups of aescin was higher than those of the model control (p<0.05); rat blood glucose content, the contents of inflammatory factors interleukin-1 beta, interleukin-6 and tumor necrosis factor-alpha as well as the protein expression of high mobility group box 1 and receptor for advanced glycation end products in sciatic nerve tissue were lower and the body mass was higher than that of the model control group (p<0.05). Comparing the high-dose aescin group as well as the positive control group, there had been no discernible change in the aforementioned indices (p>0.05). Aescin is able to effectively improve the inflammatory response in the body by regulating high mobility group box 1-receptor for advanced glycation end products levels and slow down diabetic peripheral neuropathy caused by the inflammatory response. [ABSTRACT FROM AUTHOR]

The stability of the body during locomotion is a fundamental requirement for walking animals. The mechanisms that coordinate leg movement patterns are even more complex at water–air interfaces. Water striders are agile creatures on the water surface, but they can be vulnerable to leg damage, which can impair their movement. One can assume the presence of certain compensatory biomechanical factors that are involved in the maintenance of postural balance lost after an amputation. Here, we studied changes in load distribution among the legs and assessed the effects of amputation on the locomotory behavior and postural defects that may increase the risk of locomotion failure. Apparently, amputees recover a stable posture by applying leg position modifications (e.g., widening the stance) and by load redistribution to the remaining legs. Water striders showed steering failure after amputation in all cases. Amputations affected locomotion by (1) altering motion features (e.g., shorter swing duration of midlegs), (2) functional constraints on legs, (3) shorter travelled distances, and (4) stronger deviations in the locomotion path. The legs functionally interact with each other, and removal of one leg has detrimental effects on the others. This research may assist the bioinspired design of aquatic robots. [ABSTRACT FROM AUTHOR]

Background: Pain in the postoperative period of amputation surgeries, when not managed correctly, can have consequences for the patient. Purposes and Objectives: The aim of this study was to map the scientific evidence on pain management in patients in the postoperative period of amputation surgeries. Design: Scoping review with elaboration based on the recommendations of the Joanna Briggs Institute, supported by The PAGER framework and guided by the PRISMA‐ScR Checklist. Methods: The survey was conducted in August 2022 in 10 data sources. The 3300 publications found were analysed by two independent reviewers, after applying inclusion and exclusion criteria, 16 studies were selected. Results: Publications occurred between the years 1997 and 2022 and mainly dealt with the management of residual pain and phantom limb through pharmacological measures with pain assessment made by numerical scales. Conclusions: The literature pointed out strategic uses of analgesics and highlighted technologies for neurostimulation through catheters. The need for new studies with non‐pharmacological measures and with designs that can prove their effectiveness is reinforced. Relevance to Clinical Practice: The knowledge of these strategies by health professionals allows adequate pain management and patient follow‐up for a less traumatic recovery. Patient or Public Contribution: To patient or public involvement in this scoping review. [ABSTRACT FROM AUTHOR]