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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.

Distal symmetric polyneuropathy (DSPN) is the most common chronic complication of diabetes mellitus. The pathogenesis of DSPN is not fully elucidated, but it is certainly multifactorial in nature and attributable to metabolic and microvessel disorders related to chronic hyperglycemia, diabetes duration, and several cardiovascular risk factors. Early diagnosis and appropriate management are extremely important, since up to 50% of DSPN cases may be asymptomatic, and patients are unaware of foot injury leading to foot ulcers and amputation. Simple, validated tests such as the Neuropathy Disability Score and/or Vibration Perception Threshold may be used to diagnose DSPN. Similarly, neurological dysfunction screening questionnaires should be used to assess the quality and severity of DSPN symptoms. Using both methods enables prediction of the prognosis of diabetic patients with DSPN. No causative treatment of DSPN is known, but the results of clinical trials indicate that several treatment options are highly effective in symptomatic treatment of painful DSPN. The appropriate treatment of DSPN may improve the outcome, preventing or delaying the development of numerous diabetic complications.

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 (

Pulmonary metastasis of benign giant cell tumor of bone is very rare, and its biological behavior is difficult to predict. In the present study, we analyzed the clinical characteristics of and related risk factors for pulmonary metastasis from this tumor. Forty-six patients with lung metastasis were analyzed. In total, 60.9% of the primary tumors were located around the knee joint. The Campanacci stage of all tumors was stage 3. Surgery of the primary tumor included curettage in 37 patients, resection in 8, and amputation in 1. Local recurrence after the primary surgery occurred in 34 patients. The recurrence rate, Campanacci stage, and surgical method were significant risk factors for lung metastasis. The median postoperative metastasis times in the lower limbs, upper limbs, and axial skeleton were 20.1, 7.9, and 1.4 months, respectively (p=0.010). The median metastasis times in patients with and without recurrence were 13.7 and 43.2 months, respectively (p=0.018). Eighteen patients had unilateral metastasis and 28 had bilateral metastasis. Most lesions (n=38) were located in the peripheral lung. Nineteen patients received treatment, and 12 of them underwent tumor resection. The 5-year overall survival rate was 94.4%. This study showed that local recurrence, a high Campanacci stage, and curettage were possible high-risk factors for pulmonary metastasis. The primary lesion site and local recurrence may be related to the metastasis time. The survival rate of patients with pulmonary metastasis was high.

Introduction: For chronic prosthetic joint infections (PJI), complete removal of the infected prosthesis is necessary in order to cure the infection. Unfortunately, a subgroup of patients is not able to undergo a revision surgery due to high surgical risk. Alternatively, these patients can be treated with antibiotic suppressive therapy (AST) to suppress the infection. Aim: To evaluate the efficacy and tolerability of AST. Methods: We retrospectively collected data (period 2009-2015) from patients with a PJI (of hip, knee or shoulder) who were treated with AST at the University Medical Center Groningen, the Netherlands. AST was defined as antibiotic treatment for PJI that was started after the usual 3 months of antibiotic treatment. The time of follow-up was defined from the time point AST was started. Treatment was considered as failed, when the patient still experienced joint pain, when surgical intervention (debridement, removal, arthrodesis or amputation) was needed to control the infection and/or when death occurred due to the infection. Results: We included 21 patients with a median age of 67 years (range 21 - 88) and with a median follow-up of 21 months (range 3 - 81). Coagulase negative staphylococci (CNS) (n=6), S. aureus (n=6) and polymicrobial flora (n=4) were the most frequently found causative pathogens. Most patients with CNS and S. aureus were treated with minocycline (67%) and clindamycin (83%) as AST, respectively. Overall, treatment was successful in 67% of patients. Failure was due to persistent joint pain (n=1), surgical intervention because of an uncontrolled infection (n=3), and death due the infection (n=3). We observed a treatment success of 90% in patients with a 'standard' prosthesis (n=11), compared to only 50% in patients with a tumor-prosthesis (n=10). Also, treatment was successful in 83% of patients with a CNS as causative microorganism for the infection, compared to 50% in patients with a S. aureus. Patients who failed on AST had a higher ESR in comparison to patients with a successful treatment (mean 73 ± 25SD versus 32 ± 19SD mm/hour (p = 0.007), respectively. 43% of patients experienced side effects and led to a switch of antibiotic treatment or a dose adjustment in almost all of these patients. Conclusions: Removal of the implant remains first choice in patients with chronic PJI. However, AST is a reasonable alternative treatment option in a subgroup of patients with a PJI who are no candidate for revision surgery, in particular in patients with a 'standard' prosthesis and/or CNS as the causative micro-organism.

Diabetes is a metabolic disease leading to the development of numerous health complications. In developed countries, it is the main cause of blindness, end-stage renal disease, and non-traumatic amputation of the lower limbs. Neuropathy is the most common chronic complication of diabetes. A long-term course of a metabolically unbalanced disease causing damage to the autonomic nervous system of the digestive tract results in the development of many complications, such as intensification of gastro-oesophageal reflux disease, gastroparesis, chronic diarrhoea or faecal incontinence.

Pseudomonas aeruginosaand methicillin-resistantStaphylococcus aureus(MRSA) have been considered prevalent pathogens in foot infections. However, whether empiric therapy directed against these organisms is necessary, and in whom to consider treatment, is rather unclear. The aim of this study was to develop predictive algorithms for forecasting the probability of isolating these organisms in the infected wounds of patients in a population where the prevalence of resistant pathogens is low. This was a retrospective study of regression model-based risk factor analysis that included 140 patients who presented with infected, culture positive foot ulcers to two urban hospitals. A total of 307 bacteria were identified, most frequently MRSA (11.1%).P. aeruginosaprevalence was 6.5%. In the multivariable analysis, amputation (odds ratio (OR) 5.75, 95% confidence interval (CI) 1.48–27.63), renal disease (OR 5.46, 95% CI 1.43–25.16) and gangrene (OR 2.78, 95% CI 0.82–9.59) were identified as risk factors associated with higher while diabetes (OR 0.07, 95% CI 0.01–0.34) and Infectious Diseases Society of America infection severity >3 (OR 0.18, 95% CI 0.03–0.65) were associated with lower odds ofP. aeruginosaisolation (Cstatistic 0.81). Similar analysis for MRSA showed that amputation was associated with significantly lower (OR 0.29, 95% CI 0.09–0.79) risk, while history of MRSA infection (OR 5.63, 95% CI 1.56–20.63) and osteomyelitis (OR 2.523, 95% CI 1.00–6.79) was associated with higher odds of isolation (Cstatistic 0.69). We developed two predictive nomograms with reasonable to strong ability to discriminate between patients who were likely of being infected withP. aeruginosaor MRSA and those who were not. These analyses confirm the association of some, but also question the significance of other frequently described risk factors in predicting the isolation of these organisms.

Introduction: Calcaneal osteomyelitis is an uncommon and challenging condition. In this systematic review we aim to analyse the outcomes from concomitant use of bone debridement and soft tissue management for patients diagnosed with calcaneal osteomyelitis.Materials & Methods: A complete computerised and comprehensive literature search of Pubmed and Cochrane database was undertaken from January 2000 to October 2018. During the review, studies were screened for information about the surgical and antimicrobial treatment, the complications, the reinfection rate and the functional outcome of patients with calcaneal osteomyelitis.Results: Of the 20 eligible studies included, seven (35%) described bone treatment only, six (30%) soft tissue treatment only, five (25%) soft tissue and bone treatment, and two (10%) focused on prognostic factors and differences in outcomes between diabetic and non-diabetic patients.In the studies with bone treatment only, infection recurrence ranged from 0 to 35% and the amputation rate from 0 to 29%. If soft tissue coverage was also needed, both the reinfection rate and amputation rate ranged from 0 to 24%. Studies presenting the functional status generally showed preservation or even improvement of the preoperative ambulatory status.Conclusion: Calcaneal osteomyelitis is difficult to treat. A multidisciplinary approach involving orthopaedic surgeons, plastic surgeons and infectious disease physicians is preferred. The heterogenicity of studies has hindered the development of agreed treatment protocols, which would be useful in clinical practice.

Introduction Mechanical thrombectomy is an alternative to local thrombolysis for the treatment of severe ischaemia in the femoropopliteal segment, but stent implantation is usually required after this procedure. The use of drug-eluting balloons (DEBs) may overcome long-term problems associated with stents, but it remains unclear how often such a treatment is technically feasible and efficient. Aim This post hoc single-centre study was aimed at assessment of the feasibility, safety and efficacy of mechanical thrombectomy followed by application of DEBs. Material and methods Fifty-one patients, aged 69.1 ±11.6 years, were managed for acute thrombotic or chronic critical ischaemia in the femoropopliteal segment using the Rotarex device. Following mechanical thrombectomy, on condition that there was no significant residual stenosis or dissection, lesions were managed with paclitaxel-coated DEBs, which was a desired strategy (24 patients). The remaining 25 patients underwent stent implantations, which was regarded as bailout treatment. Final follow-up was scheduled 12 months after the procedure. Results The primary-assisted patency rate after mechanical rotational thrombectomy with additional balloon angioplasty and/or stenting was 97.1% (49 patients). The early mortality rate was 2.0% (1 patient) and the amputation rate was 4.1% (2 patients). There were no late mortalities or limb amputations at 12-month follow-up, but significant restenoses occurred in 13 (27.1%) patients. These restenoses were more frequent in patients who underwent stent implantation (45.5%) than those managed with DEBs (12.5%), and in patients managed for secondary lesions. Conclusions In selected patients mechanical rotational thrombectomy in the femoropopliteal segment followed by application of DEB is a safe, effective and long-lasting method of revascularisation.

Highlights • There is a lack of evidence for composite grafting for distal finger tip amputation. • We present a systematic review protocol on the use of composite grafts. • This review will aim to provide clinicians with more guidance., Background There is much debate in the hand surgery literature as to the management of fingertip amputations. Much research continues to be published in this area. Methods of reattachment include microsurgical and non-microsurgical (composite graft) replantation. The role of composite grafts lacks clarity in terms of outcomes, success rates and complications. Hence there is a need for an evidence synthesis, which can guide patient selection, the consent process and determine graft survival rates and functional outcomes to optimise patient outcomes. Methods Search of the databases OVID MEDLINE, PubMed, EMBASE, SCOPUS, The Cochrane Library and clinical trial registries from inception using terms “fingertip” “digital tip” “digit” “finger” “thumb” “amputation” “replantation” “reattachment” “reimplantation” and “composite graft” as key terms with “AND” selected as a Boolean operator, limited to humans will be conducted by two independent researchers. The patient population will include adults and children. Studies will be included if they report: (1) primary data; (2) outcomes of ‘composite grafts’ or ‘nonmicrosurgical replantations’; (3) graft survival, (4) 5 or more cases. Articles will be excluded if surgical techniques involve: (1) composite graft pocketing, or (2) microsurgical replantation or (3) additional flaps (pulp or local). Full exclusion and inclusion criteria are described within this protocol. Data extraction will include; demographic details, patient comorbidities, amputation nature and level, functional, and aesthetic outcomes, complications and need for secondary procedures. All data extracted will be cross-checked, and discrepancies resolved through consensus. Dissemination This review will be published in a peer-reviewed journal and will be presented at national and international conferences to inform the practice of other clinicians.

Introduction. Radical procedures like calcanectomy and amputation performed for calcaneal osteomyelitis are regarded as effective in eradication of infection even though potentially functionally disabling. Bone sparing procedures offer better functional result at the expense of potentially worse infection control. The aim of the study has been to assess the influence of the surgical radicalism as much as the extent of bone infection on the final outcome in the surgical therapy of chronic calcaneal osteomyelitis (CO). Material and method. 32 patients with chronic CO have comprised the group under study: 8 with superficial type, 12 localised type and 12 with diffuse type according to Cierny-Mader classification. The aim of the treatment was to heal infection, preserve the heel shape and achieve good skin coverage over the calcaneus. The therapy consisted of 9 debridement surgeries with or without flaps, 8 drilling-operations of the calcaneus with application of collagen-gentamicin-sponge in bore holes, 15 partial and 2 total calcanectomies, and 4 below-the knee amputations. Results. The healing of infection and wound has been achieved after 7 of 9 debridements, 6 of 8 drilling-operations, 13 of 15 partial and all total calcanectomies. Conclusion. Bone preserving operations in chronic calcaneal osteomyelitis provided inferior infection control (76,47% vs 88,24%) and worse patient satisfaction (88,24% vs 100%) and almost camparable ambulation (100% vs 93,33%). Drilling of the calcaneus with application of collagen sponge containing gentamicin performed in chronic diffuse calcaneal osteomyelitis seems to offer a viable alternative to partial or radical calcanectomy. Level of evidence: V.

Background: Charcot foot is a rare but a serious diabetic condition. Recognition of this often overlooked condition to provide timely and proper management is important for a better prognosis. Limited data on Charcot foot was available in Asians. Aims: The aim of this study is to describe salient features and outcomes of Charcot foot in Thai patients. Method: We presented our experience of 40 cases of Charcot foot patients who were treated from 2000 to 2016 at Theptarin Hospital, Bangkok, Thailand. Results: A total of 40 Charcot foot patients were identified (13 acute, 27 chronic; mean age 58.7 ± 10.2 years; duration of diabetes 18.0 ± 8.8 years; T2DM 95%). The average serum HbA1c level was 9.2 ± 1.9%. While acute Charcot foot was frequently misdiagnosed as cellulitis in almost one-third of patients, osteomyelitis was a leading cause of misdiagnosis in 15% of chronic Charcot foot patients. Ulcer-free rate at 6 and 12 months were observed in 60% and 58% of patients, respectively. The mortality rate was 13% during a median follow-up period of 57 months. Only 61% of the patients resumed walking normally while almost one-fourth of them were wheelchair-bound. Conclusions: Charcot foot in Thai patients mainly developed in long-standing poorly controlled type 2 diabetes with neuropathy, and presented late in the course of the disease. It was often misdiagnosed resulting in improper management and poor outcome which included amputation. Keywords: Charcot foot, Outcomes, Thailand

Aim To establish the role of heart failure (HF) and dialysis (D) in the prognosis of diabetic patients with critical limb ischemia and foot ulcers (FUs). Methods Consecutive diabetic patients with ischemic FUs who referred to our Diabetic Foot Centre were prospectively included. All patients underwent a preset limb salvage protocol including peripheral revascularization. According to the presence of HF and D, they were divided in four groups: group 1 without HF and without D defined as ischemic foot (IF); group 2 with HF and without D defined as heart ischemic foot (H-IF); group 3 without HF and with D defined as renal ischemic foot (R-IF); group 4 with HF and with dialysis defined as heart-renal foot (HR-IF). Survival with limb salvage, survival with major amputation and death were reported after 1 year of follow-up. Results 136 patient have been included: 66 with IF, 26 with H-IF, 24 with R-IF and 20 with HR-IF. The mean age was 68,9 ± 9,7 years, the diabetes duration 20,7 ± 11,6 years, the mean HbA1c 62,7 ± 22,3 mmol/mol. 103/136 (75,7%) survived with limb salvage, 10/136 (7,4%) survived with major amputation, 23/136 (16,9%) died. The outcomes for group IF patients, H-IF, R-IF and HR-IF were respectively: survival with limb salvage (92,4%, 61,5%, 79,2% and 35%), survival with major amputation (6,1%, 7,7%, 8,3% and 10%), death (1,5%, 30,8%, 12,5% and 55%) χ = 0.0001. Heart failure was an independent predictor of death. Discussion The presence of heart failure and dialysis in diabetic patients with ischemic foot ulcers was associated to high risk of amputation and mortality.

Sloped walking is challenging for individuals with transtibial amputation (TTA) due to the functional loss of the ankle plantarflexors. Prostheses that actively generate ankle power may help to restore this lost function. The purpose of this study was to use musculoskeletal modeling and simulation to quantify the mechanical power delivered to body segments by passive and powered prostheses and the remaining muscles in the amputated and intact legs during sloped walking. We generated walking simulations from experimental kinematic and kinetic data on slopes of 0, ±3 deg and ±6 deg in eight people with a TTA using powered and passive prostheses and eight nonamputees. Consistent with our hypothesis, the amputated leg hamstrings generated more power to both legs on uphill slopes in comparison with nonamputees, which may have implications for fatigue or overuse injuries. The amputated leg knee extensors delivered less power to the trunk on downhill slopes (effect size (ES) ≥ 1.35, p ≤ 0.02), which may be due to muscle weakness or socket instability. The power delivered to the trunk from the powered and passive prostheses was not significantly different (p > 0.05), However, using the powered prosthesis on uphill slopes reduced the contributions from the amputated leg hamstrings in all segments (ES ≥ 0.46, p ≤ 0.003), suggesting that added ankle power reduces the need for the hamstrings to compensate for lost ankle muscle function. Neither prosthesis replaced gastrocnemius function to absorb power from the trunk and deliver it to the leg on all slopes.

Aims Research has shown that the ongoing rate of diabetes-related amputations remains significant despite the existence of prevention methods and that amputation in most cases can be prevented. The purpose of the study was to assess the relationship between the level of self-efficacy and performance of foot self-care in those with diabetes as they relate to the prevention of lower extremity amputation (LEA). Methods A descriptive correlational study was conducted using the theoretical framework of Bandura's social cognitive theory. The Foot Care Confidence Scale (FCCS) and the Nottingham Assessment of Functional Footcare (NAFF) survey instruments were distributed to individuals over 18 years old with diabetes Type 1 and 2 in the lower peninsula of Michigan (N = 223). Results No significant correlation was identified between the level of self-efficacy and performance of foot self-care behaviors. Statistical significance was found between foot self-care behaviors and gender with males scoring higher than females. Conclusions This study adds to the body of knowledge regarding self-efficacy and diabetic foot self-care behaviors. Further research is needed to explore the relationship of gender, diabetes education attendance, and foot self-care behaviors as influencing factors in LEA prevention., Highlights • Diabetes is the leading cause of nontraumatic lower extremity amputations (LEA). • The majority of LEA's are preventable with appropriate foot self-care. • Self-efficacy is a preeminent factor in performance of self-care behaviors. • Dual instrumentation including the FCCS and NAFF surveys was used for correlation. • Further research and possibly alternative methodology are needed.

Background: Special insoles and shoes designed to prevent foot ulcers caused by repetitive high pressures are recommended for patients with diabetes who have any of the following risk factors: neuropathy; peripheral vascular disease; foot deformities; previous ulcers; amputation; and skin pathologies. However, there is a need for increased knowledge regarding: a) differences in the peak pressure (PP) and pressure time integral (PTI) for different types of insoles; and b) the properties of the pressure distribution for insoles used over a period of several months. We present the results of a randomized trial to compare the plantar pressures of three commonly used insoles. Objectives: The primary objective was to compare the PP and PTI between three types of insoles. The secondary objective was to explore the long-term pattern of peak plantar pressure distribution and variations in specific regions of interest (ROI). The tertiary objective was to investigate the impacts of insole adjustments, how much the insoles were used, and the levels of patient satisfaction. Methods: In a 2-year trial, 114 patients with type 1 (N = 31) or type 2 (N = 83) diabetes (62 men and 52 women; mean age, 57.7 ± 15.4 years; duration of diabetes, 12.3 ± 11.2 years; neuropathy, 38%), were randomized to be supplied with one of three different insoles. The ethylene vinyl acetate (EVA) insoles were used in outdoor walking shoes. The 35 EVA group (N = 39) received soft custom-made insoles composed of EVA of 35 shore A hardness, the 55 EVA group (N = 37) received custom-made insoles composed of EVA of 55 shore hardness, and the control group (N = 38) received prefabricated insoles composed of a hard core with a top layer of soft 12 shore hardness microfiber. Using F-Scan®, the in-shoe plantar pressures were measured at seven ROI (hallux, metatarsal head 1, metatarsal head 2, metatarsal head 4, metatarsal head 5, lateral aspect of the mid-foot, heel) on five occasions during the study period. The plantar-pressure variables used were PP (main outcome) and PTI. The plantar patterns of load were explored, satisfaction and usage of the insoles were rated by the participants, and insole adjustments were recorded. Results: A mixed model analysis estimated lower PP values in the heel regions for the 35 EVA and 55 EVA insoles (171 ± 13 and 161 ± 13 kPa, respectively) than for the prefabricated insoles (234 ± 10 kPa) (p

Proof-of-concept computational models were developed and applied as tools to gain insights into biomechanical interactions and variations of oxygen gradients of wounded tissue subject to negative pressure wound therapy (NPWT), following trans-femoral amputation. A macro-scale finite-element model of a lower limb was first developed based on computed tomography data, and distributions of maximum and minimum principal stress values we calculated for a region of interest (ROI). Then, the obtained results were applied iteratively as new sets of boundary conditions for a specific spatial position in a capillary sub-model. Data from coupled capillary stress and mass- diffusion sub-models were transferred to the macro-scale model to map the spatial changes of tissue oxygen gradients in the ROI. The −70 mmHg NPWT resulted in a dramatic change of a wound surface area and the greatest relative contraction was observed at −150 mmHg. Tissue lateral to the depth of the wound cavity revealed homogenous patterns of decrease in oxygenation area and the extent of such decrease was dependent on the distance from the wound surface. However, tissue lateral to the width of the wound demonstrated heterogeneous patterns of change, as evidenced by both gradual increase and decrease in the oxygenation area. The multiscale models developed in the current study showed a significant influence of NPWT on both macro-deformations and changes of tissue oxygenation. The patterns of changes depended on the depth of the tissue, the geometry of the wound, and also the location of tissue plane. Electronic supplementary material The online version of this article (doi:10.1007/s10237-017-0921-7) contains supplementary material, which is available to authorized users.

Purpose While the orthopaedic management of open fractures has been well-documented in developed settings, limited evidence exists on the surgical outcomes of open fractures in terms of limb salvage in low- and middle-income countries. We therefore reviewed the Médecins Sans Frontières-Operational Centre Brussels (MSF-OCB) orthopaedic surgical activities in the aftermath of the 2010 Haiti earthquake and in three non-emergency projects to assess the limb salvage rates in humanitarian contexts in relation to surgical staff skills. Methods This was a descriptive retrospective cohort study conducted in the MSF-OCB surgical programmes in the Democratic Republic of Congo (DRC), Afghanistan, and Haiti. Routine programme data on surgical procedures were aggregated and analysed through summary statistics. Results In the emergency post-earthquake response in Haiti, 81 % of open fracture cases were treated by amputation. In a non-emergency project in a conflict setting in DRC, relying on non-specialist surgeons receiving on-site supervision and training by experienced orthopaedic surgeons, amputation rates among open fractures decreased by 100 to 21 % over seven years of operations. In two trauma centres in Afghanistan (national surgical staff supported from the outset by expatriate orthopaedic surgeons) and Haiti (national musculoskeletal surgeons trained in external fixation), amputation rates among long bone open fracture cases were stable at 20 % and