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This article introduces some efficient generalized class of factor-type exponential imputation techniques and their corresponding estimators using auxiliary information. Generalized ratio, product, and dual to ratio type exponential estimators are the special cases of our suggested imputation techniques. Biases and mean squared error expressions are derived up to the first order of large sample approximations. The proposed imputation techniques can be viewed as efficient extensions of the work of Singh and Horn [Compromised imputation in survey sampling. Metrika. 2000;51(3):267–276. doi: 10.1007/s001840000054], Singh and Deo [Imputation by power transformation. Statist Papers. 2003;44(4):555–579. doi: 10.1007/BF02926010], Toutenburg and Srivastava [Amputation versus imputation of missing values through ratio method in sample surveys. Statist Papers. 2008;49(2):237–247. doi: 10.1007/s00362-006-0009-4], Kadilar and Cingi [Estimators for the population mean in the case of missing data. Commun Stat Theory Methods. 2008;37(14):2226–2236. doi: 10.1080/03610920701855020], Singh [A new method of imputation in survey sampling. Statistics. 2009;43(5):499–511. doi: 10.1080/02331880802605114], Gira [Estimation of population mean with a new imputation methods. Appl Math Sci. 2015;9(34):1663–1672] and Singh et al. [An improved alternative method of imputation for missing data in survey sampling. J Stat Appl Probab. 2022;11(2):535–543. doi: 10.18576/jsap]. Our proposed estimators are compared with these estimators, including the mean, ratio, and regression imputation techniques. Thereafter, a numerical illustration and simulation study are conducted for a comparative study using real and simulated data sets, and the demonstration shows that our suggested estimators are the most efficient estimators. [ABSTRACT FROM AUTHOR]

Introduction: Electronic versions of patient-reported outcome measures (PROMs) seem to have a clear administrative logging advantage to traditional paper versions. However, most of them have not been formally evaluated for their suitability to replace paper outcome measures for assessment of individuals with lower-limb amputations. The aim of this study is to examine the usability and equivalence of electronic to paper versions of PROMs suitable for use in prosthetic clinical care and research for persons with lower-limb loss. Methods: In this cross-sectional study, 10 participants remotely completed the following PROMs online and then on paper: Orthotic and Prosthetic User Survey (OPUS), Modified Falls Efficacy Scale (MFES), Prosthetic Evaluation Questionnaire (PEQ), Patient Health Questionnaire–9 (PHQ-9), and Community Participation Indicators (CPI). Participants also answered open-ended and standardized questions regarding the usability of the electronic surveys. Wilcoxon signed rank tests, comparisons to minimum detectable change, intraclass correlation coefficients, and Bland-Altman plots were used to evaluate differences between the two survey versions, meaningful changes in scores, reliability, and systematic biases, respectively. Results: Electronic surveys had fewer missing or ambiguous responses than paper surveys; however, the PEQ Social Burdens subscale could not be evaluated due to error in the creation of the electronic survey. No significant differences were found between scores of the two versions for any of the measures, but multiple participants had meaningful changes in the Appearance and Sounds PEQ subscales. All measures demonstrated acceptable reliability between versions, except the Appearance, Perceived Response, and Sounds subscales of the PEQ. No systematic biases in scores or usability concerns were found for any measures. Conclusions: This study analysis showed that most of the electronic PROMs studied are easily used and demonstrate equivalence to the paper versions. However, the PEQ Appearance, Perceived Response, Sounds, and Social Burden subscales require further evaluation. [ABSTRACT FROM AUTHOR]

This paper presents a vibrio vulnificus Infection Patient due to above knee amputation because self-use ointment dressing admitted to the intensive care unit. From December 21, 2021 to January 21, 2022, three health problems were identified in the course of care: acute pain, body image disturbance, and a self-care deficit. Nursing care included: listening to radio music, massage to relieve acute pain; caring and asking the patient to express his thoughts; sharing the medical process of the same case through video; help with acceptance, care for the amputation wound and facing the change of body appearance; with family members and rehabilitation team to design and participate in limb rehabilitation improve self-care ability after amputation. The nursing experience described hope for providing clinical care to similar case patients. [ABSTRACT FROM AUTHOR]

Vascularized Composite Tissue Allotransplantation (VCA) allows replacement of lost body parts from brain-dead donors. These surgeries are laborious, time-intensive, and require vast planning. With the advent of better immunosuppressants, VCA will increasingly play an important role in the reconstructive field. In this paper, the authors share their standard operating protocol created after much deliberation. [ABSTRACT FROM AUTHOR]

Assistive technologies (AT) perform an important social role, interacting with cultural systems to produce or hinder accessibility to biosocial environments. This interaction profoundly shapes not only how an individual body can be experienced by users but also produce and hinder accessibility to biosocial environments. AT users have historically been viewed through a medical model, which deems them disabled by their impairments and by dominant ableist narratives. Therefore, this paper serves to provide an insight into the importance of ageing with and into AT. This paper aims to investigate polio survivors' and diabetic amputees' experiences of assistive technologies in order to better understand impacts upon narrative and identity. By applying an anthropological and sociological lens, a holistic view of the experiences of polio survivor and amputee AT users is developed. This paper draws on 16 in-depth interviews with polio survivors and diabetic amputees in the United States (US) and Australia, which were analysed using an experience-centered narrative approach. Both projects were approved by ethics boards. All participants provided written consent. Five themes were identified: a) disruption to biographies, which reflected AT impact on how narratives become altered; b) impacts to autonomy, which reflected the importance of regaining previous daily activities; c) re-engaging with community life, which highlighted how AT supported participation in valued activities; d) self-perceptions of assistive technologies, which act in opposition to external perspectives and challenge ableist narratives; and e) an intergenerational comparison of new and older AT users highlights the importance of temporalities. This paper offers new perspectives on ageing with assistive technologies, with a focus on identity and narrative. The importance of this paper is to contribute to the existing literature that demonstrates the cultural implications that arise through embodiment and assistive technologies. The use of assistive technology can help individuals regain function, but the individual circumstances require consideration The use of assistive technology is a complex entanglement of bodies, environments, biographies, and imagined futures. The use of assistive technology can provide participants autonomy over their narratives and assist with maintaining their identities [ABSTRACT FROM AUTHOR]

Chronic refractory complex regional pain syndrome (CRPS) is the severest form of this condition characterised by acute pain, other painful phenomena (hyperpathia, allodynia), severe functional impairment of the affected extremity and non-responsiveness to standard treatments. This paper presents a case of a 40-year-old man suffering from this form of CRPS, in whom all treatment options, including non-standard appeared ineffective. The patient suffered from intractable pain and a completely disabled extremity was considered by him a burden, additionally affecting his daily living. After a review of the literature and informing the patient about the potential benefits and the potential risk of failure of surgery, at the request of the patient an amputation of the upper extremity was performed at the level of 1/3 distal arm. The postoperative course was uneventful, but amputation did not result in cessation of the pain which persisted in the residual limb. The presented case shows that limb amputation for chronic refractory CRPS may not give expected beneficial effect. [ABSTRACT FROM AUTHOR]

Introduction: Phantom limb pain affects 50 percent to 85 percent of patients who have had their limbs amputated, lowering their quality of life. Clinical therapies for central pain, such as mirror therapy, motor imagery, or visual feedback, might help amputee patients suffering from phantom limb pain. Objectives: To provide a general review of the efficacy of various approaches for treating phantom limb discomfort in amputee patients. Methods: The following databases were used for a computerized literature search up to March 2022: PubMed, ScienceDirect, and Google Scholar. The modified Jadad score is utilized to measure study quality in this research. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines were followed while conducting this systematic review. Results: In all, 15 papers matched our inclusion criteria, with 5 receiving a low study quality rating and 10 receiving a good study quality rating. All the studies revealed a considerable decrease in pain; however, the patients and techniques varied. Conclusion: Mirror therapy, motor imagery, and visual feedback can alleviate phantom limb pain. However, there is a lack of scientific data to support their efficacy. Future studies should use more powerful research methodologies to investigate these medicines' short- and long-term advantages. [ABSTRACT FROM AUTHOR]

Designs of active prostheses attempt to compensate for various functional losses following amputation. Integration of sensory feedback with the functional control re-enables sensory interaction with the environment through the prosthetic. Besides the functional and sensory loss, amputation induces anatomical and physiological changes of the sensory neural pathways, both peripherally and centrally, which can lead to phantom limb pain (PLP). Additionally, referred sensation areas (RSAs) likely originating from peripheral nerve sprouting, regeneration, and sensory reinnervation may develop. RSAs might provide a non-invasive access point to sensory neural pathways that project to the lost limb. This paper aims to report on the sensory input features, elicited using non-invasive electrical stimulation of RSAs that over time alleviated PLP in two upper-limb amputees. The distinct features of RSAs and sensation evoked using mechanical and electrical stimuli were characterized for the two participants over a period of 7 and 9 weeks, respectively. Both participants received transradial and transhumeral amputation following traumatic injuries. In one participant, a relatively low but stable number of RSAs provided a large variety of types of evoked phantom hand (PH) sensations. These included non-painful touch, vibration, tingling, stabbing, pressure, warmth/cold as well as the perception of various positions and movements of the phantom hand upon stimulation. Discomforting and painful sensations were induced with both mechanical and electrical stimuli. The other participant had a relatively large number of RSAs which varied over time. Stimulation of the RSAs provided mostly non-painful sensations of touch in the phantom hand. Temporary PLP alleviation and a change in the perception of the phantom hand from a tight to a more open fist were reported by both participants. The specificity of RSAs, dynamics in perception of the sensory input, and the associated alleviation of PLP could be effectively exploited by designs of future active prostheses. As such, techniques for the modulation of the sensory input associated with paradigms from interaction with the environment may add another dimension of protheses towards integrating personalized therapy for PLP. [ABSTRACT FROM AUTHOR]

This paper presents the foundation upon which the contemporary knowledge of body integrity dysphoria (BID) is built. According to the World Health Organisation's International Classification of Diseases, 11th edition (ICD-11), the main feature of BID is an intense and persistent desire to become physically disabled in a significant way. Three putative aetiologies that are considered to explain the insurgence of the condition are discussed: neurological, psychological and postmodern theories. The concept of bodily representation within the medical context is highlighted, with the concept of dysphoria, which was brought to the fore with the introduction of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), and the ICD-11. Contemporary issues of "justice" are addressed to identify ethically relevant distinctions between BID and sex reassignment surgery. It is argued that there is no ethically relevant difference between the BID actor's desire for invasive surgical intervention and the wish of gender dysphoric individuals to undergo sex reassignment surgery procedures. Some BID actors self-mutilate, and this presents medical professionals with difficult choices regarding whether or not to intervene in order to satisfy the BID patient's desire. Both abstention and intervention may lead to severe ethical complications for doctors and patients despite the positive outcomes in terms of quality of life for BID individuals who manage to undergo such procedures. [ABSTRACT FROM AUTHOR]

Background: The treatment of neuromas with regenerative peripheral nerve interfaces (RPNI) has gained much attention in recent years. This systematic review compared the clinical outcomes of upper limb neuromas treated with free (fRPNI) versus vascularized RPNI (vRPNI). Methods: This systematic review was performed in accordance with PRISMA guidelines. The PubMed database was searched for relevant studies published between August 2016 and May 2023. The search term "RPNI" was used. Data including patient demographics, type of RPNI performed, mean pain duration prior to RPNI, post-operative follow-up period, the reduction in neuroma pain scores after RPNI and post-operative complications were extracted independently by two authors and recorded using standard computer software for data processing. Results: Of 43 papers identified, only four fulfilled the inclusion criteria. This provided data for upper limb neuromas in 32 patients where a total of 83 RPNIs (22 vascularized) were performed. The means for patient age, duration of neuroma pain, length of reported postoperative follow-up, and reduction in neuroma pain scores were 44.0 years, 3.6 years, 12.2 months and 86% respectively. Conclusions: The current evidence suggests that either fRPNI or vRPNI may be useful for treating upper extremity neuromas, both prophylactically and secondarily. However, the heterogeneity and inconsistencies in data reporting are such that further studies are required to compare clinical outcomes between fRPNI and vRPNI to determine if one is superior to the other. Level of Evidence: Not gradable. [ABSTRACT FROM AUTHOR]

Research highlights the differences and unique experiences of military veterans experiencing amputation compared to civilians. This review aimed to synthesise qualitative research exploring the experience of amputation and rehabilitation among existing or previous members of the military. A systematic search of six databases (PsycINFO, AMED, MEDLINE, CINAHL, Web of Science and Scopus) was undertaken in March 2022. The results of 17 papers reporting 12 studies published between 2009 and 2022 were synthesised using a meta-ethnographic approach to generate new interpretations reflecting the experiences of members of the military who have experienced limb loss. Three themes were developed from the data: (1) Making the physical and psychological transition to life after amputation; (2) The role of the military culture in rehabilitation; and (3) The impact of relationships and the gaze of others during rehabilitation and beyond. Military veterans with limb loss experience difficulties in navigating civilian healthcare systems and gaining appropriate support away from the military. Rehabilitation professionals, with psychological training or mentoring, involved in the care of military veterans following amputation could offer psychological support during the transition to civilian life and targeted therapies to veterans experiencing high levels of pain, and facilitate peer support programmes. Identify at an early stage of rehabilitation those veterans at risk for poorer adjustment, by examining their propensity or not to adopt goal pursuit and goal adaptation strategies Offer psychological support prior to and after the transition to civilian life Target psychological therapies, such as Cognitive Behavioural Therapy and Acceptance and Commitment Therapy, to veterans who are experiencing high levels of pain Encourage peer support programmes and provide support and training to peer mentors [ABSTRACT FROM AUTHOR]

Background: Edentulous sites with limited horizontal tooth‐implant distance pose a challenge to clinicians. This case report describes root amputation of an adjacent compromised molar to maintain an optimal tooth‐implant distance Methods and Results: A 41‐year‐old female was referred for extraction and implant placement to replace her left, maxillary second premolar (#13), which had been diagnosed with a vertical root fracture. Extraction and ridge preservation of #13 was completed without complication. The 4‐month postsurgical clinical examination revealed a narrow mesial‐distal distance (5.69 mm) of the edentulous space (#13), which was influenced by the degree of divergence of the mesial buccal root of tooth #14. Cone‐beam computed tomography (CBCT) analysis verified a periapical lesion on the mesial‐buccal root of tooth #14. The amputation of the endodontically compromised mesial‐buccal root of #14 was treatment planned to provide space and facilitate placement of a standard diameter implant without compromising the implant or adjacent teeth. Crestal bone levels were verified and maintained at the 1 year postoperative follow‐up. Conclusion: The findings of the case report demonstrate how root amputation of a compromised molar is an alternative solution for managing spatial limitations in contemporary implant dentistry. More studies are required to assess the reliability and long‐term success of this approach. Key points: Why is this case new information?There is insufficient evidence on the long‐term efficacy of narrow‐diameter implants. Clinical treatment guidelines are not sufficiently available.This paper presents an alternative approach to managing a specific scenario where mesial‐distance distance is limited using root amputation of an adjacent compromised tooth. What are the keys to successful management of this case?Comprehensive diagnosis and stringent case selectionMultidisciplinary treatment planningEvidence‐based decision making What are the primary limitations to success in this case?Very specific clinical application; adjacent compromised toothLong‐term follow up is required [ABSTRACT FROM AUTHOR]

To systematically review literature on nutritional intake, nutritional status and nutritional interventions, and to study their association with short- and long-term clinical outcomes in people with a major dysvascular lower limb amputation. PubMed, Ovid, CINAHL, and The Cochrane Library were searched. Studies were included if nutritional intake, nutritional status, or nutritional interventions in people with a major dysvascular lower limb amputation were analyzed. Of the 3038 unique papers identified, 30 studies were included. Methodological quality was moderate (1 study) or weak (29 studies). Limited information was available on nutritional intake (2 studies) and nutritional interventions (1 study). Nutritional intake and nutritional status were assessed by diverse methods. The percentage of people with a poor nutritional status ranged from 1% to 100%. In some studies, measures of poor nutritional status were associated with adverse short- and long-term clinical outcomes. The percentage of people with a poor nutritional status is inconclusive in the major dysvascular lower limb amputation population, because of the heterogeneity of the assessment methods used. Some included studies reported a negative association between poor nutritional status and clinical outcomes. However, these results should be interpreted with caution, because of the limited quality of the studies available. Studies high in methodological quality and high in hierarchy of evidence are needed. The proportion of people with a poor nutritional status in the major dysvascular lower limb amputation population is inconclusive. Poor nutritional status seems to affect clinical outcomes negatively. More uniformity in assessment of malnutrition in the major dysvascular lower limb amputation population is needed. [ABSTRACT FROM AUTHOR]

Introduction: Over the past 20 years, military medicine made great strides in the medical management of traumatically injured patients. Significant advancements were made in the treatment and rehabilitation after limb loss. These advancements can be attributed to the large number of complex patients presenting to military treatment facilities and the demand for medical professionals to provide care to patients with complex injuries and multiple traumatic amputations. The concern now is to maintain the skills needed to be prepared for the next conflict. To meet this demand, the Extremity Trauma and Amputation Center of Excellence (EACE) initiated the documentation of knowledge, skills, and abilities (KSAs) to ensure that the skill sets needed to treat this unique population are not lost. The EACE developed KSAs to sustain advanced clinical practice for physical therapists, occupational therapists, and prosthetists and is in the process of developing KSAs for orthotists and physical medicine physicians. The learning objectives [terminal and enabling learning objectives (TLOs and ELOs)] derived from each set of KSAs will drive curricula development for enduring education, residencies, and fellowships. This article describes the KSAs and learning objectives for advanced physical therapist competencies in amputation care. Methods: Clinical subject matter experts (SMEs) convened from the Department of Defense (DoD) Advanced Rehabilitation Centers (ARCs) to draft the initial KSAs. All experts had specific expertise in treating individuals with highly complex lower and upper limb amputation. In a quasi-Delphi methodology, the initial draft KSAs underwent five cycles of review and comment by an additional 15 DoD, Veterans Affairs, and civilian institution experts from clinical practice, education, and research. The consensus KSAs were then transcribed into learning objectives with collaboration between clinical subject matter experts and doctoral-level educators. Results: The final program document has 21 instructional modules with 30 TLOs and 157 ELOs. Conclusion: The KSAs and the learning objectives describe the skills expected of an advanced practice physical therapist treating patients with traumatic limb loss. Weaknesses of this document include the focus on traumatic amputation and military specific needs. However, many of the central advanced practices are universal to all physical therapists working in amputation. Thus, this document should serve as a starting point and can evolve to include dysvascular, oncology, and other etiologies. To our knowledge, this is the first paper to describe the KSAs for the advanced practice physical therapist working with traumatic limb loss population. This work will form the framework for physical therapist advanced practice training programs. [ABSTRACT FROM AUTHOR]

Lower limb amputation is a medical intervention which causes motor disability and may compromise quality of life. Several factors determine patients' health outcomes, including an appropriate prosthetic provision and an effective rehabilitation program, necessitating a thorough quantitative observation through different data sources. In this context, the role of interoperability becomes essential, facilitating the reuse of real-world data through the provision of structured and easily accessible databases. This study introduces a comprehensive 10-year dataset encompassing clinical features, mobility measurements, and prosthetic knees of 1006 trans-femoral amputees during 1962 hospital stays for rehabilitation. The dataset is made available in both comma-separated values (CSV) format and HL7 Fast Healthcare Interoperability Resources (FHIR)-based representation, ensuring broad utility and compatibility for researchers and healthcare practitioners. This initiative contributes to advancing community understanding of post-amputation rehabilitation and underscores the significance of interoperability in promoting seamless data sharing for meaningful insights into healthcare outcomes. [ABSTRACT FROM AUTHOR]

Introduction: Lower extremity amputation (LEA) is a life altering procedure, with significant negative impacts to patients, care partners, and the overall health system. There are gaps in knowledge with respect to patterns of healthcare utilization following LEA due to dysvascular etiology. Objective: To examine inpatient acute and emergency department (ED) healthcare utilization among an incident cohort of individuals with major dysvascular LEA 1 year post-initial amputation; and to identify factors associated with acute care readmissions and ED visits. Design: Retrospective cohort study using population-level administrative data. Setting: Ontario, Canada. Population: Adults individuals (18 years or older) with a major dysvascular LEA between April 1, 2004 and March 31, 2018. Interventions: Not applicable. Main outcome measures: Acute care hospitalizations and ED visits within one year post-initial discharge. Results: A total of 10,905 individuals with major dysvascular LEA were identified (67.7% male). There were 14,363 acute hospitalizations and 19,660 ED visits within one year post-discharge from initial amputation acute stay. The highest common risk factors across all the models included age of 65 years or older (versus less than 65 years), high comorbidity (versus low), and low and moderate continuity of care (versus high). Sex differences were identified for risk factors for hospitalizations, with differences in the types of comorbidities increasing risk and geographical setting. Conclusion: Persons with LEA were generally more at risk for acute hospitalizations and ED visits if higher comorbidity and lower continuity of care. Clinical care efforts might focus on improving transitions from the acute setting such as coordinated and integrated care for sub-populations with LEA who are more at risk. [ABSTRACT FROM AUTHOR]

Introduction: Minor amputation is commonly needed to treat diabetes-related foot disease (DFD). Remoteness of residence is known to limit access to healthcare and has previously been associated with poor outcomes. The primary aim of this study was to examine the associations between ethnicity and remoteness of residency with the risk of major amputation and death following initial treatment of DFD by minor amputation. A secondary aim was to identify risk factors for major amputation and death following minor amputation to treat DFD. Research design and methods: This was a retrospective analysis of data from patients who required a minor amputation to treat DFD between 2000 and 2019 at a regional tertiary hospital in Queensland, Australia. Baseline characteristics were collected together with remoteness of residence and ethnicity. Remoteness was classified according to the 2019 Modified Monash Model (MMM) system. Ethnicity was based on self-identification as an Aboriginal and Torres Strait Islander or non-Indigenous person. The outcomes of major amputation, repeat minor amputation and death were examined using Cox-proportional hazard analyses. Results: A total of 534 participants were included, with 306 (57.3%) residing in metropolitan or regional centres, 228 (42.7%) in rural and remote communities and 144 (27.0%) were Aboriginal or Torres Strait Islander people. During a median (inter quartile range) follow-up of 4.0 (2.1–7.6) years, 103 participants (19.3%) had major amputation, 230 (43.1%) had repeat minor amputation and 250 (46.8%) died. The risks (hazard ratio [95% CI]) of major amputation and death were not significantly higher in participants residing in rural and remote areas (0.97, 0.67–1.47; and 0.98, 0.76–1.26) or in Aboriginal or Torres Strait Islander people (HR 1.44, 95% CI 0.96, 2.16 and HR 0.89, 95% CI 0.67, 1.18). Ischemic heart disease (IHD), peripheral artery disease (PAD), osteomyelitis and foot ulceration (p<0.001 in all instances) were independent risk factors for major amputation. Conclusion: Major amputation and death are common following minor amputation to treat DFD and people with IHD, PAD and osteomyelitis have an increased risk of major amputation. Aboriginal and Torres Strait Islander People and residents of remote areas were not at excess risk of major amputation. [ABSTRACT FROM AUTHOR]

Osteomyelitis (OM) in diabetic foot infection could have many presentations such as an infected ulcer spreading to the bone or superimposed to Charcot neuroarthropathy. However, the sausage toe as a diabetic OM presentation was very rarely investigated; therefore, this study aims to assess the prevalence and signs of this presentation along with treatment modalities and outcomes. This is a retrospective series of patients presenting a sausage toe on admission. Several methods were conducted to diagnose OM, and three treatment modalities were applied. Two groups were compared: acute and chronic sausage toes. Outcomes were defined as sausage toe prevalence, ulcer location, OM prevalence, and comparative treatment results. Out of 82 diabetic toe infection cases, 24 (30%) presented as 'sausage toe'. The side of the proximal interphalangeal joint of the lateral toes was the most frequent ulcer location (50%), mostly on the dorsal aspect followed by the side aspect. There were 15 (62.5%) acute cases and 9 (37.5%) chronic cases. MRI showed signs of OM in 21 (87.5%) cases and signs of septic arthritis in 3 (12.5%) cases. At the final follow‐up, a successful treatment was recorded in five (20%) cases with antibiotics alone. Out of the 19 (42%) procedures, conservative surgery was performed successfully in 8 (58%) cases while amputation was needed in 11 (45.8%) cases. There was no significant difference in amputation frequency between acute and chronic groups. This is the first study documenting the sausage toe as a prevalent presentation of diabetic toe infection. The deformity is conclusive of deep infection with a very high osteomyelitis frequency. Surgery is often required for infection control and healing, mainly for chronic cases, and treatment outcomes did not differ between acute and chronic sausage toe groups. It could be beneficial to include this entity in the diabetic wound classification systems. [ABSTRACT FROM AUTHOR]

Surgical site infections (SSIs) following major lower limb amputation (MLLA) in vascular patients are a major source of morbidity. The objective of this systematic review was to determine the incidence of SSI following MLLA in vascular patients. This review was prospectively registered with the International Prospective Register of Systematic Reviews (CRD42023460645). Databases were searched without date restriction using a pre‐defined search strategy. The search identified 1427 articles. Four RCTs and 21 observational studies, reporting on 50 370 MLLAs, were included. Overall SSI incidence per MLLA incision was 7.2% (3628/50370). The incidence of SSI in patients undergoing through‐knee amputation (12.9%) and below‐knee amputation (7.5%) was higher than the incidence of SSI in patients undergoing above‐knee amputation, (3.9%), p < 0.001. The incidence of SSI in studies focusing on patients with peripheral arterial disease (PAD), diabetes or including patients with both was 8.9%, 6.8% and 7.2%, respectively. SSI is a common complication following MLLA in vascular patients. There is a higher incidence of SSI associated with more distal amputation levels. The reported SSI incidence is similar between patients with underlying PAD and diabetes. Further studies are needed to understand the exact incidence of SSI in vascular patients and the factors which influence this. [ABSTRACT FROM AUTHOR]

This study analysed the incidence of lower extremity amputation and its associated risk factors in patients with diabetic foot ulcers. This study systematically searched both Chinese and English databases, including CNKI, Wanfang, VIP, PubMed, EMBASE and Web of Science, to identify cohort studies related to lower extremity amputation and associated risk factors in patients with diabetic foot ulcers up to October 2023. The patients were stratified based on whether they underwent lower extremity amputation, and relevant data, including basic information, patient characteristics, complications, comorbidities and pertinent laboratory test data, were extracted from the included studies. The literature quality assessment in this study utilized the Newcastle‐Ottawa Scale to screen for high‐quality literature, resulting in the inclusion of 16 cohort studies, all of which were of at least moderate quality. Meta‐analysis of outcome indicators was conducted using the Stata 14.0 software. The results indicate that the overall amputation rate of lower extremities in patients with diabetic foot ulcers is 31% (0.25, 0.38). Among the 16 variables evaluated, gender (male), smoking history, body mass index (BMI), hypertension, cardiovascular disease, kidney disease, white blood cell count, haemoglobin and albumin levels were found to be correlated with the occurrence of lower extremity amputation in patients with diabetic foot ulcers. However, no significant correlation was observed between age, diabetes type, duration of diabetes, stroke, glycosylated haemoglobin, creatinine and total cholesterol levels and lower extremity amputation in patients with diabetic foot ulcers. This meta‐analysis indicates that the overall amputation rate in patients with diabetic foot ulcers is 31%. Factors such as gender (male), smoking history, high BMI, hypertension, cardiovascular disease, kidney disease, white blood cell count, haemoglobin and albumin levels are identified as significant risk factors for lower extremity amputation in diabetic foot ulcer patients. These findings suggest that attention should be focused on these risk factors in patients with diabetic foot ulcers to reduce the risk of lower extremity amputation. Therefore, preventive and intervention measures targeting these risk factors are of significant importance in clinical practice. (Systematic review registration: https://www.crd.york.ac.uk/PROSPERO/, identifier [CRD42024497538]). [ABSTRACT FROM AUTHOR]

Key Clinical Message: Elective amputation as a treatment for Body Integrity Identity Disorder (BIID) or Body Integrity Dysphoria (BID) where noninvasive treatments prove ineffective and the patient's distress is substantial, may permit long‐term remission of symptoms at follow‐up. We present the one‐year follow‐up post‐surgery of an ambidextrous male who sought elective amputation of his left hand's fourth and fifth fingers after an unsuccessful trial of psychotherapy and pharmacotherapy for Body Integrity Dysphoria. He had no psychiatric comorbidities. At one‐year follow‐up, his dysphoria was still in remission. He exhibited full adaptation in his social and occupational life, demonstrating increased ease in hand use compared to pre‐amputation. He reported sleeping well, happiness, good health and continued acceptance by friends and family. This one‐year post‐surgery follow‐up, at 22 years old, underscores the efficacy of amputation as a curative treatment, high patient satisfaction, and the quality of life gained through the procedure. [ABSTRACT FROM AUTHOR]

Background: Numerous studies have developed or validated prediction models aimed at estimating the likelihood of amputation in diabetic foot (DF) patients. However, the quality and applicability of these models in clinical practice and future research remain uncertain. This study conducts a systematic review and assessment of the risk of bias and applicability of amputation prediction models among individuals with DF. Methods: A comprehensive search was conducted across multiple databases, including PubMed, Web of Science, EBSCO CINAHL Plus, Embase, Cochrane Library, China National Knowledge Infrastructure (CNKI), Wanfang, Chinese Biomedical Literature Database (CBM), and Weipu (VIP) from their inception to December 24, 2023. Two investigators independently screened the literature and extracted data using the checklist for critical appraisal and data extraction for systematic reviews of prediction modeling studies. The Prediction Model Risk of Bias Assessment Tool (PROBAST) checklist was employed to evaluate both the risk of bias and applicability. Results: A total of 20 studies were included in this analysis, comprising 17 development studies and three validation studies, encompassing 20 prediction models and 11 classification systems. The incidence of amputation in patients with DF ranged from 5.9 to 58.5%. Machine learning-based methods were employed in more than half of the studies. The reported area under the curve (AUC) varied from 0.560 to 0.939. Independent predictors consistently identified by multivariate models included age, gender, HbA1c, hemoglobin, white blood cell count, low-density lipoprotein cholesterol, diabetes duration, and Wagner's Classification. All studies were found to exhibit a high risk of bias, primarily attributed to inadequate handling of outcome events and missing data, lack of model performance assessment, and overfitting. Conclusions: The assessment using PROBAST revealed a notable risk of bias in the existing prediction models for amputation in patients with DF. It is imperative for future studies to concentrate on enhancing the robustness of current prediction models or constructing new models with stringent methodologies. [ABSTRACT FROM AUTHOR]

Background & Aims: Surgery plays a key role in the management of complicated diabetic foot disease (DFD). Currently, indications for medical versus surgical management are poorly defined. Prompt identification of patients who require surgery may reduce morbidities and length of hospital stay. This study aims to analyse factors in DFD that necessitate early surgical interventions. Methods: All patients admitted under a multi‐disciplinary diabetic foot team in a tertiary institution over 2 years were included in a retrospective case‐control study comparing patients who received medical management and patients who received surgical management. Logistic regression was performed to identify factors associated with surgical management of diabetic foot complications. Results: Three hundred and forty patients were included. 49% of patients required surgical management. Toe ulceration, elevated C‐reactive protein (CRP), and the presence of osteomyelitis were associated with surgical management. Multivariate analysis calculated an odds ratio (OR) of 1.01 for CRP (p < 0.001), OR 2.19 (p < 0.019) favouring surgical management for forefoot ulcers, and OR 2.2 (p < 0.019) if osteomyelitis was present. Conclusions: Patients with elevated CRP levels, a forefoot diabetic ulcer and established osteomyelitis were more likely to undergo surgical management. Prompt recognition of these patients has the potential benefit of earlier decision making in definitive surgical interventions. [ABSTRACT FROM AUTHOR]

Background: This retrospective analysis of an ongoing prospective cohort study aimed to assess the outcome of revascularisation for treating lifestyle-limiting intermittent claudication caused by peripheral artery disease (PAD) in Aboriginal and Torres Strait Islander Peoples and non-Indigenous North Queenslanders. Methods: Consenting patients with PAD who underwent endovascular or open revascularisation procedures for treating lifestyle-limiting intermittent claudication were included. The primary outcome measure was major adverse limb events (MALEs), defined as major amputation or the requirement for repeat open or endovascular revascularisation. Results: Of the 378 included patients, 18 (4.8%) identified as Aboriginal and/or Torres Strait Islander Peoples. During a mean follow-up (standard deviation) of 6.0 (3.9) years, the incidence of MALE was similar in the Aboriginal and Torres Strait Islander People and non-Indigenous Australians (absolute percentage: 50.0% vs. 40.6%, log rank p = 0.59). In both unadjusted and adjusted analyses, Aboriginal and Torres Strait Islander Peoples and non-Indigenous Australians had similar risks of MALE (unadjusted hazard ratio, HR, 1.20, 95% confidence interval, CI, 0.61, 2.36; adjusted HR 1.02, 95%CI 0.50, 2.06). Conclusions: This study suggests that Aboriginal and Torres Strait Islander People are under-represented in the population of patients undergoing revascularisation to treat intermittent claudication. Due to small numbers it cannot be reliably concluded that Aboriginal and Torres Strait Islander People and non-Indigenous Australians have similar rates of MALE. [ABSTRACT FROM AUTHOR]

Limb anomalies are widespread and diversified in arthropods. From trilobites to insects, they range from the loss to the addition or fusion of legs and may appear congenitally or be induced experimentally (e.g., amputation or injury). Basal chelicerates pycnogonids, or sea spiders, also show deformities. Despite being understudied compared to other arthropods, quite a high diversity of limb malformations has been reported in the literature. The present study reports the leg anomalies of two adult females Ammothea hilgendorfi (Böhm, 1879) observed with duplicated leg podomeres. Both individuals were described ethologically and morphologically. Although the current knowledge on pycnogonids is limited, the anomaly is likely due to a problem in the molting process; the specimens were unable to totally remove their old exuviae, which then stacked after the proximal leg segments. The second specimen also showed other leg deformities, hinting at a problem during the molting process itself. The discussion emphasizes that understanding how pycnogonids normally molt would not only help our understanding of how the abnormal patterns appeared but also put pycnogonids into perspective with other arthropods, a phylum in which they have a key taxonomic position. [ABSTRACT FROM AUTHOR]

Lower limb amputation is a common surgical procedure performed worldwide. Many individuals require amputation due to various circumstances, with amputations occurring above or below the knee. Surgeons rely on published research to determine the most appropriate technique based on intraoperative and postoperative outcomes. The Gritti–Stokes amputation (GSA) procedure, introduced in 1857, has shown positive results in terms of primary wound healing, reduced mortality rates during and after surgery, and accelerated healing and mobility. However, due to the need for highly trained surgeons and limitations in functional and cosmetic prosthesis fitting, concerns have been raised regarding its utility. Additionally, the procedure is underutilized in cases where it could potentially yield better results. This article provides a comprehensive review of the documented benefits of GSA, suitable candidate selection, limitations, various modifications, and a comparison with traditional approaches to lower limb amputation. The review is focused on evidence published in the last 100 years. [ABSTRACT FROM AUTHOR]

The bioethical principle of autonomy is of paramount importance within medical practice. The extent to which a patient's autonomy overlaps or conflicts with the physician's duty of beneficence and non-maleficence, however, is not so clear cut, especially for those cases in which the patient's request for medical intervention goes against the physician's advice, either because of personal belief or because there is uncertainty regarding the therapeutic approach. Body integrity dysphoria (BID) is a condition that has been included recently in the International Classification of Diseases, 11th edition (ICD-11). It may lead an affected individual to develop an intense desire to remove a specific body part in order to restore congruity between their body and their mind. Thus, its occurrence creates challenging moral and ethical dilemmas for the medical world (Loriga, 2023). The aim of this study was to investigate how Czech physicians understood, assessed and supported patient autonomy regarding requests for invasive body modifications. The objective was to produce a blueprint regarding how much a patient could influence the medical treatment they could gain within the Czech medical system and to develop a comparison with the ethical challenges of BID. A five-section survey was designed and submitted to Czech physicians on topics relevant to the BID debate. On the surface, the results showed an apparent predisposition toward collaboration between doctors and patients. However, further investigation showed that this supposed collaboration crumbled as the physiological risk-reward ratio moved further toward risk, which caused physicians progressively to rely less on the patient's opinion and psychological needs. Moreover, a strongly authoritarian approach was evident, which became overwhelming in cases of amputation requests and removed, a priori, any collaboration. The results indicate that the Czech medical system does not accept or comprehend fully patients' psychological needs, and therefore the BID phenomenon is a long way from being understood, which requires a fundamental paradigm shift. [ABSTRACT FROM AUTHOR]

Vascularized Composite Tissue Allotransplantation (VCA) allows replacement of lost body parts from brain-dead donors. These surgeries are laborious, time-intensive, and require vast planning. With the advent of better immunosuppressants, VCA will increasingly play an important role in the reconstructive field. In this paper, the authors share their standard operating protocol created after much deliberation.

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.

Introduction: Patients with Haemophilia (PWH) need orthopaedic treatments and often they undergo surgery. Classically, PWH with inhibitors have to face such procedures earlier than other patients. Major orthopaedic surgery is not easy and complications are frequent. Emicizumab is the first monoclonal antibody introduced for haematological prophylaxis for PWH with inhibitors, achieving an efficacious haemostasis also in patients with severe haemophilia A with inhibitors, later demonstrated for PWH without inhibitors. A few years ago, emicizumab was also proposed for PWH undergoing surgery, as it supports excellent bleeding control. The literature on orthopaedic surgery using an emicizumab protocol is scarce: only isolated case reports with short-term follow-ups are available. Aim: The purpose of this study is the assessment of the mid-term outcomes of major orthopaedic surgery performed in a population of patients with and without inhibitors and an emicizumab regimen. Methods: We reviewed the records of 13 PWH (eight with high-titre inhibitors, five without) with a mean age of 54.6 years, undergoing 15 orthopaedic surgical procedures between 2017 and 2022: primary knee and hip arthroplasty, revision, pseudotumor excision, or amputation. Their prophylaxis consisted of the combination of emicizumab and boluses of rFVIIa (PWH with inhibitors) or rFVIII (PWH without inhibitors). The clinical parameters of evaluation were: VAS, Haemophilic Joint Health Score (HJHS), and standard radiologic studies. Follow-up was conducted at 1, 3, 6 months, and then yearly. The survival rate of all implants was also assessed. Results: The mean follow-up was 38.8 months (range: 12–65). All patients were successfully treated without complications during surgery. During the postoperative period, a patient affected by a septic complication two months after his pseudotumor excision underwent an above-the-knee amputation. All patients were regularly discharged to the rehabilitative ward, reporting satisfaction for pain reduction and improved joint and global function at the VAS and HJHS scores. No revisions or implant failures were recorded. Conclusions: A prophylaxis regimen with emicizumab and factor replacement in PWH with or without inhibitors undergoing major orthopaedic surgery ensures effective bleeding control and good postoperative clinical outcomes at mid-term follow-up, and may be routinely adopted in dedicated high-volume hospitals. This series is the most consistent to date reported at a single Haemophilia centre. [ABSTRACT FROM AUTHOR]

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]

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]

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]

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]