Amputation or Reconstruction? Development and Validation of a Patient Decision Aid for Treatment of Severe Lower-Extremity Trauma.

BACKGROUND: Our goal was to develop and validate the Severe Lower-Extremity Trauma decision aid (SLETRA) to help patients make treatment decisions aligned with their values regarding amputation versus reconstruction. METHODS: We recruited 62 adults (41 women) from a foot and ankle practice at a US academic hospital from June to August 2020. We excluded patients who could not read in English and who lacked internet service access. Patients completed an 8-question knowledge test regarding the risks, benefits, and outcomes of treatment options before and after reviewing SLETRA. The survey presented a hypothetical case of severe lower-extremity trauma. Respondents, imagining themselves as patients, indicated whether they would choose amputation or reconstruction. We evaluated knowledge scores (maximum, 8 points); decisional conflict scores (maximum, 400 points, with higher scores indicating greater respondent difficulty in decision making); ratings of factors influencing the decision; and SLETRA helpfulness (maximum, 7 points). Pre- and post-test knowledge scores were compared using paired Student's t-tests; Alpha = 0.05. RESULTS: Mean and standard deviation knowledge scores improved from 5.2 ± 1.6 (pre-test) to 6.7 ± 1.6 (post-test) (p < 0.001). Mean decisional conflict score was 223 ± 16, reflecting moderate difficulty. Factors affecting treatment choice were risk of complications (n = 29), recovery time (n = 27), and future prosthesis use (n = 27). No respondent had difficulty understanding SLETRA. Mean helpfulness score was 5.6 ± 0.16, reflecting considerable benefit. CONCLUSION: The SLETRA decision aid is a helpful, understandable tool that significantly improves patient knowledge regarding treatment options for severe lower-extremity trauma.

Life-saving Field Amputation During the 2023 Türkiye Earthquake: Ethical, Social, and Legal Implications Beyond the Complex Medical and Rescue Procedures in the Rubble.

Amputation as a life-saving measure for earthquake-trapped patients is supported by WHO and INSARAG guidelines. However, implementing these guidelines in highly stressful contexts can complicate decision-making. This report presents a case of life-saving amputation during the 2023 Turkey earthquake, adhering to recommended guidelines. The 16-year-old patient was trapped for 55 hours in a narrow corridor. Extensive interdisciplinary discussions led to the decision for a field amputation after alternative rescue attempts failed. Consent was obtained from the family, given the patient's delirium. Meticulous planning and anesthesia using midazolam and ketamine ensured successful amputation with minimal blood loss. Challenges encountered during the disaster response were discussed. Delays in administering antibiotics, a lack of cervical protection, ethical dilemmas, psychological concerns, and legal implications were highlighted. Continued improvement and addressing ethical, legal, and psychological aspects are essential for optimal disaster response outcomes.

Clinical outcomes of acute limb ischaemia caused by femoropopliteal stent thrombosis.

BACKGROUND: Although femoropopliteal-specific stents have durable patency, stent thrombosis (ST) may occur, which can lead to acute limb ischaemia (ALI). AIMS: We aimed to investigate the clinical features and outcomes of ALI caused by femoropopliteal ST in patients with lower extremity artery disease. METHODS: This multicentre retrospective study included 499 patients with ALI - of whom 108 patients had ALI caused by femoropopliteal ST (ST-ALI) and 391 patients had ALI caused by other aetiologies (de novo ALI) - who underwent treatment between September 2011 and March 2023. Clinical features and outcomes were compared between the two groups. The primary outcome measure was 12-month amputation-free survival; factors associated with amputation or death were investigated using multivariate Cox proportional hazards regression analysis. RESULTS: Patients with ST-ALI were significantly more likely to exhibit conventional atherosclerotic risk factors, including diabetes mellitus (63% vs 26%) and haemodialysis (51% vs 10%) compared to patients with de novo ALI, whereas patients with de novo ALI were older (80 years vs 74 years) and more likely to have atrial fibrillation (49% vs 18%) than patients with ST-ALI. The 12-month amputation-free survival rate was significantly lower in the ST-ALI group than that in the de novo ALI group (51% vs 76%; p<0.001). Multivariate analysis revealed that ST-ALI, older age, haemodialysis, atrial fibrillation, the presence of a wound, peak C-reactive protein level, and non-ambulatory status all have an independent, positive association with death or major amputation. CONCLUSIONS: The current study revealed that patients with ST-ALI had worse clinical outcomes than those with de novo ALI, highlighting the need to maximise ST prevention.

Incidence and risk factors for amputation in Chinese patients with diabetic foot ulcers: a systematic review and meta-analysis.

Objective: This study aimed to comprehensively analyze the incidence of amputation in Chinese patients with diabetic foot ulcers (DFUs). Methods: The Preferred Reporting Items for a Systematic Review and Meta-analysis (PRISMA) guidelines were used. The CNKI, Wanfang Data, VIP, PubMed, Web of Science, and Embase databases were searched to collect relevant literature on the incidence of amputation in Chinese patients with DFUs. Two researchers independently screened the literature, extracted data, and evaluated the risk of bias. The data were systematically analyzed using Stata 17.0 software to determine the incidence of amputation in this patient population. Results: A total of 25 papers were included in the study, revealing an incidence of amputation in Chinese patients with DFUs of 22.4% (95% confidence interval: 18.3-26.5%). The subgroup analysis revealed that a history of ulcers, Wagner grade >3, and diabetic peripheral vascular disease were the primary risk factors associated with a higher incidence of amputation in Chinese patients with DFUs (P<0.05). Among Chinese patients with DFUs, the amputation group and the non-amputation group showed significant differences in body mass index, duration of DFUs, total cholesterol, triglyceride, fasting blood glucose, white blood cell count, hemoglobin A1c, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, high-sensitivity C-reactive protein, and uric acid (P<0.05). Conclusion: The high incidence of amputation among Chinese patients with DFUs indicates that interventions should be implemented to prevent or minimize amputations. Systematic review registration: https://www.crd.york.ac.uk/prospero, identifier CRD42023463976.

Could fasciotomy prevent amputation in patients with electrical burn injuries? Insights from a cross-sectional study in Indonesia.

The amputation rate resulting from electrical burn injuries remains high, yet no study has investigated whether early fasciotomy may reduce the amputation rate. The aim of this study was to analyze the success rate of fasciotomy in preventing amputation and determine the optimal timing for fasciotomy in electrical burn injuries. This study was conducted at Dr. Soetomo Hospital from January 2020 to July 2023. Total sampling was employed to recruit the patients. Clinical data, voltage characteristics, burn location, affected total body surface area, burn depth, hospital arrival time, and time interval from incident to fasciotomy were assessed. Chi-squared test was used to assess factors associated with the fasciotomy incidence and factors associated with amputation after fasciotomy. A total of 45 patients were included, of which 97.8% were male, with a mean age of 37.60 years old. Approximately 73% of patients had full-thickness burn injuries, with the left upper extremity being the most affected (80%). There are seven patients (15.6%) had fasciotomy and five (11.1%) patients had an amputation. Our data indicated a significant association between voltage characteristics and fasciotomy incidence (p=0.034). Additionally, our data indicated that earlier arrival to the hospital (p=0.002) and timely fasciotomy conducted upon arrival (p<0.001) were associated with a reduced rate of amputation. This study highlights that prompt arrival to the hospital and early fasciotomy may prevent amputation in patients with electrical burn injuries.

Economic impact of limb-salvage strategies in chronic limb-threatening ischaemia: modelling and budget impact study based on national registry data.

BACKGROUND: Missed opportunities to reduce numbers of primary major lower-limb amputation and increase limb-salvage procedures when treating chronic limb-threatening ischaemia have previously been identified in the literature. However, the potential economic savings for healthcare providers when salvaging a chronic limb-threatening ischaemia-affected limb have not been well documented. METHODS: A model using National Health Service healthcare usage and cost data for 1.6 million individuals and averaged numbers of primary surgical procedures for chronic limb-threatening ischaemia from England and Wales in 2019-2021 was created to perform a budget impact analysis. Two scenarios were tested: the averaged national rates of major lower-limb amputation (above the ankle joint), angioplasty, open bypass surgery or arterial endarterectomy in the National Vascular Registry (current scenario); and revascularization rates adjusted based on the lowest amputation rate reported by the National Vascular Registry at the time of the study (hypothetical scenario). The primary outcome was the net impact on costs to the National Health Service over 12 months after the index procedure. RESULTS: In the current scenario, the proportions of different index procedures were 10% for lower-limb major amputation, 55% for angioplasty, 25% for open bypass surgery and 10% for arterial endarterectomy. In the hypothetical scenario, the procedure rates were 3% for major lower-limb amputation, 59% for angioplasty, 27% for open bypass surgery and 11% for arterial endarterectomy. For 16 025 index chronic limb-threatening ischaemia procedures, the total care cost in the current scenario was €243 924 927. In the hypothetical scenario, costs would be reduced for index procedures (-€10 013 814), community care (-€633 943) and major cardiovascular events (-€383 407), and increased for primary care (€59 827), outpatient appointments (€120 050) and subsequent chronic limb-threatening ischaemia-related surgery (€1 179 107). The net saving to the National Health Service would be €9 645 259. CONCLUSION: A shift away from primary major lower-limb amputation towards revascularization could lead to substantial savings for the National Health Service without major cost increases later in the care pathway, indicating that care decisions taken in hospitals have wider benefits.

Spitzoid melanoma of the finger: a case report.

BACKGROUND: Melanoma is the most malignant skin tumor, with a high metastatic potential. Spitzoid melanoma is a subtype of melanoma requiring rapid management and extensive tumor resection. We have set the goal to recognize anatomical peculiarities and difficulties diagnoses posed by this type of tumor, as well as to recognize the management modalities, especially the surgical one, of malignant spitzoid melanoma. CASE PRESENTATION: A 25-year-old Tunisian male patient had consulted for nodular lesion of the right index, evolving for 4 years. A malignant tumor was strongly suspected, then confirmed as a melanoma by a biopsy excision. Initially, the excision was incomplete in depth, suggesting a complementary surgery, but the patient refused it; 3 years later, the patient again consulted after the appearance of an axillary lymphadenopathy and worsening of the skin lesion. A supplement of tumor removal with lymph node biopsy were performed. It was decided to perform an amputation of the second ray and the first commissure with cheiroplasty, reconstructing a four-finger hand. An homolateral axillary cleaning was performed at the same time. The postoperative result is considered esthetically and functionally satisfying. The evolution was marked by the appearance of pulmonary metastases, requiring adjuvant chemotherapy. A regression of the nodule under the mammary skin and total disappearance of axillary nodes have been marked; but the patient's condition rapidly deteriorated, and he died after a 2-month decline. CONCLUSION: Spitzoid melanoma is exceptional, posing difficulties in diagnostics, and it should not be underestimated, considering that it may involve the vital prognosis. Knowledge of this rare form of melanoma is important to avoid misdiagnosis, which delays diagnosis and subsequent therapy.

Exploring potential risk factors for lower limb amputation in people with diabetes-A national observational cohort study in Sweden.

AIMS: Risk factors for lower limb amputation (LLA) in individuals with diabetes have been under-studied. We examined how 1/demographic and socioeconomic, 2/medical, and 3/lifestyle risk factors may be associated with LLA in people with newly diagnosed diabetes. METHODS: Using the Swedish national diabetes register from 2007 to 2016, we identified all individuals ≥18 years with an incident diabetes diagnosis and no previous amputation. These individuals were followed from the date of diabetes diagnosis to amputation, emigration, death, or the end of the study in 2017 using data from the In-Patient Register and the Total Population Register. The cohort consisted of 66,569 individuals. Information about demographic, socioeconomic, medical, and lifestyle risk factors was ascertained around the time of the first recorded diabetes diagnosis, derived from the above-mentioned registers. Cox proportional hazard models were used to obtain hazard ratios (HR) with 95% confidence intervals (CI). RESULTS: During the median follow-up time of 4 years, there were 133 individuals with LLA. The model adjusting for all variables showed a higher risk for LLA with higher age, HR 1.08 (95% CI 1.05-1.10), male sex, HR 1.57 (1.06-2.34), being divorced, HR 1.67 (1.07-2.60), smokers HR 1.99 (1.28-3.09), insulin treated persons HR 2.03 (1.10-3.74), people with low physical activity (PA) HR 2.05 (1.10-3.74), and people with an increased foot risk at baseline HR > 4.12. People with obesity had lower risk, HR 0.46 (0.29-0.75). CONCLUSIONS: This study found a higher risk for LLA among people with higher age, male sex, who were divorced, had a higher foot risk group, were on insulin treatment, had lower PA levels, and were smokers. No significant association was found between risk for LLA and education level, country of origin, type of diabetes, blood glucose level, hypertension, hyperlipidemia, creatinine level, or glomerular filtration rate. Obesity was associated with lower risk for LLA. Identified variables may have important roles in LLA risk among people with diabetes.

Fenofibrate to prevent amputation and reduce vascular complications in patients with diabetes: FENO-PREVENT.

BACKGROUND: The potential preventive effect of fenofibrate on lower extremity amputation (LEA) and peripheral arterial disease (PAD) in patients with type 2 diabetes (T2D) is not fully elucidated. METHODS: We selected adult patients ≥ 20 years of age with T2D from the Korean National Health Insurance Service Database (2009-2012). The fenofibrate users were matched in a 1:4 ratio with non-users using propensity scores (PS). The outcome variables were a composite of LEA and PAD and the individual components. The risks of outcomes were implemented as hazard ratio (HR) with 95% confidence intervals (CI). For safety issues, the risks of acute kidney injury, rhabdomyolysis and resulting hospitalization were analyzed. RESULTS: A total of 114,920 patients was included in the analysis with a median follow-up duration of 7.6 years (22,984 and 91,936 patients for the fenofibrate user and non-user groups, respectively). After PS matching, both groups were well balanced. The fenofibrate group was associated with significantly lower risks of composite outcome of LEA and PAD (HR 0.81; 95% CI 0.70-0.94), LEA (HR 0.76; 95% CI 0.60-0.96), and PAD (HR 0.81; 95% CI 0.68-0.96). The risk of acute kidney injury, rhabdomyolysis, or hospitalization for these events showed no significant difference between the two groups. Subgroup analyses revealed consistent benefits across age groups, genders, and baseline lipid profiles. CONCLUSIONS: This nationwide population-based retrospective observational study suggests that fenofibrate can prevent LEA and PAD in patients with T2D who are on statin therapy.

Temporal trends in lower extremity amputation in Middle East and North Africa (MENA) region: analysis of the GBD dataset 1990-2019.

BACKGROUND: Lower extremity amputations (LEAs) significantly contribute to mortality and morbidity, often resulting from peripheral artery disease and diabetes mellitus (DM). Traumatic injuries also account for many LEAs. Despite the global burden, the epidemiology of LEAs, particularly in the Middle East and North Africa (MENA) region, remains underexplored. This study utilizes the Global Burden of Disease (GBD) dataset to analyze temporal trends in LEAs in the MENA region from 1990 to 2019. METHODS: The study utilized the 2019 GBD dataset, which includes estimates for incidence, prevalence, and disability-adjusted life-years (DALYs) across 369 diseases. Age-standardized incidence rates (ASIRs) for LEAs were extracted for 21 MENA countries. Trends were analyzed using percentage change calculations and Joinpoint regression to identify significant shifts in LEA rates over time. RESULTS: From 1990 to 2019, male LEA rates generally decreased, while female rates increased. Significant increases in LEA rates were observed in Syria, Yemen, and Afghanistan, correlating with periods of conflict and instability. Conversely, countries like Iraq, Palestine, Sudan, Lebanon, Iran, and Kuwait saw marked decreases. The study highlighted a complex interplay of socio-political factors, natural disasters, and chronic diseases like DM in shaping LEA trends across the region. CONCLUSION: The study reveals variable LEA trends in the MENA region, influenced by conflicts, natural disasters, and chronic diseases. These findings underscore the need for targeted public health interventions, improved healthcare access, and robust data collection systems to reduce the burden of LEAs and improve patient outcomes in the MENA region.

Bone Bridge Transtibial Amputation by an Innovative Technique.

We present a case report of synostosis after transtibial amputation because of distraction regenerate formation after decortication of the lateral surfaces of the tibia and fibula, sequential compression, and distraction using the Ilizarov apparatus. Its advantage is that there is no need to shorten bone. The establishment of distal tibia-fibula synostosis (Ertl) in patients with transtibial amputation has been advocated to improve function and prosthetic wear. There are a variety of techniques to create a bone block. This case reports the successful use of an innovative technique to establish bone block. A patient with transtibial amputation underwent revision of residual limb by decorticating the lateral aspect of the distal tibia and the medial aspect of the distal fibula and acutely compressing the distal ends of the 2 bones with the Ilizarov apparatus. The distal fibula is then slowly and progressively distracted laterally, and the bone is formed in the space between the distal fibula and tibia, creating synostosis with an increased distal bone cross-sectional surface area for improved function and prosthetic wear. The follow-up period was 24 months. Within 3 months, synostosis was formed, which increased the area of the supporting surface and allowed temporary and then permanent prosthetics. After 24 months, synostosis did not differ from the structure of tibial stump bones.

Infection of Mycoplasma hominis in the left lower leg amputation wound of a patient with diabetes: a case report.

BACKGROUND: Mycoplasma hominis is typically found on the mucosal epithelium of the human genital tract, with infections being rare. However, when the mucosal barrier is compromised or in individuals with weakened immune systems, this microorganism can trigger infections in both intragenital and extragenital sites. This study offers a comprehensive overview of infections caused by the rare pathogen M. hominis. This overview helps laboratories identify M. hominis infections in a timely manner, thereby enabling earlier clinical intervention for patients. CASE PRESENTATION: A 75-year-old Taiwanese man with type 2 diabetes mellitus initially underwent a left lower extremity amputation following a severe infection caused by necrotizing fasciitis. Subsequently, a poorly healing wound developed at the site of amputation. Upon culturing the wound abscess, M. hominis was isolated and identified as the causative agent. CONCLUSIONS: Through this case, we present clinical and microbiological observations along with a review of the literature to deepen our understanding of M. hominis. Our findings can be used to develop laboratory diagnostic protocols and innovative therapeutic approaches.

Blood Hemoglobin Concentrations and the Incidence of Lower Extremity Peripheral Arterial Disease in Patients Undergoing Hemodialysis: 10-Year Outcomes of the Q-Cohort Study.

BACKGROUND: Lower extremity peripheral arterial disease is a potentially lethal cardiovascular complication in patients undergoing hemodialysis. Anemia is a risk factor for cardiovascular disease among the hemodialysis population. However, whether blood hemoglobin concentration is associated with the risk of peripheral arterial disease progression in this population remains undetermined. METHODS AND RESULTS: This is an extension of a 4-year multicenter, prospective, observational cohort study to 10 years. A total of 3504 Japanese patients undergoing maintenance hemodialysis were recruited between 2006 and 2007. The primary exposure was blood hemoglobin concentration at baseline. The main outcome was the first-ever incidence of major adverse limb events (MALE), composed of endovascular treatment, bypass surgery, and amputation. Multivariable-adjusted Cox proportional hazards model, Fine-Gray subdistribution hazards model, restricted cubic spline analysis, and restricted mean survival time analysis were used to determine the association of blood hemoglobin concentration with the incidence of MALE. During a median follow-up of 8.0 years, 257 patients experienced MALE. A Cox proportional hazards model showed that the risk of MALE in patients with blood hemoglobin concentrations <10.0 g/dL was significantly higher than in patients with concentrations of 11.0 to 11.9 g/dL, even after adjusting for confounding factors. In contrast, elevated hemoglobin concentration (≥12.0 g/dL) was not significantly associated with increased risk of MALE. Similar associations were observed when the Fine-Gray subdistribution regression model was used by setting all-cause mortality as the competing risk. CONCLUSIONS: A low blood hemoglobin concentration is an independent risk factor for peripheral arterial disease progression in patients undergoing maintenance hemodialysis.

Walking Ankle Biomechanics of Individuals With Transtibial Amputations Using a Prescribed Prosthesis and a Portable Bionic Prosthesis Under Myoelectric Control.

Individuals with transtibial amputation can activate residual limb muscles to volitionally control robotic ankle prostheses for walking and postural control. Most continuous myoelectric ankle prostheses have used a tethered, pneumatic device. The Open Source Leg allows for myoelectric control on an untethered electromechanically actuated ankle. To evaluate continuous proportional myoelectric control on the Open Source Ankle, we recruited five individuals with transtibial amputation. Participants walked over ground with an experimental powered prosthesis and their prescribed passive prosthesis before and after multiple powered device practice sessions. Participants averaged five hours of total walking time. After the final testing session, participants indicated their prosthesis preference via questionnaire. Participants tended to increase peak ankle power after practice (powered 0.80 ± 1.02 W/kg and passive 0.39 ± 0.31 W/kg). Additionally, participants tended to generate greater ankle work with the powered prosthesis compared to their passive device ( 0.13 ± .15 J/kg increase). Although work and peak power generation were not statistically different between the two prostheses, participants preferred walking with the prosthesis under myoelectric control compared to the passive prosthesis. These results indicate individuals with transtibial amputation learned to walk with an untethered powered prosthesis under continuous myoelectric control. Four out 5 participants generated larger magnitudes in peak power compared to their passive prosthesis after practice sessions. An additional important finding was participants chose to walk with peak ankle powers about half of what the powered prosthesis was capable of based on mechanical testing.

Surgical Interventions for Acute Limb Ischaemia (ALI).

OBJECTIVE: To evaluate presentations, aetiologies, interventions, and outcomes of patients presenting with acute limb ischaemia (ALI). STUDY DESIGN: An observational study. Place and Duration of the Study: Department of Surgery, The Aga Khan University Hospital, Karachi, Pakistan, from January 2000 to December 2020. METHODOLOGY: Record of 104 patients who underwent surgical interventions for ALI was retrospectively evaluated. The diagnosis was confirmed on imaging (ultrasound / CTA / conventional angiography). Demographic characteristics, co-morbidities, aetiologies, and outcomes were analysed using descriptive statistics and logistic regression. RESULTS: The cohort's mean age was 58.89 ± 12.6 years, with (54.8%, n = 57) females and (45.2%, n = 47) males. Hypertension (54.8%, n = 57), diabetes (46.2%, n = 48), and atrial fibrillation (34.6%, n = 36) were common comorbidities. Thromboembolism (67.3%, n = 70) and thrombotic occlusion (32.7%, n = 34) were primary aetiologies, predominantly affecting the lower limb (66.3%, n = 58) and femoral artery (51.9%, n = 54). The majority of cases were classified as Rutherford classification 2A (53.8%; 56 cases) and 2B (44.2%; 46 cases); 58 (55.8%) patients were classified as ASA Class III, while 36 (34.6%) patients were categorised as ASA Class IV. Embolectomy (80.8%, n = 84) was the prevailing intervention, with an amputation rate (17.3%, n = 18) and a mortality rate (5.8%, n = 6). CONCLUSION: Most patients with ALI presented with Rutherford Class II and had thromboembolism aetiology. Embolectomy was the most commonly performed procedure with a high amputation rate and mortality. KEY WORDS: Acute limb ischaemia, Embolectomy, Amputation, Thromboembolism.

Outpatient Prescriptions for Insomnia Medications During the First Year Following Combat-Related Amputations.

INTRODUCTION: Sleep-related disorders are associated with pain, fatigue, and deficits in cognitive performance, which may interfere with successful rehabilitation. The study objectives were to (1) quantify outpatient prescriptions for insomnia medications during the first year following combat-related amputations, (2) examine longitudinal changes in prescriptions for insomnia medications, and (3) analyze patient characteristics associated with prescriptions for insomnia medications. MATERIAL AND METHODS: This was a retrospective study of DoD casualty records from the Expeditionary Medical Encounter Dataset and prescriptions for outpatient medications from the Pharmacy Data Transaction Service. Patients were a total of 1,651 U.S. service members who sustained major limb amputations in Operations Iraqi and Enduring Freedom from 2001 through 2017 and had outpatient prescriptions for any medication during the first year postinjury. Prescriptions for medications recommended for insomnia were low-dose antidepressants, anxiolytic sedatives, benzodiazepines, melatonin receptor agonist, and low-dose quetiapine. These prescription medications were analyzed by medication type, postinjury time, and patient characteristics during the first year postinjury. RESULTS: During the first year postinjury, 78% of patients (1,291 of 1,651) had outpatient prescriptions for insomnia medications, primarily anxiolytic sedative drugs (e.g., zolpidem), averaging a total of 86 prescription days (median = 66). The prevalence of these prescriptions declined substantially during the first year, from 57% of patients during the first quarter to 28% during the fourth quarter postinjury. In univariate analyses, multiple patient characteristics, including high Injury Severity Score, continued opioid and non-opioid analgesic prescriptions, and diagnoses of chronic pain, mood disorder, and posttraumatic stress disorder, were significantly associated with higher prevalence and duration of outpatient prescriptions for insomnia medications. CONCLUSIONS: The present results indicate a high prevalence of outpatient prescriptions for insomnia medications following combat-related amputations, a prevalence that is substantially higher than previously reported among active duty personnel. These findings can inform DVA/DoD guidelines for amputation care and insomnia among military subpopulations. The results highlight the need for more research on the treatment of insomnia during early postinjury rehabilitation among patients who sustained serious combat injuries.

Cognitive load in individuals with a transfemoral amputation during single- and dual-task walking: a pilot study of brain activity in people using a socket prosthesis or a bone-anchored prosthesis.

OBJECTIVE: To explore cognitive load in people with transfemoral amputations fitted with socket or bone-anchored prostheses by describing activity in the left and right dorsolateral prefrontal cortices during single- and dual-task walking. DESIGN: Cross-sectional pilot study. PATIENTS: 8 socket prosthesis users and 8 bone-anchored prosthesis users. All were fitted with microprocessor-controlled prosthetic knees. METHODS: Participants answered self-report questionnaires and performed gait tests during 1 single-task walking condition and 2 dual-task walking conditions. While walking, activity in the dorsolateral prefrontal cortex was measured using functional near-infrared spectroscopy. Cognitive load was investigated for each participant by exploring the relative concentration of oxygenated haemoglobin in the left and right dorsolateral prefrontal cortex. Symmetry of brain activity was investigated by calculating a laterality index. RESULTS: Self-report measures and basic gait variables did not show differences between the groups. No obvious between-group differences were observed in the relative concentration of oxygenated haemoglobin for any walking condition. There was a tendency towards more right-side brain activity for participants using a socket prosthesis during dual-task conditions. CONCLUSIONS: This pilot study did not identify substantial differences in cognitive load or lateralization between socket prosthesis users and bone-anchored prosthesis users.

[Treatment of chronic limb-threatening ischemia (CLTI) based on BEST-CLI and BASIL-2]. / Therapie der chronischen extremitätenbedrohenden Ischämie.

The rate of vascular recanalizations in CLTI is increasing worldwide. Safety and efficacy of surgical versus endovascular treatment in CLTI patients was investigated in 2 prospective randomized trials with contrasting results. The BEST-CLI trial randomized 1830 patients with CLTI, the Bypass versus Angioplasty for Severe Ischaemia of the Leg (BASIL-2) trial included 345 patients with CLTI. Best-CLI evaluated outcome events as the primary endpoint, which includes major reinterventions in addition to major amputations and death. Only half of the CLTI patients received a crural intervention or surgery. There were no differences in major amputations or death. After a median follow-up (FU) of 2,7 years, the surgery group showed significantly better results compared to the endovascular group, due to fewer re-interventions. BASIL-2 used amputation-free survival as the primary outcome and only included patients with lower leg lesions. After a median FU of 40 months, endovascular therapy was found to be superior. The extremely high mortality rate was remarkable in both studies. The BEST-CLI study represents CLTI patients only to a limited degree, whereas the BASIL-2 study presents the treatment of CLTI patients with below-the-knee-lesions quite well. Both studies confirm that patients with CLTI should be treated in specialized centers that offer both crural surgery and endovascular therapy. Cardiovascular risk factor management must play a more important role in reducing the high mortality associated with CLTI.

Lower Extremity Amputation in Fracture-Related Infection.

OBJECTIVES: To analyze demographics, comorbidities, fracture characteristics, presenting characteristics, microbiology, and treatment course of patients with fracture-related infections (FRIs) to determine risk factors leading to amputation. DESIGN: Retrospective cohort. SETTING: Single Level I Trauma Center (2013-2020). PATIENT SELECTION CRITERIA: Adults with lower extremity (femur and tibia) FRIs were identified through a review of an institutional database. Inclusion criteria were operatively managed fracture of the femur or tibia with an FRI and adequate documentation present in the electronic medical record. This included patients whose primary injury was managed at this institution and who were referred to this institution after the onset of FRI as long as all characteristics and risk factors assessed in the analysis were documented. Exclusion criteria were infected chronic osteomyelitis from a non-fracture-related pathology and a follow-up of less than 6 months. OUTCOME MEASURES AND COMPARISONS: Risk factors (demographics, comorbidities, and surgical, injury, and perioperative characteristics) leading to amputation in patients with FRIs were evaluated. RESULTS: A total of 196 patients were included in this study. The average age of the study group was 44±16 years. Most patients were men (63%) and White (71%). The overall amputation rate was 9.2%. There were significantly higher rates of chronic kidney disease (CKD; P = 0.039), open fractures (P = 0.034), transfusion required during open reduction internal fixation (P = 0.033), Gram-negative infections (P = 0.048), and FRI-related operations (P = 0.001) in the amputation cohort. On multivariate, patients with CKD were 28.8 times more likely to undergo amputation (aOR = 28.8 [2.27 to 366, P = 0.010). A subanalysis of 79 patients with either a methicillin-sensitive Staphylococcus aureus or methicillin-resistant S. aureus (MRSA) infection showed that patients with MRSA were significantly more likely to undergo amputation compared with patients with methicillin-sensitive Staphylococcus aureus (P = 0.031). MRSA was present in all cases of amputation in the Staphylococcal subanalysis. CONCLUSIONS: Findings from this study highlight CKD as a risk factor of amputation in the tibia and femur with fracture-related infection. In addition, MRSA was present in all cases of Staphylococcal amputation. Identifying patients and infection patterns that carry a higher risk of amputation can assist surgeons in minimizing the burden on these individuals. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.