Above-Knee Amputation Following Chronically Infected Total Knee Arthroplasty: Patient-Reported Satisfaction and Functional Outcomes.

INTRODUCTION: Periprosthetic joint infection (PJI) that arises following total knee arthroplasty (TKA) can usually be resolved through surgical and antimicrobial therapy. However, in approximately 5% of cases, an infection that is chronic and persistent will require treatment by above-knee amputation (AKA). This study seeks to provide an enhanced understanding of patient functionality and satisfaction following this devastating complication of one of the most commonly performed surgeries in the world. METHODS: A retrospective chart review of all patients who underwent an AKA as a result of PJI following TKA at our center between January 2000 and November 2023 was performed. Patients completed a post-TKA AKA functionality and satisfaction questionnaire, as well as the 12-Item Short Form Survey (SF-12). Of 27 eligible patients, 14 were contacted by phone for follow-up, 6 were deceased, 6 could not be reached, and 1 declined participation. The mean age at AKA was 62 years old (range, 43 to 85). Patients had an average of 5.5 procedures (range, 3 to 8) between primary TKA and AKA. The average follow-up time post-AKA was 38.5 months (range, 12 to 102). RESULTS: Of the patients, 85.7% were satisfied with their AKA, 85.7% would choose AKA again, and 71.4% would have proceeded with AKA earlier in retrospect. Average SF-12 physical and mental component scores were 37.1 and 50.6, respectively. DISCUSSION: Despite important limitations in functional and ambulatory status, the vast majority of patients who underwent an AKA following an infected TKA are satisfied with their amputation and would choose this treatment modality again if necessary, with many indicating they would do so at an earlier time point. In light of these results, the option of amputation should, when medically indicated, be discussed in a sensitive, but timely manner with patients undergoing treatment for recalcitrant PJI.

Minor and Major Amputation Rates Following Midfoot Charcot Reconstructive Surgery.

Charcot neuroarthropathy (CNA) is a progressive disease that affects the bones and joints of the foot. To prevent collapse and loss of stability within the pedal architecture, CNA should be diagnosed and managed early. The objective of this retrospective study was to review patients who underwent midfoot CNA reconstructive surgery and evaluate subsequent rates of minor and major amputations. Secondary objectives include identifying patients that underwent midfoot CAN with and without a subtalar joint (STJ) arthrodesis. Out of the 72 patients, 4 (5.6%) underwent minor (digital, ray) amputation, 2 (2.8%) underwent proximal amputations (either below or above the knee), and none underwent midfoot amputation (transmetatarsal, Lisfranc, Chopart). A Fisher's exact test was employed to compare the outcomes of minor and major amputation rates in our CNA cohort with those who underwent midfoot CNA reconstruction with STJ arthrodesis and found no statistical significance (p = .15). Overall, a total progression to amputation was 8.4% following midfoot CNA reconstruction, with 2.8% of patients undergoing major amputation (below knee or above knee). Despite no statistical significance, we recommend surgeons to consider including an STJ arthrodesis in addition to midfoot CNA reconstruction to establish a stable and plantigrade foot.

Contemporary Outcomes of Transfemoral Amputation After Total Knee Arthroplasty.

BACKGROUND: Transfemoral amputation (TFA) is a salvage procedure for unreconstructable failed total knee arthroplasty (TKA). Prior studies have reported poor outcomes, patient survival, and prosthetic use. The purpose of this study was to analyze patient outcomes and prosthetic utilization in a contemporary group of patients undergoing TFA in the setting of a TKA. METHODS: We reviewed 112 patients undergoing TFA with a prior TKA. Indications for amputation and postoperative functional measures were captured through chart review. Patients were contacted by survey to assess the quality of life. The mean follow-up after TFA was 4 years. RESULTS: Amputations were performed for a chronically infected TKA (n = 87, 78%) and an ischemic limb without signs of an infected TKA (n = 22, 20%). The 10-year survival after TFA was 21%. Of the patients not lost to follow-up, 53 (47%) patients were fitted for a prosthesis. Patients who underwent a TFA after the year 2000 were more likely to be fit for a prosthesis (odds ratio 7.27, P < .01); however, patients were likely to be ambulatory before TFA than after TFA (odds ratio 3.68, P < .01). After TFA, the mean 12-Item Short Form Survey scores for the mental and physical components were 54 ± 13 and 34 ± 7, with no difference in scores between patients fitted for a prosthesis and those who were not (P > .05). CONCLUSION: Patients undergoing a TFA after TKA due to failure of the TKA are more likely to be fit for a prosthesis; however, they reported no better quality of life and satisfaction compared with patients not fit for a prosthesis. LEVELS OF EVIDENCE: Level III, Therapeutic.

Intracapsular fracture of the proximal femur in a bilateral above-knee amputee: A case report with technical tips for intraoperative positioning and literature review.

Intracapsular fractures of the proximal femur are one of the most common fractures of the lower limbs. Most cases require osteosynthesis with suitable implants, and intraoperative positioning of the patient on the fracture table is a prerequisite to facilitate fracture manipulation, traction, reduction and fluoroscopy assessment. However, positioning the limbs of bilateral above-knee amputees for internal fixation of related proximal femoral fractures is a difficult task, which requires customized inventory for effective limb positioning and fracture manipulation. This study reported a rare case following a crush injury of bilateral lower limb in a road traffic accident, and described some technical tips of acute femoral neck fractures in bilateral above-knee amputation. The patient was managed with immediate guillotine amputation and later secondary wound closure followed by internal fixation of the right-sided femoral neck fracture with multiple cancellous cannulated screws.

Closed incision negative pressure wound therapy may decrease wound complications in major lower extremity amputations.

OBJECTIVE: Wound complications after major lower extremity amputations (LEAs) are a cause of significant morbidity in vascular surgery patients. Recent publications have demonstrated the efficacy of the closed incision negative pressure dressing at preventing surgical site infections (SSIs); however, there are few data on its use in major LEAs. This study sought to assess if closed incision negative pressure wound therapy (NPWT) would decrease the risk of complications as compared with a standard dressing in patients with peripheral vascular disease undergoing major LEA. METHODS: Fifty-four consecutive patient limbs with a history of peripheral arterial disease underwent below-knee or above-knee amputations. This was a retrospective review of a prospectively maintained database from January 2018 to December 2019, and it included 23 amputations in the NPWT group and 31 amputations in the standard dressing group. NPWT using the PREVENA system was applied intraoperatively at the discretion of the operating surgeon and removed 5 to 7 days postoperatively. The standard group received a nonadherent dressing with an overlying compression dressing. Amputation incisions were assessed and wound complications were recorded. Student's t-test and two-sample proportion z-test were used for statistical analysis. A P value of less than .05 was considered statistically significant. RESULTS: For comorbidities, there was a higher incidence of tobacco use in the NPWT as compared with the standard group (44% vs 13%; P = .011), as well as trends toward increased prior amputations, anemia, hyperlipidemia, and chronic obstructive pulmonary disorder in the NPWT group. For risk factors, there were more dirty wounds in the NPWT as compared with the standard group (52% vs 26%; P = .046). For outcomes, there were fewer wound complications in the NPWT as compared with the standard group (13% vs 39%; P = .037). The types of wound-related complications in the NPWT group included one wound dehiscence with a deep SSI, one superficial SSI, and one incision line necrosis. In the standard group, there were four wound dehiscences with deep SSI, three superficial SSIs, four incision line necroses, and one stump hematoma. The rates of perioperative mortality and amputation revision did not differ significantly between the NPWT and the standard groups (3% vs 4% and 4.3% vs 10%, respectively). CONCLUSIONS: Closed incision NPWT may decrease the incidence of wound complications in vascular patients undergoing major LEA. This held true even among a population that was potentially at higher risk. This therapy may be considered for use in lower extremity major amputations.

Risk factor analysis for above-knee amputation in patients with periprosthetic joint infection of the knee: a case-control study.

BACKGROUND: Periprosthetic joint infection (PJI) is a severe complication following knee arthroplasty. Therapeutic strategies comprise a combination of surgical and antibiotic treatment modalities and aim to eradicate the infection. Sometimes control of the disease can only be attained by above-knee amputation (AKA). While a vast amount of literature exists illuminating predisposing factors for PJI, risk factors favoring the endpoint AKA in this context are sparsely known. METHODS: The purpose of this investigation was to delineate whether patients with PJI of the knee present specific risk factors for AKA. In a retrospective case-control study 11 cases of PJI treated with AKA were compared to 57 cases treated with limb salvage (LS). The minimum follow-up was 2 years. Comorbidities, signs and symptoms of the current infection, factors related to previous surgeries and the implant, microbiology, as well as therapy related factors were recorded. Comparative analysis was performed using student's t-test, chi-square test or Fisher's exact test. Binary differences were calculated using odds ratio (OR). Reoperation frequency was compared using Mann-Whitney U test. In-depth descriptive analysis of 11 amputees was carried out. RESULTS: A total of 68 cases aged 71 ± 11.2 years were examined, 11 of which underwent AKA and 57 had LS. Severe comorbidities (p = 0.009), alcohol abuse (p = 0.015), and preoperative anemia (p = 0.022) were more frequently associated with AKA. Preoperative anemia was found in all 11 amputees (100%) and in 33 of 57 LS patients (58%) with an average preoperative hemoglobin of 99.9 ± 15.1 g/dl compared to 118.2 ± 19.9 g/dl (p = 0.011). No other parameters differed significantly. AKA patients underwent a median of eight (range 2-24) reoperations, LS patients a median of five (range 2-15). CONCLUSION: Factors potentially influencing the outcome of knee PJI are diverse. The indication of AKA in this context remains a rarity and a case-by-case decision. Patient-intrinsic systemic factors such as alcohol abuse, severe comorbidities and preoperative anemia may elevate the individual risk for AKA in the setting of PJI. We recommend that anemia, being a condition well amenable to therapeutic measures, should be given special consideration in management of PJI patients. TRIAL REGISTRATION: This study was registered with Kantonale Ethikkommission Zürich, (BASEC-No. 2016-01048).

Knee Arthrodesis Is a Durable Option for the Salvage of Infected Total Knee Arthroplasty.

BACKGROUND: Knee arthrodesis (KA) and above-knee amputation (AKA) have been used for salvage of failed total knee arthroplasty (TKA) after periprosthetic joint infection (PJI). However, few studies have assessed the outcomes of KA after TKA PJI, as it remains an uncommon procedure. We investigated rates of AKA, control of infection, and ambulatory status after KA for TKA PJI treatment. METHODS: This was a retrospective and single-surgeon series of 51 failed TKAs due to PJI treated with two-stage KA between 2000 and 2016 with a minimum of 2-year follow-up. Patient demographics, comorbidities, surgical history, radiographic data, and outcomes of KA treatment were recorded. RESULTS: Infection was successfully controlled in 48 of 51 patients (94.1%); of these, 24 knees (50.0%) required no reoperation subsequent to the index KA, whereas the remaining 24 (50.0%) patients required a median of 1 additional operation. Nonunion, malunion, or delayed union was noted in 10 patients (19.6%). Of the 48 patients who were successfully treated with KA, 41 patients (85.4%) remained ambulatory after KA and 9 of these patients (18.8%) did not require assistive devices. Three of 51 patients (5.9%) progressed to AKA after KA. CONCLUSION: Patients undergoing KA for TKA PJI had high rates of infection control and preservation of ambulatory status, with low rates of progression to AKA in our study. LEVEL OF EVIDENCE: Level IV-case series.

Survival after major lower extremity amputation in patients with end-stage renal disease.

OBJECTIVE: This study evaluates survival of patients with end-stage renal disease (ESRD) after major lower extremity amputation (MLEA), given the burden of peripheral arterial disease in patients with ESRD, the hindrance posed by cardiovascular disease on their survival, and the national investment in ESRD-related care. METHODS: A retrospective review of all hemodialysis patients (HD) and renal transplant (RT) recipients who underwent MLEA between January 2007 and December 2011 in the United States Renal Data System was performed. Univariable, Kaplan-Meier, multivariable logistic, and Cox regression analyses were used to evaluate patient survival among HD patients and RT recipients overall; and within strata of amputation level, gender, and race. RESULTS: There were 32,540 MLEAs (HD, 92%; RT, 8%). Among HD patients, the median survival was 6 months for above knee amputation (AKA) and 16 months for below knee amputation (BKA). The risk-adjusted mortality was higher for AKA compared with BKA (adjusted hazard ratio [aHR], 1.48; 95% confidence interval [CI], 1.44-1.52; P < .001), females compared with males (aHR, 1.04; 95% CI, 1.01-1.08; P = .004), but lower for blacks (aHR, 0.78 95% CI, 0.76-0.81; P < .001) and Hispanics (aHR, 0.74; 95% CI, 0.70-0.79; P < .001) compared with white HD patients. Among RT recipients, the median survival was 16 months for AKA and 47 months for BKA. Mortality was significantly higher for above knee amputees compared with below knee amputees (aHR, 1.83; 95% CI, 1.60-2.10; P < .001). However, there was no difference in mortality between the gender and racial categories of RT recipients. There was a twofold increase in the 30-day mortality (adjusted odd ratio, 1.94; 95% CI, 1.66-2.25; P < .001) and long-term mortality (aHR, 2.18; 95% CI, 2.05-2.32; P < .001) for HD patients relative to RT recipients. CONCLUSIONS: Survival after MLEA is limited in patients with ESRD. It is relatively better for RT recipients compared with HD patients. Mortality was higher for females compared with males, but lower for blacks and Hispanics compared with white HD patients. There were no gender- or race-specific difference in mortality among RT recipients. These estimates of life expectancy should guide the informed decision- making process for patients and their healthcare providers when the need for intervention arises after MLEA in these unique categories of patients.

Peripheral nerve blocks for above knee amputation in high-risk patients.

BACKGROUND AND AIMS: Above knee amputation (AKA) is associated with considerable mortality and morbidity. There is paucity of data describing the use of peripheral nerve blocks (PNB) as the sole anesthetic technique in high-risk patients undergoing AKA. Our objectives were to evaluate the use of PNB as sole anesthetic technique in the above-mentioned population and its clinical outcomes. MATERIAL AND METHODS: This was a retrospective descriptive study conducted in a tertiary hospital. For this study, patients with American Society of Anesthesiologist [ASA] IV physical status underwent AKA using PNB between January 2010 and December 2016, were identified. The primary outcome measured was the success of the operation. The secondary outcomes were block details, intraoperative hemodynamics, usage of sedation and analgesia, patients' comorbidities, mortality rates at 30 days and one year. RESULTS: Out of fifty-seven patients, the median age (interquartile range) was 74 (57 - 81) years and 60% were males. The results show 91% successfully underwent surgery with PNB (95% CI 81% to 96%). 95% required intraoperative sedation and analgesia. 67% received combined femoral, obturator and sciatic nerve blocks, in which nine cases had an additional lateral femoral cutaneous nerve block. Interestingly, 33% only received combined femoral and sciatic nerve blocks, and they required higher sedation analgesia (p = 0.013). The 30-day and one-year mortality were 12.3% & 47.4%. Majority had stable hemodynamics during the surgery. CONCLUSION: This study shows that PNB is a viable option for reliable anesthesia for AKA in high-risk patients. Combined FOS nerve block would reduce the dose for sedation-analgesia during the operation.

Trends and Outcomes in the Treatment of Failed Septic Total Knee Arthroplasty: Comparing Arthrodesis and Above-Knee Amputation.

BACKGROUND: Options for treatment of a failed septic total knee arthroplasty (TKA) include arthrodesis and above-knee amputation (AKA). Little comparative data exist to help clinicians when considering these alternatives. METHODS: A national database was queried for patients who underwent either knee arthrodesis or AKA for an infected TKA between 2005 and 2012. Procedure volumes, postoperative complications, hospital charges, length of stay, and 90-day readmission rates were evaluated. RESULTS: A total of 2634 patients underwent arthrodesis and 5001 patients underwent AKA for septic TKA. The percentage of total patients who underwent AKA increased significantly throughout the study period compared to knee arthrodesis. Patients who underwent AKA tended to be older and have more medical comorbidities. Arthrodesis patients had a significantly higher rate of postoperative infection (14.5% vs 8.3%, P < .0001) and transfusion (55.1% vs 46.8%, P < .0001), whereas AKA patients had a higher rate of systemic complications (31.5% vs 25.9%, P < .0001) and in-hospital mortality (3.7% vs 2.1%, P < .0001). The AKA cohort had lower hospital charges ($79,686 vs $84,747, P = .004), longer length of stay (11 vs 7 days, P < .0001), and higher 90-day readmission rate (19.4% vs 16.9%). CONCLUSION: Our data suggest that there is an increasing trend toward AKA for the treatment of a failed infected TKA when compared to arthrodesis. Comparative analysis of the outcomes of these procedures should help the clinician when weighing these alternatives.

Multi-Axis Prosthetic Knee Resembles Alpine Skiing Movements of an Intact Leg.

The purpose of the study was to analyse the flexion angles of the ski boot, ankle and knee joints of an above-knee prosthesis and to compare them with an intact leg and a control group of skiers. One subject with an above-knee amputation of the right leg and eight healthy subjects simulated the movement of a skiing turn by performing two-leg squats in laboratory conditions. By adding additional loads in proportion to body weight (BW; +1/3 BW, +2/3 BW, +3/3 BW), various skiing regimes were simulated. Change of Flexion Angle (CoFA) and Range of Motion (RoM) in the ski boot, ankle and knee joints were calculated and compared. An average RoM in the skiing boot on the side of prosthesis (4.4 ± 1.1°) was significantly lower compared to an intact leg (5.9 ± 1.8°) and the control group (6.5 ± 2.3°). In the ankle joint, the average RoM was determined to be 13.2±2.9° in the prosthesis, 12.7 ± 2.8° in an intact leg and 14.8±3.6 in the control group. However, the RoM of the knee joint in the prosthesis (42.2 ± 4.2°) was significantly larger than that of the intact leg (34.7 ± 4.4°). The average RoM of the knee joint in the control group was 47.8 ± 5.4°. The influences of additional loads on the kinematics of the lower extremities were different on the side of the prosthesis and on the intact leg. In contrast, additional loads did not produce any significant differences in the control group. Although different CoFAs in the ski boot, ankle and knee joints were used, an above-knee prosthesis with a built-in multi-axis prosthetic knee enables comparable leg kinematics in simulated alpine skiing. Key pointsThe RoM in the ski boot on the side of the prosthetic leg was smaller than the RoM of the intact leg and the control group of healthy subjects.The RoM in the ankle joint of prosthetic leg was comparable to that of the intact leg and the control group of healthy subjects.The RoM in the prosthetic knee joint was greater than the RoM in the knee joint of the intact leg and smaller than that of the control group.The total knee flexions in the laboratory measurements were comparable with field measurements.Additional load affects the RoM of the ski boot, ankle and knee joints for the amputated skier in both legs. No significant influence from the additional load was found on the RoM in the control group of healthy subjects.The above-knee prosthesis with a multiple-axis prosthetic knee reproduces the alpine skiing kinematics of an intact leg.

Non-oncologic total femoral arthroplasty: retrospective review.

Total femoral arthroplasty (TFA) is an option to amputation in the setting of excessive bones loss during revision total hip and knee arthroplasty. Twenty non-oncologic TFAs with a minimum of 2years follow-up were retrospectively reviewed. The average clinical follow-up was 73±49months. The incidence of new infection was 25% (5/20), while the overall infection rate was 35% (7/20). The incidence of primary hip instability was 10% (2/20), while the overall instability rate was 25% (5/20). Six patients (30%) required revision. The average pre-operative HHS was 30.2±13.1. The average post-operative HHS was 65.3±16.9. TFA is a viable alternative to amputation in non-oncologic patients with massive femoral bone deficiency. However, TFA performed poorly in the setting of infection and instability.

Total hip arthroplasty (THA) in a patient with subcapital femoral neck fracture and ipsilateral above-knee amputation: A case report.

This case report describes the surgical and post-operative challenges encountered following a THA performed for a subcapital femoral neck fracture in a patient with an ipsilateral above-knee amputation.

Single-stage transcutaneous osseointegrated prosthesis for above-knee amputations including an antibiotic-loaded hydrogel. Preliminary results of a new surgical protocol.

INTRODUCTION: Patients with above-knee amputations (AKA) are normally treated with the traditional socket-mounted prosthesis (SMP), which is associated with a high incidence of problems. Osseointegration has been proposed as a promising option for avoiding many common SMP drawbacks. Several concerns have arisen regarding amputee osseointegration, however, mainly with respect to infection. We report on the safety of a single-stage osseointegration protocol using an antibiotic-loaded hydrogel to coat the intramedullary implant. MATERIALS AND METHODS: We retrospectively reviewed all AKA cases treated at our center between January 2019 and April 2022, in which a transcutaneous osseointegrated implant was used in a single-stage strategy, together with a rapid-resorbable hydrogel loaded with vancomycin and gentamicin. The specific protocol used, infection rate, implant osseointegration rate and implant survivorship were determined after a minimum follow-up of 12 months. RESULTS: Eleven osseointegration cases were included in the study, with an average of 16 years post-amputation (range: 3-35 years). After a median follow-up of 24 months (range 12-49 months) no patient had suffered any implant-related infection. Osseointegration of the implant had been achieved in all cases. The mid-term survivorship of the implant in our series was 100 % at the end of follow-up. Radiographs of all cases showed no loosening of the implant. Further, 91 % of the series patients were able to walk without restrictions after the rehabilitation process. CONCLUSIONS: The single-stage osseointegration protocol for AKA, using a rapid-resorbable hydrogel loaded with vancomycin and gentamicin, yields low rates of implant-related deep infection. This protocol consistently delivers high rates of radiological osseointegration, with no hydrogel-associated complications.

Feasibility of predicting changes in gait biomechanics following muscle strength perturbations using optimal control in patients with transfemoral amputation.

Bone-anchored limbs (BALs) are socket prosthesis alternatives, directly fixing to residual bone via osseointegrated implant. There is a need to quantify multi-level effects of rehabilitation for transfemoral BAL users (i.e. changes in joint loading and movement patterns). Our primary objective was determining feasibility of using optimal control to predict gait biomechanics compared to ground-truth experimental data from transfemoral BAL users. A secondary objective was examining biomechanical effects from estimated changes in hip abductor muscle strength. We developed and validated a workflow for predicting gait biomechanics in four transfemoral BAL users and investigated the biomechanical effects of altered hip abductor strengths.

The Amputated Limb Gluteus Medius is Biomechanically Disadvantaged in Patients with Unilateral Transfemoral Amputation.

Patients with transfemoral amputation (TFA) are at an increased risk of secondary musculoskeleteal comorbidities, primarily due to asymmetric joint loading. Amputated limb muscle weakness is also prevalent in the TFA population, yet all factors that contribute to muscle strength and thus joint loading are not well understood. Our objective was to bilaterally compare gluteus medius (GMED) muscle factors (volume, fatty infiltration, moment arm) that all contribute to joint loading in patients with TFA. Quantitative magnetic resonance (MR) images of the hip were collected from eight participants with unilateral TFA (2M/6F; age: 47.3 ± 14.7 y/o; BMI: 25.4 ± 5.3 kg/m2; time since amputation: 20.6 ± 15.0 years) and used to calculate normalized GMED muscle volume and fatty infiltration. Six participants participated in an instrumented gait analysis session that collected whole-body kinematics during overground walking. Subject-specific musculoskeletal models were used to calculate bilateral GMED (anterior, middle, posterior) moment arms and frontal plane hip joint angles across three gait cycles. Differences in volume, fatty infiltration, hip adduction-abduction angle, and peak moment arms were compared between limbs using paired Cohen's d effect sizes. Volume was smaller by 36.3 ± 18.8% (d = 1.7) and fatty infiltration was greater by 6.4 ± 7.8% (d = 0.8) in the amputated limb GMED compared to the intact limb. The amputated limb GMED abduction moment arms were smaller compared to the intact limb for both overground walking (anterior: d = 0.9; middle: d = 0.1.2) and during normal range of motion (anterior: d = 0.8; middle: d = 0.8) while bilateral hip adduction-abduction angles were similar during overground walking (d = 0.5). These results indicate that in patients with TFA, the amputated limb GMED is biomechanically disadvantaged compared to the intact limb, which may contribute to the etiology of secondary comorbidities. This population might benefit from movement retraining to lengthen the amputated limb GMED abduction moment arm during gait.

Active nerve management for above the knee amputation: A comparison of through the wound versus posterior approach.

Targeted muscle reinnervation (TMR) and regenerative peripheral nerve interface (RPNI) are used to prevent or treat neuromas in amputees. TMR for above-the-knee amputation (AKA) is most commonly performed through a posterior incision rather than the stump wound because recipient motor nerves are primarily located in the proximal third of the thigh. When preventative TMR is performed with concurrent AKA, a posterior approach requires intraoperative repositioning and an additional incision. The purpose of this study was to evaluate feasibility of TMR and operative times for nerve management performed through the wound compared to a posterior approach in AKA patients to guide surgical decision-making. Patients who underwent AKA with TMR between 2018-2023 were reviewed. Patients were divided into two groups: TMR performed through the wound (Group I) and TMR performed through a posterior approach (Group II). If a nerve was unable to undergo coaptation for TMR due to the lack of suitable donor motor nerves, RPNI was performed. Eighteen patients underwent AKA with nerve management were included from Group I (8 patients) and Group II (10 patients). TMR coaptations performed on distinct nerves was 1.5 ± 0.5 in Group I compared to 2.6 ± 0.5 in Group II (p = 0.001). Operative time for Group I was 200.7 ± 33.4 min compared to 326.5 ± 37.1 min in Group II (p = 0.001). TMR performed through the wound following AKA requires less operative time than a posterior approach. However, since recipient motor nerves are not consistently found near the stump, RPNI may be required with TMR whereas the posterior approach allows for more TMR coaptations.

Retrograde Trans-Amputation Embolectomy of Common, Superficial and Deep Femoral Arteries for Inflow Revascularisation During Above-Knee Amputation: A Case Report and Review of the Literature.

BACKGROUND: Primary above-knee amputation (AKA) may at times be the only option for unsalvageable acute lower limb ischemia. However, occlusion of the femoral arteries may result in poor inflow and contribute to wound complications such as stump gangrene and sepsis. Previously attempted inflow revascularisation techniques include surgical bypass and percutaneous angioplasty and/or stenting. CASE PRESENTATION: We present a case of a 77-year-old lady with unsalvageable acute right lower limb ischemia secondary to cardioembolic occlusion of the common (CFA), superficial (SFA) and deep (PFA) femoral arteries. We performed a primary AKA with inflow revascularisation using a novel surgical technique involving endovascular retrograde embolectomy of the CFA, SFA and PFA via the SFA stump. The patient made an uneventful recovery without any wound complications. Detailed description of the procedure is followed by a discussion of the literature on inflow revascularisation in the treatment and prevention of stump ischemia.

Comparison of below-knee and above-knee amputations with demographic, comorbidity, and haematological parameters in patients who died.

BACKGROUND: This study aimed to establish mortality predictive parameters with a higher contribution to mortality by comparing the demographic data, comorbid factors, and haematological values of patients who underwent below-knee and above-knee amputation and had died during the follow-up period. MATERIALS AND METHODS: Between March 2014 and January 2022, 122 patients in a single centre who developed foot gangrene due to chronic diabetes and underwent below-knee or above-knee amputation were evaluated retrospectively. Patients who died of natural causes during the post-operative period were included in the study. Those who were amputated below the knee were assigned to Group 1, and those who were amputated above the knee were assigned to Group 2. The patients' age, gender, side of amputation, comorbid diseases, American Society of Anaesthesiologists (ASA) score, Charlson comorbidity index (CCI), death time, and haematological values at the time of first admission were compared between the two groups and statistical analyses were performed. RESULTS: Group 1 (n = 50) and Group 2 (n = 37) had similar distributions in terms of age, gender, side of operation, number of comorbidities, and CCI (p > 0.05). Group 2's mean ASA score and c-reactive protein (CRP) levels were statistically higher than those of Group 1 (p < 0.05). Death time, albumin value, and HbA1c levels were statistically lower in Group 2 than in Group 1 (p < 0.05). There were no significant differences between the groups in haemogram, white blood cells (WBC), lymphocytes, neutrophils, creatinine, and Na values at the time of first admission (p > 0.05). CONCLUSION: A high ASA score, low albumin value, and high CRP value were significant predictors of high mortality. Creatinine levels and HbA1c values were quite ineffective in predicting mortality. LEVEL OF EVIDENCE: Level 3, retrospective comparative study.

Unilateral transfemoral osseointegrated prostheses improve joint loading during walking.

People with unilateral transfemoral amputation using socket prostheses are at increased risk for developing osteoarthritis in both the residual hip and intact lower-limb joints. Osseointegrated prostheses are a surgical alternative to socket prostheses that directly attach to the residual femur via a bone-anchored implant, however their multi-joint loading effect is largely unknown. Our objective was to establish how osseointegrated prostheses influence joint loading during walking. Motion capture data (kinematics, ground reaction forces) were collected from 12 participants at baseline, with socket prostheses, and 12-months after prosthesis osseointegration during overground walking at self-selected speeds. Subject-specific musculoskeletal models were developed at each timepoint relative to osseointegration. Internal joint moments were calculated using inverse dynamics, muscle and joint reaction forces (JRFs) were estimated with static optimization. Changes in internal joint moments, JRFs, and joint loading-symmetry were compared using statistical parametric mapping (p≤ 0.05) before and after osseointegration. Amputated limb hip flexion moments and anterior JRFs decreased during terminal stance (p = 0.002, <0.001; respectively), while amputated limb hip abduction moments increased during mid-stance (p < 0.001), amputated hip rotation moment changed from internal to external throughout early stance (p < 0.001). Intact limb hip extension and knee flexion moments (p = 0.028, 0.032; respectively), superior and resultant knee JRFs (p = 0.046, 0.049; respectively) decreased during the loading response following prosthesis osseointegration. These results may indicate that the direct loading transmission of these novel prostheses create a more typical mechanical environment in bilateral joints, which is comparable with loading observed in able-bodied individuals and could decrease the risk of development or progression of osteoarthritis.