ANALYSIS OF ELECTRICAL BURNS IN ALBANIA: A FOUR-YEAR REVIEW.

This is an epidemiological review of electrical burns admitted to the Service of Burns and Plastic Surgery, UHC "Mother Theresa" of Tirana, Albania, covering a four-year period, from 2019 to 2022. Twenty-seven patients were identified as having sustained an electrical burn injury, all of them males and most of them, namely 85%, belonging to the "working force" age group 19-65 years old. Most of the accidents, 70% of them, occurred at work, and these were all high voltage electrical burns. A total 65% of the cases had at least one of the upper limbs involved and the mean surface area burned was estimated at around 20% TBSA, mortality rate 11.1%, and all the fatal cases were from occupational burns. Serum level of BUN, creatinine and liver enzymes were evaluated on admission and at least 7 days after, with no significant changes. WBC count was found to be elevated in almost all the patients, and remained elevated in the second week and even longer for patients with sepsis. Four of our patients needed amputations. Besides these, no other serious complications were registered.

Nous présentons une étude épidémiologique des 37 patients admis dans le service des brûlés et de chirurgie plastique du CHU Mère Teresa de Tirana entre 2019 et 2022. Il s'agissait exclusivement d'hommes dont 85% en âge de travailler (19 à 65 ans). Il s'agissait dans la plupart (70%) des cas d'accidents du travail (AT) et dans ces cas toujours d'atteintes à haut voltage. Au moins un des membres supérieurs était atteint dans 65% des cas. La surface brûlée moyenne était de 20% SCT, la mortalité de 11,1% (toujours après AT). Urée, créatinine et enzymes hépatiques étaient mesurées à l'entrée et au moins 1 fois, à J7, sans changement notable. On observait une hyperleucocytose initiale, persistant pendant la deuxième semaine voire plus longtemps en cas de sepsis. Aucune complication sévère n'a été observée chez les survivants, hormis des amputations chez 4 patients.

Major Lower Limb Amputation for Chronic Limb-Threatening Ischemia Is Associated with Poor Long-Term Survival: 4-Year Follow-Up of a Single-Center Experience.

Objective: Despite advances in medicine, 30% of patients with chronic limb-threatening ischemia (CLTI) require major lower limb amputation (MLLA). The long-term outcome of this cohort is poorly described. Methods: In all, 154 patients undergoing MLLA for CLTI during 2018-2020 were analyzed for short-term and long-term outcomes and prosthesis use. Results: In total, 106 below-knee amputations and 48 above-knee amputations were followed up for a mean duration of 50 months (37-78). The mean age of the cohort was 63 years. The majority were male (60%) with multiple comorbidities, including diabetes (83.8%), hypertension (49.4%), ischemic heart disease (20%), and smoking (32.5%). An equal proportion underwent MLLA as primary (45%) or secondary (55%). 30-day mortality was 6%. The mean length of in-hospital stay was 18 days (3-56). Overall survival rates at 1st, 2nd, and 4th year were 73%, 64%, and 35%, respectively. On a multivariate regression analysis, a higher level of amputation had a significant impact on mortality (p = 0.015). 54% of amputees had a prosthetic limb. However, the primary use of prosthesis was for cosmesis, with only 12% mobile independently. Conclusions: MLLA for CLTI is associated with poor early and long-term survival. Prosthesis use and mobility are extremely poor in the Sri Lankan context.

Epidemiology and Impact of Limb Loss in the United States and Globally.

The main causes of limb loss include trauma, complications from diabetes and peripheral arterial disease, malignancy, and congenital limb deficiency. There are significant geographic variations in the incidence of upper and lower, and major and minor limb loss worldwide. Limb loss is costly for patients and the health care system. The availability of orthotic and prosthetic services, along with cost of services, represents barrier to care and contributes to morbidity and mortality. More research is needed, especially in low-income and middle-income countries to describe the extent of limb loss.

Amputation Surgery: Review of New and Emerging Techniques.

Major upper and lower extremity amputations are increasingly being performed for peripheral vascular disease, infectious etiologies, trauma, and oncologic purposes. Attention to technique and emerging treatments for the residual peripheral nerve is critical to prosthetic wear and quality of life following these life changing events. Here, we detail advancements in amputation surgery including targeted muscle reinnervation, regenerative peripheral nerve interface, and the use of osseointegrated implants.

Prosthesis applications and challenges in children with earthquake-related amputations.

BACKGROUND: Amputations are among the most important traumatic injuries caused by earthquakes. However, data on amputee children and prosthesis application is quite limited in the literature. The aim of the study is to evaluate the injury-related data, stump problems, prosthesis application, difficulties and complications experienced with prosthesis during follow-up of children with 2023 Kahramanmaras earthquake-related limb loss. PATIENTS AND METHODS: Sociodemographic and injury-related data, pre-amputation and post-amputation interventions, prosthesis application, current prosthetic problems, and revision surgeries of the amputee children were recorded. RESULTS: Median age of patients (n = 102) admitted to our center was 13.0 years. 67.6 % of patients had one or more concomitant injuries. Median time and number of amputations were 4 (0-57) days and 1 (1-4), respectively. Of the total 120 amputations, 67.5 % (n = 81) were lower extremity amputations. Most common amputation levels were transtibial (29.1 %, n = 35), transfemoral (22.5 %, n = 27), and transhumeral (15.8 %, n = 19). Most amputees (56.8 %) underwent revision surgery after initial amputation. Median duration of time from amputation to prosthesis application was 184 (28-314) days. For 25 prostheses, a socket revision was required. Six patients had surgical revision of the stumps to allow prosthetic fit and mobility (due to bone overgrowth, soft tissue failure, heterotopic ossification). CONCLUSION: Limited healthcare facilities, surgeries performed under emergency conditions, accompanying multiple traumas, inadequate follow-up conditions, and additional difficulties arising from the pediatric patient group lead to difficulties in the care of pediatric amputee patients. Our results will guide the care of this vulnerable patient population in the event of a similar unfortunate disaster.

A simple sore can lead to limb amputation; metastatic squamous cell carcinoma of the sole in a 22-year-old man.

INTRODUCTION AND IMPORTANCE: Squamous cell carcinoma (SCC) is a cancerous tumor that can develop when normal keratinocytes undergo a transformation into invasive cancer cells, typically due to genetic mutations that affect cell growth and differentiation. SCC is frequently found on sun-exposed areas of the skin like the face, ears, neck, and hands, but it is unusual to see it develop on the soles of the feet. CASE REPORT: This case is about a 22-year-old man who came in with a persistent sore on the bottom of his left foot. The patient mentioned sustaining a small injury to his foot about two weeks before seeking medical help, which started off as a minor wound but deteriorated over time. Ultimately, the diagnosis revealed squamous cell carcinoma that had spread to the lungs and lymph nodes. DISCUSSION: This case highlights the importance of considering the possibility of malignancy in non-healing wounds, even in young patients without known risk factors. The initial presentation of a simple sore that progressed to metastatic SCC underscores the challenges in diagnosing and managing skin cancers in atypical presentations. CONCLUSION: This case highlights cancer's aggressiveness and atypical youth presentations, stressing early detection, aggressive treatment, and comprehensive patient support. Continued research is crucial for enhancing disease management.

Limb salvage using radical combined hyperthermia and radiotherapy for myxofibrosarcoma of the lower leg in an elderly patient.

Soft tissue sarcomas account for only 1.5% of malignant tumors in adults and are therefore challenging to treat. We present a case of myxofibrosarcoma of the lower leg in an 88-year-old woman who successfully responded to combined hyperthermia and radiotherapy. We proposed a below-knee amputation because of the spread of the lesion, but the patient opted for hyperthermia with radiotherapy. One and a half years later, the tumor partially regrew, and the regrown mass was resected with an R0 margin. Unfortunately, the patient developed a surgical site infection immediately after the resection, and a skin ulcer formed. It took about 2 years for conservative treatment to result in complete ulcer epithelization. The patient has been ambulant, and has not experienced any symptoms of local recurrence or metastasis in the two and a half years since the surgery. Although adverse events related to combined hyperthermia and radiotherapy, such as delayed wound healing, should be considered, it could be an option for the treatment of localized soft-tissue sarcoma, especially in elderly patients.

Meta-Analysis of Randomised Controlled Trials Comparing Bypass and Endovascular Revascularisation for Peripheral Artery Disease.

OBJECTIVE: Peripheral artery disease affects approximately 250 million people globally. Multiple randomised controlled trials have compared bypass and endovascular interventions but the optimum revascularisation approach remains unclear. The recently published BEST-CLI and BASIL-2 trials provide current and robust data addressing this question, however their findings are not concordant. This systematic review and meta-analysis provides an overview of the worldwide randomised evidence comparing bypass surgery and endovascular revascularisation in lower limb peripheral artery disease. METHODS: A comprehensive literature search of MEDLINE, Embase and CENTRAL databases was performed of all time periods up to 7 May 2023 to identify randomised controlled trials comparing bypass and endovascular revascularisation for treating lower limb peripheral artery disease. The primary outcome was major amputation. Secondary outcomes were mortality, re-intervention, 30-day adverse events and 30-day mortality. Odds ratios were calculated and pooled using the random-effects model. Risk of bias was assessed using the Cochrane risk of bias 2 tool. RESULTS: Fourteen cohorts were identified across thirteen studies, enrolling 3840 patients. There was no significant difference in major amputation (OR 1.12; 95% CI 0.80-1.57) or mortality (OR 0.96; 95% CI 0.79-1.17) between the bypass and endovascular groups. Bypass was associated with a significant reduction in re-intervention compared with endovascular treatment (OR 0.57, 95% CI 0.40-0.82). CONCLUSIONS: These findings suggest that rates of major amputation and mortality are similar following bypass and endovascular interventions. Patients who undergo bypass surgery have a significantly lower re-intervention rate post-operatively.

Regional nerve blocks for peripheral neuropathy: a rare clinical case report.

Peripheral neuropathy is a common complication in patients with diabetes. However, the appropriateness of administering nerve block anesthesia to these patients remains uncertain. Key concerns include the potential for prolonged block duration, an increased risk of local anesthetic toxicity, and the possibility of further damaging already compromised peripheral nerves. We herein report a case involving a patient with diabetic peripheral neuropathy who underwent finger amputation under ultrasound-guided nerve block anesthesia and subsequently lost pain and temperature sensation in both hands 1 month later. For critically ill patients undergoing surgery, regional anesthesia, such as a nerve block, may be a more suitable option than general anesthesia. When performing nerve block procedures in patients with diabetes, using ultrasound guidance is recommended to ensure precise targeting and reduce the risk of complications. However, it remains unclear whether nerve block anesthesia exacerbates peripheral neuropathy.

Vein bypass first vs. best endovascular treatment first revascularisation strategy for chronic limb-threatening ischaemia due to infra-popliteal disease: the BASIL-2 RCT.

Background: Chronic limb-threatening ischaemia with ischaemic pain and/or tissue loss. Objective: To examine the clinical and cost-effectiveness of a vein bypass-first compared to a best endovascular treatment-first revascularisation strategy in preventing major amputation or death. Design: Superiority, open, pragmatic, multicentre, phase III randomised trial. Setting: Thirty-nine vascular surgery units in the United Kingdom, and one each in Sweden and Denmark. Participants: Patients with chronic limb-threatening ischaemia due to atherosclerotic peripheral arterial disease who required an infra-popliteal revascularisation, with or without an additional more proximal infra-inguinal revascularisation procedure, to restore limb perfusion. Interventions: A vein bypass-first or a best endovascular treatment-first infra-popliteal, with or without an additional more proximal infra-inguinal revascularisation strategy. Main outcome measures: The primary outcome was amputation-free survival. Secondary outcomes included overall survival, major amputation, further revascularisation interventions, major adverse limb event, health-related quality of life and serious adverse events. Methods: Participants were randomised to a vein bypass-first or a best endovascular treatment-first revascularisation strategy. The original sample size of 600 participants (247 events) was based on a hazard ratio of 0.66 with amputation-free survival rates of 0.72, 0.62, 0.53, 0.47 and 0.35 in years 1-5 in the best endovascular treatment-first group with 90% power and alpha at p = 0.05. The sample size was revised to an event-based approach as a result of increased follow-up time due to slower than anticipated recruitment rates. Participants were followed up for a minimum of 2 years. A cost-effectiveness analysis was employed to estimate differences in total hospital costs and amputation-free survival between the groups. Additionally, a cost-utility analysis was carried out and the total cost and quality-adjusted life-years, 2 and 3 years after randomisation were used. Results: Between 22 July 2014 and 30 November 2020, 345 participants were randomised, 172 to vein bypass-first and 173 to best endovascular treatment-first. Non-amputation-free survival occurred in 108 (63%) of 172 patients in the vein bypass-first group and 92 (53%) of 173 patients in the best endovascular treatment-first group [adjusted hazard ratio 1.35 (95% confidence interval 1.02 to 1.80); p = 0.037]. Ninety-one (53%) of 172 patients in the vein bypass-first group and 77 (45%) of 173 patients in the best endovascular treatment-first group died [adjusted hazard ratio 1.37 (95% confidence interval 1.00 to 1.87)]. Over follow-up, the economic evaluation discounted results showed that best endovascular treatment-first was associated with £1690 less hospital costs compared to vein bypass-first. The cost utility analysis showed that compared to vein bypass-first, best endovascular treatment-first was associated with £224 and £2233 less discounted hospital costs and 0.016 and 0.085 discounted quality-adjusted life-year gain after 2 and 3 years from randomisation. Limitations: Recruiting patients to the Bypass versus Angioplasty in Severe Ischaemia of the Leg Trial-2 trial was difficult and the target number of events was not achieved. Conclusions: A best endovascular treatment-first revascularisation strategy was associated with better amputation-free survival, which was largely driven by fewer deaths. Overall, the economic evaluation results suggest that best endovascular treatment-first dominates vein bypass-first in the cost-effectiveness analysis and cost-utility analysis as it was less costly and more effective than a vein bypass-first strategy. Future work: The Bypass versus Angioplasty in Severe Ischaemia of the Leg Trial-2 investigators have a data sharing agreement with the BEst Surgical Therapy in patients with Chronic Limb threatening Ischaemia investigators. One output of this collaboration will be an individual patient data meta-analysis. Study registration: Current Controlled Trials ISRCTN27728689. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 12/35/45) and is published in full in Health Technology Assessment; Vol. 28, No. 65. See the NIHR Funding and Awards website for further award information.

Atherosclerosis, or narrowing of the arteries, can occur as a result of smoking, high blood pressure, diabetes, or high cholesterol in the blood. Atherosclerosis can affect any artery, including those supplying the legs, where the condition is called peripheral arterial disease. The most severe form of peripheral arterial disease is chronic limb-threatening ischaemia which can cause severe pain in the foot as well as ulcers and gangrene. Unless the blood supply to the leg and foot is improved, by a process called revascularisation, people with chronic limb-threatening ischaemia are at high risk of amputation and death. The blood supply can be improved by using a vein from the leg to bypass around the blockages (vein bypass) or by using a balloon (angioplasty) or small metal tubes (stents) to reopen the blocked arteries (best endovascular treatment). There is debate about which type of revascularisation is best in terms of preventing amputation and death, especially in people who need revascularisation of the arteries below the knee. Bypass versus Angioplasty in Severe Ischaemia of the Leg Trial-2 is the first randomised controlled trial to compare vein bypass-first and best endovascular treatment-first in this group of patients. Bypass versus Angioplasty in Severe Ischaemia of the Leg Trial-2 found that people randomised to a vein bypass-first revascularisation strategy were 35% more likely to require a major amputation or die than those randomised to a best endovascular treatment-first strategy. Most of this difference in favour of best endovascular treatment-first was due to a higher number of patients dying in the vein bypass-first group. Best endovascular treatment-first was also cheaper for the National Health Service. The results of this study suggest that in patients with chronic limb-threatening ischaemia due to peripheral arterial disease in the arteries below the knee, who are suitable for both vein bypass and best endovascular treatment and where there is uncertainty as to which is best, best endovascular treatment should be offered first rather than vein bypass.

The Emotional and Ethical Dilemmas of Body Integrity Dysphoria: A Case Report From England.

Body integrity dysphoria is defined as a rare disorder with the characteristic feature of a persistent desire to have a physical disability, usually specific. Some people with body integrity dysphoria reach a stage where they search for surgical or self-removal of their body part/s. The aim of presenting this case report is to disseminate information about body integrity dysphoria and the emotional and ethical challenges that haunt the diagnosis. We present a case of a 52-year-old white British gentleman whom we diagnosed with body integrity dysphoria as he met all the International Classification of Diseases 11th Revision (ICD-11) criteria for diagnosis. Two months before his presentation to us, he went to the train tracks near his residence, also adjacent to a tertiary care hospital, with the intent to have his lower limb amputated by a moving train. He has wished to be an amputee since his childhood. He denied any intent or plan to end his life. He did not wish for an accidental death while trying to be an amputee. All other diagnoses were ruled out. As an infant, he was diagnosed with tetralogy of Fallot and underwent corrective surgery. A year ago, he was referred to secondary mental health services via his general physician and eventually received a diagnosis of autism spectrum condition. The patient himself has theorised that perhaps his 'underdeveloped heart led to poor oxygenation to his brain, or maybe his brain was broken in some way, which causes the heart's misconfiguration'. His management on the ward involved work with psychology. Rather than trying to 'change' the patient or the nature of his thoughts, as this would likely cause more distress and non-engagement, the psychological treatment plan was to focus on reducing risk. Many speculations have been made regarding the aetiology. However, the therapeutic difficulties remain a challenge in 2024 as the disorder is understudied. A literature review published in 2021 suggested that amputation remains the most 'satisfying' management strategy, even though it is shunned in the medical community. A once misunderstood and misdiagnosed disorder, body integrity dysphoria has been appreciated by the ICD-11 as a separate entity. Our duty of care urges us to understand not just the biology of the ailment but also the ethically questionable resorts used so far (self-amputation) to deal with the emotional turmoil of wanting to be an amputee. A holistic and personalised biopsychosocial model of care is needed for patients with body integrity dysphoria.

Lower Extremity Osseointegration Postoperative Rehabilitation Protocols: A Scoping Review.

OBJECTIVE: Lower-extremity transcutaneous osseointegration is a rehabilitation alternative to socket-suspended prostheses. The rehabilitation process, philosophies, and routines remain under-described. This review, primarily, identifies commonalities and differences among protocols. Secondarily, strategies are proposed to streamline future research of post-osseointegration surgery rehabilitation. METHODS: Two differently phrased queries of Google Scholar, Pubmed, Embase, and Web of Science were performed. First using either "osseointegration" or "osseointegrated" or "bone anchored prosthesis" AND [last name]. Second, replacing author name with "physical therapy" or "rehabilitation." Six hundred eighty-eight articles were identified describing lower-extremity rehabilitation following osseointegration. Following software-based deduplication, manual abstract and full-text review, article reference evaluation, and use of Google Scholar's "Cited by" feature, 35 studies were fully analyzed. First, a consolidated summary was made of protocols focusing on stages, timing, and other descriptions of postoperative rehabilitation. Subsequently, strengths and limitations of protocols were considered to propose potential strategies to investigate and optimize postoperative rehabilitation. RESULTS: All articles describe rehabilitation having this same order of goal progression: from surgery to gradual weight bearing and final goal of independent ambulation. The most impactful difference influencing the stated final goal of independent ambulation was whether 1 or 2 surgical stages were performed. No articles reported patient success rate achieving proposed goals and timing, or challenges during rehabilitation. Therefore, the first research suggestion is to investigate actual success rates achieving proposed goals and timing. Second, to further explore rehabilitation of performance deficits, beyond unaided ambulation. Finally, to incorporate technology such as mobility trackers to more objectively understand prosthesis use and mobility. CONCLUSION: All lower-extremity osseointegration rehabilitation literature recommends identical goal progression order. No studies evaluate patient challenges or variation. Understanding and addressing such challenges may enhance postoperative rehabilitation. IMPACT: This article consolidates published rehabilitation protocols post-osseointegration surgery. Specific analysis and experimentation of the protocols may enhance the uniformity and potential of patient rehabilitation.

Virtual Assessment of Functional Mobility in Lower Extremity Prosthesis Clients: An Exploratory Study.

Objective: To investigate the relationship between patient perception of lower extremity function and a home-based virtual clinician assessment of mobility in lower limb prosthesis clients. Design: Descriptive observational study using a clinician-administered functional mobility survey and timed Up and Go test to assess lower extremity function under supervision. Setting: Health Insurance Portability and Accountability Act-compliant online virtual platform. Participants: Twelve lower limb loss clients currently using prostheses, aged ≥19 years, not pregnant, and with no stroke, seizure disorder, or cancer. Interventions: Not applicable. Main Outcome Measures: Main outcomes were mobility survey scores and mean timed Up and Go duration. Results: Most participants reported significant ease of completing basic indoor ambulation and toileting tasks (66%-75%) and significant difficulty in running or prolonged ambulation activities (83%) requiring use of lower limb prosthesis. Timed Up and Go test was faster (11.0±2.9 s) than the reference range for transtibial prosthesis users and negatively associated with self-reported lower extremity functional status (r=-.70, P=.02). Conclusions: Self-reported movement with lower limb prostheses at home and evaluation of mobility via a virtual platform is a feasible assessment modality that may reduce the frequency of therapy visits, defray some rehabilitation costs, and minimize the travel burden to distant prosthetic clinics.

Below-knee amputation with an ultrasonic scalpel: evaluation of early postoperative clinical outcomes.

OBJECTIVE: Despite the development of microscopic reconstructive techniques for lower limb salvage, major limb amputation is still required for critical, unsalvageable lower leg wounds, with steadily increasing estimates of major limb amputations. In this study, the authors highlight a surgical technique for below-knee (BK) amputation using an ultrasonic scalpel, and evaluate its safety and effectiveness compared with the conventional method of using surgical blades. METHOD: A retrospective chart review was conducted at the Department of Plastic and Reconstructive Surgery, St. Vincent's Hospital, Republic of Korea, on patients who underwent BK amputation between October 2012 and January 2021. Patients were assigned to two groups: amputation using classical methods, such as surgical blades and electrocautery (group A); and amputation using an ultrasonic scalpel (group B). Numerous perioperative factors, such as operation time, intraoperative blood loss, postoperative complications and recovery time were examined. The present study adhered to the STROBE guidelines. RESULTS: A total of 41 patients (16 in group A and 25 in group B) were included in this study. Operation time was significantly shorter in group B (p=0.001) and intraoperative blood loss was lower (p=0.011). Wound healing time did not vary between groups. CONCLUSION: In this study, the use of an ultrasonic scalpel for lower limb amputation was effective in reducing operation time and blood loss, which may be helpful in improving outcomes for patients with comorbidities.

Residual diabetic foot osteomyelitis after surgery leads to poor clinical outcomes: A systematic review and meta-analysis.

The aim of this meta-analysis is to compare the clinical outcomes in patients with and without residual osteomyelitis (ROM) after surgical bone resection for diabetic foot osteomyelitis (DFO). We completed a systematic literature search using PubMed, Scopus, and Embase using keywords DFO, Residual OM (ROM), and positive bone margins. The study outcomes included wound healing, antibiotic duration, amputation, and re-infection. Five hundred and thirty patients were included in the analysis; 319 had no residual osteomyelitis (NROM), and 211 had ROM. There was not a significant difference in the proportion of wounds that healed 0.6 (p = 0.1, 95% confidence intervals [95% CI] 0.3-1.3). The risk of infection was 2.0 times higher (OR = 2.0, p = 0.02, 95% CI 1.1-3.4), and the risk of amputation was 4.3 times higher (OR = 4.3, p = 0.0001, 95% CI 2.4-7.6) in patients with ROM. Patients with ROM received antibiotics significantly longer. The mean difference was 16.3 days (p = 0.02, 95% CI 11.1-21.1).

Does complete resection of infected bone improve clinical outcomes in patients with diabetic foot osteomyelitis?

The objective of the study was to compare outcomes in patients with complete surgical resection versus partial resection of diabetic foot osteomyelitis (OM). A post hoc analysis of 171 patients with OM was performed using data from two randomized clinical trials. OM was confirmed with bone culture or histopathology. Surgical culture specimens were obtained from resected bone and sent for histopathology and microbiology. Residual osteomyelitis (RO) was defined as a positive resected margin on culture or histopathology. No residual osteomyelitis (NRO) was defined as no growth from bone culture and no histopathological inflammation in the biopsy of the resection margin. Data from the 12-month follow-up were used to determine clinical outcomes. During the index hospitalization, NRO patients had significantly shorter duration of antibiotic therapy (NRO 21.0, 13.0-38.0 vs. RO 37.0, 20.8-50.0, p <0.01) and more amputations than patients with RO (NRO 89.9% vs. RO 60.9%, p <0.01). During the 12-month follow-up, patients with NRO also had significantly shorter duration of antibiotic therapy (NRO 42, 21.0-66.5 vs. RO 50.5, 35.0-75.0, p = 0.02). During the 12-month follow-up, there was no difference in ulceration at the same site (NRO 3.7%, RO 4.3% p = 0.85), hospitalization (NRO 32.6%, RO 34.8%, p = 0.76), total re-infections (NRO 25.3%, RO 29.3%, p = 0.56), re-infection with osteomyelitis (NRO 13.3% vs. 13.5%, p = 0.36), amputation (NRO 8.8%, RO 5.4%, p = 0.86) and time to wound healing in days (NRO 94, 41.0-365 vs. RO 106, 42.8-365, p = 0.77). Successful treatment of osteomyelitis was achieved by 86.7% and 86.5% of patients. During the index hospitalization, patients with no residual osteomyelitis had more amputations and were treated with antibiotics for a shorter duration. During the 12-month follow-up, patients with no residual osteomyelitis had shorter durations of antibiotics. There were no differences in re-infection, amputation, re-ulceration or hospitalization. Level of evidence: 1.

Forequarter Amputation and Resection of Ribs 1-4 for Chronic Osteomyelitis.

A 78-year-old woman with a history of breast cancer, melanoma, and radiation therapy presented with worsening chronic osteomyelitis and radiation necrosis of her clavicle, scapula, and upper ribs. Despite treatment with vancomycin, she experienced significant lymphedema and near-total loss of motor function in the left upper extremity. Given the progression of the disease and diminished functionality of the limb, a forequarter amputation was determined to be the only viable option beyond supportive care. The forequarter amputation was successful, and it involved the removal of the left clavicle, scapula, ribs 1-4, and the upper extremity. Within a month, the patient regained independence in all activities of daily living, highlighting the potential for improved quality of life from surgical interventions under certain circumstances. Our case serves as a reminder that the utility of the forequarter amputation extends beyond its most common uses, such as trauma or sarcoma, and in rare cases can be an option for refractory osteomyelitis of the proximal upper extremity and chest wall.

Reamputation rate, mortality and the incidence of risk factors for ipsilateral reamputation among patients with dysvascular major lower limb amputation.

INTRODUCTION: A major lower-limb amputation (LLA) for dysvascular disease carries the risk of disturbed wound healing necessitating reamputation at a higher level. A reamputation causes a delay in prosthetic fitting and recovery of walking ability. The combination of a prolonged open wound and inability to walk can worsen of the physical and psychological situation. Prevention of reamputation seems therefore important. This study aims to identify risk factors for reamputation, and to evaluate a possible altered mortality rate after a dysvascular major LLA. These issues are crucial for shared decision-making prior to surgery. METHODS: Retrospective study investigating a Dutch regional cohort of patients with a dysvascular below-knee, through-knee, or above-knee LLA. RESULTS: 516 Dysvascular major LLAs were included (2014-2018). One hundred reamputations were performed within 1 year after initial amputation (19.4%). Risk factors for ipsilateral reamputation were diabetes mellitus, lipid-lowering drugs usage, and lower level of amputation (respectively P = < 0.01, 0.037, and < 0.01). The 30-day mortality rates were 1% and 12% for the reamputation group and the non-reamputation group respectively (P = < 0.01). The 1-year mortality rates were 23% and 27% for the reamputation group and the non-reamputation group respectively (P = 0.423). CONCLUSIONS: Ipsilateral reamputation within one year after initial amputation is common. Several risk factors for reamputation were identified. The 30-day and 1-year mortality rate is high, but not significantly different after one year. A clinical decision tool for dysvascular patients needs to be developed to improve shared decision-making, reduce reamputation rates, and improve survival.

Using Electrical Muscle Stimulation to Enhance Electrophysiological Performance of Agonist-Antagonist Myoneural Interface.

The agonist-antagonist myoneural interface (AMI), a surgical method to reinnervate physiologically-relevant proprioceptive feedback for control of limb prostheses, has demonstrated the ability to provide natural afferent sensations for limb amputees when actuating their prostheses. Following AMI surgery, one potential challenge is atrophy of the disused muscles, which would weaken the reinnervation efficacy of AMI. It is well known that electrical muscle stimulus (EMS) can reduce muscle atrophy. In this study, we conducted an animal investigation to explore whether the EMS can significantly improve the electrophysiological performance of AMI. AMI surgery was performed in 14 rats, in which the distal tendons of bilateral solei donors were connected and positioned on the surface of the left biceps femoris. Subsequently, the left tibial nerve and the common peroneus nerve were sutured onto the ends of the connected donor solei. Two stimulation electrodes were affixed onto the ends of the donor solei for EMS delivery. The AMI rats were randomly divided into two groups. One group received the EMS treatment (designated as EMS_on) regularly for eight weeks and another received no EMS (designated as EMS_off). Two physiological parameters, nerve conduction velocity (NCV) and motor unit number, were derived from the electrically evoked compound action potential (CAP) signals to assess the electrophysiological performance of AMI. Our experimental results demonstrated that the reinnervated muscles of the EMS_on group generated higher CAP signals in comparison to the EMS_off group. Both NCV and motor unit number were significantly elevated in the EMS_on group. Moreover, the EMS_on group displayed statistically higher CAP signals on the indirectly activated proprioceptive afferents than the EMS_off group. These findings suggested that EMS treatment would be promising in enhancing the electrophysiological performance and facilitating the reinnervation process of AMI.