The Effect of Multidimensional Spiritual Psychotherapy on the Quality of Life of Bone Cancer Survivors with a History of Lower Extremity Amputation.

INTRODUCTION: This study aimed to investigate the effect of multidimensional spiritual psychotherapy on anxiety, depression, and attitude towards self and god in bone cancer patients after amputation. METHOD: Forty one cancer patients with a history of Below-The-Knee amputation were recruited in this quasi-experimental study. The design included pre-and post-tests in experimental and control  groups. The experimental group received 15 sessions of multidimensional spiritual psychotherapy. Cattell Anxiety Inventory (CAI), Beck Anxiety Inventory (BAI), Beck's Depression Inventory (BDI), Religious Adherence Questionnaire (RAQ), and Self-concept-God concept questionnaire were administered for data collection. RESULTS: There was a significant difference between the control and experimental groups in terms of anxiety (P=0.0001), Depression (P=0.0001), God-image (P=0.035, F(1,38)=4.79), God-concept (P=0.006, F(1,38)=8.58), self-image (P=0.0001, F(1,38)=98.62), and self-concept (P=0.0001, F(1,38)=120.56), psychological evolution (P=0.0001, F(1,38)=19.36), and religious adherence (P=0.0001, F(1,38)=84.21). CONCLUSION: The results of the study indicated that the emphasis on spirituality and the implementation of spiritual care could improve the cancer amputated patients' well-being.

Application of complete decongestive therapy after lymphaticovenular anastomosis of the lower limb combined with liposuction-A retrospective study research.

BACKGROUND: Complete decongestive therapy (CDT) is a conservative treatment for lymphedema that combines interventions and lifestyle changes. We evaluated the application of CDT after lymphaticovenular anastomosis (LVA) of the lower limb combined with liposuction. METHODS: A total of 55 patients who underwent LVA of the lower limb combined with liposuction from January 2021 to July 2022 were enrolled in the study. The patients were divided into groups A (n = 24) and B (n = 31) according to whether they adhered to CDT treatment during the 12-month follow-up. Group A was the non-adherence CDT group and Group B was the adherence CDT group. Lower Extremity Lymphedema Index (LELI) and Lymphoedema Functioning, Disability, and Health Questionnaire for Lower Limb Lymphoedema (Lymph-ICF-LL) were used as prognostic indicators to observe the remission of postoperative lymphedema symptoms in the two groups. RESULTS: At 6-month and 12-month follow-up, LELI and the score of Lymph-ICF-LL in group B and group A were lower than before the operation (p < .05). The circumference of the affected limb was reduced, and the quality of life was improved in both groups after the operation. The reduction of LELI and Lymph-ICF-LL in group B was higher than in group A, and the difference was statistically significant (p < .05). CONCLUSION: This study preliminarily proves the effectiveness of CDT after LVA of the lower limb combined with liposuction, which can maintain and strengthen the surgical effect. Further, CDT treatment is still needed after the operation, which is necessary to reduce the circumference of the affected limb and improve patients' quality of life.

Implementation of holistic nursing interventions based on fast track surgery concept in patients with lower extremity arterial occlusive disease.

Lower Extremity Arterial Occlusive Disease (LEAOD) is a prevalent condition affecting many patients worldwide, which requires careful management and patient cooperation. This study aimed to evaluate the effectiveness of holistic nursing interventions based on the Fast Track Surgery (FTS) concept in patients with LEAOD. A retrospective analysis of 92 LEAOD patients, randomized into control and experimental groups, was performed. Conventional rehabilitation nursing interventions were applied to the control group, while the experimental group received holistic rehabilitation nursing interventions based on the FTS concept. Patient adherence was assessed before and after the intervention using a hospital survey, and sleep quality was evaluated using the Pittsburgh Sleep Quality Index on days 3, 7, and 15 post-interventions. Post-intervention, the experimental group exhibited significantly improved adherence to balanced diet, regular exercise, timely medication, and regular review visits compared to the control group (P < .05). Further, Pittsburgh Sleep Quality Index scores indicated significantly better sleep quality over time in the experimental group than in the control group (P < .05). The implementation of holistic nursing interventions based on the FTS concept significantly improved patient adherence and sleep quality in LEAOD patients. These findings highlight the potential benefits of integrating such interventions in the management of LEAOD patients, potentially enhancing postoperative recovery and overall health outcomes.

Decision-making processes for non-emergency diabetes-related lower extremity amputations: A scoping review.

Living with a diabetes-related foot ulcer has significant lifestyle impacts. Whilst often considered a last resort, amputation can overcome the burden of ulcer management, for an improved quality of life. However, limited research has been conducted to understand how the decision to amputate is made for people with a chronic ulcer when amputation is not required as a medical emergency. Therefore, the aim was to identify and map key concepts in the literature which describe the decision-making for diabetes-related amputations. This review followed Arksey and O'Malley's PRISMA scoping review framework. Five electronic databases and grey literature were searched for papers which described clinical reasoning and/or decision-making processes for diabetes-related amputation. Data were extracted and mapped to corresponding domains of the World Health Organisation's International Classification of functioning, Disability and Health (ICF) framework. Ninety-four papers were included. Personal factors including emotional wellbeing, quality of life, and treatment goals are key considerations for an elective amputation. It is important to consider an individual's lifestyle and personal circumstances, as well as the pathology when deciding between amputation or conservative management. This highlights the importance of a holistic and shared decision-making process for amputation which includes assessment of a person's lifestyle and function.

Hounsfield Unit-Calculated Bone Mineral Density Loss Following Combat-Related Lower Extremity Amputations.

BACKGROUND: After combat-related lower extremity amputations, patients rapidly lose bone mineral density (BMD). As serial dual x-ray absorptiometry (DXA) scans are rarely performed in this setting, it is difficult to determine the timeline for bone loss and recovery or the role of interventions. However, a strong correlation has been demonstrated between DXA BMD and computed tomography (CT) signal attenuation. We sought to leverage multiple CT scans obtained after trauma to develop a predictive model for BMD after combat-related lower extremity amputations. METHODS: We reviewed amputations performed within the United States military between 2003 and 2016 in patients with multiple CT scans. We collected pertinent clinical information, including amputation level(s), complications, and time to weight-bearing. The primary outcome measure was the development of low BMD, estimated in Hounsfield units (HU) from CT scans with use of a previously validated method. One hundred and twenty-eight patients with 613 femoral neck CT scans were available for analysis. A least absolute shrinkage and selection operator (LASSO) multiple logistic regression analysis was applied to determine the effects of modifiable and non-modifiable variables on BMD. A random-effects model was applied to determine which factors were most predictive of low BMD and to quantify their effects. RESULTS: Both amputated and non-amputated extremities demonstrated substantial BMD loss, which stabilized approximately 3 years after the injury. Loss of BMD followed a logarithmic pattern, stabilizing after 1,000 days. On average, amputated limbs lost approximately 100 HU of BMD after 1,000 days. Other factors identified by the mixed-effects model included nonambulatory status (-33.5 HU), age at injury (-3.4 HU per year), surgical complications delaying weight-bearing (-21.3 HU), transtibial amputation (20.9 HU), and active vitamin-D treatment (-19.7 HU). CONCLUSIONS: Patients with combat-related lower extremity amputations experience an initially rapid decline in BMD in both intact and amputated limbs as a result of both modifiable and non-modifiable influences, including time to walking, amputation level, surgical complications, and age. The paradoxical association of vitamin-D supplementation with lower HU likely reflects this treatment being assigned to patients with low BMD. This model may assist with clinical decision-making prior to performing lower extremity amputation and also may assist providers with postoperative decision-making to optimize management for prophylaxis against osteoporosis. LEVEL OF EVIDENCE: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Comparison of the effectiveness of the WALANT method in soft tissue and bone tissue surgeries in lower extremities.

OBJECTIVES: This study aims to investigate the effectiveness of wide-awake local anesthesia with no tourniquet (WALANT) technique in both bony and soft tissue procedures in lower extremities. PATIENTS AND METHODS: Between January 2021 and December 2022, a total of 29 patients (20 males, 9 females; mean age: 34.6±20.2 years; range, 14 to 82 years) who were operated for lower extremity pathologies with the WALANT technique in our clinic were included. The patients were divided into two groups: lower extremity soft tissue surgeries in Group A (n=10) and bone tissue surgeries in Group B (n=19). Postoperative pain onset time, pain score, the amount of intraoperative bleeding, need for additional solution, use of cautery, and the amount of bleeding in the surgical field were compared within groups. The Visual Analog Scale (VAS) was used to evaluate pain. RESULTS: There was no significant difference between the two groups in terms of age (p=0.265), sex (p=0.107), and surgical side (p=0.700). There was no significant difference between the two groups in terms of intraoperative bleeding at the discretion of the surgeon (p=0.701). There was no significant difference in the use of additional solution (p=0.105), cautery usage (p=0.522), pain onset time (p=0.636), and VAS scores (p=0.735) between the two groups. CONCLUSION: Our study results suggest that the WALANT technique is an effective and safe method in selected lower extremity surgeries. It is of utmost importance to apply the technique correctly to prevent complications that may occur.

Is mirror therapy associated with progressive muscle relaxation more effective than mirror therapy alone in reducing phantom limb pain in patients with lower limb amputation?

Mirror therapy is a widely used treatment for phantom limb pain (PLP) relief in patients with limb loss. Less common is progressive muscle relaxation (PMR), used mostly in other medical conditions (psychological, terminal cancer pain, etc). The purpose of this study is to evaluate the efficacy of a mirror therapy preceded by PMR intervention compared to mirror therapy preceded by unguided generic relaxation-mirror therapy in patients with lower limb amputation suffering from PLP. This pilot study was a single-blind, controlled, randomized trial. Thirty lower limb amputees suffering from PLP were recruited and randomly assigned to three groups respectively undergoing a PMR-mirror therapy rehabilitative intervention, generic relaxation-mirror therapy, and conventional physiotherapy (ConvPT). Selected items from Prosthesis Evaluation Questionnaire (PEQ) and the Brief Pain Inventory (BPI) were used to test the pain features at the beginning and 1 week after 3 weeks of intervention. A decrease of about 65% was found in the rate and duration of PLP at the PEQ in PMR-mirror therapy with respect to generic relaxation-mirror therapy (about 30%) and ConvPT (about 6%). A decrease of about 90% in intensity (worst and average) of PLP in PMR-mirror therapy when compared to generic relaxation-mirror therapy (about 45%) and ConvPT (about 20%) was found at the BPI. We preliminary concluded, albeit with limitations due to the small sample of patients, that mirror therapy can improve PLP when associated with PMR. Further studies are required to confirm that PMR could be an effective technique for more successful PLP management.

Osseointegration for Lower Limb Amputation: Understanding the Risk Factors and Time Courses of Soft Tissue Complications.

PURPOSE: Lower-limb osseointegrated prostheses are a novel alternative to traditional socket-suspended prostheses, which are often associated with poor fit, soft tissue damage, and pain. Osseointegration eliminates the socket-skin interface and allows for weight-bearing directly on the skeletal system. However, these prostheses can also be complicated by postoperative issues that can negatively impact mobility and quality of life. Little is known about the incidence of or risk factors for these complications as few centers currently perform the procedure. METHODS: A retrospective analysis was performed on all patients who underwent single-stage lower limb osseointegration at our institution between 2017 and 2021. Patient demographics, medical history, operative data, and outcomes were collected. Fisher exact test and unpaired t tests were performed to identify risk factors for each adverse outcome, and time-to-event survival curves were generated. RESULTS: Sixty patients met our study criteria: 42 males and 18 females with 35 transfemoral and 25 transtibial amputations. The cohort had an average age of 48 years (range, 25-70 years) and follow-up period of 22 months (range, 6-47 months). Indications for amputation were trauma (50), prior surgical complication (5), cancer (4), and infection (1). Postoperatively, 25 patients developed soft tissue infections, 5 developed osteomyelitis, 6 had symptomatic neuromas, and 7 required soft tissue revisions. Soft tissue infections were positively correlated with obesity and female sex. Neuroma development was associated with increased age at osseointegration. Neuromas and osteomyelitis were both associated with decreased center experience. Subgroup analysis by amputation etiology and anatomic location did not show significant differences in outcomes. Notably, hypertension (15), tobacco use (27), and prior site infection (23) did not correlate with worse outcomes. Forty-seven percent of soft tissue infections occurred in the 1 month after implantation, and 76% occurred in the first 4 months. CONCLUSIONS: These data provide preliminary insights into risk factors for postoperative complications arising from lower limb osseointegration. These factors are both modifiable (body mass index, center experience), and unmodifiable (sex, age). As this procedure continues to expand in popularity, such results are necessary to inform best practice guidelines and optimize outcomes. Further prospective studies are needed to confirm the above trends.

Comparison of the efficacy of 0.5% isobaric bupivacaine, 0.5% levobupivacaine, and 0.5% hyperbaric bupivacaine for spinal anesthesia in lower limb surgeries.

Various advantages of isobaric bupivacaine, levobupivacaine, and hyperbaric bupivacaine are described. There are no studies reliably determining the benefits of these forms of bupivacaine. The purpose of the study was to compare the efficacy of spinal anesthesia (SA) performed with 0.5% isobaric bupivacaine, 0.5% levobupivacaine, and 0.5% hyperbaric bupivacaine. The clinical study was approved by the ethics committee. The sample size was calculated for a confidence level of 99%. 111 patients were randomly allocated into 3 equal groups for spinal anesthesia in lower limb surgeries. In group 1 (1B) spinal anesthesia was performed with 3 ml of 0.5% isobaric bupivacaine (n = 37); in group 2 (2L)-3 ml of 0.5% levobupivacaine (n = 37), in group 3 (3H)-3 ml of 0.5% hyperbaric bupivacaine (n = 37). The criterion for assessing the effectiveness of anesthesia was the need to switch to another type of anesthesia (criterion-no anesthesia), or the need for additional use of narcotic analgesics or local anesthesia during surgery (criterion-reporting of painful feelings during the operation). In 1B anesthesia efficiency by the criterion of additional intraoperative analgesia was 100% (37 patients; 95% CI [0.88-1.0]); 2L-86.4%; (31 patients; 95% CI [0.68-0.92]); 3H-72.9% (27 patients; 95% CI [0.56-0.84]). There were significant differences between groups 1B and 2L: p < 0.05 (p = 0.0104). There were no significant differences between groups 2L and 3H (p = 0.2587). All patients in group 1B developed complete sensory block (++) within 4 (3; 5) min. In group 2L complete sensory block developed in 34 patients (89.4%) within 9 (5; 14) min, in group 3H sensory block developed in all patients within 3 (2.5; 4). The duration of analgesia period between 1B and 2L did not statistically differ (p = 0.73). In 3H the duration of analgesia was 170 (150; 200) min. The study found 83.7% efficacy of levobupivacaine and 72.9% efficacy of hyperbaric bupivacaine in comparison with isobaric bupivacaine (100%) when administered intrathecally in equal volumes and amounts (by the criterion of additional intraoperative analgesia).Trial registration: NCT05184465 (Initial Release: 12/01/2021; date of first publication-11/01/2022).

[Clinical characteristics analysis of 22 062 patients of foot and ankle deformity from QIN Sihe Orthopaedic Surgery Database between May 25, 1978 and December 31, 2020].

Objective: Based on the clinical data of patients with foot and ankle deformities in the QIN Sihe Orthopaedic Surgery Database, to analyze the characteristics and treatment strategies of foot and ankle deformities, and provide a basis for clinical decision-making. Methods: A total of 22 062 patients with foot and ankle deformities who received orthopedic surgery between May 25, 1978 and December 31, 2020 were searched in the QIN Sihe Orthopedic Surgery Database. The gender, age at operation, regional distribution, etiology, type of deformity, operation method, postoperative fixation method, and other information were collected. Results: Among the 22 062 patients, there were 13 046 males (59.13%) and 9 016 females (40.87%); the age at operation ranged from 1 to 77 years, with a median of 17 years, and 20 026 cases (90.77%) were aged 5 to 40 years. The patients came from 32 provinces, municipalities, and autonomous regions across the China and 5 countries including India and the United States, et al. The etiology and diseases type covered 154 kinds (of which sequelae of poliomyelitis, cerebral palsy, spina bifida and tethered spinal cord, congenital equinovarus foot, post-traumatic foot and ankle deformity, and Charcot-Marie-Tooth disease accounted for the highest proportion). The types of deformities included varus foot, equinus foot, valgus foot, talipes calcaneus, equinocavus, high arched foot, claw toe, and flail foot. Surgical methods included tendon lengthening, soft tissue release, tendon transposition, osteotomy orthopedics, and ankle arthrodesis. The 36 620 operations were performed, including 11 561 cases of hip, knee, and lower leg operations to correct the foot and ankle deformities. Postoperative fixation methods included Ilizarov external fixator in 2 709 cases (12.28%), combined external fixator in 3 966 cases (17.98%), and plaster or brace fixation in 15 387 cases (69.74%). Conclusion: Male patients with foot and ankle deformities account for a large proportion, and the population distribution is mainly adolescents, with a wide distribution of regions, causes and diseases, and talipes equinovarus and varus foot are the main types of deformities. Foot and ankle deformities are often combined with deformities of other parts of the lower limb, which requires a holistic treatment concept. The application of foot soft tissue and bone surgery combined with Ilizarov external fixator and combined external fixators provides a guarantee for the correction of complex foot and ankle deformities.

A core outcome set for lower limb orthopaedic surgery for children with cerebral palsy: An international multi-stakeholder consensus study.

AIM: To develop a core set of outcome domains to be measured in clinical studies on lower limb orthopaedic surgery for ambulant children with cerebral palsy (CP) that represents the priorities of an international multi-stakeholder group (children, parent/carers, and health professionals). METHOD: Potential outcome domains were identified through literature review and qualitative interviews with key stakeholders. These were scored in an international two-round Delphi survey, using a 9-point Likert scale. A final consensus meeting with key stakeholders agreed on the most important outcome domains and refined the core outcome set (COS). RESULTS: One hundred and sixty-one health professionals and 36 individuals with CP and their parents/carers rated 21 of 41 outcomes as important in the Delphi survey. The final consensus group agreed 19 outcomes within eight domains to be included in the final COS: pain and fatigue, lower limb structure, motor function, mobility (daily life activities), gait-related outcomes, physical activity, independence, and quality of life. INTERPRETATION: A COS for lower limb orthopaedic surgery for children with CP was developed. Incorporating this in the design of future clinical studies will provide a more holistic assessment of the impact of treatment while allowing meaningful comparisons and future synthesis of results from primary studies. WHAT THIS PAPER ADDS: Eight core outcome domains were identified as important to measure in future clinical research. Key stakeholders perceived pain, balance and fall, and independence as very important outcomes. Six contextual factors were identified as essential in surgical decision-making.

"I was trying to look after myself, but I really wasn't": Understanding patient's perspectives on risk factors for lower extremity amputations.

BACKGROUND: Lower extremity amputations (LEAs) as a result of type 2 diabetes mellitus (T2DM) cause considerable morbidity, mortality, and burden on the healthcare system. LEAs are thought to be preventable, yet the rate of LEAs, particularly in Australia, has risen despite the availability of preventative healthcare services. Understanding patient's perspectives of risk factors for LEAs may provide valuable insight into why many LEAs occur each year. OBJECTIVE: The aim of this study was to explore patient's perspectives of risk factors for LEAs as a result of T2DM. METHODS: A qualitative descriptive methodology involving non-probability purposive sampling was used to recruit inpatients at a tertiary metropolitan hospital in South Australia. Semi-structured interviews were conducted, and data were transcribed verbatim. Data from the interviews were analysed using thematic analysis and the constant comparison approach. RESULTS: A total of 15 participants shared their perspectives of risk factors for lower extremity amputations. Most (86%) of participants were male and Caucasian, with a median age of 66.4 years ranging from 44-80 years. The median duration of diabetes was 25.2 years, ranging from 12-40 years. More than half of the participants had undergone a previous amputation with 86% being unemployed or retired and 73% living in metropolitan Adelaide. Two main themes emerged: competing priorities and awareness. Finance and family care were identified as subthemes within competing priorities. While subthemes in the context of awareness related to lack of awareness of risk, experiences with health care professionals and perspectives of disease severity. CONCLUSIONS: The findings from this research indicate that addressing risk factors for LEAs for patients with T2DM require a holistic and nuanced approach which considers individual patient's circumstances, and its influence on how risks are viewed and managed.

Surgical Treatment and Rehabilitation Strategies for Upper and Lower Extremity Lymphedema: A Comprehensive Review.

Lymphedema is a chronic disabling condition affecting a growing number of patients worldwide. Although lymphedema is not life-threatening, several reports underlined detrimental consequences in terms of distress, pain, functional impairment, and infections with a relevant decrease in quality of life. Currently, there is no cure, and the therapeutic management of this condition aims at slowing down the disease progression and preventing secondary complications. Early diagnosis is paramount to enhance the effects of rehabilitation or surgical treatments. On the other hand, a multidisciplinary treatment should be truly integrated, the combination of microsurgical and reductive procedures should be considered a valid strategy to manage extremity lymphedema, and rehabilitation should be considered the cornerstone of the multidisciplinary treatment not only for patients not suitable for surgical interventions but also before and after surgical procedures. Therefore, a specialized management of Plastic Reconstructive Surgeons and Physical and Rehabilitative Medicine physicians should be mandatory to address patients' needs and optimize the treatment of this disabling and detrimental condition. Therefore, the aim of this review was to characterize the comprehensive management of lymphedema, providing a broad overview of the potential therapy available in the current literature to optimize the comprehensive management of lymphedema and minimize complications.

Microsurgical treatment of lower extremity lymphedema: A multidisciplinary approach to improve morbidity in advanced penile cancer patients.

INTRODUCTION: Lower extremity lymphedema is a major source of morbidity in up to 70% of penile cancer patients. Lymphedema is often thought to be incurable, though surgical treatments have started to emerge. This study is the first to apply lymphovenous bypass specifically to penile cancer patients status post lymphadenectomy. METHODS: We performed microsurgical lymphovenous bypass in 3 patients who underwent inguinal lymphadenectomy for advanced penile cancer, and later lymph node transplant in 1 patient. RESULTS: The lymphovenous bypass was performed by a trained microsurgeon: Two patients were treated as outpatients for lymphedema, and 1 patient underwent prophylactic lymphovenous bypass simultaneously with initial lymphadenectomy. We saw significant improvement in patient's clinical lymphedema as well as lymphatic drainage on infared imaging for 2 of 3 patients at 12 months, however 1 of these patients did require later lymph node transfer at 24 months. CONCLUSION: This early proof of concept study shows that these procedures should be considered and studied further in the treatment and prevention of debilitating lymphedema in the penile cancer population.

Management of surgical soft tissue defects of the lower extremities.

Management of post-operative soft-tissue defects on the lower legs is challenging owing to arterial and venous insufficiency, poor skin quality including epidermal and dermal atrophy, insufficient tissue laxity, and increased risk of infection. This paper highlights the management of post-operative soft-tissue defects on the lower extremity that cannot be closed primarily or by reconstruction with a local flap. A systematic review of the literature was performed using the National Library of Medicine (NLM) PubMed online database. Articles were included if they reported the management of post-operative lower extremity soft-tissue defects with secondary intention healing, full-thickness skin graft, split-thickness skin grafts, or skin substitutes. Sixty-three articles were included for analysis. There are several options for managing surgical defects on the lower legs and the method chosen should depend on various factors, including the quality of the skin, vascularity and size of the defect, medical history of the patient, and the experience of the surgeon.

Antiplatelet therapy with or without anticoagulant therapy for lower extremity peripheral artery disease: A systematic review.

PURPOSE: To identify randomized controlled trials that compared antiplatelet monotherapy to combination antiplatelet plus anticoagulant therapy and evaluated major adverse cardiovascular events (MACE) or major adverse limb events (MALE), death, or bleeding in patients with lower extremity peripheral artery disease (PAD). SUMMARY: A systematic search of MEDLINE, Embase, and CENTRAL databases revealed 5 trials. Two trials consisted of patients with stable PAD, while 3 trials examined patients with PAD post revascularization. Antiplatelet therapy was mostly aspirin (81-325 mg daily), and anticoagulation included rivaroxaban 2.5 mg twice daily or warfarin. Duration of follow-up ranged from 12 to 38 months. Two trials had low risk of bias, whereas 3 trials had high/unclear risk of bias. For patients with stable PAD, one trial showed that use of warfarin (or acenocoumarol) with antiplatelet therapy did not reduce MACE, MALE, or cardiovascular or all-cause death but increased the risk of life-threatening bleeding. A second trial demonstrated that low-dose rivaroxaban plus antiplatelet therapy lowered the risk of MACE and MALE, with no effect in preventing cardiovascular or all-cause death, but increased the risk of major bleeding. For patients with PAD post revascularization receiving warfarin and antiplatelet therapy, 2 trials showed no benefit in MACE or MALE but increased or similar rates of all-cause death and major bleeding. In a third trial, low-dose rivaroxaban plus aspirin reduced occurrence of the composite of MACE and MALE but increased major bleeding, with no effect on cardiovascular or all-cause death. CONCLUSION: Dual-pathway inhibition with low-dose rivaroxaban and aspirin reduced MACE and MALE in patients with stable or revascularized PAD, but net clinical benefit is questionable.

Biofeedback augmenting lower limb loading alters the underlying temporal structure of gait following anterior cruciate ligament reconstruction.

Biofeedback has recently been explored to target deviant lower extremity loading mechanics following anterior cruciate ligament reconstruction (ACLR) to mitigate the development of post traumatic osteoarthritis. The impact this feedback has on the structure of the stride interval dynamics-a barometer of gait system health-however, have yet to be examined. This study was designed to assess how feedback, used to alter lower-extremity loading during gait, affects the structure of stride interval variability by examining long-range stride-to-stride correlations during gait in those with unilateral ACLR. Twelve participants walked under three separate loading conditions: (1) control (i.e., no cue) (2) high loading, and (3) low loading. Baseline vertical ground reaction force (vGRF) data was used to calculate a target 5% change in vGRF for the appropriate loading condition (i.e., high loading was +5% vGRF, low loading was -5% vGRF). The target for the load condition was displayed on a screen along with real-time vGRF values, prescribing changes in stride-to-stride peak vertical ground reaction forces of each limb. From time-series of stride intervals (i.e., duration), we analyzed the mean and standard deviation of stride-to-stride variability and, via detrended fluctuation analysis (i.e., DFA α), temporal persistence for each feedback condition. Both the high and low loading conditions exhibited a change toward more temporally persistent stride intervals (high loading: α =0.92, low loading: α = 0.98) than walking under the control condition (α = 0.78; high vs. control: p = .026, low vs. control: p = .001). Overall, these results indicate that altering lower extremity load changes the temporal persistence of the stride internal dynamics in ACLR individuals, demonstrating the implications of the design of gait training interventions and the influence feedback has on movement strategies.

Treatment of secondary scrotal and lower extremity lymphedema using combined pedicled lymph node transfer and lymphaticovenous anastomosis: A case report.

Combined secondary scrotal and lower extremity lymphedema is an infrequent complication of radical excision of urogenital cancers associated with pelvic lymphadenectomy. Scrotal lymphedema is usually psychologically distressing, and difficult to treat. We report a case of a 41-years old male who presented with scrotal and left lower extremity lymphedema after radical prostatectomy and pelvic lymphadenectomy successfully treated with pedicled superficial inguinal lymph node (SILN) transfer and lymphaticovenous anastomosis (LVA) restoring the lymphatic drainage. The flap consisted of subscarpal adipofascial tissue between the level of the inguinal ligament and the groin crease measuring 11 × 7 cm. The flap composed of afferent lymphatics from the lower abdomen, lymph nodes, and fatty tissue without skin, the right-sided flap was transposed to the root of scrotum while the left one to the proximal left thigh, then two-level LVA were performed in the left extremity. The surgery went uneventful with no postoperative complications. At a 9 month follow-up, there was a significant reduction of the scrotal volume with a reduction of excess volume of the lower extremity from 49.6 to 9.4% compared with the healthy side. No cellulitis was reported during the follow-up period with improvement in the patient's clinical symptoms and quality of life. We believe that pedicled superficial inguinal lymph node flap together with LVA is a reliable and safe treatment option for either scrotal or lower extremity lymphedema following pelvic cancer treatment.

Epidemiology of major lower limb amputation using routinely collected electronic health data in the UK: a systematic review protocol.

INTRODUCTION: It is estimated that peripheral arterial disease occurs in one in five people aged over 60 years in the UK. Major lower limb amputation is a debilitating and life-changing potential outcome of peripheral arterial disease. A number of risk factors are involved in the development of the disease including smoking and diabetes. There is debate over the prevalence of major lower limb amputation in the UK with regional variations unexplained. The choice of data source can affect the epidemiological calculations and sources can also differ in the ability to explain variation. This study will aim to estimate the prevalence/incidence/number of major lower limb amputation in the UK. It will also identify sources of routinely collected electronic health data which report the epidemiology of major lower limb amputation in the UK. METHODS AND ANALYSIS: A systematic search of peer-reviewed journals will be conducted in Medline, Excerpta Medica database, Cumulative Index of Nursing and Allied Health Literature, Allied and Complementary Medicine Database, The Cochrane Library and Scopus. A grey literature search for government and parliament publications, conference abstracts, theses and unpublished articles will be performed. Articles will be screened against the inclusion/exclusion criteria and data extracted using a pretested extraction form by two independent reviewers. Prevalence, incidence or number of cases (depending on data reported) will be extracted. Disagreements will be resolved by discussion. Data synthesis will be performed either as a narrative summary or by meta-analysis. Heterogeneity will be assessed using the I2 statistic. If heterogeneity is low-moderate, pooled estimates will be calculated using random-effects models. If possible, meta-regression for time trends in the incidence of major lower limb amputation will be performed along with subgroup analysis, primarily in regional variation. ETHICS AND DISSEMINATION: Ethics approval is not required for this study as study data are anonymised and available in the public domain. Dissemination will be by publication in a peer reviewed journal and by appropriate conference presentation.PROSPERO registration numberCRD42020165592.

Association Between Changes in Subjective and Objective Measures of Mobility in People With Lower Limb Amputations After Inpatient Rehabilitation.

Functional recovery for people with lower limb amputations is quantified using objective or subjective measures of performance. In this brief report, the prospective relationship between objective and subjective mobility after rehabilitation was evaluated in people with lower limb amputations. Adults undergoing inpatient prosthetic rehabilitation for a first unilateral transtibial or transfemoral level lower limb amputation were recruited. Assessment times: discharge and 4-mo follow-up. Gait velocity and the L Test under single- and dual-task conditions measured objective mobility. The Prosthetic Evaluation Questionnaire (section 4 and question 5b) measured subjective mobility. Paired t tests and Pearson correlation analysis evaluated change over time and the association between mobility types, respectively. Twenty-one people with lower limb amputations (61.6 ± 8.2 yrs) participated. Gait velocity significantly improved (single- and dual-task: P < 0.001). L Test significantly improved for single-task (P = 0.002) but not dual-task conditions. No statistically significant Prosthetic Evaluation Questionnaire changes were observed. One subjective mobility question (sidewalk walking) correlated with objective mobility at follow-up (L Test single- and dual-task: r = -0.77; P < 0.001). Objective mobility improved after discharge; however, subjective reporting had no change. Lack of association may represent a mismatch between quantitative outcomes and subjective self-assessment. Both subjective and objective measures of mobility should be collected to provide a holistic picture of clinical and patient-relevant outcomes in people with lower limb amputations.