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The Journal of Bone and Joint Surgery.... Nov 2023After combat-related lower extremity amputations, patients rapidly lose bone mineral density (BMD). As serial dual x-ray absorptiometry (DXA) scans are rarely performed... (Review)
Review
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.
Topics: Humans; Bone Density; Dietary Supplements; Lumbar Vertebrae; Vitamin D; Bone Diseases, Metabolic; Absorptiometry, Photon; Lower Extremity; Amputation, Surgical; Vitamins; Retrospective Studies
PubMed: 37582168
DOI: 10.2106/JBJS.22.01258 -
Annals of Plastic Surgery Jun 2020This study aimed to present the results of a series of forequarter amputations (FQAs) and to evaluate the reconstructive methods used.
OBJECTIVE
This study aimed to present the results of a series of forequarter amputations (FQAs) and to evaluate the reconstructive methods used.
SUMMARY BACKGROUND DATA
Although FQA has become a rare procedure in the era of limb-sparing treatment of extremity malignancies, it is a useful option when resection of a shoulder girdle or proximal upper extremity tumor cannot be performed so as to retain a functional limb.
METHODS
Thirty-four patients were treated with FQA in 1989 to 2017. Various reconstructive techniques were used, including free fillet flaps from the amputated extremity.
RESULTS
All patients presented with intractable symptoms such as severe pain, motor or sensory deficit, or limb edema. Seventeen patients were treated with palliative intent. Chest wall resection was performed in 9 patients. Free flap reconstruction was necessary for 15 patients, with 11 free flaps harvested from the amputated extremity. There was no operative mortality, and no free flaps were lost. In curatively treated patients, estimated 5-year disease-specific survival was 60%. Median survival in the palliatively treated group was 13 months (1-35 months).
CONCLUSIONS
Limb-sparing treatment is preferable for most shoulder girdle and proximal upper extremity tumors. Sometimes, FQA is the only option enabling curative treatment. In palliative indications, considerable disease-free intervals and relief from disabling symptoms can be achieved. The extensive tissue defects caused by extended FQA can be safely and reliably reconstructed by means of free flaps, preferably harvested from the amputated extremity.
Topics: Amputation, Surgical; Free Tissue Flaps; Humans; Neoplasms; Plastic Surgery Procedures; Upper Extremity
PubMed: 32149840
DOI: 10.1097/SAP.0000000000002204 -
NeuroRehabilitation 2020Acquired limb loss, whether from accident or amputation, occurs with an incidence of greater than 175,000 per year in the United States. Current prevalence is estimated... (Review)
Review
Acquired limb loss, whether from accident or amputation, occurs with an incidence of greater than 175,000 per year in the United States. Current prevalence is estimated at greater than 1.5 million and is expected to double within 30 years. While many patients with amputations may have no significant pain or sensory issues after healing from the initial loss, one-quarter to one-half of patients may have ongoing difficulties with residual limb pain, phantom limb pain, or phantom limb sensation. This review explores the potential etiologies of those symptoms, as well as a variety of treatment options that a practitioner may consider when approaching this condition.
Topics: Amputation, Surgical; Amputees; Evidence-Based Medicine; Humans; Inflammation Mediators; Longitudinal Studies; Pain Measurement; Phantom Limb; Sensation
PubMed: 32986622
DOI: 10.3233/NRE-208005 -
Der Orthopade May 2020An amputation around, through or below the knee joint constitutes a "huge" change in a patient's life. In Orthopaedics, amputations are most frequently performed in...
An amputation around, through or below the knee joint constitutes a "huge" change in a patient's life. In Orthopaedics, amputations are most frequently performed in cases with musculoskeletal tumours or failed total knee arthroplasty. A multidisciplinary team approach (surgeon, anaesthetist, pain specialists, orthotist, psychologist etc.) and patient-specific treatment regime from the outset as well as a meticulous surgical technique are of the outmost importance. Nowadays, prosthetic legs can be fitted for nearly any amputation level. The functional outcome of amputations below the knee is usually superior to amputations above or through the knee joint. Postoperative stump conditioning is paramount and the final prosthetic leg should not be fitted earlier than 4-6 months postoperatively. Problems with wound healing, muscle contractures and phantom limb pain represent common complications which might adversely affect patient outcomes.
Topics: Amputation, Surgical; Amputation Stumps; Arthroplasty, Replacement, Knee; Humans; Knee; Knee Joint; Leg; Phantom Limb; Wound Healing
PubMed: 32266433
DOI: 10.1007/s00132-020-03906-8 -
South African Journal of Surgery.... Sep 2021Lower extremity amputations (LEAs) are most frequently due to diabetes mellitus (DM), a disease on the rise. The objective of this study was to determine the prevalence...
BACKGROUND
Lower extremity amputations (LEAs) are most frequently due to diabetes mellitus (DM), a disease on the rise. The objective of this study was to determine the prevalence and aetiology of LEAs at Addington Hospital from 2013 to 2017 and to explore the physiotherapy referral practices and outcomes.
METHODS
Retrospective study carried out at Addington Hospital, Durban. Patients who underwent LEAs were filtered from theatre registers and the hospital Meditech database. Data collected included patients' demographic profile, diabetic status, level of amputation, limb orientation, physiotherapy referral status, and rehabilitation outcomes. Physiotherapy files were scanned for the attendance of referred patients. Study endpoints were prevalence, diabetes status, referral status, compliance and rehabilitation outcomes.
RESULTS
From 2013 to 2017, 1 028 LEAs in 843 patients were identified with single amputations (697) and multiple amputations (146). The median age was 61 (IQR 52-68) years, and the M:F ratio was 1.3:1. A total of 574 (68.1%) patients had DM. Seven hundred and thirty-eight (71.8%) amputations were as a result of DM. The level of amputations was below-knee (479; 46.6%), toectomy (236; 23%), above-knee (196; 19%) and trans-metatarsal (117; 11.4%). Only 148 patients (17.6%) were referred for physiotherapy, of which 91 (61.5%) attended. Mobility in those who attended rehabilitation was with a walking frame (51; 56%), crutches (29; 31.9%), prosthesis and crutches (7; 7.7%), and wheelchair-bound (4; 4.4%).
CONCLUSION
Over half the amputations were associated with DM, which was also a risk factor for multiple amputations. Although referral and attendance for physiotherapy were very poor, mobility in those who attended was excellent, indicating a dire need to improve hospital referral pathways.
Topics: Amputation, Surgical; Diabetes Mellitus; Hospitals; Humans; Lower Extremity; Middle Aged; Retrospective Studies; South Africa
PubMed: 34515432
DOI: No ID Found -
The Journal of Foot and Ankle Surgery :... 2020The optimal level of lower-extremity amputation, particularly in diabetic patients with ulceration, is debated. Proximal amputations more greatly decrease function...
AIMS
The optimal level of lower-extremity amputation, particularly in diabetic patients with ulceration, is debated. Proximal amputations more greatly decrease function versus distal amputations, but healing and complication rates may differ between the 2 types. This study compares early postoperative outcomes after transmetatarsal and other partial foot amputations and major leg amputations.
METHODS
Data were derived from National Surgical Quality Improvement Program datasets covering 2012 to 2014. Outcomes studied include 30-day rates of readmission to hospital for wound complications. We matched the 2 types of amputation patients by propensity score to fairly compare between levels of amputation when either type of amputation might be indicated. The same analysis was then performed with emphasis on diabetic patients.
RESULTS
Major amputation patients were more likely to have dependent functional status, although their surgeries tended to be more complicated. Minor amputation patients had 2.5 times the odds of irrigation and debridement compared with major amputation patients, but only 0.49 and 0.47 times the odds of urinary tract infection or transfusion, respectively.
CONCLUSIONS
Although short-term complications, readmissions, and reoperations were more common in distal amputation, UTI and the need for transfusion were higher in major amputation.
Topics: Aged; Amputation, Surgical; Cohort Studies; Diabetic Foot; Female; Humans; Knee; Male; Metatarsus; Middle Aged; Patient Readmission; Postoperative Complications; Propensity Score; Reoperation; Time Factors
PubMed: 32354505
DOI: 10.1053/j.jfas.2019.09.019 -
Journal of Orthopaedic Trauma Sep 2022The objective of this study was to survey a broad group of prosthetists on their experience with amputees with knee disarticulation (KD) and transfemoral amputation...
OBJECTIVES
The objective of this study was to survey a broad group of prosthetists on their experience with amputees with knee disarticulation (KD) and transfemoral amputation (TFA) to determine their preference of amputation level, opinions on patient preference, and common problematic issues to guide decision-making for patients and surgeons faced with the decision of a high-level lower extremity amputation.
DESIGN
This is a survey-based study.
INTERVENTION
A blinded electronic mail survey was completed by 102 prosthetists.
MAIN OUTCOME MEASUREMENTS
Each prosthetist was asked (1) what amputation level (KD or TFA) do they prefer and why and (2) which amputation level do they believe patients prefer and why.
RESULTS
There was no consensus among prosthetists regarding amputation level preference. Fifty-four (53%) prosthetists preferred KD and 48 (47%) preferred TFA. Fifty-five (54%) prosthetists believed patients preferred TFA and 47 (46%) believed patients preferred KD. Amputation level preference often depended on age, functional goals, and concerns with cosmesis. The most common benefits given for KD over TFA included distal-end weight-bearing (n = 53), a lower subischial socket (n = 43), and better function (n = 30). The most common disadvantages given for KD over TFA included component limitations due to space available below amputation (n = 56), poor cosmesis (n = 49), an asymmetrical knee axis (n = 42), and difficulties with sitting/standing (n = 13).
CONCLUSION
No consensus exists between prosthetists regarding preference for KD versus TFA. The advantages and disadvantages of KD reported in this study, along with the associated decision tree, can be used for future counseling of patient's faced with high-level lower extremity amputations.
Topics: Amputation, Surgical; Amputees; Disarticulation; Humans; Knee Joint; Weight-Bearing
PubMed: 35234729
DOI: 10.1097/BOT.0000000000002364 -
The Journal of Foot and Ankle Surgery :... 2023Charcot 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...
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.
Topics: Humans; Retrospective Studies; Amputation, Surgical; Arthropathy, Neurogenic; Male; Female; Middle Aged; Arthrodesis; Plastic Surgery Procedures; Aged; Adult; Subtalar Joint
PubMed: 37524241
DOI: 10.1053/j.jfas.2023.07.007 -
Diabetes Research and Clinical Practice Dec 2023Living with a diabetes-related foot ulcer has significant lifestyle impacts. Whilst often considered a last resort, amputation can overcome the burden of ulcer... (Review)
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.
Topics: Humans; Quality of Life; Ulcer; Amputation, Surgical; Diabetic Foot; Lower Extremity; Diabetes Mellitus
PubMed: 37981124
DOI: 10.1016/j.diabres.2023.111015 -
The Journal of Hand Surgery Oct 2023Major upper extremity amputations can have a considerable impact on patients' lives, altering their ability to independently perform activities of daily living and... (Review)
Review
Major upper extremity amputations can have a considerable impact on patients' lives, altering their ability to independently perform activities of daily living and leading to changes in occupations and hobbies. Although upper extremity prosthetics have existed for millennia, recent advances have improved prosthetic motor control and sensory feedback, leading to increased overall satisfaction. The goal of this article was to describe the current options that exist for upper extremity prosthetics and explore the recent advances and future directions in prosthetic technology and surgical techniques.
Topics: Humans; Activities of Daily Living; Prosthesis Design; Amputation, Surgical; Artificial Limbs; Upper Extremity
PubMed: 37436340
DOI: 10.1016/j.jhsa.2023.05.018