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Acta Orthopaedica Jun 2024Mortality after major lower extremity amputations is high and may depend on amputation level. We aimed to examine the mortality risk in the first year after major lower... (Observational Study)
Observational Study
BACKGROUND AND PURPOSE
Mortality after major lower extremity amputations is high and may depend on amputation level. We aimed to examine the mortality risk in the first year after major lower extremity amputation divided into transtibial and transfemoral amputations.
METHODS
This observational cohort study used data from the Danish Nationwide Health registers. 11,205 first-time major lower extremity amputations were included from January 1, 2010, to December 31, 2021, comprising 3,921 transtibial amputations and 7,284 transfemoral amputations.
RESULTS
The 30-day mortality after transtibial amputation was overall 11%, 95% confidence interval (CI) 10-12 (440/3,921) during the study period, but declined from 10%, CI 7-13 (37/381) in 2010 to 7%, CI 4-11 (15/220) in 2021. The 1-year mortality was 29% overall, CI 28-30 (1,140 /3,921), with a decline from 31%, CI 21-36 (117/381) to 20%, CI 15-26 (45/220) during the study period. For initial transfemoral amputation, the 30-day mortality was overall 23%, CI 22-23 (1,673/7,284) and declined from 27%, CI 23-31 (138/509) to 22%, CI 19-25 (148/683) during the study period. The 1-year mortality was 48% overall, CI 46-49 (3,466/7,284) and declined from 55%, CI 50-59 (279/509) to 46%, CI 42-50 (315/638).
CONCLUSION
The mortality after major lower extremity amputation declined in the 12-year study period; however, the 1-year mortality remained high after both transtibial and transfemoral amputations (20% and 46% in 2021). Hence, major lower extremity amputation patients constitute one of the most fragile orthopedic patient groups, emphasizing an increased need for attention in the pre-, peri-, and postoperative setting.
Topics: Humans; Amputation, Surgical; Denmark; Male; Female; Aged; Middle Aged; Cohort Studies; Lower Extremity; Aged, 80 and over; Registries; Databases, Factual; Adult; Tibia; Femur
PubMed: 38895969
DOI: 10.2340/17453674.2024.40996 -
Health Science Reports Jun 2024Diabetic foot ulcers are a severe complication in diabetic patients, significantly impact healthcare systems and patient quality of life, often leading to...
BACKGROUND
Diabetic foot ulcers are a severe complication in diabetic patients, significantly impact healthcare systems and patient quality of life, often leading to hospitalization and amputation. Traditional Standard of Care (SOC) treatments are inadequate for many patients, necessitating advanced wound care products (AWCPs) like human placental membranes. This study conducts a retrospective analysis to compare the effectiveness of two human placental membrane products, retention-processed amnion chorion (RE-AC) and lamination-processed amnion chorion (L-AC) in managing chronic diabetic foot ulcers (DFUs).
METHODS
The study collected retrospective observational data from electronic health records (EHRs) of patients treated for DFU at three outpatient wound care centers. Patients were categorized into two cohorts based on the treatment received. Key metrics included wound size progression and the number of product applications. The analysis employed Bayesian estimation, utilizing an analysis of covariance model with a Hurdle Gamma likelihood.
RESULTS
We found that RE-AC achieved a marginally higher expected Percent Area Reduction (xPAR) in DFUs compared to L-AC at 12 weeks (67.3% vs. 52.6%). RE-AC also required fewer applications, suggesting greater efficiency in general wound closure. Probability of full wound closure was similar in both groups (0.738 vs 0.740 in RE-AC and L-AC, respectively).
CONCLUSION
The findings suggest that while L-AC might be slightly more effective in complete ulcer healing, RE-AC offers overall better treatment efficiency, especially in reducing the frequency of applications. This efficiency can lead to improved patient comfort, reduced treatment costs, and optimized resource utilization in healthcare settings.
PubMed: 38895546
DOI: 10.1002/hsr2.2196 -
Journal of Clinical Medicine Jun 2024This retrospective analysis of an ongoing prospective cohort study aimed to assess the outcome of revascularisation for treating lifestyle-limiting intermittent...
Outcomes of Revascularisation for Treating Lifestyle-Limiting Intermittent Claudication in Aboriginal and Torres Strait Islander People and Non-Indigenous Patients from North Queensland: A Retrospective Cohort Study.
This retrospective analysis of an ongoing prospective cohort study aimed to assess the outcome of revascularisation for treating lifestyle-limiting intermittent claudication caused by peripheral artery disease (PAD) in Aboriginal and Torres Strait Islander Peoples and non-Indigenous North Queenslanders. Consenting patients with PAD who underwent endovascular or open revascularisation procedures for treating lifestyle-limiting intermittent claudication were included. The primary outcome measure was major adverse limb events (MALEs), defined as major amputation or the requirement for repeat open or endovascular revascularisation. Of the 378 included patients, 18 (4.8%) identified as Aboriginal and/or Torres Strait Islander Peoples. During a mean follow-up (standard deviation) of 6.0 (3.9) years, the incidence of MALE was similar in the Aboriginal and Torres Strait Islander People and non-Indigenous Australians (absolute percentage: 50.0% vs. 40.6%, log rank = 0.59). In both unadjusted and adjusted analyses, Aboriginal and Torres Strait Islander Peoples and non-Indigenous Australians had similar risks of MALE (unadjusted hazard ratio, HR, 1.20, 95% confidence interval, CI, 0.61, 2.36; adjusted HR 1.02, 95%CI 0.50, 2.06). This study suggests that Aboriginal and Torres Strait Islander People are under-represented in the population of patients undergoing revascularisation to treat intermittent claudication. Due to small numbers it cannot be reliably concluded that Aboriginal and Torres Strait Islander People and non-Indigenous Australians have similar rates of MALE.
PubMed: 38893050
DOI: 10.3390/jcm13113339 -
Journal of Clinical Medicine Jun 2024: The subamputation of fingers with vascular compromise presents a surgical challenge. Although tissue continuity may be considered a favourable prognostic element, in...
: The subamputation of fingers with vascular compromise presents a surgical challenge. Although tissue continuity may be considered a favourable prognostic element, in our experience, we noticed that there is not always a direct correlation between soft tissue involvement, radiographic appearance and final outcome. : We included, in our study, all cases of vascular pedicle injury in which finger salvage was attempted with microsurgical revascularisation. Exclusion criteria were: integrity of both vascular pedicles, pedicle lesion without global circulatory compromise and patients treated immediately with amputation. : Between May 2018 and July 2023, 27 male patients with finger subamputation injuries were treated at our institution. In 11 cases of injured fingers, the only intact tissue was the flexor digitorum profundus (FDP) or flexor pollicis longus (FPL). Our global failure rate was 49%; whereas, in the subgroup of the 11 cases with continuity of the FDP or FPL, the failure rate rose to 73% and when the fingers showed flexor tendon integrity and radiographs demonstrated minimal bone damage, revascularisation failure was observed in all cases (100%). : The results of the study show that subamputations with devascularisation, clinically presented with the combination of flexor tendon as the only element of tissue continuity and dislocation or minimal bone/articular injury, have a worse prognosis because of their trauma mechanism. We propose to add them to the Kay-Adani Classification as a subset of the poorest prognostic injuries group (III), to help surgeons to make decisions about the management of subamputation finger injuries.
PubMed: 38893042
DOI: 10.3390/jcm13113331 -
Journal of Clinical Medicine May 2024Diabetic foot osteomyelitis (DFO) is a major complication and can lead to significant morbidity and mortality. Systemic antibiotic therapy is often initiated first line...
Diabetic foot osteomyelitis (DFO) is a major complication and can lead to significant morbidity and mortality. Systemic antibiotic therapy is often initiated first line to achieve quiescence of infection. To perform a multi-centre case review of systemic antibiotic intervention to treat adults with DFO in England and Wales and compare with national guidelines ''. Eight centres from England and Wales retrospectively collated data from a minimum of five adults (aged ≥ 18 years) from electronic case records. All patients were treated with systemic antibiotics following a new diagnosis of DFO (1 June 2021-31 December 2021). 40 patients (35 males and 5 females) were included; the mean age was 62.3 years (standard deviation (SD) 13.0). Patients commenced systemic oral 14 (35%) or intravenous 26 (65%) antibiotic therapy following a new diagnosis of DFO. Twenty-seven (67.5%) patients were medically or surgically managed in the 12-week period with clinical quiescence of infection. Twenty-one patients (52.5%) had no recurrence of DFO infection within 12 weeks; seventeen (42.5%) of these patients had clinical quiescence of infection with systemic antibiotics alone without surgical intervention and nine (22.5%) of these cases had no recurrence of DFO. There were no cases of major amputation or death. All centres showed significant in-centre variability in systemic antibiotic management; variability was reported in the clinical and quantity indicators specifically to antibiotic selection, single versus dual therapy, mode of delivery and duration of treatment. This case review identifies there is existing variation when treating adults with systemic antibiotics for DFO. Further national guidance is required to standardise service delivery and care to improve patient outcomes.
PubMed: 38892792
DOI: 10.3390/jcm13113083 -
Frontiers in Cell and Developmental... 2024Nail stem cell (NSC) differentiation plays a vital role in maintaining nail homeostasis and facilitating digit regeneration. Recently, onychofibroblasts (OFs),...
Nail stem cell (NSC) differentiation plays a vital role in maintaining nail homeostasis and facilitating digit regeneration. Recently, onychofibroblasts (OFs), specialized mesenchymal cells beneath the nail matrix, have emerged as potential regulators of NSC differentiation. However, limited understanding of OFs' cellular properties and transcriptomic profiles hinders our comprehension of their role. This study aims to characterize human OFs and investigate their involvement in NSC differentiation. Human OFs were isolated and characterized for their mesenchymal stem cell (MSC)-like phenotype through flow cytometry and multilineage differentiation assays. Bulk RNA-seq analysis was conducted on three samples of OFs and control fibroblasts from human nail units to delineate their molecular features. Integrated analysis with scRNA-seq data was performed to identify key signaling pathways involved in OF-induced NSC differentiation. Co-culture experiments, siRNA transfection, RT-qPCR, and immunocytochemistry were employed to investigate the effect of OF-derived soluble proteins on NSC differentiation. Drug treatments, RT-qPCR, western blotting, and immunocytochemistry were used to verify the regulation of candidate signaling pathways on NSC differentiation . Human OFs exhibited slow cell cycle kinetics, expressed typical MSC markers, and demonstrated multilineage differentiation potential. Bulk RNA-seq analysis revealed differential gene expression in OFs compared to control fibroblasts, highlighting their role in coordinating nail development. Integrated analysis identified BMP4 as a pivotal signal for OFs to participate in NSC differentiation through mesenchymal-epithelial interactions, with the TGF-beta pathway possibly mediating this signal. OFs synthesized and secreted more BMP4 than control fibroblasts, and BMP4 derived from OFs induced NSC differentiation in a co-culture model. Recombinant human BMP4 activated the TGF-beta pathway in NSCs, leading to cell differentiation, while the BMP type I receptor inhibitor LDN193189 attenuated this effect. This study characterizes the cellular and molecular features of human OFs, demonstrating their ability to regulate NSC differentiation via the TGF-beta signaling pathway. These findings establish a connection between the dermal microenvironment and NSC differentiation, suggesting the potential of OFs, in conjunction with NSCs, for developing novel therapies targeting nail and digit defects, even severe limb amputation.
PubMed: 38887517
DOI: 10.3389/fcell.2024.1416780 -
Journal of Diabetes Science and... Jun 2024Diabetic foot ulceration is a serious challenge worldwide which imposes an immense risk of lower extremity amputation and in many cases may lead to the death. The...
BACKGROUND
Diabetic foot ulceration is a serious challenge worldwide which imposes an immense risk of lower extremity amputation and in many cases may lead to the death. The presented work focuses on the offloading requirements using an active approach and considers the use of magnetorheological fluid-based modules to redistribute high plantar pressures (PPs).
METHODS & RESULTS
Experimentation validated a single module with a threshold peak pressure of 450 kPa, whereas an offloading test with a three-module array and complete footwear validated a maximum pressure reduction of 42.5% and 34.6%, respectively.
CONCLUSION
To our knowledge, no such active and electrically controllable offloading footwear has been reported yet that has experimentally demonstrated PP reduction of more than 30% over the offloading site.
PubMed: 38887019
DOI: 10.1177/19322968241260037 -
Journal of Foot and Ankle Research Jun 2024Diabetic foot ulcers (DFUs) are commonly contaminated with pathogenic organisms and precede most diabetes-related amputations. Antimicrobial dressings are used in the...
INTRODUCTION
Diabetic foot ulcers (DFUs) are commonly contaminated with pathogenic organisms and precede most diabetes-related amputations. Antimicrobial dressings are used in the treatment of DFUs; however, recent guidelines do not support their use. There are no data describing the experience of antimicrobial dressing use among podiatrists in Aotearoa New Zealand (AoNZ). This study aimed to (i) determine which antimicrobial dressings podiatrists in AoNZ use for the management of diabetic foot ulcers; and (ii) determine what factors influence AoNZ podiatrists' use of antimicrobial dressing when managing DFUs.
METHODS
An anonymous cross-sectional web-based survey was undertaken. Participants were AoNZ registered podiatrists who managed DFUs in their practice. The survey included questions relating to personal and professional demographic characteristics and DFU management and dressing practices. Descriptive statistics were computed to address the research aims.
RESULTS
Responses from 43 AoNZ podiatrists were included. Participants reported both cadexomer iodine and silver dressings were the most common antimicrobial dressings used, with honey dressings being the least frequently used. The most influential factors in choosing antimicrobial dressings when managing DFUs were the presence of current infection, ulcer exudate and ability to prevent future infection. The least influential factors in choosing antimicrobial dressings when managing DFUs were patient preferences, cost of dressings and comfort of dressing/pain on removal.
CONCLUSIONS
AoNZ podiatrists managing DFUs primarily use antimicrobial dressings containing cadexomer iodine or silver as active ingredients, while lower-cost options, such as honey and povidone iodine are less often used. Current recommendations highlight the lack of evidence to support positive outcomes from any particular antimicrobial dressing over another and advocate that exudate control, comfort and cost be prioritised in decision-making. As cost has been an increasing burden to our healthcare funding, clinicians and organisations may consider this before purchasing and stocking expensive dressings.
Topics: Humans; Diabetic Foot; New Zealand; Cross-Sectional Studies; Bandages; Podiatry; Male; Female; Practice Patterns, Physicians'; Middle Aged; Anti-Infective Agents; Surveys and Questionnaires; Adult; Honey
PubMed: 38884388
DOI: 10.1002/jfa2.12032 -
EJVES Vascular Forum 2024Percutaneous deep venous arterialisation (DVA) is emerging as a promising alternative for limb salvage in chronic limb threatening ischaemia (CLTI) patients without any...
INTRODUCTION
Percutaneous deep venous arterialisation (DVA) is emerging as a promising alternative for limb salvage in chronic limb threatening ischaemia (CLTI) patients without any reasonable anatomical option for conventional revascularisation techniques. However, its mechanism of action remains incompletely understood. This report aimed to find some of the histological alterations occurring in the limb following DVA.
REPORT
This short report presents the case of a 53 year old female who underwent DVA for Rutherford 5 CLTI. Although the intervention was successful and showed evidence of improved blood flow to the foot, the post-operative course was notable due to worsening infection leading to a below knee amputation four weeks later. The blood vessels were harvested for histological analysis, which found features of venous arterialisation such as smooth muscle cell proliferation and neointimal hyperplasia, even in the paired posterior tibial vein that did not undergo DVA.
DISCUSSION
This case demonstrated unexpected histological changes occurring in the paired posterior tibial vein that did not undergo DVA. This warrants further investigations to fully understand the mechanisms at play in DVA and to explore the role of the paired vein in sustaining arterialised flow to the foot.
PubMed: 38884072
DOI: 10.1016/j.ejvsvf.2024.04.003 -
EJVES Vascular Forum 2024A hybrid approach is being employed increasingly in the management of peripheral arterial disease. This study aimed to assess the surgical site infection (SSI) incidence...
Observational Study on the Risk of Surgical Site Infection in Patients Undergoing Common Femoral Endarterectomy in Conjunction With an Endovascular Procedure Compared With Common Femoral Endarterectomy Alone.
OBJECTIVE
A hybrid approach is being employed increasingly in the management of peripheral arterial disease. This study aimed to assess the surgical site infection (SSI) incidence of hybrid revascularisation (HR) compared with common femoral endarterectomy (CFEA) alone.
METHODS
This was a retrospective review of consecutive patients who underwent CFEA or HR alongside CFEA between 2017 and 2021 including one year of follow up. The primary outcome was SSI incidence. Secondary outcomes included length of surgery, duration of admission, further revascularisation surgery, limb salvage, and death. Differences in outcomes were assessed with the Student's unpaired test, chi square test, and Fisher's exact test.
RESULTS
A total of 157 groin incisions from 155 patients were included: 78 had CFEA procedures and 79 had HR procedures. No statistical difference was found between groups for age, sex, and indication for surgery. Surgical site infection occurred in five of the CFEA patients (6%) compared with seven of the HR patients (9%) ( = 0.77). The HR procedures took significantly longer, with an average of 299 minutes compared with 220 minutes for CFEA ( < 0.001). No statistically significant difference was identified for length of admission: median stay five days for CFEA four days for HR ( = 0.44). Major amputation was performed within one year in five of the CFEA procedures (6%) and five of the HR procedures (6%) ( = 1.0). Further revascularisation surgery was attempted in two patients in the HR group and six patients in the CFEA group ( =. 17). No statistically significant difference was found in the one year mortality rate: eight CFEA (10%) and seven HR (9%) ( = 0.77).
CONCLUSION
Patients who underwent HR alongside CFEA did not have a statistically significantly increased incidence of SSI, despite increased surgical time. Using HR techniques enabled patients to have multilevel disease treated in one stage without an increased incidence of SSI.
PubMed: 38884070
DOI: 10.1016/j.ejvsvf.2024.05.003