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The long-term survival of 21 520 amputations with a 20-year observation period has been calculated. The material includes 5823 amputees with diabetes and 15 697 dysvascular cases without diabetes. The mean age of the amputees with diabetes is 70.6 years and that of the group without diabetes is 75 years. Kaplan-Meier plots of the absolute mortality in relation to age, gender and level of amputation reveals a significant poor prognosis. Among the diabetic individuals, 30% were dead within 6 months and among the non-diabetic individuals 38.4% were dead during this period. The results from this study with a 20-year follow-up period are compared with the corresponding figures for a 12-year period and no clinically important differences are found. [ABSTRACT FROM AUTHOR]

Osteochondral lesions of talus are a common injury where surgery is indicated in case of failed non-operative treatment or displaced lesions. Many studies have been conducted on the effectiveness of the AMIC procedure. The goal of our study is to create an overview of the current literature. A systematic search adhering to the PRISMA guidelines was conducted in PubMed (MEDLINE) and EMBASE on May 27, 2020. All included studies were evaluated according to the modified Coleman Methodology Score and information on study type, patient numbers, age, follow-up period, grade, location and size of the lesion, study in- and exclusion criteria, associated surgery, surgical technique, scaffold- and fixation technique, postoperative restrictions, reoperation rates, study outcome score, rehabilitation program, and surgical complications was extracted. Ninety-six studies were identified with 18 studies being included in our analysis. The overall quality of the literature was fair with no studies being graded as excellent. Data on preoperative evaluation and surgical technique, complication and reoperation rates, postoperative management and study outcome was extracted in order to create an overview of the current literature. The literature supports the use of the AMIC procedure as an effective treatment for osteochondral lesions of talus. Great heterogeneity exists and comparative studies are missing. While the number of studies on the topic is increasing further are needed and especially with optimized design., (Copyright © 2021 the American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Many neuromuscular diseases can lead to paresis and/or spasticity of the peripheral muscles. Due to an unbalance between agonists and antagonists deformities of the foot and ankle may develop. These deformities can often be handled by nonoperative measures but in some patients the effect is insufficient. In these cases, surgical treatment with tendon transfers, osteotomies or arthrodesis can lead to satisfying results. The purpose of this review is to create an overview of the treatment concepts and options for these diseases.

To evaluate readmission, complication, and nonscheduled contact rates to the out-patient clinic within the first 3 months following total ankle replacement in patients planned for overnight admission. Data were collected retrospectively on all patients treated during the period the December 11, 2015 to the December 1, 2019 with 3 months of follow-up for all patients. In the study 116 patients were included. No difference in patient characteristics, readmission rates, complication rates or number of nonscheduled contacts to the outpatient clinic was found between patients discharged after 1 day when compared to those admitted >1 day. Around 58.6% was discharged as planned. The overall readmission and complication rates were 2.6% and 6.0% respectively, 20.7% had a nonscheduled contact to the out-patient clinic. No differences in prevalence of the different complications, reasons for readmission or reasons for contact to the out-patient clinic were found between overnight admission and inpatient admission. Total ankle placement with overnight admission is safe, but patient selection with a thorough plan for analgesics after discharge and optimal cast appliance is necessary., (Copyright © 2020 the American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Symptomatic ankle arthrosis affects 1-4% of the population, and the most common aetiology is post-traumatic. Symptoms include pain, swelling and reduced range of motion. Diagnosis is based on weight-bearing X-rays of the ankle joint, and treatment depends on the arthrosis grade and patient characteristics. Non-operative therapy, i.e. physiotherapy, analgesics, injection therapy and/or braces/orthoses is first-line treatment, as we argue in this review. Arthroscopy can be an effective treatment for some patients, but in case of severe arthrosis, osteotomies, total ankle replacement or arthrodesis may be necessary.

Nonoperative measures are often used as first line treatment in ankle osteoarthritis. One of these measures consists of hyaluronic acid injections in the affected ankle joint, but efficiency of this treatment is uncertain. The purpose of the study was to evaluate the effect on Self-reported Foot and Ankle Score, visual analog scale score at rest, and visual analog scale score at activity 6 months after a single dose of hyaluronic acid in patients with ankle osteoarthritis. Patients were included from December 2017 to March 2019. A single intra-articular injection of Cingal or MonoVisc was administered. Age, gender, osteoarthritis-grade, Self-reported Foot and Ankle Score, visual analog score at activity, and at rest before injection and after 6 months was registered. A total of 33 patients were included, with 14 lost to follow-up. Four were treated with MonoVisc and were excluded to reduce confounding. The remaining 15 patients were included for analysis. Median Self-reported Foot and Ankle Score remained unchanged (p = .06), whereas visual analog score at activity went from 7 to 6 (.02) and visual analog score at rest was reduced from 4 to 3 (.02). Subgroup analysis on arthrosis grade (grade I-II and III-IV) showed no statistically significant changes for all variables even though patients with grade III-IV arthrosis seemed to benefit more from the treatment. The results indicate that a single injection of hyaluronic acid is insufficient to produce at clinically relevant response after 6 months even though there is a high risk of underpowering because of a small patient population., (Copyright © 2020 the American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Background and purpose - Total ankle arthroplasties (TAAs) have larger revision rates than hip and knee implants. We examined the survival rates of our primary TAAs, and what different factors, including the cause of arthritis, affect the success and/or revision rate.Patients and methods - From 2004 to 2016, 322 primary Hintegra TAAs were implanted: the 2nd generation implant from 2004 until mid-2007 and the 3rd generation from late 2007 to 2016. A Cox proportional hazards model evaluated sex, age, primary diagnosis, and implant generation, pre- and postoperative angles and implant position as risk factors for revision.Results - 60 implants (19%) were revised, the majority (n = 34) due to loosening. The 5-year survival rate (95% CI) was 75% (69-82) and the 10-year survival rate was 68% (60-77). There was a reduced risk of revision, per degree of increased postoperative medial distal tibial angle at 0.84 (0.72-0.98) and preoperative talus angle at 0.95 (0.90-1.00), indicating that varus ankles may have a larger revision rate. Generation of implant, sex, primary diagnosis, and most pre- and postoperative radiological angles did not statistically affect revision risk.Interpretation - Our revision rates are slightly above registry rates and well above those of the developer. Most were revised due to loosening; no difference was demonstrated with the 2 generations of implant used. Learning curve and a low threshold for revision could explain the high revision rate.

Background: HemiCAP for complex osteochondral defects (OCDs) in talus has been on the market since 2008. Few follow-up studies exist. Patients with complex OCDs were followed for up to 81 months., Methods: 31 consecutive patients were assessed preoperatively and at final follow-up, mean 50 months. All patients were treated with the HemiCAP®, Arthrosurface Inc., USA inlay. Inclusion criteria were complex OCDs of the medial or lateral talus dome., Results: All outcome measures i.e. AOFAS, FAOS and NRS improved significantly. 71.8 % of the cohort were employed preoperatively. At final follow up 87.5% were employed. No revisions of the HemiCAP was performed, but 41,9% had supplementary surgery. 1 patient had a superficial infection otherwise no complications were found. Preoperative and final follow-up x-rays were analysed., Conclusions: Mid-term results after HemiCAP talus are good. Patient information and selection is mandatory due to the high numbers of additional surgeries following the HemiCap implantation., (Copyright © 2019 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.)

Background: The Patient Compensation Association (PCA) receives claims for financial compensation from patients who believe they have sustained damage from their treatment in the Danish health care system. In this study, we have analysed closed claims in which patients suffered injuries due to the surgical treatment of their ankle fracture. We identified causalities contributing to these injuries and malpractices, as well as the economic consequences of these damages., Methods: Fifty-one approved closed claims from the PCA database from the years 2004-2009 were analysed in a retrospective systematic review. All patients were adults with an iatrogenic injury, and received compensation. A root cause analysis was performed to identify whether the patient suffered the damage preoperatively, during surgery or postoperatively, and to determine the level of education of the injurious doctor. Economic compensation, co-morbidities and end-result complications were registered., Results: In 9 of the cases the injuries happened preoperatively, but the majority of the injuries, namely 34 occurred during surgery. In 21 of the cases the damage happened postoperatively. Thirty percentages of the patients were mistreated in more than one phase. Level of competence was medical specialists in 2/3 and junior doctors in 1/3 of the cases. In the preoperative phase both groups were equally responsible for the inflicted damage. In the perioperative- and postoperative group, medical specialists inflicted the majority of damages. General recommendations regarding ORIF were not followed in 21/49 of the perioperative damages. The pronation fracture was the most common. The patients received a total average compensation of 17.561 USD each., Conclusion: Managing the complex ankle fracture, requires considerable experience. This study indicates that extra attention should be paid to the most technically demanding fractures as the pronation-external-rotation-, diabetic- and fragility fractures. Surgeons should follow the recommendations for ORIF. Emphasis should also focus on adequate postoperative plans. This study finds a high readmission-burden, re-operation rate and great expenses in form of compensation., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

The purpose of the present study was to investigate the long-term effect of deep infection, sural nerve injury, and repeat rupture in the treatment of acute Achilles tendon rupture. A total of 324 patients had made a claim to the Danish Patient Insurance Association from 1992 to 2010 for a complication after acute Achilles tendon rupture. Of the 324 patients, 119 (36.7%) (77 [64.7%] males and 42 [35.3%] females) returned the Achilles tendon total rupture score and the 36-item short-form survey questionnaires. Patients with deep infection (n = 10), sural nerve injury (n = 10), and repeat rupture (n = 16) participated in a follow-up investigation. The mean follow-up period was 8.9 (range 3 to 21) years. The mean Achilles tendon total rupture score was 49 ± 27. The summary scores of the physical component and mental components scales of the 36-item Short Form Survey were 43 ± 11 and 52 ± 11, respectively. No significant differences were found among the subpopulations with deep infection, injury to the sural nerve, or repeat rupture. The physical evaluation investigating tendon length and heel rise work revealed a statistically significant difference between the affected and unaffected limb after repeat rupture (p < .01) but not after injury to the sural nerve (p > .05) or deep infection (p > .05). In conclusion, patients with from a complication after acute Achilles tendon rupture had a remarkable reduction of the Achilles tendon total rupture score and physical component scale score at mean follow-up point of 9 years. Patients with repeat rupture had a significant elongation of the tendon and reduction of strength in the affected limb., (Copyright © 2017 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Treatment of acute Achilles tendon rupture in Denmark has changed from being predominantly operative to being non-operative treatment over the past five years. However, no clear evidence is found in the literature in favour of one treatment modality over another. Non-operative treatment leads to an increased risk of re-rupture and operative treatment to an increased risk of other complications such as adhesions, infection and nerve injury. When a non-operative treatment protocol is chosen it is paramount that sufficient expertise is present to guide the treatment and rehabilitation.

Introduction: Only a few randomised studies have been published on the treatment of tibial shaft fractures. We therefore expected a great diversity in the choice of treatment methods in Denmark. In order to analyse this, we carried out a questionnaire investigation., Material and Methods: In autumn 1997, a questionnaire was sent to all departments in Denmark where tibial fractures are treated. The fractures were classified according to stability, amount of energy, and the degree of soft tissue injury., Results: Ninety-three per cent of the departments answered the questionnaire. We present here the results with respect to the use of antibiotics, thrombosis prophylaxis, invasive pressure measuring, and the choice of treatment: conservative or operative methods and techniques., Discussion: As expected, we found a significant variation in the choice of treatment of tibial shaft fractures in Denmark. This is consistent with the recommendations in the literature, which vary somewhat and are mostly based on non-randomised studies.

Seventy-six consecutive patients were operated on for advanced Dupuytren's contracture and the results evaluated after nine months with special reference to the use of a dynamic extension splint. The patients were separated into three groups: those in whom the splint was used according to our guidelines (n = 15); those in whom the splint was used, but inadequately (n = 15); and those who did not require splinting (n = 24). Our results nine months postoperatively were similar to those of other studies in showing that the fifth proximal interphalangeal joint constituted the greatest problem. Comparison of the three groups indicated that splinting the way we used it did not influence the natural course of the disease after operation.

Objectives: To determine if the level of amputation after failed vascular reconstruction was comparable to the level of amputation after primary amputation., Design and Methods: Medline literature search (1975-1996), meta-analysis., Results: The odds ratio of transtibial to transfemoral (TT/TF) amputations was 927/657 = 1.41 (95% confidence limits: 1.278-1.561) in postrevascularisation amputation (PRVA) and 1590/1162 = 1.37 (95% confidence limits: 1.269-1.477) in primary amputation (PA) (p = 0.65). The pooled data show that the number of conversions from transtibial (TT) to transfemoral (TF) amputations due to amputation stump complications were 85/369 (23%) in PRVA against 93/752 (12.4%) in PA (p < 0.01)., Conclusions: We could not detect any difference in TT/TF ratio between PRVA and PA. However, the risk of conversion i.e. reamputation to a higher level is higher after PRVA compared to PA. The chance of having a successful transtibial amputation is approximately 58% for postrevascularisation amputation as well as for primary amputations. An aggressive approach towards vascular reconstruction seems justified.

Objective and Design: Pituitary adenylate cyclase activating polypeptide (PACAP) is a neuropeptide homologous with vasoactive intestinal polypeptide (VIP) which is known to induce histamine release in human skin mast cells. PACAP has not been detected in human skin. The purposes of the study were to investigate the occurrence of PACAP in human skin and to evaluate the histamine releasing activity of the two common pro-PACAP products, PACAP-27 and PACAP-38., Material: Fourteen human surgical skin samples were obtained. PACAP and VIP were visualized by immunohistochemistry. A microdialysis technique was used to measure histamine release in intact skin samples following intradermal injections of the peptides., Results: PACAP and VIP were localized in dermal nerves in connection with sweat glands. Intradermal injection of 3 or 10 microm PACAP significantly released histamine. Kinetics of histamine release showed peak release 2-4 min after skin challenge. Ten microm of PACAP-27, VIP and somatostatin caused histamine release with similar efficacy, whereas PACAP-38 was less effective. Substance P was twice as efficient as PACAP-27, whereas calcitonin gene-related peptide did not release histamine., Conclusions: PACAP is found in human skin and is capable of releasing histamine from skin mast cells.

The aim of our study was to determine the incidence of operative treatment for carpal tunnel syndrome in Denmark and to see whether there was a consensus about the place of preoperative electromyography and nerve conduction studies. A questionnaire was mailed to all surgical departments (n = 70) and all registered private surgical practices (n = 214) in Denmark. The incidence of operation was about 0.61 per 1,000 population. Most surgeons used preoperative electromyograms and nerve conduction studies in less than 50% of cases. The use of preoperative testing was related to the surgical speciality.

Seventy-six consecutive patients suffering from advanced Dupuytren's contracture were analysed in order to evaluate the safety of day care surgery. The complication rates for haematoma, necrosis, infection and reflex sympathetic dystrophy were acceptable, but we found an unacceptably high percentage of nerve lesions. Day care treatment was achieved in all but seven cases. We concluded that advanced Dupuytren's contracture can be treated by day care surgery but the operations should be performed by surgeons who are skilled in hand surgery, and individual selection of patients with recurrence seems advisable.

A nationwide epidemiological study included 3516 primary major lower limb amputations in diabetic patients, during the period 1982 to 1992. On this well defined diabetic amputee population the relative mortality (Standard Mortality Ratio, SMR) has been analysed. The mortality rate was found to be 8 times the expected during the first year following amputation. The relative mortality is higher for females than males. An inverse relation between age and SMR was found, and the SMR was significantly related to the level of amputation. No significant difference could be detected when analysing SMR in relation to subdiagnosis (NIDDM vs IDDM) or SMR in relation to the period of treatment 1982-87 versus 1988-92.

The Danish Patient Insurance Society (Patientforsikringsforeningen) was established by law in July 1992. The aim was to provide a just system of compensation for complications following medical treatment, that are not caused by culpous actions or omissions. The first 34 case records concerning position-related nerve injury were reviewed. The material has national coverage. The exact incidence of position related nerve injury in Denmark is unknown, but transitory neurological symptoms after otherwise uncomplicated surgical procedures are probably not infrequent complications. The material includes 17 males and 17 females. Position-related injury most often affects the peroneal nerve, followed by the ulnar nerve and lesions to the brachial plexus. The etiology is often difficult to establish precisely, and may often be multifactorial. In our material the main reason is believed to be direct pressure to the nerve in 76% of cases. Predisposition (e.g. subclinical neuropathy or diabetes) often complicates the case, but neurophysiological examination and the relation in time between an operation and the onset of neurological symptoms often clarifies the etiology.

We report the long-term social and functional results in 53 patients receiving free tissue transfer after trauma to the lower extremity. The results are compared with those of a matched group of patients receiving primary amputation. The microsurgically treated patients had significantly more complaints over pain during walk (p = 0.02) and edema (p < 0.00005). Regarding social results, no significant differences between the two groups were found. Time until surgery, infection, or bone defect before free flap surgery did not alter the overall results significantly. It is concluded that the long-term functional and social results after free tissue transfer are almost the same as those achieved after simple amputation. Because the median time until free flap surgery in this series was 158 days, early limb-saving procedures could possibly improve the long-term results.

The number of amputations performed for vascular disease in Denmark has decreased from 1777 (34.5 per 100,000 population) in 1983 to 1288 (25.0 per 100,000) in 1990, a reduction of 28 per cent. This decline coincided with an increase in vascular surgical activity of up to 100 per cent, including a marked rise in the rate of femorodistal reconstruction. Moreover, regional variation in vascular surgical activity correlated with percentage reduction in amputation rate (rS = 0.65, P < 0.01). The relative number of above-knee amputations also decreased in favour of more distal levels during the period studied. These findings suggest that vascular surgery may be responsible for the lower amputation rate.

The decision whether a severely traumatized limb should undergo primary amputation or be exposed to limb salvage procedures is often extremely difficult. A large number of clinical parameters should be evaluated and some specific damages should lead to primary amputation. Four limb salvage indexes are evaluated.

The annual number of major lower limb amputations in Denmark as a consequence of trauma was constant during the period 1978 through 1990, with about 70 (1.4 per 100,000 population) per year. The mean age of the amputation population was 49.4 years (males, 44.8 years; females, 58.8 years). Analysis of the age distribution shows characteristic differences between male and female patients. The average hospital stay was 49 days, and 56% of patients were discharged to their homes. The most prevalent amputation levels were transtibial and above-knee, which accounted for about 80% of all amputations. The only systematic change during the period under study was the increase in the number of through-knee amputations. The in-hospital mortality was related to sex, level of amputation, and age. The relative number of amputations varied in the different counties of Denmark and a positive correlation between population density and rate of amputation was found.

A retrospective review of amputations in patients with vascular disease during 10 years in Bispebjerg Hospital was undertaken. There were 1383 amputations leading to 1167 final level amputations. In previously independent patients there were 482 below knee amputations (BKA), 476 above knee amputations (AKA) and 43 had disarticulations in the ankle, knee or hip. During the period studied the number of final level amputations in independent patients were halved from 122 in 1981 to 58 in 1990. A similar reduction was also found in the total number of amputations: from 171 to 90, and in the number of reamputations: from 35 to 21. However, amputations in patients from long stay institutions remained at a constant level by on average 17 per year. The decrease in amputation rate took place synchronously with an increasing use of bypass to crural and pedal arteries as well as an overall increase in vascular reconstructions and angioplasties of more than 100%. However, the BKA/AKA ratio decreased from 1.12 to 0.67 (p < 0.005).

The annual number of amputations in Denmark as a consequence of malignant melanoma on the limbs has been constant during the period 1978-1987. In contrast, the number of malignant melanoma localized to the extremities increases. For lower limb amputation the mean age is 58 y for males and for females, 72 y. The sex ratio, male to female is 1:2.2. Of the 13 male amputees 7 (54%) had died after 18 mo, of the 28 female amputees 20 (74%) had died after 19 mo. An analysis (Kaplan-Meier) shows a 5-y survival rate of about 28%. The mortality is found to be related to sex and level of amputation. Six cases of upper extremity amputation are presented. A review of the literature in order to compare the demographic factors and to outline the indications for amputation reveals a number of differences, most significantly the higher mean age at time of amputation (about 65 y) in Denmark than the figures earlier published (about 45 y). The consensus seems to be that amputation is rarely indicated except as a form of palliation.

The Danish Amputation Register and the nationwide National Patient Register are presented. Based upon the code numbers in the WHO classification system (ICD), 4 etiology groups i.e. vascular insufficiency, diabetes mellitus, malignant neoplasma and trauma were extracted. The purpose was to analyse the relationship between level of amputation (i.e. foot, below-knee, through-knee, above-knee and hip) and etiology (cause of amputation). The material represents all such amputations in Denmark during the period 1978 to 1989 (n = 25.767). The number of amputations because of vascular insufficiency with and without diabetes mellitus decreased over the period studied. The number of tumour and trauma amputations seemed unchanged. There was a significant reduction in the number of amputations at proximal levels (above-knee) for vascular insufficiency with and without diabetes mellitus and in the trauma group. No such change was found regarding tumour amputations. There was a characteristic pattern in the distribution of level respectively of etiological factors for each etiology group and for each level of amputation.

A study has been made of 18,225 admissions to Danish hospitals for lower limb amputation in cases of diabetic or non-diabetic vascular insufficiency. Clear correlations were found between the type of department and the level of amputation, mortality and duration of hospitalisation, orthopaedic departments being characterized by lower levels of amputation, lower mortality, and shorter hospitalisation than general surgery or mixed departments.

From 1980 to 1989, 4852 diabetic patients in Denmark underwent 5642 lower limb amputations. Records of the Danish Amputation Register and the National Patient Register indicate a decrease of amputations in diabetics from 681 to 463 per year in this time. There has also been a decrease in above knee amputations in diabetics from 30 to 20 percent of all amputations with a corresponding increase of amputations at or below the knee. Demographic factors and possible reasons for these changes are reviewed. There seems to be a relationship between the improvement of diabetic foot care by the free service of trained podiatrists and the reduction of amputations in diabetics in Denmark.