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AbstractPurposeMaterials and methodsResultsConclusion\nIMPLICATIONS FOR REHABILITATIONTo explore behavioral risk factors contributing to fall and near-fall scenarios for Veterans with dysvascular lower-limb amputation.Participants were a convenience sample of Veterans with unilateral dysvascular lower-limb amputation, receiving care at a single Veterans Administration Regional Amputation Center, who participated in an interview (12/2021–04/2023). We used phenomenological research and directed content analysis to explore participant perspectives on fall scenarios. Two frameworks informed a priori codes (The Health Action Process Approach, and the Falls-Type Classification Framework); however, analysis was also inductive, with additional codes emerging. Following an independent and iterative coding process, codes were categorized, and patterns identified to create final themes.Twenty-one veterans completed interviews. Five themes were identified that were salient across a behavioral fall risk factor spectrum from low to high: self-efficacy, trust in the prosthesis, dual-task awareness, participation, and emotional regulation, and one theme pertaining to context surrounding the index fall.Different levels of behavioral fall risk factors exist for Veterans with dysvascular lower-limb amputation. Understanding individuals’ perceptions of these behavioral risk factors is important as a first step in developing comprehensive fall-risk management rehabilitation interventions for Veterans with amputation.Behavioral fall risk factors are important to consider for individuals with lower limb amputation who experience high fall risk.With lower limb amputation behaviors on the high and low end can both contribute to fall risk (e.g., high self-efficacy vs. low self-efficacy, or high trust in the prosthesis vs. low trust in the prosthesis) and both should be addressed.Rehabilitation targets for fall risk management in individuals with lower limb amputation should consider different types of self-efficacy, trust in the prosthesis, dual-task awareness, participation, and emotional regulation.Further, the variability in levels of risk associated with each of these factors can operate independently, underscoring the need to tailor interventions for individuals with lower limb amputation.Behavioral fall risk factors are important to consider for individuals with lower limb amputation who experience high fall risk.With lower limb amputation behaviors on the high and low end can both contribute to fall risk (e.g., high self-efficacy vs. low self-efficacy, or high trust in the prosthesis vs. low trust in the prosthesis) and both should be addressed.Rehabilitation targets for fall risk management in individuals with lower limb amputation should consider different types of self-efficacy, trust in the prosthesis, dual-task awareness, participation, and emotional regulation.Further, the variability in levels of risk associated with each of these factors can operate independently, underscoring the need to tailor interventions for individuals with lower limb amputation. [ABSTRACT FROM AUTHOR]

Background: Lower limb amputation is the complete loss of any part of the lower extremity for any reason. It is one of the oldest and most common surgical procedures, with the earliest known case dating to 31,000 years ago. Despite its prevalence, lower limb amputation remains a significant public health concern globally, with substantial implications for individuals' quality of life. Methods: To investigate the prevalence, risk factors, outcomes, and management of lower limb amputation, we conducted a retrospective cross-sectional study at Hoima Regional Referral Hospital. We collected data from operating room registries, patient medical files, and the physiotherapy department registry. Our study included 60 participants, with a prevalence of 6.7% for lower limb amputation. Results: We found significant associations between lower limb amputation and age, sex, diabetes mellitus, BMI, and gangrene. We also observed that 25% of cases required reamputation, and the in-hospital mortality rate was 25%. Half of the cases reported using physiotherapy, while 25% of participants experienced psychological distress. These findings highlight the complex interplay of factors contributing to lower limb amputation and the importance of preventive measures and comprehensive management strategies. We recommend early detection, proactive management of associated risk factors, and holistic rehabilitation to improve patient outcomes and quality of life. Conclusion: Our study provides valuable insights into the epidemiology and management of lower limb amputation, informing targeted interventions and healthcare policies aimed at reducing its prevalence and mitigating its impact on affected individuals. [ABSTRACT FROM AUTHOR]

BackgroundObjectiveMethodsResultsConclusionThe Upper Quarter Y Balance Test (YBT-UQ) assesses upper limb dynamic balance in able-bodied individuals but lacks a reliable version for those with disabilities.This study aimed to introduce a modified YBT-UQ (mYBT-UQ) for physically impaired individuals (PI) and establish its validity and reliability.The study involved 33 male athletes aged 18–55, divided into three equal groups: able-bodied, spinal cord injury with trunk control (SCI), and below-the-knee amputation (BKA). To ensure test validity, able-bodied athletes completed both tests. Test-retest reliability was evaluated by repeating the mYBT-UQ seven days after the first test by PI groups. The validity was assessed using the Pearson correlation and Bland-Altman plot. The intraclass correlation coefficient (ICC) (2,1), standard error of measurement (SEM), and the minimal detectable change with 95% confidence (MDC95%) were calculated to assess relative and absolute reliability.There were significant differences and excellent relationships between YBT-UQ and the mYBT-UQ. Also, the Bland-Altman plot showed minimal bias and an acceptable range of agreement. In athletes with BKA, the ICC (2,1) was above 0.90 for both limbs. The SEM ranged from 2.4%-2.7%, and MDC95% ranged from 6.7%-7.5%. In athletes with SCI, the ICC (2,1) ranged from 0.72–0.80. The SEM ranged from 3.1%-3.2% and MDC95% ranged from 8.6%-8.9%.The results indicate that the mYBT-UQ is a reliable test to assess upper quarter dynamic balance in athletes with SCI and BKA. However, regarding the small sample size of the study, there is a need to conduct other research to establish the validity of the test. [ABSTRACT FROM AUTHOR]

Background: Limited data are available about the epidemiological characteristics and the risk factors for amputation, particularly in developing countries from Asia, especially in China. Objective: We aim to investigate the age features of patients with Type 2 diabetic foot ulcers (DFUs) and analyze the critical influencing factors predicting lower extremity amputation and major amputation. Methods: Data were retrieved from the electric medical record system to identify patients aged > 18 years with Type 2 DFU from January 1, 2017, to December 31, 2023. A logistic regression model was adopted to analyze the risk factors for amputation and major amputation. Results: Nine hundred eighteen patients with Type 2 DFU were eligible for our study, 68.2% of whom were male. In patients with Type 2 diabetes in the hospitals we studied, the prevalence of Type 2 DFU was 1.07%. A majority of patients with DFU were in the 70–79 age group in the winter season, and deaths also peaked in this age group. A total of 38.8% of patients aged 50–59 years underwent amputation. Vascular CTA, complications, history of amputation, and infection sites were the important contributing factors in patients with DFU lower extremity amputation. History of amputation and hemoglobin were the main influencing factors of patients with major amputation resulting from DFU. Conclusion: Most patients with DFU were in the age group of 50–59 years, but the majority of deaths occurred in the 70–79‐year age group. Several factors influence the amputation, and those findings provide new insights into the relationship between the severity of narrowed blood vessels and the likelihood of amputation. [ABSTRACT FROM AUTHOR]

Major limb amputation in a child is a rare but devastating injury associated with significant psychosocial and financial burden. This, combined with the higher growth and remodelling potential despite segmental limb loss, decreases the threshold for replantation in children. Advances in microsurgical techniques and a better understanding of such injuries have led to lower limb replantation becoming a feasible option, with good long-term functional outcomes, even in bilateral amputations. However, long-term sequelae such as limb length discrepancy (LLD) are common, and patients are often subject to multiple surgical interventions. We present a case of replantation in a 2-year-old child following traumatic right below knee amputation, followed up over a period of 5 years. After multiple surgeries, the patient gained good functional recovery and sensibility of the replanted limb. We reviewed and discussed the management of subsequent long-term sequelae, including LLD, lower limb contractures and valgus deformity. Level of Evidence: Level V (Therapeutic) [ABSTRACT FROM AUTHOR]

Objective To explore the relationship between sociodemographic, clinical, and neurophysiological variables and health-related quality of life (HR-QOL) of patients with phantom limb pain (PLP). Methods This is a cross-sectional analysis of a previous clinical trial. Univariate and multivariate linear and logistic regression analyses were used to model the predictors of HR-QOL. We utilized a sequential modeling approach with increasing adjustment levels, controlling for age and sex, and other relevant clinical variables (time since amputation, level of amputation, and pain). HR-QOL was assessed by the SF-36 Health Survey and its 8 subdomains. Results We analyzed baseline data from 92 patients with lower-limb amputations. They were mostly male (63%), 45.2 ± 15.6 years, with a mean time since amputation of 82.7 ± 122.4 months, and an overall SF-36 score of 55.9 ± 21.5. We found an association between intracortical facilitation (ICF) in the affected hemisphere, gabapentin usage, and HR-QOL. ICF is a predictor of better HRQOL, whereas gabapentin usage was associated with a poorer HR-QOL, with the main model explaining 13.4% of the variance in the outcome. For the SF-36 subdomains, ICF was also a positive predictor for social functioning, bodily pain, and vitality, while medication usage was associated with lower scores in mental health, general health perception, bodily pain, and vitality. Conclusion We found firsthand 2 new independent predictors of HR-QOL in individuals with PLP, namely, the neurophysiological metric ICF and gabapentin usage. These results highlight the role of the motor cortex excitability in the HR-QOL and stress the need for treatments that favor the neuroplastic adaptation after amputation, for which ICF may be used as a possible marker. [ABSTRACT FROM AUTHOR]

Purpose: The aim of this review is to synthesise the experiences and needs of people who had undergone dysvascular lower extremity amputations. Given the increasing global prevalence of vascular diseases like diabetes mellitus and peripheral arterial disease, the risk of requiring an amputation remains high. Materials and methods: This systematic review follows the PRISMA and ENTREQ reporting guidelines. Seven databases were searched for qualitative studies from January 2011 to October 2023. In total 6435 studies were obtained, where 1146 were duplicates and 5271 studies failed to meet the eligibility criteria. The remaining 18 studies were synthesised using Sandelowski and Barroso's approach and appraised using the CASP checklist. Results: Four themes emerged from the meta-synthesis: (1) making the decision to amputate, (2) difficulties in the physical adaptation to limb loss, (3) psychosocial consequences of living with an amputation, and (4) regaining control and building hope. Conclusions: Having dysvascular lower extremity amputations is a complicated experience as not only was the pre-amputation pain relieved, but a new set of physical, emotional and social challenges would surface after the amputation. These synthesised findings serve as a platform to explore the factors behind the various experiences faced by these people and how healthcare professionals can help them in their adjustment. IMPLICATIONS FOR REHABILITATION: Dysvascular lower extremity amputations can affect the physical and mental well-being of people who have experienced them. Healthcare professionals (HCPs) are encouraged to individualise care that meets the physical and emotional needs of patients. Sufficient time and information should be provided before the operation for these people to be better prepared for the changes following the amputation. Physical support by HCPs should include physical rehabilitation, checking on the wound healing and managing any existing co-morbidities. Emotional support can be given through additional referral to medical social workers or psychologists and the involvement of support groups. [ABSTRACT FROM AUTHOR]

Abstract Introduction Lower limb amputation significantly impacts individuals’ quality of life, with prostheses playing a crucial role in rehabilitation and mobility restoration. In Nepal, where access to advanced medical care is limited, understanding the factors affecting the well-being of prosthesis users is essential for optimizing rehabilitation services. This study investigates the sociodemographic and health-related variables influencing the quality of life among lower-limb amputees using prostheses in Nepal. Methods A cross-sectional study was conducted at a super-specialized disability care center within a tertiary care hospital. The study included 43 amputees who had received prostheses at least five years prior and were regular users. The sample was drawn from patients at the same hospital. The study collected data on sociodemographic characteristics, health components, and pain experiences. Health-related quality of life (HrQoL) was assessed using the SF-12 tool, with scores above 50 indicating high HrQoL on the Mental Component Summary (MCS) and Physical Component Summary (PCS). Scores below 50 indicated low HrQoL. Factors associated with these variables were analyzed using Chi-square (χ²) at a 95% confidence interval. Results Our study assessed the health-related quality of life among lower limb amputees, finding that 76.74% of participants scored high in mental health and 81.40% in physical health. Significant associations were identified between age and marital status with the Mental Component Summary (MCS) and Physical Component Summary (PCS). Additionally, the reason for amputation and the experience of the Phantom pain were linked to the MCS. Factors like treatment for stump pain, perceived effectiveness of stump pain treatment, and residual stump pain were associated with both the PCS and MCS, while actions taken for stump pain and extremity dominance were associated significantly with the PCS. The level of amputation and treatment for phantom pain also showed significant association. All associations were significant (p > 0.05) at a 95% confidence interval. Conclusion These findings indicate that age, marital status, extremity dominance, reason for amputation, stump pain treatment, and pain management are critical factors influencing the quality of life among lower limb amputees. The study underscores the need for comprehensive rehabilitation programs incorporating effective pain management, spouse support, and tailored interventions based on individual demographic and clinical characteristics.

Introduction: Lower limb amputation significantly impacts individuals' quality of life, with prostheses playing a crucial role in rehabilitation and mobility restoration. In Nepal, where access to advanced medical care is limited, understanding the factors affecting the well-being of prosthesis users is essential for optimizing rehabilitation services. This study investigates the sociodemographic and health-related variables influencing the quality of life among lower-limb amputees using prostheses in Nepal. Methods: A cross-sectional study was conducted at a super-specialized disability care center within a tertiary care hospital. The study included 43 amputees who had received prostheses at least five years prior and were regular users. The sample was drawn from patients at the same hospital. The study collected data on sociodemographic characteristics, health components, and pain experiences. Health-related quality of life (HrQoL) was assessed using the SF-12 tool, with scores above 50 indicating high HrQoL on the Mental Component Summary (MCS) and Physical Component Summary (PCS). Scores below 50 indicated low HrQoL. Factors associated with these variables were analyzed using Chi-square (χ²) at a 95% confidence interval. Results: Our study assessed the health-related quality of life among lower limb amputees, finding that 76.74% of participants scored high in mental health and 81.40% in physical health. Significant associations were identified between age and marital status with the Mental Component Summary (MCS) and Physical Component Summary (PCS). Additionally, the reason for amputation and the experience of the Phantom pain were linked to the MCS. Factors like treatment for stump pain, perceived effectiveness of stump pain treatment, and residual stump pain were associated with both the PCS and MCS, while actions taken for stump pain and extremity dominance were associated significantly with the PCS. The level of amputation and treatment for phantom pain also showed significant association. All associations were significant (p > 0.05) at a 95% confidence interval. Conclusion: These findings indicate that age, marital status, extremity dominance, reason for amputation, stump pain treatment, and pain management are critical factors influencing the quality of life among lower limb amputees. The study underscores the need for comprehensive rehabilitation programs incorporating effective pain management, spouse support, and tailored interventions based on individual demographic and clinical characteristics. [ABSTRACT FROM AUTHOR]

Introduction: Having a lower extremity amputation is a life‐changing decision for people living with a diabetes‐related foot ulcer. Although previous research has described both positive and negative lifestyle and function outcomes of diabetes‐related amputations, limited research has been conducted on the decision‐making processes leading up to the amputation. This study aimed to explore the perspectives of persons, healthcare practitioners and experts (including academics and specialists) on decision‐making for people with a diabetes‐related foot ulcer who may require a non‐emergency amputation. Methods: A qualitative descriptive study using semi‐structured interviews enabled people to share their thought processes when making decisions for amputation. Twenty‐six participants were interviewed, including nine people with a diabetes‐related foot ulcer or amputation, nine health practitioners and eight experts located across five countries. There were 13 female and 13 male participants. Thematic analysis was used for data analysis. Results: Four themes described the decision‐making considerations for amputation: 'Balancing the evidence in decision‐making', 'Trust, respect and timing of conversations inform decision‐making', 'Tailoring decisions for individual circumstance' and 'Reaching the tipping point in decisions for the future'. Work commitments, functional and lifestyle impacts of amputation, the presence of support networks and clinical wound features formed the evidence for a decision for amputation. Conclusion: Understanding quality of life needs ensured that decisions for amputation addressed expectations and lifestyle needs. Living with a diabetes‐related foot ulcer presented daily challenges that pushed people to a tipping point, at which amputation was considered to overcome these hardships and enable them to move on to the next chapter of their life. Further research is required to understand how person‐centred factors can be better incorporated alongside objective clinical assessments in decisions for amputation. Patient or Public Contribution: People with diabetes‐related foot ulcers, health practitioners and experts shared their perspectives on the decision‐making process for amputation through one‐to‐one interviews. Consideration of the person in the context of their life, environment and personal needs alongside the pathological factors is warranted. Practitioner Points: The decision for amputation incorporates a balance between health concerns, health practitioner assessments and the quality of life expectations and lifestyle needs of the person with DFU.Open discussions about living situation and future goals can determine readiness for amputation and initiate consideration of amputation as a possible option.'Leaving the door open' for people with DFU to have ongoing conversations about amputation supports people to feel in control of their decisions. [ABSTRACT FROM AUTHOR]

Background: Phantom limb pain (PLP) is highly prevalent after amputation. However, the influence of non-painful sensations (PLS) remains unclear. This study examines the PLP-PLS index as a novel tool to differentiate PLP from PLS and explores the association of clinical factors with the index. Methods: We conducted a cross-sectional analysis of baseline data from 112 participants in a previous factorial trial in patients with unilateral traumatic lower limb amputation. Linear regression models were used to examine the associations between the index and various demographic, psychological and clinical factors. Logistic and Poisson regression, and e-value calculation were utilized for sensitivity analyses. Results: Adjusted multivariable linear regression models demonstrated significant associations of phantom movement sensation (β: −1.532; 95% CI: −2.615 to −0.449; p = 0.006) and time since amputation (β: 0.005; 95% CI: 0.0006 to 0.0101; p = 0.026) with the PLP-PLS index. These findings were confirmed by multivariable logistic regression (phantom movement sensation OR: 0.469; 95% CI: 0.200 to 1.099, p = 0.082; time since amputation OR: 1.003; 95% CI: 1.00003 to 1.007; p = 0.048) and sensitivity analyses. Conclusions: Time since amputation and phantom movement sensation likely reflect distinct phenotypes and potential mechanisms for PLP and PLS. The PLP-PLS index is a promising clinical tool for selecting therapies to prevent/treat PLP and for measuring treatment effects to modulate phantom pain. These findings emphasize the importance of understanding the mechanisms underlying PLP and PLS for improving clinical management and guiding future research. [ABSTRACT FROM AUTHOR]

AbstractAfter lower limb amputation, the primary challenge is to facilitate the patient’s adoption of a prosthetic limb seamlessly, without encountering complications or discomfort. Elevated stress levels within the residual limb, experienced when wearing the socket and while standing or walking, contribute to patient discomfort. As an initial step in this study, we developed a finite element model of above-knee amputation. Additionally, we designed a prototype orthopedic implant composed of several parts, with the lower section featuring a honeycomb structure aimed at absorbing and diminishing stresses at the interface of the residual limb and prosthetic. In this study, finite element models with and without orthopedic implants were analyzed to assess the feasibility and impact of incorporating a honeycomb structure within the implants on stress distribution, particularly at the stump-prosthetic interface. Models with honeycomb-structured implants, at varying densities, showed a reduction in interface stress to approximately 2.15e-2 MPa and 2.01e-2 MPa, compared to 4.5e-2 MPa in model without honeycomb structure in the implant and 7.97e-2 MPa in models without any implants. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to explore healthcare professionals' (HCPs) perceptions and experiences related to 3D scanning and 3D printing for fabricating lower limb prosthetic sockets. Materials and methods: This study used a qualitative descriptive approach. Participants were recruited through HCPs' professional associations, social media posts, and snowball sampling. Purposive sampling was used to attain variation in provider type. One-on-one telephone interviews were conducted using a semi-structured interview guide. Inductive thematic analysis was performed to identify the main themes. Results: Three themes were identified: (1) 3D scanning of the residual limb for designing prosthetic sockets is perceived as clean, quick, and convenient; (2) concerns about the strength and safety of 3D printed sockets for long-term use; (3) Adoption of 3D scanning and 3D printing technology for fabricating prosthetic sockets. Conclusion: We identified perceived benefits and challenges with digital technologies for fabricating prosthetic sockets. To increase adoption, more research demonstrating its efficacy compared to conventional methods, increasing 3D printing material quality, and improving software training programs are needed. Implications for Rehabilitation: 3D printing and 3D scanning are emerging digital technologies that can be used as alternative methods for prosthetic socket manufacturing in the field of rehabilitation. Our research identified perceived benefits of using digital technologies for fabricating prosthetics sockets (3D scanning is perceived as clean, quick, and convenient) and perceived challenges (concerns about the strength and safety of 3D printed sockets for long-term use and a prolonged learning curve). To increase adoption of these digital technologies, more training should be provided to prosthetists and support provided to integrate new processes into staff workloads. [ABSTRACT FROM AUTHOR]

BACKGROUND: The National Board of Health and Welfare manages several national registers in Sweden. This includes the Swedish National Inpatient Register (IPR), covering all surgical operations, and SwedeAmp, focusing on outcomes after lower limb amputations (LLA). However, coverage rates of amputation levels between these registers have not been externally analyzed. OBJECTIVE: To compare SwedeAmp's coverage with IPR for LLA cases and to assess SwedeAmp's accuracy in capturing LLA data. The goal of this study was also to identify potential discrepancies and establish benchmarks for common amputation levels. METHODOLOGY: Data from both registers, covering the years 2018 to 2023, were compared regarding the amputation levels and patient demographics. The coverage rate of the SwedeAmp register was calculated using SwedeAmp data as the numerator and IPR data as the denominator. FINDINGS: The IPR registry recorded 10,788 LLAs across 21 regions (67 hospitals). The SwedeAmp documented 5,246 LLAs covering 17 regions (36 hospitals), leaving 5,542 amputations unaccounted for, mainly due to regions or hospitals not participating in the SwedeAmp registry and lower registration rates in some areas. Key findings include: • Achieving full coverage in SwedeAmp (17 regions) would require registering 9,305 LLAs. • Both men and women over 85 years were significantly underrepresented. • Thirteen regions in SwedeAmp obtained more than 40% coverage rate. • 5 regions had more than 50% rate of above-knee amputations (range: 50.9% - 68.2%). • 8 regions reporting more than 50% rate of below-knee amputations (range: 53.1% - 88.9%). • Among the 67 hospitals performing LLAs, 36 reported to SwedeAmp. Six of these hospitals performed fewer than 10 LLAs over a six-year period. CONCLUSION: SwedeAmp captured 48.6% of initial LLAs in Sweden, highlighting the need for improved data completeness in LLA records, especially as only 13 regions achieved over 40% Coverage. For hospitals performing regular amputation, the proposed benchmark - coverage of ≥60%, with ≤36.3% for transfemoral amputation (TF), ≤8.4% for knee disarticulations (KD), and ≥55.3% for transtibial amputations (TT) – could serve as a target to enhance consistency and accuracy in reporting. Expanding coverage can improve the register's utility in tracking outcomes, setting national standards, aiding research, and supporting clinical decision-making. Layman's Abstract The Swedish National Board of Health and Welfare manages different health records, including the Swedish National Inpatient Register (IPR), which tracks all surgeries, and SwedeAmp, which focuses on people who have had lower limb amputations. This study looked at how much of SwedeAmp’s data matches the IPR, aimed to identify differences and set standards for common types of amputations. We compared the levels of amputation and patient details between the two records to better understand their coverage. The IPR registered 10,788 lower limb amputations (LLAs) across 21 regions and 67 hospitals, while SwedeAmp reported 5,246 LLAs from 17 regions (36 hospitals), leaving 5,542 amputations unaccounted for. To achieve full coverage in SwedeAmp, 9,305 LLAs would need to be registered, representing 86.3% of all amputations in Sweden. Fewer men over 80 years and women over 85 years were included in the SwedeAmp registry compared to the IPR. Thirteen regions in SwedeAmp had a coverage rate of more than 40%. Five regions reported an above-knee amputation rate of over 50%, while eight regions had a below-knee amputation rate exceeding 50%. Among the 67 hospitals performing LLAs, 36 reported data to SwedeAmp. Six of these hospitals performed fewer than 10 LLAs over a six-year period. For hospitals performing regular amputations, a benchmark of ≥60% coverage, with ≤36.3% for transfemoral, ≤8.4% for knee disarticulations, and ≥55.3% for transtibial amputations, could improve consistency in reporting. Increasing SwedeAmp's participation would strengthen the reliability of national data, supporting better outcome tracking, research, and clinical standards. Article PDF Link: https://jps.library.utoronto.ca/index.php/cpoj/article/view/44089/33369 How To Cite: Johannesson A.G, Scheving R, Westlund k.L, Fridriksson T. Evaluation of the SwedeAmp database: Focus on coverage and amputation level rates. Canadian Prosthetics & Orthotics Journal. 2024; Volume 7, Issue 2, No.2. https://doi.org/10.33137/cpoj.v7i2.44089 Corresponding Author: Anton G. Johannesson, PhD, CPO Össur Clinics EMEA, Stockholm, Sweden. E-Mail: ajohannesson@ossur.com ORCID ID: https://orcid.org/0000-0001-8729-458X

BACKGROUND: Treatment of deep chronic wounds with the bone tissue involvement against the background of lower limb atherosclerosis and diabetic foot syndrome does not fit any reasonable hospital stay duration and at the same time has no effective outpatient methods. Therapy with conditioned medium derived from human mesenchymal stem cells (CM-MSC) may be a solution for this problem. CLINICAL CASE DESCRIPTION: Patient F., 77-year-old, arrived for an outpatient treatment of local necrosis in the area of the 1st toe of the left foot in April, 2022. The main diagnosis: Peripheral arterial disease of the lower extremities. Multifocal atherosclerosis. Occlusion of the superficial femoral and popliteal arteries, diffuse lesions of the lower leg arteries on the left. Chronic arterial insufficiency of the 4th degree. Attempts of revascularisation of the left lower limb. Limited gangrene (Wagner IV) of the 1st toe of the left foot. Associated diseases: insulin-dependent type 2 diabetes mellitus (for more than 30 years). Diabetic polyneuropathy. Diabetic foot syndrome, neurotrophic form. Local treatment was performed by the microsurgical debridement of the affected surface in combination with the method of multilayered dressings, according to the previously patented technology. The microsurgical treatment of the bone surface in the wound area was carried out with the use of CM-MSC. Positive dynamics in the form of a partial closure of the bone fragment with soft tissue was observed on the sixth month of therapy. The complete closure of the open bone fragment was observed in 12 months from the beginning of the outpatient treatment. CONCLUSION: The developed method of treatment using CM-MSC can be effective for chronic wounds with open bone surfaces.

Background: Currently, there is limited literature available on hip disarticulation for primary malignant bone tumours. The purpose of this retrospective study is to evaluate the demographic distribution, clinical behaviour, and oncological outcomes and functional outcomes following hip disarticulation in patients with lower extremity sarcoma. Aims and objectives: The current study's aims and objectives were to examine clinical behaviour, oncological outcome, prognostic variables, and quality of life in patients who underwent hip disarticulation for primary sarcoma of the femur. Material & methods: This study includes a retrospective examination of patients with primary femoral sarcoma who had hip articulation between May 2015 and December 2018. Neoadjuvant chemotherapy was administered to all patients with osteosarcoma and Ewing's sarcoma per institutional policy. The R0 resection had been performed on each patient. There were 24 patients with primary femur sarcoma (16 men and 8 women). The patients' median age was 28.5 years (range 11 years–70 years). Results: Among 24 patients, 5 patients had distant metastasis at presentation. The computed median overall survival was 23.1 months (95 % CI:(14.76, 31.44)). Osteosarcoma, Ewing's sarcoma, and chondrosarcoma were the three most frequent cancers associated with hip disarticulation. During follow-up, thirteen patients (68.4 %) out of 19 patients suffered a recurrence. Disease-free survival was 16.97 months(95 % CI:(1.89, 32.04)). Metastatic disease at presentation was associated with a low overall survival rate. Both overall survival and disease-free survival were found to have strong positive correlation with pathological fracture at presentation. Quality of Life assessment of live patients shows reasonable ECOG and general health to maintain personal care. Conclusion: Hip disarticulation is a surgical option reserved for individuals with non-salvageable tumours around the knee and hip joint. Hip disarticulation is associated with a poor prognosis, a high recurrence rate, and a low long-term survival rate. To employ emerging technology to enhance the quality of life and prosthetic limb, more research and study must be done.

Cellulitis of the lower limb is a complex pathologic entity which might progress to life-threatening complications, such as sepsis, without a prompt and appropriate treatment. Therefore, a delayed diagnosis often requires life-saving amputations. This paper outlines the therapeutic approach in such situations by describing a patient who had already undergone amputation of the right lower limb and where the rapid institution of targeted therapy saved the left lower limb affected by cellulitis. The conclusion of this research is that in extensive infections of the extremities, the institution of triple antibiotic therapy in combination with staged surgical treatment may avoid limb amputation and save the lives of these patients. [ABSTRACT FROM AUTHOR]

The purpose of this paper is to identify the intervention components, key actors and models of social innovation that can contribute to the improvement of health rehabilitation services from a biopsychosocial perspective, aimed at people with lower limb amputation in a situation of disability. Likewise, it aims to analyze the ways in which Community Based Rehabilitation (CBR) facilitates the elimination of barriers in rehabilitation services and promotes a better quality of life for people with disabilities. A systematic review of scientific literature for the period 2001 to 2019 was carried out, starting with a bibliometric analysis of publications found in the Web of Science and Scopus databases; followed by content analysis with NVivo 12 software. Among the findings, it was identified that the optimization of health services for the population with disabilities in emerging countries requires investment and training. In addition, the success and deficiencies in CBR programs were analyzed, since according to the systematic review, these are limited to the care of people with lower limb amputation in contexts of armed conflict. [ABSTRACT FROM AUTHOR]

To describe admission and discharge characteristics of participants admitted to prosthetic rehabilitation following a lower limb amputation and determine changes in participant characteristics including if the population has gotten older over time at admission. A retrospective chart audit of consecutive admissions to an amputee rehabilitation program. Study criteria were transtibial level LLA and above and ≥ 18 years old. Admission characteristics included: age, Montreal Cognitive Assessment (MoCA), Functional Comorbidity Index (FCI) and days between amputation surgery and admission. Discharge characteristics included the L -Test of Functional Mobility (L-Test), 2-Minute Walk Test (2MWT), 6-Minute Walk Test (6MWT), and Activities-specific Balance Confidence (ABC) scale. Multivariable linear regression modelling quantified the association between participant characteristics and admission time. A total of 601 participants (62.3 ± 14.1 years) were included, 63 were (84.9 ± 3.7 years) aged 80 and over. FCI scores [β = 70.34, (95% CI: 20.93, 119.74), p = 0.005] and days between amputation surgery [β = −0.08, (95% CI: −0.13, −0.02), p = 0.011] were independently associated with admission time. People with an LLA are presenting with a higher number of comorbidities at admission over time while being admitted faster from amputation surgery. Future research should investigate the impact of these changing characteristics on rehabilitation outcomes to better assist this population. It is expected that the rate of inpatient prosthetic rehabilitation admissions due to lower limb amputations will increase amongst those over eighty. An analysis of participant characteristics of people admitted to inpatient prosthetic rehabilitation over time will inform modification and developments to future programs. Future prosthetic rehabilitation programs should consider an increased number of comorbidities when developing prognostic expectations for participants. A shortened interval between amputation surgery and admission should be considered when developing prosthetic rehabilitation programs. [ABSTRACT FROM AUTHOR]

• Higher levels of prosthesis sophistication was associated with better patient-reported outcomes in both transtibial (TT) and transfemoral (TF) amputees, however, the results are paradoxical. • In TT amputees, greater sophistication was associated with higher levels of mobility satisfaction but not higher levels of mobility. • In TF amputees, greater sophistication was associated with achieving higher levels of mobility but not higher levels of mobility satisfaction. • These results suggest further research is needed to better understand the relation between mobility level and satisfaction with mobility in TT and TF amputees. To determine if lower limb prosthesis (LLP) sophistication is associated with patient-reported mobility and/or mobility satisfaction, and if these associations differ by amputation level. Cohort study that identified participants through a large national database and prospectively collected self-reported patient outcomes. The Veterans Administration (VA) Corporate Data Warehouse, the National Prosthetics Patient Database, participant mailings, and phone calls. 347 Veterans who underwent an incident transtibial (TT) or transfemoral (TF) amputation due to diabetes and/or peripheral artery disease and received a qualifying LLP between March 1, 2018, and November 30, 2020. Basic, intermediate, and advanced prosthesis sophistication was measured by the accurate and reliable PROClass system. Patient-reported mobility using the advanced mobility subscale of the Locomotor Capabilities Index-5; mobility satisfaction using a 0–10-point Likert scale. Lower limb amputees who received intermediate or advanced prostheses were more likely to achieve advanced mobility than those who received basic prostheses, with intermediate nearing statistical significance at nearly twice the odds (adjusted odds ratio (aOR)=1.8, 95% confidence interval (CI),.98–3.3; P =.06). The association was strongest in TF amputees with over 10 times the odds (aOR=10.2, 95% CI, 1.1–96.8; P =.04). The use of an intermediate sophistication prosthesis relative to a basic prosthesis was significantly associated with mobility satisfaction (adjusted β coefficient (aβ)=.77, 95% CI,.11–1.4; P =.02). A statistically significant association was only observed in those who underwent a TT amputation (aβ=.79, 95% CI,.09–1.5; P =.03). Prosthesis sophistication was not associated with achieving advanced mobility in TT amputees but was associated with greater mobility satisfaction. In contrast, prosthesis sophistication was associated with achieving advanced mobility in TF amputees but was not associated with an increase in mobility satisfaction. [ABSTRACT FROM AUTHOR]

Globally, over 1 million lower limb amputations are performed annually, with approximately 75% of patients experiencing significant pain, profoundly impacting their quality of life and functional capabilities. Targeted muscle reinnervation (TMR) has emerged as a surgical solution involving the rerouting of amputated nerves to specific muscle targets. Originally introduced to enhance signal amplification for myoelectric prosthesis control, TMR has expanded its applications to include neuroma management and pain relief. However, the literature assessing patient outcomes is lacking, specifically for lower limb amputees. This systematic review aims to assess the effectiveness of TMR in reducing pain and enhancing functional outcomes for patients who have undergone lower limb amputation. A systematic review was performed by examining relevant studies between 2010 and 2023, focusing on pain reduction, functional outcomes and patient-reported quality of life measures. In total, 20 studies were eligible encompassing a total of 778 extremities, of which 75.06% (n = 584) were lower limb amputees. Average age was 46.66 years and patients were predominantly male (n = 70.67%). Seven studies (35%) reported functional outcomes. Patients who underwent primary TMR exhibited lower average patient-reported outcome measurement information system (PROMIS) scores for phantom limb pain (PLP) and residual limb pain (RLP). Secondary TMR led to improvements in PLP, RLP and general limb pain as indicated by average numeric rating scale and PROMIS scores. The systematic review underscores TMR's potential benefits in alleviating pain, fostering post-amputation rehabilitation and enhancing overall well-being for lower limb amputees. [ABSTRACT FROM AUTHOR]

Abstract Smoking may increase the risk of diabetic foot disease and ulceration. It does so by impairing glycaemic control and promoting the formation of advanced glycated end-products. Additionally, smoking is known to delay surgical wound healing and accelerate peripheral arterial disease. We aimed to determine whether toe pressures differed in smokers with a foot ulcer, when compared to non-smokers and ex-smokers, as well as ulcer outcomes at 12 months, among patients attending Blacktown Hospital High Risk Foot Service (HRFS). This study is a retrospective analysis of our prospectively collected clinic database. Eligible participants were adults attending the HRFS between June 2020 and April 2022. Participants were included if they had an ulcer, at least one systolic toe pressure reading completed at their initial visit and attended at least one follow-up visit. Participants were followed until healing, loss to follow-up or a minimum of 12 months. A total of 195 participants were included; 36 smokers, 82 ex-smokers, and 77 controls who had never smoked. Smoking status was by self-report. Current smokers were significantly younger at initial presentation (p = .002) and tended towards lower socioeconomic status (p = .067). Current smokers were significantly more likely to have ischaemic grade 3 toe pressures (

Smoking may increase the risk of diabetic foot disease and ulceration. It does so by impairing glycaemic control and promoting the formation of advanced glycated end-products. Additionally, smoking is known to delay surgical wound healing and accelerate peripheral arterial disease. We aimed to determine whether toe pressures differed in smokers with a foot ulcer, when compared to non-smokers and ex-smokers, as well as ulcer outcomes at 12 months, among patients attending Blacktown Hospital High Risk Foot Service (HRFS). This study is a retrospective analysis of our prospectively collected clinic database. Eligible participants were adults attending the HRFS between June 2020 and April 2022. Participants were included if they had an ulcer, at least one systolic toe pressure reading completed at their initial visit and attended at least one follow-up visit. Participants were followed until healing, loss to follow-up or a minimum of 12 months. A total of 195 participants were included; 36 smokers, 82 ex-smokers, and 77 controls who had never smoked. Smoking status was by self-report. Current smokers were significantly younger at initial presentation (p =.002) and tended towards lower socioeconomic status (p =.067). Current smokers were significantly more likely to have ischaemic grade 3 toe pressures (< 30 mmHg) of their left foot (p =.027), suggestive of reduced perfusion. At the end of follow up period, smokers had the numerically highest rates of minor amputations. In conclusion, smokers ulcerate younger and are more likely to have grade 3 ischaemia. Collecting information about the brachial artery pressures and the time since the last cigarette may clarify any relationship between smoking and toe pressures. Trial registration: WSLHD HREC ethics approval 2111-02 and ANZCTR registration 382470. Registered on 15/09/2021. [ABSTRACT FROM AUTHOR]

To perform a detailed psychometric Rasch analysis of the Prosthesis Embodiment Scale (PEmbS) administered in adults with lower limb amputation (LLA). A convenience sample of German-speaking adults with LLA (n = 150), recruited from German state agencies' databases, was asked to complete the PEmbS, a 10-item patient-reported scale assessing prosthesis embodiment. The local dependency between two items was resolved by keeping for the global score only the lower score of these two items (#9 and #10). Collapsing the seven response categories to four (two expressing disagreement and two agreement) eliminated disordered thresholds. After that, the PEmbS demonstrated unidimensionality, acceptable item fit, and good reliability indices. A keyform plot was created to transform raw scores into linear measures of prosthesis embodiment, making it possible to compare the individual's item responses with those expected by the Rasch model, and to manage missing responses. The PEmbS is useful for assessing prosthesis embodiment in people with LLA, both for research and clinical purposes. We propose a revised version of the PEmbS for lower limb amputees; its appropriateness in other LLA contexts requires further investigation. Prosthesis embodiment has been empirically related to positive clinical outcomes in limb amputees. The Prosthesis Embodiment Scale (PEmbS) is a patient-reported scale that has been recently recommended for use in research on prosthesis embodiment. Rasch analysis showed that the revised version of the German PEmbS is a psychometrically sound instrument for the assessment of prosthesis embodiment in lower limb amputees. The PEmbS thus also allows reliable and valid diagnosis of prosthesis embodiment in clinical and rehabilitation contexts. [ABSTRACT FROM AUTHOR]

To compare the accuracy and reliability of 10 different accelerometer-based step-counting algorithms for individuals with lower limb loss, accounting for different clinical characteristics and real-world activities. Cross-sectional study. General community setting (ie, institutional research laboratory and community free-living). Forty-eight individuals with a lower limb amputation (N=48) wore an ActiGraph (AG) wGT3x-BT accelerometer proximal to the foot of their prosthetic limb during labeled indoor/outdoor activities and community free-living. Not applicable. Intraclass correlation coefficient (ICC), absolute and root mean square error (RMSE), and Bland Altman plots were used to compare true (manual) step counts to estimated step counts from the proprietary AG Default algorithm and low frequency extension filter, as well as from 8 novel algorithms based on continuous wavelet transforms, fast Fourier transforms (FFTs), and peak detection. All algorithms had excellent agreement with manual step counts (ICC>0.9). The AG Default and FFT algorithms had the highest overall error (RMSE=17.81 and 19.91 steps, respectively), widest limits of agreement, and highest error during outdoor and ramp ambulation. The AG Default algorithm also had among the highest error during indoor ambulation and stairs, while a FFT algorithm had the highest error during stationary tasks. Peak detection algorithms, especially those using pre-set parameters with a trial-specific component, had among the lowest error across all activities (RMSE=4.07-8.99 steps). Because of its simplicity and accuracy across activities and clinical characteristics, we recommend the peak detection algorithm with set parameters to count steps using a prosthetic-worn AG among individuals with lower limb loss for clinical and research applications. [ABSTRACT FROM AUTHOR]

Aim: The present study aimed to determine the narrative experiences of individuals undergoing lower limb amputation. Method: This study was a qualitative study conducted using the phenomenological pattern. Using purposive sampling, 13 individuals with lower limb amputation were selected and interviewed. Data were collected using semi-structured interviews and analyzed using the content analysis method. Results: The mean age of the 13 individuals was 51.17 ± 8.7 years. Five of the individuals were female and eight of them were male. A main theme and four sub-themes were identified. This main theme together with sub-themes were Dead End (Process of Loss, Negative Feelings, Change, Adapting to New Lif e). The individuals expressed mostly negative feelings and thoughts while also emphasizing the rehabilitation process (positive sides). Conclusions: Individuals with lower limb amputations stated there were positive factors affecting the rehabilitation process while emphasizing negative thoughts and feelings during the amputation process. These results can be used in planning for training, counseling and therapeutic interviews to protect the psychosocial health of individuals with lower limb amputation. [ABSTRACT FROM AUTHOR]

Background: Phantom limb pain (PLP) and symptomatic neuroma can be debilitating and significantly impact the quality of life of amputees. However, the prevalence of PLP and symptomatic neuromas in patients following dysvascular lower limb amputation (LLA) has not been reliably established. This systematic review and meta-analysis evaluates the prevalence and incidence of phantom limb pain and symptomatic neuroma after dysvascular LLA. Methods: Four databases (Embase, MEDLINE, Cochrane Central, and Web of Science) were searched on October 5th, 2022. Prospective or retrospective observational cohort studies or cross-sectional studies reporting either the prevalence or incidence of phantom limb pain and/or symptomatic neuroma following dysvascular LLA were identified. Two reviewers independently conducted the screening, data extraction, and the risk of bias assessment according to the PRISMA guidelines. To estimate the prevalence of phantom limb pain, a meta-analysis using a random effects model was performed. Results: Twelve articles were included in the quantitative analysis, including 1924 amputees. A meta-analysis demonstrated that 69% of patients after dysvascular LLA experience phantom limb pain (95% CI 53-86%). The reported pain intensity on a scale from 0-10 in LLA patients ranged between 2.3 ± 1.4 and 5.5 ±.7. A single study reported an incidence of symptomatic neuroma following dysvascular LLA of 5%. Conclusions: This meta-analysis demonstrates the high prevalence of phantom limb pain after dysvascular LLA. Given the often prolonged and disabling nature of neuropathic pain and the difficulties managing it, more consideration needs to be given to strategies to prevent it at the time of amputation. [ABSTRACT FROM AUTHOR]

Lower limb trauma often results in mangled extremities, and in some cases, complete amputation may be necessary. However, limiting the extent of amputation and preserving the major knee joint are crucial to enhance mobility and overall functionality. By providing painless soft tissue coverage on the stump, early prosthesis use and the initiation of physiotherapy become more feasible. Soft tissue transfers hold the potential to benefit patients in two essential aspects: first, resolving soft tissue deficiencies without causing bone shortening, and second, preparing the stump to enhance overall functionality. A retrospective study conducted at Chang Gung Memorial Hospital (2009–2016) focused on lower limb amputation patients who underwent soft tissue transfers at different time periods compared to those without stump reconstruction. Out of the 2391 cases of lower limb injuries treated operatively, 117 amputations were performed in 110 patients (44 above the knee and 73 below the knee). Among them, 12 patients received soft tissue transfers for limb salvage and soft tissue deficiency after amputations. It was observed that patients in this group were typically younger, predominantly female, had longer hospital stays, and underwent a greater number of surgical procedures (p < 0.05). Through the use of soft tissue transfers, successfully preserved tibial bone length and functional knee joint in selected patients was achieved. This approach effectively resolved soft tissue deficiencies following lower limb amputations, optimizing physiotherapy and facilitating functional rehabilitation. [ABSTRACT FROM AUTHOR]

Objective The aim of this study was to understand therapist-identified factors influencing clinical adoption of a telehealth walking self-management intervention for individuals with lower limb amputation. Methods Semi-structured focus groups were completed with actively practicing physical and occupational therapists treating populations that are medically complex. A qualitative explorative design was employed with conventional content analysis and iterative independent parallel coding using 2 analysts. Themes and subthemes were generated with a consensus building process identifying patterns and collapsing codes to represent participant perspectives. Results Thematic saturation was met after 5 focus groups (24 therapists). Therapists were on average 34 years old and predominantly female (n  = 19; 79%) physical therapists (n  = 17; 71%). Three primary facilitator and barrier themes were identified for intervention adoption: system, therapist, and person. System considerations included telehealth support and interprofessional care coordination. Therapist facilitators included self-management programming that overlapped with standard of care and personalization methods. However, limited behavioral theory training was a therapist level barrier. Finally, person factors such as patient activation could influence both positively and negatively. Person facilitators included social support and barriers included the complex health condition. Conclusion System, therapist, and person facilitators and barriers must be considered to maximize the adoption of similar telehealth walking self-management interventions and prior to larger scale implementation of the current intervention for individuals with lower limb amputation. Impact A telehealth walking self-management intervention has potential impact for individuals with lower limb amputation and must be considered in terms of optimizing system, therapist, and person level facilitators and barriers to implementation. [ABSTRACT FROM AUTHOR]

Background: Phantom limb pain (PLP) is highly prevalent after amputation. However, the influence of non-painful sensations (PLS) remains unclear. This study examines the PLP-PLS index as a novel tool to differentiate PLP from PLS and explores the association of clinical factors with the index. Methods: We conducted a cross-sectional analysis of baseline data from 112 participants in a previous factorial trial in patients with unilateral traumatic lower limb amputation. Linear regression models were used to examine the associations between the index and various demographic, psychological and clinical factors. Logistic and Poisson regression, and e-value calculation were utilized for sensitivity analyses. Results: Adjusted multivariable linear regression models demonstrated significant associations of phantom movement sensation (β: −1.532; 95% CI: −2.615 to −0.449; p = 0.006) and time since amputation (β: 0.005; 95% CI: 0.0006 to 0.0101; p = 0.026) with the PLP-PLS index. These findings were confirmed by multivariable logistic regression (phantom movement sensation OR: 0.469; 95% CI: 0.200 to 1.099, p = 0.082; time since amputation OR: 1.003; 95% CI: 1.00003 to 1.007; p = 0.048) and sensitivity analyses. Conclusions: Time since amputation and phantom movement sensation likely reflect distinct phenotypes and potential mechanisms for PLP and PLS. The PLP-PLS index is a promising clinical tool for selecting therapies to prevent/treat PLP and for measuring treatment effects to modulate phantom pain. These findings emphasize the importance of understanding the mechanisms underlying PLP and PLS for improving clinical management and guiding future research.

Background: An amputation is a dramatic event that brings marked changes in an individual life which may affect the person physically and psychologically. Objective: To determine the frequency of non-specific low back pain and its effect on function and health-related quality of life across three levels of lower limb amputation. Methods: A cross-sectional study was conducted at the Pakistan Institute of Prosthetic and Orthotics Peshawar (PIPOS) from May 2020 to Sep 2020. The inclusion criteria were: both males and females ages 18-65 years, patients with unilateral transfemoral, knee disarticulation, and transtibial amputation. The data were collected via a self-administered questionnaire. The outcomes were measured by the Roland Morris disability questionnaire (RMDQ), The short form 36 health survey (SF-36), and questions about the prevalence of LBP. The data was analyzed by SPSS v.25. Results: A total of 264 amputees with a frequency of male 219 (83%) and female 45(17%) participated in this study. There was a significant association between pre and post-amputation back pain (P< 0.05) while no significant association was found between LBP and across the three levels of amputation (P> 0.05). There was no statistical difference between disability and level of amputation (P> 0.05). A statistical difference was found between low back pain and all domains of quality of life except mental and physical health with (P< 0.05) while no statistical difference was found in the quality of life and across the three levels of amputation (P> 0.05). Conclusion: This study found that LBP was prevalent after amputation. There was a significant association between low back pain before and after amputation while no significant association was found in low back pain across the three levels of amputation. The effect of low back pain on disability was found statistically significant and the effect of low back pain on quality of life was significant in some domains like Physical function, and social function.

This study aimed to determine leisure participation and constraints experienced by individuals with lower limb amputation (LLA) in South Africa. A one-time, crosssectional quantitative approach was used, incorporating the Trinity Amputation and Prosthesis Experience Scale-Revised (TAPES-R questionnaire) and the Constraints to Participation Questionnaire. These instruments were integrated into an electronic survey hosted on Google Forms. Fifty participants, with an average of 10 years since their amputation, were included in the study, with 62% having undergone below-knee LLA. Data were analysed using SPSS (version 27). Participants enjoyed a variety of recreational programme areas/activities: sport (52%), aquatics (14%), going to church (14%), adventure (8%) and social recreation (2%), and 10% did not report any recreational activity participation. The frequency of activity participation was high: 56% of participants reported engagement in recreational activities more than once a week or even daily, 16% participated moderately, 20% reported low participation and 8% gave no response. The Constraints to Participation Questionnaire showed overall low values for intrapersonal (1.89±0.38) and interpersonal (1.88±0.22) constraints and slightly higher values for structural constraints (2.22±0.46). Results indicated that individuals with LLA continued to engage in leisure activities by negotiating leisure constraints. [ABSTRACT FROM AUTHOR]

Background: Major Lower Extremity Amputation (MLEA) is a life-saving surgical procedure, with diabetes mellitus being the leading factor. This study aims to determine the pattern and indications for amputation in our region and analyze clinical and demographical design. Methods: A retrospective cross-sectional study was conducted at the Victoria Hospital, a Bangalore Medical College and Research Institute component, to analyze patients undergoing major LEA. The study included 132 patients, including 87 patients treated with AKA and 45 patients with BKA. The analysis included demographic information, co-morbidities, amputation level, level of hospitalization, condition at discharge, and history of COVID-19 infection. The study used descriptive statistics, frequency analysis, percentage analysis, mean and standard deviation for categorical variables, and the Chi-square test for qualitative categorical data. Results: A total of 132 patients underwent major lower limb amputation at Victoria Hospital between January and August 2022, with a high prevalence of co-morbid medical conditions such as diabetes, hypertension, smoking, alcohol, and COVID-19 infection. The most common indication for amputation was diabetic foot, followed by peripheral vascular disease. Patients with diabetic foot were significantly more likely to undergo AKA than BKA (p<0.05). The most common complication encountered was surgical site infection, seen in 53(40.15%) patients. Conclusion: Diabetes mellitus and vascular insufficiency are common indications for nontraumatic limb amputation. Despite advanced endovascular therapy, the number of patients requiring amputation has decreased marginally. Health education, early diagnosis, and follow-up are crucial to prevent complications and ensure patients can lead normal or near-normal lives with timely intervention. [ABSTRACT FROM AUTHOR]

Objectives. To examine whether possibilities to improve care among patients with diabetes are reflected in the numbers of cardiovascular complications at national and regional level in Finland. Methods. The study population included all patients with diabetes in Finland since 1964. The incidences of first acute coronary syndrome, ischemic stroke and lower limb amputation were examined for the period from 2010 to 2017. The age- and sex-standardised incidence rates were calculated for the first events. Adjusted Poisson regression mixed models were used to calculate average annual trends and assess regional variation of incidences during the periods 2010 to 2013 and 2014 to 2017 in the university hospital districts (UHDs) and hospital districts (HDs). Results. The nationwide incidence of first acute coronary syndrome decreased among patients with diabetes by 2.7% (95% confidence interval 2.3%; 3.0%), ischemic stroke by 2.0% (1.5%; 2.4%) and major lower limb amputation by 4.6% (3.1%; 5.9%) annually. The sexes differed only in the decrease in acute coronary events. The annual decrease among males was 2.1% (1.6%; 2.6%) and among females was 3.4% (2.8%; 4.0%) (p =.001). Marked variation was observed among UHDs and HDs in the incidences of cardiovascular events and lower limb amputations in patients with diabetes. The variation in annual trends of diabetic complications was most pronounced in acute coronary syndrome among UHDs with an estimated variance of 0.0006 (p =.034). Conclusions. The decrease in the incidence of first cardiovascular events among patients with diabetes continued from 2010 to 2017 in Finland. However, the declining national incidence rates hide regional differences which should be a target for improvement. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the effect of age on functional outcomes at discharge from prosthetic rehabilitation. Design: Retrospective chart audit. Setting: Rehabilitation hospital. Participants: Individuals ≥50 years with a transtibial level lower limb amputation (LLA) and above admitted to the inpatient prosthetic rehabilitation program from 2012 to 2019 (n=504). A secondary analysis included a subset of matched participants (n=156). Interventions: Not applicable. Main Outcome Measures: The L-Test of Functional Mobility (L-Test), 2-Minute Walk Test (2MWT), 6-Minute Walk Test (6MWT), and Activities-specific Balance Confidence scale. Results: A total of 504 participants (66.7±10.1 years) met the inclusion criteria, 63 participants (84.9±3.7 years) were part of the oldest old group. The sample was stratified into 4 age groups (50-59, 60-69, 70-79, and 80+) for data analysis. The analysis of variances were statistically significant for all outcome measures (P <.001). Post-hoc testing for the L-Test, 2MWT, and 6MWT demonstrated that the oldest old had significantly reduced performance compared with people 50-59 years old (P <.05), but there were no significant differences between the oldest old and the 60-69 [(L-Test, P =.802), (2MWT, P =.570), (6MWT, P =.772)] and 70-79 [(L-Test, P =.148), (2MWT, P =.338), (6MWT, P =.300)] age groups. The oldest old reported significantly lower balance confidence compared with all 3 age groups (P <.05). Conclusion: The oldest old achieved similar functional mobility outcomes as people 60-79 years, the most common age group of people with an LLA. Advanced age alone should not disqualify individuals from prosthetic rehabilitation. [ABSTRACT FROM AUTHOR]

Below-knee prosthetics are used to restore the functional activity and appearance of persons with lower limb amputation. This work attempted to design and manufacture a low-cost, novel, comfortable, lightweight, durable, and flexible smart below-knee foot prosthesis prototype. This prosthesis foot was designed according to the natural leg measurement of an adult male patient. The foot is composed of rigid PVC layers interspersed with elastic strips of PTFE, and the axis of the ankle joint is flexible and consists of metal layers and a composite of polymeric damping strips with different mechanical properties, making it flexible and allowing it to absorb shocks and store and release energy. The design, modeling, and simulation of the manufactured prosthetic foot were performed via the ANSYS 18.0 software and the finite element method (FEM), where a large number of parallel and oblique planes and sketches were created. This work included four adult patients weighing 50, 75, 90, and 120 kg with different walking cycles. The results show that the highest equivalent von Mises stress and total deformations for the prosthetic limb occur at the beginning of the walking step, while the highest equivalent elastic strains and strain energy release rates are observed at the end of the walking step, regardless of the weight. This prototype can satisfactorily perform the biomechanical functions of a natural human foot, and it can be produced in attractive sizes, models, and shapes to suit different levels of below-knee amputations for different ages and weights, especially for patients with limited income.

Aims: This study aimed to investigate the association between the use of sodiumglucose transporter 2 inhibitors (SGLT-2i) and the risk of diabetic ketoacidosis (DKA), lower limb amputation (LLA), urinary tract infections (UTI), genital tract infections (GTI), bone fracture, and hypoglycemia in cohort studies. Methods: A systematic search was conducted in the PubMed and Embase databases to identify cohort studies comparing the safety of SGLT-2i versus other glucose-lowering drugs (oGLD) in patients with type 2 diabetes mellitus (T2DM). The quality of the studies was assessed using the Newcastle-Ottawa Scale. Primary endpoints were DKA and LLA, while secondary endpoints included UTI, GTI, bone fracture, and hypoglycemia. Hazard ratios (HR) with 95% confidence intervals (CI) were calculated. Results: A total of 9,911,454 patients from 40 cohort studies were included in the analysis. SGLT-2i use was associated with a higher risk of DKA (HR: 1.21, 95% CI: 1.07–1.38, p = 0.003) and GTI (HR: 2.72, 95% CI: 2.48–2.98, p < 0.01). However, it was not associated with an increased risk of LLA (HR: 1.06, 95% CI: 0.92–1.23, p = 0.42), UTI (HR: 0.99, 95% CI: 0.89–1.10, p = 0.83), or bone fracture (HR: 0.99, 95% CI: 0.94–1.04, p = 0.66). Furthermore, SGLT-2i was associated with a reduced risk of hypoglycemia. Furthermore, compared to dipeptidyl peptidase 4 inhibitors, SGLT-2i as a class and individually was associated with an increased risk of DKA. Canagliflozin specifically increased the risk of LLA (HR: 1.19, 95% CI: 1.04–1.36, p = 0.01). The subgroup analysis suggested that SGLT-2i increased the risk of LLA among patients with a history of cardiovascular disease. Conclusion: SGLT-2i versus oGLD was associated with a similar occurrence of LLA, UTI, and bone fracture. However, SGLT-2i was associated with a higher risk of DKA and GTI than oGLD. These findings provide valuable information on the safety profile of SGLT-2i in patients with T2DM and can help inform clinical decisionmaking. [ABSTRACT FROM AUTHOR]

Introduction: Individuals with lower limb loss experience an increased risk of falls partly due to the lack of sensory feedback from their missing foot. It is possible to restore plantar sensation perceived as originating from the missing foot by directly interfacing with the peripheral nerves remaining in the residual limb, which in turn has shown promise in improving gait and balance. However, it is yet unclear how these electrically elicited plantar sensation are integrated into the body's natural sensorimotor control reflexes. Historically, the H-reflex has been used as a model for investigating sensorimotor control. Within the spinal cord, an array of inputs, including plantar cutaneous sensation, are integrated to produce inhibitory and excitatory effects on the H-reflex. Methods: In this study, we characterized the interplay between electrically elicited plantar sensations and this intrinsic reflex mechanism. Participants adopted postures mimicking specific phases of the gait cycle. During each posture, we electrically elicited plantar sensation, and subsequently the H-reflex was evoked both in the presence and absence of these sensations. Results: Our findings indicated that electrically elicited plantar sensations did not significantly alter the H-reflex excitability across any of the adopted postures. Conclusion: This suggests that individuals with lower limb loss can directly benefit from electrically elicited plantar sensation during walking without disrupting the existing sensory signaling pathways that modulate reflex responses. [ABSTRACT FROM AUTHOR]

Context: Glycemic variation had been demonstrated to be associated with several complications of diabetes. Objective: Investigation of the association between visit to visit hemoglobin A1c (HbA1c) variation and the long-term risk of major adverse limb events (MALEs). Methods: Retrospective database study. Average real variability was used to represent glycemic variations with all the HbA1c measurements during the 4 following years after the initial diagnosis of type 2 diabetes. Participants were followed from the beginning of the fifth year until death or the end of the follow-up. The association between HbA1c variations and MALEs was evaluated after adjusting for mean HbA1c and baseline characteristics. Included were 56 872 patients at the referral center with a first diagnosis of type 2 diabetes, no lower extremity arterial disease, and at least 1 HbA1c measurement in each of the 4 following years were identified from a multicenter database. The main outcome measure was incidence of a MALE, which was defined as the composite of revascularization, foot ulcers, and lower limb amputations. Results: The average number of HbA1c measurements was 12.6. The mean follow-up time was 6.1 years. The cumulative incidence of MALEs was 9.25 per 1000 person-years. Visit to visit HbA1c variations were significantly associated with MALEs and lower limb amputation after multivariate adjustment. People in the highest quartile of variations had increased risks for MALEs (HR 1.25, 95% CI 1.10-1.41) and lower limb amputation (HR 3.05, 95% CI 1.97-4.74). Conclusion: HbA1c variation was independently associated with a long-term risk of MALEs and lower limb amputations in patients with type 2 diabetes. [ABSTRACT FROM AUTHOR]

Introduction: Mobility restriction following limb loss might lead to a sedentary lifestyle, impacting health. Daily activity monitoring of amputees has focused on prosthetic steps, neglecting overall activity. Purpose: To assess daily activity in individuals with an established amputation and to explore the amount of activity recorded from the prosthesis as compared to the overall activity. Methods: Individuals with a unilateral transfemoral amputation or knee disarticulation who had used a prosthesis in daily life for >1 year and could walk 100 m (unsupported or single aided) were recruited. Descriptive information and prosthetic mobility were collected. Two activPAL™ accelerometers were attached to the nonamputated thigh and the prosthesis, respectively. The mean daily activity over 7 days was compared between the nonamputated limb and the prosthesis. Results: Thirty-nine participants (22 men/17 women; mean age 54 [14.5] years) with amputation mainly due to trauma (59%) or tumor (28%) were included. Overall, participants took 6,125 steps and spent 10.2 hr sedentary, 5.0 hr upright, and 8.7 hr laying per day. Compared to recordings from the nonamputated limb, 85% of sit-to-stand transitions (32/38), 73% of steps (4,449/6,125), and 68% of walking time (1.0/1.5 hr) were recorded from the prosthesis. Recordings seemed to be less adequate for incidental prosthetic steps than for walks. Conclusions: Sedentary behavior accounted for most of the day demonstrating the importance to encourage physical activity among established prosthetic users. The prosthesis is used for daily activity to a great extent. However, noted pitfalls in the recordings call for further refinement of the measurements. [ABSTRACT FROM AUTHOR]

Untreated chronic osteomyelitis presentations are becoming less common, especially in industrialized countries, however the post-traumatic and post-surgical osteomyelitis are the most frequent causes of bone infection in the developed countries, accounting for 80% of bone infections. Around 10 to 30% of cases of the acute form become chronic. Moreover, chronic osteomyelitis and extensive bone defect still represent a challenging medical condition for orthopedic surgeons. [ABSTRACT FROM AUTHOR]

Aims: Chronic osteomyelitis (COM) of the lower limb in adults can be surgically managed by either limb reconstruction or amputation. This scoping review aims to map the outcomes used in studies surgically managing COM in order to aid future development of a core outcome set. Methods: A total of 11 databases were searched. A subset of studies published between 1 October 2020 and 1 January 2011 from a larger review mapping research on limb reconstruction and limb amputation for the management of lower limb COM were eligible. All outcomes were extracted and recorded verbatim. Outcomes were grouped and categorized as per the revised Williamson and Clarke taxonomy. Results: A total of 3,303 records were screened, of which 99 studies were included. Most studies were case series (77/99; 78%) and assessed one method of reconstruction (68/99; 69%). A total of 511 outcomes were reported, which were grouped into 58 distinct outcomes. Overall, 143/511 of all outcomes (28%) were provided with a clear, in-text definition, and 231 outcomes (45%) had details reported of how and when they were measured. The most commonly reported outcome was ‘recurrence of osteomyelitis’ (62; 12%). The single-most patient-reported outcome measure was ‘pain’. Conclusion: This study has highlighted significant inconsistencies in the defining, reporting, and measuring of outcomes across studies investigating surgical management for chronic osteomyelitis of the lower limb in adults. Future studies should clearly report complete details of how outcomes are defined and measured, including timing. The development of a standardized core outcome set would be of significant benefit in order to allow evidence synthesis and comparison across studies. Cite this article: Bone Jt Open 2023;4(3):146–157.

Additionally, it has been demonstrated that osseointegrated implantation offers superior proprioception and control over the prosthesis, enabling more natural movement and improved functional results. Additionally, it lowers the chance of falling and increases energy transfer efficiency, making it simpler for amputees to engage in physical activity. Furthermore, as compared to conventional socket prosthesis attachment, osseointegrated implantation has been linked to higher patient satisfaction and quality of life. It is crucial to remember that osseointegration is a surgical operation with risks including infection and implant failure. Additionally, for effective implantation, it needs a specific amount and quality of bone, which may restrict its usage in some individuals. Furthermore, osseointegrated implantation could be more expensive than conventional socket prosthetics. Understanding the efficacy and safety of this method requires research on complication rates and outcome metrics in patients having osseointegrated prosthesis implantation. You may acquire information on things like infection rates, implant failure, patient satisfaction, and functional results by studying original research papers. Clinical decision-making can then be improved with the use of this information. In transfemoral amputees, osseointegration has showed promise as a powerful substitute for socket prostheses. A growing corpus of research has shown that osseointegrated implantation provides advantages in terms of increasing mobility, decreasing discomfort, and improving general quality of life. The efficiency of osseointegration for transtibial and upper extremity implants has received little attention. Minor soft tissue infections are the most frequent consequences, although they are manageable with the right treatment and monitoring. To further reduce the risk of problems and improve the overall success of osseointegrated implantation, research and development are ongoingly focused on enhancing surgical methods and implant design. Although osseointegration has a lot of potential, not all amputees may be good candidates for it. Considerations for osseointegrated implantation must take into consideration elements including the degree and nature of the amputation, the quality and density of the bone, and the desires of the patient.

Advancements in instrumentation support improved powered ankle prostheses hardware development. However, control algorithms have limitations regarding number and type of sensors utilized and achieving autonomous adaptation, which is key to a natural ambulation. Surface electromyogram (sEMG) sensors are promising. With a minimized number of sEMG inputs an economic control algorithm can be developed, whereas limiting the use of lower leg muscles will provide a practical algorithm for both ankle disarticulation and transtibial amputation. To determine appropriate sensor combinations, a systematic assessment of the predictive success of variations of multiple sEMG inputs in estimating ankle position and moment has to conducted. More importantly, tackling the use of nonnormalized sEMG data in such algorithm development to overcome processing complexities in real-time is essential, but lacking. We used healthy population level walking data to (1) develop sagittal ankle position and moment predicting algorithms using nonnormalized sEMG, and (2) rank all muscle combinations based on success to determine economic and practical algorithms. Eight lower extremity muscles were studied as sEMG inputs to a long-short-term memory (LSTM) neural network architecture: tibialis anterior (TA), soleus (SO), medial gastrocnemius (MG), peroneus longus (PL), rectus femoris (RF), vastus medialis (VM), biceps femoris (BF) and gluteus maximus (GMax). Five features extracted from nonnormalized sEMG amplitudes were used: integrated EMG (IEMG), mean absolute value (MAV), Willison amplitude (WAMP), root mean square (RMS) and waveform length (WL). Muscle and feature combination variations were ranked using Pearson’s correlation coefficient (r > 0.90 indicates successful correlations), the root-mean-square error and one-dimensional statistical parametric mapping between the original data and LSTM response. The results showed that IEMG+WL yields the best feature combination performance. The best performing variation was MG + RF + VM (rposition = 0.9099 and rmoment = 0.9707) whereas, PL (rposition = 0.9001, rmoment = 0.9703) and GMax+VM (rposition = 0.9010, rmoment = 0.9718) were distinguished as the economic and practical variations, respectively. The study established for the first time the use of nonnormalized sEMG in control algorithm development for level walking. [ABSTRACT FROM AUTHOR]

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