Replantation of the amputated complex mass of fingers.

Objective To study the replantation methods of the amputated complex tissue mass of fingers. Methods Nine cases were replanted using the routine method and the artery-vein bridge grafting method respectively. Results All 9 cases survived. At 1 year postoperation, the length of the replanted finger was comparable to that of the healthy side with satisfactory appearance. The average finger function increased 30% when compared with pre-operation one. Conclusion For the amputated complex tissue mass of fingers, routine replantation should be carried out if there was one or two digital proper arteries. If a defect was present, the artery-vein bridge grafting method was chosen accordingly. 5 refs,2 figs.

Voluntary Thigh Muscle Strength with Resection Stump-Dependent Blood Flow and Vasodilation in an Amputated Lower Leg with Total Surface Bearing Prosthesis during Dynamic Knee Extensor: A Case Trial

Background: The magnitude of the hyperemic response due to repeated thigh stump exercise on incremental contraction intensity might be useful information in localized exercise tolerance for devising cardiovascular physical therapy for amputees. The effect of exercise on amputated leg blood flow (LBF) may potentially be altered due to voluntary muscle contractions after loss of the lower leg compared with the healthy leg. Case Presentation: A 57-year-old male patient with Burger disease attempted 3 min unilateral repeat/dynamic knee extensor exercise at a target muscle contraction frequency (1 s thigh muscle contraction and 1 s relaxation, 90 repetitions) with each leg <right transtibial amputated leg (AL) using a total surface-bearing prosthesis (TSB) and left non-AL> at six different contraction intensities (rubber resistance belt). Simultaneous measurement of blood velocity/flow (Doppler ultrasound) in the femoral artery, blood pressure, leg vascular conductance (LVC), and peak muscle strength (PMS) were performed during the 3 min exercise period. The maximum voluntary contraction by one-legged isometric knee muscle contraction was 14.7 kg in non-AL and 7.9 kg in the AL with prosthesis. The relative PMS was defined as “PMS/maximum voluntary contraction × 100 (%)”. Pre-exercise LBF was lower in the AL (200 ± 25 ml/min) than the non-AL (275 ± 74 ml/min). Both the non-AL and AL showed good positive linear relationships between absolute-/relative-PMS and LBF or LVC during 30 s at steady-state before the end of the exercise period. Furthermore, there was also similarity seen in the increase rate in LBF and/or LVC for the incremental relative PMS compared with the absolute PMS. Conclusion: In this case, the muscle strength depended on blood flow increase/vasodilation was seen in this “AL” using a TSB prosthesis for repeated dynamic knee extensor exercise. The present amputee’s limb muscle strengthening with the resection stump closely related to the degree of hyperemia in the amputated limb.

Study on the preservation effects of the amputated forelimb by machine perfusion at physiological temperature

Purpose:Ischemia and hypoxia are the main factors limiting limb replantation and transplantation.Static cold storage(SCS),a common preservation method for tissues and organs,can only prolong limb ischemia time to 4-6 h.The normothermic machine perfusion(NMP)is a promising method for the preservation of tissues and organs,which can extend the preservation time in vitro by providing continuous oxygen and nutrients.This study aimed to evaluate the difference in the efficacy of the 2 limb preservation methods.Methods:The 6 forelimbs from beagle dogs were divided into 2 groups.In the SCS group(n=3),the limbs were preserved in a sterile refrigerator at 4°C for 24 h,and in the NMP group(n=3),the perfusate prepared with autologous blood was used for the oxygenated machine perfusion at physiological temperature for 24 h,and the solution was changed every 6 h.The effects of limb storage were evaluated by weight gain,perfusate biochemical analysis,enzyme-linked immunosorbent assay,and histological analysis.All statistical analyses and graphs were performed using GraphPad Prism 9.0 one-way or two-way analysis of variance.The p value of less than 0.05 was considered to indicate statistical significance.Results:In the NMP group,the weight gained percentage was 11.72%±4.06%;the hypoxia-inducible factor-1αcontents showed no significant changes;the shape of muscle fibers was normal;the gap between muscle fibers slightly increased,showing the intercellular distance of(30.19±2.83)μm;and the vascularα-smooth muscle actin(α-SMA)contents were lower than those in the normal blood vessels.The creatine kinase level in the perfusate of the NMP group increased from the beginning of perfusion,decreased after each perfusate change,and remained stable at the end of perfusion showing a peak level of 4097.6 U/L.The lactate dehydrogenase level of the NMP group increased near the end of perfusion and reached the peak level of 374.4 U/L.In the SCS group,the percentage of weight gain was 0.18%±0.10%,and the contents of hypoxia-inducible factor-1αincreased gradually and reached the maximum level of(164.85±20.75)pg/mL at the end of the experiment.The muscle fibers lost their normal shape and the gap between muscle fibers increased,showing an intercellular distance of(41.66±5.38)μm.The contents of vascularα-SMA were much lower in the SCS group as compared to normal blood vessels.Conclusions:NMP caused lesser muscle damage and contained more vascularα-SMA as compared to SCS.This study demonstrated that NMP of the amputated limb with perfusate solution based on autologous blood could maintain the physiological activities of the limb for at least 24 h.

Surgical management of the diabetic foot:The current evidence

The prevalence of diabetes mellitus and its associated complications,particularly diabetic foot pathologies,poses significant healthcare challenges and economic burdens globally.This review synthesises current evidence on the surgical management of the diabetic foot,focusing on the interplay between neuropathy,ischemia,and infection that commonly culminates in ulcers,infections,and,in severe cases,amputations.The escalating incidence of diabetes mellitus underscores the urgency for effective management strategies,as diabetic foot complications are a leading cause of hospital admissions among diabetic patients,significantly impacting morbidity and mortality rates.This review explores the pathophysiological mechanisms underlying diabetic foot complications and further examines diabetic foot ulcers,infections,and skeletal pathologies such as Charcot arthropathy,emphasising the critical role of early diagnosis,comprehensive management strategies,and interdisciplinary care in mitigating adverse outcomes.In addressing surgical interventions,this review evaluates conservative surgeries,amputations,and reconstructive procedures,highlighting the importance of tailored approaches based on individual patient profiles and the specific characteristics of foot pathologies.The integration of advanced diagnostic tools,novel surgical techniques,and postoperative care,including offloading and infection control,are discussed in the context of optimising healing and preserving limb function.

Prevalence and risk factors of wound complications after transtibial amputation in patients with diabetic foot

BACKGROUND Diabetic foot(DMF)complications are common and are increasing in incidence.Risk factors related to wound complications are yet to be established after transtibial amputation under the diagnosis of DMF infection.AIM To analyze the prognosis and risk factors related to wound complications after transtibial amputation in patients with diabetes.METHODS This retrospective cohort study included seventy-two patients with DMF complications who underwent transtibial amputation between April 2014 and March 2023.The groups were categorized based on the occurrence of wound complications,and we compared demographic data between the complication group and the non-complication group to analyze risk factors.Moreover,a multivariate logistic regression analysis was performed to identify risk factors.RESULTS The average follow-up period was 36.2 months.Among the 72 cases,31(43.1%)had wound complications.Of these,12 cases(16.7%)received further treatment,such as debridement,soft tissue stump revision,and re-amputation at the proximal level.In a group that required further management due to wound complications after transtibial amputation,the hemoglobin A1c(HbA1c)level was 9.32,while the other group that did not require any treatment had a 7.54 HbA1c level.The prevalence of a history of kidney transplantation with wound complications after transtibial amputation surgery in DMF patients was significantly greater than in cases without wound complications(P=0.02).Other factors did not show significant differences.CONCLUSION Approximately 43.1%of the patients with transtibial amputation surgery experienced wound complications,and 16.7%required additional surgical treatment.High HbA1c levels and kidney transplant history are risk factors for postoperative wound complications.

Jaffe-Campanacci syndrome resulted in amputation: A case report

BACKGROUND Jaffe-Campanacci syndrome(JCS)is a very rare syndrome.The treatment of JCS is more conservative,and most authors recommend that no surgery should be done in asymptomatic patients.The conventional concept holds that the natural course of non-ossifying fibromas(NOFs)grows with the development of bones,and the osteolytic region gradually stops expanding and self-healing through bone ossifying around the lesion and ossification within the lesion.But in this case,the bone lesions were potentially biologically aggressive,which led to severe limb deformities and pain.CASE SUMMARY We present the case of a 5-year-old girl with JCS presenting with not only NOF sand café-au-lait macules,but also showed features not mentioned before,severe limb pain,and at last resulted in amputation.She was admitted to our hospital after presenting with claudication and mild pain over her right thigh,which worsened when stretching or being touched.Skin examination revealed multiple café-au-lait macules on the neck,arm,axilla,and torso,including the nipples and perineum.Radiographs revealed multiple lytic lesions in the proximal part of the right humerus,distal part of the right clavicle,proximal and distal parts of the right femur,and proximal parts of the right tibia and fibula.Curettage and biopsy were performed on the distal part of the right femur.At the age of 7,the girl was re-admitted to our hospital for a pathological fracture in the middle in the right femur and underwent Intralesional excision,internal fixation,bone grafting,and spica casting.At the age of 10,the girl came to our hospital again for severe pain of the right leg.Amputation from the middle level of the right femur was performed.We present the case of a 5-year-old girl with JCS presenting with not only NOFs and café-au-lait macules,but also showed features not mentioned before,severe limb pain,and at last resulted in amputation.She was admitted to our hospital after presenting with claudication and mild pain over her right thigh,which worsened when stretching or being touched.Skin examination revealed multiple café-au-lait macules on the neck,arm,armpit,and torso,including the nipples and perineum.Radiographs revealed multiple lytic lesions in the proximal part of the right humerus,distal part of the right clavicle,proximal and distal parts of the right femur,and proximal parts of the right tibia and fibula.Curettage and biopsy were performed on the distal part of the right femur.At the age of 7,the girl was re-admitted to our hospital for a pathological fracture in the middle in the right femur and underwent Intralesional excision,internal fixation,bone grafting,and spica casting.At the age of 10,the girl came to our hospital again for severe pain of the right leg.Amputation from the middle level of the right femur was performed.CONCLUSION In our opinion,education on preventing pathological fractures and explaining the consequent serious consequences to the parents is a matter of prime significance.At the same time,prophylactic treatment(restricted exercise,support,or surgery)is also considerable for JSC.

Clinical comprehensive treatment protocol for managing diabetic foot ulcers:A retrospective cohort study

BACKGROUND Diabetic foot ulcers(DFUs)are a common complication of diabetes,often leading to severe infections,amputations,and reduced quality of life.The current standard treatment protocols for DFUs have limitations in promoting efficient wound healing and preventing complications.A comprehensive treatment approach targeting multiple aspects of wound care may offer improved outcomes for patients with DFUs.The hypothesis of this study is that a comprehensive treatment protocol for DFUs will result in faster wound healing,reduced amputation rates,and improved overall patient outcomes compared to standard treatment protocols.AIM To compare the efficacy and safety of a comprehensive treatment protocol for DFUs with those of the standard treatment protocol.METHODS This retrospective study included 62 patients with DFUs,enrolled between January 2022 and January 2024,randomly assigned to the experimental(n=32)or control(n=30)group.The experimental group received a comprehensive treatment comprising blood circulation improvement,debridement,vacuum sealing drainage,recombinant human epidermal growth factor and anti-inflammatory dressing,and skin grafting.The control group received standard treatment,which included wound cleaning and dressing,antibiotics administration,and surgical debridement or amputation,if necessary.Time taken to reduce the white blood cell count,number of dressing changes,wound healing rate and time,and amputation rate were assessed.RESULTS The experimental group exhibited significantly better outcomes than those of the control group in terms of the wound healing rate,wound healing time,and amputation rate.Additionally,the comprehensive treatment protocol was safe and well tolerated by the patients.CONCLUSION Comprehensive treatment for DFUs is more effective than standard treatment,promoting granulation tissue growth,shortening hospitalization time,reducing pain and amputation rate,improving wound healing,and enhancing quality of life.

Portraying Diabetic Foot Ulcers: Comparative Evaluation of Diabetic Foot Infections versus Diabetic Foot Ulcers

Background: Confusion often arises in caring for diabetic foot infections and ulcers, especially with antimicrobials;we aim to shed light on this entity and alert healthcare workers to its stewardship. Methods: Records were reviewed between February 2016 and September 2023. Data for patients diagnosed with diabetes and foot ulcers, infected or not, were examined following ICD 9 search terms. Records for patients were included if they were prediabetic/diabetic adults with foot ulcers, more than 18 years old, and on antidiabetic treatment. Patients were excluded if they insulin resistant, with normal HgbA1c levels, wheel-chair dependent, bed-bound, non-diabetic patients, diabetic patients who had vascular lower limb surgery earlier to ulcers, diabetic patients who had aortocoronary bypass, deep venous thrombosis within six months, malignancy, and severe clinical depression. A modified IWGDF/IDSA guidelines definitions for DFI and DFU was considered. Statistical analysis was done using R programming. Statistical methods were employed as appropriate, and a significant P-value was considered for P Results: Most characteristics were well balanced between DFI and DFU, on imaging osteomyelitis and tissue swelling were significantly more in DFI. Endovascular radiological procedures showed angiograms to be considerably more in DFI, while angioplasty was more in DFU, in addition to smoking. Bacteremia was uncommon, and swab cultures were mostly polymicrobial in both ulcers;no clear association with blood bacteria was detected with the polymicrobial growth, though few were concordant. Antimicrobials prescribed for both ulcers were not statistically different except for carbapenems, which were more in DFI (P Conclusion: Attention should be paid to best practices while caring for diabetic ulcers. These include swab culture interpretations, the use of antimicrobials, and plan management according to DFI or DFU to utilize either local care or combination with antimicrobials.

Oral Mucosa Graft Glanuloplasty—Ten Years in Retrospect

Penile glans amputation is a tragic complication of circumcision. Beyond the psychological trauma parents go through, they have to deal with the lower urinary tract symptoms including acute urine retention their baby boys suffer due to meatal stenosis from the scaring process that ensues. We report on the cosmetic and functional outcomes in two patients ten years after neo-glans reconstruction following total glans amputation as a complication of circumcision and discuss the lessons learned over the period.

Management of neglected femoral neck fracture in above knee amputated limb： A case report

The treatment of an above knee amputee who has sustained a fracture of the femoral neck is a chal- lenging situation for both the orthopedic surgeon and the rehabilitation team. These fractures may be managed acutely either by reduction and internal fixation or by endoprosthetic replacement based on the same criteria as in any other patient with otherwise intact limbs, We present a neglected case treated successfully with valgus osteotomy. We conclude that these fractures should be treated with the same urgency and expertise as similar fractures in non-amputees as long-term survival and good quality of life can be exoected.

Amputation in diabetic foot ulcer:A treatment dilemma

Diabetic foot is a clinical manifestation of diabetes with a wide range of symptoms,including ulceration,osteomyelitis,osteoarticular destruction,and gangrene,as a consequence of advanced disease.Some diabetic foot cases present general indications for amputation,including dead limb,threat to the patient’s life,pain,loss of function,or nuisance.Various tools have been introduced to help decision-making in amputation for diabetic foot.However,it remains a conundrum because diabetic foot involves multiple pathomechanisms and factors that hinder its outcomes.Sociocultural issues often impede treatment from the patient’s side.We reviewed different perspectives in diabetic foot management,particularly related to amputation.In addition to deciding whether to amputate,physicians should address amputation level,timing,and ways to avoid patient deconditioning.Surgeons should not be autocratic in these circumstances and should be aware of beneficence and maleficence when considering whether to amputate.The main goal should be improving the patients’quality of life rather than preserving the limb as much as possible.

Preemptive targeted muscle reinnervation:the single incision approach should be avoided in trans‑tibial traumatic amputation

Dear Editor,Chronic pain is a significant concern after major lower limb amputations that often preclude prosthetic fitting,decrease ambulation,and impact the quality of life[1,2].In the last decade,targeted muscle reinnervation(TMR)has been proposed as a surgical strategy for treating or preventing symptomatic neuromas and phantomlimb phenomena in major amputees[1].This technique involves the transfer of an amputated mixed-motor and sensory nerve to a nearby recipient motor nerve[1,2].Unlike most surgical strategies that aim to hide or protect the neuroma,TMR gives the amputated nerves“somewhere to go and something to do”[2].In a randomized clinical trial on neuroma and phantom pain,Dumanian et al.[1]demonstrated that TMR reduces amputationrelated chronic pain at 1-year post-intervention when compared with the excision and muscle-burying technique,which remains the current gold standard.Valerio et al.[2]also proposed applying TMR at the time of major limb amputation for preventing chronic pain and found that TMR patients experienced less residual limb pain(RLP)and phantom limb pain(PLP)when compared with untreated amputee controls.

A new passive transfemoral prosthesis mechanism based on 3R36 knee and ESAR foot providing walking and squatting

Researchers have proposed various linkage mechanisms to connect knee and ankle joints for above-knee prosthe-ses,but most of them only offer natural walking.However,studies have shown that people assume a squatting posture during daily activities.This paper introduces a novel mechanism that connects the knee joint with the foot-ankle joint to enable both squatting and walking.The prosthetic knee used is the well-known 3R36,while the energy storing and return(ESAR)prosthetic foot is used for the ankle-foot joint.To coordinate knee and ankle joint movements,a six-bar linkage mechanism structure is proposed.Simulation results demonstrate that the proposed modular transfemoral prosthesis accurately mimics the motion patterns of a natural human leg during walking and squatting.For instance,the prosthesis allows a total knee flexion of more than 140°during squatting.The new prosthesis design also incorporates energy-storing mechanisms to reduce energy expenditure during walking for amputees.

Diabetic wounds and artificial intelligence:A mini-review

Diabetic wound takes longer time to heal due to micro and macro-vascular ailment.This longer healing time can lead to infections and other health complications.Foot ulcers are one of the most common diabetic wounds.These are one of the leading cause of amputations.Medical science is continuously striving for improving quality of human life.A recent trend of amalgamation of knowledge,efforts and technological advancement of medical science experts and artificial intelligence researchers,has made tremendous success in diagnosis,prognosis and treatment of a variety of diseases.Diabetic wounds are no exception,as artificial intelligence experts are putting their research efforts to apply latest technological advancements in the field to help medical care personnel to deal with diabetic wounds in more effective manner.The presented study reviews the diagnostic and treatment research under the umbrella of Artificial Intelligence and computational science,for diabetic wound healing.Framework for diabetic wound assessment using artificial intelligence is presented.Moreover,this review is focused on existing and potential contribution of artificial intelligence to improve medical services for diabetic wound patients.The article also discusses the future directions for the betterment of the field that can lead to facilitate both,clinician and patients.

Future applications of exosomes delivering resolvins and cytokines in facilitating diabetic foot ulcer healing

Type 2 diabetes mellitus(T2DM)increases the risk of many lethal and debilitating conditions.Among them,foot ulceration due to neuropathy,vascular disease,or trauma affects the quality of life of millions in the United States and around the world.Physiological wound healing is stalled in the inflammatory phase by the chronicity of inflammation without proceeding to the resolution phase.Despite advanced treatment,diabetic foot ulcers(DFUs)are associated with a risk of amputation.Thus,there is a need for novel therapies to address chronic inflammation,decreased angiogenesis,and impaired granulation tissue formation contributing to the non-healing of DFUs.Studies have shown promising results with resolvins(Rv)and anti-inflammatory therapies that resolve inflammation and enhance tissue healing.But many of these studies have encountered difficulty in the delivery of Rv in terms of efficiency,tissue targetability,and immunogenicity.This review summarized the perspective of optimizing the therapeutic application of Rv and cytokines by pairing them with exosomes as a novel strategy for targeted tissue delivery to treat non-healing chronic DFUs.The articles discussing the T2DM disease state,current research on Rv for treating inflammation,the role of Rv in enhancing wound healing,and exosomes as a delivery vehicle were critically reviewed to find support for the proposition of using Rv and exosomes in combination for DFUs therapy.The literature reviewed suggests the beneficial role of Rv and exosomes and exosomes loaded with antiinflammatory agents as promising therapeutic agents in ulcer healing.

Lower limb amputation rehabilitation status in India: A review

Rehabilitation of lower limb amputation in developing countries is quite challenging.Though there are basic to highly advanced prostheses available in India,the set-up is still facing difficulties in developing countries.Prosthetic management is difficult due to lack of availability of prostheses and reduced affordability among low income populations.In this review we highlighted the lower limb amputation and prosthetic rehabilitation status in India.Currently,India is advancing well in the rehabilitation field,but further studies are required to provide more evidence and recommendation.

Detection,management,and prevention of diabetes-related foot disease in the Australian context

Diabetes-related foot disease(DFD)is a widely feared complication among people who live with diabetes.In Australia and globally,rates of disability,cardiovascular disease,lower extremity amputation,and mortality are significantly increased in patients with DFD.In order to understand and prevent these outcomes,we analyse the common pathogenetic processes of neuropathy,arterial disease,and infection.The review then summarises important management considerations through the interdisciplinary lens.Using Australian and international guidelines,we offer a stepwise,evidence-based practical approach to the care of patients with DFD.

Self-strangulation induced penile partial amputation:A case report

BACKGROUND Traumatic amputation of the penis is a rare surgical emergency,usually caused by self-mutilation,accidents,circumcision,assault and animal attacks.This study aimed to summarize our treatment experience involving penile reconstruction in a rare case of a self-strangulation induced chronical penile partial amputation.CASE SUMMARY A 22-year-old man presented with self-strangulation induced chronical penile partial amputation for 3 mo where the penile proximal part was 1 cm far from the pubis.Reconstruction methods included end-to-end anastomosis of the urethral mucosa,proximal anastomosis of the corpus cavernosum and tunica albuginea of the penis,anastomosis of the deep dorsal vein,dorsal artery,and superficial dorsal vein.Patient urinated smoothly after the catheter was removed on day 21.3 mo after the surgery,the patient's penile preliminary cosmetic appearance was satisfactory,with occasional morning erections.Distal penile sensation was preserved,yet erection hardness of the distal penis was not satisfactory.CONCLUSION Complete preoperative assessment and prompt surgical intervention decreases loss of residual penile functions.

Preserving finger length in a patient with symmetric digital gangrene under local anesthesia:A case report

BACKGROUND Case reports of symmetric digital gangrene resulting from high-dose vasopressors use in patients with alcoholic ketoacidosis,leading to cardiac arrest,are rare.To date,no specific treatment method for autolysis or surgical amputation or guidelines for determining the level of amputation have been established.CASE SUMMARY In this case report,we describe a treatment method that effectively preserved the function of fingers by surgical treatment under local anesthesia with a minimum operative time,while also preserving finger length to the maximum possible extent.CONCLUSION Our approach may contribute to improved postoperative quality of life by preserving finger length.

Gait Analysis of a Subject with Tarsometatarsal Prosthesis

Introduction: Gait analysis of an adult man after trans-metatarsal unilateral amputation is described. Objective: Instrumental gait analysis of a subject 15 years after trans-metatarsal unilateral amputation in two footwear conditions: while walking barefoot and with prosthesis. Materials and Methods: In a movement analysis laboratory, locomotion studies were carried out at freely chosen walking speed by a 65-year-old subject, obtaining kinematic, kinetic and surface electromyographic data in time and space. Gait analysis was performed using instrumental technologies from a digital eco-system applying walking protocols. Results: When the patient wore the prosthesis, several positive improvements were observed in various aspects of gait. These included enhancements in the base of support, gait speed, and joint range of movements. Additionally, there was a slight improvement in the vertical ground reaction forces pattern, indicating a positive effect of the assistive technology. Furthermore, the use of the prosthesis led to a more organized pattern of muscle activity, which further supports its beneficial impact. However, it is worth noting that some challenges still persisted, particularly regarding stabilizing the body during the double support phase. Despite this difficulty, the overall findings suggest that the use of the prosthesis offers valuable improvements to the patient’s gait dynamics. Conclusions: After conducting a thorough analysis of the parameters related to the gait of a subject who underwent a trans-metatarsal unilateral amputation fifteen years ago, it was found that the use of prosthesis had a positive impact. This study demonstrated important improvements in some kinematic and kinetic parameters, including muscle activation patterns, indicating an increase in comfort and confidence while utilizing the prosthetic device.