Search Results (561)

Diabetic foot ulcers drive non-traumatic lower-limb amputation; limb salvage surgery is often pursued to preserve function and survival. Predictors of adverse outcomes remain incompletely defined, and evidence for multidisciplinary team (MDT) care is heterogeneous. We aimed to clarify risk factors for major amputation and death after diabetic limb salvage and evaluate MDT impact. We systematically reviewed 49 studies (2020–2025) reporting major amputation or mortality after limb salvage in diabetes (PROSPERO CRD420251044859). Risk factors spanned demographic, clinical, and surgical domains (e.g., older age, male sex, renal/cardiovascular disease, ischemia, osteomyelitis, advanced ulcer classification). MDT models generally showed lower amputation rates and improved wound healing, with occasional survival benefits; heterogeneity precluded meta-analysis. As a real-world comparator, the Mid Essex Diabetes Amputation Reduction Plan (MEDARP) treated 72 high-risk patients using a “toe and flow” MDT. Major amputation occurred in 6.9% and mortality in 12.5%, both at or below published ranges, with gains in patient-reported outcomes. Findings support MDT-based strategies, but conclusions should be interpreted cautiously given the predominantly observational evidence, and highlight the need for standardized outcome definitions and reporting. Full article

Background/Objectives: The aim of this study was to determine whether incomplete follow-up and competing event risks may be associated with the clinical course after treatment and with known risk factors, such as chronic limb-threatening ischemia (CLTI), in peripheral artery disease (PAD) patients. Methods: Patients hospitalized with PAD who were treated by endovascular or open-surgical means and followed up were included in this retrospective observational study. The primary outcome was reintervention-free survival (RFS); the secondary outcomes and competing events were major amputation and death. The follow-up index (FUI), defined as the ratio between the real and the maximal follow-up interval, was determined for each patient. Results: The FUI depended significantly on the disease stage of CLTI (estimate: −0.16; p: 0.003), endovascular (0.17; p: 0.007) or open-surgical intervention (0.21; p: 0.007) and intra-hospital re-operation (−0.29; p: 0.002) and tended to decrease with age (−0.004; p: 0.09). Independent of disease stage, patients with claudication or CLTI with an FUI < 0.5 had shorter RFS than patients with a FUI ≥ 0.5 (Cox regression, p: 0.07; log-rank test, p: 0.03). When both the FUI and competing risks were considered using Fine–Gray regression analysis, CLTI was associated with RFS (p: 0.016), while FUI (p: 0.004), CLTI (p < 0.001), and the involvement of common femoral (p < 0.001) and posterior tibial arteries (p < 0.001) were associated with major amputation-free survival. Conclusions: Incomplete follow-up is associated with advanced PAD and may itself mask a worse outcome, such as reintervention, restenosis, major amputation, or death. Competing events should also be considered potential sources of bias. Therefore, the FUI and competing events should be reported, and conclusions should be drawn cautiously in both observational and randomized prospective clinical studies. Full article

Bone-anchored implants have transformed prosthetic technology by providing a promising alternative to traditional socket-based prostheses through enhanced stability, comfort, and natural limb functionality. These advancements result from developments in osseointegration techniques, improved surgical methods, and innovative implant materials. To address current limitations, continued research remains essential to enhance safety and effectiveness, thereby promoting wider adoption of these advanced prosthetic solutions. This study focuses on modeling bone-anchored implants for limb prostheses in amputees. The research evaluates structural behavior and performance of osseointegrated implants under various conditions while optimizing implant design. The investigation examines different materials including aluminum, Ti-6Al-4V, and Ti-6Al-4V coated with 10 µm platinum. Additionally, implants of different lengths (207 mm, 217 mm, and 197 mm) were analyzed. The results indicate that Ti-6Al-4V and Ti-6Al-4V coated with ten µm platinum reduce stress by 46% and 65%, respectively. Ti-6Al-4V coated with platinum demonstrates the lowest equivalent stress, highlighting the coating’s effectiveness. Furthermore, the coated implant exhibits the lowest deformation—22.92% less than aluminum and 5.13% less than uncoated Ti-6Al-4V. Shorter implant lengths reduce deformation through increased stiffness, whereas longer implants, such as the 217 mm length display greater deformation due to enhanced flexibility. Full article

Background/Objectives: Despite their low incidence, popliteal artery aneurysms (PAAs) are the most common aneurysms of the peripheral arteries and carry a high risk of limb loss. The optimal treatment, either with open (OR) or endovascular repair (ER), remains debated due to the lack of high-level evidence. Methods: In accordance with STROBE guidelines, we conducted a retrospective observational study with a prospective follow-up. All patients presenting with a PAA who underwent elective OR in the Vascular and Endovascular Surgery Unit of Agostino Gemelli Hospital (Rome, Italy) over the last four years were enrollved. Urgent and endovascular cases were excluded. Clinical examination, Doppler ultrasound (DUS), and contrast-enhanced computed tomography angiography (CTA) were performed preoperatively. Clinical and DUS follow-up was performed at 1, 3, 6, and 12 months postoperatively and annually thereafter. Endpoints were the primary, primary assisted, and secondary patency calculated using a Kaplan–Maier estimate based on the “first event” (arterial stenosis, occlusion, or reintervention) after the procedure. Amputation rate and overall mortality were also assessed. The results were compared with the success and complication rates reported in contemporary endovascular series. Results: Overall, 62 open interventions for popliteal artery aneurysms were performed during the study period; 49 patients (100% male, 70.3 SD ± 8.8 years) were included for a total of 52 PAAs treated electively (median diameter 30.5 mm, range 20–75; 92.3% fusiform). Aneurysm involved P1 segment in 38.5% of cases (20), P2 in 48.1% of cases (25), and P3 in 13.5% of cases (7). Two runoff vessels were present in most patients (37, 71.2%). Surgery consisted of the aneurysm’s exclusion through ligation and autologous vein or prosthetic bypass (25, 48.1%) or aneurysmectomy and interposition graft or end-to-end anastomosis (27, 51.9%). At a mean follow-up of 18 months (SD ± 17.7), the primary, the primary assisted, and the secondary patency were 94.3%, 100%, and 100% respectively. No minor nor major amputations and no deaths were reported. Conclusions: In the endovascular era, our results highlight that regardless the specific characteristics—including age, comorbidities, and aneurysm anatomy—OR provides excellent early and mid-term outcomes with high patency and low complication rate compared with contemporary endovascular series reported in the literature. Full article

Background: Diabetes-related foot diseases represent a global health problem because of the associated complications, the risk of amputation, and the economic burden on health systems. Negative pressure wound therapy (NPWT) is a technique that uses sub-atmospheric pressure to help promote wound healing by reducing the inflammatory exudate while keeping the wound moist, inhibiting bacterial growth, and promoting the formation of granulation tissue. Objective: This study aimed to assess the effectiveness of NPWT in preventing major amputation in diabetic patients with complicated foot or lower limb infections and to contextualize the results through a review of the existing literature. Materials and methods: We conducted a retrospective study at the First Surgical Department of “Dr. I. Cantacuzino” Clinical Hospital in Bucharest, Romania, over a 15-year period, including 30 consecutive adult patients with diabetes and soft tissue foot or lower limb infections treated with NPWT. Patients with non-diabetic ulcers, incomplete medical data, or aged under 18 were excluded. All patients underwent initial surgical debridement, minor amputation, or drainage procedures, followed by the application of NPWT using a standard protocol. Dressings were changed every 2–4 days for a total of 7–10 days. Antibiotic therapy was adapted according to the culture results. The primary outcome was limb preservation, defined as avoidance of major amputation. Secondary outcomes included in-hospital mortality and wound status at discharge. Results: NPWT was associated with a favorable outcome in 24 patients (80%), defined by wound granulation or healing without the need for major amputation. Five patients (16.6%) underwent major amputation because of failure of the primary lesion treatment, and one patient died. No statistically significant association was observed between the outcomes and standard classification scores (WIFI, IWGDF, and TPI). A comprehensive literature review helped to integrate these findings into the existing pool of knowledge. Conclusions: NPWT may support limb preservation in selected diabetic foot cases. While the retrospective design and the small sample size of the study limit generalizability, these results reinforce the need for further controlled studies to evaluate NPWT in real-life clinical settings. The correct use of NPWT combined with etiological treatment may offer a maximum chance to avoid major amputation in patients with diabetes-related foot diseases. Full article

Background and Objectives: Diabetic foot gangrene remains a major cause of lower limb amputation, driven by vascular, neuropathic, and infectious mechanisms. Identifying predictors for amputation type is essential to optimizing outcomes and reducing disability. We aimed to analyze the burden of diabetic foot gangrene and the patients’ characteristics according to the type of surgery, minor or major amputations. Methods: We conducted a retrospective observational study including 295 diabetic patients who underwent surgery for foot lesions at a Romanian tertiary center (January 2023–December 2024). Patients were classified according to surgical outcome as minor (toe/foot-level) or major (below/above-knee) amputations. Clinical, demographic, and pathological variables were compared between groups. Statistical analysis was performed with IBM SPSS Statistics 20.0. Categorical variables were expressed as frequencies and percentages, and continuous variables as mean ± SD or median (min–max). Group comparisons used Student’s t-test, Mann–Whitney U, Chi-square, or Fisher’s exact test, and binary logistic regression was applied to calculate odds ratios (OR) with 95% confidence intervals (CI). Results: Among the patients included (mean age 64.8 ± 10.8 years; 69.2% male), 191 (64.7%) underwent minor amputations/debridement and 104 (35.3%) required major amputations. Patients with major amputations were older (66.8 ± 11.3 vs. 63.7 ± 10.4 years, p = 0.012) and less frequently male (56.7% vs. 75.9%, p = 0.001). Lesion extension to the foot or beyond strongly predicted major amputation (p < 0.001). Peripheral arterial disease was more prevalent in the major group (85.6% vs. 65.4%, OR = 3.13, 95% CI = 1.68–5.84), while neuropathy was associated with minor procedures (12.6% vs. 3.8%, p = 0.015). Anemia (70.2% vs. 56.5%, p = 0.021) and leukocytosis (68.3% vs. 49.2%, p = 0.002) were also independent predictors of major amputation. Conclusions: The study highlights the need for early detection, coordinated multidisciplinary care, and personalized assessment of diabetes burden and its complications to minimize the risk of major limb amputation. Full article

Background: Mobility assessment is a crucial aspect of rehabilitation for individuals with lower limb amputation, as it directly influences their independence and quality of life. The objective of this study was to translate and cross-culturally adapt the Special Interest Group in Amputee Medicine (SIGAM) mobility grades questionnaire in the Persian language and to investigate its psychometric properties. Methods: The SIGAM mobility scale was translated into Persian according to international guidelines for cross-cultural adaptation of self-reported measures and was administered to forty Persian-speaking people with lower limb amputations. Measurement properties were evaluated following COSMIN (COnsensus-based Standards for the Selection of Health Measurement INstruments) recommendations and included internal consistency, test–retest reliability, and hypotheses testing for construct validity by comparing SIGAM mobility grades to the Locomotor Capabilities Index-5 (LCI-5), Houghton scale, Activities-specific Balance Confidence (ABC) scale, the 2-Minute Walk Test (2-MWT), and the Timed Up and Go (TUG). Results: SIGAM mobility scale demonstrated acceptable internal consistency (Kuder-Richardson 20 coefficient = 0.72) and excellent test–retest reliability (Cohen Kappa coefficient = 0.85). Hypothesis testing for construct validity confirmed the good to very good correlations of the Persian SIGAM mobility scale with the LCI-5 (r = 0.63, 0.55, and 0.63 for the general, basic, and advanced activities components, respectively), Houghton scale (r = 0.63), ABC scale (r = 0.73), 2-MWT (r = 0.50), and TUG test (r = −0.51). Conclusion: The Persian version of the SIGAM mobility scale demonstrated preliminary evidence of acceptable psychometric properties, supporting its clinical applicability. Full article

Background: In Peripheral Artery Disease (PAD), there is an association between risk factors, the location of atherosclerotic lesions, and outcomes. Methods: This is a retrospective single-center analysis of adult PAD patients admitted between 2018 and 2021 with a follow-up until the end of 2023. Lesions were allocated to “suprainguinal”, “infrainguinal-to-popliteal”, “infrapopliteal”, “two of three levels” and “all three levels” categories based on angiogram findings. The primary endpoint at the patient level was amputation-free survival and was major adverse limb events (MALEs) at the limb level. Results: A total of 2067 patients with 2633 affected limbs were analyzed, and 28.8% were female. At first admission, the median age was 68, and the most frequent PAD Fontaine stage was IIb (44.9%). Lesions were suprainguinal in 11.6%, infrainguinal-to-popliteal in 18.3%, infrapopliteal in 11.4%, two levels in 36.0%, and all three levels in 8.3%. Over 1020 days as the median follow-up, amputation-free survival was 67.6%, highest (92.5%) for suprainguinal lesions, and lowest (59.3%) for infrapopliteal lesions. At the patient level, the risk of major amputation or death was highest in infrapopliteal lesions and was equally likely in cases of two or three affected locations and was reduced in infrainguinal-to-popliteal lesions (Hazard Ratio, HR 0.62, 95% CI 0.44–0.87, p = 0.007) and suprainguinal lesions (HR 0.42, 95% CI 0.21–0.79, p = 0.008). At the limb level, compared to lesions in all three locations, the risk of MALEs was reduced in infrainguinal-to-popliteal lesions (HR 0.51, 95% CI 0.27–0.98, p = 0.044) and was equally likely in all other cases. Conclusions: Amputation-free survival was lowest in cases of infrapopliteal lesions or multi-level disease. At the limb level, isolated infrainguinal-to-popliteal lesions were associated with the lowest risk of MALEs. Full article

Background: Lower limb amputation (LLA), due to non-traumatic causes such as vascular diseases and diabetes, significantly impacts patients’ physical, psychological, and social well-being. While multidisciplinary rehabilitation programs commonly address physical and functional recovery, psychological and subjective experiences related to limb loss remain less explored. Thus, this preliminary study aimed to investigate the psychological and behavioral adaptation processes in patients undergoing rehabilitation following lower limb amputation. Methods: A preliminary observational study with a mixed-method approach based on quantitative and qualitative data triangulation was conducted. This approach involves integrating multiple data sources and methodologies—in this case, quantitative psychometric measures and qualitative interviews via the prospective of amputees and those who use prostheses—to enhance the validity and depth of the research findings. Results: Fourteen inpatient amputees and fourteen inpatient prosthesis users (years: 66.6 ± 2.5 for amputee and 61.5 ± 1.9 for prosthesis users, male amputees: 85.7%, male prosthesis users: 100%) of a research hospital in the North of Italy were assessed using validated psychometric tools (GAD-7, PHQ-9, PID-5-BF, BIS, ASonA) alongside semi-structured interviews analyzed through the Interpretive Description approach. Key themes highlighted illness acceptance, prosthesis adaptation, body image, medication and behavioral adherence, anxiety, depression, quality of life, denial, optimism, and social support. Overall, anxiety–depressive symptomatology tended to decrease with the prosthesis, and pharmacological and behavioral adherence improved, as did the disease acceptance. Body image was fairly preserved in all patients despite some fears of others’ judgment with respect to the prosthesis. Interestingly, there was poor agreement between quantitative and qualitative data in both the amputee’ and prosthesis users’ groups: while the former returned a partial and neutral picture, a more multifaceted picture emerged from the interviews collected. Conclusions: These findings underline the importance of integrating quantitative psychometric evaluations with qualitative methods to comprehensively understand patients’ adaptive experiences. Such combined insights are essential to inform tailored psychological interventions throughout the rehabilitation journey. Full article

Background: Although most amputations caused by diabetes and peripheral artery disease (PAD) are preventable, current limb preservation efforts in the United States remain poorly understood. This study aims to identify key barriers and facilitators to limb preservation from the primary care provider (PCP) perspective. We plan to use the insights from this work to promote targeted intervention strategies. Methods: Using a mixed-methods design, an online 5–10 min survey was distributed to Oklahoma primary care providers who could elect to participate further in a semi-structured, audio-recorded interview. Descriptive analysis was used to summarize survey results. Interviews were transcribed and qualitatively analyzed using grounded theory. Donabedian’s structure, process, and outcome framework was used to categorize how each identified barrier and facilitator increases or reduces the risk of limb loss for at-risk patients at the practice level. Finally, we compared and contrasted survey and interview findings. Results: Thirty surveys were completed (approximately 14% response rate), and seven interviews were conducted with PCPs geographically dispersed across Oklahoma. Most clinicians reported in the survey that they see at-risk limbs at least once every 1–2 months (n = 29, 96.7%). Half of clinicians were satisfied or very satisfied with access to vascular surgery (n = 15, 50.0%), interventional specialists (n = 13, 43.3%), and endocrinologists (n = 12, 40.0%). Finally, survey respondents reported that social needs most often affecting their patients with a limb at risk of amputation include income, health education, transportation, and health insurance. Interviews confirmed PCPs frequently see at-risk limbs. We identified thematic barriers to limb preservation that included limited access to specialty care, limited PCP and patient amputation prevention education, and patient social struggles surrounding transportation, finances, and insurance. Patient advocates (community, clinical, or personal), affordable medications, and more time with patients were reported as facilitators in amputation prevention. Conclusions: Oklahoma PCPs frequently see at-risk feet, realize poor access to care, and desire structural change to support excellent preventive care in diabetes and PAD. Limb preservation in Oklahoma is contingent upon shifting from disempowerment to engagement that requires systemic reform, clinical innovation, and community engagement. We identified several intervention strategies, including increasing education for PCPs to empower them to initiate early prevention, improving early identification and preventive therapy for patients at risk for limb loss, and cultivating specialty care access via networking and policy change. Full article

Background: Post-traumatic osteomyelitis (PTO) of the lower extremity is among the most demanding problems in orthoplastic reconstructive surgery. It typically follows open fractures, failed osteosynthesis, or implant infection. Effective management requires coordinated infection control, stable skeletal fixation, and timely vascularized soft-tissue coverage. Methods: We conducted a retrospective case series of 20 consecutive patients with PTO of the lower limb treated between 2021 and 2024 at a tertiary orthoplastic center. All patients underwent radical debridement, culture-directed intravenous antibiotic administration, and soft-tissue reconstruction using local muscle, fasciocutaneous, or free flaps; vascularized bone flaps were used to select nonunion cases. The primary outcomes were flap survival, complications, infection resolution, and limb salvage. Exploratory analyses included descriptive subgroup summaries by flap category. Results: Among 20 patients (15 men, 5 women; mean age 53.6 years), reconstructions included reverse/pedicled sural flaps (n = 9), hemisoleus muscle flaps (n = 7), medial gastrocnemius muscle flaps (n = 2), peroneus brevis muscle flaps (n = 2), and free flaps (n = 6), which comprised anterolateral thigh (ALT), medial femoral condyle (MFC) osteoperiosteal, deep circumflex iliac artery (DCIA) osteocutaneous, and radial forearm free flaps (RFFFs). Single-flap reconstructions were performed in 13 cases, whereas multistage/multiflap strategies were used in 7. Overall flap survival was 90%. Major flap complications comprised partial necrosis in two reverse sural flaps and one complete loss of a reverse sural flap; two patients had minor wound dehiscence. Infection resolved in 18/20 patients (90%; 95% CI ≈ 0.70–0.97). One patient requested below-knee amputation due to persistent nonunion associated with a pathological fracture. At a mean 10-month follow-up, all limb-salvaged patients were ambulatory. Conclusions: Effective reconstruction of PTO is improved by using a patient-specific algorithm that considers the defect location, vascular status, and host comorbidities. Local muscle and fasciocutaneous flaps remain dependable for most defects, with free or vascularized bone flaps reserved for composite or recalcitrant cases. Early referral to high-volume centers, radical debridement, and orthoplastic collaboration are critical for optimizing limb salvage. Our findings should be interpreted in light of the study’s retrospective design and small sample size. Full article

A three year old male neutered mixed breed dog presented with a mass on the right carpus and accompanying lameness. A Jamshidi bone biopsy was performed, and histopathology results were consistent with a sarcoma. The dog received oncolytic virotherapy (OV) with vesicular stomatitis virus (VSV) as part of a clinical trial in dogs with osteosarcoma (OSA). Ten days after VSV treatment, the affected limb was amputated, and histopathology was consistent with intramedullary HSA. Considering the new diagnosis, standard doxorubicin chemotherapy was prescribed. With this combination of therapies, the dog had an extended survival of more than seven years and remains alive at the time of writing. This is the first case report documenting OV given in conjunction with the standard of care for canine appendicular HSA. Full article

This study proposes a feature extraction scheme that fuses accelerometric (ACC) and electromyographic (EMG) data to improve shoulder movement identification in individuals with transhumeral amputation, in whom the clinical need for intuitive control strategies enabling reliable activation of full-arm prostheses is underinvestigated. A novel spatiotemporal warping feature extraction architecture was employed to realize EMG and ACC information fusion at the feature level. EMG and ACC data were collected from six participants with intact limbs and four participants with transhumeral amputation using an NI USB-6009 device at 1000 Hz to support the proposed feature extraction scheme. For each participant, a leave-one-trial-out (LOTO) training and testing approach was used for developing pattern recognition models for both the intact-limb (IL) and amputee (AMP) groups. The analysis revealed that the introduction of ACC information has a positive impact when using windows of length (WLs) lower than 150 ms. A linear discriminant analysis (LDA) classifier was able to exceed the accuracy of 90% in each WL condition and for each group. Similar results were observed for an extreme learning machine (ELM), whereas k-nearest neighbors (kNN) and an autonomous learning multi-model classifier showed a mean accuracy of less than 87% for both IL and AMP groups at different WLs, guaranteeing applicability over a large set of shallow pattern-recognition models that can be used in real scenarios. The present work lays the groundwork for future studies involving real-time validation of the proposed methodology on a larger population, acknowledging the current limitation of offline analysis. Full article

Background and Objectives: The impact of peripheral below-the-knee (BTK) fractional flow reserve (FFR) on long-term clinical outcomes remains unknown. Materials and Methods: We enrolled 40 patients with severe BTK lesions (Rutherford 4–6). FFR (using 40 mg papaverin) and skin perfusion toe pressure (SPTP) by laser Doppler were measured during the index procedure. The primary outcomes were major adverse limb events (MALEs) (defined as reintervention on the index arterial segment or amputation of the index limb) and death during follow-up. Results: The median follow-up was 7 [IQR 4–8] years. After the index procedure, FFR increased significantly (p < 0.001) and post-revascularization SPTP was significantly higher in the FFR ≥ 0.80 group (p = 0.022). Multivariable regressions showed no association between change in FFR (absolute or percentage) and the risk of death (p = 0.39, p = 0.28) or MALEs (p = 0.83, p = 0.29), but both pre- and post-revascularization FFR values could predict MALEs at follow-up (p = 0.018, p = 0.012). Lower SPTP was also associated with the risk of MALEs (p = 0.027). SPTP > 97.8 mmHg was 100% specific for FFR ≥ 0.80. Conclusions: While there is no association between change in FFR and the risk of death or MALEs, lower FFR values either before or after revascularization were associated with higher long-term risk of MALEs. Moreover, a lower SPTP was associated with a higher risk of MALEs. Aiming for approximately 100 mmHg in SPTP represents a non-invasive surrogate of FFR ≥ 0.80. Larger studies are needed to validate the impact of post-revascularization FFR-SPTP-adjacent values on clinical outcomes. Full article

Systems presenting haptic information have emerged as an important technological advance in assisting individuals with sensory impairments or amputations, where the aim is to enhance sensory perception or provide sensory substitution through tactile feedback. These systems provide information on limb positioning, environmental interactions, and gait events, significantly improving mobility in amputees and their confidence about using such devices. This review summarizes recent progress in haptic feedback systems by providing a comparative analysis of different feedback approaches, evaluating their clinical effectiveness and usability, tactile feedback system design, and user experience, while identifying key gaps in the literature. These insights can contribute to the advancement of more effective, user-centered haptic feedback systems tailored for lower limb prosthetics. The findings are aimed at guiding future research in designing adaptive, intuitive, and clinically viable feedback mechanisms, fostering the widespread implementation of haptic systems in both assistive and rehabilitative applications. Full article