Aims

This study describes the Osseointegration Group of Australia’s Accelerated Protocol two-stage strategy (OGAAP-1) for the osseointegrated reconstruction of amputated limbs.

Introduction. Lower limb amputation is associated with significant morbidity and mortality. Reflecting the predominance of vascular or diabetic disease as a cause for lower limb amputation, much of the available literature excludes lower limb amputation secondary to trauma in the reporting of complication rates. This paucity in the literature represents a research gap in describing the incidence of complications in lower limb amputation due to trauma, which we aim to address. Materials and Methods. Retrospective analysis of a prospectively collected database of all traumatic lower limb amputations secondary to trauma from a regional multidisciplinary amputee service at Queen Mary's Hospital. Electronic patient records and paper notes were consulted for evidence of re-operation, infection (superficial or deep), phantom limb pain and neuroma. 222 patients were screened and 108 included in the data analysis. Results. Records identified 108 lower limb amputations secondary to trauma in 99 patients with a mean age of 34 years (at time of amputation). Average follow-up was 225 months. 33.6% of patients underwent re-operation, 25.2% had at least one episode of infection. Of those who underwent re-operation, 47.2% had evidence of infection. 42% and 3.7% of patients described phantom limb pain and neuroma respectively. Conclusions. Lower limb amputations secondary to trauma exhibit higher rates of re-operation and infection compared to vascular or diabetic amputees. This first study to provide high quality data describing the incidence of complications such as re-operation, infection, phantom limb pain and neuroma in lower limb amputations secondary to trauma

A major cause of morbidity in lower limb amputees is phantom limb pain (PLP) and residual limb pain (RLP). This study aimed to determine if surgical interposition of nerve endings into adjacent muscle bellies at the time of major lower limb amputation can decrease the incidence and severity of PLP and RLP. Data was retrospectively collected from January 2015 to January 2021, including eight patients that underwent nerve interposition (NI) and 36 that received standard treatment. Primary outcomes included the 11-point Numerical Rating Scale (NRS) for pain severity, and Patient-Reported Outcomes Measurement Information System (PROMIS) pain intensity, behaviour, and interference. Secondary outcome included Neuro-QoL Lower Extremity Function assessing mobility. Cumulative scores were transformed to standardised t scores. Across all primary and secondary outcomes, NI patients had lower PLP and RLP. Mean ‘worst pain’ score was 3.5 out of 10 for PLP in the NI cohort, compared to 4.89 in the control cohort (p=0.298), and 2.6 out of 10 for RLP in the NI cohort, compared to 4.44 in the control cohort (p=0.035). Mean ‘best pain’ and ‘current pain’ scores were also superior in the NI cohort for PLP (p=0.003, p=0.022), and RLP (p=0.018, p=0.134). Mean PROMIS t scores were lower for the NI cohort for RLP (40.1 vs 49.4 for pain intensity; p=0.014, 44.4 vs 48.2 for pain interference; p=0.085, 42.5 vs 49.9 for pain behaviour; p=0.025). Mean PROMIS t scores were also lower for the NI cohort for PLP (42.5 vs 52.7 for pain intensity; p=0.018); 45.0 vs 51.5 for pain interference; p=0.015, 46.3 vs 51.1 for pain behaviour; p=0.569). Mean Neuro-QoL t score was lower in NI cohort (45.4 vs 41.9;p=0.03). Surgical interposition of nerve endings during lower limb amputation is a simple yet effective way of minimising PLP and RLP, improving patients’ subsequent quality of life. Additional comparisons with targeted muscle reinnervation should be performed to determine the optimal treatment option

Aims. In recent conflicts, most injuries to the limbs are due to blasts resulting in a large number of lower limb amputations. These lead to heterotopic ossification (HO), phantom limb pain (PLP), and functional deficit. The mechanism of blast loading produces a combined fracture and amputation. Therefore, to study these conditions, in vivo models that replicate this combined effect are required. The aim of this study is to develop a preclinical model of blast-induced lower limb amputation. Methods. Cadaveric Sprague-Dawley rats’ left hindlimbs were exposed to blast waves of 7 to 13 bar burst pressures and 7.76 ms to 12.68 ms positive duration using a shock tube. Radiographs and dissection were used to identify the injuries. Results. Higher burst pressures of 13 and 12 bar caused multiple fractures at the hip, and the right and left limbs. Lowering the pressure to 10 bar eliminated hip fractures; however, the remaining fractures were not isolated to the left limb. Further reducing the pressure to 9 bar resulted in the desired isolated fracture of the left tibia with a dramatic reduction in the fractures to other sites. Conclusion. In this paper, a rodent blast injury model has been developed in the hindlimb of cadaveric rats that combines the blast and fracture in one insult, necessitating amputation. Experimental setup with 9 bar burst pressure and 9.13 ms positive duration created a fracture at the tibia with total reduction in non-targeted fractures, rendering 9 bar burst pressure suitable for translation to a survivable model to investigate blast injury-associated diseases. Cite this article: Bone Joint Res 2021;10(3):166–173

Context: Diabetes is associated with a several fold increase in the risk of lower extremity amputation. Although a number of epidemiologic studies have reported positive associations between glycaemia and lower extremity amputation, the magnitude of the risk has not been adequately quantified. Objective: To synthesize the available prospective epidemiologic data on the association between glycaemia as measured by glycosylated haemoglobin and lower extremity amputation in individuals with diabetes. Data Sources: We searched electronic databases (MED-LINE and EMBASE) and the reference lists of relevant articles. Study Selection: We considered prospective epidemiologic studies of cohort or nested case-control design that measured glycosylated haemoglobin level and assessed lower extremity amputation as an outcome. Of 2,398 citations identified, we included 14 studies comprising 94,640 subjects and 1,227 cases. Data Extraction: Data were abstracted using standardized forms or obtained from investigators when published information was insufficient. Data included characteristics of case and control populations, measurement of glycaemia, assay methods, outcome, and covariates. Results: The overall risk ratio for lower extremity amputation was 1.26 (95% CI, 1.16–1.36) for each percentage point increase in glycosylated hemoglobin level. There was significant heterogeneity across studies (I2: 76%, 67–86%; p< 0.001) not accounted for by recorded study characteristics. Among studies that reported the type of diabetic population, the combined estimate was 1.44 (1.25–1.65) for individuals with type 2 diabetes and 1.18 (95% CI, 1.02–1.38) for type 1 diabetes, but the difference was not statistically significant (p=0.09). We found no significant publication bias. Conclusions: There a substantial increase in risk of lower extremity amputation associated with every 1% higher HbA1c in individuals with diabetes, highlighting a potential benefit of blood glucose control. In the absence of evidence from clinical trials, this paper supports glucose-lowering as a component of overall care in the patient at high risk of amputation

A common injury pattern in current military experience is traumatic lower limb amputation from improvised explosive devices. This injury can coexist with pelvic girdle fractures. Of 67 consecutive patients with traumatic lower limb amputations treated in Camp Bastion Hospital Afghanistan, 16 (24%) had an associated pelvic fracture (10 APC/vertical shear and 6 acetabular or pubic rami fractures). Traumatic single amputees (n=28) had a 14% incidence of associated pelvic fracture with traumatic double amputees (n=39) increasing this association to 31%. However if the double amputations were above knee the incidence of associated open book fractures was 26% (6/23) with 39% (9/23) sustaining some form of pelvic bony injury. The majority of patients (95%) had a pelvic X-ray as part of the primary survey. Of these 51% (n=34) had a Sam sling(r) in situ but only fifteen were deemed appropriately applied. Given the high risk of pelvic fractures in patients with traumatic bilateral lower limb amputations, particularly those involving opening of the pelvic ring, it is imperative that the earliest and proper application of a pelvic binder be initiated

Introduction. A common injury pattern in current military experience is traumatic lower limb amputation from improvised explosive devices. This injury can co-exist with pelvic girdle fractures. Methods. We reviewed 67 consecutive patients with traumatic lower limb amputations treated in Camp Bastion Hospital, Afghanistan. Results. 16 (24%) had an associated pelvic fracture (10 APC/vertical shear and 6 acetabular or pubic rami fractures). Traumatic single amputees (n=28) had a 14% incidence of associated pelvic fracture with traumatic double amputees (n=39) increasing this association to 31%. However, if the double amputations were above knee, the incidence of associated open book fractures was 26% (6/23) with 39% (9/23) sustaining some form of bony pelvic injury. The majority of patients (95%) had a pelvic X-ray as part of the primary survey. Of these 51% (n=34) had a Sam sling. (r). in situ but only fifteen were deemed appropriately applied. Conclusions. Given the high risk of pelvic fractures in patients with traumatic bilateral lower limb amputations, particularly those involving opening of the pelvic ring, it is imperative that the earliest and proper application of a pelvic binder be initiated

Amputation is one of the most feared injuries in service personnel, particularly a worry that it will mean the end of their military career. The aim of this study was to determine the outcome, in relation to military service in UK military amputees. UK service personnel who sustain an amputation undergo rehabilitation and prosthetic limb fitting at the Defence Medical Rehabilitation Centre Headley Court. This includes a realistic assessment of their employment capabilities, and they are graded by a Functional Activity Assessment (FAA). FAA ranges from 1 (fully fit) to 5 (unfit all duties). In addition the Short Form-36 Health Survey (SF-36) is completed on initial admission and at follow-up. We reviewed this information to determine the outcome of military amputees. We identified 53 casualties who had sustained amputations. 8 had sustained an upper limb amputation, 41 a lower limb amputation, and 4 had sustained both an upper and lower limb amputation. 9 patients (including 1 Reservist) have left the forces by medical discharge, with the remaining 44 continuing to serve. 32 of the 44 have returned to work, albeit at a lower level. 49 patients have FAA grades and are at least 6 months post-injury. No patients were graded as FAA 1, 8 as FAA 2 (Fit for Trade and fit for restricted General or Military Duties), 18 as FAA 3 (Unfit for Trade but fit for restricted General or Military Duties), 18 as FAA 4 (Unfit for all but Sedentary Duties) and 5 as FAA 5. All bilateral and triple amputees were FAA 4 or 5. Other injuries such as blindness, severe brain injury or mental health issues also increased the FAA. Of the 32 patients who have returned to work, 8 are FAA 2, 12 are FAA 3, 11 are FAA 4, and 1 has not been graded. SF-36 data was available in 40 patients, available as paired scores for 34. The mean time between SF-36 scoring was 6.7 months (range 0.2 – 17.4). The mean SF-36 scores for Physical Component Summary (PCS) increased from 34.40 (SD 9.3) to 42.06 (SD 11.1), with Mental Component Summary (MCS) 52.01 (SD12.9) remaining similar at 52.92 (SD 12.0). Pre- and post-rehabilitation PCS scores improved with rehabilitation (p=0.0003). MCS scores were similar in these patients to the normal population, 50 (SD 10). No differences could be found within the unilateral lower limb amputation group regarding amputation level (trans-tibial, through-knee disarticulation, trans-femoral) and SF-36 scoring. Furthermore due to the low numbers, no conclusion could be made comparing the unilateral lower limb amputation group with the bilateral lower limb group, the unilateral lower limb plus upper limb, the bilateral lower limb and upper limb (trilateral), and the isolated upper limb groups. This study is the first to report the outcomes, with regards to return to work, of the UK military amputee population injured in Afghanistan and Iraq. There is an almost even distribution of FAA score between 2, 3, and 4 for those back at work. Level of amputation and SF-36 scores do not seem to correlate, partly due to other injuries sustained that confound the patients’ perception of their health. SF-36 PCS scores increase significantly with rehabilitation, whilst MCS remain similar to the normal population

The accepted mechanism of traumatic limb amputation following blast is initial bone disruption due to the shock wave, with amputation completed by the blast wind; survival is considered unlikely. The high survival rate of traumatic amputees following explosion, from the current conflict in Afghanistan, is at odds with previous work. We reviewed extremity injuries, sustained in Afghanistan by UK military personnel, over a 2 year period. 774 British servicemen and women sustained AIS >1 injuries, 72.6% of whom survived. No significant difference was found in the survival rates following explosive blast or gunshot (p>0.05). 169 casualties (21.8%) sustained 263 lower limb and 74 upper limb traumatic amputations. Amputations were more common in the lower than the upper limbs and more common in the extremity proximal bone. Bilateral lower limb amputations were more common than a unilateral lower limb amputation. The majority (99%) of major amputations were sustained as a result of explosion. 46.3% (74) of those who sustained a major amputation following explosion survived. Rates of fatalities caused by explosion, or by small arms are not statistically different. Blast-mediated amputations are not universally fatal, and a significant number were through joint, calling into question previously proposed mechanisms

The UK Military Trauma Registry was searched for all cases of primary bilateral lower limb amputation sustained over 6-years between March 2004 and March 2010. There were 1694 UK military patients injured or killed during this six-year study period. Forty-three of these (2.8%) were casualties with bilateral lower limb amputations. All were men injured in Afghanistan by Improvised Explosive Devices. Six casualties were in vehicles when they were injured with the remaining 37 (80%) patrolling on foot. The mean New Injury Severity Score was 48.2 (SD 13.2). Nine patients also lost an upper limb (triple amputation); no patients survived loss of all four limbs. Six patients (14%) sustained an open pelvic fracture. Perineal/genital injury was a feature in 19 (44%) patients, ranging from unilateral orchidectomy to loss of genitalia and permanent requirement for colostomy and urostomy. The mean requirement for blood products was 66 units (SD=41.7). The minimum transfusion requirement was 8 units and the greatest was a patient requiring a total of 193 units of blood products. Our findings detail the severe nature of these injuries together with the massive surgical and resuscitative efforts required to firstly keep patients alive and secondly reconstruct and prepare them for rehabilitation

Aim. The aim of this study was to compare outcomes between patients with diabetic foot soft-tissue infection and osteomyelitis. Methods. Medical records of patients with diabetic foot infection involving either soft-tissue (STI) or bone (OM) were retrospectively reviewed. Diagnosis was determined by bone culture, bone histopathology or imaging with magnetic resonance imaging (MRI) or single-photon emission computed tomography (SPECT/CT). Patient outcomes were recorded up to 1 year after admission. Results. Out of 294 patients included in the study, 137 were diagnosed with STI and 157 had OM. No differences in age (p=.40), sex (p=.79), race (p=.83), body-mass index (p=.79) or type of diabetes (p=.77) were appreciated between groups. Frequency of comorbidities (neuropathy, chronic kidney disease, peripheral arterial disease) also did not differ except for increased prevalence of cardiac disease in patients with STI (86.9%) compared to those with OM (31.8%) (p<.00001) and decreased prevalence of retinopathy (24.8% vs. 35.7%) (p=.04). Patients with OM had greater C-reactive protein (p<.00001), erythrocyte sedimentation rate (p<.00001) and white blood cell count (p<.00001). Among 1-year outcomes, patients with OM more often underwent surgery (p<.00001), had lower limb amputations (p<.00001), became reinfected (p=.0007), were readmitted for the initial problem (p=.008), had longer time to healing (p=.03) and had longer hospital length of stay (p=.00002). However, no differences in 1-year mortality (p=1.000), overall 1-year readmission (p=.06) or healing within 1-year (p=.64) were appreciated. Conclusion. In our study, OM was associated with more aggressive treatment, reinfection and longer time to healing than STI. However, despite being associated with more aggressive care and readmissions, patients with diabetic foot OM has similar 1-year mortality and healing rates to those with diabetic foot STI

Background. The decision to attempt limb salvage vs to amputate in a significant traumatic limb injury is based on patient´s best predicted outcome. When amputation cannot be avoided the aim is to provide a pain free limb whilst preserving the soft tissue and limb length. Methods. Retrospective study covering 5 years (2011–2016), all the trauma patients requiring lower limb amputation (LLA) included. Demographics, mechanism, type of injury, amputation type, cause and level, theatre trips for stump management were analysed. Results. 19 patients aged 27–93 included. RTC was the leading cause (47%) of LLA. Amputation type: traumatic, caused by the injury itself (31.5%) acute surgical, amputation performed in a limb threatening injury (37%); 72% of them had vascular compromise delayed amputations after failure of limb salvage surgery (31.5%); failed soft tissue coverage and poorly functioning limb were the lead cause (33% each) Type of injury: open fractures (89%), isolated to a limb segment (53%). One level/extended level=9/10 patients. More than 50% of initial amputations were extended with multiple subsequent theatre trips (33/10 patients) for stump management. Conclusions. It was difficult to predict the patients needing an extended amputation. Early MDT and prosthetic rehab service involvement is crucial in LLA decision. When consenting patients for LLA consider a 50% change to extend the initial level of amputation with subsequent theatre trips

Aim. For which patients is bone defect reconstruction with the Masquelet-technique after the treatment of osteomyelitis suitable and which results did we have. Methods. From 11/2011 to 4/2018 we treated 112 Patients (36f, 76m) with bone defects up 150mm after septic complications with the Masquelet-technique. We had infected-non-unions of upper and lower extremity, chronic osteomyelitis, infected knee-arthrodesis and knee- and ankle-joint-empyema. On average the patients were 52 (10–82) years old. The mean bone defect size was 48 mm (15–150). Most of our patients came from other hospitals, where they had up to 20 (mean 5.1) operations caused by the infection. Time before transfer in our hospital was on average 7,1 months (0,5–48). 77 patients received free (25) or local (52) flaps because of soft tissue-defects. 58 patients suffered a polytrauma. In 23 cases femur, in 4 cases a knee arthrodesis, in 68 cases tibia, in 1 case foot, 6 times ankle-joint arthrodesis, in 6 cases humerus, in 4 cases forearm were infected resulting in bone defects,. In most cases the indication for the Masquelet-technique was low-/incompliance due to higher grade of brain injury and polytrauma followed by difficult soft tissue conditions and problems with segmenttransport. In 2/3 positive microbial detection succeeded at the first operation. Mainly we found difficult to treat bacteria. After treating the infection with radical sequestrectomy, removal of foreign bodies and filling the defect with antibiotic loaded cementspacer and external fixation we removed the spacer in common 6–8 weeks later and filled the defect with autologeous bone graft. Most of the patients needed an internal fixation after removing of the fixex. All patients were examined clinically and radiologically every 4–6 weeks in our outpatient department until full weight bearing, later every 3 Months. Results. in 93 of 112 cases the infection was clinically treated successful. 48 patients are allowed full weight bearing (45 with secondary internal plates). There were 18 recurrences of infection, 3 patients underwent lower limb amputation. Conclusions. For patients with low-/incompliance for various reasons and for those with difficult soft tissue conditions following flaps the masquelet technique is a valuable alternative to normal bone graft or segmenttransport. The stiffness of the new masquelet-bone as a rod seems a problem and internal fixation is necessary

Aim. To assess the spread of foot infection and its impact on the outcomes of major amputations of lower extremities in diabetic patients. Method. In a multicentre retrospective and prospective cohort study, we included adult diabetic patients (≥ 18 years) who underwent a major amputation of a lower limb in 5 hospitals between 2000 and 2009, 2012 and 2014. A total of 51 patients were included (of which 27 (52.94%) were men and 24 (47.06%) were women) with the mean age of 65.51 years (SD=16.99). Concomitant section's osseous slice biopsy (BA) and percutaneous bone biopsy of the distal site (BD) were performed during limb amputation. A new surgical set-up and new instruments were used to try and reduce the likelihood of cross-contamination during surgery. A positive culture was defined as the identification of at least 1 species of bacteria not belonging to the skin flora or at least 2 bacteria belonging to the skin flora (CoNS (coagulase negative staphylococci), Corynebacterium spp, Propionibacterium acnes) with the same antibiotic susceptibility profiles. A doubtful culture was defined as the identification of 1 species of bacteria belonging to the skin flora. The patients were followed-up for 1 year. Stump outcomes were assessed on the delay of complete healing, equipment, need of re-intervention and antibiotics. Results. In total, 51 BA were performed during major lower limb amputations (17 above the knee and 34 below the knee) in diabetic patients. Nine (17.65%) bacterial culture results from BA specimens were positive, 7 (13.73%) doubtful and 35 (68.63%) sterile. Before amputation, 23 patients (45.1%) had not received any antibiotics, including 16 (31.37%) with an antibiotic-free interval of 15 days or more. Microorganisms identified in BA were also cultured from the distal site in 33.33% of the cases. Positive BA was associated with prolonged complete stump healing, delay of complete healing (more than 6 months), re-amputation and the need of antibiotics. Conclusions. The microorganisms identified from BA play a role in stump healing in diabetic patients. BA is useful during major limb amputation due to infectious complications and antibiotic therapy could be corrected on the basis of the BA culture results

Conflict in Afghanistan demonstrated predominantly lower extremity and pelvi-perineal trauma secondary to Improvised Explosive Devices (IEDs). Mortality due to pelvic fracture (PF) is usually due to exsanguination. This study group comprised 169 military patients who sustained a PF and lower limb injury. There were 102 survivors and 67 fatalities (39% mortality). Frequent fracture patterns were a widened symphysis (61%) and widening of the sacroiliac joints (SIJ) (60%). Fatality was 20.7% for undisplaced SIJs, 24% for unilateral SIJ widening and 64% fatality where both SIJs were disrupted, demonstrating an increase in fatality rate with pelvic trauma severity. A closed pubic symphysis was associated with a 19.7% mortality rate versus 46% when widened. Vascular injury was present in 67% of fatalities, versus 45% of survivors. Of PFs, 84% were associated with traumatic amputation (TA) of the lower limb. Pelvic fracture with traumatic lower limb amputation presents a high mortality. It is likely that the mechanism of TA and PF are related, and flail of the lower limb(s) is the current hypothesis. This study prompts further work on the biomechanics of the pelvic-lower limb complex, to ascertain the mechanism of fracture. This could lead to evidence-based preventative techniques to decrease fatalities

The April 2012 Trauma Roundup. 360 . looks at fibula-pro-tibia plating, galeazzi fractures, distal radial fractures in the over 65s, transverse sacral fractures, acute dislocation of the knee, posterior malleolar fractures, immobilising the broken scaphoid, the terrible triad, lower limb amputation after trauma, and whiplash injuries

Aims

Safety concerns surrounding osseointegration are a significant barrier to replacing socket prosthesis as the standard of care following limb amputation. While implanted osseointegrated prostheses traditionally occur in two stages, a one-stage approach has emerged. Currently, there is no existing comparison of the outcomes of these different approaches. To address safety concerns, this study sought to determine whether a one-stage osseointegration procedure is associated with fewer adverse events than the two-staged approach.

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.

The operative workload at the surgical facility in Camp Bastion, Afghanistan, has previously been reported for the two-year period 1 May 2006 to 1 May 2008. The nature of the Afghanistan conflict has changed considerably since 2007, and wounds from improvised explosive devices (IEDs) have replaced those of small arms fire as the signature injury of the insurgency. The severity of injury from IEDs has increased such that casualties routinely present with high bilateral traumatic lower limb amputations and associated pelvic, perineal, upper limb and facial wounds. These complex injuries affecting multiple anatomical zones necessitate a multi-surgeon team approach in their management. We present recent data for the surgical activity at the JF Med Gp Role 3 Hospital, Camp Bastion, for the two-year period 1 November 2008 to 1 November 2010. During the study period, a total of 4276 cases required 5737 surgical procedures, representing a 2.6-fold increase in activity compared with the previously reported 2-year period. Of these cases, 42% were coalition troops (ISAF) and 6% children. Wound debridement (44%) and relook/delayed primary closure of wounds (10%) remain the most commonly performed procedures. There has been a marked increase in the rates of amputation (8% of procedures, 48% being above-knee), laparotomy (9%), application of external fixation (4.5%), and fasciotomies (3%). Scrotal exploration accounted for 1.9% of procedures, resulting in 17 orchidectomies. During the 2-year study period, we have also observed a considerable increase in the incidence of cases requiring 5 or more surgeons operating simultaneously

Introduction. Around the knee high-energy fractures/dislocation may present with vascular injuries. Ischaemia time i.e. the time interval from injury to reperfusion surgery is the only variable that the surgeon can influence. It has been traditionally taught that 6-8 hours is revascularisation acceptable. There are only limited case series that have documented the time-dependent lower limb salvage rate (LSR) or the lower limb amputation rate (LAR). We have conducted a meta-analysis to look at LSR and LAR to inform clinical standard setting and for medicolegal purposes. Methods. Two authors conducted an independent literature search using PubMed, Ovid, and Embase. In addition the past 5 years issues of Journal of Trauma, Injury and Journal of Vascular surgery were manually scrutinised. Papers included those in the English language that discussed limb injuries around the knee, and time to limb salvage or amputation surgery. The Oxman and Guyatt index was used to score each paper. Results. 21 retrospective case series articles were identified from 8 different journals. A total of 1575 patients were compiled, 92 patients were lost or died. 263 lower limbs underwent amputation and 1220 limbs were salvaged. 984 lower limbs were salvaged within the 8 hours. The LAR increased with time from 3% with reperfusion surgery in less than 4 hours to 13% at 6 hours and 32% at 8 hours. A lower LAR of 20% for patients presenting after 12 hours was seen

Aims

The aims of this study were to determine the incidence and factors for developing periprosthetic joint infection (PJI) following hemiarthroplasty (HA) for hip fracture, and to evaluate treatment outcome and identify factors associated with treatment outcome.

1. Twenty-five lower limbs, amputated above the knee for senile atherosclerosis with peripheral gangrene, have been investigated radiologically and histologically to determine the vascular patterns in ischaemic bone with particular reference to the tibia. These have been contrasted with the patterns found in non-atherosclerotic tubular bone. 2. The principal changes are the development of a diffuse vascularisation of compact and spongy bone; a widening of Haversian spaces which come to contain a variable number of sinusoidal blood vessels; and an increasing periosteal participation in cortical nutrition which is related to the severity and chronicity of the ischaemic process. 3. Views on the normal blood supply of long bones are discussed, and evidence is presented for regarding this as discrete and end-arterial in nature; in particular it is suggested that the normal cortex has a wholly medullary, centrifugal, arterial supply

Aims

Circular RNA (circRNA) is involved in the regulation of articular cartilage degeneration induced by inflammatory factors or oxidative stress. In a previous study, we found that the expression of circStrn3 was significantly reduced in chondrocytes of osteoarthritis (OA) patients and OA mice. Therefore, the aim of this paper was to explore the role and mechanism of circStrn3 in osteoarthritis.

Introduction: Infection with Neisseria Meningitidis remains one of the most devastating illnesses in paediatrics. Affected patients can progress from a mild viral-like illness to septicaemia and death within a matter of hours. We present our clinical experience in identifying and managing the orthopaedic complications associated with meningococcal septicaemia and highlight the long-term problems of physeal growth arrest especially after limb amputation. Methods: Between August 1997 and June 2005, 88 consecutive children aged from 1 month to 17 years were admitted to the paediatric intensive care unit with meningococcal septicaemia. These patients were retrospectively assessed for orthopaedic manifestations. Results: During the acute phase of the disease, there were six deaths and 22 patients suffered tissue loss from amputations. Twenty digits were allowed to demarcate and were subsequently amputated. Ten lower limb amputations were performed in 6 patients, all of which developed physeal growth arrests proximal to the level of amputation. Four patients had a substantial rise in lower leg compartmental pressures but only two patients underwent fasciotomies, one of which required bilateral below knee amputations. Conclusions: Meningococcal septicaemia is a potentially lethal paediatric disease. In the acute phase, 22 patients needed orthopaedic input to address complications related to tissue loss, vascular and ischemic problems. Limb amputations due to meningococcal septicaemia will invariably result in physeal damage and our recommendation is that patients should always be screened for this late sequela after index admission. Additionally, early compartment decompression does not appear to improve limb survival

Aims

Registry studies on modified acetabular polyethylene (PE) liner designs are limited. We investigated the influence of standard and modified PE acetabular liner designs on the revision rate for mechanical complications in primary cementless total hip arthroplasty (THA).

Aims

The aims of the study were to analyze differences in surgical and oncological outcomes, as well as quality of life (QoL) and function in patients with ankle sarcomas undergoing three forms of surgical treatment, minor or major limb salvage surgery (LSS), or amputation.

Background: This meta-analysis aims to evaluate the quality of life in post traumatic amputees in comparison with a limb salvage group, using peer-reviewed studies in these areas. Methods: Electronic databases were searched for studies on lower limb amputation and limb reconstruction following trauma. A manual review of the literature and abstracts was also conducted. Only studies having more than 24 months of follow up, and those using generic scales using physical and psychological parameters (SIP or SF36), were included. Two reviewers performed the search, inclusion, and data extraction independently. Results: 214 studies were identified after extensive searching, Eleven studies fulfilled all the inclusion criteria, reviewing the outcomes of 1874 patients including 899 cases of amputation and 975 cases of reconstruction. Outcome assessments were based on two generic scales of measurement for quality of life, namely SIP or SF 36. In the studies using SF36, the mean Physical Component Summary (PCS) for the amputation group was 39.76 +/−7.06 and mean Mental Component Summary (MCS) was 52.05+/−3.39. The mean PCS for the reconstruction group was 38.5+/−0.78 and the mean MCS was 50.76 +/− 3.09. The mean physical SIP score for amputation was 13.033 with SEM of 3.048, and the psychological SIP score was 15.953 with SEM of 1.153. The mean Physical SIP for reconstruction was 10.686 with SEM of 1.034 and the psychological SIP was 10.754 with SEM of 0.647. The Unpaired t test was used to compare the outcomes of amputation and reconstruction, studies using SF36 and SIP scores were compared independently. Our results show that physical morbidity in both groups is not significantly influenced by the modality of surgical intervention, but there is a statistically significant difference noted in psychological morbidity, the group with reconstruction being better. These results were consistent in studies using either of the two generic scales namely, SF36 or SIP scores. Conclusion: This meta-analysis provides evidence that limb reconstruction in lower limb trauma yields better psychological outcomes without significant difference in physical morbidity compared to amputation

Summary Statement. A porcine model using Yucatan minipigs was found to be very promising for the investigation of healing around transcutaneous osseointegrated implants. Pigs demonstrated surprising agility and adaptability including the ability to ambulate on three legs during the immediate postoperative period. Introduction. Previous non weight-bearing and weight-bearing caprine, canine and ovine models have evaluated design, material, and biological coating variations in an attempt to improve the wound healing and skin-implant seal around transcutaneous osseointegrated implants. Although these models have primarily been used as a window into the application of transcutaneous osseointegrated implants in humans, some important model characteristics affecting wound healing and infection have been missing including: 1) replication of the physiological tissue response, and 2) availability of a transcutaneous site with sufficient soft tissue coverage. Pig skin, like human, is relatively hairless, tightly attached to the subcutaneous tissue, vascularised by a cutaneous blood supply, and healed by means of epithelialization. Swine have been extensively utilised for superficial and deep wound healing studies and can offer ample soft tissue coverage following a lower limb amputation. Development of a porcine model is important for continued understanding and improvement of weight-bearing transcutaneous osseointegration. Methods. Two male Yucatan mini-pigs (9 months, 36kg) were fit with transcutaneous osseointegrated prostheses using a single-stage transtibial amputation and prosthesis implantation procedure. The endo-prosthesis consisted of a cylindrical intraosseous threaded section and a smooth transcutaneous section. The transcutaneous sections were smooth to promote epithelialization and deter direct skin-implant adhesion. The implants were custom manufactured from medical grade Ti-6Al-4V alloy. The exo-prosthesis, consisting of an adjustable length leg and foot, was attached by clamp to the supercutaneous portion of the implant following either one or two days of sling constraint to limit initial weight-bearing. Various exo-prosthesis designs and configurations were trialed. The animals’ behavior and gait were closely observed. Weight-bearing was monitored using a force plate. At 5 and 8 weeks, clinical, microbiological, and histological data were examined to assess wound healing and infection at the skin-bone-implant interface. Results. The pigs demonstrated surprising agility and adaptability. They were able to successfully ambulate on three legs during the post-op period before weight-bearing was permitted. They adapted quickly to changes in exo-prosthesis design, position, and length. Although bacterial colonization was verified, neither of the animals exhibited clinical signs of infection over the respective eight and five week studies. Histological results indicated that there was no skin to implant adhesion but that epithelial growth was progressing towards the implant in one animal. Healing of the transcutaneous wound site showed substantial progress but a definitive skin seal was non-existent at the eight week time point. Discussion/Conclusion. This is likely the first animal model developed, having soft tissue characteristics similar to those found in humans, in which an axially-loaded, weight-bearing implant was successfully used. Results indicated that this porcine model offers many advantages over previous models for the development, evaluation, and comparison of the various techniques being advocated to achieve successful transcutaneous osseointegration in humans. The Yucatan miniature pig's ability to ambulate on three legs during the immediate post-operative period and quickly adjust to changes in the exo-prosthesis design, coupled with their physiological similarity to humans, makes them a valuable model for future studies

During the second Lebanon war, between 12/07/06 to 14/08/06, 241 war injuries were admitted to Rambam Medical Center emergency room: 202 soldiers and 39 citizens. (Post traumatic stress disorders victims were not included). Majority of the injured soldiers (98%) were mobilized by the Israeli Air Force helicopters. More then 40 helicopters had landed in the hospital heliport during the war. Distribution of injuries according to the injury type:. 110 patients (44% of all injured) had Orthopedic injuries (including hand injuries). 76 patients (31% of all injured) had Orthopedic injuries combined with other injuries. Not orthopedic injury – 63 patients (25%) Majority of all wounded (75%) had suffered from an orthopedic injury. Distributions of soldier’s injuries among soldiers were similar to the above :. 81 soldiers (41%) Orthopedic injuries (including hand injuries). 64 soldiers (33%) Orthopedic injuries combined with other injuries. 50 soldiers (26 %) Not orthopedic injury. About 75 % of the injured soldiers suffered from orthopedic injuries. Vast majority of the injuries were shrapnel injuries, which were divided to 3 levels:. Mild soft tissue damage due to few or superficial shrapnel injury – 107 (49%) soldiers. Moderate soft tissue injuries due to multiple shrapnel injuries – 54 (25%) soldiers. Severe soft tissue injuries had muscular and neurovascular damage. Organs injury distribution:. 24 Patients total of 54 fractures, 24 of those had been long bone fractures. 17 Patients had sustained a Major vascular injury. 20 Patients had sustained a nerves injury. Amputation – 5 soldiers were underwent completion of traumatic lower limb amputation. One soldiers had bilateral below knee amputation, 1 above knee amputation and 3 unilateral below knee amputation. Two hundred and three orthopedic surgery interventions were done by Orthopedics’ B’ department in Rambam Medical Hospital, during the Second Lebanon War

Background: Simultaneous pancreas-kidney transplantation is performed in type 1 diabetic patients with long standing diabetes and end stage renal disease. Morbidity and mortality rates early after transplantation are high, with lower limb amputations being an important event. However, no data are available on the exact rate of Charcot foot presentation after simultaneous pancreas-kidney transplantation. The aim of the present study was to examine the prevalence of Charcot foot in the population of simultaneous pancreas-kidney transplanted patients at our institution. Methods: We retrospectively examined the medical files and radiographic documents of 66 consecutive patients transplanted in our institution. Demographic and historical data collected included gender, date of diagnosis of DM and nephropathy, mean HbA1c and mean C-peptide, retinopathy and data on renal replacement therapy. Data on immunosuppressive therapy and transplant outcome were also collected. Results: None of the patients was found to have Charcot foot before transplantation. 8 patients (12%) developed a Charcot foot afterwards (mean 1.8 ± 1.9 years post-transplantation) and four of them developed bilateral involvement in time (6%). No new Charcot foot attacks in the previously affected foot were recorded. Considering the pre-transplant demographic characteristics, all 66 patients were at high risk to develop Charcot foot. Comparing patients who developed Charcot foot to those who did not, a significant difference was only found for pre-transplant glycemic control (mean HbA1c 9.2 ± 1.0 vs. 8.0 ± 1.4, p = 0.01). In patients developing Charcot foot, acute rejection, graft failure and mortality show a trend to be more frequent (HR = 3.57, p = 0.164, HR = 4.56, p = 0.165 and HR = 2.46, p = 0.236, respectively). Conclusions: Charcot foot proves to be a frequent complication early after simultaneous pancreas-kidney transplantation. Considering the important morbidity and mortality of this complication, awareness of all healthcare providers treating transplanted patients is mandatory to detect a presentation early after onset. Prompt referral to a multidisciplinary diabetic foot clinic for further diagnosis and specialised treatment must always be considered

In major lower limb amputation, preservation of the knee joint significantly improves outcome. In the severely compromised limb, to preserve the knee joint, high tibial transection may be necessary creating a less than optimal stump. This study reviews the outcome in below knee amputees with stumps 10cm or shorter. All 209 below knee (BK) amputees attending the New Zealand Artificial Limb Board’s Dunedin Centre were reviewed. The centre is the sole provider of prosthetic services in the southern region. Forty-four amputees (21% of total) had stumps of 10cm or less in length as measured by caliper rule. After a minimum twelve month follow-up these amputees were placed in two groups. Group 1: Short Stump (10cm to 8cm). Group 2: Ultra Short Stump (7.5cm to 5cm). Wood-Stanmore Grades were given for walking ability (Hanspal and Fisher 1991). Rehabilitation was further assessed using a modified Houghton Questionnaire (Houghton et al 1992). Mean stump length for all 209 BK amputees was 12.5 centimeters (range 5 to 25 centimeters). Group 1. Short Stump (ten to eight centimeters 0 – 37 amputees. Nineteen amputees – Good to Excellent (Wood – Stanmore Grade V and V1) i.e. walking indoors and outdoors without aids and with near normal gait. (10 trauma, four dysvascular, four tumour, one infection). Fourteen amputees-Satisfactory (Grade 1V) i.e. walking aid indoors and outdoors (13 dysvascular, one congenital). 4 amputees – Fair Only (Grade 111) i.e. mostly indoors with frame (four dysvascular). Group 2. Ultra Short Stump (7.5cm to 5cm) – seven amputees. Six amputees – Good to Excellent (Grade V or V1) – (all trauma). One amputee – Fair Only (Grade 111) – (dysvascular). Group one mostly had a posterior myocutaneous flap amputation with retention of the proximal fibula. In Group two, all had resection of the proximal fibula with varied flaps often with skin grafting. The patellar tendon was intact but two patients had lost the hamstring insertion with hyperextension of the knee, one requiring prosthesis with side steels and thigh corset. In group two the best results followed high resection of the common peroneal nerve and careful shaping of the tibial remnant. Cortical bone formed at the transection level allowing total contact prosthetic fitting with some end bearing. BK amputation is described as optimally 12.5 centimeters to 17.5 centimeters below the knee joint (10 to 12.5 centimeters in vascular disease). Saving the knee should always be considered and with combined surgical and prosthetic skill a stump as short as five centimeters may be fitted satisfactorily particularly in the young and following trauma

Aims

Deep surgical site infection (SSI) remains an unsolved problem after hip fracture. Debridement, antibiotic, and implant retention (DAIR) has become a mainstream treatment in elective periprosthetic joint infection; however, evidence for DAIR after infected hip hemiarthroplaty is limited.

Aims

In our unit, we adopt a two-stage surgical reconstruction approach using internal fixation for the management of infected Charcot foot deformity. We evaluate our experience with this functional limb salvage method.

Aims

Limb salvage for diabetic foot infections often require multiple procedures. Some patients will eventually end up with below knee amputation (BKA) when all limb salvage attempts fail. We seek to study the patients’ ability to return to normal life, functional status, prosthesis usage and perspectives on multiple limb salvage procedures that culminated in BKA to review if they would undertake a similar path if their situation was repeated.

Objectives

The surgical challenge with severe hindfoot injuries is one of technical feasibility, and whether the limb can be salvaged. There is an additional question of whether these injuries should be managed with limb salvage, or whether patients would achieve a greater quality of life with a transtibial amputation. This study aims to measure functional outcomes in military patients sustaining hindfoot fractures, and identify injury features associated with poor function.

Large bone defects remain a tremendous clinical challenge. There is growing evidence in support of treatment strategies that direct defect repair through an endochondral route, involving a cartilage intermediate. While culture-expanded stem/progenitor cells are being evaluated for this purpose, these cells would compete with endogenous repair cells for limited oxygen and nutrients within ischaemic defects. Alternatively, it may be possible to employ extracellular vesicles (EVs) secreted by culture-expanded cells for overcoming key bottlenecks to endochondral repair, such as defect vascularization, chondrogenesis, and osseous remodelling. While mesenchymal stromal/stem cells are a promising source of therapeutic EVs, other donor cells should also be considered. The efficacy of an EV-based therapeutic will likely depend on the design of companion scaffolds for controlled delivery to specific target cells. Ultimately, the knowledge gained from studies of EVs could one day inform the long-term development of synthetic, engineered nanovesicles. In the meantime, EVs harnessed from in vitro cell culture have near-term promise for use in bone regenerative medicine. This narrative review presents a rationale for using EVs to improve the repair of large bone defects, highlights promising cell sources and likely therapeutic targets for directing repair through an endochondral pathway, and discusses current barriers to clinical translation.

Cite this article: E. Ferreira, R. M. Porter. Harnessing extracellular vesicles to direct endochondral repair of large bone defects. Bone Joint Res 2018;7:263–273. DOI: 10.1302/2046-3758.74.BJR-2018-0006.

Patients who have limb amputation for musculoskeletal tumours are a rare group of cancer survivors. This was a prospective cross-sectional survey of patients from five specialist centres for sarcoma surgery in England. Physical function, pain and quality of life (QOL) outcomes were collected after lower extremity amputation for bone or soft-tissue tumours to evaluate the survivorship experience and inform service provision.

Of 250 patients, 105 (42%) responded between September 2012 and June 2013. From these, completed questionnaires were received from 100 patients with a mean age of 53.6 years (19 to 91). In total 60 (62%) were male and 37 (38%) were female (three not specified). The diagnosis was primary bone sarcoma in 63 and soft-tissue tumour in 37. A total of 20 tumours were located in the hip or pelvis, 31 above the knee, 32 between the knee and ankle and 17 in the ankle or foot. In total 22 had hemipelvectomy, nine hip disarticulation, 35 transfemoral amputation, one knee disarticulation, 30 transtibial amputation, two toe amputations and one rotationplasty. The Toronto Extremity Salvage Score (TESS) differed by amputation level, with poorer scores at higher levels (p < 0.001). Many reported significant pain. In addition, TESS was negatively associated with increasing age, and pain interference scores. QOL for Cancer Survivors was significantly correlated with TESS (p < 0.001). This relationship appeared driven by pain interference scores.

This unprecedented national survey confirms amputation level is linked to physical function, but not QOL or pain measures. Pain and physical function significantly impact on QOL. These results are helpful in managing the expectations of patients about treatment and addressing their complex needs.

Cite this article: Bone Joint J 2015;97-B:1284–90.

The April 2013 Research Roundup³⁶⁰ looks at: when the ‘residency cake’ is done; steroids, stem cells and tendons; what exactly is osteoarthritis; platelet-rich plasma; CRPS; d-Dimer for DVT; reducing bacterial adhesion; and fin or limb?

This is a case series of prospectively gathered data characterising the injuries, surgical treatment and outcomes of consecutive British service personnel who underwent a unilateral lower limb amputation following combat injury. Patients with primary, unilateral loss of the lower limb sustained between March 2004 and March 2010 were identified from the United Kingdom Military Trauma Registry. Patients were asked to complete a Short-Form (SF)-36 questionnaire. A total of 48 patients were identified: 21 had a trans-tibial amputation, nine had a knee disarticulation and 18 had an amputation at the trans-femoral level. The median New Injury Severity Score was 24 (mean 27.4 (9 to 75)) and the median number of procedures per residual limb was 4 (mean 5 (2 to 11)). Minimum two-year SF-36 scores were completed by 39 patients (81%) at a mean follow-up of 40 months (25 to 75). The physical component of the SF-36 varied significantly between different levels of amputation (p = 0.01). Mental component scores did not vary between amputation levels (p = 0.114). Pain (p = 0.332), use of prosthesis (p = 0.503), rate of re-admission (p = 0.228) and mobility (p = 0.087) did not vary between amputation levels.

These findings illustrate the significant impact of these injuries and the considerable surgical burden associated with their treatment. Quality of life is improved with a longer residual limb, and these results support surgical attempts to maximise residual limb length.

Cite this article: Bone Joint J 2013;95-B:224–9.

We investigated whether an asymmetric extension gap seen on routine post-operative radiographs after primary total knee replacement (TKR) is associated with pain at three, six, 12 and 24 months’ follow-up. On radiographs of 277 patients after primary TKR we measured the distance between the tibial tray and the femoral condyle on both the medial and lateral sides. A difference was defined as an asymmetric extension gap. We considered three groups (no asymmetric gap, medial-opening and lateral-opening gap) and calculated the associations with the Western Ontario and McMaster Universities osteoarthritis index pain scores over time.

Those with an asymmetric extension gap of ≥ 1.5 mm had a significant association with pain scores at three months’ follow-up; patients with a medial-opening extension gap reported more pain and patients with a lateral-opening extension gap reported less pain (p = 0.036). This effect was still significant at six months (p = 0.044), but had lost significance by 12 months (p = 0.924). When adjusting for multiple cofounders the improvement in pain was more pronounced in patients with a lateral-opening extension gap than in those with a medial-opening extension gap at three (p = 0.037) and six months’ (p = 0.027) follow-up.

Cite this article: Bone Joint J 2013;95-B:472–7.

Although the Western Ontario and McMaster Universities (WOMAC) osteoarthritis index was originally developed for the assessment of non-operative treatment, it is commonly used to evaluate patients undergoing either total hip (THR) or total knee replacement (TKR). We assessed the importance of the 17 WOMAC function items from the perspective of 1198 patients who underwent either THR (n = 704) or TKR (n = 494) in order to develop joint-specific short forms. After these patients were administered the WOMAC pre-operatively and at three, six, 12 and 24 months’ follow-up, they were asked to nominate an item of the function scale that was most important to them. The items chosen were significantly different between patients undergoing THR and those undergoing TKR (p < 0.001), and there was a shift in the priorities after surgery in both groups. Setting a threshold for prioritised items of ≥ 5% across all follow-up, eight items were selected for THR and seven for TKR, of which six items were common to both. The items comprising specific WOMAC-THR and TKR function short forms were found to be equally responsive compared with the original WOMAC function form.

Cite this article: Bone Joint J 2013;95-B:239–43.

We studied a cohort of 26 diabetic patients with chronic ulceration under the first metatarsal head treated by a modified Jones extensor hallucis longus and a flexor hallucis longus transfer. If the first metatarsal was still plantar flexed following these two transfers, a peroneus longus to the peroneus brevis tendon transfer was also performed. Finally, if ankle dorsiflexion was < 5° with the knee extended, a Strayer-type gastrocnemius recession was performed.

The mean duration of chronic ulceration despite a minimum of six months’ conservative care was 16.2 months (6 to 31). A total of 23 of the 26 patients were available for follow-up at a mean of 39.6 months (12 to 61) after surgery. All except one achieved complete ulcer healing at a mean of 4.4 weeks (2 to 8) after surgery, and there was no recurrence of ulceration under the first metatarsal.

We believe that tendon balancing using modified Jones extensor hallucis longus and flexor hallucis longus transfers, associated in selected cases with a peroneus longus to brevis transfer and/or Strayer procedure, can promote rapid and sustained healing of chronic diabetic ulcers under the first metatarsal head.