The development and implementation of a multidisciplinary limb salvage program has been shown to improve amputation-free survival and decrease need for major amputations; however, the impact of this approach on patients who eventually progress to major amputation is unclear. The goal of this study is to assess the effect of a multidisciplinary limb salvage team (MLT) on revascularization rates before major amputation and outcomes after major amputation in patients in an urban setting.

Patients in a single health care system who underwent major lower extremity amputations between January 1, 2014, and December 31, 2021, were identified using Current Procedural Terminology codes within our electronic medical records. Patient demographic data, comorbidities, pre-amputation revascularization, limb salvage procedures, and 1-year mortality rates were collected by chart review. The χ2 test, likelihood ratio tests, Mann-Whitney U test, and Student t test were used to compare patient variables and outcomes between before and after the launch of a MLT. Univariate and multivariate logistic regression analysis were used to assess patient characteristics associated with 30-day pre-amputation revascularization and one year mortality rates.

During the study period, 471 patients underwent major lower extremity amputations: 52% below-knee amputations, 47% above-knee amputations, and 1% through knee disarticulation. Comparing preamputation revascularization procedures stratified by involvement of a multidisciplinary limb care team, there was no significant difference in 30-day revascularization rate (30.2% vs 30.6%; P = .93). Preamputation revascularization rates within 90 days (45.1%% vs 45.8%; P = .87) and 1 year (56.1% vs 51.9%; P = .84) remained similar between groups as well. There was a statistically significant increase in 30-day preamputation debridement/minor amputation (25.9% vs 44.9%; P < .001) after MLT implementation; this significant increase was also shown within 90 days and 1 year before major amputation. The 1-year mortality rate in above-knee amputations (28% vs 18.7%; P = .15) was not significantly different after MLT implementation, but 1-year mortality in the major amputations (26.4% vs 14.3%; P = .002) and below-knee amputations (24.8% vs 12.2%; P = .013) groups were significantly different after MLT implementation. Patient characteristics associated with increased 30-day pre-amputation revascularization included hypertension (odds ratio [OR], 2.1; 95% CI, 1.2-3.8), smoking status (OR, 1.7; 95% CI, 1.1-2.6), and requiring debridement/minor amputation within 30 days before major amputation (OR, 2.3; 95% CI, 1.4-3.6). Patients older than 65 (OR, 3.2; 95% CI, 1.6-6.3) with end-stage renal disease (OR, 2.7; 95% CI, 1.5-4.9) were associated with higher risk for 1-year mortality. Implementation of limb salvage program was associated with improved 1-year postamputation mortality overall (OR, 0.54; 95% CI, 0.31-0.96).

For patients with chronic limb-threatening ischemia who eventually progressed to require major lower extremity amputations, the implementation of a limb salvage program did not change pre-amputation revascularization practice. However, it was associated with significantly improved 1-year postamputation mortality. Our findings further support the global vascular guidelines, demonstrating the benefit of limb salvage services in patients with major amputations.

Introduction: Apart from their high burden of disease, major amputations, especially due to macro- and microangiopathic malperfusion, persist to inflict a relevant socioeconomic impact in most geographic regions. It has been repeatedly shown that lower extremity amputations are associated with impaired post-operative survival. In the present study, we investigated whether metrics derived from routine laboratory studies after amputation are associated with post-operative survival. Methods: In this retrospective single-center analysis, 244 patients undergoing lower extremity amputation between 2012 and 2016 were included. Serum hemoglobin and leukocyte counts of the first 21 post-operative days as well as derived metrics were analyzed in addition to clinical and demographic variables. Kaplan-Meier estimates and adjusted Cox regressions were fitted including relevant parameters. Results: In summary, 71.3% of patients underwent transtibial and 28.7% transfemoral amputations. The most frequent post-operative complications were wound-related (43.0%). Long-term survival analyses showed that advanced age and higher ASA class were significantly associated with reduced post-operative survival, while no significant survival differences were observed based on sex, smoking history, or type of amputation. Laboratory parameter analysis showed impaired peri-operative outcomes in patients with elevated leukocyte counts, with leukocyte-derived metrics showing significant associations with long-term survival after adjustment for age and ASA class. Conclusions: This study highlights the potential of routine laboratory parameter-derived metrics in predicting mortality after major lower extremity amputations in PAD patients.

Chronic limb-threatening ischemia (CLTI), the severest stage of peripheral artery disease, frequently necessitates amputation. In CLTI patients, heart failure with reduced ejection fraction (HFrEF) markedly raises mortality risk, with increased peripheral vascular resistance contributing to this exacerbation. This investigation aimed to assess the impact of major amputation (MA) on the cardiovascular (CV) prognosis in CLTI patients with HFrEF by lowering peripheral vascular resistance. Conducting a retrospective, observational analysis at a single center, a total of 60 patients with CLTI and HFrEF (EF < 50%) who underwent endovascular therapy (EVT) at our institution were assessed. We compared CV outcomes in CLTI patients with HFrEF who received MA (n = 17) to those who did not (n = 43) after undergoing EVT. During the follow-up period, which median 641 (IQR: 245 to 1,734) days post-EVT, a composite primary endpoint of CV death or hospitalization for HF was observed. During the study period, 19 patients (32%) were admitted for HF or died as a consequence of CV events. Kaplan-Meier analysis revealed a significantly reduced incidence of the primary endpoint in the MA cohort (log-rank test: p = 0.035). Adjustments for age and sex showed MA was significantly linked to improved CV prognosis (HR: 0.19; 95% confidence interval: 0.04 to 0.87). A nonsignificant trend toward decreased overall mortality was noted in the MA group, with infections being the predominant cause of death across both groups. In conclusion, in CLTI patients with HFrEF, MA might be linked to reduced CV events, proposing it as a potential definitive strategy for improving CV outcomes in this high-risk population.

The purpose of this study was to create a risk score for 30-day and 1-year mortality after major lower extremity amputation to facilitate clinical expectations and the identification of patients in need of heightened vigilance in longitudinal care.

In the Vascular Quality Initiative, 25,150 patients were identified who underwent lower extremity amputation. Two primary outcomes were investigated: 30-day mortality after major lower extremity amputation and 1-year mortality after amputation. Univariable analysis for the 30-day and 1-year mortality analysis was conducted with χ2 analysis. Significant (P < .05) univariable factors were then included in binary logistic regression analysis to perform multivariable investigation toward the outcomes. Variables that achieved multivariable significance (P < .05) for the outcomes were then used in the respective risk scores with the regression beta coefficient being used to weigh the variables.

Overall, 7.2% of patients experienced 30-day mortality and 22.4% suffered mortality within 1 year. Variables with a significant multivariable association (P < .05) with 1-year mortality were female sex, advancing age, body mass index less than 20 kg/m2, coronary artery disease, history of coronary revascularization, congestive heart failure (CHF), chronic obstructive pulmonary disease, dialysis status at presentation, baseline renal insufficiency, anemia, lack of statin medication at presentation, being on anticoagulation at presentation, need for above-knee amputation, and need for emergent amputation. Variables that were protective vs mortality on multivariable analysis (P < .05) were body mass index greater than 30 kg/m2, history of ipsilateral amputation at a lower level, and history of ipsilateral infrainguinal bypass. Pertinent negatives included all socio-demographic variables including rural living status, insurance status, and area deprivation index home area. Variables with a statistically significant (P < .05) multivariable association with 30-day mortality were female sex, advancing age, history of coronary artery disease, history of prior coronary revascularization, history of CHF, class 3 or 4 CHF, chronic obstructive pulmonary artery disease, dialysis requirement at presentation, baseline renal insufficiency, lack of antiplatelet medication at time of presentation, lack of statin medication at time of presentation, need for above-knee amputation, acute ischemia indication, and need for emergent amputation. Variables that were protective (P < .05) vs 30-day mortality on multivariable analysis were diabetes, prior ipsilateral amputation at a lower level, prior infrainguinal bypass ipsilateral to amputation, prior ipsilateral infrainguinal endovascular revascularization (endovascular or bypass), and prior ipsilateral inflow arterial bypass. For receiver operating curve analysis, the 30-day risk score had an area under the curve of 0.715 and the 1-year risk score analysis 0.722. Hosmer-Lemeshow investigation of the multivariable regressions resulted in an overall accuracy of 92.8% for the 30-day mortality investigation (99% accurate for survival) and 78% overall accuracy on the 1-year mortality risk score (96.8% in predicting survival accurately). This indicates that these models perform far better in determining which patients will survive rather than precisely determining who will experience 1-year mortality.

Risk scores for mortality at 30 days and 1 year after major lower extremity amputation have been created that have good accuracy and steep escalation with advancing comorbidity. Variables with the most potent deleterious effect on survival were renal insufficiency, dialysis requirement, CHF, and need for emergent amputation. Patients who have already been receiving care from vascular specialists at the time of amputation have improved survival vs those without prior arterial interventions or a lower level of amputation. Social determinants of health do not impact survival among patients undergoing major lower extremity amputation at Vascular Quality Initiative centers.

The TRACE (Routine posTsuRgical Anaesthesia visit to improve patient outComE) RCT did not show any perioperative benefit from ward-based visits by anaesthetists after surgery. The aim of this study was to evaluate the impact of this intervention on longer-term outcomes.

Patients were followed up in the TRACE RCT to 1 year in nine hospitals in the Netherlands. Patients undergoing elective non-cardiac surgery, and at risk for adverse postoperative outcome, were included. Patients in the intervention group additionally received routine anaesthesia visits on postoperative days 1 and 3. Clinical outcome measures included 1-year mortality, hospital readmission, and reoperation. Functional recovery (FR) was measured using the patient-reported global surgical recovery (GSR) index, ability to perform activities of daily living (ADL), and functional recovery index (FRI). Quality of life (QoL) was measured using EQ-5D-5L.

Some 5473 adult patients were followed up. No differences were found between the control and intervention groups for clinical, FR, and QoL outcome measures. One-year mortality was 5.4% in the control group and 5.8% in the intervention group, readmission was 27% and 26% respectively, and reoperation was 20% and 18% respectively. At 1 year, FR and QoL had recovered to preoperative levels. However, 30% of patients were not able to fully perform ADL and 40%-51% of patients still reported a problem in the EQ-5D-5L dimensions mobility, usual activities, and pain/discomfort.

Routine postoperative anaesthesia ward visits of patients did not improve clinical, functional, and QoL outcomes. A substantial proportion of patients still experienced health-related limitations in daily life 1 year after surgery. In conclusion, an early postoperative intervention with postoperative anaesthesia visits in the ward after non-cardiac surgery had no effect on 30-day or 1-year clinical outcome. Remarkably, TRACE shows that compared with data sampled 10 years ago, 1-year mortality has not improved in the Netherlands. At 1 year, functional recovery or QoL showed little improvement compared with baseline. Importantly, a substantial number of patients still reported incomplete recovery and problems that limit QoL, which indicate that there is still room for improvement.

To determine mortality rates after lower extremity amputation (LEA) in individuals with and without diabetes mellitus (DM).

Retrospective, observational study using data from a database covering >99 % of the Dutch population. LEAs in 2016 were identified, and mortality data from 2016 to 2021 were analyzed. Study group 1 (SG1) included individuals with DM and LEA (DM+/LEA+) with two control groups (CG), DM+/LEA- (matched by age, sex, without (1a) and with (1b) socioeconomic status matching). Study group 2 (SG2) (DM+/LEA+) was composed after matching with non-DM individuals with LEA (DM-/LEA+ (2a)).

Among 5145 individuals with LEA in 2016, 56 % had DM. Five-year mortality was 61.2 % in SG1 (DM+/LEA+) and 27.9 % in CG1a (DM+, LEA-) and 1b. Study group 2 (DM+/LEA+) had a 62.6 % five-year mortality rate, compared to 56.4 % in CG2a (DM-/LEA+).

Mortality after LEA is high, especially in DM; socioeconomic status (SES) does not significantly impact mortality.

Level III retrospective cohort study.

Persistent pain is a complicated phenomenon associated with a wide array of complex pathologies and conditions (e.g., complex regional pain syndrome, non-freezing cold injury), leading to extensive disability and reduced physical function. Conventional resistance training is commonly contraindicated in load compromised and/or persistent pain populations, compromising rehabilitation progression and potentially leading to extensive pharmacological intervention, invasive procedures, and reduced occupational status. The management of persistent pain and utility of adjunct therapies has become a clinical and research priority within numerous healthcare settings, including defence medical services.

Blood flow restriction (BFR) exercise has demonstrated beneficial morphological and physiological adaptions in load-compromised populations, as well as being able to elicit acute hypoalgesia. The aims of this narrative review are to: (1) explore the use of BFR exercise to elicit hypoalgesia; (2) briefly review the mechanisms of BFR-induced hypoalgesia; (3) discuss potential implications and applications of BFR during the rehabilitation of complex conditions where persistent pain is the primary limiting factor to progress, within defence rehabilitation healthcare settings. The review found BFR application is a feasible intervention across numerous load-compromised clinical populations (e.g., post-surgical, post-traumatic osteoarthritis), and there is mechanistic rationale for use in persistent pain pathologies. Utilisation may also be pleiotropic in nature by ameliorating pathological changes while also modulating pain response. Numerous application methods (e.g., with aerobic exercise, passive application, or resistance training) allow practitioners to cater for specific limitations (e.g., passive, or contralateral application with kinesiophobia) in clinical populations. Additionally, the low-mechanical load nature of BFR exercise may allow for high-frequency use within residential military rehabilitation, providing a platform for conventional resistance training thereafter.

Future research needs to examine the differences in pain modulation between persistent pain and pain-free populations with BFR application, supporting the investigation of mechanisms for BFR-induced hypoalgesia, the dose-response relationship between BFR-exercise and pain modulation, and the efficacy and effectiveness of BFR application in complex musculoskeletal and persistent pain populations.

Background and aim Coronary artery disease (CAD) is a leading cause of morbidity and mortality in the United States, with peripheral arterial disease (PAD) and lower limb (LL) amputation contributing to poor cardiovascular outcomes. While previous studies have identified the link between CAD and PAD-related amputations, data on short-term in-hospital outcomes remain limited. This study aimed to compare in-hospital mortality and complications between CAD patients undergoing LL amputation and those without it. Methods We conducted a retrospective cohort study using the Nationwide Inpatient Sample (NIS) from 2016 to 2021, identifying CAD patients with and without LL amputation via International Classification of Diseases, 10th Revision (ICD-10) codes. Propensity score matching (PSM) was performed using a 1:1 nearest-neighbor algorithm to minimize selection bias, adjusting for demographics, comorbidities, and hospital characteristics. The primary outcome was in-hospital all-cause mortality, while secondary outcomes included acute heart failure, cardiogenic shock, acute kidney injury (AKI), major adverse cardiac and cerebrovascular events (MACCE), and healthcare resource utilization. Results A total of 31,379,939 CAD patients were identified, with 119,320 (0.4%) undergoing LL amputation. After propensity score matching (PSM), 23,261 patients were included in each group. The LL amputation cohort exhibited significantly higher in-hospital mortality (5.5% vs. 3.3%, p<0.001), cardiac arrest (2.3% vs. 1.4%, p<0.001), acute kidney injury (AKI) (29.3% vs. 26.8%, p<0.001), and acute limb ischemia (5.2% vs. 0.4%, p<0.001). Conversely, CAD patients without amputation had higher rates of acute heart failure (18.3% vs. 10.7%, p<0.001), major adverse cardiac and cerebrovascular events (MACCE) (22.5% vs. 12.2%, p<0.001), and percutaneous coronary intervention (6.7% vs. 0.9%, p<0.001). The length of stay and total hospital charges were significantly higher in the amputation group (10 days vs. four days; $26,590 vs. $11,686, p<0.001). Conclusion Lower limb amputation in CAD patients is associated with increased in-hospital mortality, cardiac complications, and healthcare resource utilization. These findings underscore the need for early intervention strategies targeting PAD progression and comprehensive perioperative cardiovascular risk management in amputees. Future research should focus on optimizing revascularization approaches, rehabilitation programs, and tailored preventive measures to improve outcomes in this high-risk population.

A large proportion of people die in the years following dysvascular partial foot amputation (PFA) or transtibial amputation (TTA) given the long-term consequences of peripheral vascular disease and/or diabetes. A critical appraisal of recent research is needed to understand the underlying cause of variation and synthesise data for use in consultations about amputation surgery and patient-facing resources. This systematic review aimed to describe proportionate mortality following dysvascular PFA and to compare this between PFA and TTA.

The review protocol was registered in PROSPERO (CRD42023399161). Peer-reviewed studies of original research were included if they: were published in English between 1 January 2016, and 12 April 2024, included discrete cohorts with PFA, or PFA and TTA, and measured proportionate mortality following dysvascular amputation.

Seventeen studies were included in the review. Following dysvascular PFA, proportionate mortality increased from 30 days (2.1%) to 1-year (13.9%), 3-years (30.1%), and 5-years (42.2%). One study compared proportionate mortality 1-year after dysvascular PFA and TTA, showing a higher relative risk of dying after TTA (RR 1.51).

Proportionate mortality has not changed in recent years. These results are comparable to a previous systematic review that included studies published before 31 December 2015.Implications for rehabilitationIt is important to ensure data describing mortality in the years following dysvascular partial foot or transtibial amputation is up to date and accurate.Evidence about proportionate mortality has not changed in recent years and the results are comparable to previous systematic reviews.Data describing mortality outcomes can be used in decision aids that support conversations about the choice of amputation level.

Patients who undergo major lower extremity amputation (MLEA) have the highest postoperative mortality among orthopedic patient groups. The comorbidity profile for MLEA patients is often extensive and associated with elevated postoperative mortality. This study primarily aimed to investigate the increased short- and long-term mortality following first and subsequent major lower extremity amputation. Secondarily, to examine the mediation role of post-amputation complications.

With data from the Danish National Patient Registry, 11,695 first-time MLEAs in patients aged ≥50 years were identified between January 1, 2010, and December 31, 2021, along with 58,466 unamputated persons matched 1:5 by year of birth, sex, and region of residence. Mediators were identified through diagnosis codes (ICD-10) present in 6 months following MLEA.

The increased mortality following MLEA was highest in the month following MLEA, hazard ratio (HR) 38.7 (95% confidence interval (CI) 30.5-48.9) in women and HR 55.7 (CI 44.3-70.2) in men compared to a matched unamputated cohort. Subsequent amputation resulted in an increased mortality the month after a subsequent amputation (overall HR 3.2 (CI 2.8-3.7) in women and HR 3.2 (CI 2.8-3.6) in men) and almost normalized after the first year. The proportion of the mortality risk that potentially could be reduced by preventing sepsis was 16% (CI 11.7-20.3) for women and 17% (CI 13.4-20.4) for men. For pneumonia, it was 10.5% (CI 7.1-13.9) in women and 14.9% (11.6-18.2) in men.

We observed an increased mortality in the month following MLEA, which remained elevated for years compared to the matched unamputated cohort. A subsequent amputation results in increased mortality in the following year, but declined and normalized after the first year. Sepsis and pneumonia arising after the amputation appeared to be important factors that contributed to the increased postoperative mortality.

Major amputations are a standard procedure being done for various etiologies of the lower limb. Surgical site infections often complicate the postoperative outcome of patients. Negative pressure wound therapy has evolved to have a preventive role in SSI. According to the best of our knowledge, this is the first study that compared the wound and overall outcomes of incisional application of NPWT against standard dressing in patients undergoing stump closure following major lower limb amputations. The primary goal was to compare the rate of surgical site infections. The secondary objectives were to compare the postoperative hospital stay, reinterventions, readmission, and mortality.

A randomized controlled trial was conducted in a healthcare institute and included 62 patients who underwent closure of major lower limb amputation stumps. After stump closure, patients were randomized into iNPWT and standard groups for the dressing over the suture line. Surgical site infection and other outcomes were assessed.

A statistically significant difference was found in the rate of surgical site infection (16% vs 51%, P = 0.003). Also, it appreciated a significant reduction in the number of patients needing reinterventions (26% vs 52%, P = 0.037) and the duration of postoperative hospital stay (5.8 days vs 8.2 days, P = 0.043) in the iNPWT group.

Incisional application of NPWT following lower limb amputations is an effective tool to reduce surgical site infections, the need of multiple reinterventions, the cost of treatment, and hospital stay. We should use this special dressing as a standard protocol for the high-risk patients undergoing stump closure following major amputations; therefore, it can reduce the morbidity of patients.

Objective: Despite advancements in vascular surgery, the mortality among peripheral arterial disease (PAD) patients undergoing major amputations remains high. While a large body of evidence has previously covered survival rates after major amputation, there is less evidence regarding the associated survival penalty from an epidemiological perspective. The present analysis aimed at quantifying the survival disadvantage after major lower limb amputation while investigating which factors are associated with mortality in this patient cohort. Methods: Data from 246 PAD patients undergoing major amputations were retrospectively collected and matched with mortality records from the Austrian National Death Registry. Life expectancy was estimated using population-based life tables, and differences between observed and expected survival were analyzed across subgroups. Results: The median follow-up was 492 days (Q1-Q3: 73-1438), and 82.5% (n = 203) of patients died, with cardiovascular events being the leading cause (41%). A profound discrepancy between estimated (4697 days, Q1-Q3: 2962-6236) and observed survival (457 days, Q1-Q3: 73-1438, p < 0.001) was seen. In men, an associated median survival penalty of 11.2 years was observed, equivalent to a proportionate reduction in life expectancy of over 90%, while the difference in women was 8.7 years, equaling a reduction of 84.6%. In a multiple regression model, 1 year in life expectancy was associated with a survival penalty of -0.96 years, thereby affecting younger patients with the highest life expectancies the most. Conclusions: Major amputation in PAD patients is associated with a significant reduction in survival compared to standardized mortality rates in the general population. The survival disadvantage exceeds 70% of estimated survival times in over 70% of patients. Elevated mortality rates after major amputation in PAD patients should not be interpreted as a causal relationship but as a surrogate for impaired systemic cardiovascular health.

To describe perceptions and experiences of people who have undergone a major dysvascular lower limb amputation (LLA) regarding nutrition, and to identify perceived barriers and facilitators regarding nutritional intake.

In this phenomenological qualitative study, individual, semi-structured, face-to-face, interviews were conducted with people who had undergone a major dysvascular LLA and were living independently. Sample size was guided on information power. Interviews were transcribed verbatim, and reflexive thematic analysis was performed.

Thirteen participants were interviewed. Four themes were generated: (1) mainly non-health-related factors determine food choices, (2) limited perceived awareness of the nutritional value and the impact of nutrition on health and clinical outcomes, (3) support is mainly practical by personal network, while professional nutritional care is limited, and (4) low need to change eating habits.

Findings of this study underscore the urgency to increase awareness of healthy and adequate nutritional intake. Patient-centered nutritional care should be provided with techniques of motivational interviewing, to potentially improve health and clinical outcomes in people who have undergone a major dysvascular LLA.

Chronic limb-threatening ischemia is a condition of the lower extremities that requires therapeutic intervention. It is characterized by ischemia, tissue loss, neuropathy, infection, and risk of amputation.

An 82-year-old woman with a history of bilateral total knee arthroplasty and rheumatoid arthritis underwent a left ankle arthroplasty. Wound healing was delayed, and chronic limb-threatening ischemia was diagnosed. When endovascular therapy was found ineffective, novel low-density lipoprotein apheresis was initiated. Pedicle flap and split-thickness skin grafting were performed to save the affected limb. However, skin necrosis progressed, and the patient underwent left lower limb amputation 17 days after ankle arthroplasty. The stump included a skin graft area, and the decision to fabricate a prosthetic leg was difficult because of the patient's advanced age, rheumatoid arthritis, and poor upper limb function. However, her cognitive function, muscle strength, and joint range of motion were good. No sign of wound infection was observed, and the patient was able to walk before surgery. Therefore, we decided to fabricate a prosthetic leg. Seventy-five days after amputation, the patient achieved independent walking using a cane and a silver-wheel walker.

The benefit of novel low-density lipoprotein apheresis helped our decision to fabricate a prosthesis when uncertainty existed about the maturity of a recent amputation in an elderly patient with chronic limb-threatening ischemia. The patient successfully achieved a prosthetic gait under challenging conditions.

Foot ulcers are a major complication of diabetes mellitus that increase morbidity and mortality in patients with diabetes, affect their quality of life, and increase the overall social burden. A considerable number of patients with diabetic foot ulcers (DFUs) require amputations every year.

This nation population-based study included 1 923 483 patients with diabetes who underwent regular health screening through the National Health Insurance Service during January 2009 and December 2012. We investigated the association between changes in physical activity (PA) status and the incidence of lower extremity amputation (LEA). Based on changes in PA status, participants were categorized into four groups: "remained inactive," "remained active," "active-to-inactive," and "inactive-to-active."

Regular PA is an independent factor associated with a decreased risk of LEA in patients with diabetes. During the follow-up period, 0.23% (n = 4454) of the patients underwent LEA. Compared with the "remained inactive" group, the "remained active" group were at the lowest risk of LEA (adjusted hazard ratio 0.5888; 95% confidence interval 0.524-0.66). A protective effect of regular PA against LEA was observed in the "remaining active" group.

Our findings suggest a protective role of PA against LEA in individuals with diabetes. This highlights the importance of recommending appropriate levels of PA for patients with diabetes. The study also showed a dose-response relationship, indicating that engaging in vigorous-intensity PA was most beneficial, and higher amounts of PA may provide additional benefits.

Multidisciplinary teams are necessary to treat complex patients with chronic limb-threatening ischemia (CLTI). The need for adequate wound care and control of comorbid conditions cannot be accomplished by the vascular specialist alone. Numerous specialties have a role in this group to include surgical podiatrists, orthopedic surgery, plastic and reconstructive surgery endocrinology, and wound care. However, the vascular specialist must drive this team as the patients are usually referred to them and numerous studies have shown a direct correlation between major amputations and the lack of vascular involvement. Creating these teams is unique in each community and must consider practice patterns that are relevant in the local region. CLTI is a challenging disease to manage, and multidisciplinary teams have demonstrated an ability to improve outcomes and deliver superior care to this patient population.

Diabetic foot ulcers (DFUs) are a growing public health problem, paralleling the increasing incidence of diabetes. While prevention is most effective treatment for DFUs, challenge remains on selecting the optimal treatment in cases with DFUs. Health sciences have greatly benefited from the integration of artificial intelligence (AI) applications across various fields. Regarding amputations in DFUs, both literature and clinical practice have mainly focused on strategies to prevent amputation and identify avoidable risk factor. However, there are very limited data on assistive parameters/tools that can be used to determine the level of amputation. This study investigated how well ChatGPT, with its lately released version 4o, matches the amputation level selection of an experienced team in this field. For this purpose, clinical photographs from patients who underwent amputations due to diabetic foot ulcers between May 2023 and May 2024 were submitted to the ChatGPT-4o program. The AI was tasked with recommending an appropriate amputation level based on these clinical photographs. Data from a total of 60 patients were analysed, with a median age of 64.5 years (range: 41-91). According to the Wagner Classification, 32 patients (53.3%) had grade 4 ulcers, 16 patients (26.6%) had grade 5 ulcers, 10 patients (16.6%) had grade 3 ulcers and 2 patients (3.3%) had grade 2 ulcers. A one-to-one correspondence between the AI tool's recommended amputation level and the level actually performed was observed in 50 out of 60 cases (83.3%). In the remaining 10 cases, discrepancies were noted, with the AI consistently recommending a more proximal level of amputation than what was performed. The inter-rater agreement analysis between the actual surgeries and the AI tool's recommendations yielded a Cohen's kappa coefficient of 0.808 (SD: 0.055, 95% CI: 0.701-0.916), indicating substantial agreement. Relying solely on clinical photographs, ChatGPT-4.0 demonstrates decisions that are largely consistent with those of an experienced team in determining the optimal level of amputation for DFUs, with the exception of hindfoot amputations.

The potential preventive effect of fenofibrate on lower extremity amputation (LEA) and peripheral arterial disease (PAD) in patients with type 2 diabetes (T2D) is not fully elucidated.

We selected adult patients ≥ 20 years of age with T2D from the Korean National Health Insurance Service Database (2009-2012). The fenofibrate users were matched in a 1:4 ratio with non-users using propensity scores (PS). The outcome variables were a composite of LEA and PAD and the individual components. The risks of outcomes were implemented as hazard ratio (HR) with 95% confidence intervals (CI). For safety issues, the risks of acute kidney injury, rhabdomyolysis and resulting hospitalization were analyzed.

A total of 114,920 patients was included in the analysis with a median follow-up duration of 7.6 years (22,984 and 91,936 patients for the fenofibrate user and non-user groups, respectively). After PS matching, both groups were well balanced. The fenofibrate group was associated with significantly lower risks of composite outcome of LEA and PAD (HR 0.81; 95% CI 0.70-0.94), LEA (HR 0.76; 95% CI 0.60-0.96), and PAD (HR 0.81; 95% CI 0.68-0.96). The risk of acute kidney injury, rhabdomyolysis, or hospitalization for these events showed no significant difference between the two groups. Subgroup analyses revealed consistent benefits across age groups, genders, and baseline lipid profiles.

This nationwide population-based retrospective observational study suggests that fenofibrate can prevent LEA and PAD in patients with T2D who are on statin therapy.

Around 1%-2% of patients with peripheral arterial disease will require a lower limb amputation at some point. Despite advancements in prevention and treatment, mortality after major amputation remains high. The aim of this study was to investigate the risk factors related to mortality and promoting factors for ambulation postamputation.

A multicenter retrospective study of consecutive major lower limb amputation patients performed at the department of thoracic and vascular surgery of the University Hospitals Ghent and Leuven between January 2008 and December 2017.

Three hundred and thirteen patients met the inclusion criteria. Overall, 1-year mortality rate was 29.7% with age being the most important risk factor. Above-knee amputations had significantly higher mortality (37%) than below-knee amputations (22%) at 1 year. Diabetes and number of vascular interventions were not linked to higher mortality. Age, amputation level, and presence of hypertension were the most important determining factors for successful ambulation.

Maintaining the independency of patients, whether this is obtained by maximizing limb salvage or primary amputation, is critical. Knowledge about the factors that play a role in the risk of death and the chance of regaining ambulation is important to include in the decision-making conversation with the patient.

Lower extremity amputation continues to be necessary in a significant number of patients with peripheral vascular disease. The 5-year survival following lower limb loss is markedly reduced. Many of these patients are never fitted with a prosthesis, and there is a dearth of knowledge regarding the barriers to prosthetic attainment. The goal of this study was to identify the risk factors for not receiving a prosthesis and the effect of mobility level on survival following major amputation.

This was a retrospective analysis of all patients that underwent lower extremity amputation by surgeons in our practice from January 1, 2010, to December 31, 2019. Abstracted data included: age, sex, race, body mass index, comorbidities, American Society of Anesthesiologists score, statin use, level of amputation, stump revision, fitting for prosthesis, type of prosthesis, and the United States' Medicare Functional Classification Level, also called K level. Survival was determined using a combination of sources, including the Social Security Death Master File, searches of multiple genealogic registries, and general internet searches. Multivariable logistic regression was used to determine risk factors associated with prosthesis attainment. Multivariable Cox proportional hazard regression with time-dependent covariates was performed to assess risk factors associated with 5-year mortality.

A total of 464 patients were included in this study. The mean age was 65 years, and mean body mass index was 27 kg/m2. The majority of patients were male (68%), White (56%), diabetic (62%), and hypertensive (76%), and underwent below-the-knee amputation (69%). Prosthetic attainment occurred in 185 (40%). On multivariable analysis, age >81 years and current tobacco use were associated with no prosthetic fitting. Overall 5-year survival was 41.9% (95% confidence interval [CI], 37.6%-46.6%) (below-the-knee amputation, 47.7% [95% CI, 42.5%-53.5%]; above-the-knee amputation, 28.7% [95% CI, 22.1%-37.2%]). On multivariable analysis, age >60 years, congestive heart failure, above-the-knee amputation, and no prosthetic attainment were associated with decreased survival. Increasing K level was incrementally associated with improved survival.

This study has identified several patient factors associated with prosthetic attainment, as well as multiple factors predictive of reduced survival after amputation. Being referred for prosthetic fitting was associated with improved survival not explained by patient characteristics and comorbidities. The Medicare Functional Classification Level K level predicts survival. More research is needed to determine the barriers to prosthetic attainment and if improving a patients K level will improve survival.

Lower limb amputation surgery is associated with a high risk of venous thromboembolism. There is evidence that pharmacological thromboprophylaxis is not widely prescribed to patients undergoing this type of procedure.

To investigate the profile of the thromboprophylaxis practices of angiologists and vascular surgeons in Brazil during the perioperative period of lower limb amputation surgery and conduct a descriptive analysis of the findings.

This is a cross-sectional, descriptive study, with simple probabilistic sampling, carried out with angiologists and vascular surgeons working in Brazil. Data were collected through electronic questionnaires, from February to June 2023.

There were 237 respondents, 58.6% of whom conduct thrombotic risk stratification. Of these, 86.3% use the Caprini score. Only 27% of participants stratify patients' bleeding risk. Low molecular weight heparin is the medication of choice for 85.7% of study participants, 78.9% of whom use a dosage of 40 IU per day. Around 46.8% use direct oral anticoagulants in addition to low molecular weight heparin and rivaroxaban is the drug they most often prescribe (94.6%). A little more than half (51.15%) routinely recommend pharmacological thromboprophylaxis until hospital discharge.

The study revealed the heterogeneous nature of conduct related to prescription of pharmacological thromboprophylaxis, highlighting the need for more studies to support prophylaxis decision-making in this patient population.

Half of those undergoing major lower limb amputation for peripheral arterial disease die within 1 year. Advance care planning reduces days in hospital and increases the chance of dying in a preferred place.

To investigate the prevalence and content of advance care planning for people having a lower limb amputation due to acute or chronic limb-threatening ischaemia or diabetes. Secondary aims were to explore its association with mortality, and length of hospital stay.

A retrospective observational cohort study. The intervention was advance care planning.

Patients admitted to the South West England Major Arterial Centre between 1 January 2019 and 1 January 2021 who received unilateral or bilateral below, above, or through knee amputation due to acute or chronic limb-threatening ischaemia or diabetes.

116 patients were included in the study. 20.7% (n = 24) died within 1 year. 40.5% (n = 47) had an advance care planning discussion of which all included cardiopulmonary resuscitation decisions with few exploring other options. Patients who were more likely to have advance care planning discussions were ≥75 years (aOR = 5.58, 95%CI 1.56-20.0), female (aOR = 3.24, 95%CI 1.21-8.69), and had multimorbidity (Charlson Comorbidity Index ≥5, aOR = 2.97, 95%CI 1.11-7.92). Discussions occurred more often in the emergency pathway and were predominantly initiated by physicians. Advance care planning was associated with increased mortality (aHR = 2.63, 95%CI 1.01, 5.02) and longer hospital stay (aHR = 0.52, 95%CI 0.32-0.83).

Despite a high risk of death for all patients in the months following amputation, advance care planning occurred in fewer than half of people and mostly focused on resuscitation.

Lower extremity amputation (LEA) is a life altering procedure, with significant negative impacts to patients, care partners, and the overall health system. There are gaps in knowledge with respect to patterns of healthcare utilization following LEA due to dysvascular etiology.

To examine inpatient acute and emergency department (ED) healthcare utilization among an incident cohort of individuals with major dysvascular LEA 1 year post-initial amputation; and to identify factors associated with acute care readmissions and ED visits.

Retrospective cohort study using population-level administrative data.

Ontario, Canada.

Adults individuals (18 years or older) with a major dysvascular LEA between April 1, 2004 and March 31, 2018.

Not applicable.

Acute care hospitalizations and ED visits within one year post-initial discharge.

A total of 10,905 individuals with major dysvascular LEA were identified (67.7% male). There were 14,363 acute hospitalizations and 19,660 ED visits within one year post-discharge from initial amputation acute stay. The highest common risk factors across all the models included age of 65 years or older (versus less than 65 years), high comorbidity (versus low), and low and moderate continuity of care (versus high). Sex differences were identified for risk factors for hospitalizations, with differences in the types of comorbidities increasing risk and geographical setting.

Persons with LEA were generally more at risk for acute hospitalizations and ED visits if higher comorbidity and lower continuity of care. Clinical care efforts might focus on improving transitions from the acute setting such as coordinated and integrated care for sub-populations with LEA who are more at risk.

Patients with peripheral artery disease (PAD) have 40-70% higher three-year mortality after lower limb amputation compared to non-amputees. In this study, we examined the consequences of delayed treatment for patients with PAD during the coronavirus disease 2019 (COVID-19) pandemic.

This study employed a retrospective single-centre cohort design at a large tertiary care hospital. We compared amputees with PAD during the initial COVID-19 outbreak period in 2020 with a control group of amputees from 2019 after a three-year follow-up.

In total, 134 amputees with PAD were included due to unsuccessful revascularization (n = 84 in 2020 vs. n = 50 in 2019). Patients in 2020 were significantly younger than those in 2019 (p = 0.01) and mostly admitted with advanced stages of PAD (p < 0.03). The proportion of major limb amputations increased significantly in 2020 (p = 0.03). Non-COVID-19-related deaths among patients in 2020 were more than twice as many as those in 2019, and long-term mortality in 2020 was 49% compared to 39% in 2019 (p = 0.04). Diabetes and renal insufficiency had a significantly negative impact on the survival of amputees with PAD (p < 0.01).

Delayed treatment in patients with PAD leads to high long-term mortality risk after amputation, especially in PAD patients with diabetes and renal insufficiency. Therefore, in future pandemics, continuously monitoring patients with PAD will be crucial to prevent delayed treatment and severe short-term and long-term consequences.

Peripheral artery disease (PAD) is a highly prevalent disorder with a high risk of mortality and amputation despite the introduction of novel medical and procedural treatments. Microvascular disease (MVD) is common among patients with PAD, and despite the established role as a predictor of amputations and mortality, MVD is not routinely assessed as part of current standard practice. Recent pre-clinical and clinical perfusion and molecular imaging studies have confirmed the important role of MVD in the pathogenesis and outcomes of PAD. The recent advancements in the imaging of the peripheral microcirculation could lead to a better understanding of the pathophysiology of PAD, and result in improved risk stratification, and our evaluation of response to therapies. In this review, we will discuss the current understanding of the anatomy and physiology of peripheral microcirculation, and the role of imaging for assessment of perfusion in PAD, and the latest advancements in molecular imaging. By highlighting the latest advancements in multi-modality imaging of the peripheral microcirculation, we aim to underscore the most promising imaging approaches and highlight potential research opportunities, with the goal of translating these approaches for improved and personalized management of PAD in the future.

People with diabetes are susceptible to serious and disabling foot complications, which increase their morbidity and mortality rates. Examining the perspectives of people with diabetes on their foot care routines could help elucidate their beliefs and offer practical ways to prevent foot problems.

We explored the perspectives of adults with diabetes on their foot care practices to identify and enhance foot care education and support strategies.

Using the Zoom platform, 29 adults with diabetes completed a 3-month telehealth educational program, during which interviews were conducted. This article reports the results of thematic content analysis of the qualitative data. Coded participant statements were organized into categories and reexamined to identify emergent themes.

Analysis of participants' perceptions revealed four main themes of influences that facilitated and/or hindered their foot care practices. Foot care behaviors were facilitated by patients' personal knowledge of others with diabetes-related foot consequences (theme 1). Foot care practices were hindered by the emotional impact of living with diabetes (theme 2), and the physical, social, and lifestyle limitations associated with foot care (theme 3). Finally, patients noted that interactions with family could be either a facilitator or hindrance to their foot care routines (theme 4).

These findings highlight multiple patient-centered factors related to personal, physical, psychosocial, and cultural influences that affect foot care behaviors.

An understanding of how patients manage diabetes-related foot care can help nurse practitioners enhance foot care education and support strategies in this population.

The diabetic foot interacts with anatomical, vascular, and neurological factors that challenge clinical practice. This study aimed to compile the primary scientific evidence based on a review of the main guidelines, in addition to articles published on the Embase, Lilacs, and PubMed platforms. The European Society of Cardiology system was used to develop recommendation classes and levels of evidence. The themes were divided into six chapters (Chapter 1 - Prevention of foot ulcers in people with diabetes; Chapter 2 - Pressure relief from foot ulcers in people with diabetes; Chapter 3 -Classifications of diabetic foot ulcers; Chapter 4 - Foot and peripheral artery disease; Chapter 5 - Infection and the diabetic foot; Chapter 6 - Charcot's neuroarthropathy). This version of the Diabetic Foot Guidelines presents essential recommendations for the prevention, diagnosis, treatment, and follow-up of patients with diabetic foot, offering an objective guide for medical practice.

The COVID-19 pandemic has affected the healthcare systems worldwide since the dawn of 2020. In March 2020, the United Kingdom government announced the first national lockdown which severely disturbed all National Health Service (NHS) healthcare elective services. Our aim is to assess the long-term impact of COVID-19 related disruption of NHS elective services on emergency major lower limb amputations (MLLAs).

Patients' data for emergency MLLA for critical limb-threatening ischemia and diabetic foot infections performed at Aberdeen Royal Infirmary was collected through Trakcare and divided into the control prepandemic group (April 2018-March 2020) and the pandemic group (April 2020-March 2022). The statistical analysis was conducted using the IBM SPSS software (v28.0.1.1 [14]).

A total of 358 patients underwent MLLA and 206 (57.5%) of these had diabetes mellitus. There was a 17% increase in the number of urgent referrals and every 1 in 5 of these finally underwent an amputation. There was an increase in the absolute number of Above- and Below-Knee amputations. There was a statistically significant increase by 33% in emergency MLLAs during the pandemic period (P < 0.05). A total of 165 postoperative deaths up to December 2022 were recorded with 30-day mortality rate of 7.26% (n = 26).

NHS vascular management groups should update themselves with evolving technologies to optimize the care provided during future unprecedented times. Furthermore, more effective measures should also be implemented to avoid delayed presentations, which can potentially lead to higher rates of major limb amputations.

Diabetic foot syndrome is a global challenge best managed through multidisciplinary collaboration. This study aimed to investigate the effect of a systematic multidisciplinary team (MDT) on the overall survival and major amputation-free survival of hospitalized patients with diabetic foot infection (DFI).

This retrospective cohort study was conducted at Tampere University Hospital. Cohorts of hospitalized patients with DFI before and after the initiation of multidisciplinary wound ward were compared after an 8-year follow-up.

Kaplan-Meier analysis revealed significantly higher overall survival in the post-MDT cohort (37.8 % vs 22.6 %, p < 0.05) in 8-year follow-up. Similarly, major amputation-free survival was superior in this cohort (31.8 % vs 16.9 %, p < 0.05). Additionally, early major amputation was associated with inferior overall survival (35.1 % vs 12.0 %, p < 0.05). In a multivariable Cox-regression analysis cohort (hazard ratio [HR] 1.38, 95 % confidence interval [CI95%] 1.01-1.87), early amputation (HR 1.64, CI95% 1.14-2.34) and diagnosed peripheral artery disease (HR 2.23, CI95% 1.61-3.09), congestive heart failure (HR 2.13, CI95% 1.47-3.08), or moderate kidney disease (HR 1.95, CI95% 1.34-2.84) were identified as significant risk factors affecting overall survival.

After systematic MDT approach we found improved long-term overall and major amputation-free survival. Multidisciplinary approach is therefore highly recommended for managing patients hospitalized for DFI.

Major lower extremity amputation (LEA) is associated with significant morbidity and mortality. The modified frailty index (mFI-5) has been used to predict outcomes including ambulation and mortality after LEA. It remains unknown for which patient demographics the mFI-5 is a reliable predictor.

This was a retrospective review of all patients who underwent a first-time major LEA at our institution from 2015 to 2022. Patients were stratified into 2 risk groups based on their mFI-5 score: non-frail (mFI<3) and frail (mFI≥3) and assessed on outcomes.

Our sample consisted of 687 patients of whom 134 (19.6%) were considered frail and 551 (80.4%) were considered non-frail. A higher mFI-5 is associated with decreased ambulation rates (OR: 0.565, P = .004), increased hospital readmission (OR: 1.657, P = .021), and increased mortality (OR: 2.101, P = .001) following major LEA. In African American patients, frail and non-frail patients differed on readmission at 90 days (P = .008), mortality at 1 year (P = .001), ambulatory status (P < .001), and prosthesis use (P = .023). In male patients, frail and non-frail patients differed on readmission at 90 days (P = .019), death at 1 year (P = .001), and ambulatory status (P = .002). In Caucasian patients and female patients, frail and non-frail patients did not differ significantly on outcomes.

The mFI-5 is a valuable predictor of outcomes following major LEA, specifically in males and African American patients. Moreover, surgeons should consider using frailty status to risk stratify patients and inform treatment plans.

Background: The use of free tissue transfer (FTT) is efficacious for chronic, non-healing lower extremity (LE) wounds. The four pillars of managing patient comorbidities, infection control, blood flow status, and biomechanical function are critical in achieving successful limb salvage. The authors present their multidisciplinary institutional experience with a review of 300 FTTs performed for the complex LE limb salvage of chronic LE wounds. Methods: A single-institution, retrospective review of atraumatic LE FTTs performed by a single surgeon from July 2011 to January 2023 was reviewed. Data on patient demographics, comorbidities, preoperative management, intraoperative details, flap outcomes, postoperative complications, and long-term outcomes were collected. Results: A total of 300 patients who underwent LE FTT were included in our retrospective review. Patients were on average 55.9 ± 13.6 years old with a median Charlson Comorbidity Index of 4 (IQR: 3). The majority of patients were male (70.7%). The overall hospital length of stay (LOS) was 27 days (IQR: 16), with a postoperative LOS of 14 days (IQR: 9.5). The most prevalent comorbidities were diabetes (54.7%), followed by peripheral vascular disease (PVD: 35%) and chronic kidney disease (CKD: 15.7%). The average operative LE FTT time was 416 ± 115 min. The majority of flaps were anterolateral thigh (ALT) flaps (52.7%), followed by vastus lateralis (VL) flaps (25.3%). The immediate flap success rate was 96.3%. The postoperative ipsilateral amputation rate was 12.7%. Conclusions: Successful limb salvage is possible in a highly comorbid patient population with a high prevalence of diabetes mellitus, peripheral vascular disease, and end-stage renal disease. In order to optimize patients prior to their LE FTT, extensive laboratory, arterial, and venous preoperative testing and diabetes management are needed preoperatively. Postoperative monitoring and long-term follow-up with a multidisciplinary team are also crucial for long-term limb salvage success.

Diabetic foot (DMF) complications are common and are increasing in incidence. Risk factors related to wound complications are yet to be established after trans-tibial amputation under the diagnosis of DMF infection.

To analyze the prognosis and risk factors related to wound complications after transtibial amputation in patients with diabetes.

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.

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.

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.

The aim was to describe the baseline characteristics of French patients referred with acute limb ischaemia (ALI), and their clinical management and outcome (death, amputation).

This retrospective observational cohort study used the National Health Data System. All adults hospitalised for ALI who underwent revascularisation with an endovascular or open surgical approach between 1 January 2015 and 31 December 2020 were included and followed up until death or the end of the study (31 December 2021). A one year look back period was used to capture patients' medical history. The risks of death, and major and minor amputations were described using Kaplan-Meier and Aalen-Johansen estimators. A Cox model was used to report the adjusted association between groups and risk of death and Fine-Gray models for the risk of amputations considering the competing risk of death.

Overall, 51 390 patients (median age 70 years, 69% male) were included and had a median follow up of 2.7 years: 39 411 (76.7%) were treated with an open approach and 11 979 (23.3%) with a percutaneous endovascular approach. The preferred approach for the revascularisation varied between French regions. The one year overall survival was 78.0% and 85.2% in the surgery and endovascular groups, respectively. The surgery group had a higher risk of death (hazard ratio [HR] 1.17, 95% CI 1.12 - 1.21), a higher risk of major amputation (sub-distribution HR 1.20, 95% CI 1.10 - 1.30) and lower risk of minor amputation (sub-distribution HR 0.66, 95% CI 0.60 - 0.71) than the endovascular group. Diabetes and dialysis increased the risk of major amputation by 52% and 78%, respectively. Subsequent ALI was the third most common cause of hospital re-admission within one year.

ALI remains a condition at high risk of death and amputation. Individual risk factors and ALI severity need to be considered to choose between approaches. Continued prevention efforts, improved management, and access to the most suitable approach are necessary.

Low socioeconomic status (SES), distance lived from hospital, and insurance status are well documented in the literature to increase the risk of post-operative morbidity and mortality for some disease processes however there is a paucity of data regarding how this association impacts patients with peripheral artery disease (PAD). This study aimed to evaluate if SES, distance lived from hospital, and insurance status increased the risk of developing major graft failure in patients undergoing revascularization procedures for symptomatic PAD in a prospective, observation study.

In this prospective, observational study, all patients undergoing lower extremity revascularization (endovascular or open) were included from December 2020 to February 2022. Demographic factors, insurance status, operative details, and median income and distance from hospital were documented through chart review. Complications were defined as thrombosis/occlusion of the revascularized vessel or bypass graft or infection of the distal wound or surgical incision wound. Univariate and multivariate analysis were performed comparing patients that developed complications and those that did not. This project was undertaken at the Massachusetts General Hospital and was governed by the Institutional Review Board (IRB: 2020P000263) all patients agreed to participation via informed written consent prior to enrollment in the study.

A total of 108 patients were enrolled in the study of which 94 underwent successful revascularization procedures. Of those 94 patients, 38 (40.4%) underwent open bypass, 39 (41.5%) underwent endovascular revascularization, and 17 (18.1%) underwent a hybrid approach. There were no significant differences in post-operative outcomes between operative approaches. Twenty-five patients (28.7%) experienced major revascularization complications as defined as re-occlusion of the treated vessel/thrombosis of the bypass graft (n = 13) or development of post-operative infection (n = 12). There was no significant difference in median income ($75,295 vs $87,757, p = NS), distance lived from hospital, (27.4 miles vs. 29.7 miles, p = NS), or type of insurance (private 24% vs 26%, government 76% vs 73%, p = NS between patients that experienced complications versus those that did not have complications. These findings suggest the risk of major graft failure is independent of a patient's socioeconomic status, distance lived from hospital, or insurance type in patients undergoing revascularization procedures for PAD.

While socioeconomic factors impact access to and have a known association with negative outcomes, complications in patients with PAD appear to be independent of these factors. To mitigate the negative outcomes in patients with peripheral artery disease, a focus should be on patient risk factors and modifiable medical factors that contribute to adverse outcomes.

Painful diabetic neuropathy (PDN) can result in the loss of protective sensation, in which people are at twice the likelihood of foot ulceration and three times the risk of lower extremity amputation. Here, we evaluated the long-term effects of high-frequency (10 kHz) paresthesia-independent spinal cord stimulation (SCS) on protective sensation in the feet and the associated risk of foot ulceration for individuals with PDN.

The SENZA-PDN clinical study was a randomized, controlled trial in which 216 participants with PDN were randomized to receive either conventional medical management (CMM) alone or 10 kHz SCS plus CMM, with optional treatment crossover after 6 months. At study visits (baseline through 24 months), 10-g monofilament sensory assessments were conducted at 10 locations per foot. Two published methods were used to evaluate protective sensation via classifying risk of foot ulceration.

Participants in the 10 kHz SCS group reported increased numbers of sensate locations as compared to CMM alone (P < .001) and to preimplantation (P < .01) and were significantly more likely to be at low risk of foot ulceration using both classification methods. The proportion of low-risk participants approximately doubled from preimplantation to 3 months postimplantation and remained stable through 24 months (P ≤ .01).

Significant improvements were observed in protective sensation from preimplantation to 24 months postimplantation for the 10 kHz SCS group. With this unique, disease-modifying improvement in sensory function, 10 kHz SCS provides the potential to reduce ulceration, amputation, and other severe sequelae of PDN.

The SENZA-PDN study is registered on ClinicalTrials.gov with identifier NCT03228420.

To assess the impact of diabetes, amputation level, sex and age on mortality rates after lower extremity amputation (LEA) in Belgium, and to assess temporal trends in one-year survival rates from 2009 to 2018.

Nationwide data on individuals who underwent minor and major LEA from 2009 to 2018 were collected. Kaplan-Meier survival curves were constructed. A Cox regression model with time-varying coefficients was used to estimate the likelihood of mortality after LEA in individuals with or without diabetes. Matched amputation-free individuals with or without diabetes were used for comparison. Time trends were analysed.

Amputations 41,304 were performed: 13,247 major and 28,057 minor. Five-year mortality rates in individuals with diabetes were 52% and 69% after minor and major LEA, respectively (individuals without diabetes: 45% and 63%, respectively). In the first six postoperative months, no differences in mortality rates were found between individuals with or without diabetes. Later, hazard ratios (HRs) for mortality in individuals with diabetes (compared with no diabetes) after minor LEA ranged from 1.38 to 1.52, and after major LEA from 1.35 to 1.46 (all p ≤ 0.005). Among individuals without LEA, HRs for mortality in diabetes (versus no diabetes) were systematically higher compared to the HRs for mortality in diabetes (versus no diabetes) after minor and major LEA. One-year survival rates did not change for individuals with diabetes.

In the first six postoperative months, mortality rates after LEA were not different between individuals with or without diabetes; later, diabetes was significantly associated with increased mortality. However, as HRs for mortality were higher in amputation-free individuals, diabetes impacts mortality less in the minor and major amputation groups relative to the comparison group of individuals without LEA.

To systematically review literature on nutritional intake, nutritional status and nutritional interventions, and to study their association with short- and long-term clinical outcomes in people with a major dysvascular lower limb amputation.

PubMed, Ovid, CINAHL, and The Cochrane Library were searched. Studies were included if nutritional intake, nutritional status, or nutritional interventions in people with a major dysvascular lower limb amputation were analyzed.

Of the 3038 unique papers identified, 30 studies were included. Methodological quality was moderate (1 study) or weak (29 studies). Limited information was available on nutritional intake (2 studies) and nutritional interventions (1 study). Nutritional intake and nutritional status were assessed by diverse methods. The percentage of people with a poor nutritional status ranged from 1% to 100%. In some studies, measures of poor nutritional status were associated with adverse short- and long-term clinical outcomes.

The percentage of people with a poor nutritional status is inconclusive in the major dysvascular lower limb amputation population, because of the heterogeneity of the assessment methods used. Some included studies reported a negative association between poor nutritional status and clinical outcomes. However, these results should be interpreted with caution, because of the limited quality of the studies available. Studies high in methodological quality and high in hierarchy of evidence are needed.IMPLICATIONS FOR REHABILITATIONThe proportion of people with a poor nutritional status in the major dysvascular lower limb amputation population is inconclusive.Poor nutritional status seems to affect clinical outcomes negatively.More uniformity in assessment of malnutrition in the major dysvascular lower limb amputation population is needed.

Prosthesis use in persons with amputation can improve mobility and functional independence. Better understanding of the reasons for and outcomes associated with prosthesis nonuse is important to optimize function and long-term health in persons with amputation.

Study objectives were to describe the rate, reasons for, and factors associated with never using or discontinuing prosthesis use in United States (US) veterans with amputation.

Cross-sectional study design.

The study used an online survey to assess prosthesis use and satisfaction in veterans with upper-limb and lower-limb amputation. Survey participation invitations were distributed by email, text message, and mail to 46,613 potential participants.

The survey response rate was 11.4%. After exclusions, an analytic sample of 3,959 respondents with a major limb amputation was identified. The sample was 96.4% male; 78.3% White, with mean age of 66.9; and mean of 18.2 years since amputation. The rate of never using a prosthesis was 8.2%, and the rate of prosthesis discontinuation was 10.5%. Functionality (62.0%), undesirable prosthesis characteristics (56.9%), and comfort (53.4%) were the most common reasons for discontinuation. After controlling for the amputation subgroup, the odds of prosthesis discontinuation were higher for those with unilateral upper-limb amputation, female gender, White race (compared with Black race), diabetes, above-knee amputation, and lower prosthesis satisfaction. Prosthesis satisfaction and quality of life were highest for current prosthesis users.

This study adds new understanding regarding the rate and reasons for prosthesis nonuse in veterans and highlights the important relationship between prosthesis discontinuation and prosthesis satisfaction, quality of life, and satisfaction with life.

Patients with peripheral arterial disease (PAD) have a poorer prognosis than those without PAD. PAD complications worsen the prognosis of patients with chronic kidney disease (CKD), especially those on maintenance dialysis. Although low-density lipoprotein apheresis (LDL-A) is expected to be effective in treating severe PAD, there are no large-scale reports on the prognosis of patients undergoing LDL-A.

We obtained a clinical database from April 2008 to August 2021 and selected 924 238 patients with CKD. We selected patients with disease codes of lower limb arteriosclerosis obliterans, arteriosclerosis obliterans, and critical limb ischemia or foot ulcer. Patients who were prescribed antithrombotic medications were included. Patients who used steroids were excluded. Among these patients, those undergoing blood purification considered LDL-A were selected, and their current status was investigated.

We included 147 patients (113 males and 34 females). The mean patient age was 70 ± 10 years. Diabetes mellitus was present in 86%, ischemic heart disease in 34%, and stroke in 48%. Maintenance dialysis patients accounted for 86% of the patients. Statins were administered to 40% of the patients, and bypass surgery was performed in 2.7%. The median observation period was 812 days, and the mortality rate was 41%.

LDL-A was performed in a small population of patients with CKD with the most severe form of PAD. The prognosis for these patients is extremely poor. Therefore, strategies to improve prognosis are important.

Despite advances in techniques and care, major amputation bears a high risk for mortality. Previously identified factors associated with increased risk of mortality include amputation level, renal function, and pre-operative white cell count.

A single center retrospective chart review was conducted identifying patients who had undergone a major amputation. Chi-squared, t-testing, and Cox proportional hazard modeling were performed examining death at 6 months and 12 months.

Factors associated with an increased risk of six-month mortality include age (OR 1.01-1.05, P < .001), sex (OR 1.08-3.24, P < .01), minority race (OR 1.18-18.19, P < .01), chronic kidney disease (OR 1.40-6.06, P < .001), and use of pressors at the induction of anesthesia for index amputation (OR 2.09-7.85, P < .000). Factors associated with increased risk of 12 month mortality were similar.

Patients undergoing major amputation continue to suffer high mortality. Those patients who received their amputation under physiologically stressful conditions were more likely to die within 6 months. Reliably predicting six-month mortality can assist surgeons and patients in making appropriate care decisions.

Previous studies have demonstrated that timely podiatric surgery consultation results in positive patient outcomes. However, there are limited studies focused on readmission rates in teaching community hospitals. The primary aim of this study is to determine if consulting podiatric services was associated with lower 30-day readmission rates and impact on length of stay in patients with lower extremity wounds. The secondary aim was to investigate medical and socio-economic factors associated with better outcomes. This study was a cross-sectional descriptive study. A retrospective chart review utilizing the hospital's electronic medical record system identified patients with lower extremity wounds (based on ICD-10 codes) admitted between July 2018 and December 2020. The results showed a 3-fold decrease in 30-day readmission rates in patients with podiatric surgery consultation compared to patients without consultation with lower extremity wounds (4.2% vs 11.3%, p = .03). Multivariate regression models showed patients with gangrene (AOR = 7.61; p = .04) or osteomyelitis (AOR = 9.07; p = .013) had a higher likelihood of readmission than patients with venous ulcer (reference category) after controlling for podiatric consultation. Among the group of patients with podiatric consultation, earlier podiatric consultations resulted in decreased length of stay. This study identifies prior amputation history and lack of podiatric consultation increased 30-day readmission rates.