The Effect of Adding Virtual Reality Training on Traditional Exercise Program on Balance and Gait in Unilateral, Traumatic Lower Limb Amputee.

Objective: Lower limb amputation is common in war combat and armed conflict as well as in traumatic settings and presents a challenge for health care providers. The incorporation of advanced technologies, particularly virtual reality, presents an opportunity to address the main consequences of amputation, principally balance and gait. The aim of this study was to investigate the additional effect of virtual reality with a traditional rehabilitation exercise program on balance and gait in unilateral, traumatic lower limb amputees. Materials and Methods: Thirty-two traumatic lower limb amputees, fulfilling a postfitting rehabilitation program at least 6 months ago, were recruited and randomly assigned into two identically sized groups; group C (control group) experiencing the traditional exercise program and group VR (virtual reality group) experiencing an addition of a virtual reality training. The intervention was conducted over 6 weeks at a rate of three sessions per week. Outcome measures assessed before and after 6 weeks were the Berg Balance Scale (BBS), Timed Up and Go (TUG) test, Dynamic Gait Index (DGI), and 6-minute walk test (6 MWT). Results: Both interventions induced improvement in all measured parameters (P < 0.05); however, virtual reality demonstrated significant superior effects only on the balance markers, TUG test, DGI, and BBS (P < 0.05), but not on the 6 MWT (P > 0.05). Conclusion: Virtual reality is a promising, amusing, and safe intervention for addressing balance and gait in unilateral, traumatic lower limb amputees.

An Institutional Protocol for the Treatment of Severe Frostbite Injury-A 6-Year Retrospective Analysis.

The treatment of severe frostbite injury has undergone rapid development in the past 30 years with many different diagnostic and treatment options now available. However, there is currently no consensus on the best method for management of this disease process. At our institution, we have designed a protocol for severe frostbite injury that includes diagnosis, medical treatment, wound cares, therapy, and surgery. This study assess the efficacy of our treatment since its implementation six years ago. During this time, all patients with severe frostbite injury were included in prospective observational trial of the protocol. We found that this protocol results in significant tissue salvage with over 80.7% of previously ischemic tissue becoming viable and not requiring amputation. We also were able to improve our center's efficiency over the course of six years and now our current average time from rapid rewarming to delivery of thrombolytics is under six hours.

Contemporary Endovascular Outcomes for Critical Limb Ischemia Are Still Failing to Meet Society for Vascular Surgery Objective Performance Goals.

OBJECTIVES: The Society for Vascular Surgery (SVS) created Objective Performance Goals (OPGs) for critical limb ischemia (CLI) in 2009. It was previously shown that endovascular therapy for CLI was not meeting these benchmarks. The OPG for all peripheral interventions is <8% for major adverse cardiac events (MACE), <8% for major adverse limb events (MALE), and <3% for major amputation. The goal of this study is to evaluate if outcomes have improved for CLI in recent years, specifically 2015-2018. METHODS: The Targeted Vascular Module from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) was queried to identify patients who underwent endovascular intervention for critical limb ischemia from 2011-2018. Cohorts were divided into 2011-2014 and 2015-2018. Primary 30-day outcomes were MACE, MALE, and major amputation. Univariate analyses were performed using the Fisher's exact test and the Wilcoxon rank-sum test. Multivariate analysis comparing groups was performed using inverse probability weights and trend over time analysis was performed using logistic regression with year of intervention as a continuous variable. RESULTS: From 2011 to 2018, 7,168 patients underwent an endovascular intervention for CLI. 28% were classified as "OPG high anatomic risk," and 17% were classified as "OPG high clinical risk." The 2015-2018 cohort vs. the 2011-14 cohort experienced MACE in 3.3% vs. 2.7% (p = .23), MALE in 9.1% vs. 8.9% (p = 0.83), and amputation in 4.0% vs. 4.2% (p = 0.71). When only high anatomic risk patients were considered (n = 1988), MACE was experienced in 2.4% vs. 2.2% (p = 0.87), MALE by 9.5% vs. 10.6% (p = 0.47) and amputation by 5.1% vs. 6.0% (p = 0.40). When only high clinical risk patients were considered (n = 1224), MACE was experienced in 5.2% vs. 3.9% (p = 0.33), MALE by 8.0% vs. 7.4% (p = 0.74) and amputation by 3.9% vs. 3.7% (p = 0.88). Comparing 2015-2018 to the reference 2011-2014, MALE adjusted odds ratio (AOR) = 0.99, 95% CI [0.83-1.18], MACE AOR = 1.19 95% CI [0.88-1.60], and major amputation AOR = 0.91 95% CI [0.70-1.17]. There were no decreases in the trend over time for MALE (AOR per year 0.97, CI [.94-1.02], major amputation (AOR per year: 0.97, CI [0.91-1.03], nor for MACE (AOR per year: 1.05, CI [.98-1.13]). CONCLUSION: Outcomes following endovascular interventions for CLI continue to underperform when compared to OPG benchmarks for MALE and amputations. There is no decrease over time for these target outcomes. Target MACE events remain acceptable despite the increasing clinical complexity of patients being treated.

A Global Vascular Guidelines-Based Bypass-Preferred Population and Their Surgical Risk Among CLTI Patients Treated With Endovascular Therapy in a Real-World Practice.

PURPOSE: To determine in a chronic limb-threatening ischemia (CLTI) population who underwent endovascular therapy (EVT) how many patients would have been categorized as preferred for bypass surgery according to the Global Vascular Guidelines (GVG) and ascertain their surgical risk. MATERIALS AND METHODS: The current study analyzed 1043 CLTI patients who presented WIfI (wound, ischemia, and foot infection) stage ≥2 and underwent EVT between April 2010 and December 2017. Of these, 176 were excluded for lack of angiographic or other data, leaving 867 CLTI patients (mean age 74±10 years; 523 men) for stratification according to the GVG into bypass-preferred, indeterminate, or EVT-preferred groups. The GVG recommend bypass as the first-line treatment when the wound is severe (WIfI stage ≥3) and lesions are complex (GLASS stage III). Surgical risk was estimated using the modified PREVENT III risk score. To further stratify the bypass-preferred population according to mortality risk, a survival decision tree was constructed using recursive partitioning. RESULTS: The bypass-preferred group accounted for 55% [95% confidence interval (CI) 51% to 58%] of the overall population. The decision tree analysis extracted a low-mortality risk subgroup with a survival rate of 99% (95% CI 98% to 100%) at 1 month and 80% (95% CI 73% to 87%) at 2 years. According to the PREVENT III score, 34% (95% CI 27% to 42%) of the low mortality risk subgroup were classified as high surgical risk. CONCLUSION: A high proportion of patients undergoing EVT were considered bypass preferred based on the GVG, and the survival of these patients was not significantly different whether they were high or low surgical risk.

Digital Subtraction Angiography Prior to an Amputation for Critical Limb Ischemia (CLI): An Expert Recommendation Statement From the CLI Global Society to Optimize Limb Salvage.

Despite recent guideline updates on peripheral artery disease (PAD) and critical limb ischemia (CLI) treatment, the optimal treatment for CLI is still being debated. As a result, care is inconsistent, with many CLI patients undergoing an amputation prior to what many consider to be mandatory: consultation with an interdisciplinary specialty care team and a comprehensive imaging assessment. More importantly, quality imaging is critical in CLI patients with below-the-knee disease. Therefore, the CLI Global Society has put forth an interdisciplinary expert recommendation for superselective digital subtraction angiography (DSA) that includes the ankle and foot in properly indicated CLI patients to optimize limb salvage. A recommended imaging algorithm for CLI patients is included.

Educational assessment of the major lower limb amputations videos on YouTube.

OBJECTIVE: Videos of surgical procedures are viewed by some as potential training resources for surgeons and residents. However, there is little evidence on the effectiveness of surgical videos on learning and understanding complex three-dimensional surgical procedures. Lower extremity amputation is a complex surgery, and many residents and surgeons have low exposure to this type of procedures. This paper investigates the educational quality of lower extremity amputation videos posted on YouTube. METHODS: The search was limited to the first 100 videos. Full-length videos of any major lower limb amputation or disarticulation were included. Key basic video data such as title, YouTube address (http://), country of origin, channel source, uploading date, video duration time, number of views, number of up-voters and number of down-voters were collected. An educational assessment tool has been developed specifically for limb amputations. It consists in 11 items: three general and eight amputation-specific, each having a maximum score of 2. RESULTS: In total, 13 videos met the inclusion criteria for final analysis. Four videos reported the surgical technique of above knee amputation, two reported that of knee disarticulation and the remaining seven videos described below knee amputation. The average score (±SD) was 12.77 ± 5.2 yielding an average grade close to "Fair." A high level of concordance was found between the two assessors (κ = 0.79). No correlation was found between educational assessment tool score and the pre-set variables (r = 0.6, R2 = 35.4%, F = 1.09, P = 0.4). CONCLUSIONS: Most videos describing lower extremity amputation techniques were found to be of low-to-moderate quality. Only 4 out of 13 (30.7%) had an excellent educational and technical quality. Surgeons and surgical residents should be aware that not all posted videos on YouTube are beneficial. High educational quality videos are needed since many surgeons and residents have a low exposure to such surgeries.

The Effectiveness of the DoD/VA Mobile Device Outcomes-Based Rehabilitation Program for High Functioning Service Members and Veterans with Lower Limb Amputation.

INTRODUCTION: The objective was to determine if the Mobile Device Outcomes-based Rehabilitation Program (MDORP) improved strength, mobility, and gait quality in service members (SMs) and Veterans with lower limb amputation (LLA). METHODS: Seven SMs and 10 Veterans with LLA enrolled and were trained to use a mobile sensor system, called Rehabilitative Lower Limb Orthopedic Analysis Device (ReLOAD). ReLOAD provided participants with real-time assessment of gait deviations, subsequent corrective audio feedback, and exercise prescription for normalizing gait at home and in the community. After baseline testing, prosthetic gait and exercise training, participants took ReLOAD home and completed an 8-week walking and home exercise program. Home visits were conducted every 2 weeks to review gait training and home exercises. RESULTS: Significant improvements in hip extensor strength, basic and high-level mobility, musculoskeletal endurance, and gait quality (P < 0.05) were found at the completion of the 8-week intervention. CONCLUSION: Preliminary MDORP results are promising in its ability to improve basic and high-level mobility, lower limb strength, and gait quality in a group of SMs and Veterans with LLA. In addition, "booster" prosthetic training may be justified in an effort helps maintain an active lifestyle, promotes prosthetic use, and mitigates secondary health effects.

Adherence to the EAU guidelines on Penile Cancer Treatment: European, multicentre, retrospective study.

PURPOSE: The European Association of Urology (EAU) guidelines for penile cancer (PC) are exclusively based on retrospective studies and have low grades of recommendation. The aim of this study was to assess the adherence to guidelines by investigating the management strategies for primary tumours and inguinal lymph nodes. METHODS: We retrospectively reviewed the clinical charts of 176 PC patients who underwent surgery in eight European centres from 2010 to 2016. The stage and grade were assessed according to the 2009 AJCC-UICC TNM classification system. To assess adherence rates, we compared theoretical and practical adherence to the EAU guidelines. RESULTS: Overall, 176 patients were enrolled. Partial amputation was the most frequent surgical approach (39%). 53.7% of tumours were stage Tis-T1b and the remaining 46.3% were stage T2-T4. Palpable lymph nodes were detected in 30.1% of patients and 45.1% underwent lymphadenectomy (LY). A sizeable group of tumours (43.2%) were N0. For primary treatment, adherence to the EAU guidelines was good (66%). In non-adherent cases, reasons for discrepancy were patient's choice (17%), surgeon's preference (36%), and other causes (47%). For LY, the guideline adherence was 70%, with either patient's or surgeon's choice or other causes accounting for discrepancy in 28, 20, and 52% of non-adherent cases, respectively. CONCLUSION: Adherence to the EAU guidelines for PC was quite high across the eight European centres involved in the study. This notwithstanding, strategies for further improvement should be developed and evenly adopted.

Objective Performance Goals for Surgical Treatment of Critical Limb Ischemia.

BACKGROUND: Based on prospective vein bypass trials for lower leg ischemia, objective performance goals (OPG) were established by the Society for Vascular Surgery (SVS) and are used as a benchmark tool for open and endovascular treatments. This study aims to analyze OPG of all patients with critical limb ischemia (CLI) treated by open revascularization techniques at a tertiary care facility in routine practice. METHODS: From January 2005 to March 2013, 315 patients (mean age 72 years) with CLI were retrospectively included in this study. Inclusion criteria were patients with Fontaine stage III and IV, realized revascularization with open surgical procedures (bypass grafting or endarterectomy), or hybrid method (open + endovascular). Exclusion criteria were primary major amputations, patients with revascularization treatments of the index leg within the last 3 months, and missing aftercare. Primary end point was "amputation-free survival" (AFS), and secondary end point was "freedom from major adverse limb event + perioperative death (30 days)" (MALE + POD) according to the SVS. The technical end point was primary patency. Mean follow-up was 34 months. The following variables were studied: clinical stage (Fontaine), previous interventions, bypass material used, and site of the distal anastomosis. The statistical evaluation and preparation was carried out using the Kaplan-Meier estimator and the log-rank test. A multivariate analysis was performed using the Cox proportional hazards model. A P value ≤0.05 was considered to be statistically significant. RESULTS: A total of 128 patients (31%) fulfilling the adjusted SVS OPG criteria showed significantly better results for AFS, MALE + POD, and primary patency (P = 0.013, P = 0.015, P = 0.002, respectively). Regarding the AFS (1 year: 74%), multivariate analysis displayed significant worse results for patients with end-stage renal disease (hazard ratio [HR] 2.90, 95% confidence interval [CI] 1.83-4.60, P < 0.001) and Fontaine stage IV (HR 1.69, 95% CI 1.11-2.57, P = 0.015). Regarding MALE + POD (1 year: 64%), male patients (HR 0.64, 95% CI 0.46-0.90, P = 0.011) showed a significantly better outcome and patients without previous interventions of the index leg (HR 1.51, 95% CI 1.09-2.09, P = 0.013) showed a significantly worse outcome. CONCLUSIONS: In this study, we were able to show that it is possible to reach the efficacy of OPGs set by SVS in a surgically treated all-comers cohort of CLI patients. Nevertheless, patients who did not fulfill the SVS OPG criteria showed significantly worse results for AFS and MALE + POD.

Amputation: Evaluation and Treatment.

Combat extremity injury and amputation is a life threatening injury. Initial surgical care should focus on hemostasis followed by irrigation and debridement of contaminated and nonviable tissue. Preservation of limb length begins at the initial surgical procedure, to include retention of atypical soft tissue flaps for later reconstruction and treatment of proximal fractures. Serial irrigation and debridements are required throughout the MEDEVAC system as the evolving zone of injury becomes more mature, followed by the appropriate timing of closure outside the combat theater.

Indicators of outcome quality in peripheral arterial disease revascularisations - a Delphi expert consensus.

INTRODUCTION: Peripheral arterial disease (PAD) affects a continuously increasing number of people worldwide leading to more invasive treatments. Indication to perform invasive revascularisations usually arises from consensus-based recommendations of practice guidelines and from few randomized controlled trials where outcome measures focus mainly on risk factors associated with mortality and morbidity. To date, no broad consensual agreement of experts on valid indicators of outcome quality exists for PAD. METHODS: A literature review was conducted to collect indicators of outcome quality from studies of PAD. The Delphi technique was used to achieve a consensual agreement on a set of core indicators. The expert panel of the two-round Delphi approach was formed by leading vascular specialists joining the IDOMENEO study, physician assistants, wound nurses, and patient representatives. Items were scored via a web-based anonymised electronic questionnaire using a five-point Likert-scale. RESULTS: Out of 40 invited experts 30 joined the panel and completed round one. Twenty-four experts completed the second and final round. Forty-three indicators of outcome quality were initially identified and validated by the panel. After two Delphi rounds, 12 indicators (27.9 %) achieved the limit of agreement for relevance and four (9.3 %) for practicability. Major adverse limb events (MALE), major amputation, and major re-intervention (or re-operation) were consented as both highly relevant and practicable. Additionally, major adverse cardiovascular events (MACE), myocardial infarction, stroke or transient ischaemic attack, all-cause death, all re-intervention (or re-operation), wound infection, vascular access-related major complication, walking distance, and Rutherford-classification were consented as highly relevant. Ankle-brachial-index was consented as highly practicable. CONCLUSIONS: This Delphi approach of vascular experts identified three indicators as highly relevant and clinically practicable to be recommended as indicators of outcome quality in invasive PAD treatment. Among others, these consented items may help in harmonising future studies and quality benchmarking increasing their comparability, validity, and efficiency.

Analysis of Patients Undergoing Major Lower Extremity Amputation in the Vascular Quality Initiative.

BACKGROUND: Despite an aggressive climate of limb salvage and revascularization, 7% of patients with peripheral artery disease undergo major lower extremity amputation (LEA). The purpose of this study was to describe the current demographics and early outcomes of patients undergoing major LEA in the Vascular Quality Initiative (VQI). METHODS: The VQI amputation registry was reviewed to identify patients who underwent major LEAs. Patient factors, limb characteristics, procedure type, and intraoperative variables were analyzed by the level of amputation. Factors associated with amputation level, 30-day complications, and mortality were analyzed using chi-squared analysis for significance with associated P values. Propensity score adjustment was used to balance statistically significant differences observed in subject characteristics by amputation level for the associated relative risk of a given outcome. RESULTS: Between 2013 and 2015, 2,939 major LEAs were recorded in the VQI amputation registry. The ratio of below-knee to above-knee amputation (BKA:AKA) was 1.29:1. The mean age was 66 years, 64% were male, 84% lived at home before admission, and 68% were ambulatory. Comorbidities included diabetes (67%), coronary artery disease (32%), end-stage renal disease (22%), and chronic obstructive pulmonary disease (23%). The mean preoperative ankle-brachial index (ABI) was 0.78. Overall, 43% had a history of prior ipsilateral revascularization. Indications for amputation were ischemic rest pain or tissue loss (58%), uncontrolled infection (31%), acute ischemia (9%), and neuropathic tissue loss (2%). The overall perioperative complication rate was 15%, 25% were discharged home, and the 30-day mortality was 5%. Patients who received an AKA versus BKA were more likely to be female (40.61% vs. 31.70%), more than age 70 (48.79% vs. 32.55%), underweight (18.63% vs. 9.18%), nonambulatory (40.22% vs. 25.18%), have an ABI <0.6 (58.00% vs. 45.26%), and carry nonprivate insurance (77.40% vs. 69.08%) (all P < 0.001). Patients undergoing AKA were less likely to have 30-day postoperative complications (12.24% vs. 17.87%) but had higher 30-day mortality (6.70% vs. 3.09%) than BKA patients (all P < 0.001). CONCLUSIONS: In the VQI registry, major LEA was performed predominantly for ischemic rest pain and tissue loss with a BKA:AKA ratio of 1.29:1. Patients undergoing AKA versus BKA were older, had lower ABI, lower rates of 30-day postoperative complications but higher rates of 30-day mortality. This registry offers an important real-world resource for studies pertaining to vascular surgery patients undergoing major lower extremity amputation.

Evaluation of NU-FlexSIV Socket Performance for Military Service Members with Transfemoral Amputation.

Ischial containment sockets are the current standard of care for military service members with transfemoral amputation. However, they fit intimately with the ischium, which may limit hip motion and contribute to proximal socket discomfort, a common complaint among prosthesis users. Subischial sockets, such as the newly described Northwestern University Flexible Subischial Vacuum (NU-FlexSIV) Socket technique, do not interact with the ischium, potentially increasing hip motion and improving comfort. PURPOSE: To transfer the NU-FlexSIV Socket technique to military prosthetists and evaluate performance among military service members with transfemoral amputation. STUDY DESIGN: case series. METHODS: Four of the 11 enrolled subjects completed the study protocol comparing the NU-FlexSIV Socket to the ischial containment socket. Gait kinematics (over ground and on stairs), physical performance measures (Four-Square Step Test, T-test of Agility, and an obstacle course), limb-socket motion, and socket comfort were assessed after accommodation time in each socket. RESULTS: While wearing the NU-FlexSIV Socket, sagittal plane hip motion generally increased while coronal plane trunk motion and walking speed remained largely unaffected during over ground walking. During stair ascent, sagittal plane hip motion increased while wearing the NU-FlexSIV Socket, with minimal changes in walking speed for all subjects. Pre- and post-walking fluoroscopy measures suggest fit of the NU-FlexSIV Socket was less affected by activity. Most subjects reported that the NU-FlexSIV Socket was more comfortable for sitting but some found it less comfortable for walking and running. Performance measure results were mixed. Although attempts were made to consistently implement the NU-FlexSIV Socket technique, some challenges were experienced. CONCLUSIONS: The NU-FlexSIV Socket provided greater hip motion across a variety of tasks without adversely affecting other movement mechanics but did not consistently improve socket comfort. Variability in the liners and socket materials used may have contributed to variability in results. Overall, the design was a viable alternative to traditional ischial containment sockets for some individuals with transfemoral amputation.

Major Lower Limb Amputation: Outcomes are Improving.

BACKGROUND: Outcomes following major lower limb amputation (MLLA) between 2000 and 2002 from the Department of Vascular Surgery at Royal Perth Hospital have been published; mean postoperative length of stay 20 days, inpatient complication rate 54%, and 30-day mortality 10%. The last decade has seen increasing endovascular revascularization techniques, increased focus on MLLA patients, and general improvements in the model of care. The aim of this study is to compare outcomes between 2000-2002 and 2010-2012. METHODS: Data on all patients undergoing MLLA, transtibial or proximal, in the 2 time periods were extracted from the department of vascular surgery database. Medical records, government registries, and phone calls to primary care providers were used to clarify mortality. RESULTS: Limb ischemia remains the most common indication for MLLA with smoking, hypertension, and diabetes being the main comorbid diseases. The rates of wound infections have fallen from 26.4% to 12.4% (P = 0.023), rate of admission to ICU has fallen from 48.3% to 17.5% (P = 0.001), and revision amputation to a higher level has fallen from 11.5% to 7.2% (P = 0.043). Acute hospital, postoperative length of stay has trended down from 15.74 to 20.29 days (P = 0.075). Mortality overall has fallen from 60.92% to 46.39% (P = 0.049). Thirty-day mortality fallen from 10.34% to 5.15% (P = 0.185), 6-month 28.76% to 16.5% (P = 0.046), and 1-year 40.22% to 21.65% (P = 0.006). CONCLUSIONS: Patients undergoing MLLA still carry a high burden of comorbid disease. With changes in revascularization technique, consultant supervision, and multidisciplinary model of care, we have seen the rate of complications fall, length of stay trend down, and overall mortality reduce. Despite improvements, outcomes remain sobering and more can be done.

Comparison of five systems of classification of diabetic foot ulcers and predictive factors for amputation.

Diabetes mellitus is a common metabolic disorder. Among various complications, diabetic neuropathy and peripheral vascular disorders are closely associated with diabetic foot ulcers (DFUs). Lower extremity ulcers and amputations are ongoing problems among individuals with diabetes. There are several classification systems for DFUs; however, no prognostic system has to date been accepted as the gold standard or the optimum prediction tool for amputations. A retrospective study was designed. Demographic data and baseline laboratory data were gathered and scored or evaluated using five representative DFU classification systems. These included (i) the diabetic ulcer severity score (DUSS); (ii) University of Texas (UT) diabetic wound classification; (iii) Meggitt-Wagner classification; (iv) depth of the ulcer, extent of bacterial colonisation, phase of ulcer and association aetiology (DEPA) scoring system; and (v) site, ischaemia, neuropathy, bacterial infection and depth (SINBAD) score. Finally, a statistical analysis was performed. A total of 137 patients were included in this study. During the follow-up, DFU had healed in 51·1% of subjects and 48·9% of the individuals underwent lower extremity amputations (LEAs). In a univariable logistic regression analysis, history of previous DFU, hypertension, neuropathy, haemoglobin, C-reactive protein (CRP) and ankle-brachial index (ABI) showed a statistically significant difference between the healed group and the LEA group. Moreover, the stages, grades or overall prognostic ability of all five classifications were highly associated with the overall occurrence of LEA. On multivariable logistic regression analysis of the risk of LEA, all classifications showed a significant positive trend with an increased number of amputations. All the five classification systems exhibited high sensitivity, specificity, classification accuracy, positive predictive, negative predictive and area under the curve (AUC) values. They showed substantial accuracy and their main variables were associated with LEA occurrence. The Wagner and UT systems, although they are relatively simple to assess, were better predictors of LEA.

Lower extremity amputation rates in people with diabetes as an indicator of health systems performance. A critical appraisal of the data collection 2000-2011 by the Organization for Economic Cooperation and Development (OECD).

AIMS: Critical appraisal of secondary data made available by the OECD for the time frame 2000-2011. METHODS: Comparison of trends and variation of amputations in people with diabetes across OECD countries. Generalized estimating equations to test the statistical significance of the annual change adjusting for major potential confounders. RESULTS: A total of 26 OECD countries contributed to the OECD data collection for at least 1 year in the reference time frame, showing a decline in rates of over 40 %, from a mean of 13.2 (median 9.4, range 5.1-28.1) to 7.8 amputations per 100,000 in the general population (9.9, 1.0-18.4). The multivariate model showed an average decrease equal to -0.27 per 100,000 per year (p = 0.015), adjusted by structural characteristics of health systems, showing lower amputation rates for health systems financed by public taxation (-4.55 per 100,000 compared to insurance based, p = 0.002) and non-ICD coding mechanisms (-7.04 per 100,000 compared to ICD-derived, p = 0.001). Twelve-year decrease was stronger among insurance-based financing systems (tax based: -0.16 per 100,000, p = 0.064; insurance based: -0.36 per 100,000; p = 0.046). CONCLUSIONS: In OECD countries, amputation rates in diabetes continuously decreased over 12 years. Still, in 2011, one amputation every 7 min could be directly attributed to diabetes. Although interesting, these results should be taken with extreme caution, until common definitions are improved and data quality issues, e.g., a different ability in capturing diabetes diagnoses, are fully resolved.

Osteomyoplastic Transtibial Amputation: The Ertl Technique.

Amputation may be required for management of lower extremity trauma and medical conditions, such as neoplasm, infection, and vascular compromise. The Ertl technique, an osteomyoplastic procedure for transtibial amputation, can be used to create a highly functional residual limb. Creation of a tibiofibular bone bridge provides a stable, broad tibiofibular articulation that may be capable of some distal weight bearing. Several different modified techniques and fibular bridge fixation methods have been used; however, no current evidence exists regarding comparison of the different techniques. Additional research is needed to elucidate the optimal patient population, technique, and postoperative protocol for the Ertl osteomyoplastic transtibial amputation technique.