Validity of exploration for suitable vessels for replantation in the distal fingertip amputation in early childhood: Replantation or composite graft

Abstract

Composite grafting, grafting without microvascular anastomoses, has been widely performed for distal fingertip amputation in children with variable results, whereas successful replantation of these amputations using microsurgical technique has been reported. However, most of these reports included a wide age-range and a mix of different amputation levels. This study reviewed our cases of paediatric digital amputation, in order to verify the value of distal fingertip replantation over composite grafting, especially in early childhood. Seventeen young children (aged 3 years and 8 months on average), with single-digit fingertip amputations in Tamai zone I were reviewed from 1993–2008. Each amputation was subdivided into three types: distal, middle, and proximal. There were three distal, 13 middle, and one proximal type zone I amputations. All were crush or avulsion injuries. All three distal-type cases were reattached as primary composite grafts with one success. For middle-type cases, the survival rate of primary composite graft without exploration for possible vessels for anastomosis was 57%. On exploration, suitable vessels for anastomosis were found 50% of the time, in which all replantations were succeeded. The remaining cases were reattached as secondary composite grafts, with one success using the pocket method. Consequently, the success rate after exploration was 67%. The only one proximal-type amputation was failed in replantation. For the middle-type zone I amputation in early childhood, replantation has a high success rate if suitable vessels can be found. Therefore, exploration is recommended for amputations at this level with a view to replantation, irrespective of the mechanism of injury.     

Clinical outcomes of salvage revision surgery following finger replantation with vascular insufficiency: A retrospective study

ObjectiveThe aim of this study was to analyze the outcomes of revision surgery following replantation of single digital amputations.MethodsIn this study, first, a total of 403 patients (339 male, 64 female; mean age=28 years; age range=1–76) in whom a single finger replantation was performed were retrospectively reviewed, and then 60 patients with arterial or venous insufficiency in whom revision surgery was performed were reanalyzed. The second finger was observed to be the most injured one (32.8%). Injury type was classified as clean cut (25.3%), local crush (38.7), extensive crush (7.9%), and avulsion (28.1%). When taking the levels of injuries of the artery-only finger replantations into account, one finger (0.8%) was nail distal third, 70 fingers (56%) were nail distal third to lunula, 43 fingers (34.4%) were lunula to distal phalanx basis, 10 fingers (8%) were distal interphalangeal (DIP) joint, and one finger (0.8%) was middle phalanx. Operative revision was performed on 60 (14.9%) fingers. The need for operative revision was arterial insufficiency in 37 fingers (61.7%) and venous insufficiency in 23 fingers (38.3%). The average revision time was 43 (range=6–144) hours. While the average elapsed time for artery procedures was 35.3 (range=8–110) hours, the average elapsed time for vein procedures was 47.1 (range=6–144) hours. Finger survival rates were examined. Injury mechanism, amputation level, the number of artery/vein repairs and methods were examined in all patients and revision patients separately.ResultsAfter the replantations, according to survival analysis, while 342 (84.9%) fingers were operated upon successfully, 61 (15.1%) fingers developed necrosis. In the patients with revision surgery, the survival rate was 78.3%. The need for revision was arterial insufficiency in 37 fingers (61.7%) and venous insufficiency in 23 fingers (38.3%). The revision rate was significantly lower than other injury types in clean-cut cases. In terms of levels of injury, no revisions were required from distal to lunula level, and the highest revision rate was observed at the proximal interphalangeal (PIP) joint level.ConclusionThe results of the present study have shown that early re-exploration can provide a 78.3% success rate and can increase the survival rate from 67.6% to 84.2% following replantation of single digital amputations. Surgical re-exploration seems to be a reasonable salvage for replanted fingers with vascular insufficiency.Level of EvidenceLevel IV, Therapeutic study     

Thoughts on the management of amputation and amputation-like injuries in the upper extremities

Summary Between 1982 and 1993, 65 amputation and amputation-like injuries in the upper arm (n = 18), proximal and middle forearm (n = 32) and distal forearm and wrist level (n = 15) were treated in our institution. The overall survival rate in our series was 92.3 % (60/65). In 3 of 65 cases early secondary amputation because of vascular failure was necessary. There was one reamputation because of deep infection with beginning sepsis. Severe systemic disturbances were seen in one patient, requiring early reamputation. Twenty-five patients with a follow-up of more than 2 years were reviewed in a retrospective clinical study and evaluated according to the Chen classification. Of 8 patients with upper-arm involvement, 2 had a grade II result, 4 a grade III and 2 a grade IV result. There were 1 grade I, 2 grade II, 2 grade III and 5 grade IV results in the proximal forearm group. In the distal forearm group 2 patients each showed a grade I, II and III result and 1 a grade IV. Taking grades I and II results together, a “functional extremity” could be reconstructed at the upper arm level in 25 %, proximal forearm 30 %, and the distal forearm in 58 %. The main advantage of replantation/revascularization of the upper limb is the possibility of restoring some sensitivity to the hand in addition to partial motor recovery, which always provides twice as much individual motor function as is offered by any type of prosthesis currently available. The higher cost and number of operations needed, as well as the longer postoperative care and longer disability time after replantation/revascularization are nevertheless justified by the significant increase in quality of life.      

Composite grafting for pediatric fingertip injuries

Background

Fingertip injuries are common in the pediatric population. Composite grafting is a frequently used technique for distal amputations in children given the reported success rate. We sought to study the early clinical results of composite grafting for fingertip injuries in the pediatric population.

Methods

A retrospective review was performed over a 5-year period at a tertiary care pediatric hospital to identify those patients who underwent composite grafting of fingertip injuries. Patients were included if they were 18 years old or younger and sustained an injury distal to the distal interphalangeal joint (or thumb interphalangeal joint). Demographic information was recorded. Graft viability was characterized as no take, partial take, or complete take. The number of secondary procedures and number and duration of follow-up appointments were recorded. Hypothesis testing was done using ordinal logistic regression analysis.

Results

Thirty-nine patients underwent fingertip composite grafting. The mean age was 5.9 years (1–18 years); there were 24 males (61.5 %) and 15 females (38.5 %). Thirteen patients had no graft take (33.3 %), 23 patients had partial take (59.0 %), and three patients had complete take (7.7 %). Only four patients underwent secondary revision (10 %). The median number of follow-up appointments was 3 and the average follow-up time was 4.5 months. Age did not appear to have a statistically significant influence on graft take.

Conclusions

Fingertip composite grafts rarely take completely even in young children. Despite poor viability, however, most patients will have at least partial graft take and do not undergo additional reconstructive procedures.     

Replantation or revascularisation injuries in children: Incidence,epidemiology, and outcome

Abstract

We studied the epidemiology, incidence, and outcome among children and adolescents admitted for possible replantation or revascularisation of an injured upper extremity during the period 1998–2008. Twenty-nine patients with 38 finger injuries were admitted. Eight of the 29 had a severe amputation injury. The annual rate of all amputations in the referral area of 300 000 children was 0.42/100 000 children/year and total amputation injuries 0.18/100 000 children/year. Most injuries occurred in patients aged 12–15 years. The survival after total amputations was 6/14 and after subtotal amputations 13/15. Mean total active movement after replantation was 84° (n = 5) and after revascularisation 152° (n = 10). Four patients were re-examined in the outpatient department and nine answered a questionnaire. Cold intolerance was reported by most of the patients. Patients’ satisfaction with outcome of treatment was good.     

Factors affecting composite graft survival in digital tip amputations

Distal fingertip amputations present the hand surgeon with a myriad of treatment options. Composite tissue replantation offers the patient the possibility of maintaining digital length and function. The purpose of this study was to determine the efficacy of this treatment modality and to support its use. During a 2.5-year period, 53 patients with 57 digital tip amputations distal to the distal interphalangeal (DIP) joint underwent composite tissue grafting of the tip with minimal defatting. All patients were evaluated in a prospective manner. Specific information regarding the patient and the injury were recorded. The survival rates for amputations distal to the eponychium and between the DIP joint and eponychium were 58% and 43%, respectively. Smoking was the only significant factor that had a strong, independent association with graft loss. Age older than 18 years and alcohol use appeared only initially to have an effect on graft survival because they were so closely linked with smoking. Diabetes mellitus and crush-type injuries may potentially predispose a graft to fail, but a larger sample size is needed to prove this with significance. There were no infections or serious complications, even in those grafts that failed. After reviewing the data, the authors recommend using composite tissue replantation for fingertip amputations distal to the DIP joint in nonsmokers.     

Long-term outcome of secondary alveolar bone grafting in cleft lip and palate patients: A 10-year follow-up cohort study

Abstract

The objective was to assess the long-term outcome of secondary alveolar bone grafting (SABG) in cleft lip and palate patients and to examine relationships between preoperative and postoperative factors and overall long-term bone graft success. The records of 97 patients with cleft lip and palate, who had secondary alveolar bone grafting of 123 alveolar clefts, were examined. Interalveolar bone height was assessed radiographically a minimum of 10 years after grafting using a 4-point scale (I–IV), where types I and II were considered a success. After an average follow-up of 16 years after SABG (range = 10.2–22.7 years), 101 of the 123 grafts (82%) were categorised as successes. Mean age in the success group was 12.1 years and 13.6 years in the failure group (p = 0.03). It was found that the success rate was significantly lower (p = 0.02) if SABG was performed after eruption of the tooth distal to the cleft. No significant differences were found with regard to the other parameters investigated. The timing of secondary alveolar bone grafting is critical with regard to the age of the patient and the stage of eruption of the tooth distal to the cleft.     

Primary vs delayed primary closure in patients undergoing lower limb amputation following trauma: A randomised control study

Lower limb crush injury is a major source of mortality and morbidity in trauma patients. Complications, especially surgical site infections (SSIs) are a major source of financial burden to the institute and to the patient as it delays rehabilitation. As such, every possible attempt should be made to reduce any complications. We, thus, aimed to compare the outcomes in early vs delayed closure of lower extremity stumps in cases of lower limb crush injury requiring amputation, so as to achieve best possible outcome. A randomised controlled study was conducted in the Division of Trauma Surgery & Critical Care at Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi from 1 September 2018 to 30 June 2019 and included patients undergoing lower limb amputation below hip joint. Patients were randomised in two groups, in one group amputation stump was closed primarily, while in the second group delayed primary closure of stump was performed. We compared rate of SSI, length of hospital stay, and number of surgeries in both the groups. Fifty‐six patients with 63 amputation stumps were recruited in the study. Mean age of patients in the study was 34 years, of which about 95% patients were males. The most common mechanism of injury was road traffic injury in 66% of patients. Mean injury severity score was 12.28 and four patients had diabetes preoperatively. Total 63 extremities were randomised with 30 cases in group I and 33 cases in group II as per computer‐generated random number. Above knee amputations was commonest (57.14%) followed by below knee amputations (33.3%). Two patients died in the current study. In group I, In‐hospital infection was detected in 7 cases (23.3%) and in group II 9 cases (27.3%) had SSI during hospital admission (P > .05). Mean hospital stay in group I was 10.32 ± 7.68 days and in group II was 11 ± 8.17 days (P > .05). Road traffic injuries and train‐associated injuries are a major cause of lower limb crush injuries, leading to limb loss. Delayed primary closure of such wounds requires extra number of surgical interventions than primary closure. There is no difference in extra number of surgical interventions required in both the groups. Thus, primary closure can be safely performed in patients undergoing lower limb amputations following trauma, provided that a good lavage and wound debridement is performed.     

Characterization of disability following traumatic through knee and transfemoral amputations

IntroductionThe purpose of this study is to characterize through knee and transfemoral amputations following severe traumatic injuries.MethodsA retrospective review of all transfemoral and through knee amputations sustained by United States military service members from 1 October 2001 to 30 July 2011 was conducted. Data from the Department of Defense Trauma Registry, the Armed Forces Health Longitudinal Technology Application, inpatient medical records and the Physical Evaluation Board Liaison Offices were queried in order to obtain characteristics related to injury sustained, demographics, treatment, and disability/mental health outcome data.ResultsA total of 1631 amputations in 1315 patients were identified. Of these there were 37 through knee and 296 were transfemoral amputations. Adequate records for detailed analysis were available on 140 and 25 transfemoral and through knee amputations respectively. There were no significant differences in demographic information, injury mechanism, initial injury severity score, or associated injuries, to include contralateral amputations. There was no significant difference in average disability rating (67.9% vs 78.3%, p = 0.46) or number of service members determined to be fully disabled (42.2% vs 28.6% p = 0.33) between the transfemoral and through knee amputation groups. Whereas there was no difference between groups preoperatively, the knee disarticulation group displayed a higher rate of mental health diagnoses post-amputation (96% vs 72%, p < 0.001) and a higher preponderance of anxiety related disorders than the transfemoral amputees (26.92% vs 12.96%, p = 0.0129).Discussion/conclusionAmong this military amputee through knee and transfemoral amputees displayed similar physical disability profiles. However, the through knee amputees displayed a higher level of anxiety related disorders and mental health diagnosis overall. While we don’t believe this relationship to be causal in nature, this finding reflects the importance of paying particular attention to mental health in the final disposition of traumatic lower extremity amputees.     

Eight years experience in crush and avulsion type finger amputation

Between July 1986 and July 1994, we studied 125 total finger amputations due to crush and avulsion type injuries at the lzmir Hand and Microsurgery Hospital. Of the 125 fingers replanted, 88 were successful, for a general survival rate of 70.4%. In the period between 1986 and 1991, we performed end-to-end anastomoses and achieved a survival rate of 48.3% (Group I). Between 1991 and 1994, with the application of a primary interpositional vein graft for the required indications in this type of injury, the general survival rate increased to 77.1% (Group II; P < 0.05). We conclude that the significant increase in the survival rate in Group II is related to both the increased experience of the surgical team and the application of the primary interpositional vein graft. © 1995 Wiley-Liss, Inc.     

Complications and revision amputation following trauma-related lower limb loss

IntroductionTrauma-related amputations are a common cause of limb loss in the United States. Despite the military and public health impact of trauma-related amputations, distributions of various lower limb amputations and the relative frequency of complications and revision amputations have not been well described. We used the National Trauma Data Bank (NTDB) in order to investigate the epidemiology of trauma-related lower extremity amputations among civilians in U.S. trauma centers.Materials and methodsWe conducted a secondary data analysis of the 2011–2012 NTDB research data sets, using means and frequencies to characterize the patient population and describe the distribution of major lower extremity amputations. Multivariable regression models were fit to identify predictors of major post-surgical complications, revision amputation, length of hospitalization, and in-hospital mortality.ResultsA total of 2879 patients underwent a major lower extremity amputation secondary to a trauma-related lower limb injury, representing 0.18% of all NTDB trauma admissions from 2011 to 2012. 80.4% were male and 67.6% were white. The three most frequent definitive amputations preformed included trans-tibial (46%), trans-femoral (37.5%), and through foot (7.6%). The average length of hospitalization for all amputees was 22.7 days. Patients with at least one revision amputation stayed in the hospital approximately 5.5 days longer than patients not needing a revision amputation. 1204 patients (41.8%) required at least one revision amputation. 27.5% of amputees experienced at least one major post-surgical complication. African Americans experienced a 49% higher major post-surgical complication incidence and stayed, on average, 2.5 days longer in the hospital compared to whites. Injury severity score, age, hospital teaching status, presence of a crush injury, fracture location, presence of compartment syndrome, and experiencing a major post-surgical complication were all significant predictors of revision amputation.ConclusionWe report a high rate of complications and revision amputations among trauma-related lower limb amputees, and identify predictors of surgical outcomes that have not been described in the literature including African American race. Compartment syndrome is a significant predictor of major post-surgical complications, revision amputation, and length of hospitalization.     

The DeBakey classification exactly reflects late outcome and re-intervention probability in acute aortic dissection with a slightly modified type II definition

Objective: The DeBakey classification was used to discriminate the extent of acute aortic dissection (AD) and was correlated to long-term outcome and re-intervention rate. A slight modification of type II subgroup definition was applied by incorporating the aortic arch, when full resectability of the dissection process was given. Methods: Between January 2001 and March 2010, 118 patients (64% male, mean age 59 years) underwent surgery for acute AD. As many as 74 were operated on for type I and 44 for type II AD. Complete resection of all entry sites was performed, including antegrade stent grafting for proximal descending lesions. Results: Patients were comparable with respect to demographics and preoperative hemodynamic status. They underwent isolated ascending replacement, hemiarch, or total arch replacement in 7%, 26%, and 67% in type I, versus 27%, 37%, and 36% in type II, respectively. Additional descending stent grafting was performed in 33/74 (45%) type I patients. In-hospital mortality was 14%, 16% (12/74) in type I versus 9% (4/44, type II), p = 0.405. After 5 years, the estimated survival rate was 63% in type I versus 80% in type II, p = 0.135. In type II, no distal aortic re-intervention was required. In type I, the freedom of distal re-interventions was 82% in patients with additional stent grafting versus 53% in patients without, p = 0.022. Conclusions: The slightly modified DeBakey classification exactly reflects late outcome and aortic re-intervention probability. Thus, in type II patients, the aorta seems to be healed without any probability of later re-operation or re-intervention.     

Evaluation of a Clinically Applicable Post-Surgical Classification System for Primary Retroperitoneal Soft-Tissue Sarcoma

Background: The present AJCC/TNM staging system is of limited value for prediction of prognosis for patients with retroperitoneal sarcoma. The objective of the present study was to develop a postsurgical classification system that would enable comparison of outcomes for patients with primary retroperitoneal soft-tissue sarcoma.Methods: Four classes were defined: I, low-grade/complete resection/no metastasis; II, high-grade/complete resection/no metastasis; III, any-grade/incomplete resection/no metastasis; and IV, any-grade/any resection/distant metastasis. The prognostic value of this classification system was analyzed in a population-based multicenter group(MCG) of patients with primary retroperitoneal soft-tissue sarcoma (n = 124) and in a cohort of patients treated in a single tertiary referral center (SCG; n = 107).Results: Overall 5-year survival rates were 55% in the SCG and 43% in the MCG (P = 0.02). Class III (incomplete resection) was more frequent in the MCG than in the SCG (33% vs. 16%; P = 0.02). In the SCG, stage-specific 5-year survival rates were 89%, 40%, 26%, and 17% for classes I, II, III, and IV, respectively (P < 0.001), in comparison with 68%, 46%, 24%, and 0% in the MCG (P < 0.001). In a comparison of class-specific survival between the groups, only class I patients in the SCG had significantly better survival than class I patients in the MCG (P = 0.048).Conclusions: Classification based on grade, completeness of resection, and distant metastasis offers a reproducible prognostic tool that can be used to evaluate treatment strategies for primary retroperitoneal soft-tissue sarcoma. The probability of complete resection was significantly higher in the SCG than in the MCG. In patients with low-grade, completely resected sarcoma, there is a significant survival benefit with treatment in a high-volume tertiary center of excellence.     

Fingertip replantation at or distal to the nail base: use of the technique of artery-only anastomosis

The authors describe the functional and aesthetic results of microsurgical replantation of 21 fingertip amputations at or distal to the nail base-namely, zone I amputations. There were 15 male and 6 female patients, with an average age of 26 years (age range, 1-41 years). Replantations were performed using the anastomosis of the artery-only technique, with neither vein nor nerve repair. Venous drainage was provided by an external bleeding method with a fish-mouth incision in "distal" zone I amputations for approximately 7 days, and by the use of leeches in more "proximal" zone I amputations for 10 to 12 days. Results indicated that the overall survival rate was 76%, with 16 of 21 digits surviving. Sensory evaluation at an average follow-up of 12 months (range, 6-18 months) revealed an average static two-point discrimination of 6.1 mm (range, 2.0-8.0 mm). Considering the unfavorable results and the donor site morbidity of various fingertip reconstructions, a microsurgical fingertip replantation should always be considered except in extremely distal, clean-cut, pediatric cases, in which case a composite graft is a possibility. The results of this series indicate that an amputated fingertip in zone I can be salvaged successfully by microvascular anastomosis of the artery only, with a nonmicrosurgical method of venous drainage. Furthermore, acceptable sensory recovery can be expected without any nerve coaptation.     

Incidence,epidemiology, and operative outcome of replantation or revascularisation of injury to the upper extremity

Abstract

We retrospectively studied the epidemiology of adult patients admitted for possible replantation or revascularisation of an injured upper extremity during the period June 2003 to May 2008. A total of 121 patients were admitted (71 graded severe), mean 24 (14 graded severe), being admitted each year. The annual rate of amputation injuries in the referral area of 1.5 million was 1.5/100 000 and for severe amputation injuries 0.9/100 000. Most injuries occurred in patients aged 41–50. Fifty-eight patients had the accident during working hours (36 severe), and 62 during leisure time (34 severe). The survival rate for subtotal amputations was 77% and for total amputations 55%. Of 15 further vascularisation procedures, two succeeded at the metacarpal level. Most of the accidents occurred during wood-processing with circular saws or powered wood splitters. More efforts should focus on preventing such injuries.     

Macroreplantations of the upper extremity: a series of 11 patients

Introduction

Micro- or macroreplantation is classified depending on the level of amputation, distal or proximal to the wrist. This study was performed to review our experience in macroreplantation of the upper extremity with special attention to technical considerations and outcomes.

Materials and methods

Between January 1990 and December 2010, 11 patients with a complete amputation of the upper extremity proximal to the wrist were referred for replantations to our department. The patients, one woman and ten men, had a mean age of 43.4?±?18.2?years (range 19?C76?years). There were two elbow, two proximal forearm, four mid-forearm, and three distal forearm amputations. The mechanism of injury was crush in four, crush-avulsion in five and guillotine amputation in two patients. The Chen classification was used to assess the postoperative outcomes. The mean follow-up after macroreplantation was 7.5?±?6.3?years (range 2?C21?years).

Results

All but one were successfully replanted and regained limb function: Chen I in four cases (36?%), Chen II in three cases (27?%), Chen III in two cases (18?%), and Chen IV in one patient (9?%). We discuss the steps of the macroreplantation technique, the need to minimize ischemic time and the risk of ischemia reperfusion injuries.

Conclusion

Thanks to improvements in technique, the indications for limb preservation after amputation can be expanded. However, because of their rarity, replantations should be performed at specialist replantation centers. Level of evidence: Level IV     

Prognosis of critical limb ischemia: Major vs. minor amputation comparison

Healthcare providers treating wounds have difficulties assessing the prognosis of patients with critical limb ischemia who had been discharged after complete healing of major amputation wounds. The word “major” in “major amputation” gives the impression of “being more severe” than “minor amputation.” Therefore, even if wounds are healed after major amputation, they imagine that prognosis after major amputation would be poorer than that after minor amputation. We investigated the prognosis of diabetic nephropathy patients 2 years after amputations. Those patients underwent dialysis as well as amputation following percutaneous transluminal angioplasty for their foot wounds. They were ambulatory prior to these surgeries. Among 56 cases of minor amputation, 45 were males and 11 were females, and mortality was 41.1%. The mortality of cases with and without a coronary intervention history was 53.1% and 25.0%, respectively (p = 0.034). Among 10 cases of major amputation, 9 were males and 1 was female, and mortality was 60%. The mortality of cases with and without a coronary intervention history was 75.0% and 0%, respectively. Although we predicted poor prognosis in cases with major amputation, there was no significant difference in mortality 2 years after amputations (p = 0.267). Thus far poor prognosis has been reported for major amputation. It might be due to inclusion of the following patients: patients with wounds proximal to ankle joints, patients with extensive gangrene spreading to the lower legs, patients with septicemia from wound infection and who died around the time of operation, and patients with malnutrition. The results of our present study showed that the outcomes at 2 years postoperatively were similar between patients with major amputations and those with minor amputations, if surgical wounds were able to heal. We should not estimate the prognosis by the level of amputation, rather we should consider the effect of coronary intervention history on prognosis.     

Non-traumatic lower limb amputation in patients with end-stage renal failure on dialysis: an Australian perspective

Background: End-stage renal failure (ESRF) and dialysis have been identified as a risk factor for lower limb amputations (LLAs). High rate of ESRF amongst the Australian population has been reported, however till date no study has been published identifying magnitude and risk factors of LLA in subjects on renal dialysis.

Objective: The study aims to document trends in the prevalence and identify risk factors of non-traumatic LLA in Australian patients on dialysis.

Methods: A retrospective review of all patients (218) who attended the regional dialysis center between 1st January 2009 and 31st December 2013 was conducted. Demographic, clinical and biochemical data were analyzed.

Results: We identified a high prevalence of 13.3% of LLAs amongst Australian patients with ESRF on dialysis at our center. The associated risk factors were the presence of diabetes (OR 1.67 [1.49–1.88] p?<?0.001), history of foot ulceration (OR 81 [18.20–360.48] p?<?0.001), peripheral arterial disease (OR 31.29 [9.02–108.56] p?<?0.001), peripheral neuropathy (OR 31.29 [9.02–108.56] p?<?0.001), foot deformity (OR 23.62 [5.82–95.93] p?<?0.001), retinopathy (OR 6.08 [2.64–14.02] p?<?0.001), dyslipidemia (OR 4.6 [1.05–20.05] p= 0.049) and indigenous background (OR 3.39 [1.38–8.33] p= 0.01). 75% of the amputees had aboriginal heritage. We also identified higher HbA1c and CRP levels as well as low serum albumin, hemoglobin and vitamin D levels to have a strong association with LLAs (p?<?0.05).

Conclusion: There is high prevalence of LLAs amongst Australian indigenous patients with diabetes on dialysis in North Queensland. Other strongly associated risk factors include history of foot ulceration, foot deformity and peripheral neuropathy as well as high HbA1c levels and low serum albumin levels.     

Influence of decortication of the recipient graft bed on graft integration and tissue neoformation in the graft-recipient bed interface

The objective of the present study was to assess the influence of decortication of the posterior elements of the vertebra (recipient bed) and the nature of the bone graft (cortical or cancellous bone) on graft integration and bone, cartilage and fiber neoformation in the interface between the vertebral recipient bed and the bone graft. Seventy-two male Wistar rats were divided into four experimental groups according to the presence or absence of decortication of the posterior vertebral elements and the use of a cortical or cancellous bone graft. Group I—the posterior elements were decorticated and cancellous bone used. Group II—the posterior elements were decorticated and cortical graft was used. Group III—the posterior elements were not decorticated and cancellous graft was used. Group IV—the posterior elements were not decorticated and cortical graft was used. The animals were killed 3, 6 and 9 weeks after surgery and the interface between the posterior elements and the bone graft was subjected to histomorphometric evaluation. Mean percent neoformed bone was 40.8% in group I (decortication and cancellous graft), 39.13% in group II (decortication and cortical graft), 6.13% in group III (non-decorticated and cancellous graft), and 9.27% in group IV (non-decorticated and cortical graft) for animals killed at 3 weeks (P = 0.0005). For animals killed at 6 weeks, the mean percent was 38.53% for group I, 40.40% for group II, 10.27% for group III, and 7.6% for group IV (P = 0.0005), and for animals killed at 9 weeks, the mean was 25.93% for group I, 30.6% for group II, 16.4% for group III, and 18.73% for group IV (P = 0.0026). The mean percent neoformed cartilage tissue was 8.36% for group I, 7.46% for group II, 11.1% for group III, and 9.13% for group IV for the animals killed at 3 weeks (P = 0.6544); 6.6% for group I, 8.07% for group, 7.47% for group III and 6.13% for group IV (P = 0.4889) for animals killed at 6 weeks, and 3.13% for group I, 4.06% for group II, 10.53% for group III and 12.07% for group IV (P = 0.0006) for animals killed at 9 weeks. Mean percent neoformed fibrous tissue was 11% for group I, 6.13% for group II, 26.27% for group III and 21.87% for group IV for animals killed at 3 weeks (P = 0.0008); 7.67% for group I, 7.1% for group II, 9.8% for group III and 10.4% for group IV (P = 0.7880) for animals killed at 6 weeks, and 3.73% for group I, 4.4% for group II, 6.67% for group III and 6.8% for group IV (P = 0.0214) for animals killed at 9 weeks. The statistically significant differences in percent tissue formation were related to decortication of the posterior elements. The use of a cortical or cancellous graft did not influence tissue neoformation. Ossification in the interface of the recipient graft bed was of the intramembranous type in the decorticated animals and endochondral type in the non-decorticated animals.