Association of diabetic foot care and amputation rates in Germany

Podologists are nurses who care for the diabetic foot (orthotics, offloading devices, blisters, calluses, treatment of fungus infection and patient education). In contrast to podiatrists, they are not qualified to perform any surgical treatment or wound care. We analysed whether there is an association between the decrease in major amputations and the number of podologic foot care (PFC) visits prescribed in Germany. Detailed list of all major lower limb amputations (OPS 5‐864) performed from 2007 to 2011 was provided by the Federal Statistical Office. Data were separated for the 16 federal states in Germany. Detailed lists of the number of PFC treatments for each of the 5 years were derived from the federal report of the statutory health insurance. The total numbers of hospitalised cases per year having diabetes mellitus documented as an additional diagnosis were used to adjust for the different rates of people with diabetes in each federal state. Within a 5‐year time period, population‐based major amputations per 100 000 people dropped from 21·7 in 2007 to 17·5 in 2011 (?18·5%); whereas the number of PFC treatments per 1000 insured increased from 22 in 2007 to 60 in 2011 (+172·7%). The total number of major amputations divided by the total number of hospitalised cases with the additional diagnosis of diabetes mellitus (DM) shows an inverse correlation with the number of PFC treatments per 1000 insured (Pearson's correlation factor is ?0·52049). The five countries with the highest increase in PFC compared with the five countries with the lowest increase (35·6 versus 15·4 per 1000 insured) will have only small differences in the decrease in major amputation rates in this period (?5·1 versus ?3·4 per 100.000). There is a strong association between increasing utilisation PFC and decreasing major amputations in Germany. Further study is required to document the cost‐effectiveness of this service.     

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.     

The impact of gender on diabetes-related lower extremity amputations: An Italian regional analysis on trends and predictors

BackgroundDiabetes-related lower extremity amputations (LEAs) are a major public health issue. The aim of the study was to evaluate trends by gender and predictors of LEAs in an Italian region.MethodsData were collected from hospital discharge records between 2006 and 2015. Gender- and age-adjusted standardised hospitalisation rates for major and minor amputations were calculated. Poisson regression model was performed to estimate trends in LEAs.ResultsHospitalisation rates decreased for minor amputations both among males (?30.0%) and females (?5.3%), while the major amputation rates decreased only for males (?44.7%). Males were at higher risk of undergoing major (IRR 1.41, 95%CI 1.19–1.67) and minor (IRR 1.62, 95%CI 1.45–1.82) amputations. Peripheral vascular disease was the leading predictor of major and minor amputations.ConclusionA significant reduction of LEAs was observed only for males. Identifying their predictable factors may help caregivers to provide higher standards of diabetes care.     

Amputations and foot‐related hospitalisations disproportionately affect dialysis patients

Patients with diabetes have increased risk for foot ulcers, amputations and hospitalisations. We evaluated a closed cohort of patients with diabetes and established risk factors in two high risk groups: (i) dialysis patients and (ii) patients with previous foot ulceration. We used claims data for diabetes (ICD‐9 250.X), ulceration (ICD‐9 707·10, 707·14 and 707·15) and dialysis (CPT 90935–90937) from the Scott and White Health Plan to identify 150 consecutive patients with diabetes on dialysis (dialysis group) and 150 patients with a history of foot ulceration (ulcer history group). We verified these diagnoses by manually reviewing corresponding electronic medical records. Each patient was provided 30 months follow‐up period. The incidence of foot ulcers was the same in dialysis patients and patients with an ulcer history (210 per 1000 person‐years). The amputation incidence rate was higher in dialysis patients (58·0 versus 13·3, P < 0·001). Hospital admission was common in both study groups. The incidence of hospitalisation was higher in the ulcer history group (477·3 versus 381·3, P < 0·001); however, there were more foot‐related hospital admissions in the dialysis group (32·9% versus 14·0%, P < 0·001) during the 30‐month evaluation period. The incidence of ulcers, amputations and all‐cause hospitalisations is high in persons with diabetes and a history of foot ulceration or on dialysis treatment; however, those on dialysis treatment have disproportionately higher rates of foot‐related hospitalisations. Intervention strategies to reduce the burden of diabetic foot disease must target dialysis patients as a high‐risk group.     

Risk factors for amputation in patients with diabetic foot infection: a prospective study

There is a variety of diagnostic and therapeutic algorithms for diabetic foot infections (DFIs). Some of them are too difficult to be applied in routine clinical approach. In the routine clinical approach, it is necessary to find new risk factors and end up with a quick and easy assessment of DFIs. In this study, we aimed to evaluate the independent risk factors for osteomyelitis, amputation and major amputation in patients with DFI using standard scoring procedures. We prospectively studied 379 patients with DFI. The variables were analysed using logistic analysis. A total of 126 cases (33·2%) underwent amputation. The odds ratios in the amputation model were 3·09 for osteomyelitis (P < 0·001), 4·90 for arterial stenosis (AS) (P < 0·001), 3·67 for the history of DFI (P = 0·001), 2·47 for ulcer duration >60 days (P = 0·001), 3·10 for ulcer depth > 15 mm (P < 0·001) and 10·28 for fungal DFI (P = 0·015). In this study, the unusual result of well‐known literature was fungal DFI as an independent risk factor for amputation in patients with DFI.     

Diabetic foot in primary and tertiary (DEFINITE) Care: A health services innovation in coordination of diabetic foot ulcer (DFU) Care within a healthcare cluster - 18-month results from an observational population health cohort study

Diabetic Foot in Primary and Tertiary (DEFINITE) Care is an inter-institutional and multi-disciplinary team (MDT) health systems innovation programme at a healthcare cluster in Singapore. We aim to achieve coordinated MDT care across primary and tertiary care for patients with diabetic foot ulcers (DFU), within our public healthcare cluster - an integrated network of seven primary care polyclinics and two acute care tertiary hospitals (1700-bed and 800-bed) with a total catchment population of 2.2 million residents. Results from prospective DEFINITE Care is referenced against a retrospective 2013–2017 cohort, which was previously published. Cardiovascular profile of the study population is compared against the same population's profile in the preceding 12 months. Between June 2020 and December 2021, there were 3475 unique patients with DFU with mean age at 65.9 years, 61.2% male, mean baseline HbA1c at 8.3% with mean diabetes duration at 13.3 years, mean diabetes complication severity index (DCSI) at 5.6 and mean Charlson Comorbidity Index (CCI) at 6.8. In the 12-months preceding enrolment to DEFINITE Care, 35.5% had surgical foot debridement, 21.2% had minor lower extremity amputation (LEA), 7.5% had major LEA whilst 16.8% had revascularisation procedures. At 18-months after the implementation of DEFINITE Care programme, the absolute minor and major amputation rates were 8.7% (n = 302) and 5.1% (n = 176), respectively, equating to a minor and major LEA per 100000 population at 13.7 and 8.0, respectively. This represents an 80% reduction in minor amputation rates (P < .001) and a 35% reduction in major amputation rates (P = .005) when referenced against a retrospective 2013–2017 cohort, which had minor and major LEA per 100000 population at 68.9 and 12.4, respectively. As compared to the preceding 12 months, there was also a significant improvement in cardiovascular profile (glycemic and lipid control) within the DEFINITE population, with improved mean HbAc1 (7.9% from 8.4%, P < .001), low-density lipoprotein (LDL) levels (2.1 mmol/L from 2.2, P < .001), total cholesterol (3.9 mmol/L from 4.1, P < .001) and triglycerides levels (1.6 mmol/L from 1.8, P = .002). Multivariate analysis revealed a history of minor amputation in the preceding 12 months to be an independent predictor for major and minor amputation within the study period of 18 months (Hazard Ratio 3.4 and 1.8, respectively, P < .001). In conclusion, within DEFINITE care, 18-month data showed a significant reduction of minor and major LEA rates, with improved medical optimisation and cardiovascular profile within the study population.     

Timing of minor and major amputation in patients with diabetes-related foot ulceration admitted to two public tertiary referral hospitals in Australia

Background

There is limited information regarding the number of patients with diabetes-related foot ulceration (DFU) who receive minor or major amputation, and how quickly these amputations occur. This study aimed to identify the incidence of index minor and major amputation among inpatients with DFU over 4 years, and where amputation occurred during the patient's index DFU-related admission, investigate prognostic factors.

Methods

The incidence of index minor and major amputation, and the admission sequence during which amputation occurred were identified from DFU-related admissions to two public hospitals during 2014–2018. Where minor or major amputation occurred during the patient's index DFU-related admission, prognostic factors were investigated using logistic regression.

Results

DFU-related hospital admissions were required by 564 patients. The incidence of minor amputation over 4 years was 34% (n = 193). The incidence of minor amputation during the patient's index DFU-related admission was 28% (n = 155), which was associated with requiring revascularisation (odds ratio [OR] 2.33, 95% CI 1.53–3.55, P < 0.001). The incidence of major amputation over 4 years was 8% (n = 45). The incidence of major amputation during the patient's index DFU-related admission was 6% (n = 31), which was associated with having more comorbidities (OR 1.58, 95% CI 1.10–2.26, P = 0.01) and receiving care for a mental health condition (OR 3.85, 95% CI 1.48–10.01, P = 0.006).

Conclusion

Most amputations occurred during the patient's index DFU-related hospital admission. Major amputation during a patient's index admission was associated with more comorbidities and mental health conditions.     

Angiosome‐targeted revascularisation in diabetic foot ulcers

Peripheral vascular disease is a common complication of type 2 diabetes and is often more severe and diffuse than in non‐diabetic individuals with a higher risk of major amputations in the lower limbs. Diabetic foot revascularisation using both traditional bypass surgery and endovascular therapy are often burdened by the failure and the inevitable subsequent massive amputation. In this study, we examined the clinical response of diabetic patients with critical limb ischaemia and extended ischaemic wounds, treated with a new angiosome‐based revascularisation technique. In a 3‐year period, nine diabetic patients with imminent amputation threatening and foot ulcers with no feasible arterial revascularisation options were treated by the angiosome‐based surgical technique by means of deep vein arterialisation. The postoperative tcPO2 evaluation showed a mean increase in the cutaneous oxygen tension in all patients treated. The overall survival rates were 88·88%, 88·88% and 77·77% at 12, 24 and 36 months, respectively. Limb salvage was 100% at 1 year and steady at 88·88% thereafter. Surgical deep venous arterialisation might be considered as an extreme alternative to attempt tissue preservation in limbs unfit for conventional arterial revascularisations. This technique would give advantages to the patients in terms of better compliance to the minor amputations and thus avoiding major limb amputations.     

Comparative study of the microvascular blood flow in the intestinal wall during conventional negative pressure wound therapy and negative pressure wound therapy using paraffin gauze over the intestines in laparostomy

Higher closure rates of the open abdomen have been reported with negative pressure wound therapy (NPWT) than with other kinds of wound management. We have recently shown that NPWT decreases the blood flow in the intestinal wall, and that the blood flow could be restored by inserting a protective disc over the intestines. The aim of the present study was to investigate whether layers of Jelonet? (Smith & Nephew) dressing (paraffin tulle gras dressing made from open weave gauze) over the intestines could protect the intestines from hypoperfusion. Midline incisions were made in ten pigs and were subjected to treatment with NPWT with and without four layers of Jelonet over the intestines. The microvascular blood flow was measured in the intestinal wall before and after the application of topical negative pressures of ?50, ?70 and ?120 mmHg, using laser Doppler velocimetry. Baseline blood flow was defined as 100% in all settings. The blood flow was significantly reduced, to 61 ± 7% (P < 0·001), after the application of ?50 mmHg using conventional NPWT, and to 62 ± 7% (P < 0·001) after the application of ?50 mmHg with Jelonet dressings between the dressing and the intestines. The blood flow was significantly reduced, to 38 ± 5% (P < 0·001), after the application of ?70 mmHg, and to 42 ± 6% (P < 0·001) after the application of ?70 mmHg with Jelonet dressings. The blood flow was significantly reduced, to 34 ± 9% (P < 0·001), after the application of ?120 mmHg, and to 38 ± 6% (P < 0·001) after the application of ?120 mmHg with Jelonet dressings. The use of four layers of Jelonet over the intestines during NPWT did not prevent a decrease in microvascular blood flow in the intestinal wall.     

Which cleansing care is better,foot bath or shower? Analysis of 236 limb ulcers

Foot baths and showering are two widely used methods to cleanse limb ulcers. However, some clinicians warn that foot baths may contribute to the spread of infection at the ulcer site. This study aimed to retrospectively investigate the relationship between cleansing methods and the limb prognoses of 236 patients with chronic limb ulcers. These patients were divided into two groups according to the method used to cleanse their ulcers, foot bath and showering. Limb prognosis, including loss of all toes and major amputation, was retrospectively analysed. The rates of loss of all toes and major amputation were 53·0% and 30% in the foot bath group, and 35·3% and 18·4% in the showering group, respectively. The rates of loss of all toes (adjusted odds ratios = 2·07; P = 0·0066; 95% confidence intervals, 1·22–3·50) and major amputation (adjusted odds ratio = 1·90; P = 0·037; 95% confidence intervals, 1·03–3·50) were significantly higher in the foot bath group than those in the showering group. Our results demonstrate that showering is preferable to foot baths for the cleansing of chronic limb ulcers. Clinicians should be cautious that inappropriate cleansing may cause ulcer infections to spread.     

Matrix metalloproteinases and risk stratification in patients undergoing surgical revascularisation for critical limb ischaemia

Critical limb ischaemia (CLI) is the most advanced form of peripheral artery disease (PAD) and it is often associated with foot gangrene, which may lead to major amputation of lower limbs, and also with a higher risk of death due to fatal cardiovascular events. Matrix metalloproteinases (MMPs) seem to be involved in atherosclerosis, PAD and CLI. Aim of this study was to evaluate variations in MMP serum levels in patients affected by CLI, before and after lower limb surgical revascularisation through prosthetic or venous bypass. A total of 29 patients (7 females and 22 males, mean age 73·4 years, range 65–83 years) suffering from CLI and submitted to lower extremity bypass (LEB) in our Institution were recruited. Seven patients (group I) underwent LEB using synthetic polytetrafluoroethylene (PTFE) graft material and 22 patients (group II) underwent LEB using autogenous veins. Moreover, 30 healthy age‐sex‐matched subjects were also enrolled as controls (group III). We documented significantly higher serum MMPs levels (P < 0·01) in patients with CLI (groups I and II) with respect to control group (group III). Finally, five patients with CLI (17·2%) showed poor outcomes (major amputations or death), and enzyme‐linked immunosorbent assay (ELISA) test showed very high levels of MMP‐1 and MMP‐8. MMP serum levels seem to be able to predict the clinical outcomes of patients with CLI.     

Validation of an algorithm to predict reulceration in amputation patients with diabetes

The aim of this article was to assess the ability to predict reulceration in people with diabetes and a history of minor amputation according to the formula proposed by Miller et al. A retrospective study was performed on 156 consecutive records of patients with a recent history of simple or multiple forefoot amputation. The sample was divided according to Miller's formula into patients at low risk of reulceration and those at high risk; those were further divided into two subgroups according to whether or not the first segment of the forefoot had been amputated. Forty‐eight (47·1%) individuals suffered forefoot reulceration, showing a median reulceration‐free survival time of 8 months [interquartile range (IR) 3·6–14·8]. Nephropathy (P = 0.005) and Miller's formula (P = 0.028) were risk factors for reulceration‐free survival time in the univariate analysis. The pattern relating to the first segment amputated [hazard ratio (HR) 2·853; P = 0·004; 95% confidence interval (CI) 1·391–5·849] and nephropathy (HR 2·468; P = 0.004; 95% CI 1.328–4.587) showed a significant hazard ratio in the multivariate Cox model. Participants with first segment amputation and one other amputation showed an association with the probability of reulceration in comparison with any other specific type of minor amputation.     

Variations in locoregional therapy in postmenopausal patients with early breast cancer treated in different countries

Background:

The Tamoxifen and Exemestane Adjuvant Multinational (TEAM) trial is an international randomized trial evaluating the efficacy and safety of exemestane, alone or following tamoxifen. The large number of patients already recruited offered the opportunity to explore locoregional treatment practices between countries.

Methods:

Patients were enrolled in Belgium, France, Germany, Greece, Ireland, Japan, the Netherlands, the UK and the USA. The core protocol had minor differences in eligibility criteria between countries, reflecting variations in national guidelines and practice regarding adjuvant endocrine therapy.

Results:

Between 2001 and 2006, 9779 patients of mean(s.d.) age 64(9) years were randomized. Some 58·4 per cent had T1 tumours (range between countries 36·8–75·9 per cent; P < 0·001) and 47·3 per cent were axillary node positive (range 25·9–84·6 per cent; P < 0·001). Independent factors for type of breast surgery were country, age, tumour status and calendar year of surgery. After breast‐conserving surgery, radiotherapy was given to 93·2 per cent of patients, 86·0 per cent in the USA and 100 per cent in France. Axillary lymph node dissection was performed in 82·0 (range 74·6–99·1) per cent.

Conclusion:

Despite international consensus guidelines, wide global variations were observed in treatment practices of early breast cancer. There should be further efforts to optimize locoregional treatment for breast cancer worldwide. Copyright © 2010 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.     

The analgesic effect of electrostimulation (WoundEL®) in the treatment of leg ulcers

This study aims to demonstrate the analgesic efficacy of electrostimulation (ES), a recognised treatment for leg ulcers. Patients treated by ES for leg ulcers between 2011 and 2013 were included in the study. The pain score obtained with the numerical rating scale (NRS) was reported before the start of the ES (D0), after 3 days (D3) and 1 week following treatment initialisation. The analgesic treatments (AT) were reported at each assessment. Seventy‐three patients were included (mean age 75·19 years): 31 venous leg ulcers, 21 mixed venous leg ulcers, 2 arterial ulcers, 17 hypertensive ischaemic ulcers, 1 Hydrea^®‐induced ulcer and an amputation stump ulcer. The NRS at D0 was on average 5·3 (median = 6) while it was 2·2 at D7 (median = 2), that is P < 0·001. The results were also significant between D0 and D3 (P < 0·001). A decrease in the number of AT used was observed between D0 (2·0 AT per patient on average) and D7 (1·7 AT on average) (P < 0·001). We also observed a decrease in the consumption of grade 3 analgesics on D0 and D7 (P = 0·03). This study demonstrates the rapid analgesic efficacy of ES in leg ulcers, with a clear impact on the NRS score and especially on the decrease in analgesic consumption.     

Strumachirurgie in Deutschland

Background

The increase of certain operations in the wake of the introduction of the German Diagnosis-Related Groups (G-DRG) system rekindled debate on the risk–benefit profile of what is widely being perceived as a too high number of thyroidectomies for benign goiter in Germany.

Material and methods

The numbers of thyroidectomy for benign goiter from 2005–2011 were obtained from the Federal Bureau of Statistics (“Statistisches Bundesamt”). For the purpose of the study, the following operation and procedure key (OPS) codes were selected: hemithyroidectomy (OPS code 5-061); partial thyroid resection (OPS code 5-062); total thyroidectomy (OPS code 5-063); and thyroid surgeries via sternotomy (OPS code 5-064). The rates of permanent hypoparathyroidism and vocal cord palsy were calculated based on two prospective multicenter evaluation studies conducted in 1998–2001 (PETS 1) and 2010–2013 (PETS 2) in Germany.

Results

Between 2005 and 2011, the number of thyroidectomies for benign thyroid goiter decreased by 8?%, and the age-standardized surgery rate decreased by 6?% in men (2005: 599 per 1 million; 2011: 565 per 1 million) and 11?% in women (2005: 1641 per 1 million; 2011: 1463 per 1 million). At the same time, the rates of partial and subtotal thyroidectomy decreased by 59?% in men and 64?% in women, whereas the rates of hemithyroidectomy and total thyroidectomy increased by 65?% (113?%) in men and 42?% (97?%) in women. Despite a greater proportion of thyroidectomies over time, the approximated rates for postoperative hypoparathyroidism were reduced from 2.98 to 0.83?% and for postoperative vocal cord palsy from 1.06 to 0.86?%. Irrespective of that decline, either complication was more frequent after total than after subtotal thyroidectomy.

Conclusion

The total number of thyroid surgeries due to benign goiter has decreased substantially in Germany from 2005 through 2011. Despite changes in the resectional strategy with an increase in the total number thyroidectomies and a decrease of subtotal resections, the rates for postoperative hypoparathyroidism and vocal cord palsy have decreased. The complication rates for total thyroidectomy, however, are still higher compared to subtotal resection. An individualized risk-oriented surgical approach is warranted.     

The perioperative and long-term fates of patients with chronic limb-threatening ischaemia who underwent secondary major amputations

This study investigated the perioperative and long-term fates of patients with chronic limb-threatening ischemia (CLTI) who underwent secondary major amputations. From April 2010 to December 2018, 1653 CLTI patients primarily underwent endovascular therapy (EVT). Of these patients, 138 who underwent secondary major amputations were included in this study. The primary outcome measure was the mortality. Prognostic factors associated with perioperative (30-day) and late mortality (after 30 days) were assessed. The 30-day mortality was 9.6%. Patients who died during the perioperative period had lower ejection fractions on echocardiography than those in the perioperative survivors (49.5 ± 14.9% vs 58.6 ± 12.4%, P = .018). None of the other clinical characteristics were significantly associated with perioperative death. Two-years postoperatively, 49.6%, 12.2%, and 4.3% of the patients had died, had contralateral amputations, and had additional above-knee amputations, respectively. In the alive patients who had not undergone additional amputation at 2 years, only 25.9% were ambulatory, whereas 51.7% and 22.4% were in wheelchairs and bedridden, respectively. An age ≥80 years and serum albumin <3.0 g/dL were significantly associated with late mortality (P = .032 and P = .042, respectively). In conclusion, the perioperative and long-term fates after secondary major amputation in CLTI patients who underwent EVT were considerably poor.     

A survey on causes of amputation in a 9-year period in Iran

Background

Limb loss occurs as a result of different causes and has been increasing in many countries. This study determines the demography of amputees in one of the relatively large cities of Iran.

Methods

This retrospective study was undertaken on all of the amputees between 2003 and 2011. Patients’ demographics including age, sex, the limb that had undergone amputation, etiology of limb loss and side and level of amputation were recorded. Also, the level of amputation was recorded as minor (below wrist or ankle) or major (above wrist or ankle).

Results

In total, 624 patients were enrolled in the study. The number of amputees was from 53 to 118/year. Of the patients, 508 were male (81.4?%) and 118 were female (18.6?%). The men with amputation were younger on average than women; 61.9?% of the amputations (386) were major and 38.1?% were minor (238). Overall, the most common cause of amputation was trauma and the most common level was transmetatarsal. The most common level for major amputations was below knee.

Conclusion

In contrast to similar studies in developed countries, trauma was found to be the major cause of all types of amputations and in all age groups, which emphasizes the need for preventive measures in the country.     

Zehenamputation und Strahlresektion

BackgroundAlthough toe amputation and ray resection are suitable for the treatment of many pathologies, diabetic foot syndrome is the main cause for these amputations. In recent years there has been an increase in minor amputations compared to major amputations. By avoiding or turning away from major amputations, the minor amputations of the foot and their procedures have become the focus of surgical attention.Material and MethodsThe aim of this overview is to present the surgical technique of toe amputation and ray resection and its results in the current literature.ConclusionsToe amputations and ray resections are safe minor amputation procedures for many indications and offer quick weight bearing postoperatively. Despite good primary healing rates, interdisciplinary perioperative treatment in diabetic patients is substantial to keep re-amputation and mortality rates low.     

Epidemiologie und Behandlung der PAVK und der akuten Extremitätenischämie in deutschen Krankenhäusern von 2005 bis 2012

Background

Due to the demographic changes an increase in peripheral arterial occlusive disease (PAOD) and acute ischemia of the extremities can be assumed. Simultaneously, the options for revascularization have been extended with the chance of a decreasing rate of amputation. It is unclear whether these developments can also be realized at a national level in Germany.

Material and methods

An analysis of the thoroughly categorized diagnosis data of hospital patients and the diagnosis-related groups (DRG) statistics of the Statistisches Bundesamt (StBA, Federal Statistical Office) from the years 2005 to 2012) was carried out. The numbers of cases, the incidence and mortality of chronic ischemia of the extremities and the main diagnoses (HD) 170 (atherosclerosis), E10.5–E14.5 (diabetes mellitus with peripheral vascular complications) and acute ischemia of the extremities (HD I74, arterial embolism and thrombosis) were analysed. All open and endovascular treatment modalities and major and minor amputations were assessed based on the DRG statistics of the StBA.

Results

The inhospital incidence of chronic and acute ischemia of the extremities increased from 199 to 241 and from 22 to 27 HDs per 100,000 inhabitants, respectively. The incidence of all cases of ischemia of the extremities showed a clear increase after the age of 70 years. The mortality associated with HD 170 has decreased since 2005 from 3.6?% to 2.7?%. The mortality over the age of 80 years is 5–10?%. The corresponding mortality associated with HD 174 was 9.7 % with an increase to 10-20 % in both sexes above 80 years old. The total number of all cases of peripheral balloon angioplasty increased from 73,000 in 2005 to approximately 130,000 in 2012. The number of peripheral bypass operations decreased from approximately 43,000 to 39,500 (?8.4 %). The number of cases of embolectomy and thrombectomy increased from approximately 38,000 to 60,000 and endovascular therapy of acute ischemia of the extremities increased from approximately 12,000 to 21,000. The number of major amputations could be reduced by 32 % since 2005.

Conclusion

The incidence of acute and chronic ischemia of the extremities is increasing. The mortality risk increases with age and is particularly high for acute ischemia of the extremities. Despite the increase in hospitalized cases with the threat of amputation due to ischemia, the number of major amputations has clearly decreased.     

Study of clinical pattern of limb loss in electrical burn injuries

Introduction: Electrical burn injuries are devastating and cause not only loss of life but also severe disabilities in the form of limb loss. Increase in urbanization, industrialization and overcrowding has led to an increase in electric injuries. Material and methods: The study was prospective in nature evaluating electric burns and studied the pattern of limb loss for a duration of 18 months from October 2016 to March 2018. Parameters recorded were demographic data, clinical data regarding the electrical injuries, complications, and outcomes. Results: Male patients made up 85.3% of cases. Mean TBSA was 24.76 ± 19.18%. Mean age was 27.59 ± 13.73 years. Pediatric patients made up 17%. High voltage burns constituted 68.2 %. Electric contact burn was the most common type making up 49.5% of cases. The most common cause was occupational (38.9%). A fasciotomy was required in 22% of cases with an amputation rate of 38% (209 out of 550). There were 190 major amputations and 106 minor amputations. Overall, the right upper limb amputations were twice as common as the left. The ratio of upper limb: lower limb amputation was 4:1. Fifty patients (23.9%) required revision amputation. The age group 11 to 30 years made up 55.5% of amputations. There was no statistical difference in amputation rates between males (31.31%) and females (41.97%). In patients with TBSA less than 25% amputation rate was 47.77% as compared to patients with more than 25% TBSA, 19.47% (p<0.001). Most amputations occurred due to electric contact burns (74.16%). In the high voltage group, 46.1% underwent amputation vs low voltage group -20.6% (p<0.001). Overall mortality rate was 12.7%. Three hundred patients (55%) had low level of awareness regarding consequences of electric injury. Thirty one percent had medium level of awareness and only 14 % had high level of awareness. There was a significant correlation between education level and awareness in adult patients (p<0.001). Seventy percent of persons with occupational injuries used only footwear and no other protective equipment. Conclusion: Increasing public awareness, safety measures at workplaces are measures that will help reducing electrical burns which reduce limb and life loss.