OBJECTIVE: This study assessed whether changes associated with cerebral small vessel disease (CSVD) evaluated from head computed tomography (CT) images captured for non-related clinical purposes predict overall survival (OS), leg salvage (LS), and amputation-free survival (AFS) after lower extremity amputation (LEA).
METHODS: We retrospectively included a cohort of 240 patients who had undergone a lower extremity amputation in Tampere University Hospital between the years 2007 and 2020 and had a head CT scan (within one year before amputation). A neuroradiologist graded the white matter lesions (WMLs) and reported infarcts, and the latter\'s effects on OS, LS, and AFS were evaluated.
RESULTS: Altogether, 162 (67.5 %) and 91 (38.1 %) patients had WMLs and infarcts, respectively. Mild/moderate (HR 1.985, CI 95 % 1.317-2.992) and severe (HR 2.259, CI 95 % 1.501-3.399) WMLs and infarcts (HR 1.413, CI 95 % 1.029-1.940) were associated with inferior OS. After a minor amputation, mild/moderate (HR 2.012, CI 95 % 1.054-3.843) and severe (HR 3.879, CI 95 % 2.096-7.180) WMLs were similarly associated with inferior AFS.
CONCLUSIONS: Overall, WML and infarcts detected on head CT scans were associated with impaired OS after LEA and AFS after minor LEA. Evaluation of CSVD could provide useful prognostic information for clinicians.

OBJECTIVE: To explore the relationship between sociodemographic, clinical, and neurophysiological variables and health-related quality of life (HR-QOL) of patients with phantom limb pain.
METHODS: This is a cross-sectional analysis of a previous clinical trial. Univariate and multivariate linear and logistic regression analyses were used to model the predictors of HR-QOL. We utilized a sequential modeling approach with increasing adjustment levels, controlling for age and sex, and other relevant clinical variables (time since amputation, level of amputation, and pain). HR-QOL was assessed by the SF-36 Health Survey and its eight subdomains.
RESULTS: We analyzed baseline data from 92 patients with lower-limb amputations. They were mostly male (63%), 45.2 ± 15.6 years, with a mean time since amputation of 82.7 ± 122.4 months, and an overall SF-36 score of 55.9 ± 21.5. We found an association between intracortical facilitation in the affected hemisphere (ICF), gabapentin usage, and HR-QOL. ICF is a predictor of better HRQOL, whereas gabapentin usage was associated with a poorer HR-QOL, with the main model explaining 13.4% of the variance in the outcome. For the SF-36 subdomains, ICF was also a positive predictor for social functioning, bodily pain, and vitality, while medication usage was associated with lower scores in mental health, general health perception, bodily pain, and vitality.
CONCLUSIONS: We found firsthand two new independent predictors of HR-QOL in individuals with PLP, namely, the neurophysiological metric ICF and gabapentin usage. These results highlight the role of the motor cortex excitability in the HR-QOL and stress the need for treatments that favor the neuroplastic adaptation after amputation, for which ICF may be used as a possible marker.

BACKGROUND: Residual limb discomfort and injury is a common experience for people living with lower limb amputation. Frequently, inadequate load distribution between the prosthetic device and the residual limb is the root cause of this issue. To advance our understanding of prosthetic interface fit, tools are needed to evaluate the mechanical interaction at the prosthetic interface, allowing interface designs to be evaluated and optimised.
OBJECTIVE: Present a methodology report designed to facilitate comprehension of the mechanical interaction between the prosthetic interface and the residual limb. As a pilot study, this methodology is used to compare a hands-on and hands-off interface for a single transtibial prosthesis user using secondary Magnetic Resonance Imaging (MRI) data.
METHODS: MRI data of the residual limb while wearing a prosthetic interface is segmented into a hard tissue and a skin surface model. These models are exported as stereolithography (STL) files. Two methods are used to analyse the interface designs. Firstly, CloudCompare software is used to compute the nearest vertex on the skin surface for every vertex on the compiled internal bony surface for both interface types. Secondly, CloudCompare software is used to compare registered skin surfaces of the residual limb while wearing the hands-on and hands-off interfaces.
RESULTS: The maximum and minimum nearest distances between the internal bony surface and skin surface were similar between interface types. However, the distribution of nearest distances was different. When comparing the skin surface while wearing both interfaces, where the fit is more compressive can be visualized. For the dataset used in this study, the classic features of a hands-on Patella Tendon Bearing interface and hands-off pressure cast interface could be identified.
CONCLUSIONS: The methodology presented in this report may give researchers a further tool to better understand how interface designs affect the soft tissues of the residual limb.

Gefitinib is an epidermal growth factor tyrosine kinase inhibitor used as a targeted chemotherapeutic agent in the treatment of lung cancer and other solid malignancies. The most common adverse effects of gefitinib include dermatological side effects and gastrointestinal symptoms, with rare reports of vascular side effects such as myocardial infarction and stroke. We recently reported a case of a patient with diabetes and multiple comorbidities who developed a serious lower limb vascular adverse event after gefitinib treatment, ultimately leading to amputation surgery. This is the first reported case of lower extremity amputation following gefitinib therapy in a patient with type 2 diabetes mellitus and lung adenocarcinoma. This case highlights the potential risk of amputation in diabetic patients receiving targeted therapies like gefitinib, especially in those with vascular complications. It emphasizes the importance of exercising extra caution when dealing with these patients.

To date, there have been no reported cases of patients walking with a prosthesis after receiving an ipsilateral transfemoral amputation following the Girdlestone procedure. We administered a four-month prosthetic rehabilitation program to a 66-year-old man after his transfemoral amputation following the Girdlestone procedure. As a result, he was able to walk using the prosthesis for his daily activities. The prosthesis socket featured a quadrilateral configuration. The patient\'s ability to ambulate after the Girdlestone procedure was attributed to his ischial tuberosity serving as the primary load-bearing site in the transfemoral prosthesis. With appropriate prosthetic design, fabrication, and rehabilitation, patients can walk using a transfemoral prosthesis even in cases of transfemoral amputation following the Girdlestone procedure.

BACKGROUND: Patients often feel unprepared and concerned about their new life after a major lower extremity amputation (LEA). Therefore, we implemented an integrated care program, Safe Journey, to optimize the quality and continuity of care for patients with LEA due to vascular disease when transitioning from hospital to home. This study aims to illuminate and explore the experiences of patients with LEA and their relatives with the transition from hospital to home after implementing Safe Journey.
METHODS: This qualitative, exploratory study individually interviewed six patients with a major LEA and four relatives and jointly interviewed eight patients with their relatives.
RESULTS: The participants\' experiences transitioning from hospital to home were centered around two major themes: (1) Going home: mixed emotions and confusion, and (2) bridging the gap. The main themes encompassed six subthemes: (1) simultaneously expectant and worried, (2) a lack of knowledge creating uncertainty, (3) an unexpressed but pending need for psychosocial support, (4) reassurance but safety comes at a price, (5) navigating the system, and (6) lack of involvement.
CONCLUSIONS: Transitioning from hospital to home after a major LEA creates mixed emotions. Knowledge, feeling involved, and being prepared and cared for were highlighted as important during the transition. The Safe Journey program made patients and relatives feel physically reassured and safe, but all the home visits strained the families. The program\'s benefits are consistent with existing knowledge on patients with complex needs benefitting from integrated care models. However, a more individualized and person-centered approach is needed.

BACKGROUND: Lower limb amputation does not affect only physical and psychological functioning but the use of a prosthetic device can also lead to increased cognitive demands. Measuring cognitive load objectively is challenging, and therefore, most studies use questionnaires that are easy to apply but can suffer from subjective bias. Motivated by this, the present study investigated whether a mobile eye tracker can be used to objectively measure cognitive load by monitoring gaze behavior during a set of motor tasks.
METHODS: Five prosthetic users and eight able-bodied controls participated in this study. Eye tracking data and kinematics were recorded during a set of motor tasks (level ground walking, walking on uneven terrain, obstacle avoidance, stairs up and ramp down, as well as ramp up and stairs down) while the participants were asked to focus their gaze on a visual target for as long as possible. Target fixation times and increase in pupil diameters were determined and correlated to subjective ratings of cognitive load.
RESULTS: Overall, target fixation time and pupil diameter showed strong negative and positive correlations, respectively, to the subjective rating of cognitive load in the able-bodied controls (-0.75 and 0.80, respectively). However, the individual correlation strength, and in some cases, even the sign, was different across participants. A similar trend could be observed in prosthetic users.
CONCLUSIONS: The results of this study showed that a mobile eye tracker may be used to estimate cognitive load in prosthesis users during locomotor tasks. This paves the way to establish a new approach to assessing cognitive load, which is objective and yet practical and simple to administer. Nevertheless, future studies should corroborate these results by comparing them to other objective measures as well as focus on translating the proposed approach outside of a laboratory.

Smoking may increase the risk of diabetic foot disease and ulceration. It does so by impairing glycaemic control and promoting the formation of advanced glycated end-products. Additionally, smoking is known to delay surgical wound healing and accelerate peripheral arterial disease. We aimed to determine whether toe pressures differed in smokers with a foot ulcer, when compared to non-smokers and ex-smokers, as well as ulcer outcomes at 12 months, among patients attending Blacktown Hospital High Risk Foot Service (HRFS). This study is a retrospective analysis of our prospectively collected clinic database. Eligible participants were adults attending the HRFS between June 2020 and April 2022. Participants were included if they had an ulcer, at least one systolic toe pressure reading completed at their initial visit and attended at least one follow-up visit. Participants were followed until healing, loss to follow-up or a minimum of 12 months. A total of 195 participants were included; 36 smokers, 82 ex-smokers, and 77 controls who had never smoked. Smoking status was by self-report. Current smokers were significantly younger at initial presentation (p = .002) and tended towards lower socioeconomic status (p = .067). Current smokers were significantly more likely to have ischaemic grade 3 toe pressures (< 30 mmHg) of their left foot (p = .027), suggestive of reduced perfusion. At the end of follow up period, smokers had the numerically highest rates of minor amputations. In conclusion, smokers ulcerate younger and are more likely to have grade 3 ischaemia. Collecting information about the brachial artery pressures and the time since the last cigarette may clarify any relationship between smoking and toe pressures.Trial registration: WSLHD HREC ethics approval 2111-02 and ANZCTR registration 382470. Registered on 15/09/2021.

BACKGROUND: Globally, over 1 million lower limb amputations are performed annually, with approximately 75% of patients experiencing significant pain, profoundly impacting their quality of life and functional capabilities. Targeted muscle reinnervation (TMR) has emerged as a surgical solution involving the rerouting of amputated nerves to specific muscle targets. Originally introduced to enhance signal amplification for myoelectric prosthesis control, TMR has expanded its applications to include neuroma management and pain relief. However, the literature assessing patient outcomes is lacking, specifically for lower limb amputees. This systematic review aims to assess the effectiveness of TMR in reducing pain and enhancing functional outcomes for patients who have undergone lower limb amputation.
METHODS: A systematic review was performed by examining relevant studies between 2010 and 2023, focusing on pain reduction, functional outcomes and patient-reported quality of life measures.
RESULTS: In total, 20 studies were eligible encompassing a total of 778 extremities, of which 75.06% (n = 584) were lower limb amputees. Average age was 46.66 years and patients were predominantly male (n = 70.67%). Seven studies (35%) reported functional outcomes. Patients who underwent primary TMR exhibited lower average patient-reported outcome measurement information system (PROMIS) scores for phantom limb pain (PLP) and residual limb pain (RLP). Secondary TMR led to improvements in PLP, RLP and general limb pain as indicated by average numeric rating scale and PROMIS scores.
CONCLUSIONS: The systematic review underscores TMR\'s potential benefits in alleviating pain, fostering post-amputation rehabilitation and enhancing overall well-being for lower limb amputees.

OBJECTIVE: To determine if lower limb prosthesis (LLP) sophistication is associated with patient-reported mobility and/or mobility satisfaction, and if these associations differ by amputation level.
METHODS: Cohort study that identified participants through a large national database and prospectively collected self-reported patient outcomes.
METHODS: The Veterans Administration (VA) Corporate Data Warehouse, the National Prosthetics Patient Database, participant mailings, and phone calls.
METHODS: 347 Veterans who underwent an incident transtibial (TT) or transfemoral (TF) amputation due to diabetes and/or peripheral artery disease and received a qualifying LLP between March 1, 2018, and November 30, 2020.
METHODS: Basic, intermediate, and advanced prosthesis sophistication was measured by the accurate and reliable PROClass system.
METHODS: Patient-reported mobility using the advanced mobility subscale of the Locomotor Capabilities Index-5; mobility satisfaction using a 0-10-point Likert scale.
RESULTS: Lower limb amputees who received intermediate or advanced prostheses were more likely to achieve advanced mobility than those who received basic prostheses, with intermediate nearing statistical significance at nearly twice the odds (adjusted odds ratio (aOR)=1.8, 95% confidence interval (CI), .98-3.3; P=.06). The association was strongest in TF amputees with over 10 times the odds (aOR=10.2, 95% CI, 1.1-96.8; P=.04). The use of an intermediate sophistication prosthesis relative to a basic prosthesis was significantly associated with mobility satisfaction (adjusted β coefficient (aβ)=.77, 95% CI, .11-1.4; P=.02). A statistically significant association was only observed in those who underwent a TT amputation (aβ=.79, 95% CI, .09-1.5; P=.03).
CONCLUSIONS: Prosthesis sophistication was not associated with achieving advanced mobility in TT amputees but was associated with greater mobility satisfaction. In contrast, prosthesis sophistication was associated with achieving advanced mobility in TF amputees but was not associated with an increase in mobility satisfaction.