Impact of Medical Advancement: Prostheses

This chapter shall provide a brief introduction to the prostheses and their development in the current advance technological era. The prosthesis design, control, and architecture completely changed with the change in the amputation level. The transradial amputee stump design, electronics, battery, and circuit placement change significantly with the change of the residual arm of the amputee. This leads to designing the prostheses with the focus of the amputation level and ease of customization. Recent development in the 3D printing and open source prosthetic design leads the user to choose, modify, and print the prostheses with the required sets of functionalities. In this chapter, a brief introduction of the prostheses has been given, starting with the types of prostheses according to the level of amputation and functionality. Then, the state-of-the-art prostheses available commercially and under research will be introduced. Afterward, the 3D printed prostheses are discussed. This chapter will end with the comparison of the medical advancement over the average life of people in general and comparison of the same for countries with low and high per capita income

Effect of alloying elements on the compressive mechanical properties of biomedical titanium alloys: A systematic review

Due to problems such as the stress-shielding effect, strength-ductility trade-off dilemma, and use of rare-earth, expensive elements with high melting points in Ti alloys, the need for the design of new Ti alloys for biomedical applications has emerged. This article reports the effect of various alloying elements on the compressive mechanical performance of Ti alloys for biomedical applications for the first time as a systematic review following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines on this subject. The search strategy in this systematic review used Scopus, Web of Science, and PubMed databases and searched the articles using (Beta-type OR β) AND Titanium AND (Mechanical property OR Microstructure) AND Alloying element keywords. Original articles from 2016 to 2022 published in English have been selected for this study as per the inclusion criteria. The results have shown that Nb can be used as the primary alloying element with Ti as it is a strong β-stabilizer element which also reduces the elastic modulus of Ti alloys. The β-eutectic elements (Fe, Cr, and Mn) have also emerged as cost-effective alloying elements that could improve the mechanical performance of Ti alloys. Ti-Nb-Zr-Ta alloyed with Si has shown potential to withstand the strength-ductility trade-off dilemma. The combination of a Ti-Nb binary alloy has emerged as an attractive material for designing low elastic modulus Ti alloys. The mechanical performance of the Ti-Nb alloy can be further improved using the β-eutectic (Fe, Cr, and Mn) and neutral (Zr, Sn) elements to be alloyed with a Ti-Nb binary alloy. The strength-ductility trade-off issue can be overcome using Si as an alloying element in Ti-Nb-Zr-Ta alloys

Effect of Nb on β→α″ martensitic phase transformation and characterization of new biomedical Ti-xNb-3Fe-9Zr alloys

A new generation of Ti-xNb-3Fe-9Zr (x=15, 20, 25, 30, 35 wt %) alloys have been designed using various theoretical approaches including DV-xα cluster, molybdenum equivalency, and electron to atom ratio. Afterward, designed alloys are fabricated using cold crucible levitation melting technique. The microstructure and mechanical performances of newly designed alloys are characterized in this work using scanning electron microscope and universal testing machine, respectively. Each alloy demonstrates monolithic β phase except Ti-35Nb-3Fe-9Zr alloy which display dual α″+β phases. Typically, niobium acts as an isomorphous beta stabilizer. However, in this work, formation of martensitic α″ phases occurs at 35 wt % of niobium among the series of newly designed alloys. Furthermore, none of the alloys fail till the maximum load capacity of machine, i.e., 100 KN except Ti-35Nb-3Fe-9Zr alloy. Moreover, the Vickers hardness test is carried out on Ti-xNb-3Fe-9Zr alloys which demonstrate slip bands around the indentation for each alloy. Notably, the deformation bands and cracks around the indentations of each alloy have been observed using optical microscopy; Ti-35Nb-3Fe-9Zr demonstrates some cracks along with slip bands around its indentation. The Ti-25Nb-3Fe-9Zr alloy shows the highest yield strength of 1043±20 MPa, large plasticity of 32±0.5%, and adequate hardness of 152±3.90 Hv among the investigated alloys. The Ti-25Nb-3Fe-9Zr alloy demonstrates good blend of strength and malleability. Therefore, Ti-25Nb-3Fe-9Zr can be used effectively for the biomedical applications

Laparoscopy in management of appendicitis in high-, middle-, and low-income countries: a multicenter, prospective, cohort study.

BACKGROUND: Appendicitis is the most common abdominal surgical emergency worldwide. Differences between high- and low-income settings in the availability of laparoscopic appendectomy, alternative management choices, and outcomes are poorly described. The aim was to identify variation in surgical management and outcomes of appendicitis within low-, middle-, and high-Human Development Index (HDI) countries worldwide. METHODS: This is a multicenter, international prospective cohort study. Consecutive sampling of patients undergoing emergency appendectomy over 6 months was conducted. Follow-up lasted 30 days. RESULTS: 4546 patients from 52 countries underwent appendectomy (2499 high-, 1540 middle-, and 507 low-HDI groups). Surgical site infection (SSI) rates were higher in low-HDI (OR 2.57, 95% CI 1.33-4.99, p = 0.005) but not middle-HDI countries (OR 1.38, 95% CI 0.76-2.52, p = 0.291), compared with high-HDI countries after adjustment. A laparoscopic approach was common in high-HDI countries (1693/2499, 67.7%), but infrequent in low-HDI (41/507, 8.1%) and middle-HDI (132/1540, 8.6%) groups. After accounting for case-mix, laparoscopy was still associated with fewer overall complications (OR 0.55, 95% CI 0.42-0.71, p < 0.001) and SSIs (OR 0.22, 95% CI 0.14-0.33, p < 0.001). In propensity-score matched groups within low-/middle-HDI countries, laparoscopy was still associated with fewer overall complications (OR 0.23 95% CI 0.11-0.44) and SSI (OR 0.21 95% CI 0.09-0.45). CONCLUSION: A laparoscopic approach is associated with better outcomes and availability appears to differ by country HDI. Despite the profound clinical, operational, and financial barriers to its widespread introduction, laparoscopy could significantly improve outcomes for patients in low-resource environments. TRIAL REGISTRATION: NCT02179112

Global economic burden of unmet surgical need for appendicitis

Background: There is a substantial gap in provision of adequate surgical care in many low-and middle-income countries. This study aimed to identify the economic burden of unmet surgical need for the common condition of appendicitis. Methods: Data on the incidence of appendicitis from 170 countries and two different approaches were used to estimate numbers of patients who do not receive surgery: as a fixed proportion of the total unmet surgical need per country (approach 1); and based on country income status (approach 2). Indirect costs with current levels of access and local quality, and those if quality were at the standards of high-income countries, were estimated. A human capital approach was applied, focusing on the economic burden resulting from premature death and absenteeism. Results: Excess mortality was 4185 per 100 000 cases of appendicitis using approach 1 and 3448 per 100 000 using approach 2. The economic burden of continuing current levels of access and local quality was US $92 492 million using approach 1 and$73 141 million using approach 2. The economic burden of not providing surgical care to the standards of high-income countries was $95 004 million using approach 1 and$75 666 million using approach 2. The largest share of these costs resulted from premature death (97.7 per cent) and lack of access (97.0 per cent) in contrast to lack of quality. Conclusion: For a comparatively non-complex emergency condition such as appendicitis, increasing access to care should be prioritized. Although improving quality of care should not be neglected, increasing provision of care at current standards could reduce societal costs substantially

Pooled analysis of WHO Surgical Safety Checklist use and mortality after emergency laparotomy

Background The World Health Organization (WHO) Surgical Safety Checklist has fostered safe practice for 10 years, yet its place in emergency surgery has not been assessed on a global scale. The aim of this study was to evaluate reported checklist use in emergency settings and examine the relationship with perioperative mortality in patients who had emergency laparotomy. Methods In two multinational cohort studies, adults undergoing emergency laparotomy were compared with those having elective gastrointestinal surgery. Relationships between reported checklist use and mortality were determined using multivariable logistic regression and bootstrapped simulation. Results Of 12 296 patients included from 76 countries, 4843 underwent emergency laparotomy. After adjusting for patient and disease factors, checklist use before emergency laparotomy was more common in countries with a high Human Development Index (HDI) (2455 of 2741, 89.6 per cent) compared with that in countries with a middle (753 of 1242, 60.6 per cent; odds ratio (OR) 0.17, 95 per cent c.i. 0.14 to 0.21, P <0001) or low (363 of 860, 422 per cent; OR 008, 007 to 010, P <0.001) HDI. Checklist use was less common in elective surgery than for emergency laparotomy in high-HDI countries (risk difference -94 (95 per cent c.i. -11.9 to -6.9) per cent; P <0001), but the relationship was reversed in low-HDI countries (+121 (+7.0 to +173) per cent; P <0001). In multivariable models, checklist use was associated with a lower 30-day perioperative mortality (OR 0.60, 0.50 to 073; P <0.001). The greatest absolute benefit was seen for emergency surgery in low- and middle-HDI countries. Conclusion Checklist use in emergency laparotomy was associated with a significantly lower perioperative mortality rate. Checklist use in low-HDI countries was half that in high-HDI countries.Peer reviewe

Global variation in anastomosis and end colostomy formation following left-sided colorectal resection

Background End colostomy rates following colorectal resection vary across institutions in high-income settings, being influenced by patient, disease, surgeon and system factors. This study aimed to assess global variation in end colostomy rates after left-sided colorectal resection. Methods This study comprised an analysis of GlobalSurg-1 and -2 international, prospective, observational cohort studies (2014, 2016), including consecutive adult patients undergoing elective or emergency left-sided colorectal resection within discrete 2-week windows. Countries were grouped into high-, middle- and low-income tertiles according to the United Nations Human Development Index (HDI). Factors associated with colostomy formation versus primary anastomosis were explored using a multilevel, multivariable logistic regression model. Results In total, 1635 patients from 242 hospitals in 57 countries undergoing left-sided colorectal resection were included: 113 (6·9 per cent) from low-HDI, 254 (15·5 per cent) from middle-HDI and 1268 (77·6 per cent) from high-HDI countries. There was a higher proportion of patients with perforated disease (57·5, 40·9 and 35·4 per cent; P < 0·001) and subsequent use of end colostomy (52·2, 24·8 and 18·9 per cent; P < 0·001) in low- compared with middle- and high-HDI settings. The association with colostomy use in low-HDI settings persisted (odds ratio (OR) 3·20, 95 per cent c.i. 1·35 to 7·57; P = 0·008) after risk adjustment for malignant disease (OR 2·34, 1·65 to 3·32; P < 0·001), emergency surgery (OR 4·08, 2·73 to 6·10; P < 0·001), time to operation at least 48 h (OR 1·99, 1·28 to 3·09; P = 0·002) and disease perforation (OR 4·00, 2·81 to 5·69; P < 0·001). Conclusion Global differences existed in the proportion of patients receiving end stomas after left-sided colorectal resection based on income, which went beyond case mix alone

Mortality of emergency abdominal surgery in high-, middle- and low-income countries

Background: Surgical mortality data are collected routinely in high-income countries, yet virtually no low- or middle-income countries have outcome surveillance in place. The aim was prospectively to collect worldwide mortality data following emergency abdominal surgery, comparing findings across countries with a low, middle or high Human Development Index (HDI). Methods: This was a prospective, multicentre, cohort study. Self-selected hospitals performing emergency surgery submitted prespecified data for consecutive patients from at least one 2-week interval during July to December 2014. Postoperative mortality was analysed by hierarchical multivariable logistic regression. Results: Data were obtained for 10 745 patients from 357 centres in 58 countries; 6538 were from high-, 2889 from middle- and 1318 from low-HDI settings. The overall mortality rate was 1⋅6 per cent at 24 h (high 1⋅1 per cent, middle 1⋅9 per cent, low 3⋅4 per cent; P < 0⋅001), increasing to 5⋅4 per cent by 30 days (high 4⋅5 per cent, middle 6⋅0 per cent, low 8⋅6 per cent; P < 0⋅001). Of the 578 patients who died, 404 (69⋅9 per cent) did so between 24 h and 30 days following surgery (high 74⋅2 per cent, middle 68⋅8 per cent, low 60⋅5 per cent). After adjustment, 30-day mortality remained higher in middle-income (odds ratio (OR) 2⋅78, 95 per cent c.i. 1⋅84 to 4⋅20) and low-income (OR 2⋅97, 1⋅84 to 4⋅81) countries. Surgical safety checklist use was less frequent in low- and middle-income countries, but when used was associated with reduced mortality at 30 days. Conclusion: Mortality is three times higher in low- compared with high-HDI countries even when adjusted for prognostic factors. Patient safety factors may have an important role. Registration number: NCT02179112 (http://www.clinicaltrials.gov)

Analysis of orthosis with biomechanical interventions and gait modifications for medial knee osteoarthritis patients / Saad Jawaid Khan

The study aimed at (1) investigating the effects of altering foot progression angles on physical balance in healthy and medial knee osteoarthritis (kOA) participants, (2) assessing the immediate effects of orthoses (valgus knee brace and wedged insoles) and gait modification techniques (toe-in and toe-out gait) in improving the physical function of kOA participants, and (3) testing the hypothesis that toe-in gait will reduce first peak of knee adduction moment (fKAM), while toe-out gait will reduce its second peak (sKAM) when combined with knee brace and laterally wedged insoles in kOA patients. Biodex Balance System was used to measure postural stability and fall risk at different foot progression angles (from -20º to 40º, with 10º increments) on 20 healthy and 20 kOA patients randomly with different static and dynamic platform settings. Five performance-based tests: (1) 30-second Chair Stand Test (30CST) (2) 40m Fast-Paced Walk test (40FPW) (3) Stair Climb Test (SCT) (4) Timed Up-and-Go test (TUG) (5) 6-Minute Walk Test (6MWT) were applied on 20 healthy and 20 kOA patients randomly to measure physical function. fKAM and sKAM were determined through 3-dimensional gait analysis with nine randomized conditions: (1) N (natural gait, without any intervention), (2) brace, (3) brace + toe-in gait, (4) wedged insole, (5) wedged insole + toe-in gait, (6) knee brace + wedged insole + toe-in gait, (7) brace + toe-out gait, (8) wedged insole + toe-out gait, (9) brace + wedged insole + toe-out gait. Fall risk was assessed by the Biodex Balance System® using three stability settings, (i) static (ii) moderate dynamic setting (FR12) and (iii) high dynamic setting (FR8). Data from the tests were analyzed using independent sample t-test, 3-way mixed methods ANOVA and repeated-measures ANOVA. Platform settings had a significant interaction effect with participant group (p < 0.01) and toe angles (p < 0.01). Toe-out gait impaired the physical function while knee brace improved it during 40FPW, SCT and 6MWT. fKAM reduced maximally (19.7%) by brace + toe-in gait, while sKAM reduced maximally by brace + wedged insole + toe-out gait (25.5%). Fall risk increased significantly at FR8 when knee brace and wedged insoles were combined with toe-in gait (35.7%) and toe-out gait (42.9%). Changing platform settings had a more pronounced effect on balance in kOA group than healthy group. Changing toe angles produced similar effects in both the participant groups, with decreased stability and increased fall risk at extreme toe-in and toe-out angles. Physical function was improved maximally by the knee brace, while toe-out gait impaired it the most. There is a synergistic effect of toe-in gait and toe-out gait when combined with knee brace and wedged insole concurrently in the reductions in the first and the second peaks of knee adduction moment respectively but with a greater risk of fall

Combined effects of knee brace, laterally wedged insoles and toe-in gait on knee adduction moment and balance in moderate medial knee osteoarthritis patients

Objective: To test the hypothesis that toe-in gait (TI) will further reduce first peak (Knee Adduction Moment) KAM and decrease balance when combined with a knee brace (KB) and laterally wedged insoles (LWI) in medial knee osteoarthritis (kOA) patients. Participants: Twenty patients with bilateral symptomatic medial kOA. Interventions: 4-point leverage-based KB, full-length LWI with 5° inclination and toe-in gait (TI). Main outcome measures: First and second peak knee adduction moment (fKAM and sKAM respectively), balance and pain. Methods: The fKAM and sKAM were determined from 3-dimensional gait analysis with six randomized conditions: (1) N (without any intervention), (2) KB, (3) KB + TI, (4) LWI, (5) LWI + TI, (6) KB + LWI + TI. Balance was assessed by Biodex Balance System using three stability settings, (i) Static (ii) Moderate dynamic setting for fall risk (FR12) and (iii) High dynamic setting for fall risk (FR8). Results: The reduction in fKAM and sKAM was greatest (19.75% and 12%) when TI was combined with KB and LWI respectively. No change in balance was observed when TI combined with KB, and LWI and when used concurrently with both the orthosis at static and FR12 conditions. Significant balance reduction was found at FR8 for KB + TI (22.22%), and KB + LWI + TI (35.71%). Pain increased significantly for KB (258%), KB + TI (305%), LWI + TI (210%) and KB + LWI + TI (316%). LWI showed no effect on pain. Conclusions: There is a synergistic effect of TI when combined with KB and LWI concurrently in sKAM reduction. However, the concurrent use of TI, KB and LWI decreases balance and pain as assessed on a highly dynamic platform