Background
Guillotine amputations involve amputating an extremity with the wound left open, and are indicated in the setting of contamination. With lower extremity amputation, surgical options include below-knee amputation (BKA), through-knee amputation or knee disarticulation (KD), and above-knee amputation (AKA). BKAs preserve the knee joint and have been shown to have fewer complications and improved rehabilitation compared to KDs and AKAs. When BKAs are not feasible for a traumatic injury, an AKA is often chosen, due to difficulty or lack of understanding of KD surgery. While few RCTs have compared KDs to AKAs, they may be a viable alternative to AKAs.
Case Presentation
A 28-year-old male presented to the ED after being hit by a truck while on a motorcycle. Physical exam revealed severe injuries to the left lower extremity (LLE), including open tibia and fibula fractures, degloving of the associated soft tissue, obliteration of the anterior compartment of muscles, and a cool foot with no identifiable pulse. Radiographs revealed open, comminuted fractures of the left tibia and fibula. CTA of the LLE revealed abrupt cut-off of contrast at the level of the distal trifurcation of the popliteal artery, proximally in the tibia. 
The patient was urgently taken to the OR, where a guillotine amputation was performed through the knee joint (KD), due to the proximal nature of the fractures and level of vessel tear. KD was chosen over AKA in order to preserve the thigh musculature and therefore maximal function in this young, healthy patient. Three days later, he underwent irrigation and debridement of the LLE with wound closure. The patient was discharged home five days after wound closure, or eight days after admission. Three months out of surgery, the patient has done well with physical therapy and prosthetic usage; he will continue to be followed closely for rehabilitation and recovery. 
Discussion
Factors to be considered in the level of amputation include soft tissue viability for bone coverage, blood vessel viability, and wound contamination. When BKA is not possible, KD can offer an alternative to AKA. KDs present concerns of poor wound healing and stump breakdown, as well as increased risk of revision surgery. However, compared to ambulating on a normal leg, patients undergoing AKAs require 70% more energy expenditure. As compared to AKA, KD preserves the adductor muscles, leading to improved stability and reduced metabolic expenditure with ambulation. Therefore, KDs may result in improved rehabilitation and increased long-term functionality.


A Case of Traumatic Guillotine Knee Disarticulation

Background: Childhood obesity affects 1 in 3 children in the U.S. and is associated with a myriad of comorbidities. Executive functions (EF), including goal-directed behavior and self-management, are hypothesized to be impaired in obesity. Additionally, parental mental health issues such as depression, anxiety, and ADHD have seen a significant increase during the COVID-19 pandemic. The EF of children living with parents suffering from mental illnesses such as depression is likely to be impaired. To what degree parental mental health issues are associated with executive dysfunction (ED) in treatment seeking children with obesity is yet to be explored. The primary objective of this study was to compare the presence of ED in children with parents who have mental health diagnoses to those with parents who do not.

Methods: This was a double-blinded, cross-sectional study of 11-17 year old patients who were recruited from a multidisciplinary pediatric weight management (PWM) clinic. At initial appointments, all parents were asked about a family history of mental health diagnoses. Parents also completed the Behavior Rating Inventory of Executive Function-2 (BRIEF-2) parent form, to assess for ED in their presenting children. The scores that were analyzed from the BRIEF-2 assessments included the patients’ global executive composite (GEC), inhibit, and shift scores, which provide a global summary of all BRIEF-2 clinical scales, insight into impulsive behavior, and shifting attention between tasks, respectively. These scores were compared utilizing t-tests between the children of parents with and without mental health diagnoses.

Results: Of the 39 participants analyzed, 21 (53.8%) had one parent with a mental health diagnosis and 7 (17.9%) had both parents with a mental health diagnosis. Furthermore, 17 (43.5%) of the children had ED, 14 (35.9%) had problematic inhibit scores, and 19 (48.7%) had problematic shift scores. There were no significant differences in GEC, inhibit, and shift scores between children whose parents did and did not have mental health diagnoses, p = 0.07, 0.09, 0.08, respectively.

Conclusion: This study was underpowered to associate child ED with parental mental health diagnoses. Given that this is an interim analysis of an ongoing study, this association may be proven with a larger cohort. Of interest is that over half of our treatment seeking population had at least one parent with a mental health diagnosis, much higher than a global estimate of 15-23%. This suggests that parental mental health illnesses may be concentrated among children seeking PWM, over 70% of whom have severe obesity. Thus, further investigation is needed on how parental mental health illnesses impact patient PWM outcomes.


Relationship between Executive Dysfunction and Parental Mental Health in a Pediatric Weight Management Clinic

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Abdullah Arif

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A Case of Traumatic Guillotine Knee Disarticulation

Relationship between Executive Dysfunction and Parental Mental Health in a Pediatric Weight Management Clinic

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