Amputation surgery in peripheral vascular disease.
Explore the source record for details and available documents.
Amputation, Surgical↗
Biomedical subjects
M S Pinzur
Publications and source records attributed to M S Pinzur.
Amputations and prosthetics.
The author presents in a condensed way an overview of the principles of limb amputations and further treatment of patients who underwent such a procedure. The metabolic cost of walking, load transfer, and wound healing are reviewed in a concise manner. Particular attention is given to blood supply to the wound and methods to determine adequate perfusion with a clear analysis of the pro and cons of the Doppler method. Pediatric amputations, because of their specificity, are considered apart. Disarticulation of limbs is the method of choice in children, because of it retains growth potential of the bone and prevents bony overgrowth of the stump. The article discusses the main indications for limb amputations: trauma, peripheral vascular disease, musculoskeletal tumors and gas gangrene. In every case the specificity of the amputation is considered by the author. Postoperative care is also presented, with a short description of possible complications. Pain is the most common and treatment strategies should be similar to those used in treating patients with major reflex sympathetic causalgia. Edema, joint contracture, wound failure and dermatologic problems are all shortly reviewed. The last part of the article treats with the principles of prosthetics in both the upper and lower limb. These principles are presented basing on the level of amputation: for the upper limb hand, transradial, transhumeral amputations and shoulder disarticulation. For the lower limb foot and ankle, transtibial and transfemoral amputations are considered.
Adult↗
Risk of contamination of the wound in a hydrotherapeutic tank.
Over a 4-week period, samples for culture were taken from active hydrotherapeutic tanks (whirlpools) from two institutions in a university medical center. Samples were obtained in the morning before treatments began, and in the evening after, the final patient had been treated. Specific attention was directed toward recovery of S. aureus, P. aeruginosa, and E. coli, organisms felt to be especially dangerous for the diabetic dysvascular patients utilizing the hydrotherapeutic tanks involved in this study. Only eleven of 96 cultures (11.5%) were positive for these prospective pathogens. Of the positive cultures, nine (9.4%) were taken from near the agitator-jet, and only two (2.1%) from the floor of the hydrotherapeutic tanks, where the extremity is likely to be placed. Our results reveal that hydrotherapeutic immersion is not likely to expose patients with open wounds to potential iatrogenic contamination of the wound.
Diabetic Foot↗
Salvage of failed amputation about the hip in peripheral vascular disease by open wound care and nutritional support.
Five consecutive patients with wound and/or plastic surgical flap failure after hip disarticulation or amputation at the lesser trochanteric transfemoral level were treated with local tissue debridement, open wound management, culture-specific antibiotic therapy, and nutritional supplementation. All of the patients underwent amputation about the hip as a result of ischemic necrosis of the lower extremity. Four of the five patients were able to achieve wound healing by second intention. The fifth patient died 2 months after the surgery. None of the patients required revision surgery. One patient underwent split-thickness skin grafting to minimize the need for continued wound care. Local wound management combined with nutritional support and culture-specific antibiotic therapy is an acceptable alternative to major amputation stump revision in patients with potentially high morbidity who fail to heal after amputation about the hip.
Adult↗
Hand infections in the diabetic patient.
Between 1984 and 1994, 23 diabetic patients were admitted to a university hospital/Department of Veterans Affairs (DVA) Medical Centre with a primary or secondary diagnosis of hand infection. We also identified 726 patients admitted to all DVA Medical Centres during the years 1989 through 1994 with co-diagnoses of diabetes mellitus and hand infection. Contrary to previously published literature, most diabetic hand infections are non-specific, confined to the soft tissues, and respond to broad spectrum parenteral antibiotic therapy. When surgery is necessary, most patients do not require amputation.
Adult↗
Walking pattern of midfoot and ankle disarticulation amputees.
Measurements of the vertical component of ground reaction force (ORF) and dynamic center of pressure (COP) were recorded for five subjects with midfoot level amputations and six with Syme's ankle disarticulation amputations. All of the subjects underwent amputation surgery as a consequence of peripheral vascular disease and diabetes. GRF measurement was accomplished with the F-Scan system (Tekscan, Boston, MA). Each group exhibited a consistent, reproducible pattern of gait. Subjects with Syme's ankle disarticulation initiated initial loading response, i.e., heel strike, with a concentration of GRF in the center of the anatomic heel. COP progressed along the midline to the center of the anatomic forefoot, where GRF was concentrated at push-off. Midfoot amputees initiated loading at the lateral-posterior heel. COP progressed medially to the midline, where it progressed distally to the level of the distal residual limb (proximal metatarsal metaphyses). It then shifted medially under the base of the first metatarsal, where a small concentration of GRF occurred at push-off, similar to the normal foot. These findings explain the decreased magnitude of propulsion seen in midfoot level amputees and may explain the seemingly paradoxical increased metabolic cost of walking observed in midfoot amputees as compared with Syme's ankle disarticulation amputees.
Adolescent↗
Charcot ankle fusion with a retrograde locked intramedullary nail.
Twenty patients with severe neuropathic (Charcot) ankle deformities underwent 21 attempted ankle fusions with a retrograde locked intramedullary nail as an alternative to amputation. All had insensate heel pads and had failed at nonoperative methods of accommodative ambulatory bracing. In 11, the talus was either absent, or the deformity was of sufficient magnitude to require talectomy to align the calcaneus under the tibia for plantigrade weightbearing. Ages ranged from 28 to -68 (average 56.3) years. Nineteen were diabetic, 12 being insulin-dependent. Their average body weight was 102 kg, with 11 greater than 90 kg at the time of surgery. Eight had chronic large full thickness ulcers overlying, but not involving bone of the medial malleolus, medial midfoot, or proximal fifth metatarsal, at the time of surgery. At a follow-up of 12 to 31 months, 19 achieved bony fusion. In the 10 patients where talectomy was not required, fusion was achieved at an average of 5.3 months without complications. In the patients who required talectomy, six of the patients required eight additional operations to achieve fusion. Three achieved fusion following removal of the nail and prolonged bracing. One opted for ankle disarticulation for chronic persistent infection, rather than attempt reoperation. One died of unrelated causes during the early postoperative period. Retrograde locked intramedullary ankle fusion is a reasonable alternative to amputation in the neuropathic (Charcot) ankle that cannot be controlled with standard bracing techniques. The potential for morbidity requiring reoperation is greatly increased when the deformity is of sufficient magnitude to require talectomy to achieve alignment of the calcaneus in a plantigrade weight-bearing position under the tibia or when there are large open ulcers.
Adult↗
Is urban frostbite a psychiatric disorder?
We reviewed the records of 20 patients admitted with a diagnosis of frostbite. In addition to their thermal injury, all had overt, or covert, psychiatric disease. This prompted us to review hospital records of patients admitted to the Department of Veterans Affairs (DVA) Hospital system with a diagnosis of frostbite. During fiscal years 1991 and 1992, 37% and 36.7% of all patients admitted to DVA hospitals had a psychiatric disorder as primary or secondary diagnosis. When we selected those patients who additionally had a primary or secondary diagnosis of frostbite, the incidence increased to 61% and 65.6%, respectively. Urban patients with frostbite sufficiently severe to necessitate hospital admission have concomitant psychiatric disease at a rate that far exceeds the expected. Urban patients admitted to the hospital with a diagnosis of frostbite should be carefully screened for the presence of psychiatric disorder.
Adolescent↗
Current concepts: amputation surgery in peripheral vascular disease.
Explore the source record for details and available documents.
Amputation, Surgical↗
Reconstruction of the heel pad in ankle disarticulation with a free muscle transfer.
An otherwise healthy 17-year-old young man developed bilateral heel pad necrosis due to meningococcemia, adult respiratory distress syndrome, and disseminated intravascular coagulation. Bilateral ankle disarticulation amputations were salvaged by use of a dorsally based local flap on one residual limb and a free muscle transfer to reconstruct the weight-bearing surface of the contralateral residual limb. The case report illustrates two methods of unusual salvage of the end-bearing, weight-bearing surface of the residual limbs in a bilateral end-bearing amputation.
Adolescent↗
The metabolic cost of lower extremity amputation.
Amputation surgery should be approached as the first step in the rehabilitation of a patient with a non-functioning, salvageable limb. Before performing amputation surgery, the rehabilitation team should have an understanding of outcome expectations for the individual patient. Biologic joints are energy couples. When performing amputation surgery, more proximal amputations, accompanied by the removal of more joints, decreases the ability of patients to walk and live independently. Functional outcome appears to increase with the length of the residual limb.
Amputation, Surgical↗
Control of the residual tibia in transtibial amputation.
Eight transtibial amputees had localized unremitting discomfort and pain in the distal anterior residual limb during prosthetic wear while weightbearing. Modification of the prosthetic socket did not change this pain. It was not consistent with "phantom limb" or causalgia/reflex sympathetic dystrophy-type etiologies. Thirteen randomly selected, pain-free, transtibial amputees were selected for comparison. The subjects in both groups used similar total-contact, "patellar tendon-bearing" prosthetic sockets fabricated and aligned with similar technique. The angles formed between the femur and tibia, femur and prosthetic socket, and tibia and socket were measured. Significant differences were found at each angle measurement between those patients who experienced pain and those who did not. The variable of tibia length had no effect. We conclude that bone alignment within the transtibial total-contact prosthetic socket may be partially dependent on surgical technique and not solely on prosthetic socket configuration.
Amputation, Surgical↗
Benchmark analysis on diabetics at high risk for lower extremity amputation.
After the 1990 establishment of a multidisciplinary foot salvage clinic, 1346 diabetic patients, at high risk for the development of foot ulcers and eventual lower limb amputation, were followed for 4 years. Of the 224 high-risk patients admitted to the hospital, 74 amputations (5.5%) of all or part of a lower limb were performed. Patients undergoing amputation were younger, more severely ill, and required more frequent hospitalizations because of greater organ system involvement. They were also more likely to be institutionalized after discharge. Overall, patients with long-standing adult-onset diabetes, identified as at high risk for foot ulcer development, have a substantially increased risk for lower limb amputation, multiple organ system failure, hospitalization, and institutionalization than do diabetic patients as a whole. Clinical benchmarking facilitates the identification and reduction of unnecessary variations in patient care practices. Here, a formal benchmark analysis provides the current outcome expectations for amputation rates and co-morbidities in patients with diabetes who are classified as at high risk for lower extremity amputation. Management of these patients in a structured, multidisciplinary foot salvage clinic, augmentation of baseline services, and preliminary benchmark data may provide a standard for the measurement of therapeutic interventions that improve patient care.
Adult↗
Continuous postoperative infusion of a regional anesthetic after an amputation of the lower extremity. A randomized clinical trial.
We performed a prospective, randomized clinical trial to determine whether continuous infusion of bupivacaine hydrochloride decreased the use of narcotics for the relief of pain after an amputation. Twenty-one patients who were to have an amputation of the lower extremity because of ischemic necrosis secondary to peripheral vascular disease were divided into two groups with use of a table of random numbers. Group A (the treatment group) included nine patients who were to have a transtibial amputation, one patient who was to have a disarticulation at the knee, and one patient who was to have a transfemoral amputation. Group B (the control group) included seven patients, two patients, and one patient, respectively. After the amputation had been performed, a Teflon catheter was placed adjacent to the transected end of the sciatic or posterior tibial nerve. Postoperatively, the patients received continuous infusion of either bupivacaine (Group A) or normal saline solution (Group B) for seventy-two hours. Intravenous administration of morphine with use of a patient-controlled pump also was permitted during this period. The amount of morphine that was used was recorded meticulously. The patients in Group A used less morphine during the first and second days after the operation than did those in Group B. There was no difference between the groups with regard to the amount of morphine used on the third postoperative day. Over-all, eleven of fourteen patients who completed questionnaires reported a decrease in pain between the three and six-month evaluations. We concluded that continuous perineural infusion of an anesthetic appears to be a safe, effective method for the relief of postoperative pain but that it does not prevent residual or phantom-limb pain in patients who have had an amputation of the lower extremity because of ischemic changes secondary to peripheral vascular disease.
Adult↗
Carpectomy and fusion in adult-acquired hand spasticity.
Five adult patients with voluntary hand control, complicated by severe flexion contracture and spasticity secondary to brain injury, underwent subtotal carpectomy and radio-carpal or radio-metacarpal fusion. None of the patients were capable of functional prehension before surgery, and all had difficulty with hygiene due to their deformity. The deformities were beyond the scope of correction with soft tissue release. Two of the patients had previously undergone flexor-pronator origin release, musculo-tendinous lengthening of the wrist and finger flexors, or a combination of both. All five patients progressed to union without complication. Four achieved meaningful gains in functional grasp-release of the hand following the surgery.
Activities of Daily Living↗
Syme ankle disarticulation in peripheral vascular disease and diabetic foot infection: the one-stage versus two-stage procedure.
A prospective randomized trial compared performing a Syme ankle disarticulation using a one-stage versus Wagner's two-stage technique. Surgery was performed at two University Medical Centers where patients underwent amputation surgery for gangrene or nonsalvageable diabetic foot infection. Those undergoing surgery subsequent to trauma or congenital anomaly were eliminated. Initially, 21 patients were randomized into one-stage and two-stage surgery. The randomization was stopped for ethical reasons when the results of both procedures appeared to be similar. The next 22 consecutive patients underwent 23 Syme ankle disarticulations in one-stage surgery. Selection of amputation level was based on clinical examination, transcutaneous oximetry as a measure of vascular inflow, serum albumin as a measure of tissue nutrition, and total lymphocyte count as a measure of immunocompetence. As a total group, 31 of 44 amputations progressed to amputation wound healing and prosthetic limb fitting. In the randomized group, 9 of 13 one-stage and 5 of 8 two-stage surgeries healed. In the subsequent consecutive group, 17 of 23 healed. In all, 26 of 36 one-stage and 5 of 8 two-stage surgeries healed successfully. We concluded from this study that Syme ankle disarticulation may be performed as safely in one stage as in two stages in properly selected patients and, therefore, recommend the one-stage Syme ankle disarticulation in those patients suitable for this level amputation.
Adult↗
The effect of prosthetic alignment on relative limb loading in persons with trans-tibial amputation: a preliminary report.
The prosthetic sockets of 14 independent persons with unilateral trans-tibial (BK) amputation were mounted on an adjustable alignment pylon. Vertical ground reaction forces were recorded in neutral prosthetic alignment and in 10 degrees of prosthetic socket varus, valgus, flexion, and extension. Stance phase time, peak vertical ground reaction force, and impulse were all found to be increased on the sound limb when compared to the amputated residual limb. Significant differences were found in stance phase time and peak vertical ground reaction force when comparing malaligned with neutrally aligned prosthetic limbs. Significant differences were also seen in impulse between neutrally aligned and malaligned prosthetic limbs. The results suggest that prosthetic malalignment in persons with trans-tibial amputation leads to increased loading of the contralateral limb.
Adult↗
Functional outcome following traumatic upper limb amputation and prosthetic limb fitting.
Nineteen consecutive patients underwent traumatic upper limb amputation for nonreconstructible or replantible upper limb injury at a Level I trauma center over a 9-year-period. Eleven amputations were at the transradial level, five were transhumeral, and three were shoulder disarticulation. Eighteen patients underwent prosthetic limb fitting. Fifteen of the 18 initially underwent preparatory prosthetic limb fitting within 30 days following amputation with a body-powered, cable-driven prosthesis. Seventeen of the 18 achieved sufficient proficiency with their prostheses to allow them to return to work. Of these, 15 maintained daily functional prosthetic use of at least 8 hours daily at a followup examination of 12 to 110 months. Use of prosthetic limb following traumatic upper limb amputation carries a high probability for functional rehabilitation if limb fitting and prosthetic training are instituted as soon as the residual limb can tolerate the prosthetic socket as opposed to waiting for the residual limb to "mature".
Adolescent↗