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PubMedDate not supplied

Response of balloon-expandable endoprosthetic metallic stents subjected to over-expansion in vitro.

We attempted to evaluate the in vitro behavior and performance of balloon-expandable endoprosthetic metallic stents subjected to over-expansion (OE). Seventy-two balloon-expandable endoprosthetic stents, representing 22 models from six manufacturers, were overexpanded in vitro. Stents were initially expanded to their maximum manufacturer- recommended diameter and then over-expanded incrementally to their endpoints. Endpoints for OE were either stent disarticulation or an inability to undergo further expansion despite balloon insufflation to maximum burst pressure. Measurements of stent dimensions were recorded at each overexpanded diameter and comparisons were made to manufacturer's specifications. A total of 288 balloon-driven expansions were performed on 72 stents. Sixteen stents were expanded to large diameters (> or = 16 mm), 20 stents underwent OE of 50% or greater. One model tended to disarticulate after OE greater than 50%. There were five models that had a tendency to disarticulate after minimal OE. Five models were resistant to OE (25% or less OE) but did not disarticulate. Nearly all stents showed some degree of foreshortening with OE, while 36 stents underwent foreshortening of 30% or more. Models that are not recommended for OE include Intrastent, Intrastent DoubleStrut, NIR Royale and Omniflex. Good candidates for OE include Intrastent DoubleStrut LD, Palmaz large, Medtronic Extra Support Biliary Plus and Medtronic Flexible Biliary. Palmaz XL remains the only model available for expansion from 20 to 28 mm in diameter. For the remaining stents, OE is possible, however, caution should be used.

Catheterization↗
PubMed2002

Transtibial amputation with plantar flap for congenital deficiency of the tibia.

Disarticulation of the knee has been the preferred treatment for the severe type (Type Ia and Type Ib classification of Jones et al) of congenital deficiency of the tibia because of marked flexion contracture of the knee and loss of quadriceps function. In such cases, the disarticulated stump is often small and poorly covered by soft tissues because of dysplastic femoral condyles and calf muscles. Therefore, stump complications after disarticulation may prevent early aggressive walking exercises and delay independent ambulation. To overcome this problem, a greater weightbearing surface was created by a transtibial amputation with a short stump of the fibula using the flexed knee. By this method, the distal femoral condyle and the anterior surface of the fibula were used for weightbearing. In addition, coverage of the new weightbearing area by a neurovascular pedicled sensate plantar flap provided a more tolerable weightbearing site. The purpose of the current study was to report a 5-year-old boy with bilateral congenital total deficiency of both tibias, who was treated using this technique. The patient was ambulating independently 15 weeks after surgery. A transtibial amputation with a plantar flap is an alternative procedure to knee disarticulation for the severe type of congenital deficiency of the tibia.

Amputation, Surgical↗
PubMed2004

Long-term results of through-knee amputation with dorsal musculocutaneous flap in patients with end-stage arterial occlusive disease.

A modified technique of knee joint disarticulation using a dorsal musculocutaneous flap of the gastrocnemius muscle was first described in 1985. The operative results in 66 patients (33 women, 33 men; mean age 66.7 +/- 11.3 years, range 42-93 years) with gangrene due to peripheral vascular disease with 69 knee disarticulations are reported. After a mean survival period of 35.2 months (0-116 months), 88% ( n = 58) of the patients had died owing to cardiopulmonary reasons. The in-hospital 48-day mortality was 9%. Nine patients (14%) underwent reamputation at the above-knee level, and five patients underwent operative revision of the soft tissue. After discharge from the hospital, 35 of 60 patients (58%) were able to walk with the aid of a prosthesis. We conclude that knee disarticulation with the use of a myocutaneous gastrocnemius flap is a safe, functionally acceptable operative method in high risk vascular patients.

Adult↗
PubMedDate not supplied

[Kinematics of various joint mechanisms for the prosthetic substitution of the knee joint following knee exarticulation].

In the past, long amputation stumps of the thigh after knee disarticulation were difficult to fit with a knee prosthesis. Apart from other difficulties, one essential problem was caused by the fact that in preservation of the femoral length there was little or even no space to assemble a knee prosthesis at the level of the axis of the natural knee joint, that is to say at a position somewhere within the femoral condyles. In the meantime the number of knee disarticulations has increased and thus substituted the conventional above knee amputation. Consequently some new, partly polycentric knee joint mechanisms have been designed for the prosthetic fitting of knee disarticulation stumps as well as for long amputation stumps of the thigh. These mechanisms try to cope with the space problem in different ways and, moreover, some of them can also produce a moving centre of rotation at joint flexion similar to the natural knee joint. The motion pattern in current knee joint mechanisms is investigated by graphical construction of their centrodes and it is compared to the motion pattern of the natural knee joint.

Artificial Limbs↗
PubMed2004

Amputation through the hip joint during the pre-anaesthetic era.

Even to the present day, hip disarticulation is one of the most radical orthopaedic operations. First carried out on the Continent in 1774 and in Britain in 1779, this procedure was only deemed necessary in circumstances where death was otherwise inevitable. George James Guthrie claimed to have undertaken the first amputation through the hip joint in which the patient survived. We describe some of these cases from the pre-anaesthetic surgical literature in which amputation through the hip joint was undertaken, and we comment on the surgical techniques used. This information is complemented by the views of certain authorities on this procedure. Many surgeons during the first half of the 19th century, including Guthrie, sought alternative surgical operations to hip joint disarticulation. The removal of the head and neck of the femur was far less traumatic than disarticulation through the hip joint, and proved an extremely effective alternative procedure for lesions involving the proximal part of the femur where there was any possibility that the limb could be saved.

Amputation, Surgical↗
PubMed1986

[Knee joint exarticulation in arterial occlusive disorders of the lower extremity].

In 35 patients suffering from peripheral ischemic disease of the legs, disarticulation of the knee joint was performed instead of above-knee amputation. Operations were executed primarily or after failed bypass procedures for the salvation of the limb. 24 cases (67%) showed primary or delayed secondary stump healing. In 11 cases (31%), however, no stump healing was achieved due to either a wound infection (4 cases) or a necrosis of the anterior flap covering the weight bearing area of the stump (7 cases). Factors influencing the outcome of stump healing are discussed and different techniques of knee disarticulation are evaluated as to their benefits and disadvantages in ischemic limbs. As the method offers several advantages over above-knee amputation, a more frequent use of knee disarticulation in the surgical treatment of ischemic legs which cannot be preserved by other surgical measures and usually would be amputated at above-knee level is recommended.

Adult↗
PubMed1998

Magnetic resonance imaging of articular cartilage: ex vivo study on normal cartilage correlated with magnetic resonance microscopy.

The aims of this study were (a) to compare the MR appearance of normal articular cartilage in ex vivo MR imaging (MRI) and MR microscopy (MRM) images of disarticulated human femoral heads, (b) to evaluate by MRM the topographic variations in articular cartilage of disarticulated human femoral heads, and subsequently, (c) to compare MRM images with histology. Ten disarticulated femoral heads were examined. Magnetic resonance images were obtained using spin-echo (SE) and gradient-echo (GE) sequences. Microimages were acquired on cartilage-bone cylindrical plugs excised from four regions (superior, inferior, anterior, posterior) of one femoral head, using a modified SE sequence. Both MRI and MRM images were obtained before and after a 90 degrees rotation of the specimen, around the axis perpendicular to the examined cartilage surface. Finally, MRM images were correlated with histology. A trilaminar appearance of articular cartilage was observed with MRI and with a greater detail with MRM. A good correlation between MRI and MRM features was demonstrated. Both MRI and MRM showed a loss of the trilaminar cartilage appearance after specimen rotation, with greater evidence on MRM images. Cartilage excised from the four regions of the femoral head showed a different thickness, being thickest in the samples excised from the superior site. The MRM technique confirms the trilaminar MRI appearance of human articular cartilage, showing good correlation with histology. The loss of the trilaminar appearance of articular cartilage induced by specimen rotation suggests that this feature is partially related to the collagen-fiber orientation within the different layers. The MRM technique also shows topographic variations in thickness of human articular cartilage.

Aged↗
PubMed2005

Hand-assisted laparoscopic nephroureterectomy: analysis of distal ureterectomy technique, margin status, and surgical outcomes.

OBJECTIVES: To review our experience with various techniques used to manage the distal ureter during hand-assisted laparoscopic nephroureterectomy and to evaluate the surgical outcomes, including pathologic margin status and the incidence of disease recurrence. METHODS: We retrospectively analyzed 55 hand-assisted laparoscopic nephroureterectomies performed to treat transitional cell carcinoma (TCC), with the distal ureter managed as follows: cystoscopic disarticulation in 16 patients, stapled division in 7, open distal ureterectomy in 3, and hand-assisted laparoscopic extravesical en bloc distal ureterectomy with bladder cuff in 29. The cystotomy was not closed in 7 patients. RESULTS: The coexistence of renal pelvic and ureteral tumors was common but in 27% of cases was not recognized preoperatively. One outer and four distal ureteral margins were positive for tumor (n = 2) or carcinoma in situ (n = 3). Two (29%) of the seven cystotomies that were not closed and only 1 (2%) of the 42 that were closed demonstrated extravasation. The operative time was 60 to 90 minutes longer and the estimated blood loss, open conversion rate, and indwelling catheterization time were two to three times greater for the cystoscopic ureteral disarticulation cohort. The stapled division cohort had a greater positive margin rate (29%) than the other cohorts (10% or less). With a mean follow-up of 24 months, 19 patients had developed bladder cancer, 1 prostate cancer, 1 an extravesical malignancy with synchronous liver metastasis, and 4 distant recurrence (lung in 2 and the retroperitoneum and spine in 1 each). CONCLUSIONS: The results of our study have shown that distal ureteral tumors have the greatest likelihood for a positive margin. Cystoscopic ureteral disarticulation increased the operative time and estimated blood loss. Cystotomy closure reduced the extravasation rate. We favor hand-assisted laparoscopic en bloc distal ureterectomy followed by cystotomy closure to minimize the risk of distal ureteral or extravesical recurrence.

Aged↗
PubMed2002

Diffraction-enhanced X-ray imaging of articular cartilage.

OBJECTIVE: To introduce a novel X-ray technology, diffraction-enhanced X-ray imaging (DEI), in its early stages of development, for the imaging of articular cartilage. DESIGN: Disarticulated and/or intact human knee and talocrural joints displaying both undegenerated and degenerated articular cartilage were imaged with DEI. A series of three silicon crystals were used to produce a highly collimated monochromatic X-ray beam to achieve scatter-rejection at the microradian level. The third crystal (analyser) was set at different angles resulting in images displaying different characteristics. Once the diffraction enhanced (DE) images were obtained, they were compared to gross and histological examination. RESULTS: Articular cartilage in both disarticulated and intact joints could be visualized through DEI. For each specimen, DE images were reflective of their gross and histological appearance. For each different angle of the analyser crystal, there was a slight difference in appearance in the specimen image, with certain characteristics changing in their contrast intensity as the analyser angle changed. CONCLUSIONS: DEI is capable of imaging articular cartilage in disarticulated, as well as in intact joints. Gross cartilage defects, even at early stages of development, can be visualized due to a combination of high spatial resolution and detection of X-ray refraction, extinction and absorption patterns. Furthermore, DE images displaying contrast heterogeneities indicative of cartilage degeneration correspond to the degeneration detected by gross and histological examination.

Adult↗
PubMed2001

Lower limb amputations: registration of all lower limb amputations performed at the University Hospital of Trondheim, Norway, 1994-1997.

The authors consecutively recorded all lower limb amputations performed at the University Hospital of Trondheim from January 1st, 1994 to January 1st, 1997. A total of 215 primary lower limb amputations were carried out in the study period: 40 partial foot amputations, 2 ankle disarticulations, 51 trans-tibial amputations, 68 knee disarticulations, 50 transfemoral amputations and 4 hip disarticulations. Seventy-four (74) (34%) of the amputees had diabetes mellitus, 113 (53%) had peripheral vascular disease and 28 (13%) of the amputees had various diagnoses. In those who were amputated due to diabetic and peripheral vascular disease the overall reamputation rate was 19% and 20%, respectively. The rates of reamputation at the trans-tibial and knee level were similar. In the city of Trondheim the annual incidence of primary amputations was 34 per 100,000 and 4.4 per 1,000 diabetic subjects. The incidence of lower limb amputations was 25 times higher in diabetic subjects compared to non-diabetic subjects.

Adolescent↗
PubMed2003

Life within death: towards a metapsychology of catastrophic psychic trauma.

In this paper the author offers a phenomenology and a metapsychology for the effects on the mind of catastrophic psychic trauma, defined as the reaction of the psyche to an utterly external event, which the person is helpless to resist, and against which there is no possible defense. The author affirms that the experience of 'infinite affliction' produces a radical break in being which disarticulates the psyche and causes a headlong descent to the most primitive levels of psychic functioning. When there is a complete surrender to the process of disarticulation, it continues until it extinguishes even the most basic level of mental activity, contact with sensation, producing psychic and then psychogenic death. The author then offers a phenomenological and metapsychological analysis of how the process of disarticulation is stopped so that the state of survival is assured, affirming that, faced with this situation of utter emergency, the survival urge instantly mobilizes the organism in furious activity to preserve life and regenerates psychic activity by sensing the ongoing existence of the psychesoma. Then anguish precipitates on to the body and is sensed as psychophysical pain, which diverts conscious attention from the infinite destruction of utter affliction which is thus encapsulated so that, as an experience, it is no longer present to the mind. This assures survival, but it leaves the psyche in a state of non-integration and begins the unending battle for mastery over the deadly inner object which ceaselessly threatens to become present. This constitutes the precariousness of the state of survival.

Attitude to Death↗
PubMed1997

Palliative major amputation and quality of life in cancer patients.

Limb sparing surgery has replaced the amputation surgery in the treatment of limb sarcomas. Recurrent or persistent disease constitutes a major problem. Local symptoms such as agonizing pain, fractures, tumor fungation, inability to walk and inability to maintain daily activities, further impair the patient's quality of life. In this clinical set-up palliative amputation should be considered. Eighteen patients with soft-tissue or bone sarcomas and 3 patients with metastatic carcinoma underwent palliative major amputation. Hemipelvectomy was performed in 3 patients, hip disarticulation in 10, knee disarticulation or below-knee amputation in 3 patients, shoulder disarticulation in one patient and forequarter amputation in 4 patients. Local control of the disease and pain and improvement of the performance status were observed in 19 evaluable patients. The mobility was restored in 15 patients with lower limb surgery. The median survival following the procedure was 9 months. There was only one case of immediate post-operative death. Severe phantom pain was not reported by any of the patients. Quality of life was reported to be improved by two-thirds of the patients. To conclude, we have, found palliative major amputation surgery worth performing in low-performance status cancer patients with locally advanced disease.

Adolescent↗
PubMed2004

Lower limb landmine injuries.

The medical records of 186 patients seeking treatment for landmine injuries in the authors' region between 1993 and 2001 were evaluated. Of these patients 13 died of accompanying complications. Ten (10) patients with general body trauma and upper limb trauma were excluded from the study. Of 163 patients with lower-limb injuries included in the study, 21 with traumatic amputation underwent surgical amputation at different levels. Patients without traumatic amputation were divided into 2 groups. There were 41 patients (29%) in Group I who were treated by limb salvage procedures. Treatments used in Group I including wound debridement, tendon repair, skin approximation, minimal osteosynthesis, external fixation of long bones and secondary wound coverage. In Group II, there were 101 patients (71%) with primary amputation. Trans-tibial amputation was performed in 52 cases (51.4%), ankle disarticulation in 24 (23.7%), trans-femoral amputation in 9 (8.9%), partial foot amputation in 8 (7.9%), knee disarticulation in 7 (6.9%) and hip disarticulation in 1 case. In Group I, there was infection in 21 patients (51.2%), revision in 27 (65.8%), and amputation in 15 (36.5%). In Group II, there was infection in 28 patients (27.7%), revision in 17 (16.8%), and amputation at a higher level in 8 (7%). In crush injuries such as those resulting from landmines, soft tissue, vascular, and neurological assessment must be performed with utmost care. Even so, the desired success in interventions intended to save a limb is complicated by a high infection rate, soft tissue complications, and high revision amputation rates. Therefore, a decision to amputate in the early term based on an accurate preoperative assessment is crucial.

Adolescent↗
PubMedDate not supplied

Lower-limb deficiencies and amputations in children.

Important differences exist in the management of child and adult amputees. Many factors, including the etiology of childhood limb deficiencies, expected skeletal growth, functional demand on the locomotor system and prosthesis, appositional bone stump overgrowth, and psychological challenges, make caring for these young patients particularly challenging. Adherence to the general principles of childhood amputation surgery will typically guide one to the optimal functional result. These principles can be summarized as follows: (1) Preserve length. (2) Preserve important growth plates. (3) Perform disarticulation rather than transosseous amputation whenever possible. (4) Preserve the knee joint whenever possible. (5) Stabilize and normalize the proximal portion of the limb. (6) Be prepared to deal with issues in addition to limb deficiency in children with other clinically important conditions. A large proportion of young amputees undergo a Syme disarticulation, modified Boyd amputation, or knee disarticulation. A modified Van Nes rotationplasty procedure is also useful in this age group. All these provide the child with a weight-bearing stump with good growth potential and no complications due to bone overgrowth. Appropriate timing of amputation procedures and prosthetic fittings is essential to maximize functional benefit to the patient.

Age Factors↗
PubMed1989

Canid scavenging/disarticulation sequence of human remains in the Pacific Northwest.

Greater understanding of animal scavenging of human remains can assist forensic science investigators in locating and recovering dispersed skeletal elements, in recognizing damage produced by scavengers, and in making more informed estimates of the postmortem interval. The pattern of skeletal damage can indicate whether the body was scavenged while intact or at some time after other natural processes of disarticulation had begun. This study analyzed thirty partially to fully skeletonized human remains with respect to scavenging at the time of body discovery in order to determine if a patterned consumption sequence existed. The scavengers were primarily coyotes (Canis latrans) and domestic dogs (C. familiaris). Sixteen non-carnivore-scavenged remains were also examined and contrasted with the carnivore-scavenged sample. Observed postmortem intervals from death to recovery ranged from 4 h to 52 months. Results demonstrate that canid scavenging of human remains takes place in sequential stages: Stage 0 = no bony involvement; Stage 1 = ventral thorax damaged and one or both extremities removed; Stage 2 = lower extremity involvement; Stage 3 = only vertebral segments remain articulated; and Stage 4 = total disarticulation. Results revealed a clear correspondence between stages of disarticulation and the postmortem interval.

Adolescent↗
PubMed1994

[Dedifferentiated chondrosarcoma. A study of 13 clinical cases and review of the literature].

PURPOSE OF STUDY: Dedifferentiated chondrosarcoma is a variant of chondrosarcoma of bone consisting in a highly anaplasic sarcoma associated with low grade chondrosarcoma. The histopathology and the poor prognosis characterize these tumors. The clinical, radiographical and histological features are described before proposing a therapeutic approach to improve prognosis. MATERIAL AND METHODS: Thirteen cases of dedifferentiated chondrosarcoma having the histological requirements described by Dahlin and Beabout were identified and treated between 1977 and 1992 at the Cochin Hospital. These tumors represented 10 per cent of all chondrosarcomas registered in the same period. Eleven cases were primary and in two cases the dedifferentiated chondrosarcomas were first found in recurrent tumors. The average of age was 53 years. This was a retrospective study. The clinical reports, radiograms and histological reports were reevaluated. In doubtful cases the histological sections were reviewed. RESULTS: The clinical features were no different from chondrosarcoma except for the high incidence of pathological fractures. The histology was associated in all cases with a grade 1 or 2 chondrosarcoma and a grade 3 or 4 anaplasic component. The anaplasic components were: 5 osteosarcomas, 5 fibrosarcomas, 2 fibrous histiocytomas, 1 rhabdomyosarcoma. All the patients underwent surgical treatment. Only one patient was treated by adjuvant chemotherapy. Among the eleven primary chondrosarcomas: two disarticulations were performed. En bloc resection was performed in nine patients: one wide margin, six marginal and two intralesional. The two secondary dedifferentiated chondrosarcomas were treated by disarticulation. No local recurrences were observed after disarticulation or wide resection. All patients presented pulmonary metastasis leading to death except one patient with only three months follow up. The average survival time was nine months (1 to 36 months). DISCUSSION: Prognosis is uniformly poor. The five years survival rate is 0 per cent in our series and 10.5 per cent in the series published by Unni and Frassica. The physiopathologic hypothesis which prevails is that the two histologic components originate from two different primitive cell clones, one of which differentiates into a low grade chondrosarcoma while the others fails to differentiate and remains a high grade sarcoma expressing different morphologic features. Treatment was not always adequate, because the diagnosis was missed at time of biopsy in five cases. The biopsies showed the two histological components in only six cases. All our patients presented pulmonary metastasis excepted one patient. This feature was also noted in other series (70 to 100 per cent). Those metastasis originate from the anaplasic component. Chemotherapy has not been well evaluated for these tumors but its effectiveness is evident for treatment of osteosarcoma. CONCLUSION: These tumors, which are characterized by their histology and their poor prognosis, are frequently inadequately treated. It is necessary to improve the prognosis: by performing a large biopsy adjusted on the lytic bone. by performing a wide resection or amputation. We believe that it is necessary to associate a chemotherapy to surgical treatment. We have decided to treat our patients with an osteosarcoma protocol.

Adult↗
PubMed1994

[Results of transgenicular amputation with dorsal skin-muscle flap-plasty in patients in the final stage of arterial occlusive disease].

A modified technique of knee joint disarticulation by using a dorsal musculocutaneous flap of the gastrocnemius muscle was first described in 1985. The retrospective operative results in 60 patients with gangrene due to peripheral vascular disease (mean age 69 +/- 12 [43-93] years, 29 female, 31 male) with 62 knee disarticulations are reported. After a mean survival period of 18 (1-53) months 47% (n = 28) of the patients had died due to cardiopulmonal reasons after a mean follow-up period of 26 (3-71) months. In-hospital 48 day-lethality was 10%. 9 patients (15%) were re-amputated at above-knee level and in 5 patients operative revisions of the soft tissue were performed. After discharge from hospital 29 of 54 patients (54%) were able to walk with the aid of a prosthesis. We conclude that knee disarticulation with the use of a myocutaneous gastrocnemius flap is a safe and functionally acceptable operative method in high-risk vascular patients.

Adult↗
PubMed1992

[Transgenicular amputation with myocutaneous gastrocnemius flap in arterial occlusive disease].

41 knee disarticulations in patients with gangrene due to periphere vascular disease were performed using a myocutaneous flap of the gastrocnemius muscle as described by Klaes and Eigler in 1985. In many cases disarticulation was preceeded by reconstructive vascular procedures or amputation at a lower level. Primary healing of the stump was achieved in 80% of the cases. 29% of the patients were able to walk with the aid of a prosthesis.

Aged↗