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[Effect of primary and secondary below-knee amputation of war injuries on the length of hospitalization and rehabilitation].

The results of below-knee amputations in 36 war wounded (mean age 35.42) were reviewed. The majority of the patients was wounded by land mines (94.4%). Most of them were between 25 and 35 years old. Bilateral amputation was done in 2.8% of cases. The amputation was performed on the day of wounding (primary below-knee amputation) in 30 (83.3%) amputees. Secondary amputation after the attempt to save the severely injured lower-limb was performed in 6 patients (16.7%) average 4.61 +/- 11.67 days after wounding. Reamputation was necessary in 6 cases (16.7%). Time period from the beginning of rehabilitation to the fitting of prosthesis, was 36.25 +/- 14.97 days for primary amputations, 32 +/- 17.8 days for secondary amputations and 68.66 +/- 33.52 days for reamputations. There was no significant correlation between the duration of rehabilitation to prosthetic management and the period between wounding and amputation (r = -0.102). The attempt to save the limb after severe below-knee injuries and the secondary amputation afterwards, did not significantly influence the ensuing rehabilitation and prosthetic works.

Adult↗
PubMed2001

Functional status of persons with diabetes-related lower-extremity amputations.

OBJECTIVE: It is reasonable to predict that diabetes-related lower-extremity amputations have a detrimental impact on quality of life. However, we are unaware of any study in the medical literature describing the functional level of diabetic patients with amputations. The objective of this study was to evaluate amputations among diabetic patients and to determine the functional level of these patients with the Sickness Impact Profile (SIP). RESEARCH DESIGN AND METHODS: We enrolled 124 patients with diabetes. Case subjects (n = 35) were defined as patients who had undergone amputation of the lower-extremity, and control subjects (n = 89) were defined as patients who had not undergone amputation. Study participants received a standard history and physical examination. RESULTS: Both the physical dimension scores (33.5 +/- 14.9 vs. 22.3 +/- 14.7, P < 0.001) and the total SIP scores (27.6 +/- 9.9 vs. 22.5 +/- 10.3, P = 0.013) were significantly higher for amputees. However, the psychosocial dimension scores were not significantly different between case and control subjects (14.9 +/- 8.9 vs. 15.2 +/- 10.0, P > 0.05). Post hoc analysis showed that the group of patients who had undergone transtibial amputation had a significantly higher total impairment score than patients who had not undergone amputation (P = 0.039). This is in contrast to patients with toe or midfoot amputations, for whom total impairment scores were not significantly higher than those for the control subjects. Interestingly, bilateral amputees did not have significantly higher scores on either SIP dimension compared with unilateral amputees. CONCLUSIONS: These findings exemplify the detrimental physical and psychosocial health status of patients with diabetes-related lower-extremity amputation.

Activities of Daily Living↗
PubMed2001

Unchanged incidence of lower-limb amputations in a German City, 1990-1998.

OBJECTIVE: A reduction of diabetes-related amputations by at least one-half within 5 years was declared a primary objective for Europe (St. Vincent Declaration, 1989). We collected data about incidence rates of amputations in one German city (Leverkusen, with a population of approximately 160,000 inhabitants) between 1990 and 1998 to ascertain a potential change in rates of incidence. RESEARCH DESIGN AND METHODS: From all three hospitals in Leverkusen, we obtained complete lists of lower-limb amputations. From each patient record, diabetic status was determined. Only the first observed amputation was counted for the analysis. We estimated incidence rates of amputations in the entire population, the diabetic population, and the nondiabetic population. To test for time trend, we fitted Poisson regression models, adjusting for age and sex. RESULTS: During, the defined period (the years 1990, 1991, and 1994-1998), 339 patients (all residents of Leverkusen) without previous amputations had nontraumatic lower-limb amputations. Of all subjects. 46% were female. Moreover, 76% of the subjects were known to have diabetes. Mean age was 71.3 years. Incidence rates in the diabetic population (standardized to the estimated German diabetic population, per 100,000 person-years) were as follows: 1990, 549; 1991, 356; 1994, 544; 1995, 386; 1996, 426; 1997, 433; and 1998, 463. The Poisson models showed no significant change of incident amputations over time in the diabetic population or in the nondiabetic population. CONCLUSIONS: Beyond random variation, no change of incidence rates could be observed over the past 9 years. More specific interventions are needed to achieve a substantial reduction of diabetes-related amputations.

Adolescent↗
PubMed2004

Reduction in diabetes-related lower-extremity amputations in The Netherlands: 1991-2000.

OBJECTIVE: Lower-extremity amputation is a common complication among patients with diabetes throughout the world. However, few data exist on the actual impact of the recent moves to improve the management of diabetic foot ulcers to reduce the incidence of lower-extremity amputations. The aim was to determine the incidence of lower-extremity amputations among diabetic patients from 1991 to 2000 in The Netherlands. RESEARCH DESIGN AND METHODS: A secondary database containing information regarding all hospital admissions in which a lower-extremity amputation occurred for the years 1991-2000 was obtained from the Dutch National Medical Register. Because a patient-unique identifier was included, multiple amputations and hospitalizations for a single individual could be identified. Furthermore, age- and sex-specific diabetes prevalence rates were calculated using a 3-year average for every year, calculating the total diabetic population in the Netherlands at risk for every year. RESULTS: In 1991, a total of 1,687 patients with diabetes had been admitted 1,865 times for 2,409 amputations. In 2000, a total of 1,673 patients with diabetes were admitted 1,932 times for 2,448 amputations. The overall incidence rates of the number of patients who underwent lower-extremity amputation decreased over the years from 55.0 to 36.3 per 10,000 patients with diabetes (P < 0.05). Both in men (71.8 vs. 46.1, P < 0.05) and women (45.0 vs. 28.0, P < 0.05) with diabetes, a significant decrease could be observed. Mean duration of hospitalization decreased from 45.0 days (SD 44.4) in 1991 to 36.2 days (SD 38.4) in 2000; decreases were observed for both men and women. CONCLUSIONS: Over the years observed in this study, the incidence rates of diabetes-related lower-extremity amputation in The Netherlands was found to decrease in both men (36%) and women (38%) with diabetes. Furthermore, the duration of hospitalization decreased over time.

Amputation, Surgical↗
PubMed1982

Wound healing complications following major amputations of the lower limb.

A series of 320 amputations was analyzed with regard to wound healing complications and re-amputation rates. Among 111 AK amputations complications in wound healing were encountered in 14 per cent (15/111) of the cases, leading to re-amputation in 2 per cent (2/111). TK amputations were followed by wound healing problems in 30 per cent (20/66) of the cases with re-amputation in 20 per cent (13/66) at AK level, as compared to 40 per cent (57/143) with wound healing complications and 20 per cent (28/143) re-amputations in BK-amputees. As failure of BK amputation leads to re-amputation at AK level it is recommended that the TK level be selected in doubtful cases.

Adult↗
PubMed1992

Level of lower limb amputation in relation to etiology: an epidemiological study.

The Danish Amputation Register and the nationwide National Patient Register are presented. Based upon the code numbers in the WHO classification system (ICD), 4 etiology groups i.e. vascular insufficiency, diabetes mellitus, malignant neoplasma and trauma were extracted. The purpose was to analyse the relationship between level of amputation (i.e. foot, below-knee, through-knee, above-knee and hip) and etiology (cause of amputation). The material represents all such amputations in Denmark during the period 1978 to 1989 (n = 25.767). The number of amputations because of vascular insufficiency with and without diabetes mellitus decreased over the period studied. The number of tumour and trauma amputations seemed unchanged. There was a significant reduction in the number of amputations at proximal levels (above-knee) for vascular insufficiency with and without diabetes mellitus and in the trauma group. No such change was found regarding tumour amputations. There was a characteristic pattern in the distribution of level respectively of etiological factors for each etiology group and for each level of amputation.

Amputation, Surgical↗
PubMed1979

Bone vascularization and bone healing in the amputation stump. An experimental study.

The osseous healing process of the amputation stump was investigated in adult rabbits. Histological investigation showed that the medullary cavity was closed after 2-3 weeks, chiefly by endosteal callus. After closure of the cavity there was a gradual spongious change in the bone tip and simultaneously the cortex atrophied and the medullary cavity dilated. After amputation on the crus bone rebuilding dominated, whereas after amputation on the femur deterioration of bone was most noticeable. A combination of amputation and medullary plugging caused a change in the course of healing. The medullary cavity did not close until 7-10 weeks after operation and there was distinct periosteal callus formation. The microangiographic investigation showed a transient hypervascularization in the cortex 3-4 weeks after amputation; whereas after simultaneous plugging of the medullary cavity the hypervascularization continued for up to 7 weeks after operation. Following amputation proximally on the crus the arterial supply of the cortex came mainly from the periost, whereas the cortex after distal amputation was vascularized from the medullary cavity. This finding can be due to an interruption of the arterial supply from the nutrient artery associated with proximal amputation, whereas this artery remains intact with amputation distally on the crus.

Amputation Stumps↗
PubMed1995

Complete versus incomplete nonviable amputations of the thumb. Comparison of the survival rate and functional results.

81 patients with 84 complete (55) or incomplete (29) nonviable amputations of the thumb were studied to compare the survival rate and functional results between the two groups. 3 of these patients had bilateral thumb amputations. Of the 55 completely amputated thumbs, 43 survived (78 percent), while of the 29 incomplete nonviable amputations, 25 were salvaged (86 percent). Excluding patients with an amputation at the level of or distal to the interphalangeal (IP) joint, motion at the IP joint which did not exceed 40 degrees flexion even when a secondary procedure was done, did not show a statistical difference between the 2 groups. Average two-point discrimination was 14 mm for patients with complete amputations and 11 mm for patients with incomplete nonviable amputations. We conclude that incomplete nonviable amputations of the thumb are associated with a higher survival rate and better sensibility than complete thumb amputations, while motion at the IP joint does not differ between the two groups of patients.

Activities of Daily Living↗
PubMed1998

Upper-extremity self-amputation and replantation: 2 case reports and a review of the literature.

BACKGROUND: Patients who deliberately amputate 1 or more of their own extremities present a unique set of challenges for the entire treatment team. Decisions regarding replantation of the amputated extremity must be made quickly, and the psychiatrist is involved early in the care of these difficult patients. Surgical staff may feel that replantation surgery is inappropriate for such patients, although there is limited literature addressing this issue. Therefore, the psychiatrist must also address the strong feelings that such patients generate in nonpsychiatric caregivers. METHOD: Two cases of deliberate upper-extremity self-amputation are discussed, and the world literature on self-amputation and replantation from 1966 to the present, identified via a MEDLINE search, using the key words self-amputation, self-inflicted, upper extremity, and amputation, is reviewed. RESULTS: There have been 11 reported cases (plus 2 in the current report) of deliberate upper-extremity amputation in the last 30 years. All patients have been psychotic, and many of the case reports note that patients with this presentation are rarely suicidal. Instead, the amputation usually stems from psychotically driven feelings of guilt and concrete religious preoccupations. Patients who undergo replantation often are pleased with the reattachment, and both psychiatric and surgical outcomes appear to benefit from prompt and aggressive psychiatric treatment. CONCLUSION: Patients who deliberately amputate one or more of their extremities can be unsettling as well as challenging. The psychiatrist must coordinate diagnosis and treatment among multiple services to ensure the best possible outcome. As replantation surgery becomes more common, the psychiatric implications of surgical reattachment are of increasing importance. More cases need to be described to better understand the best treatment options for this particular patient population.

Adult↗
PubMed2002

Balance confidence among people with lower-limb amputations.

BACKGROUND AND PURPOSE: Confidence in a person's balance has been shown to be an important predictor of social activity among people with lower-limb amputations. The purposes of this study were to describe confidence in balance among people with transtibial or transfemoral lower-limb amputations and to compare people whose amputations were due to vascular and nonvascular causes. SUBJECTS AND METHODS: A survey of a sample of 435 community-dwelling individuals from 2 regional clinics was conducted. The sample consisted of people with unilateral transfemoral (26.7%) and transtibial (73.3%) amputations who lost their limb for vascular (53%) and nonvascular (47%) reasons. The mean age of the primarily male (71%) sample was 62.0 years (SD=15.7). RESULTS: Mean scores, using the Activities-specific Balance Confidence (ABC) Scale, were 63.8 for the total sample, 54.1 for the subjects with amputations due to vascular reasons, and 74.7 for the subjects with amputations due to nonvascular reasons. Given a maximum possible ABC Scale score of 100, the results suggest that confidence was low. A difference between the subjects with amputations due to vascular reasons and those with amputations due to nonvascular reasons was observed over each item of the ABC Scale. Variables that were statistically related to balance confidence included age, sex, etiology, mobility device use, the need to concentrate while walking, limitations in activities of daily living, depression, and fear of falling. DISCUSSION AND CONCLUSION: Balance confidence scores among the study sample were low when compared with values previously reported by other researchers. Confidence was particularly low among individuals who had their amputation for vascular reasons. Balance confidence might be an important area of clinical concern.

Accidental Falls↗
PubMed2002

Regional differences in the use of a vascular surgical service and incidence of amputations in a well-defined geographical area.

OBJECTIVE: To evaluate regional differences in the use of a vascular surgical service in the treatment of critical lower limb ischaemia and incidence of amputation in the 1990s in a well-defined geographical area. DESIGN: Retrospective study. SETTING: One university and five county hospitals, Finland. SUBJECTS: All referrals to the university hospital vascular surgical unit for chronic critical lower limb ischaemia and the number of major amputations in the region. MAIN OUTCOME MEASURES: Numbers of new vascular surgical consultations and amputations in 11 municipalities. Correlation between numbers of consultations and amputations. RESULTS: Between the subregions the age-standardised incidence of new vascular surgical consultations in the 15-85 year old population varied from 52.4 to 104.7/10(5) and the incidence of amputation from 10.2 to 24.8/10(5). There was an inverse correlation between the numbers of consultations and amputations. The most significant inverse correlation was between consultations and below knee amputations in diabetic patients (r = -0.70). For above knee amputations there was no correlation (r = -0.21). CONCLUSION: An active referral policy leads to reduced amputation rates.

Ambulatory Care↗
PubMed2006

[Trends and characteristics of diabetes-related lower limb amputations in the Negev, 1996-1999].

BACKGROUND: The loss of a lower limb because of diabetic foot problems such as infections is an important complication of diabetes mellitus. The goals of this study were: (1) to examine trends in incidence of diabetic-related lower limb amputations in the Negev, (2) to describe the clinical characteristics of patients who underwent amputations in the Soroka University Medical Center and (3) to estimate in-hospital mortality and its predictors. METHODS: This study included all diabetic patients who underwent non-traumatic lower limb amputation in the Soroka Hospital during the period 1996-1999. The computerized hospitalization files and surgery logs during the study period were reviewed for ICD-9 diagnoses of diabetes and amputations. For each patient, hospitalization records were abstracted and data on socio-demographic and clinical characteristics were collected. RESULTS: During the study period 411 amputations were performed on 250 diabetic patients (1.6 amputation/person). The estimated mean annual incidence rate of lower limb amputations in the Negev was 5 per 1000 diabetic patients, 27.3 per 100,000 total population, and 45 per 100,000 adults above 18 years of age. The mean age was 68 (SD +/- 11.4) years. The most frequent types of surgery were standard below-knee amputation. Fourteen percent of patients died during hospitalization. Systolic blood pressure, white blood count and serum creatinine at admission were independent predictors of in-hospital mortality. CONCLUSIONS: The incidence of lower limb amputation in the Negev is similar to that reported in other countries. Interventions directed to early detection of diabetic foot problems may have an impact on the reduction of lower limb amputations and related mortality.

Aged↗
PubMed1985

Management of infection of major amputation stumps after failed femorodistal grafts.

A retrospective review was performed of 174 patients who underwent 199 lower-extremity amputations for unreconstructable vascular insufficiency from 1976 to 1983 at the Northwestern University Medical Center. This study was initiated to identify the cause of amputation wound healing complications and secondary ascending prosthetic graft infection, as well as to propose a plan of management for the failed prosthetic grafts at the time of major limb amputation. Ninety-eight amputations were performed primarily, 12 were performed secondary to graft infection, and 89 were performed in patients who had previously undergone infrainguinal arterial bypass procedures. At the time of amputation, graft management consisted of high transection and suture ligation, allowing the graft to retract into the substance of the stump and away from the skin suture line and weight-bearing area of the limb. Delayed stump healing was noted to occur more commonly in the group who had undergone previous bypasses as opposed to those who had undergone primary amputation (34.8% versus 14.3%). Fourteen graft infections developed in 89 patients after amputation (15.7%), which is significantly higher than the overall 1.4% incidence of lower-extremity bypass infections that occurred during the same interval in patients with intact extremities. In addition, it was found that when infected grafts in amputated limbs were completely removed, stump healing without recurrent wound and graft sepsis was better than when treated locally or with partial graft removal. We therefore recommend removal of a thrombosed graft with an infected wound or an infected graft at the time of major limb amputation to decrease the incidence of wound complications and graft infection.

Amputation Stumps↗
PubMed1984

[An experimental study of the effect of fluorocarbon perfusion for amputated limb preservation. The effect of inhibition for replantation toxemia and muscle tissue destruction].

In replantation surgery, it is widely accepted that replantation toxemia or muscle destruction in replanted limbs might occur after a long time of ischemia. Their possibilities are particularly high after replantation of the amputated limbs which contain more muscle tissue than tendon and bones. The present study was performed to investigate the efficacy of fluorocarbon (FC: artificial blood) perfusion to the amputated limbs in preventing these problems after replantation. The hind limbs of dogs were completely amputated at mid-thigh. Amputated limbs were divided into two groups. One was stored in ice water and the other at room temperature for six hours. Each group was furthermore divided into four subgroups. The amputated limbs were perfused with oxygenated FC or Hartmann's solution before replantation and remaining limbs were not perfused. All of them were replanted under an operating microscope. The results were as follows: Perfusion with FC had an inhibiting effect on the anaerobic metabolism in an amputated limb and also decreased the rate of death due to replantation toxemia. Perfusion with FC was effective for inhibiting leakage of creatine phosphokinase from the replanted limb and preventing muscle destruction. Both these effects were detected biochemically and histologically. The reactive hyperemia of the replanted limb usually occurred after replantation. This rate, however, was significantly decreased after replantation of the amputated limb perfusion with FC. These effects described above were more remarkable when the amputated limb was perfused continuously rather than intermittently. It is therefore reasonable to conclude that for prevention of systemic ill effect after replantation and for preservation of function of the amputated limb, continuous perfusion with FC in ice water is more effective than ice water cooling alone.

Amputation, Traumatic↗
PubMed1982

Level of amputation after failure of limb salvage procedures.

It has been claimed that the level of amputation is rendered higher by unsuccessful limb salvage bypass procedures. To evaluate this premise, we analyzed 242 major amputations performed for atherosclerotic vascular disease. One hundred and sixty-one amputations were performed as primary operations--50 per cent being below knee and 50 per cent, above knee amputations. Eighty-one amputations followed failure of an arterial revascularization. Twenty-three amputations, 13 below knee and ten above knee, followed late closure of such bypass procedures. Early failure of the bypass in 58 patients resulted in 46 below knee and 12 above knee amputations. After failure of 45 bypasses to arteries distal to the popliteal, 14 of the patients required above knee amputation. Following 28 unsuccessful femoropopliteal bypasses, only two patients needed above knee amputation. Thus, the risk of jeopardizing the knee joint should not be considered a major contraindication to limb salvage procedures, especially if a femoropopliteal bypass is contemplated.

Amputation, Surgical↗
PubMed1982

The assessment of skin viability using fluorescein angiography prior to amputation.

Fluorescein angiography was used for the preoperative assessment of skin viability and the determination of the level of amputation in patients with peripheral vascular disease. In twenty-two patients requiring twenty-seven lower-extremity amputations (including five revisions), a retrospective comparison was made between the surgeon's choice of amputation level based on clinical criteria and that based on the fluorescein angiogram. As was evident by the failure of the amputation to heal, the surgeon's prediction was too distal in nine (33 per cent) of twenty-seven amputations and revisions. The assessor of fluorescein angiograms predicted five of these nine failures; therefore, the failure rate could have been reduced to four (15 per cent) of twenty-seven amputations. The amputation level predicted on the basis of the fluorescein angiogram was unnecessarily high in three lower limbs (11 per cent). These three amputations healed at the level chosen by the surgeon, but did so by prolonged secondary healing. Fluorescein angiography is a simple, safe, and useful preoperative bedside technique for the assessment of skin viability and the determination of amputation level in patients with peripheral vascular disease.

Aged↗
PubMed1995

Changes in hip muscles after above-knee amputation.

To learn about the changes appearing in hip muscles after an above-knee amputation, 3-dimensional reconstructions of the hip and thigh region of 12 patients with above-knee amputations were made based on transverse magnetic resonance images. In all patients, the amputations were done at least 2 years before the study and were necessitated by trauma or osteosarcoma. The results show that, at higher amputation levels, the geometry of the once-biarticular muscles was changed. The cleaved muscles (40%-60%) and the intact muscles (0-30%) at the amputated side were atrophied. The amount of atrophy of the intact muscles at the amputated side was related to stump length. To avoid an abduction contracture in 8 patients with amputations, the iliotibial tract was not fixed. In 4 of these 8 patients, a flexion contracture was visible. If the tract was not fixed, the hip extension torque of the gluteus maximus, which inserts into the tract, decreased. As a result, the risk of appearance of a flexion contracture increased because the strongest hip flexor (iliopsoas muscle) was not involved in the amputation. Abduction contracture could be avoided only if the hip adductors were fixed accurately, especially at higher amputation levels.

Adult↗
PubMed1994

Limb loss in association with vascular surgery--a five-year series of major lower-limb amputation.

OBJECTIVE: To evaluate the type, timing and number of vascular reconstructions that preceded amputation; to compare the characteristics of amputees who had had reconstructions with those of amputees who had not, and to compare the results of amputation. DESIGN: Retrospective study of case notes. SETTING: University hospital, Sweden. SUBJECTS: All 219 patients who underwent amputation between 1987 and 1992. MAIN OUTCOME MEASURES: Incidence of amputations; presenting features, and type and results of vascular reconstructions. RESULTS: The number of amputations decreased after 1988, and that of vascular reconstructions increased. 56 of the 99 who had amputations after reconstruction (57%) had had their last procedure within a month. This group had had a mean of three operations, had worse run-off as assessed by angiography, and 2 of them (5%) had amputations after failed suprainguinal reconstruction for claudication alone. 68 of the total (31%) had amputations without first being assessed by a vascular surgeon. 52 (24%) required reamputation. CONCLUSION: Better objective methods are needed for the assessment of patients before primary as well as secondary vascular reconstructions. All patients should be seen by a vascular surgeon before amputation is recommended.

Adult↗