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PubMed1994

Diabetic foot ulcers in a multidisciplinary setting. An economic analysis of primary healing and healing with amputation.

OBJECTIVES: To perform an economic analysis of primary healing and healing with amputation in diabetic patients with foot ulcers. DESIGN: A retrospective economic analysis based on a prospective study of consecutively presenting diabetic patients admitted to the Department of Internal Medicine because of foot ulcer. SETTING: A multidisciplinary foot-care team. SUBJECTS: A total of 314 consecutively presenting diabetic patients with foot ulcers. Forty patients died before healing occurred. In those patients who healed primarily (n = 197) or after amputation (n = 77), a retrospective economic analysis was performed. INTERVENTIONS: All patients were treated by a multidisciplinary foot care team consisting of diabetologist, orthopaedic surgeon, diabetes nurse, podiatrist and orthotist both as in- and out-patients. The patients were followed by the team from admittance until final outcome, i.e. primary healing or healing with amputation or death. MAIN OUTCOME MEASURES: Data from both the prospectively collected patient material and from patient records were used to estimate the cost for hospital care, antibiotics, surgery, out-patient care, staff attendance, drugs and material for ulcer dressings, and orthopaedic appliances. RESULTS: The total costs were SEK 51,000 (3000-808,000) for patients with primary healing and SEK 344,000 (27,000-992,000) for healing with amputation. Costs for in-patient care were 37% of total average costs for primary healing and 82% for patients with amputation. The costs for topical treatment of the ulcers in out-patient care were 45% of the total average cost for primary healed and 13% for patients who healed with amputation. The costs for products used for ulcer dressings were 21% of total costs for topical treatment, i.e. 9% and 3% of total average costs for primary healing and healing with amputation, respectively. Costs for visits to the foot care team, antibiotics and orthopaedic appliances were low in relation to total costs. CONCLUSION: Treatment of diabetic patients with foot ulcers in a multidisciplinary system was associated with relatively low costs. Healing with amputation was associated with high costs mainly due to multiple and extended hospitalization. These findings indicate the potential cost savings of preventive and multidisciplinary foot care.

Aged↗
PubMed2006

Concepts of transtibial amputation: Burgess technique versus modified Brückner procedure.

The technique of a long posterior myocutaneous flap described by Ernest M. Burgess in the late 1960s is one of the most frequent procedures for below-knee amputations worldwide. To account for some potential problems associated with this procedure in patients with occlusive arterial disease, Lutz Brückner developed a modified amputation technique for transtibial amputation in the 1980s. Although this new standardized procedure has been widely used in Germany, it is not well known outside central Europe, secondary to its lack of description in English published work. In this review article, we describe a comparison of the technical aspects of the Burgess procedure with the modified Brückner technique for transtibial amputations. In addition, the charts of 69 consecutive patients with end-stage occlusive arterial disease undergoing below-knee amputation by either of the two standardized procedures (Burgess, n = 29; Brückner, n = 40) were reviewed. The clinical results of the two procedures are reported and compared. Review of the German published work suggests that the two techniques for transtibial amputation in patients with occlusive arterial disease appear to have similar results. This is further supported by data from our own 10-year experience with 69 patients undergoing below-knee amputation by either of the two standardized procedures. This suggests that the Brückner technique is at least equivalent to the Burgess procedure with regard to the clinical outcome in patients with occlusive arterial disease. The potential advantages of the standardized modified Brückner procedure compared with the 'classical' Burgess technique for transtibial amputation remain to be assessed in prospective multicentre trials.

Amputation, Surgical↗
PubMed1995

The costs of diabetes-related lower extremity amputations in the Netherlands.

Diabetes mellitus is a common problem in the Netherlands and in the rest of the world. A complication seen in association with diabetes is peripheral neuropathy which can lead to lower extremity amputation. The purpose of this study is to identify the duration of hospital stay and the direct costs associated with diabetes-related lower extremity amputations in the Netherlands in 1992. Total direct costs included costs associated with hospital stay and the average procedure specific costs (surgeons' fees, anaesthetists' fees, and operating room fees) for the specific level of amputation. In the Netherlands in 1992, 1575 hospitalizations for 1810 diabetes-related lower extremity amputations occurred. The total number of days in the hospital for the diabetic population was 65,778 days with a mean of 41.8 days per hospitalization. Mean costs associated with diabetes-related hospitalizations for amputation were pounds 10,531 (Dfl. 28,433) per hospitalization. Persons who underwent multiple amputations during their hospitalization stayed in the hospital longer and the costs associated with these hospitalizations were higher when compared to hospitalization with a single amputation. An increase in length of stay and costs with increasing age and higher level of amputation was identified.

Amputation, Surgical↗
PubMed1991

Perturbation of the motor system in freely walking cockroaches. I. Rear leg amputation and the timing of motor activity in leg muscles.

1. The effects of amputation of a rear leg on the pattern of motor activity in the legs of freely walking cockroaches (Periplaneta americana L.) were studied. 2. Amputation affected both the frequency and the timing (phase) of motor bursts during a stepping cycle. Bursts in the stump of an amputated rear leg and in the contralateral (intact) rear leg often occurred at two or three times the frequency of bursts in the other legs. The remaining legs also showed multiple bursting during some steps. 3. Amputation affected the phase of motor bursts in two different ways. First, for every leg pair, phase was more variable after amputation, whether or not the mean phase was affected. Second, for some leg pairs, the mean phase itself was altered. During most steps, the timing of motor bursts in the stump of the amputated leg was walking-speed-dependent relative to bursts in the anterior legs. In contrast, the timing of bursts in the stump relative to bursts in the legs across the body from it showed no such speed-dependent timing. Timing between bursts in pairs of intact legs also showed either speed-dependent or speed-independent effects, depending on the pair under consideration. 4. The effects of amputation were not consistent. After loss of a leg, bursts in some leg pairs occurred synchronously in some insects and alternately in others. Even in single insects there were cases in which the timing between bursts in two legs switched from one value to another during walking. 5. These effects of amputation were manifest during slow walking only. At higher speeds, the timing of motor bursts in different pairs of legs was consistently closer to that seen during walking in intact insects. 6. Three conclusions are drawn from these results. (i) During slow walking, sensory feedback from the legs helps maintain the timing of adjacent ipsilateral leg pairs, but has little influence on contralateral pairs. (ii) During slow walking, either sensory input is quite variable, or it has variable effects on the motor pattern. (iii) During fast walking, sensory input from the legs seems to play a minimal role, if any, in the timing of the motor pattern of walking.

Amputation, Surgical↗
PubMed2006

Prevalence of lower-extremity amputation among patients with diabetes mellitus: is height a factor?

BACKGROUND: Taller diabetic patients are at higher risk of peripheral sensory loss than shorter diabetic patients and thus may be at increased risk of lower-extremity ulcers and amputation. In a large telephone survey, the prevalence of lower-extremity amputation among patients with diabetes mellitus was determined and the association between height and lower-extremity amputation evaluated. METHODS: Of 256,036 patients identified from hospital and clinic databases who had a diagnosis of diabetes and were seen at those institutions between 1995 and 1998, 128,572 were randomly selected to be interviewed by telephone between 1995 and 2002. Of the 93,484 patients who agreed to be interviewed, 386 were excluded (age < 18 years); this left 93,116 diabetec patients (42,970 men and 50,146 women) for inclusion in the study. RESULTS: Of the 93,116 patients interviewed, 3259 (3.5%) had type 1 diabetes. Lower-extremity amputation was performed in 1.7% and 0.8% of the patients with type 1 and type 2 diabetes, respectively. The prevalence of amputation did not differ significantly between men and women with type 1 diabetes but was significantly higher among men than among women with type 2 diabetes (0.9% v. 0.7%). Height (every 10-cm increment) was significantly associated with lower-extremity amputation (adjusted odds ratio [OR] 1.16, 95% confidence interval [CI] 1.03-1.32). In a subgroup of 9295 patients for whom data on fasting plasma glucose levels and dyslipidemia were available, and after additional adjustment for these 2 variables, body height remained an independent predictor of lower-extremity amputation (adjusted OR for every 10 cm of height 1.79, 95% CI 1.14-2.82). INTERPRETATION: Height is an independent predictor of lower-extremity amputation among patients with type 1 and type 2 diabetes mellitus.

Aged↗
PubMed1984

[Evaluation of amputation techniques for the study of limb regeneration in the newt and toad].

A comparison between forelimb amputations through the radius-ulna and the humerus was made in the adult newt, Cynops pyrrhogaster pyrrhogaster and the young toad, Xenopus laevis. Newts regenerated their forelimbs after the amputations and the new parts resembled the old in structure and function. Toads regenerated their forelimbs incompletely after the amputations. The new parts lacked joints and fingers showing a simply elongate pattern. The effect of re-amputation of exposed bone on the regeneration was evaluated in the adult newt. A left forelimb was amputated through the humerus and the exposed bone which protruded from the cut surface due to the relationships of the soft tissues, was then re-amputated a few minutes later. A right forelimb of the same individual was simply amputated without re-amputation of the exposed bone. Newts regenerated both forelimbs simultaneously. The new parts resembled the old in structure and function.

Amputation, Surgical↗
PubMed2006

Risk factors for primary major amputation in diabetic patients.

CONTEXT AND OBJECTIVE: Diabetic patients present high risk of having to undergo minor or major amputation during their lifetimes, because of ischemia or infection. The aim of this study was to identify and quantify risk factors for major amputation in diabetic patients with foot infections. DESIGN AND SETTING: Retrospective clinical-surgical trial at the Vascular Surgery Service of Santa Casa de São Paulo. METHODS: Ninety-nine patients with diabetic foot infections who underwent 129 hospitalizations in the Vascular Surgery Unit were analyzed in accordance with a pre-established protocol to compare two groups of diabetic patients: one that underwent major amputations and the other that underwent minor amputations or debridements. The patients were predominantly male, in their sixth decade of life, and had type 2 diabetes mellitus. Chronic arterial insufficiency, age, diabetes mellitus duration, ascending lymphangitis, calcaneal lesions, Wagner's classification, laboratory tests and different microorganisms in deep tissue cultures were the risk factors evaluated in all patients. RESULTS: The statistically significant risk factors for major amputation included age, ascending lymphangitis (odds ratio, OR: 2.5), calcaneal lesions (OR: 10.5), Wagner grade 5 lesions (OR: 3.4), chronic arterial insufficiency without possibility of revascularization (OR: 5.4) and diabetes duration. Presence of Gram-positive microorganisms was associated with the need of major amputation. The serum urea, creatinine, glucose and white blood cell levels were not significant risk factors for major amputation. CONCLUSIONS: The risk factors for major amputation were: age, ascending lymphangitis, calcaneal lesions, Wagner grade 5 lesions, arterial insufficiency, diabetes duration and Gram-positive microorganisms in cultures.

Adult↗
PubMed1988

Lower-extremity amputations in NIDDM. 12-yr follow-up study in Pima Indians.

The incidence of lower-extremity amputations was estimated in the Pima Indians of the Gila River Indian Community in Arizona, a population with a high prevalence of non-insulin-dependent diabetes mellitus (NIDDM). Between 1972 and 1984, from a study population of 4399 subjects, lower-extremity amputations were performed on 84 patients, 80 (95%) of whom had NIDDM. Among diabetic subjects, the incidence rate of first lower-extremity amputations was higher in men than in women. Rates increased significantly with increasing duration of diabetes. Presence of medial arterial calcification, retinopathy, or nephropathy; absence of patellar tendon reflexes; impaired great toe vibration-perception threshold; and degree of fasting and 2-h postload hyperglycemia were significant risk factors for amputations. Serum cholesterol concentration, blood pressure, age, and absence of Achilles tendon reflexes were not predictive of amputations. The death rate was greater in diabetic amputees than in diabetic nonamputees of similar age, sex, and duration of diabetes, and a significant increase in cardiovascular deaths was observed in diabetic subjects with amputations. The incidence rate of lower-extremity amputations in diabetic Pima Indians is higher than that reported in other diabetic populations. This may reflect differences in risk or a more complete case ascertainment than was possible in previous studies. If the latter is true, the rate of amputations in diabetic individuals may be higher than has been previously appreciated.

Adolescent↗
PubMed1996

Diabetes and nontraumatic lower extremity amputations. Incidence, risk factors, and prevention--a 12-year follow-up study in Nauru.

OBJECTIVE: To measure the 12-year incidence (1982-1994) of nontraumatic lower extremity amputations (LEAs) in Nauruans, a population at high risk for NIDDM, and to determine the risk factors for amputation in Nauruans with diabetes. RESEARCH DESIGN AND METHODS: Amputation data were abstracted from operating theater records in Nauru, hospital databases in Australia, and Nauru government records. Baseline characteristics of a cohort of 1,564 Nauruans aged > or = 20 years examined during a population-based survey in 1982 were used to determine risk factors for first LEAs. RESULTS: Over this 12-year period, 46 first LEAs were performed on people with NIDDM, of whom 30 were members of the 1982 study cohort. The incidence of first LEAs in Nauruans aged > or = 25 years with NIDDM was 8.1 per 1,000 person-years in the study cohort and an estimated 7.6 per 1,000 person-years nationally. Amputations were associated significantly with lower BMI, lower blood pressure, higher fasting plasma glucose (FPG) level, and longer mean duration of diabetes at baseline, but levels of other risk factors, including cigarette smoking, plasma triglycerides, and plasma cholesterol, were also elevated in amputees. There were no amputations among individuals with baseline FPG levels < 7.8 mmol/l, irrespective of diabetes duration. FPG, baseline diabetes duration, and male sex were independent risk factors for first amputation using the Cox proportional hazards model. There was a decrease in the incidence of amputations after the commencement of a national foot care health education and prevention campaign in June 1992. CONCLUSIONS: The incidence of LEAs in diabetic Nauruans was higher than in other populations after adjusting for age and duration. Given the apparent success of the Nauruan footcare program in reducing amputation rates, other populations with high rates of NIDDM and LEAs should consider population-wide prevention strategies.

Adult↗
PubMed2004

Explanations for the high risk of diabetes-related amputation in a Caribbean population of black african descent and potential for prevention.

OBJECTIVE: Diabetes-related lower-extremity amputation (LEA) rates are elevated in blacks compared with whites in the U.S., but are lower in African Caribbeans in the U.K., whereas anecdotal reports suggest high rates in the Caribbean. We aimed to establish the incidence and risk factors for diabetes-related LEA in a Caribbean population. RESEARCH DESIGN AND METHODS: We conducted an incident and prospective case-control study of case patients (individuals with diabetes having a LEA) and community-based control subjects (individuals with diabetes without a LEA) in Barbados, West Indies. Participants completed an interview and examination of risk factors for amputation, including footwear use. RESULTS: The overall 1-year incidence of LEA (n = 223) was 173 per 10(5) population and 936 per 10(5) population with diabetes (557 per 10(5) for minor amputation and 379 per 10(5) for major amputation). Women had higher amputation rates than those reported in the Global Lower Extremity Amputation Study, apart from the U.S. Navajo population. Independent risk factors for all diabetes-related LEAs were poor footwear (odds ratio [OR] 2.71 [95% CI 1.23-5.97]), elevated GHb (1.40 per percent increase [1.26-1.57]), peripheral neuropathy (1.05 per volt increase [1.03-1.08]), and peripheral vascular disease. CONCLUSIONS: Diabetes LEA rates in Barbados are among the highest in the world. Inadequate footwear independently tripled amputation risk. Education of professionals and patients, particularly about footwear and foot care, coupled with improved diabetes clinical care, is key to reducing amputation risk in this population.

Aged↗
PubMed1994

Local signs and symptoms in relation to final amputation level in diabetic patients. A prospective study of 187 patients with foot ulcers.

Local signs and symptoms were evaluated in 187 consecutively presenting diabetic patients undergoing amputation for foot ulcers. From admission until final outcome the patients were treated by the same multidisciplinary team both as in- and out-patients. At the time of amputation, the types of lesions were superficial/deep ulcer (n 17), ulcer with deep infection, but without gangrene (n 40), and gangrene with or without infection (n 130). Healing after a minor amputation (below the ankle) occurred in 74 patients, while 88 patients healed after a major amputation (above the ankle), and 25 patients died before healing had occurred. Deep infection and presence of popliteal or pedal pulses were associated with healing after minor amputation and so were ulcers on the small toes, metatarsal head area and midfoot. Pain, progressive gangrene, intermittent claudication, and decubital and multiple ulcers were related to healing after major amputation. In a logistic regression analysis, pain, progressive gangrene and intermittent claudication remained. However, none of these factors excluded healing of a minor amputation and thus selection of amputation level in diabetic patients with foot ulcers cannot be based upon these factors exclusively.

Adult↗
PubMed1999

[Amputation due to chronic peripheral vascular disease. Risks and prognosis].

A series of 181 amputations in 156 patients treated between 1985 and 1996 because of chronic peripheral vascular disease was reviewed. 107 major amputations (above- and below-knee) and 74 minor amputations (foot and forefoot) were performed. 81% of the patient population had previous vascular operations. Complications, revisions and mortality of all patients were retrospectively analyzed. The operative mortality rate of major amputations was 20% and the operative mortality rate of minor amputations was 9%. By a vessel-reconstruction before amputation the complication- (wound healing) and revision-rate could be reduced. By examination of the family-doctors, the survival times of the patients and the rehabilitation status of 69 living patients were recorded. Minor amputations, below-knee amputations and knee-disarticulations had the best results of rehabilitation.

Adult↗
PubMed2000

Do foot examinations reduce the risk of diabetic amputation?

BACKGROUND: Foot examinations are widely recommended as a means to reduce amputation risk, but no investigators have studied their independent effect on this outcome. METHODS: We conducted a population-based case-control study of primary care provided to Pima Indians from the Gila River Indian Community. Sixty-one Pima Indians with type 2 diabetes and a first lower-extremity amputation between January 1, 1985, and December 31, 1992, were compared with 183 people who had no amputation by December 31, 1992. The type of foot examination conducted, comorbid conditions, and foot risk factors present in the 36 months before the pivotal event were abstracted from medical records. All ulcer care was excluded. The independent effect of foot examinations on the risk of amputation was assessed by logistic regression. RESULTS: During the 36 study months, 1857 foot examinations were performed on 244 subjects. The median number of preventive foot examinations was 7 for case patients and 3 for control patients. After controlling for differences in comorbid conditions and foot risk conditions, the risk of amputation for persons with 1 or more foot examinations was an odds ratio (OR) of 0.55 (95% confidence interval [CI], 0.2-1.7; P=.31). The risk of amputation associated with written comments of nonadherence with therapeutic foot care recommendations or diabetic medication was an OR of 1.9 (95% CI, 0.9-4.3; P=.10). CONCLUSIONS: Our study failed to demonstrate that foot examinations decrease the risk of amputation in Pima Indians with type 2 diabetes. However, foot examinations detect high-risk conditions for which specific interventions have been shown to be effective in reducing amputation risk.

Adult↗
PubMed2002

Major lower-extremity amputation: contemporary experience in a single Veterans Affairs institution.

Our objective is to describe our current experience with major lower-extremity amputation secondary to vascular disease. We conducted a retrospective review of sequential amputations over a 3-year period at one Veterans Affairs institution. One hundred thirteen amputations were performed in 99 men (age 70 +/- 11 years). Seventy-five per cent were diabetic and 23 per cent were on dialysis. Fifty-six per cent were primary amputations. The final AKA/BKA (above-knee to below-knee amputation) ratio was 3:2 and was not related to prior bypass, ethnicity, or dialysis status (P > 0.5). Forty-three per cent of amputations were BKAs in diabetics versus 26 per cent in nondiabetics (P = 0.08). The in-hospital and 30-day mortality rates were 2.6 and 8 per cent and were not related to amputation level (P = 0.76). Forty per cent experienced postoperative complications that were most frequently wound related (22%). Wound complications were more frequent with BKA than AKA (P = 0.04). At an average follow-up of 10 +/- 8 months only 65 per cent were alive. Although 51 per cent were discharged to rehabilitation units only 26 per cent regularly wore a prosthesis with 23 per cent ambulating. BKA patients were more likely to ambulate than AKA (34% vs 9%; P = 0.001), and dialysis patients were less likely to ambulate than nondialysis patients (5% vs 25%; P < 0.02). During follow-up 17 per cent of patients discharged with an intact contralateral limb required amputation of that limb and 7 per cent had bypass surgery on that limb. Complication rates were higher in African Americans and Hispanics than in whites (59%, 45%, and 23%, respectively; P < 0.001), although mortality and ambulation rates were similar. Despite an acceptable perioperative mortality complication rates remain high especially in nonwhites. One-year mortality is high. Low rehabilitation rates especially in dialysis patients mandate further efforts in this regard. Vigilant follow-up of the contralateral limb is essential.

Aged↗
PubMedDate not supplied

Indications for amputations in Ile-Ife, Nigeria.

This is a retrospective study of limb amputations in Ile-Ife, Nigeria during a thirteen-year period (1987-1999). 82 patients were studied with a mean age of 35 +/- 22 years. 63 of the patients were adults, while 19 patients were children aged 15 years and below. Trauma was indicated as a reason for amputation in 60 patients (73.4%). Road traffic accident with peripheral vascular compromise was the single most common reason for amputation (41.7%). Forty-seven of the 82 patients had lower limb amputations, while the others were in the upper limbs. There was delay in performing amputation in some patients due to refusal to accept the procedure in 10(12.1%), logistics in 5(6.1%) and lack of finance in 3 (3.7%). The average healing time of the amputation stump wounds was 47 +/- 36 days. In 68.3% of cases, there was wound infection and the wound healing time was 63 +/- 45 days, much longer than than the general average. Other complications were flap necrosis, gas gangrene, osteomyelitis of the bony stump, and tetanus. Six patients died from sepsis and one from chronic renal failure, a hospital mortality rate of 8.5%. Prosthesis could not be fitted in any of the patients during the hospital admission and only three of the diabetic patients attended follow up clinic for up to two years; others absconded within 3 months of discharge from hospital. It will be possible to reduce the rate of amputation and improve the quality of life of patients with amputation if more attention is placed on accident prevention and injury control.

Adolescent↗
PubMed1992

The changing role of amputation for soft tissue sarcoma of the extremity in adults.

The role of amputation in soft tissue sarcoma of the extremity has decreased at Memorial Sloan-Kettering Cancer Center during the last 20 years. In an attempt to determine the reasons for this change in therapy, an analysis of two separate databases involving 1,057 patients compiled during the periods of 1968 to 1978 and 1982 to 1990 was performed. The patients requiring amputation for soft tissue sarcoma of the extremity in the two databases (n = 233) were compared in an attempt to determine any significant differences between the two time periods. The groups were specifically compared for differences in risk factors, indications for amputations and the effect a decreasing incidence of amputation in the 1982 to 1990 group had on local recurrence and overall survival between the two groups. Despite similarity of risk factors and indications for amputation, the decreased incidence of amputation during the 1982 to 1990 period was associated with a significant decrease in local recurrence after amputation and no significant change in overall survival compared with the 1968 to 1978 group. Absence of local recurrence was associated with significant improvement in survival. Possible reasons for the shift in therapy, as well as the present and future role of amputation in soft tissue sarcoma of the extremity, are discussed.

Adolescent↗
PubMed2003

Self-concept and body image in persons who are spinal cord injured with and without lower limb amputation.

Spinal cord injury (SCI) requires considerable psychological adjustment to physical limitations and complications. One particularly severe complication of SCI is foot skin breakdown, which can result in lower limb amputation. Relative to SCI adjustment, amputation may produce one of two psychological outcomes: (a.) the fragile self-concept of a person with SCI may be reduced further by limb amputation, or (b.) amputation of a diseased, nonfunctional limb may be associated with restored health and improved self-concept. To better understand the effects of amputation, 26 males with SCI, 11 of whom had a lower limb amputation, were administered the Tennessee Self-Concept Scale (TCS) and the Personal Body Attractiveness Scale (PBAS). The study revealed that persons with SCI with amputation had higher Physical and Total self-concept scores on the TSCS, showing a slightly more positive self-concept. On the PBAS, although there were no significant differences in the scores for the legs, ankles, or feet, the persons with SCI with amputation had higher score on the Satisfaction subscale, indicating a slightly greater satisfaction with their thigh in their body image. Implications for future study include replication with larger sample sizes, inclusion of women in the sample, and a longitudinal study. Several nursing interventions are identified.

Activities of Daily Living↗
PubMedDate not supplied

Experience with physiologic amputation using the CryoCare Extremity Stabilization System (CESS).

Five years of experience gained with the CryoCare Extremity Stabilization System (CESS) were evaluated in this study. Twenty-one patients underwent freezing amputation. Five patients died before undergoing surgical amputation. Symptomatic relief, control of odor, decreased demand on nursing staff, and appreciation of the family make this approach valuable even when long-term survival is not anticipated. Ten patients who underwent freezing amputation subsequently underwent surgical amputation and were discharged. Six patients underwent freezing and surgical amputation but died prior to discharge. The patients selected for the freezer application were deemed to be prohibitive operative risks because they were experiencing systemic toxicity from their ischemic limb and underlying diseases. Six patients demonstrated myoglobinuria prior to freezing which cleared with CESS. The physiologic amputation allowed stabilization of medical problems including cardiac arrhythmias, congestive heart failure, sepsis, renal failure, diabetes, and respiratory failure. Freezing of an ischemic extremity allows delay in amputation enabling physicians to achieve maximal medical stabilization. It permits symptomatic relief in patients whose long-term survival is not anticipated. Physiologic freezing amputation should be included in the repertoire of all surgeons.

Adult↗