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PubMed1990

Combined orthopedic and vascular injury in the lower extremities: indications for amputation.

A retrospective review was undertaken to determine risk factors associated with amputation after open fractures of the lower extremity that were complicated by vascular injury. During an 11-year period ending in December 1987, we observed open fractures in 31 patients and injuries to the popliteal artery in 16 patients, to the tibial arteries in eight patients, to the femoral artery in five patients, and to the dorsal artery of the foot in two patients. Vascular repair was accomplished in 25 patients; 12 patients had primary end-to-end anastomosis, 12 patients had reverse saphenous vein grafts, and one patient had a bovine graft. Of these 25 patients, five patients required amputation because of infection and three patients required amputation because of continued ischemia. Three patients with irreparable damage had immediate amputation, and three patients without distal ischemia had vessel ligation only. The risk factors associated with amputation were shock on admission (10 of 19 patients [p less than 0.02]) and a crushed extremity (10 of 18 patients [p less than 0.01]). The overall amputation rate, which included three immediate amputations and eight late amputations, was 35.2%. The data suggest that limb salvage is possible in two thirds of patients with combined orthopedic and vascular injuries of the lower extremity, but a history of shock or crush injury with vascular compromise is an unfavorable prognostic sign.

Accidents, Traffic↗
PubMedDate not supplied

Selection of amputation level and prediction of healing using transcutaneous tissue oxygen tension (PtcO2).

Pre-operative measurement of transcutaneous tissue oxygen tension (PtcO2) by reflecting oxygen delivery at proposed amputation sites may allow accurate prediction of post-operative healing. Thirty-eight patients requiring amputation had PtcO2 measured with a Clark electrode on the foot, anteriorly and posteriorly below knee and above the knee while lying supine. PtcO2 greater than 24 mmHg was chosen to predict healing and indicated 13 above-knee (AK) and 25 below-knee (BK) amputations. Clinical criteria indicated 12 AK and 26 BK amputations. PtcO2 and clinical judgement differed on five occasions, a lower amputation was indicated by PtcO2 twice and by clinical selection three times (PtcO2 16 mmHg). Amputation was performed at the more distal level indicated (25 BK, 13 AK). Foot PtcO2 in both groups did not differ significantly, 4.08 +/- 2.00 mmHg (BK) and 3.9 +/- 1.29 mmHg (AK) (p greater than 0.5), nor did above knee PtcO2 (p greater than 0.3). Anterior below knee PtcO2 in both groups differed significantly, 34.92 +/- 10.84 mmHg (BK) and 9.5 +/- 5.60 mmHg (AK) (p less than 0.001). Likewise, posterior PtcO2, 39.64 +/- 6.85 mmHg (BK) and 14.1 +/- 4.43 mmHg (AK) (p less than 0.001). Amputation sites healed primarily within two weeks except the site with a pre-operative PtcO2 of 16 mmHg, where healing was delayed and occurred by second intention. These results indicate that PtcO2 is a valid predictor of primary healing following amputation.

Adult↗
PubMed1988

The role of non-invasive vascular studies in determining levels of amputation.

Various non-invasive vascular studies have been reported to provide valuable data for selection of the optimum level of amputation in limbs in patients who have vascular disease. We evaluated three such methods: (1) measurement of the change in the transcutaneous PO2 after inhalation of oxygen; (2) determination, by the Doppler method, of segmental blood pressure; and (3) measurement of the temperature of the skin. The records of eighty patients (ninety amputations) were retrospectively reviewed for correlations between the results of the vascular studies and the outcome of the amputation. Measurement of transcutaneous PO2 was found to be the most accurate predictor of successful healing of an amputation; the other two measurements were less reliable. The values for transcutaneous PO2 both at rest and after inhalation of oxygen were significantly different (p less than 0.001) for the patients who had a healed amputation compared with those who had a failed amputation. Regardless of the initial value, if, after inhalation of oxygen, the transcutaneous PO2 reached ten millimeters of mercury or more, it predicted healing of the amputation stump with a sensitivity of 98 per cent. When the level of amputation was selected on the basis of clinical judgment at the time of operation, the sensitivity was only 90 per cent.

Adult↗
PubMed1988

One-stage versus two-stage amputation for wet gangrene of the lower extremity: a randomized study.

Although the two-stage amputation technique entails an additional operation, several authors have advocated this approach to deal with wet gangrene because it allows primary wound closure with a reduced chance of wound infection. To examine this issue, 47 patients with necrotizing wet gangrene of the foot were randomized prospectively to receive either a one-stage amputation (definitive below- or above-knee amputation with delayed secondary skin closure in 3 to 5 days) or a two-stage amputation (open ankle guillotine amputation followed by definitive, closed below- or above-knee amputation). Antibiotic coverage was standardized with clindamycin and gentamicin used in all patients. Preoperative blood cultures and intraoperative foot cultures were obtained, as well as cultures from the deep muscle and lymphatic area along the saphenous vein to determine the presence of bacteria at the level of initial amputation. Twenty-four patients (11 diabetic and 13 nondiabetic) were randomized to the one-stage procedure. Twenty-three patients (14 diabetic and nine nondiabetic) were randomized to the two-stage procedure. Five of 24 patients in the one-stage group (21%) had positive muscle cultures vs 10 of 23 patients in the two-stage group (43%). Two of 24 patients in the one-stage group (8%) had positive lymphatic cultures vs 7 of 23 patients in the two-stage group (30%). Five of 24 patients in the one-stage group (21%) had wound complications attributable to the amputation technique vs none of 23 patients in the two-stage group (p = 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1987

Amputation in the diabetic: ten years experience in a district general hospital.

Over a period of 10 years, 149 amputations were performed for lower limb ischaemia in 119 diabetic patients. Thirty patients required amputation of the second limb. Ninety per cent of the patients were over the age of 60 years. Sixty four ischaemic limbs were treated by primary local amputation or debridement--29 healed successfully, 30 proceeded to a higher amputation. The incidence of multiple local operations was high. A below knee amputation was performed in 56 limbs--7 failed to heal and required a more proximal amputation. Seventy five patients in the series have died; 58 of these survived less than 3 years from their first amputation. The hospital stay for all patients was long; for an unsuccessful local amputation the average stay was 109 days. Conservative management with the Scotchcast boot has been shown to be satisfactory. This must be compared with the significant costs to the patient of early operative intervention.

Adult↗
PubMed1986

Lower extremity amputation: the control series.

Although various techniques to determine amputation level have become available, obvious clinical factors may yet identify patients in whom a major amputation is unlikely to heal. We have analyzed the association of multiple clinical factors with the morbidity of 1028 consecutive amputations performed in 786 patients during a 13-year period. The overall operative mortality rate was 7% (57 of 786 patients). Cardiac complications were the leading cause of death (43%). In the 729 patients surviving operation, 345 above-knee amputations (AKAs) and 626 below-knee amputations (BKAs) were performed. After operation, 15.4% of these amputations failed to heal and required proximal revision. The AKA failure rate was 9% and the BKA failure rate was 19%. Significantly higher failure rates were noted in whites, nondiabetics, and those patients with heart disease. It is concluded that major amputation continues to be associated with significant morbidity and mortality rates despite changes in perioperative care and surgical technique. Common clinical characteristics indicate high-risk patients in whom a BKA is unlikely to heal and who may benefit from prospective attempts to determine amputation level.

Amputation, Surgical↗
PubMed1985

The clinical value of preoperative indirect systolic ankle pressure measurements in wound healing after amputation of the lower extremity.

With the intention towards more distal amputation of the lower extremity for peripheral vascular disease, failure of amputation wound healing remains a common clinical problem. Because calf blood flow correlates well with the indirect systolic ankle pressure, this pressure could be a prognostic guide to the outcome of amputation wound healing. To evaluate the clinical role of systolic ankle pressure measurements for selecting the most appropriate level of amputation, data of 93 patients undergoing 100 amputations were studied retrospectively. Of the 54 initial below knee (BK) amputations 83% healed and 17% failed to heal. Of the 46 initial above knee (AK) amputations 88% healed and 12% needed stump correction. Although all extremities with a systolic ankle pressure of more than 70 mm Hg healed in BK amputations there was no clinical predictive value of indirect systolic ankle pressure measurements. There was no difference in wound healing between diabetic and non-diabetic patients.

Aged↗
PubMed1981

Toe blood pressure by photoplethysmography: an index of healing in forefoot amputation.

The relative merits of toe systolic blood pressure and ankle systolic pressure in predicting the result of forefoot amputation were evaluated in 30 limbs of 27 patients who underwent digit or transmetatarsal amputation. Twenty-four (89%) patients were diabetic. An infrared photoplethysmograph placed distal to a pneumatic digit occluding cuff allowed rapid, simple preoperative assessment of toe systolic pressures. Ankle pressures was measured by Doppler ultrasound. Twenty (67%) amputations healed primarily, whereas 10 ultimately required reamputation at the below-knee level. The mean ankle pressure of limbs with healing of forefoot amputation, 136 +/- 39 mm Hg (+/- SD), did not differ significantly from those that failed to heal, 121 +/- 72 mm Hg (P greater than 0.4). Failure of an amputation to heal occurred in association with ankle pressures ranging from 60 to over 300 mm Hg. The mean value of toe pressures associated with healing of forefoot amputation, 86 +/- 39 mm Hg, was significantly higher than those not healing, 25 +/- 18 mm Hg (P less than 0.001). Failure of a forefoot amputation to heal occurred in all eight limbs with toe pressures less than 45 mm Hg, and in two of eight (25%) limbs with toe pressure between 45 and 55 mm Hg. Primary healing occurred in all 14 limbs with toe pressures greater than 55 mm Hg. These data suggest that toe pressure measurement may be a useful hemodynamic correlate of the healing potential of a forefoot amputation.

Amputation, Surgical↗
PubMed1980

Extremity amputation: disseminated intravascular coagulation syndrome.

There are occasional reports in medical literature of peripheral gangrene and subsequent extremity amputation following systemic infection. Although the authors of these case reports speculated that the gangrene was due to septic embolization, pathologic study of the amputated tissue failed to reveal evidence of septic emboli. In reviewing reports of amputation following scarlet fever, varicella, pneumococcemia, and appendicitis, we found cases with clinical, hematologic, and pathologic evidence of disseminated intravascular coagulation (DIC). We describe 2 patients who required extremity amputation following an acute, systemic infection: transmetatarsal and Lisfranc amputation following meningococcal meningitis and bilateral below-knee amputation following pneumococcal meningitis. Both of these patients had clinical, hematologic, and pathologic evidence of DIC. Following amputation, both of these patients had significant problems with skin healing and prosthetic fitting. The presence of an acute systemic bacterial or viral infection, coagulation abnormalities and pathologic tissue indicative of DIC, and skin lesions of the extremities progressing to dry gangrene and ultimately requiring bilateral amputation are the key clinical features of this syndrome. We conclude that DIC is a major pathophysiologic mechanism responsible for peripheral gangrene following systemic infection.

Adult↗
PubMed1980

Amputation level following unsuccessful distal limb salvage operations.

Distal arterial grafting for limb salvage remains controversial. Among the criticisms is the potential adverse effect of failed distal bypass on subsequent amputation level. Measurement of popliteal pressure with Doppler ultrasound is useful in predicting healing at the below-knee (BK) level and, pressure of greater than or equal to 60 mm Hg was associated with 87% BK healing in 51 limbs undergoing amputation without prior distal bypass. This study examined the outcome in 40 limbs amputated after unsuccessful distal revascularization and compared the final amputation level with that predicted by popliteal pressure measurements obtained prior to bypass. Forty limbs underwent amputation after unsuccessful limb salvage following attempted femoropopliteal grafts (13), femorotibial grafts (10), a combination of both procedures (10) or tibial artery exploration alone (7). Of 33 limbs with initial pressure of greater than or equal to 60 mm Hg, eventual healing at the BK level was achieved in only 17 (52%). Four of seven limbs with initial pressures of less than 60 mm Hg healed at the BK level, and increased popliteal pressure prior to amputation was shown in three of these. Of the total 40 limbs, only 21 (53%) obtained final healing at the BK level. These results indicate that unsuccessful limb salvage attempts adversely affected ultimate amputation level in limbs initially considered to be candidates for BK amputation.

Adult↗
PubMed1994

Trauma-related major lower limb amputations: an epidemiologic study.

The annual number of major lower limb amputations in Denmark as a consequence of trauma was constant during the period 1978 through 1990, with about 70 (1.4 per 100,000 population) per year. The mean age of the amputation population was 49.4 years (males, 44.8 years; females, 58.8 years). Analysis of the age distribution shows characteristic differences between male and female patients. The average hospital stay was 49 days, and 56% of patients were discharged to their homes. The most prevalent amputation levels were transtibial and above-knee, which accounted for about 80% of all amputations. The only systematic change during the period under study was the increase in the number of through-knee amputations. The in-hospital mortality was related to sex, level of amputation, and age. The relative number of amputations varied in the different counties of Denmark and a positive correlation between population density and rate of amputation was found.

Adolescent↗
PubMed1994

Long-term cost comparison of major limb salvage using the Ilizarov method versus amputation.

Hospital costs and professional fees of Ilizarov limb reconstruction patients were compared with hospital costs, professional fees, and prosthetic costs of lower-extremity amputation patients. Ten patients with tibial nonunions, osteomyelitis, infected nonunions, and/or bone defects underwent Ilizarov limb reconstruction while six patients with similar traumatic injuries underwent amputation (three acute and three delayed). The average age was 41 years for the Ilizarov group and 40 years for the amputation group. Both the Ilizarov and the amputation groups required an average of four surgical procedures. The average hospital length of stay was 16 days for the Ilizarov group and 25 days for the amputation group. The total average treatment time was 322 days for the Ilizarov group and 175 days for the amputation group. The total cost of the Ilizarov limb reconstruction averaged $59,213.71. The hospital costs and professional fees for the amputation group averaged $30,148.02 without prosthetic costs, but with the projected lifetime prosthetic costs included, averaged $403,199.18. This study suggests that Ilizarov limb reconstruction is cost-effective when compared with amputation when prosthetic costs are also considered.

Adult↗
PubMed1993

Lower-limb amputations.

The current epidemiological situation with regard to lower-limb amputations in southern Finland was analysed for the year 1989. Lower-limb amputations were performed on 268 patients. The amputation rate was 22.0 per 100,000 inhabitants, and the mean age of amputees was 70 years. Peripheral vascular disease was the main reason for amputation (79%). The most common level of amputation was above-knee (49%) followed by below-knee (29%). Two thirds (64%) of the patients lived over one year, and half (53%) over two years after the amputation. In the group of patients undergoing unilateral amputation and surviving over two months, 26% of the above-knee and 63% of the below-knee amputation patients received a prosthesis. The (average) time lag between surgery and fitting the prosthesis was 97 days. Incidence and mortality were decreased after 1985. The rate of prosthesis fitting was still low but the time lag between surgery and prosthetic fitting had decreased.

Adult↗
PubMed1993

Survivorship of healed partial foot amputations in dysvascular patients.

The results of 94 initially successful, partial foot amputations in dysvascular patients were reviewed with survivorship analysis at a minimum of 6.5 years after surgery. Partial foot amputations were divided into three types: transmetatarsal amputations, metatarsophalangeal disarticulations, and ray resections. No amputation type was more or less likely to be treated with subsequent amputation of the foot or to develop recurrent ulceration. Taking all groups together, the chance of retaining the foot after an initially healed partial foot amputation was 86% at four years after operation and 76% at eight years after operation. Of these surviving feet, however, 53.8% developed ulceration or needed local reoperation. The chance of completely avoiding any surgery after an initially healed partial foot amputation was 71% at four years after operation and 52% at eight years after operation. In properly selected patients, partial foot amputations have significant longevity.

Amputation, Surgical↗
PubMed1996

[Forefoot gangrene and infra-crural bypass: simultaneous amputation].

Patients presented for amputation mostly have chronic limb ischaemia caused by atherosclerosis, with signs of severe arterial insufficiency including rest pain, non-healing skin lesions, ulceration or gangrene. Foot infections, especially in diabetic patients, are often multimicrobial, deeply invasive and frequently require aggressive measures, like debridement and drainage or partial open forefoot amputation in addition to broad-spectrum antibiotics, in patients with critical limb ischaemia and limited necrosis and forefoot gangrene, distal bypass surgery is the treatment of choice. The main question is whether amputation should be performed simultaneously or in a secondary stage. Our own experience deals with 342 femorocrural and femoropedal bypass grafts for the treatment of critical limb ischaemia. The results showed no significant difference in graft patency between crural and pedal grafts. Clinical factors like diabetes mellitus, poor distal run-off and site of the distal anastomosis had no adverse effect on the functioning and patency of the graft. In this series we found that in diabetic patients significantly more amputations were required because of persistent foot infection. Since in these patients amputation was performed in a secondary stage, we changed our policy to simultaneous amputation. After completion of the bypass, closure and coverage of all the wounds, the gangrenous part is amputated. In case of deep, wet or infectious gangrene of the forefoot, an open transmetatarsal amputation is performed. Using this approach we have further increased limb-salvage and especially the number of usuable limbs.

Amputation, Surgical↗
PubMed1997

Role of Gritti-Stokes amputation in peripheral vascular disease.

The perigenicula lower limb amputations performed for peripheral vascular disease in Nottingham between April 1987 and September 1992 were reviewed. Of the 434 amputations, 173 were below-knee amputations (BKA), 144 Gritti-Stokes amputations (GSA) and 117 above-knee amputations (AKA). The 30-day mortality was significantly greater for AKA patients than either GSA or BKA patients. There was no difference in mortality within 30 days of amputation between GSA and BKA. Re-amputation rate to a more proximal level was significantly higher in BKA compared with GSA. Mobility after prosthetic rehabilitation was assessed using the Stanmore grading. A greater number of patients achieved mobility grade III and above in the GSA and BKA groups when compared with the AKA group, but there was no significant difference between GSA and BKA groups. At follow-up, a median of 23 months after amputation, there was a tendency for more patients to have given up using their limb prosthesis in the GSA group than either the BKA or AKA groups. However, there remained no significant difference between the BKA and GSA groups in the numbers of patients who remained successfully rehabilitated to Stanmore grade III or above. When a BKA is not possible, GSA offers a better prospect for rehabilitation compared with AKA in patients with occlusive arterial disease.

Adult↗
PubMed2005

Bipolar head regeneration induced by artificial amputation in Enchytraeus japonensis (Annelida, Oligochaeta).

The Enchytraeida Oligochaeta Enchytraeus japonensis propagates asexually by spontaneous autotomy. Normally, each of the 5-10 fragments derived from a single worm regenerates a head anteriorly and a tail posteriorly. Occasionally, however, a head is formed posteriorly in addition to the normal anterior head, resulting in a bipolar worm. This phenomenon prompted us to conduct a series of experiments to clarify how the head and the tail are determined during regeneration in this species. The results showed that (1) bipolar head regeneration occurred only after artificial amputation, and not by spontaneous autotomy, (2) anesthesia before amputation raised the frequency of bipolar head regeneration, and (3) an extraordinarily high proportion of artificially amputated head fragments regenerated posterior heads. Close microscopic observation of body segments showed that each trunk segment has one specific autotomic position, while the head segments anterior to the VIIth segment do not. Only the most posterior segment VII in the head has an autotomic position. Examination just after amputation found that the artificial cutting plane did not correspond to the normal autotomic position in most cases. As time passed, however, the proportion of worms whose cutting planes corresponded to the autotomic position increased. It was suspected that the fragments autotomized after the artificial amputation (corrective autotomy). This post-amputation autotomy was probably inhibited by anesthesia. The rate at which amputated fragments did not autotomize corresponded roughly to the rate of bipolar regeneration. It was hypothesized then that the head regenerated posteriorly if a fragment was not amputated at the precise autotomic position from which it regenerated without succeeding in corrective autotomy.

Animals↗
PubMed1985

Responses of host motor and sensory neurons to a neural tube implant in amputated chick limbs.

The right wingbuds of stage 23-25 chick embryos were amputated at the future elbow region and a segment of 2-day neural tube was implanted longitudinally into the limb stump of experimental embryos to induce limb regeneration. Control embryos had no implant in the amputated limb stump. To analyze effects of the neural tube implant (NTI) upon the host nervous system, quantitative determinations were made of the peripheral limb field (PLF), dorsal root ganglia (DRG) and spinal cord lateral motor column (LMC) of the amputated side for comparison with similar determinations of the unamputated side in all embryos. The PLF was estimated by determining the area of the skeletal elements of the amputated and unamputated limb of each embryo. The size of the DRG was estimated by determining the sectional-profile area of a pair of ganglia; the LMC was determined by counting the neurons on both sides of a single spinal cord segment. The PLF was less on the amputated than on the unamputated side but was significantly greater in amputated limbs that received a NTI. The size of the DRG was positively correlated with the size of the PLF in all groups, indicating the DRG was not directly affected by the NTI but did respond to target structures. The number of neurons in the LMC was not positively correlated with the PLF and was not reduced by limb amputation in embryos with a NTI. The data suggest that the NTI may have protected host spinal cord cells from the induced-cell death expected to follow limb amputation; perhaps the implant produces a neuronal survival factor.

Animals↗