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PubMed2002

Experience in prosthetic supply of patients with lower limb amputations in Croatia.

This study analyses some demographic characteristics of the amputees in Croatia, reason and level of amputation, care the amputees receive, the first prosthetic supply and functional level after rehabilitation. Anonymised data on all amputees in the Clinical Institute for Rehabilitation and Orthopaedic Aids in Zagreb (a national centre) were collected during the year 2000. Follow-up was undertaken for one year. As a result, the authors analysed 221 patients, classified into 3 groups according to the level of amputations: trans-tibial, except foot (TT), trans-femoral (TF) and bilateral amputations (bilateral). Among the population there were: 76% men and 24% women with average age of about 62 years (the average age of women was 8 years more than men). The most common diseases that resulted in amputation were: diabetes mellitus (DM) 48.9%; obstructive vascular diseases (OD): occlusive peripheral arterial disease, Buerger's disease and atherosclerosis 27.1%; trauma 11.3%; both OD and DM 7.2%; osteomyelitis (OM) 3.2% and tumours (TM) 2.3%. Average period from the amputation to admission for prosthetic supply was over 190 days but the average period from admission to discharge from the Institute was about 40 days. Prosthetic supply was accompanied by certain complications: flexion contractures of neighbouring joints, knee 37.9% and hip 35.2%; local complications of soft tissues: necrosis, wound dehiscence, soft tissue surplus, ischaemic tissue damage (the most frequent in TT amputation 35.9%) and phantom pain (55.7% of patients). Hours of daily use of the prosthesis at discharge was about 5 hours. Greater independence in fitting and removing the prosthesis was observed in patients with TT amputation (86.4%). In conclusion, it can be said that the time between the amputation and the beginning of the prosthetic supply, mobility at the time of admission, frequency of general and local complications and number of days in prosthetic supply, are very important for the result of rehabilitation.

Adult↗
PubMed1991

[Degenerative changes in the sacroiliac joint in persons with amputations of the thigh and biomechanical disorders of gait].

In order to evaluate degenerative changes with amputated persons' sacroiliacal joints--upper leg amputations, 20 male subjects aging 31-57 years and a control group of 56 subjects with no amputation were tested. Changes evaluation was confirmed by a radiologic and scintigraphic result. Changes were observed after amputation-0 level 6 months' walk with an artificial limb. There was a comparison to a control group-56 subjects with no amputation. After evaluating degenerative changes of lumbocoxal triangle it could be concluded that the amputation and the time of amputation were a relevant factor in the beginning of degenerative changes. 6-12 months after the amputation, sacroiliacal joint's degenerative changes on ipsylateral side begin using an adequate orthopedic expedient-an artificial limb used permanently, degenerative changes can be held up at reversibility level or stagnation. Using an adequate physical therapy and an orthopedic expedient by an early discovery of degenerative changes their progress can be prevented.

Adult↗
PubMed1991

[Amputation of the leg in arterial occlusive disease].

The until recently held opinion that above-knee amputations were the method of choice for treating stage IV chronic occlusive arterial disease, is outdated. Determining the appropriate level for amputation in patients with peripheral arterial obstruction is difficult, and requires much experience. Successful fitting of a prosthetic device and subsequent rehabilitation depend not only on the patient's bodily and emotional reserves, but also on the operative technique employed. The more distal the amputation, the better is the prognosis for satisfactory prosthetic function and social reintegration. A total of 280 amputations on 268 patients was performed over a 48-month period. In 181 patients (68%) primary healing occurred without complications. Total mortality was 10%, occurring mainly in the group of above-knee amputees. The majority of local wound complications was found in transmetatarsal resections and below-knee amputations. A total of 42 patients (15%) underwent re-amputation. Only half of the above-knee amputees could be fitted with a prosthesis and rehabilitated, whereas nearly all patients amputated more distally experienced satisfactory outcomes in this respect.

Adult↗
PubMed1995

Bioenergetic comparison of a new energy-storing foot and SACH foot in traumatic below-knee vascular amputations.

In this study, the metabolic performances of a new energy-storing foot (Proteor) and of the solid-ankle cushion heel (SACH) are compared. Twelve patients with traumatic below-knee amputations (mean age: 50.0 +/- 19.9 years) and 12 patients with vascular below-knee amputations (mean age: 73 +/- 7 years) were studied. Oxygen uptake (VO2) was measured in all the subjects on a walkway at a self-selected velocity; only the subjects with traumatic amputation were tested on a level treadmill (progressive speed: 2.4-4 and 6 km/h), and then in two randomized trials: incline (+5%) and decline walking treadmill test at 4 km/h. Vascular explorations were done in the vascular patients: distal pressure measurements, pulse plethysmography, transcutaneous oxygen tension. Free walking was improved in subjects with traumatic amputation using the energy-storing foot (+6%), with a better bioenergetic efficiency (0.24 +/- 0.4mL/kg.m vs 0.22 +/- 0.04mL/kg.m). However, in subjects with vascular amputation, this foot did not produce an increased free velocity nor an improved energy cost. During the level treadmill test, the traumatic amputee subjects showed a decrease of energy expenditure with the new prosthetic foot, more significant at sufficient speed (4 km/h): 17.00 +/- 3.42 vs 14.67 +/- 2.05 mL/kg/min (p < .05). The same effect is shown during the incline (19.31 +/- 2.80 vs 16.79 +/- 2.32 mL/kg/min-p < .02) and decline walking tests (14.13 +/- 3.64 vs 11.81 +/- 1.54mL/kg/min-p < .02). There is no significant difference in cardiocirculatory effects between the two types of prosthetic foot. Despite a lower velocity, the subjects with vascular amputation exceed 70% of the maximal heart rate, with the cardiocirculatory factor being the main cause of walking restriction. The energy-storing foot should be reserved for active and fast walkers, whereas the SACH foot seems more suitable for elderly patients with amputation with a slow walk.

Age Factors↗
PubMed2000

Unna and elastic postoperative dressings: comparison of their effects on function of adults with amputation and vascular disease.

OBJECTIVES: To compare the functional outcome associated with the use of Unna semirigid dressings (SRD) and elastic bandage soft dressings (ED) for adults with lower limb amputation. DESIGN: Experimental design. SETTING: Inpatient rehabilitation unit of an urban academic medical center. PARTICIPANTS: A successive series of adults with vascular disease who had lower limb amputation surgery. Subjects were randomly assigned to the SRD (12 patients with 12 recent amputations) or the ED (9 patients with 10 recent amputations) group. Subjects in each group were not significantly different except for age; those in the SRD group were somewhat older. INTERVENTION: Subjects in the SRD group had Unna dressings applied to the amputation limb by physical therapists trained in the technique. Those in the ED group had elastic bandaging by therapists, nurses, family, and themselves, all of whom were trained in the technique. RESULTS: Sixty-seven percent of the SRD group and 20% of those in the ED group were discharged from the rehabilitation unit ambulating with prostheses. Of those who received prostheses, time from admission to the rehabilitation unit to readiness for fitting averaged 20.8 days for the SRD group and 28.7 days for the ED group. Comparison of survival curves shows that the time from surgery to fitting in the SRD group was almost half that of the ED group; 30% of the SRD group was fitted within 34 days, whereas it took 64 days for the same percentage of the ED group to be fitted. CONCLUSIONS: Unna semirigid dressings are more effective in fostering amputation limb wound healing and preparing the amputation limb for prosthetic fitting. Subjects treated with SRDs were more likely to be fitted with prostheses and to return home walking with a prosthesis.

Aged↗
PubMed1997

Sciatic nerve: paradoxic hypertrophy after amputation in young patients.

PURPOSE: To evaluate the appearance of the sciatic nerve after leg amputation. MATERIALS AND METHODS: Magnetic resonance (MR) images were obtained in seven patients (age at amputation, 11-19 years) who underwent above-knee amputation to treat osteogenic sarcoma. Images were evaluated for sciatic nerve enlargement. Findings were correlated with the time after amputation. RESULTS: All seven patients were found to have a markedly enlarged sciatic nerve in the stump of the amputated leg. The enlargement extended proximally from the point of nerve transection to a level posterior to the femoral neck (8-27 cm) depending on the length of the stump. No evidence of sciatic nerve enlargement was found in the opposite leg or on preoperative MR images that were available in three of the patients. Moreover, in one patient with a sarcoma who underwent a leg-sparing procedure, no sciatic nerve enlargement was seen postoperatively. The thickness of the distal sciatic nerve was related to the time after amputation. CONCLUSION: Hypertrophy of the sciatic nerve occurred after above-knee amputation in young patients. This finding differed from atrophy of the nerve that has been reported previously in older patients.

Adolescent↗
PubMed1999

Amputations and prosthetics.

The author presents in a condensed way an overview of the principles of limb amputations and further treatment of patients who underwent such a procedure. The metabolic cost of walking, load transfer, and wound healing are reviewed in a concise manner. Particular attention is given to blood supply to the wound and methods to determine adequate perfusion with a clear analysis of the pro and cons of the Doppler method. Pediatric amputations, because of their specificity, are considered apart. Disarticulation of limbs is the method of choice in children, because of it retains growth potential of the bone and prevents bony overgrowth of the stump. The article discusses the main indications for limb amputations: trauma, peripheral vascular disease, musculoskeletal tumors and gas gangrene. In every case the specificity of the amputation is considered by the author. Postoperative care is also presented, with a short description of possible complications. Pain is the most common and treatment strategies should be similar to those used in treating patients with major reflex sympathetic causalgia. Edema, joint contracture, wound failure and dermatologic problems are all shortly reviewed. The last part of the article treats with the principles of prosthetics in both the upper and lower limb. These principles are presented basing on the level of amputation: for the upper limb hand, transradial, transhumeral amputations and shoulder disarticulation. For the lower limb foot and ankle, transtibial and transfemoral amputations are considered.

Adult↗
PubMed1976

Changes in composition and metabolic activity of the skeletal parts of the extremity of the adult rat following below-knee amputation.

Below-knee amputation in adult male rats resulted in characteristic quantitative and qualitative changes of the tibia stump and of the femur in the amputated leg. These changes were followed for periods of 1 to 32 weeks after the amputation. The femur of the amputated leg underwent a significant reduction of its total bone mass and a significant decrease of its percentage ash content, whereas its percentage water and organic contents increased significantly. The bone specific activity was initially decreased and began to increase after the 10th week post surgery with a positive linear regression. The amputated tibia underwent a significant, though declining, increase of its percentage water and organic contents and a likewise significant decrease of its percentage ash content. The specific activity of the amputated tibia was significantly higher than that of the tibia from the non-amputated leg, the difference showing a negative linear regression. The specific activity of the femur was decreased initially and increased later on.

Amputation, Surgical↗
PubMed1987

A prospective randomized comparison of healing in Gritti-Stokes and through-knee amputations.

Twenty-two patients with a median age of 79 years had 24 amputations about knee joint level. The patients were randomised to undergo either Gritti-Stokes or through-knee amputations. In two-thirds of limbs transcutaneous oxygen was less than 4.65 KPa (35 mmHg) or there were no audible Doppler signals at the ankle, indicating that a below-knee amputation would have been at risk of failing to heal, and in the remainder an amputation at the knee joint was considered the preferable site for a variety of reasons. Nine of 12 (75%) Gritti-Stokes amputations underwent uncomplicated primary healing compared with only 2 of 12 (17%) through-knee procedures (P = 0.04). Two through-knee amputations required revision to above the knee (17%) while all Gritti-Stokes amputations healed. Three patients in each group became mobile on a prosthesis, the remainder being bilateral amputees or unable to manage an artificial limb.

Aged↗
PubMed1982

Influence of failed vascular bypass procedures on conversion of below-knee to above-knee amputation levels.

From 1975 to 1980, 79 major limb amputations were performed from a group of 552 lower extremity vascular reconstructions with glutaraldehyde-stabilized umbilical vein grafts. All amputations were performed in instances in which limb salvage had been the indication for the attempted bypass (n = 520)--an incidence of 15.2%. Twelve of 51 below-knee (BK) amputations were converted to above-knee (AK) levels (crude failure rate, 23.5%). The highest crude failure rate occurred after failed bypass to the popliteal artery (33.3%); the lowest occurred after failed tibial bypass (16.7%), and the peroneal arteries were intermediate (22.2%). In addition to these 12, 28 primary AK amputations were performed. Excluding nine cases judged to require AK amputations before the attempted vascular reconstruction, success/failure rates for the entire series and each of the reconstruction types were calculated. Success, defined as a healed BK stump, occurred least after failed popliteal bypass, 44.5%, compared to 71.4% and 53.8% for the tibial and peroneal groups, respectively. Thus, failure of a popliteal bypass was more apt to lead to an AK amputation (56.5%) than failure of a distal bypass. In fact, tibial bypass failure leading to an AK stump occurred at a frequency (28.6%) almost similar to that obtained by other investigators when no previous bypass had been performed. Comparative cumulative graft patency and limb salvage rate data confirm the value of reconstructive vascular surgery, particularly in the peroneal group where negativism with regard to its clinical usefulness persists. With improved case selectivity and surgical expertise, increasing limb salvage rates can be secured while minimizing the definite morbidity of conversion of BK to AK amputation with failed vascular bypass.

Aged↗
PubMed2000

Peripheral bypass surgery and amputation: northern Illinois demographics, 1993 to 1997.

HYPOTHESIS: This study tests whether age, sex, income, and racial differences predict rates of aortoiliac and femorodistal bypass surgery and above- and below-knee amputation for residents of northern Illinois from 1993 to 1997. DESIGN: A hospital discharge survey study describing standardized procedure rates and the odds of undergoing amputation vs bypass procedures for specified sociodemographic populations. Multiple logistic regression was used to compare the odds of undergoing major amputation vs bypass surgery controlling for the prevalence of diabetes, gangrene, high-risk comorbid conditions, and treatment at major area teaching hospitals. RESULTS: Between 1993 and 1997, 19,250 study procedures were performed during 18,603 admissions at 105 Illinois hospitals. The mean annual major amputation rate per 100,000 was 20.77; femorodistal and aortoiliac bypass rates were 24.26 and 4.70, respectively. Significantly higher odds (between 1.14 and 1.36) of undergoing amputation were found for low-income areas and ZIP codes with large and medium African American populations. Severe comorbidity, diabetes, and especially gangrene (odds ratio, 12.9) predicted amputation, while treatment at a major teaching hospital and male sex predicted a higher odds of undergoing bypass procedures. CONCLUSIONS: Results are consistent with unmeasured racial and income differences in the severity of atherosclerosis (or related risk factors such as smoking, diet, and exercise), barriers to timely primary care, or selective referral of lower-income and African American patients to hospitals with less vascular surgery capacity. These findings imply a particular need to identify and review the quality of care for patients undergoing primary lower-extremity amputations.

Adult↗
PubMed2004

Major lower extremity amputation: outcome of a modern series.

HYPOTHESIS: Major lower extremity amputation results in significant morbidity and mortality. DESIGN: Retrospective database query and medical record review for January 1, 1990, to December 31, 2001. Mean follow-up was 33.6 months. SETTING: Academic tertiary care center. PATIENTS: Nine hundred fifty-nine consecutive major lower extremity amputations in 788 patients, including 704 below-knee amputations (BKAs) (73.4%) and 255 above-knee amputations (AKAs) (26.6%). MAIN OUTCOME MEASURES: Patient survival, cardiac morbidity, infectious complications, and subsequent operation. RESULTS: Overall 30-day mortality was 8.6%, worse for AKA (16.5%) than BKA (5.7%) patients (P<.001). Thirty-day mortality for guillotine amputation for sepsis control was 14.3% compared with 7.8% for closed amputation (P =.03). Complications included cardiac (10.2%), wound infection (5.5%), and pneumonia (4.5%). Twelve AKA (4.7%) and 129 BKA (18.4%) limbs required subsequent operation. Only 66 BKAs (9.4%) required conversion to AKA (average, 77.1 days postoperatively). Overall survival was 69.7% and 34.7% at 1 and 5 years, respectively. Survival was significantly worse for AKAs (50.6% and 22.5%) than BKAs (74.5% and 37.8%) (P<.001). Survival in patients with diabetes mellitus (DM) was 69.4% and 30.9% vs 70.8% and 51.0% in patients without DM at 1 and 5 years, respectively (P =.002). Survival in end-stage renal disease patients was 51.9% and 14.4% vs 75.4% and 42.2% in patients without renal failure at 1 and 5 years, respectively (P<.001). CONCLUSIONS: Major amputation continues to result in significant morbidity and mortality. Survivors with BKA require revision or conversion to AKA infrequently. Long-term survival is dismal for patients with DM and end-stage renal disease and those undergoing AKA.

Adult↗
PubMed1979

Noninvasive prediction of amputation level in diabetic patients.

Noninvasive laboratory testing was used to predict successful amputation levels in 150 diabetic patients. The cases of 100 patients undergoing forefoot amputation and 50 patients undergoing below-knee amputation were evaluated using segmental systolic pressures and pulse volume recordings (PVRs). The decision for and the level of amputation were based solely on clinical judgment. In patients undergoing forefoot amputation, segmental systolic pressures were falsely high or predicted incorrectly in over half the cases. Segment PVRs were correctly predictive in only half of the cases. In patients undergoing below-knee amputation, segment systolic pressures were falsely high or predicted incorrectly in over one third of cases. Segmental PVRs were correctly predictive in less than one third of the cases. In the diabetic patient, clinical judgment continues to provide the most accurate and reliable information by which the type of amputation and likelihood of its success can be judged.

Adult↗
PubMed1985

Improved results with diabetic below-knee amputations.

This study of 100 consecutive below-knee amputations in 98 diabetic patients was undertaken to review our results and to compare them with a similar report of 20 years ago. Ninety-three limbs were ischemic, and 79% of the patients had significant infection. This finding was similar to that in our previous study group. Twenty-one percent of the patients had previous arterial reconstruction, 11% had had a toe or metatarsal amputation, and 17% required a guillotine (open) amputation to control sepsis. The below- to above-knee amputation ratio was 2.3/1. The selection of level was made on clinical grounds. None of the 100 amputations required revision to above-knee amputation. The mortality rate was 3% and the wound complication rate was 18%. Eighty-three percent of the patients were ambulatory at the time of discharge, which occurred at an average of 35 days. There has been a significant improvement in the number of successful below-knee amputations performed since our previous study. We attribute these results to aggressive surgical control of infection and to close follow-up with early recognition and treatment of healing problems.

Adult↗
PubMed1991

The mangled extremity. When to amputate?

To determine indications for immediate or delayed amputation of the mangled lower extremity, we reviewed the cases of 80 patients. Vascular, neurologic, bone, and soft-tissue status were reviewed, as were postoperative complications, requirements for mechanical ventilation, fluid balance, delayed amputation, and survival. Although neurologic, bone, and soft-tissue status did influence decisions regarding immediate amputation, they had little to do with delayed loss of limb or life. The circulation, as determined by the presence or absence of a palpable or Doppler-detected pulse, however, was critical. Of six patients in whom salvage was attempted and in whom fluid balances of greater than 3 L were detected in the first 24 hours post-operatively, five eventually required amputation. Salvage should usually be attempted if a distal pulse is present. If no distal pulse is present, the decision for immediate amputation should be based on functional prognosis. In cases in which salvage is attempted, amputation should be performed at 24 hours if the patient's condition, including a markedly positive fluid balance, indicates systemic compromise. In the absence of a distal pulse on presentation, the eventual amputation rate is high.

Adult↗
PubMed1991

Extremity epithelioid sarcoma. Amputation vs local resection.

Amputation has traditionally been advised for extremity epithelioid sarcoma because of its pattern of innocuous presentation and relentless soft-tissue and nodal metastasis. To assess the role of amputation in extremity epithelioid sarcoma, we reviewed our experience with 42 patients treated between 1961 and 1986. On presentation with localized primary tumor (n = 18), nine of 11 patients who underwent wide local excision and four of six patients who underwent excisional biopsy were free of disease, and one patient who underwent amputation died. After presentation with localized recurrence (n = 12), four of six patients who underwent wide local excision and two patients who underwent excisional biopsy were free of disease; three other patients who underwent wide local excision had margins that tested positive on pathologic examination, of whom one was free of disease; one patient who underwent amputation died of disease. On presentation with regional metastasis (n = 12), only one of five patients who underwent wide local excision and one of seven patients who underwent amputation were free of disease. Primary amputation offered no apparent overall survival benefit to patients presenting with regional metastasis. The favorable outcome after local resections for localized disease indicates that wide local excision with margins that test negative on pathologic examination is preferable to radical amputation in these patients.

Adult↗
PubMed1997

Transcutaneous partial oxygen pressure changes following skew flap and Burgess-type below-knee amputations.

OBJECTIVE: To evaluate the degree of flap hypoxia following different types of below-knee amputations. DESIGN: Prospective preoperative and postoperative measurements of transcutaneous partial oxygen pressure (TcPo2) at the site of amputation in 10 consecutive patients who underwent a Burgess-type below-knee amputation (group 1) and in 10 consecutive patients who underwent a skew flap amputation (group 2). SETTING: An academic, tertiary care Veterans Affairs medical center. PATIENTS: Individuals with severe arterial occlusive disease of the lower extremity, in many of whom vascular reconstruction has failed. INTERVENTION: Measurements of TcPo2 (in millimeters of mercury). MAIN OUTCOME MEASUREMENT: The decrease in TcPo2 associated with the different "flaps" of a Burgess-type below-knee amputation. RESULTS: In all skin flaps, regardless of the type of amputation, an early postoperative reduction of the TcPo2 was noted. The greatest reduction (11 mm Hg) and persistence at 20 postoperative days were noted in posterior flaps. CONCLUSIONS: Strict conformity to the Burgess-type of below-knee flap design may not provide an optimal incisional blood supply. Consideration should be given to the skew flap technique in patients who require amputation for severe lower limb arterial insufficiency.

Aged↗
PubMed2006

An assessment and quantification of the rates, costs, and risk factors of occupational amputations: analysis of Kentucky workers' compensation claims, 1994-2003.

BACKGROUND: Assessments of the impact of occupational amputations with outcomes of pain, disfigurement, and often an inability to return to the same job, are limited. The present study examines and quantifies the rates, risk factors, and costs of occupational amputations in the workplace in the State of Kentucky. METHODS: Worker's compensation data from 1994 through 2003 from Kentucky was used to investigate job-related amputations (n = 2,297). The US Department of Labor's Current Population Survey (CPS) was used to estimate injury rates. RESULTS: The average amputation claim rate for all Kentucky workers was 1.37 per 10,000, with an average per-claim indemnity cost of $8,822. A declining trend was found in the rate over the last 7 years studied. Accidents resulting in amputations occurred at twice the rate on weekends than on weekdays. Amputations affecting the hand constituted 94.6% of all injuries. Workers in the mining industry had the highest estimated claim rate of 5.92 (95% CI 5.23-6.66), and machine operators and assemblers had the highest rate of all occupations with 3.35 (95% CI 3.23-3.47). CONCLUSIONS: Workplace amputations remain a significant workplace concern and represent a particular hazard for those in the mining and manufacturing industries. Future research should examine causes of the weekend effect to develop human resource and safety interventions for risk reduction.

Accidents, Occupational↗