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PubMed1987

Role of computed tomography in selecting patients for hindquarter amputation.

Nine patients with soft tissue sarcomas close to the pelvic girdle and one patient with a primary malignant bone tumour of the pelvis were referred for consideration of hindquarter amputation. Patients were considered unsuitable for hindquarter amputation on clinical grounds if malignant disease infiltrated into the perineum or across the sacro-iliac joint. If disease in the femoral triangle extended above the inguinal ligament the tumour's operability was seriously questioned. Buttock tumours which had passed through the greater sciatic notch to become palpable on pelvic examination were also considered likely to be inoperable. On computed tomographic (CT) examination, tumours were considered inoperable if the psoas muscle was involved above the inguinal ligament, or if malignant disease involved the sacro-iliac joint, sacrum or perineal structures. Soft tissue tumours of the buttock extending significantly through the greater sciatic notch were also considered likely to be inoperable. Five patients thought suitable for hindquarter amputation on clinical assessment had no excluding features on CT; four undergoing hindquarter amputation were proven on histological examination to have good clearance of their tumours. In another patient, considered suitable for hindquarter amputation on clinical grounds, CT suggested that en bloc wide excision of the tumour was feasible enabling the affected limb to be preserved. Four patients after clinical examination were considered unsuitable for hindquarter amputation and in all cases inoperability was confirmed by CT. CT complements clinical examination and provides an objective and reliable means of selecting patients for hindquarter amputation which should avoid unnecessary surgical exploration.

Adult↗
PubMed1994

Pattern of injury in those dying from traumatic amputation caused by bomb blast.

Traumatic amputation of limbs caused by bomb blast carries a high risk of mortality. This paper describes 73 amputations in 34 deaths from bomb blast in Northern Ireland. The principal aim was to determine the sites of traumatic amputation to provide a biophysical basis for the development of protective measures. Few amputations were through joints; nearly all were through the bone shafts. The most common site in the tibia was the upper third. The distribution of femoral sites resulting from car bombs differed from that characterizing other types of explosion. For car bombs the principal site of amputation was the upper third; for other types of device it was the lower third. It is concluded that flailing is not a notable contributor to limb avulsion. The pattern of amputation is consistent with direct local pressure loads leading to bone fracture; the amputation itself is a secondary event arising from the flow of combustion products.

Amputation, Traumatic↗
PubMed1976

Regenerative abnormalities in Notophthalmus viridescens induced by repeated amputations.

The fidelity of the regenerative response in the adult newt, Notophthalmus viridescens, was examined following repeated amputations at the level of the distal one-third of humerus. Three to four months following amputation, all regenerates were scored for gross morphology, reamputated, and stained with methylene blue for skeletal elements. The occurrence of abnormal regeneration with respect both to gross morphology and to skeletal structure was found to increase directly with the number of times the limb stumps were required to initiate dedifferentiation and repair. The initial amputation-regeneration process produced structurally normal replacement limbs in 91% of the cases examined. Reamputations of 4-digit regenerates (3--4 months after the previous transection) resulted in structurally abnormal regenerates in 28% of the cases following two amputations; 50% of the cases following three amputations; 65% of the cases following four amputations; and 81% of the cases following five amputations. The relationships between repeated dedifferentiation, proliferation, and redifferentiation and normal limb development are discussed.

Amputation, Surgical↗
PubMed1993

Major amputation for malignant melanoma: an epidemiological study.

The annual number of amputations in Denmark as a consequence of malignant melanoma on the limbs has been constant during the period 1978-1987. In contrast, the number of malignant melanoma localized to the extremities increases. For lower limb amputation the mean age is 58 y for males and for females, 72 y. The sex ratio, male to female is 1:2.2. Of the 13 male amputees 7 (54%) had died after 18 mo, of the 28 female amputees 20 (74%) had died after 19 mo. An analysis (Kaplan-Meier) shows a 5-y survival rate of about 28%. The mortality is found to be related to sex and level of amputation. Six cases of upper extremity amputation are presented. A review of the literature in order to compare the demographic factors and to outline the indications for amputation reveals a number of differences, most significantly the higher mean age at time of amputation (about 65 y) in Denmark than the figures earlier published (about 45 y). The consensus seems to be that amputation is rarely indicated except as a form of palliation.

Aged↗
PubMed1991

Epidemiology of lower limb amputations in diabetics in Denmark (1980 to 1989).

From 1980 to 1989, 4852 diabetic patients in Denmark underwent 5642 lower limb amputations. Records of the Danish Amputation Register and the National Patient Register indicate a decrease of amputations in diabetics from 681 to 463 per year in this time. There has also been a decrease in above knee amputations in diabetics from 30 to 20 percent of all amputations with a corresponding increase of amputations at or below the knee. Demographic factors and possible reasons for these changes are reviewed. There seems to be a relationship between the improvement of diabetic foot care by the free service of trained podiatrists and the reduction of amputations in diabetics in Denmark.

Aged↗
PubMed1989

A modified scintigraphic technique for amputation level selection in diabetics.

A modified 123I-antipyrine cutaneous washout technique for the selection of amputation levels is described. The modifications imply a reduction of time needed for the examination by simultaneous recordings on different levels, and a better patient acceptance by reducing inconvenience. Furthermore, both skin perfusion pressure (SPP) and skin blood flow (SBF) are determined from each clearance curve. In a prospective study among 26 diabetic patients presenting with ulcers or gangrene of the foot, both SPP and SBF were determined preoperatively on the selected level of surgery and on adjacent amputation sites. These 26 patients underwent 12 minor foot amputations and 17 major lower limb amputations. Two of these amputations failed to heal. SBF values appeared indicative for the degree of peripheral vascular disease, as low SBF values were found with low SPP values. SPP determinations revealed good predictive values: all surgical procedures healed when SPP greater than 20 mmHg, but 2 out of 3 failed when SPP less than 20 mmHg. If SPP values would have been decisive, the amputation would have been converted to a lower level in 6 out of 17 cases. This modified scintigraphic technique provides accurate objective information for amputation level selection.

Aged↗
PubMed1994

Wound healing in forefoot amputations: the predictive value of toe pressure.

A retrospective study of 136 men undergoing forefoot amputation was done to test the hypothesis that preoperative toe pressure (TP) could predict the likelihood of wound healing. Demographic data included age, smoking history, diabetes mellitus (DM), hypertension, hyperlipidemia, and coronary artery disease. Clinical data included infection, preoperative arterial Doppler data, TP, wound disposition, concomitant revascularization (REV), and healing outcome. Among diabetics, no primary amputation healed with a preoperative TP < 38 mm Hg. Among REV diabetics, no healing occurred with a TP < 40 mm Hg after bypass, but no failures occurred either with a TP > 68 mm Hg or an increase in TP > or = 30 mm Hg after bypass. Nondiabetic patients exhibited no threshold TP values. Univariate analysis revealed that DM and REV were significantly different in the healed (N = 83) vs. nonhealed (N = 53) populations (p = 0.027 and 0.034). In healed patients mean TP (71.8 +/- 3.5 mm Hg SEM) was significantly higher than in nonhealed patients (45.1 +/- 4.3 mm Hg SEM, p = 0.000). Logistic regression analysis identified age > 60 years (p = 0.03), DM (p = 0.003), preoperative TP (p < 0.001), and REV (p < 0.001) as significant independent predictors of forefoot amputation healing. Healing probability was calculated and plotted vs. TP for subpopulations based on age, DM, and REV status for both primary forefoot amputation and amputation concomitant with bypass. In this study population, therefore, preoperative TP appeared to be a useful clinical tool for predicting the healing potential of both primary forefoot amputations and amputations plus concomitant bypass for any given patient.

Adult↗
PubMed2001

Risk factors, ethnic differences and mortality associated with lower-extremity gangrene and amputation in diabetes. The WHO Multinational Study of Vascular Disease in Diabetes.

AIMS/HYPOTHESIS: We aimed to examine geographic differences, risk factors and mortality associated with amputation. METHODS: Data from 10 of the original 14 centres of the WHO Multinational Study of Vascular Disease in Diabetes were used. This included 3443 men and women aged 35 to 55 years at baseline. RESULTS: Incidences of amputation, adjusted for sex and duration in Type I (insulin-dependent) diabetes mellitus, were 31.0, 8.2, 3.5 and 1.0 per 1,000 person years in the American Indian, Cuban, European and East Asian centres respectively. In Type II (non-insulin-dependent) diabetes mellitus, incidences of amputation were 9.7, 2.0, 2.5 and 0.7 per 1000 person years in the American Indian, Cuban, European and East Asian centres respectively. Key risk factors for amputation included glucose, triglyceride, and retinopathy, and were similar for American Indians and Europeans. The age, duration and sex adjusted relative risk for amputation in American Indians compared with Europeans was 11.48 (95% CI 3.56, 36.98) in Type I diabetes and 3.86 (95 % CI 2.36, 6.32) in Type II diabetes. Adjusting for heart disease, retinopathy, proteinuria, glucose, blood pressure and triglyceride attenuated these relative risks to 10.83 (95 % CI 3.20, 36.65) and 3.15 (1.91, 5.20) in Type I and Type II diabetes respectively. Amputation doubled mortality rates in all groups. CONCLUSION/INTERPRETATION: Vascular complications and their risk factors are themselves risk factors for amputation in both Type I and Type II diabetes and are common to several geographical regions worldwide. However, reasons for differences between geographical regions and the degree to which different health care systems could be responsible is not clear.

Adult↗
PubMed2004

Amputation as a marker of the quality of foot care in diabetes.

Strategic targets for the management of foot ulcers focus on reducing the incidence of amputation. While data on the incidence of amputation can be obtained relatively easily, the figures require very careful interpretation. Variation in the definition of amputation, population selection and the choice of numerator and denominator make comparisons difficult. Major and minor amputation have to be distinguished as they are undertaken for different reasons and are associated with different costs and functional implications. Many factors influence the decision of whether or not to remove a limb. In addition to disease severity, co-morbidities, and social and individual patient factors, many aspects of the structure of care services affect this decision, including access to primary care, quality of primary care, delays in referral, availability and quality of specialist resources, and prevailing medical opinion. It follows that a high incidence of amputation can reflect a higher disease prevalence, late referral, limited resources, or a particularly interventionist approach by a specialist team. Conversely, a low incidence of amputation can indicate a lower disease prevalence or severity, good management of diabetes in primary and secondary care, or a particularly conservative approach by an expert team. An inappropriately conservative approach could conceivably enhance suffering by condemning a person to months of incapacity before they die with an unhealed ulcer. The reported annual incidence of major amputation in industrialised countries ranges from 0.06 to 3.83 per 10(3) people at risk. Some centres have documented that the incidence is falling, but this is often from a baseline value that was unusually high. Other centres have reported that the incidence has not changed. The ultimate target is to achieve not only a decrease in incidence, but also a low overall incidence. This must be accompanied by improvements in morbidity, mortality, and patient function and mood.

Amputation, Surgical↗
PubMed2000

Transganglionic gracile response following limb amputation in man.

Gracile neuroaxonal dystrophy (NAD) is an distinctive morphological alteration of central projecting axon terminals of dorsal root ganglion neurons. Experimentally, lower limb amputation has been shown to accelerate the formation of gracile NAD, suggesting that the transganglionic response to peripheral axotomy may play a role in its development. To determine if a similar response occurs in the human sensory nervous system following peripheral nerve injury, we have performed postmortem histopathological examinations of the dorsal column nuclei of three patients (aged 15, 55, and 77 years old); all of whom had undergone accidental or therapeutic unilateral limb amputation (1 year, 38 years, and 1 year 8 months prior to death, respectively). In a 15-year-old man who underwent therapeutic leg amputation, the gracile nuclei on the transected side revealed reactive gliosis and many small axonal spheroids. The spheroids and fine neurites were immunolabelled with antibodies for growth-associated protein-43, ubiquitin and neuropeptide Y (NPY). Neither routine histological nor immunohistochemical methods demonstrated comparable changes in the contralateral gracile nucleus. In a 77-year-old man who underwent leg amputation, the gracile nucleus on the amputated side was gliotic and showed several NPY and ubiquitin-immunoreactive spheroids, which were not seen in the contralateral non-transected side. A 55-year-old man with a history of accidental arm amputation showed well-developed NAD in the cuneate nucleus only on the transected side. This study clearly demonstrates the occurrence of transganglionic response to limb amputation in human dorsal column nuclei. The extent of the regenerative and/or degenerative responses may vary depending on the age of the patient and the time interval following the peripheral axotomy.

Adolescent↗
PubMed1993

Amputations in the treatment of Dupuytren's disease.

23 finger amputations in 19 patients operated on for Dupuytren's disease were reviewed 6 months to 8.5 years after operation (mean 4 years). The distribution of amputations were 17 little fingers and six ring fingers. We found a recurrent lack of extension in nine out of 16 finger amputations distal to the MP joint and painful neuroma or phantom limb pain in five out of seven little finger amputations through or proximal to the MP joint. When amputation in the little finger is necessary, disarticulation of the MP joint may be preferable to amputation at a more distal level. Alternatives to finger amputation should be sought in difficult cases of Dupuytren's disease.

Adult↗
PubMed1991

The acute effects of amputation on peripheral trigeminal afferents in Gallus gallus var domesticus.

In 10 adult Brown Leghorn hens electrical recordings were made from sensory afferent fibres in dissected nerve filaments of the trigeminal nerve innervating the lower beak. The lower beak was subjected to partial amputation using a heated blade and recordings were taken before, during and after amputation. Amputation produced a massive injury discharge which lasted from 2 to 48 sec (mean 15 sec). There were still active units present in the filament with receptive fields proximal to the site of cautery and for 90 min after amputation no abnormal activity was recorded in these units and no abnormal spontaneously active units were observed. From 90 to 270 min post-amputation single units were dissected and of the 93 rapidly adapting mechanoreceptors, 78 slowly adapting mechanoreceptors, 23 mechanothermal (polymodal) nociceptors, 7 cold and 3 warm thermoreceptors none showed any abnormal pattern of response to cutaneous stimulation. This absence of change in the peripheral neural input following amputation could provide a mechanism to explain the absence of observed pain immediately following partial beak amputation.

Action Potentials↗
PubMed2006

[Replantation of traumatic amputated ears by Mladick procedure: 6 cases].

UNLABELLED: Traumatic ear amputations are relatively rare. Whenever possible, ear reimplantation should be attempted, however the choice of the surgical procedure must be judicious. PATIENTS AND METHODS: We present 6 cases of partial ear amputation treated by the pocket technique described by Mladick. The series comprises 5 partial amputations severing less than half of the auricule and 1 subtotal amputation preserving the ear lobule. RESULTS: Necrosis of the avulsed fragment occurred in the only case of subtotal amputation. In the 5 other cases the revascularisation of the severed part was successful. Morphological results are often very good when the ear is freed from the pocket before 4 weeks. Beyond this delay skin grafting is necessary and inaesthetic scar retraction occurs. CONCLUSION: The success rate depends on the size and the degree of contusion of the amputated ear. We recommend the Mladick's procedure for reimplantation of fragments less than 1/2 of the auricle with favorable tissue condition. We believe that other procedures described in the literature could offer a good alternative for amputations exceeding half of the ear pavilion.

Adolescent↗
PubMed2006

Early and five-year amputation and survival rate of diabetic patients with critical limb ischemia: data of a cohort study of 564 patients.

OBJECTIVE: To evaluate the early and late major amputation and survival rates and related risk factors in diabetic patients with critical limb ischemia (CLI). DESIGN: Retrospective study. METHODS: Revascularization feasibility, major amputation, survival rate and related risk factors were recorded in 564 diabetic patients consecutively hospitalized for CLI from 1999 to 2003 and followed until June 2005. RESULTS: Peripheral angioplasty (PTA) was carried out in 420 (74.5%), bypass graft (BPG) in 117 (20.7%) patients. In 27 (4.8%) patients both PTA and BPG were not possible. Twenty-three above-the-ankle amputations (4.1%) were performed at 30 days: 6 in PTA patients, 3 in BPG patients, 14 in non revascularized patients. In the follow-up of 558 patients (98.9%), 62 repeated PTAs and 9 new BPGs, 32 new major amputations (16 in PTA patients, 14 in BPG patients and 2 in non-revascularized patients) were performed. Major amputation was associated with absence of revascularization (OR 35.9, p < 0.001, CI 12.9-99.7), occlusion of each of the three crural arteries (OR 8.20, p = 0.022, CI 1.35-49.6), wound infection (OR 2.1, p = 0.004 CI 1.3-3.6), dialysis (OR 4.7, p = 0.001 CI 1.9-11.7) increase in TcPO2 after revascularization (OR 0.80, p < 0.001 CI 0.74-0.87). One hundred seventy three patients died during follow-up and this was associated with age (HR 1.05, p < 0.001 CI 1.03-1.07), history of cardiac disease (HR 2.16, p < 0.001 CI 1.53-3.06), dialysis (HR 3.52, p < 0.001 CI 2.08-5.97), absence of revascularization (HR 1.68, p < 0.001, CI 1.29-2.19) and impaired ejection fraction (HR 1.08, p < 0.001, CI 1.05-1.09). CONCLUSIONS: In diabetic patients with CLI the revascularization is feasible in most cases and allows a low rate of early major amputation. This rate is higher in the follow-up period. Major amputation is very high in patients where revascularization is not feasible while the high mortality rate is due to the serious comorbidities observed in these patients.

Aged↗
PubMed1995

Foot amputations.

When presented with an ischemic limb with forefoot necrosis of varying amounts, the surgeon often categorizes the need for amputation into toe, ray, transmetatarsal, below-knee, and above-knee. Adherence to this type of algorithm ensures a primary above- or below-knee amputation rate of 10% to 20%. The utility of the more uncommon amputations advocated here is an increase of limbs deemed eligible for revascularization and limb salvage. Furthermore, delaying the amputations until the vascular supply is normalized maximizes tissue salvage and minimizes prolonged hospitalizations with multiple amputations performed as a prelude to major amputation. Although these amputations are often looked upon as an afterthought by many vascular surgeons, careful execution here is as important to effective limb salvage as any distal bypass procedure.

Amputation, Surgical↗
PubMed2001

Perceptual phenomena after unilateral arm amputation: a pre-post-surgical comparison.

Painful and non-painful phantom phenomena occur frequently after amputations but are rarely investigated in the perioperative stage. The goal of the present study was the assessment of phantom phenomena, pain and changes in primary somatosensory cortex prior to and after upper limb amputation. Two patients who suffered from metastatic carcinoma were examined 2 days prior to and 7 days after the amputation of an arm using comprehensive psychometric assessments and neuroelectric source imaging. Both patients reported phantom limb pain that was similar to their pre-amputation pain. In one patient, reorganization of the mouth area into the deafferented hand area took place immediately after the amputation. In the other patient reorganization had occurred prior to the amputation possibly related to non-use of the arm several years prior to the amputation.

Aged↗
PubMed2003

Functional outcome in a contemporary series of major lower extremity amputations.

PURPOSE: We undertook this study to document the functional natural history of patients undergoing major amputation in an academic vascular surgery and rehabilitation medicine practice. METHODS: A retrospective review was conducted of consecutive patients undergoing major lower extremity amputation and rehabilitation in a university and Department of Veterans Affairs hospital. Main outcome variables included operative mortality, follow-up, survival, median time to incision healing, secondary operative procedures for wound management, and conversion from below-knee amputation (BKA) to above-knee amputation (AKA). For surviving patients, quality of life was determined by degree of ambulation, eg, outdoors, indoors only, or no ambulation; use of a prosthesis; and independence, eg, community housing or nursing facility. RESULTS: From August 1997 through March 2002, 154 patients (130 men; median age, 62 years) underwent 172 major amputations, 78 AKA and 94 BKA, because of either critical limb ischemia (87%) or diabetic neuropathy (13%). Thirty-day operative mortality was 10%. Mean follow-up was 14 months. Healing at 100 and 200 days, as determined with the Kaplan-Meier method, was 55% and 83%, respectively, for BKA, and 76% and 85%, respectively, for AKA. Twenty-three BKA and 16 AKA required additional operative revision, and 18 BKA ultimately were converted to AKA. Survival was 78% at 1 year and 55% at 3 years. Function in surviving patients at 10 and 17 months, respectively, was as follows: 21% and 29% of patients ambulated outdoors, 28% and 25% ambulated indoors only, and 51% and 46% of patients were nonambulatory; 32% and 42% of patients used prosthetic limbs; and 17% and 8% of patients who lived in the community before amputation required care in a nursing facility. CONCLUSIONS: We were surprised to find that vascular patients in a contemporary setting who require major lower extremity amputation and rehabilitation often remain independent despite infrequent prosthesis use and outdoor ambulation. Although any hope for postoperative ambulation in this population requires salvaging the knee joint, because of the morbidity incurred in both wound healing and rehabilitation efforts, aggressive effort should be reserved for selected patients at good risk. Ability to predict ambulation after BKA in the vascular population is poor.

Activities of Daily Living↗
PubMed1991

[Digital flap autografts for pulp coverage in distal amputations of the fingers. 68 flaps].

Sixty-one patients underwent 68 digital pulp amputations involving the distal phalanx (Zone 2 and 3). 46 unipedicular Vankataswami-Subramanian island flaps (VS flap) and 22 bipedicular Moberg-O'Brien flaps (MOB flap) were performed. All distal thumb amputations were treated by MOB flap, whereas all lateral finger distal amputations of the long digits were treated by VS flap. Both flaps were used for the other types of amputation. Four digits developed complications and needed a delayed regularisation. The mean follow-up for the 46 flaps was two years. Pulp reconstruction was satisfactory in all flaps. Sensation was normal or slightly decreased in 66%. Nail dystrophy was considered to be poor in 56% and was attributed to initial trauma and the distal phalanx shortening. 20 degrees of extension deficit was found in 8 patients. We obtained 61 excellent and good results justifying our indications: MOB flap for all types of distal amputation of thumb in zone 2 and 3, VS flap for lateral distal amputations of the long fingers. In transverse amputation of the long fingers, MOB flaps seem to give better results than VS flaps.

Adult↗