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PubMed1991

Transmetatarsal amputation in patients with peripheral vascular disease.

Transmetatarsal amputation has the reputation of being an operation with a poor healing rate, and less than a 50% success rate had recently been reported. The outcome of this amputation in patients with peripheral vascular disease has been retrospectively studied in this paper by examining 34 transmetatarsal amputations performed over a 5-year period. Twelve patients had had previous toe amputations and 22 were diabetic with an overall healing rate of 68%. There was no significant difference in the success rate between diabetics and non-diabetics. One patient died in the postoperative period, giving an early post-operative mortality of 3%. Revision of failed transmetatarsal below-knee amputation resulted in healing in seven patients out of nine, suggesting that it does not compromise later amputation at a higher level. Healing did not appear to be influenced by factors such as sympathectomy, previous arterial reconstruction or peripheral pulses. Transmetatarsal amputation provides patients who have a short life expectancy with a durable functional stump which is prosthesis free.

Adult↗
PubMedDate not supplied

The impact of gender on amputation.

The purpose of this report is to compare the proportion of lower extremity amputations among men and women with and without diabetes mellitus. We abstracted data from a database supplied by the State of New York for 14,555 nontraumatic amputations performed from 1990 through 1991, 58.8% of which were performed on patients with diabetes mellitus. We categorized amputations into three different levels (foot, leg, and thigh). Fifty-seven percent of the diabetes mellitus group were male, compared with 50% of the nondiabetic group. Men were younger than women regardless of the level of amputation in both the diabetic and nondiabetic population. Men with and without diabetes were significantly more likely to have a foot amputation, while diabetic and nondiabetic women were more likely to have a thigh amputation. When controlling for age, prevalence of vascular disease was not significantly different by gender in diabetic and nondiabetic groups at all amputation levels.

Age Factors↗
PubMedDate not supplied

Local anesthetic infusion through nerve sheath catheters for analgesia following upper extremity amputation. Clinical report.

BACKGROUND AND OBJECTIVES: Reports about the efficacy of local anesthetic perfusion of nerve stumps following lower extremity amputation are conflicting. We report our experience with this technique following amputation of the upper extremity. METHODS: Six consecutive patients undergoing proximal upper extremity amputations (four forequarter amputations and two shoulder disarticulations) for malignancy were prospectively observed. In all patients, catheters were placed within the amputated nerve sheaths at the conclusion of the procedure. Bupivacaine. 0.25%, was administered through each catheter as a bolus and then as a continuous infusion for at least 72 hours after surgery. Narcotic usage, level of pain as reported verbally, and presence of phantom limb pain during the infusion were recorded. For at least 1 year after operation, data were gathered on the presence of phantom limb pain and its intensity during each follow-up visit. RESULTS: Complete analgesia was achieved in all patients by postoperative day 2. Narcotic usage was low. Three of the six patients reported phantom limb pain during follow-up evaluation. CONCLUSIONS: Continuous local anesthetic perfusion of amputated nerves via a catheter placed under direct vision provided excellent postoperative analgesia. The incidence of phantom limb pain for cancer patients did not differ from that previously reported but was easily managed pharmacologically. The technique may also be efficacious for traumatic amputations.

Adult↗
PubMed2004

Diabetic foot ulcers and amputations: estimates of health utility for use in cost-effectiveness analyses of new treatments.

OBJECTIVES: Diabetic foot ulcers (DFU), infections and amputations are associated with high costs of care and loss of health. To evaluate new treatments, both the extra costs incurred and the health utility gained need to be examined. However, evaluations of treatments in diabetes are hampered by the lack of utility values for health states such as DFU. We estimated utility values for health states seen amongst DFU patients. METHODS: We identified 13 unique health states based on presence/type of DFU and amputation. Members of the general public (n=107) received a description of each health state. They were then asked to indicate how undesirable each health state was (using the time trade-off method). Each answer was then transformed to create a value representing the "utility" of the health state, the utility value represented on a 0-1 scale. RESULTS: Valid responses could be obtained from 96 persons. Mean values included: 0.84 (diabetes with no DFU or amputation), 0.75 (uninfected DFU, no amputation), 0.68 (no DFU, previous foot amputation), and 0.63 (uninfected DFU, previous amputation of other foot). The impact of an ulcer depended on amputation status. CONCLUSIONS: Our values correspond with previously published results but are more detailed. In addition, since our values were derived from the general public, economic evaluations that incorporate them will use the generally preferred societal perspective. Therefore, these values are appropriate, practical and sensitive weights to calculate QALYs for cost-effectiveness analyses of foot ulcer treatments.

Adolescent↗
PubMedDate not supplied

In-field extremity amputation: prevalence and protocols in emergency medical services.

OBJECTIVE: To determine current experience, attitudes, and training concerning the performance of in-field extremity amputations in North America. DESIGN: Cross-sectional, epidemiological survey. PARTICIPANTS: Emergency medical services (EMS) directors from the 200 largest metropolitan areas in North America and attendees at the 1992 Mid-Year National Association of EMS Physicians Meeting. INTERVENTIONS: The survey consisted of five questions focusing on demographic and operational data, the frequency of occurrence of the performance of in-field amputations, personnel responsible for performing the procedure, existing written protocols for the procedure, and the scope of training provided. RESULTS: A total of 143 surveys was completed. Eighteen respondents (13%) reported a total of 26 in-field extremity amputations in the past five years. The most common cause for the injuries requiring amputations was motor-vehicle accidents. In the majority of cases (53.2%), trauma surgeons were responsible for performing the amputation, followed by emergency physicians (36.4%). Of respondents, 96% stated that there was no training available through their EMS agencies related to the performance of in-field extremity amputations. Only two EMS systems had an existing protocol regarding in-field amputations. CONCLUSIONS: The results suggest a need for established protocols to make the procedure easily accessible when needed, especially in large metropolitan EMS systems. This information should be emphasized during EMS training and reinforced through continuing education.

Accidents, Occupational↗
PubMed2003

Does infection affect amputation rate in chronic critical leg ischemia?

BACKGROUND: Aim was to analyze the association between local infection and amputation rate in patients with chronic critical limb ischemia (CLI) with or without successful revascularization. PATIENTS AND METHODS: We performed a retrospective analysis of 56 consecutive patients with 57 critically ischemic legs seen at the University Hospital Bern. Patients with CLI were selected if ischemic lesions and follow-up of more than 2 months were documented. Infection was suggested when 2 of the following criterion were present: temperature > 37 degrees C, C-reactive protein > 50 mg/L, leukocytes > 10 x 10(3)/microliter ("2 of 3" criterion), or a putrid secretion was documented ("secretion" criterion). RESULTS: In patients with successful revascularization (n = 39), there was a significant shift from 10.3% major to 33.3% minor amputations (Chi Square p value = 0.014) as compared to patients without or with failed revascularization (n = 18) with 44.4% and 11.1% (Chi Square p value = 0.008), respectively. An infection was suggested in 22 of 53 limbs (41.5%) according to the "2 of 3" criterion, and 30 of 57 limbs (52.6%) satisfying the "secretion" criterion. Both criteria, were significantly more common in patients undergoing amputation as compared to patients without amputation (p = 0.001). Multiple lesions were more common in patients with major amputations (p = 0.026). CONCLUSION: Successful revascularization effectively reduces major amputations and leads to healing of ischemic ulcers. Secondary foot infections are frequent. Infections are associated with a significantly higher rate of minor and major amputations, also in patients with successful revascularization, and should be treated adequately as well as in time with antibiotics.

Adult↗
PubMed2006

Validity of an alternative anthropometric trait as cardiovascular diseases risk factor: example from individuals with traumatic lower extremity amputation.

BACKGROUND: Published studies reveal that individuals with lower extremity amputation are vulnerable to cardiovascular diseases (CVD) because of poor physical activity level. Many cardiovascular risk assessment studies have utilized anthropometric traits (primarily body mass index and waist circumference) as cardiovascular risk factor. However, some studies emphasized the technical limitations of measuring waist circumference for studying cardiovascular risk, and so it is difficult to obtain correct measurement from the individuals with lower extremity amputation. OBJECTIVES: The objectives of the present article are to study the prevalence of CVD risk factors among the individuals with traumatic lower extremity amputation and to test the validity of upper arm circumference (UAC) as an alternative anthropometric measurement for screening the CVD risk condition. SUBJECTS AND SETTING: Anthropometric data and other cardiovascular traits data have been collected from unilateral traumatic lower extremity amputated adult males (n = 85) residing in Calcutta and adjoining areas. RESULTS: Results show higher prevalence of cardiovascular risk factor among individuals with above-knee amputation than below-knee amputation. The receiver operating characteristics curve analysis shows significant ability of upper arm circumference to diagnose cardiovascular risk condition. The cutoff value of UAC > 26.6 cm show maximum sensitivity and specificity for the diagnosis of cardiovascular risk condition. Although, binomial tests for equality of proportion does not show any significant difference, however, agreement statistics reveal better diagnostic ability of cutoff value of UAC than the existing cutoff value of waist circumference. CONCLUSIONS: Therefore, UAC provides a better assessment of cardiovascular risk condition than does waist circumference especially for individuals with lower extremity amputation. SPONSORSHIP: Indian Statistical Institute, Kolkata.

Adult↗
PubMed2003

The long-term mobility and mortality of patients with peripheral arterial disease following bilateral amputation.

OBJECTIVES: To study the postoperative course, mobility, housing conditions and the mortality following bilateral amputations in patients with peripheral arterial occlusive disease (PAD). DESIGN: Part retrospective, part prospective open study. SETTING: Vascular unit of a university hospital. PATIENTS: Sixty-six consecutive patients with PAD undergoing bilateral trans-metatarsal (TM), below-knee, through-knee and above-knee amputations between 1980 and 1989 were studied. Their medium are at the time of an amputation in the second limb was 58 years (range 27-91 years). CHIEF OUTCOME MEASURES: Initial and subsequent amputation levels, co-morbidity, mobility, housing conditions and mortality were recorded from 1989 until 2001. MAIN RESULTS: Follow-up was 98%. Hospital mortality after amputation of the second leg was 12%. The mortality after 2 years was 38% and after 5 years 69%. At the end of the observation period, truly three patients were still alive (15%). Coronary heart disease was the leading cause of death and accounted for 37%, cerebro-vascular incidents for 14%. During follow-up, 56% of the patients needed at least one stump revision or reamputation to a higher level. Reamputations occurred after TM in 63%, below-knee in 42% and/through-knee amputations in 69%, respectively. Of 58 patients who were discharged, 38% became able to walk, 52% were mobile with a wheelchair and 10% remained bedridden. Of the patients who were able to walk, 82% returned to individual homes as compared to 63% of those who were mobile with a wheelchair. CONCLUSIONS: Amputation levels should be kept as distal as possible in the interest of mobility which is one of the primary keys to social reintegration. However reamputations to higher levels are frequent as PAD progresses. The well-known very high mortality is clearly related to generalised atherosclerosis.

Adult↗
PubMed2003

Discharge destination after dysvascular lower-limb amputations.

OBJECTIVE: To examine postacute care rehabilitation services use after dysvascular amputation. DESIGN: State-maintained hospital discharge data from the Maryland Health Services Cost Review Commission were analyzed. SETTING: Maryland statewide hospital discharge database. PARTICIPANTS: Persons discharged from nonfederal acute care hospitals from 1986 to 1997 with a procedure code for lower-limb amputation (ICD-9-CM code 84.12-.19), excluding toe amputations. Those persons with amputations due to trauma, bone malignancy, or congenital anomalies were excluded. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Postacute care service utilization. RESULTS: There were 16,759 discharges with an amputation procedure over this period. The average age was 69.3+/-14.3 years, and 51.9% were men. Black persons comprised 42.4% of the sample. Diabetes was present in 42.0%, and peripheral vascular disease was noted for 66.1% of amputees. Amputations were at the foot (19.4%), transtibial (38.1%), and transfemoral (42.4%) levels. The largest proportion (40.6%) of patients was discharged directly home after acute care, 37.4% went to a nursing home, 9.2% went home with home care, and 9.6% were discharged to an inpatient rehabilitation unit. From 1986 to 1997, there were downward trends in the rate of discharges directly home and corresponding upward trends in nursing home and inpatient rehabilitation dispositions. CONCLUSIONS: Inpatient rehabilitation use is infrequent after dysvascular amputation. Prospective studies are necessary to examine outcomes for persons receiving rehabilitation services in different care settings to define the optimal rehabilitation venue for functional restoration.

Aged↗
PubMed1990

The Syme amputation: success in elderly diabetic patients with palpable ankle pulses.

The Syme amputation is an old operation that has been used during this century primarily as a means of treating traumatic injuries to the forefoot in military patients. In 1984 we made a deliberate attempt to perform the operation in a highly selective group of dysvascular patients with forefoot necrosis who happened to have a palpable posterior tibial pulse. We reviewed the charts of 26 patients who underwent a one-stage (3 patients) or two-stage (23 patients) Syme amputation. The mean age was 60 years, (range 32 to 74 years). There were 17 insulin-dependent diabetic patients, and 3 diet-controlled diabetic patients. Twenty-two patients (85%) had a palpable posterior tibial pulse before surgery. Fourteen patients (54%) underwent a preliminary Ray (4) or transmetatarsal (10) amputation to rid the forefoot of an active infection. Overall, 20 patients (77%) had successful Syme amputations. Nineteen of 22 patients (85%) with a palpable posterior tibial pulse had a successful amputation in contrast to one out of four patients (25%) who did not have a palpable pulse before surgery (p = 0.04). The mean follow-up of all patients was 23 months. The durability of the operation was demonstrated in finding that only one patient in 20 initially successful Syme amputations required revision to the below-knee level. The two-stage Syme amputation can be a very gratifying operation with success rates approaching 85%, even if offered to elderly diabetic patients. The single most important feature for success is to limit the operation to those patients with a palpable posterior tibial pulse before operation.

Amputation, Surgical↗
PubMed2003

Health related quality of life and related factors in 539 persons with amputation of upper and lower limb.

PURPOSE: Limb amputation is followed by an important rehabilitation process, especially when a prosthesis is involved. The objective of this study is to assess the nature of factors related to health related quality of life (HRQL) of persons with limb amputation. METHOD: The Nottingham Health Profile (NHP) treated 1011 subjects with major amputation of one or several limbs. Correlations were sought in multivariate regression model analyses between the six categories of distress explored by the NHP and age, sex, cause and level of amputation and rehabilitation programme. RESULTS: Response rate was 53.3%. HRQL measured by the NHP was mostly impaired in the categories of physical disability, pain and energy level. Controlling for sex and age, young age at the time of amputation, traumatic origin and upper limb amputation were independently associated with better HRQL. CONCLUSION: It is concluded that HRQL is largely related to factors which are inherent to the patient and the amputation.

Age Factors↗
PubMedDate not supplied

A two-year longitudinal study of social support following amputation.

PURPOSE: (1) To describe one aspect of social support, social integration, longitudinally for 2 years following lower limb amputation and (2) to explore the impact of social support on depression, pain interference, life satisfaction, mobility, and occupational functioning. METHOD: Eighty-nine adults recruited from consecutive admissions to an orthopaedic surgery service completed telephone interviews 1, 6, 12 and 24 months following amputation surgery. Dependent variables included the Social Integration (SI) sub-scale of the Craig Handicap Assessment and Reporting Technique (CHART) and the Multidimensional Scale of Perceived Social Support (MSPSS). RESULTS: There was a high level of SI among most persons following lower limb amputations that was relatively unchanged in the 2 years following surgery. However, mean levels of SI were lower in this group compared to a sample without disabilities. MSPSS scores were highly variable, ranging from almost no support to the maximum amount of support. MSPSS was an important concurrent predictor of pain interference, life satisfaction, and mobility, controlling for demographic and amputation-related factors. Baseline MSPSS predicted mobility and occupational functioning 6 months post-amputation, controlling for demographic and amputation-related factors. CONCLUSIONS: Findings suggest that interventions aimed at improving the quality of social relationships after amputation may facilitate participation in activities.

Activities of Daily Living↗
PubMed2002

Nerve sheath catheter analgesia after amputation.

Although continuous infusion of local anesthetic through nerve sheath catheters provides excellent pain control after amputation, the influence of this technique on the incidence of phantom limb pain is controversial. The current retrospective study examined the influence of continuous nerve sheath catheter analgesia and primary anesthetic technique (general or regional anesthesia) on the incidence of phantom limb pain. After institutional review board approval, data were gathered on patients who had amputation from 1990 to 1999. Medical records were reviewed to determine the level of and indication for amputation, age at time of amputation, current disease status, date of diagnosis and surgery, and primary anesthetic technique. Six months after amputation, preoperative pain, phantom limb sensations, and phantom limb pain were assessed using a verbal scale ranging from 0 (no pain) to 10 (worst pain) and methods of pain control also were evaluated. Thirty-nine patients completed the study. The incidence of phantom limb pain (visual analog scale score > or = 3) was 67% and was lower than the historic incidence (80%) before the use of this analgesia technique. Incidence of phantom limb pain was higher for patients requiring proximal versus distal amputations. The primary anesthetic technique (general versus regional) did not affect the incidence of phantom limb pain. Long-term followup showed that the incidence of phantom limb pain in patients receiving continuous nerve sheath catheter infusion is lower than previously reported for patients who had amputation for oncologic indications.

Amputation, Surgical↗
PubMed2002

Lower extremity nontraumatic amputation among veterans with peripheral arterial disease: is race an independent factor?

OBJECTIVES: To determine if race/ethnicity is independently associated with an increased risk for nontraumatic lower extremity amputation versus lower extremity bypass revascularization among patients with peripheral arterial disease (PAD). METHODS: Data were analyzed from the National VA Surgical Quality Improvement Program (NSQIP) and from the Veterans Affairs Patient Treatment File (PTF). Race/ethnicity was defined as non-Hispanic white, black, or Hispanic. Variables that were univariately associated (P < or = 0.05) with the outcome of amputation were placed into a multiple logistic regression model to determine independent predictors for the dependent variable, lower extremity amputation versus lower extremity bypass revascularization. RESULTS: Three thousand eighty-five lower extremity amputations and 8409 lower extremity bypass operations were identified. Among all cases included, there were 416 Hispanic patients (3.6%), 2337 black patients (20.3%), and 8741 non-Hispanic white patients (76.1%). Among all variables within the model, Hispanic and black race were each associated with a greater risk for amputation than a history of rest pain/gangrene (Hispanic race 1.4, 95% CI 1.1, 1.9; black race 1.5, 95% CI 1.4, 1.7; rest pain/gangrene 1.1, 95% CI 1.0, 1.3). The final model had a c statistic of 0.83. CONCLUSION: Hispanic race and black race were independent risk factors for lower extremity amputation in patients with PAD. Although the burden of certain atherosclerotic risk factors (eg, diabetes and hypertension) is higher in minority patients, the impact of this burden does not account for the increased risk for the outcome of lower extremity amputation in these two populations. Further research is needed to better understand the reason(s) why race/ethnicity is independently associated with poor outcomes in PAD.

Activities of Daily Living↗
PubMed1999

Reconstruction of fingertip amputations with full-thickness perionychial grafts from the retained part and local flaps.

The treatment of fingertip amputations distal to the distal interphalangeal joint when the amputated part is saved is difficult and controversial. Both reattachment of the amputated portion as a composite graft and microvascular anastomosis are prone to failure in this distal location. The authors have evolved a reconstructive plan that uses the nail matrix, perionychium, and hyponychium of the amputated fingertip as a full-thickness graft when the amputation is between the midportion of the nail bed andjust proximal to the eponychial fold. Various flaps are used to lengthen and augment the finger pulp, and skeletal pinning is carried out as necessary. The charts of 15 patients who underwent this procedure over a 38 month period were evaluated retrospectively. Seven returned to the office for examination at least 1 year after the fingertip reconstruction described above; four others were interviewed by telephone. Nail deformity, fingertip sensation, and joint range of motion were evaluated, and the reconstructed fingertips were photographed in standardized views. In six of the seven patients seen in the office, aesthetic and functional results were judged as good by both patient and physician; one of the six had minimal nail curvature. The seventh patient had no nail growth, although finger length was retained and there was no functional disability. The four patients interviewed by phone reported normal fingertip use with no dysesthesias or cold intolerance; all had nail growth, although three patients described slight nail curvature that required care in trimming. The authors favor salvage of all perionychial parts when a distal fingertip amputation occurs. Reconstruction of the fingertip with grafting of the hyponychium, perionychium, and nail matrix from the amputated part combined with local flaps can provide a very satisfactory functional and aesthetic result.

Adolescent↗
PubMedDate not supplied

Farm-related limb amputations in children.

The purpose of this study was to review results for children sustaining traumatic farm-related limb amputations. Farm machinery accidents were responsible for 12 limb amputations among 260 consecutive childhood traumatic amputations. All amputations resulted in open, grade III-C fractures. Treatment consisted of operative debridement, antibiotics, possible replantation, and delayed wound closure. Mean follow-up was 8 years (range 1-20). Wound closure was achieved at a mean of 22 days (range 2-88) after an average of seven operative procedures (range, 2-11 operations). Skin grafting was necessary for 9 of the 12 limbs. Blood replacement was necessary for all but one patient. Initial wound cultures revealed polymicrobial contamination in all patients. Clinical infections developed exclusively and in all (6/6) patients who underwent attempted replantation. Replantation was considered in all cases and was attempted for six limbs but was successful in only two patients. Failure of replantation in four limbs was due to vascular insufficiency and infection. The surviving replanted limbs have continued to grow and have regained protective sensation. Prosthetic use ranges from excellent to intermittent among the 10 patients with permanent amputation. Farm-related limb amputations are among the most severe orthopaedic injuries sustained by children. Despite massive contamination, infection occurred only in replanted limbs. Because of the mutilating nature of these amputations, less than 20% can be successfully replanted.

Adolescent↗
PubMed2005

Promoting primary healing after ray amputations in the diabetic foot: the plantar dermo-fat pad flap.

BACKGROUND: Amputation of the toe at the level of the distal metatarsal head (ray amputation) is a common surgical procedure in diabetic foot ulcers. The aim of this study was to introduce a new technique promoting primary healing by minimizing the dead space with the plantar dermo-fat pad flap after central ray amputation in diabetic foot ulcers. METHODS: Thirty-eight patients who had undergone central ray amputation and closure with the plantar dermo-fat pad flap between 1996 and 2003 were incorporated into the study. RESULTS: The mean follow-up period was 3.56 years. Single and multiple middle toe amputations were performed in 33 and five cases, respectively. In 14 cases with acute infection, split-thickness skin graft was used with the plantar dermo-fat pad flap to close the defect on the foot dorsum. Healing time was uneventful in all patients except three (8 percent), who were healed with local wound care. No patient showed signs of ulceration at the operative site during the follow-up. The mean time to total healing was 40.31 +/- 34.56 days. CONCLUSIONS: The plantar dermo-fat pad flap promotes primary wound healing after central ray amputation in diabetic foot ulcers by filling the dead space. The osteotomy to the base of the remaining adjacent metatarsal base in an effort to close the defect can be avoided by using the plantar dermo-fat pad flap; thus, undesirable angulation of the remaining parts of the foot can be eliminated. The plantar dermo-fat pad flap also supports the weak articular capsule of the adjacent metatarsophalangeal joints while covering the amputated metatarsal end. The thick, healthy plantar soft tissue advanced up to the width of the deepithelialized area reestablishes a good, tough plantar surface which--in association with the pad effect of the flap--decreases the recurrence rates and provides comfortable ambulation.

Amputation, Surgical↗
PubMedDate not supplied

Function of children with myelodysplasia and lower extremity amputations.

This is a retrospective study of the functional status of children who underwent a lower extremity amputation for complications of myelodysplasia. With a computerized surgical database, 12 children with myelodysplasia who underwent an amputation at the Boyd level or above at a single children's referral hospital between 1983 and 2001 were identified. Four patients could not be contacted, but the remaining 8 patients were evaluated through chart review and interview to assess the impact of the amputation on their function. With a mean follow-up time of 9 years (range, 5-15 years), all 6 of the patients with a below-knee or Boyd amputation continued to ambulate using a prosthesis. Most patients occasionally reported having ulcers on their residual limb, but these cases were easily managed and did not result in amputation revisions.The only patient in this series with an above-knee amputation and the only patient with a knee disarticulation were exclusively wheelchair ambulators and no longer owned a prosthesis. This study supports the notion that children with myelodysplasia can have amputations and successfully wear a prosthesis to maintain their ambulation.

Adolescent↗