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PubMed1986

Skin blood flow measurement with xenon-133 to predict healing of lower extremity amputations.

Many techniques have been proposed to help the surgeon select the most distal amputation level that will heal. Skin blood flow measurement with xenon-133 (133Xe) is one of the best documented predictors of amputation healing, but the lowest flow consistent with healing has not been agreed upon. Our early experience with the method is reported. Skin blood flow was measured in 16 patients undergoing 17 lower extremity amputations. Twelve amputations healed (mean skin blood flow 3.69 +/- 2.73 ml/100 g of tissue/min) and five failed (mean skin blood flow 0.80 +/- 0.61 ml/100 g of tissue/min) (P less than 0.05). No amputation healed if the skin blood flow was less than 1.0 ml/100 g of tissue/min. A skin blood flow above 1 ml/100 g of tissue/min, measured with 133Xe, may be a useful guide to the level at which to amputate while minimizing unnecessary proximal amputation, but the method requires further prospective evaluation.

Aged↗
PubMed2001

Potentiation of sensory responses in the anterior cingulate cortex following digit amputation in the anaesthetised rat.

The anterior cingulate cortex (ACC) is important for processing different types of information, including sensory inputs. In the present study on anaesthetised rats, we recorded in vivo sensory responses of the ACC to peripheral electrical shocks. Peripheral electrical stimulation at high intensities sufficient to activate nociceptive sensory fibres elicited EPSPs within the ACC. Digit amputation caused long-lasting potentiation of ACC responses to peripheral electrical stimulation. Evoked field EPSPs remained enhanced for at least 120 min after the amputation. Because electrical shocks were delivered to the normal hindpaw, it is likely that plastic changes occur centrally in the spinal cord or the supraspinal structures following amputation. We also recorded field EPSPs of the ACC in response to focal cortical stimulation within the ACC. Like the sensory responses, field EPSPs produced by focal cortical stimulation within the ACC were potentiated after digit amputation, suggesting that long-lasting changes occurred locally within the ACC. Local blockade of peripheral activity by QX-314 at the amputated hindpaw 120 min after amputation did not significantly affect sensory responses induced within the ACC. Thus, peripheral ongoing inputs do not play an important role in maintaining potentiation within the ACC. Two pulses of hindpaw stimulation caused paired-pulse depression in the ACC. Local stimulation within the ACC also caused depression of sensory responses to hindpaw stimulation, suggesting that the population of synapses activated by local stimulation may overlap with that activated by peripheral hindpaw stimulation. Our results suggest that rapid enhancement of sensory responses can be observed in the ACC after amputation and that enhanced neuronal responses to subsequent somatosensory stimuli may contribute to phantom-limb pain.

Amputation, Surgical↗
PubMed2001

The effect of age, gender, risk level and glycosylated hemoglobin in predicting foot amputation in HMO patients with diabetes.

PURPOSE: To determine if age, gender, risk level and glucosylated hemoglobin could predict foot amputations in HMO patients with diabetes. DATA SOURCES: A retrospective chart review of a non-random sample of 27 patients with amputation and 110 randomly selected patients without amputation during the same time period. Chi-square, t-tests and logistic regression were used to analyze the data. CONCLUSIONS: There was no significant difference between the group with amputation and those without amputation in age or gender. However, there was a significant difference between the two groups in the risk stratification (p = .005) and glycosylated hemoglobin levels (p = .058). IMPLICATIONS FOR PRACTICE: Nurse practitioners can effectively screen for amputation risk factors and closely monitor glycosylated hemoglobin levels of diabetic patients to reduce the incidence of vascular complications and related lower extremity amputation.

Adult↗
PubMed2006

Health-related quality of life in patients with transtibial amputation and reconstruction with bone bridging of the distal tibia and fibula.

BACKGROUND: Bone-bridging (arthrodesis of the distal tibia and fibula) at the time of transtibial amputation is a controversial operative technique that is anecdotally reported to improve the weightbearing capacity of the residual limb and to decrease residual limb discomfort. METHODS: Thirty-two consecutive patients with multiple diagnoses had transtibial amputation with a distal tibial-fibular bone-bridge, all done by a single surgeon (MAP). At an average of 16.3 months after surgery all patients completed the Prosthetics Evaluation Questionnaire (PEQ), a validated outcomes instrument specifically created to evaluate quality of life and functional demands in patients with a lower extremity amputations. Their responses were compared with those of 17 preselected, highly functional transtibial amputees from two academic medical centers who previously had transtibial amputations using a traditional non bone-bridge operative technique; their time since amputation averaged 14.7 years. RESULTS: The "nonselected" consecutive patients with a bone-bridged residual limb scored higher (more favorable) in the Ambulation (p = 0.037) and Frustration (p < 0.001) domains of the PEQ and lower (less favorable) in the Appearance (p = 0.025) subscale. Their scores were similar in the other six domains. CONCLUSIONS: Patients of multiple ages with multiple diagnoses who had bone-bridging of the distal tibia and fibula at the time of transtibial amputation had scores on a validated outcomes instrument that were better than or comparable to those of a selected group of highly functional transtibial amputees. The results of this study suggest that bone-bridging at the time of transtibial amputation may enhance patient-perceived functional outcomes.

Adolescent↗
PubMed1994

Outpatient foot care: correlation to amputation level.

A retrospective analysis of Department of Veterans Affairs automated inpatient and outpatient records was performed for 3945 patients who underwent lower extremity amputation surgery due to peripheral vascular disease during fiscal year 1991. Demographic and clinical data were collected from reviewing patient database information for all Department of Veterans Affairs Hospitals nationwide. Patients were identified from the Physicians' Current Procedural Terminology codes for lower extremity amputations, and then divided into three groups (above the knee, below the knee, and foot and ankle) based on the most proximal level of amputation performed. Results indicate that increased use of designated foot care clinics was significantly associated with more distal level amputation surgery. Patients with above-the-knee amputations averaged 1.0 foot care clinic visit in the 2 years prior to amputation, whereas below-the-knee and foot and ankle amputees averaged 2.8 and 5.3 foot care clinic visits, respectively (F[df = 2,3939] = 94.20, P < .05). The same finding was noted when only users of foot care clinics were examined. Patients with a codiagnosis of diabetes were more likely to undergo distal amputation than those with other diagnoses (P < .05). The results of this study suggest the potential effectiveness of designated foot care clinics in preserving limb length in individuals with peripheral vascular disease and diabetes.

Adult↗
PubMed2004

Perioperative and rehabilitation outcome after lower-limb amputation in elderly Chinese patients in Hong Kong.

PURPOSE: Major amputation of the lower limb is considered the last resort when limb salvage is impossible. The aim of this study is to determine the morbidity, mortality, and rehabilitation outcome of patients that underwent a lower-limb amputation. METHODS: A retrospective cohort study was conducted among 100 elderly patients who underwent a total of 120 lower-limb amputations in a regional hospital in Hong Kong from 1996 to 2001. RESULTS: The mean age of the amputees was 77.9 years; 58 were female. 95% of the amputations were performed because of infection with or without vascular compromise; 55 transfemoral and 60 transtibial amputations contributed 96% of the case mix. Some 43% of patients experienced early complications and 12% required re-amputation. The early (30-day) mortality rate was 15%. Only 55% of the amputees survived after 4 years. A 44% return-home rate was achieved. However, only 11% of the amputees could walk without help from other people. Although prostheses were issued to 42% of the survivors, compliance was only 53%; 24% of the survivors lost their remaining leg within 2 years. CONCLUSION: The outcome of major lower-extremity amputation remains poor. Efforts should be made to retain these limbs. When it is proven impossible, one should strive to preserve the knee joint whenever feasible.

Aged↗
PubMed1999

Long-term reorganization of motor cortex outputs after arm amputation.

OBJECTIVE: To investigate the reorganization of the corticospinal system long after arm amputation at different levels. METHODS: Focal transcranial magnetic stimulation (TMS) was performed in 15 patients 21 to 65 years after arm amputation at the level of the forearm, upper arm, or shoulder. Cortically elicited electromyographic responses were investigated in muscles immediately proximal to the stump. TMS was performed on a skull surface grid overlying the motor cortex. The response threshold, number of effective stimulation sites, and the sum of the amplitudes elicited at these sites were evaluated for slightly contracted muscles. RESULTS: Seven of eight patients with forearm amputation had larger stimulation effects in the biceps supplied by the motor cortex contralateral to amputation, as indicated by variable patterns of lowered response thresholds, increased response amplitudes, or increased numbers of effective stimulation sites. In seven patients with a more proximal amputation, the motor responses were investigated in the deltoid and trapezoid muscle. In only two of them, the motor cortex contralateral to amputation showed an increased excitability. Three patients presented with a higher excitability of the motor cortex contralateral to the intact arm and two with a balanced type of excitability. CONCLUSION: Reorganization of the motor system can be present more than 20 years after amputation. Furthermore, differential patterns of reorganized corticospinal output were found for different stump muscles, which might be due to varying amounts of ipsilateral corticospinal projections.

Adult↗
PubMed1997

Management of fibular hemimelia: amputation or limb lengthening.

We reviewed retrospectively 22 patients (23 limb segments) with fibular hemimelia treated by amputation or limb lengthening to evaluate these methods of treatment. There were 12 boys and 10 girls, all with associated anomalies in the lower limbs. Twelve patients (13 limb segments) had early amputation and prosthetic fitting and ten had tibial lengthening using the Ilizarov technique. At the latest follow-up, the twelve patients who had amputation were functioning well and had few complications. The ten patients who had lengthening had suffered numerous complications, and all had needed either further corrective surgery or to wear braces or shoe-raises. Two of the ten lengthened limbs required late amputation for poor function or cosmesis. There were fewer hospital admissions, clinic visits, and periods of absence from school in the amputation group. Our findings suggest that amputation is a more effective method of management than limb-lengthening in severe fibular hemimelia. The Ilizarov method is an attractive alternative for selected patients, but its exact role is not yet established. One problem is that families often have unrealistic expectations of the surgical and prosthetic technology available and may refuse amputation when this has been recommended.

Amputation, Surgical↗
PubMed2005

A method for determining the rate of major limb amputations in battle casualties: experiences of a British Field Hospital in Iraq, 2003.

INTRODUCTION: The majority of battle casualties undergoing surgery at 34 Field Hospital, the sole Coalition field hospital in Iraq during the conflict, sustained injuries to the extremities. To compare our experiences with those from previous conflicts, we report data on major limb amputations and propose a method for determining the rate of major limb amputation in a conflict setting. PATIENTS AND METHODS: A retrospective review of battle casualties admitted to the hospital was carried out based on casualty records and operating theatre logbooks. Data were collected for the period 26 March and 8 May 2003, focusing on casualties undergoing surgery for battle-injured extremities during the conflict. RESULTS: 68 (55%) casualties underwent surgery for battle injuries to extremities. Six upper and eight lower limb amputations (proximal to carpals and tarsals) were carried out from a total of 87 battle-injured limbs that had surgery, giving an overall amputation rate of 16% (14/87). CONCLUSIONS: In presenting our amputation rate of 16%, we highlight the lack of uniformity in describing 'amputation rates' between conflicts. A consistent method for quantifying amputations performed in a conflict setting could prove to be a useful tool.

Amputation, Surgical↗
PubMed1999

Rates of lower-extremity amputation and arterial reconstruction in the United States, 1979 to 1996.

OBJECTIVES: This report describes trends in the rates of lower-extremity amputation and revascularization procedures and vascular disease risk factors. METHODS: We analyzed trends in National Hospital Discharge Survey data for 1979 through 1996 and in National Health Interview Study data for 1983 through 1994. RESULTS: Despite a decline between 1983/84 and 1991/92, by 1995/96 the rate of major amputation had increased 10.6% since 1979/80. The earlier 12-year decline was positively correlated with reductions in the prevalence of smoking (r = 0.88, P < .0001), hypertension (r = 0.65, P = .02), and heart disease (r = 0.73, P = .007), but not diabetes (r = -0.33, P = .29). During the 1980s, amputation and angioplasty rates were inversely correlated (r = -0.75, P = .001), but the decline in amputation rates occurred before the increase in angioplasty. The major amputation rate, which has increased since 1993, was 24.95 per 100,000 people in 1996. CONCLUSIONS: Major amputation rates fell in the years following the diffusion of distal bypass surgery but before the widespread use of peripheral angioplasty. Because disease prevalence and primary amputation rates are unknown, it is difficult to estimate the contribution of recent improvements in vascular surgery to limb preservation.

Adult↗
PubMed1993

Open tibial fractures with severe soft-tissue loss. Limb salvage compared with below-the-knee amputation.

The long-term outcomes and the quality of life were studied in patients who had had an open fracture of the tibial shaft with severe soft-tissue loss. Limb salvage with a free flap was attempted in twenty-seven patients (sixteen of whom had a successful procedure and were examined personally by us), while eighteen patients were managed concurrently with an early below-the-knee amputation. Soft-tissue coverage was successful in all but one patient in whom limb salvage had been attempted. Ultimately, however, five extremities were amputated, with an infection at the site of a non-union being the most common reason for amputation. The patients who had had limb salvage had more complications (p < 0.001), more operative procedures (p < 0.001), and a longer stay in the hospital (p < 0.05) than the patients who had had an early below-the-knee amputation. The long-term functional results for sixteen patients who had had a successful limb-salvage procedure (average duration of follow-up, thirty-five months) were compared with those for eighteen patients who had had a below-the-knee amputation (average duration of follow-up, forty-four months). The patients who had had a successful limb-salvage procedure took significantly more time to achieve full weight-bearing (p < 0.05), were less willing or able to work (p < 0.01), and had higher hospital charges (p < 0.006) than the patients who had been managed with an early below-the-knee amputation. They also had a significant decrease in motion at the ankle and subtalar joint in the injured leg compared with the contralateral leg (p < 0.001). A quality-of-life evaluation was possible for only thirteen of the patients who had had a successful limb-salvage procedure and for sixteen of the patients who had had a below-the-knee amputation. The two groups were similar in terms of their responses, but significantly more patients who had had limb salvage considered themselves severely disabled (p < 0.05). They also had more problems with the performance of occupational and recreational activities (p < 0.05). This study confirmed the reliability of modern microvascular free tissue techniques for the coverage of large soft-tissue defects associated with tibial fractures. It also showed that complications and difficulties in the restoration of osseous union are common and may be directly related to the less satisfactory functional, occupational, recreational, and quality-of-life outcomes that are seen in many patients who have had limb salvage.(ABSTRACT TRUNCATED AT 400 WORDS)

Adolescent↗
PubMed2000

Correlations with patients' perspectives of the result of lower-extremity amputation.

BACKGROUND: Patients' perceptions of the result of lower-extremity amputation vary widely, yet the factors associated with this variability are not well understood. Our objective was to identify important correlations with the perceived result that may help to indicate the factors that deserve particular emphasis in the management of patients who have had an amputation. METHODS: In this retrospective study, 148 patients who had had a major lower-extremity amputation completed a standardized questionnaire designed to assess the demographic characteristics, comorbidities, amputation characteristics, prosthetic function, and social function at a mean of seven years after surgery. We correlated each of these variables with four result metrics: general satisfaction, quality of life, freedom from frustration, and walking distance. RESULTS: The four result metrics were significantly and strongly correlated with (1) the comfort of the residual limb; (2) the condition of the contralateral limb; (3) the comfort, function, and appearance of the prosthesis; (4) social factors; and (5) the ability to exercise recreationally (p < 0.0001). Interestingly, the level and laterality of the amputation were not significantly correlated with the patients' perceived result. CONCLUSIONS: The perceived result of amputation is not associated with the amount of the limb that was amputated but rather with factors that may be optimized by surgical, prosthetic, and social management.

Amputation, Surgical↗
PubMed1994

Critical leg ischaemia in New Zealand: economic cost of amputation versus intravenous iloprost.

The purpose of this study was to establish the incidence of surgical amputation for critical leg ischaemia in New Zealand, and estimate the hospital, prostheses and indirect costs of this intervention. The cost of amputations was then compared with the cost of treating such patients with iloprost. The study was retrospective. Individual patient records relating to 1991 for both public and private hospitals were analysed. Unit costs relevant to 1991 were applied to the volume data of patients and procedures to derive total costs. Costs were estimated on an incremental basis taking a societal perspective. Conservative estimates were obtained for hospital costs, prostheses and for production loss (loss of output or productivity). Total cost was $NZ15.9 million (hospital and prosthesis cost $NZ13.1 million, production loss $NZ2.8 million). The total quantified cost per amputation was $NZ23 038 (hospital and prosthesis cost $NZ19 020, production loss $NZ4017). 32% of patients requiring amputations were in the working age group. The theoretical avoidance of amputation by treatment with iloprost resulted in net savings of hospital and prosthetic costs of between $NZ6660 and $NZ8720 per patient. Amputation for critical leg ischaemia is costly and has a high mortality, but for iloprost treatment to be cost effective in a New Zealand hospital setting, patients must be targeted and a success rate of at least 55% achieved in avoidance of amputation and reduction of pain while at rest.

Amputation, Surgical↗
PubMed2002

Foot ulceration and lower limb amputation in type 2 diabetic patients in dutch primary health care.

OBJECTIVE: To determine the incidence of foot ulceration and lower limb amputation in type 2 diabetic patients in primary health care. RESEARCH DESIGN AND METHODS: Data on type 2 diabetes were collected by the Nijmegen Monitoring Project between 1993 and 1998 as part of a study of chronic diseases. The records of all patients recorded as having diabetic foot problems and those who died, moved to a nursing home, or were under specialist care were included. The annual incidence of foot ulceration was defined as the number of type 2 diabetic patients per patient-year who developed a new foot ulcer. Incidence of lower limb amputation was similarly defined. Additional information was collected on treatment of foot ulcers. RESULTS: The study population of type 2 diabetic patients increased from 511 patient-years in 1993 to 665 in 1998. The annual incidence of foot ulceration varied between 1.2 and 3.0% (mean 2.1) per year; 25% of the patients had recurrent episodes. The annual incidence of lower limb amputation varied between 0.5 and 0.8% (mean 0.6). Ten of the 15 amputees died, and 12 of 52 (23%) patients with ulceration had a subsequent amputation or a previous history of amputation. In 35 of the 73 (48%) episodes of ulceration, only the family physician provided treatment. Patients with foot problems were older and had more cardiovascular disease, retinopathy, and absent peripheral pulses. CONCLUSIONS: The incidence of foot ulceration and lower limb amputation in type 2 diabetes is low; nevertheless, recurrence rates of ulceration and risk of amputation are high, with high mortality.

Age Factors↗
PubMed2003

Ulcer recurrence following first ray amputation in diabetic patients: a cohort prospective study.

OBJECTIVE: To evaluate the reulceration and reamputation rates in a cohort of diabetic patients following first ray amputation. RESEARCH DESIGN AND METHODS: We evaluated a cohort of 89 diabetic patients, 63 men and 26 women, who underwent first ray amputation in the period from January 2000 to December 2001. The first ray lesions were Wagner grade 2 in 3 patients, Wagner grade 3 in 47 patients, and Wagner grade 4 in 39 patients. Following surgical wound healing, all patients wore special footwear with rocker bottom soles and custom molded insoles and were put on an intensive secondary prevention program. RESULTS: The mean follow-up duration was 16.35 +/- 6.76 months (range 7-28). Fifteen patients developed new ulcerations, with 11 lesions occurring ipsilaterally and 4 contralaterally to the first ray amputation. In seven patients, the new lesion was treated and healed with dressing. Eight patients underwent a new surgical procedure: panmetatarsal head resection in four patients, toe amputation in two patients, a transmetatarsal amputation in one patient, and Lisfranc's amputation in one patient. CONCLUSIONS: In the population studied, the first ray amputation presented a lower reulceration and reamputation rate with respect to that reported in the literature. This finding should therefore be attributed to the follow-up program, which uses shoes with a rocker bottom sole and custom molded insoles and intensive ambulatory check-ups.

Aged↗
PubMed2006

Risk of reamputation in diabetic patients stratified by limb and level of amputation: a 10-year observation.

OBJECTIVE: This study examined the risk of reamputation, stratified by original level of amputation, in a population of diabetic patients. We also illustrated reamputation rates by ipsilateral and contralateral limbs. RESEARCH DESIGN AND METHODS: The study population included 277 diabetic patients with a first lower-extremity amputation performed between 1993 and 1997 at University Hospital in San Antonio, Texas. Reamputation episodes for the ipsilateral and contralateral limbs were recorded through 2003. Using a cumulative incidence curve analysis, we compared the reamputation rate by limb. Cumulative rates of reamputation were calculated for each limb at each amputation level at 1, 3, and 5 years. RESULTS: Cumulative rates of reamputation per person were 26.7% at 1 year, 48.3% at 3 years, and 60.7% at 5 years. Ipsilateral reamputation per amputation level at the 1-, 3-, and 5-year points were toe: 22.8, 39.6, and 52.3%; ray: 28.7, 41.2, and 50%; midfoot: 18.8, 33.3, and 42.9%; and major: 4.7, 11.8, and 13.3%. For contralateral reamputation, the rates at 1, 3, and 5 years were toe: 3.5, 18.8, and 29.5%; ray: 9.3, 21.6, and 29.2%; midfoot: 9.4, 18.5, and 33.3%; and major: 11.6, 44.1, and 53.3%. CONCLUSIONS: This study showed that a patient is at greatest risk for further same-limb amputation in the 6 months after the initial amputation. Although risk to the contralateral limb rises steadily, it never meets the level of that of the ipsilateral limb. This finding will help clinicians focus preventive efforts and medical resources during individualized at-risk periods for diabetic patients undergoing first-time amputations.

Adult↗
PubMed1992

Function after through-knee compared with below-knee and above-knee amputation.

Fifty-nine amputees, 24 below-knee (BK), 17 through-knee (TK) and 18 above-knee (AK) who had prosthetic replacements, were evaluated using a questionnaire which provided a quantitative and qualitative assessment scale for the prosthetic function. The ability to apply or don the prosthesis was noted in 100% of the BK, 70% of the TK and 56% of the AK amputations (p < 0.001). Daily use of the prosthesis was recorded in 96% of the BK, 76% of the TK and 50% of the AK amputations (p < 0.001). A higher level of amputation resulted in a significantly lower degree of rehabilitation (p < 0.05). The qualitative evaluation shows that the higher the level of amputation, the lower the usefulness of the prosthesis. Four percent of the BK, 12% of the TK and 39% of the AK amputees had no use whatsoever of their prosthesis (p < 0.01). From a functional standpoint, TK amputation should always be considered as the primary alternative to AK amputation when a BK amputation is not feasible.

Aged↗
PubMed1995

Pre and post-amputation mobility of trans-tibial amputees: correlation to medical problems, age and mortality.

This retrospective study compares pre and post-amputation mobility and the influence of age and associated medical problems. Data from the charts of 120 male patients who underwent unilateral trans-tibial (below-knee) amputation at the Dallas Veteran's Administration Hospital between June, 1983 and October, 1991, were collected and analyzed. Mobility was assessed with a six level scale developed by Volpicelli et al. (1983). The presence of cardiac disease, pulmonary disease (COPD), peripheral vascular disease (PVD), diabetes mellitus, degenerative joint disease, blindness, cerebral vascular accident (CVA), and age are correlated with changes in mobility after amputation. Older patients had more medical problems and lower post-amputation scores Individual medical problems did not influence mobility scores, but the presence of COPD and PVD lowered pre-amputation mobility scores. Cardiac disease and diabetes mellitus influenced post-amputation mobility scores by lowering them, either together or individually. Regardless of age, however, patients with more medical problems were poor ambulators. The cause of amputation per se did not influence mobility scores.

Activities of Daily Living↗