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PubMed1992

Electron microscopic observations of degeneration of human Pacinian corpuscles in amputated fingers.

Amputated human fingers were used to observe the morphologic changes in degeneration of Pacinian corpuscles, and postoperative moving two-point discrimination of the replanted fingers was examined to analyze sensory recovery after replantation. Normal corpuscles are composed of an axon terminal and inner and outer cores, resembling a sliced onion. The inner core is composed of thin, multilayered lamellar cells, and the outer core consists of multiple layers of thin perineurial cells. Based on our morphologic findings, following mitochondrial degeneration in the axon terminal, the terminal and inner core cells disappeared within 9 to 16 hours, but the outer core did not lose its structure until more than 24 hours after amputation. Collagen fibrils in the corpuscles appeared from 5 hours after amputation and periodically increased their amount up to 27 hours after amputation. Postoperative sensory recovery of the replanted fingers was significantly poorer with 9 hours or more of cold ischemia. These findings suggest that the inner core cells originating from Schwann cells degenerate at over 9 hours after amputation, and this may be related to the poor sensory recovery of replanted fingers. It also appears that the outer core cells originating from the perineurial cells in the amputated fingers survive even up to 27 hours after amputation and produce collagen fibrils in the extramatrix spaces of the outer core cells.

Adult↗
PubMed1990

Physiologic amputation for acute pedal sepsis.

There are three options for management of pedal sepsis requiring lower extremity amputation: one-stage emergency, two-stage guillotine, or physiologic amputation. The excessive mortality usually ascribed to amputation surgery is basically derived from the selection of one of these options in emergency situations, with published mortalities of 10 per cent to 40 per cent being the norm. We have performed 465 lower-extremity amputations for vascular insufficiency for seven years, with overall 30-day operative mortalities of 0.5 per cent for below-knee amputations and 2.7 per cent for above-knee amputations. One hundred sixteen of these patients presented with acute pedal sepsis superimposed on significant medical disability, and were managed initially with physiologic amputation and intensive hemodynamic monitoring; the overall mortality for this select group was 5.1 per cent. An algorithm of management of patients presenting with acute pedal sepsis has thereby been derived, and is herein presented.

Acute Disease↗
PubMed1989

Major amputation for advanced malignant melanoma.

The Memorial Sloan-Kettering Cancer Center experience with major amputation for advanced malignant melanoma from 1965 to 1984 is reported. This is a retrospective review of 58 patients who underwent hemipelvectomy, disarticulation of the hip and above knee or forequarter amputation for advanced or recurrent malignant melanoma. Major amputation with curative intent was performed upon 43 patients. There were three deaths that occurred 30 days postoperatively (7 per cent). Intransit metastasis was one of the indications for amputation in 33 patients, and local control of disease was achieved in 30 of 43 patients. The median time to recurrence in those patients who did have a recurrence was 12 months (a range of 18 days to 16 years). Fifteen of 40 patients who survived the operation had no evidence of disease five years after undergoing a major amputation. Age, sex, primary site, stage of disease at diagnosis and amputation, disease-free interval and positive node status at any time during the course of the disease were not predictive of the outcome. Neurovascular involvement with melanoma and positive margins of resection predicted early failure. A palliative amputation for impending major vascular disruption or extensive, fungating disease was performed upon 15 patients. There was one death 30 days after the operation, and generally, hospitalization did not exceed 30 days. Median survival time was five months. All of the patients died of local or distant disease within 33 months of treatment. Local recurrence preceded death in nine of 15 patients.

Adolescent↗
PubMed1988

Sequelae of limited amputation.

Ninety patients underwent toe amputations because of vascular disease; 21% required higher amputation and 21% healed without further surgery (i.e., revascularization). Of 60 patients who required bypass surgery, 52 underwent successful first amputations and eight required higher amputations. No difference was seen between diabetic and nondiabetic patients in eventual limb salvage; however, men fared better than women. Without bypass surgery, 11 of 30 patients required a higher level of amputation. No patient's toe amputation site healed with an ankle-to-brachial index of less than 0.35. The judicious use of toe amputation remains an important tool in the surgeon's quest for limb salvage.

Adult↗
PubMed1988

Blastema cell proliferation in vitro: effects of limb amputation on the mitogenic activity of spinal cord extracts.

Primary cultures of mesenchymal cells of axolotl limb blastemas provide a very sensitive in vitro bioassay for studying nerve dependence of newt regeneration. These cells can be stimulated by crude spinal cord extracts of non-amputated animals in a dose-dependent manner up to 60 micrograms protein/ml of culture medium; at this concentration the mitotic index is increased 4-fold. Spinal cord extracts of axolotls 14 days after forelimb amputation (i.e., late bud stage) are more efficient in stimulating blastema cell proliferation (+50%) than extracts of axolotls 7 days after forelimb amputation (i.e., early bud stage) or of axolotls without amputation. In a similar manner, spinal cord extracts of young axolotls 14 days after forelimb amputation, are more stimulatory than older axolotls 14 d after forelimb amputation which regenerate only a very small blastema during the same time. It appears that spinal cord mitogenic activity is enhanced after limb amputation, probably in correlation with blastema cell requirements for limb regeneration.

Ambystoma mexicanum↗
PubMed1986

Amputations at the middle level of the foot. A retrospective and prospective review.

Recent trends in amputation surgery favor amputation at the most distal level to preserve the patient's ability to walk. This paper reports the results of sixty-four amputations performed at the level of the middle of the foot in fifty-eight patients. All were performed in patients with peripheral vascular disease who had a diagnosis of either gangrene or resistant, nonhealing ulcers. Forty-three patients (74 per cent) had diabetes. Nutritional evaluation of the patient was used to improve the potential for healing. In the initial forty-six patients, a retrospective review of the serum albumin level, the blood total-lymphocyte count, and the Doppler ischemic index was performed. A prospective study was performed in the final twelve patients, in whom a minimum level in each of these three factors was required before the distal amputation was done. The healing rate for all sixty-four amputations was 81 per cent. When all three factors were above the minimum level, the healing rate was increased to 92.2 per cent. When one or two of the factors was below the minimum level, the rate of healing decreased to 38.5 per cent. Aggressive distal amputation can be performed with a high rate of success when the factors influencing the decision on the amputation level include non-invasive vascular testing and nutritional evaluation.

Aged↗
PubMed1985

The results of replantation after amputation of a single finger.

We reviewed fifty-nine consecutive cases of patients who had replantation of a single finger (excluding the thumb) after traumatic amputation, with an average follow-up of fifty-three months. Fifty-one (86 per cent) of the replanted fingers survived. Survival was found to be affected by the age of the patient, the number of vessels that were anastomosed, and the replantation experience of the surgeons. The survival rate was not affected by the gender of the patient, the mechanism of injury, or which finger was amputated. As compared with survival only, the functional results were most dependent on the level of amputation. The proximal interphalangeal joint in amputated fingers that were replanted distal to the insertion of the flexor superficialis tendon had an average range of motion of 82 degrees after replantation, while those amputated proximal to the insertion had an average range of motion of only 35 degrees after replantation. The average operating time was six hours and ten minutes, and the average time until the patient returned to work was 2.3 months. Based on this experience, it is our opinion that replantation of a single finger that was amputated distal to the insertion of the flexor superficialis tendon is justified, but that replantation of a single finger that was amputated proximal to this insertion is seldom indicated.

Adolescent↗
PubMed1993

Syme's amputation: a neglected procedure.

Over a 9-year period nine patients underwent Syme's amputation, one patient undergoing a staged bilateral procedure. Six of the ten amputations were carried out for the complications of peripheral vascular disease, including one with Buerger's disease who had bilateral amputations. Three patients had amputations for infected diabetic gangrene and one amputation was performed as a result of trauma. Five patients had previously undergone surgery to improve their peripheral circulation. Two patients required a subsequent below knee amputation. The indications for and technique of Syme's amputation are discussed.

Adult↗
PubMed1994

Relative risks of limb revascularization and amputation in the modern era.

A retrospective review of 266 patients undergoing infrainguinal revascularization for limb salvage and/or major amputation (transmetatarsal, below-knee or above-knee) from 1984 to 1990 was conducted to determine comprehensive procedure-specific 30-day operative morbidity and mortality rates. Some 211 patients underwent 295 infrainguinal vascular reconstructions (195 primary and 100 secondary reconstructions). There were 122 major amputations in 98 patients (29 above-knee, 70 below-knee and 23 transmetatarsal). Most amputations were performed in patients with unreconstructable vascular disease, including 39 patients (41 extremities) with failed infrainguinal reconstruction. Procedure-specific morbidity and mortality rates were 48 and 2% for primary revascularization, 35 and 2% for secondary revascularization and 37 and 4%, for amputation, respectively. The difference in mortality between revascularization and amputation approached but did not achieve statistical significance. Cardiac, graft and wound complications were the major causes of morbidity in all groups. Nine of the 12 deaths were of cardiac etiology. Revascularization can be performed in almost all patients with advanced limb ischemia, with a mortality rate equivalent to, or perhaps lower than, that of amputation. When limb amputation is required, it can be performed with a mortality rate remarkably lower than that described in the older literature.

Acute Disease↗
PubMed1994

Amputations in the surgical budget.

AIM: To describe the extent and distribution of in patient costs of nontraumatic lower limb amputations and to identify areas of high cost as a basis for cost saving strategic planning. METHODS: Retrospective review of 134 consecutive admissions resulting in lower limb amputations for reasons other than trauma over a 33 month period. General surgical and orthopaedic costs were compared. More detailed cost distribution analysis was then conducted for a group of general surgical amputees corroborating data from the resource utilisation system, Otago surgical audit and patient records. RESULTS: The mean cost of admission for nontraumatic lower limb amputations performed by general surgeons was $11,342 (median $21,439 range $144-$43,022) and was significantly more expensive than orthopaedic amputations, mean $2318 (median $6277 range $307-$13,907) p < 0.001. Of general surgical patients, 38.7% had diabetes and these accounted for 36.1% of total costs. Most amputations (73.9%) in diabetics were of the minor type compared with 29.0% in the nondiabetic group (p < 0.001). Ward costs accounted for the largest proportion of total cost 55.6% (95% CI 45.1, 66.0). For major amputees 40% (95% CI 31.4, 48.1) of in-hospital time was used for rehabilitation. CONCLUSION: Nontraumatic amputations are costly. Diabetics, having mainly minor amputations, account for a disproportionate amount of the cost. Length of hospital stay is the most important determinant of cost, much of which is spent on rehabilitation. A case is made for early definitive surgery and a greater use of community based services and low cost centres in rehabilitation.

Amputation, Surgical↗
PubMed1997

[Incomplete penile amputation: diagnostic and therapeutic challenge].

Traumatic penile amputation is a severe injury associated with a potential for multidisciplinary dysfunction. Since such injuries are rare, diagnostic and therapeutic experience is minimal. While complete penile amputation is a straight-forward diagnosis, incomplete amputations are not as evident and diagnosis may be delayed. The therapeutic endpoint includes restoration of an acceptable appearance of the phallus and a urethral meatus that allows normal voiding. Other objectives include re-establishment of sexual potency and fertility. As in other amputations, the treatment of choice is meticulous microsurgical replantation, including re-anastomosis of dorsal and cavernosal arteries, the deep dorsal vein, the urethra and nerves, as well as suturing the tunica albuginea. While appropriate cosmetic results and normal voiding can be achieved in most cases, potency is less frequently achieved due to neurological deficit leading to impaired erection and loss of sensation. Penile amputation is thus a complex therapeutic challenge, as meticulous anatomic reconstruction of blood vessels and nerves is essential for restoration of function. Since incomplete penile amputation may be overlooked when other more obvious injuries draw attention, this injury should be suspected in all cases of penetrating injury of the male genitalia. We present a 17-year-old man who sustained an incomplete penile amputation in a traffic accident.

Accidents, Traffic↗
PubMed1997

[Diabetic foot--an attempt at defining the risk factors for amputation].

The study included 65 patients--42 males and 23 females aged 67 +/- 17 with the diabetic foot syndrome. They were divided into 2 groups: those who underwent amputation (25 patients) and 40 who were treated conservatively. Amputations were preceded most frequently by ulceration (17 cases), phlegmona (5 cases) or dry necrosis (3 cases). The high percentage of amputations in the studied patients could be explained, at least in part, by poor general condition and advanced local changes. In the group of patients, who underwent amputation--in relation to those treated conservatively a decrease in filtration function was found (46.0 +/- 24.3 vs 89.5 +/- 26.2) and a higher percentage in the prevalence of microalbuminuria or proteinuria (80% vs 45%) as well as a higher percentage of cigarettes smokers in this group (72% vs 40%). The majority of the studied patients was characterized by poor education, lack of self-control of glycaemia, no efficient metabolic control of diabetes, measured by glycated haemoglobin and the presence of neuropathy and retinopathy. In addition, in 4 patients among the whole studied group (including 1 patient who underwent amputation), diabetes was newly diagnosed. These results indicate the necessity of improving education, early diagnosis of insulin independent diabetes, more frequent foot examinations and the elimination of amputation risk factors. Prophylaxis of diabetes foot associated with the proper treatment of diabetes is a necessary condition for decreasing of the amputation rate according to St. Vincent Declaration.

Aged↗
PubMed1998

Distal amputations: impact of the introduction of femorocrural and femoropedal arterial bypass.

The aim of the study was to assess the impact of the introduction of femorodistal arterial bypass grafting on the patterns of lower limb amputation and reconstructive surgery, in particular the success rates of distal, conservative, amputations. Two 2-year cohorts of patients 7 years apart were analysed by a retrospective analysis of departmental audit and patient records. Significantly more patients undergoing distal amputation were considered to have reconstructible arterial disease in the later cohort. This was paralleled by an increase in the rate of suprapopliteal/popliteal and distal arterial bypass and a fall in below-knee amputation rate in this group of patients. The overall healing rate and rate of conversion of distal amputations were not adversely affected by the introduction of femorodistal bypass grafting, despite the fact that more distal amputees were non-diabetic in this second group. There was a high rate of success for distal amputations combined with femorodistal bypass, but the subgroup was too small for statistical analysis. We conclude that the use of distal amputation, with or without distal arterial bypass, offers a promising, although unproven, prospect for lower limb conservation even in non-diabetics.

Aged↗
PubMed1998

Plantar pressures are higher in diabetic patients following partial foot amputation.

The purpose of this study was to compare peak plantar pressure in diabetic patients with and without foot-level amputation. This project was conducted as a case-control study. We enrolled 27 cases and 150 controls diagnosed with diabetes mellitus. Cases were defined as patients with a history of forefoot-level amputation (digit or ray amputations distal to the tarsometatarsal joint) secondary to an infected forefoot wound. Controls were defined as subjects that had never had a foot ulceration. We used a pressure platform system to evaluate dynamic barefoot pressure on the sole of the foot. There was no significant difference in vascular perfusion or body mass index between the case and control groups. Patients with a foot-level amputation were nearly ten times more likely to present with limited joint mobility or a rigid foot deformity than those without amputation (92.6% vs. 44.0%, p < 0.0001, X2 = 13.0, Odds Ratio = 9.8 CI = 2.2 to 43.0). Peak plantar pressure was significantly higher for patients with amputations compared to controls (80.0 +/- 31.1 N/cm2, vs, 62.5 +/- 21.0 N/cm2, p < 0.001). Peak pressure and limited joint mobility have long been associated with ulceration. We conclude that increased pressure and contractures associated with biomechanical compensation following a partial foot amputation further increase plantar pressure, placing an already high-risk limb at further risk for tissue breakdown and reamputation.

Adult↗
PubMed1998

Outcome after trans-tibial amputation for vascular disease. A follow-up after eight years.

All 112 patients (55 females and 57 males) with a primary unilateral trans-tibial amputation for vascular disease performed in one year at all five hospitals in Malmöhus county, Sweden were examined at 6 months according to the prosthetic function and prospectively followed-up 8 years after the amputation for survival, and prosthetic fitting. The prosthetic function was re-examined among the survivors 8 years postoperatively. At 6 months 50% were fitted with a prosthesis and later (up to 8 years) a further 13%, in total 32 females and 39 males. The mortality at 6 months was 33%, at 2 years 47% and at 8 years 92%. Age at amputation (p = 0.015), to be amputated on the left leg (p = 0.0004), to be able to walk alone outdoors before the amputation (p = 0.007) and not using a wheelchair (p = 0.02) were all found to be statistically significant predictors for receiving a prosthesis. Predictors for good function with the prosthesis 6 months postoperatively was male sex (23 of 57 vs 8 of 55 females) (p = 0.006) and greater ability to walk alone outdoors before the amputation (p = 0.01). There was no significant age difference in this comparison. The finding that it is more favourable to be amputated on the left leg merits further study.

Adult↗
PubMedDate not supplied

Osseous overgrowth after amputation in adolescents and children.

We retrospectively studied the incidence of primary surgical revision for stump overgrowth in a population of childhood and adolescent amputees. The anatomic location and the etiology of amputation are critical to the occurrence of overgrowth needing revision. Metaphyseal-level amputations are the most likely to develop overgrowth requiring revision (50%), whereas diaphyseal amputations are slightly less likely (45%). Joint disarticulations never develop overgrowth. Traumatic amputations are the most frequent mode of injury requiring revision of overgrowth (43%), followed by congenital or intrauterine amputations (30%) and elective amputations (20%). Radiographic classification of the osseous overgrowth helps define its severity and degree of ossific progression. Surgical revisions are usually performed when overgrowth reaches a grade 3 classification. The majority of skeletally immature diaphyseal- or metaphyseal-level amputees, including those with certain preexisting orthopaedic conditions, retain the ability to develop osseous overgrowth at the apex of the stump skeleton.

Adolescent↗
PubMed2006

High failure rates when avoiding obstacles during treadmill walking in patients with a transtibial amputation.

OBJECTIVE: To investigate if and to what extent patients with a transtibial amputation are less successful in avoiding unexpected obstacles while walking than healthy adults. DESIGN: Experimental 2-group design. SETTING: Dutch rehabilitation center. PARTICIPANTS: Eleven patients with a transtibial amputation and 14 healthy controls. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Subjects walked on a treadmill at .56m/s. In 2 series of 12 trials each, an obstacle was dropped in front of the prosthetic or the nonprosthetic leg of the amputation group and the left leg of the control group at different phases during the step cycle. It was noted which avoidance strategy was used (a long step strategy [LSS] or a short step strategy [SSS]) and whether the obstacle was avoided successfully or not. These data were expressed as a percentage of the total number of trials completed by each subject. RESULTS: With either leg, the amputation group made significantly more errors than the control subjects (prosthetic leg, 24%+/-17%; nonprosthetic leg, 21%+/-17% vs 2%+/-2% for the control group). Highest failure rates were in the amputation group when time pressure was high, requiring an SSS, especially on the prosthetic side. An LSS under time pressure, however, nearly always resulted in failure for both the prosthetic and nonprosthetic legs. Subjects with the longest time since amputation were most successful in avoiding unexpected obstacles. CONCLUSIONS: Under time pressure, patients with a lower-leg prosthesis perform best when they use their nonprosthetic leg as the lead limb in an SSS. The fact that some subjects with the longest time since amputation made no errors suggests that over many years it is possible to relearn the appropriate avoidance reactions sufficiently fast.

Adult↗
PubMedDate not supplied

[Asymmetry of posture and truncal musculature following unilateral arm amputation--a clinical, electromyographic, posture analytical and photogrammetric study].

Unilateral upper limb amputation causes changes in statics of the spine. As a result asymmetrical posture of the spine, muscular asymmetries follow. In this study a population of upper limb amputees (above and below elbow amputees) is examined by clinical, electromyographical analysis and gait analysis. Upper limb amputations cause in correlation to weight loss a shift of the trunk to the side of the amputation, a scoliosis with a bowing to the side of the amputation, an elevation of the shoulder on the amputation side and a torsion of the trunk. Muscular asymmetries result from loss of function (muscles of the arm, M. latissimus, M. trapezius) and by shifting of the center of gravity. In order to get the center of gravity over the legs, the amputee compensates the loss of weight by shifting the upper trunk to the side of the amputation. As a result the shift of the segmental center of gravity at the lumber height to the side of the normal arm with muscular asymmetry in the erector trunci lumbalis results. As well we saw an overactivity of musculus glutaeus medius and resulting stress of the amputation sided hip joint. There was a remarkable difference between above and below elbow amputees caused by differences in weight loss. Muscular and static asymmetries in amputees who lost their arm only a short period before could be reduced by compensating the weight loss. Results for technical orthopaedic fitting and stress on gymnastic procedures to compensate these statistical problems are discussed.

Adult↗