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PubMed2003

Physical, mental, and social predictors of functional outcome in unilateral lower-limb amputees.

OBJECTIVE: To study the value of physical, mental, and social characteristics as predictors of functional outcome of elderly amputees. DESIGN: Prospective, inception cohort study; comparisons with reference populations. SETTING: Main hospitals, rehabilitation centers, nursing homes, patients' own residence settings in 1 of the 3 northern provinces in the Netherlands. PARTICIPANTS: Forty-six patients older than 60 years, with unilateral transtibial or transfemoral amputation or knee disarticulation because of vascular disease. INTERVENTIONS: Measurement of physical, mental, and social predictors 2 and 6 weeks postamputation. MAIN OUTCOME MEASURES: The Sickness Impact Profile (SIP-68), Groningen Activity Restriction Scale (GARS), Timed up and go (TUG) test, and prosthetic use. RESULTS: A total of 15% of amputees died within the first year after amputation. Seventy percent lived independently at home 1 year postamputation. The functional level of the patients was low, as shown by high scores on the SIP-68 (mean, 23.6), GARS (mean, 41.2), and TUG test (mean, 23.9s). Functionally effective prosthetic use, as measured with the classification of Narang and Pohjolainen, was reached by 49%. For the SIP-68 scores, age, comorbidity, 1-leg balance, and the 15-word test predicted functional outcome in 69% of amputees. For the GARS score, age, 1-leg balance, and the 15-word test predicted functional outcome in 64%. For the TUG test, age and 1-leg balance predicted functional outcome in 42% of amputees. After correction for age, the only significant predictor for prosthetic use was 1-leg balance. CONCLUSIONS: Elderly patients with a leg amputation had a low functional level 1-year postamputation. An important part of functional outcome could be predicted 2 weeks after amputation by age at amputation, 1-leg balance on the unaffected limb, and cognitive impairment. Severe comorbidity probably also played a role. The results may be used in the general policy concerning leg amputees.

Activities of Daily Living↗
PubMed2003

Rehabilitation after total femur replacement: a report of 2 cases.

We describe the rehabilitation of 2 patients who underwent total femur replacement after neoplastic involvement of the bone. In the past, patients with cancer of the femur were generally advised to undergo a hip disarticulation or transfemoral amputation. It is now feasible to salvage the limb in selected patients, by excising the entire femur together with any contiguous soft tissue tumor and replacing it with an endoprosthesis. The surgical literature contains a number of reports on total femur replacement, which mention the rehabilitation aspects only briefly, but we found nothing on this relatively uncommon form of surgery in the rehabilitation literature. Physiotherapy techniques such as active assisted exercises, isometric exercises, and hydrotherapy are extremely useful during the early phase of rehabilitation to facilitate a graduated strengthening program. Certain exercises, such as active hip abduction or knee flexion, may not be permitted for several weeks to protect muscles that have been reattached to the prosthesis. Partial weight bearing may be required to allow incorporation of bone allograft around the prosthetic hip joint. Because of these factors patients with total femur replacement may need a longer period of rehabilitation (6-8wk) than patients with total hip or knee replacement. Patients with total femur replacement can, however, achieve full independence with an appropriate rehabilitation program.

Activities of Daily Living↗
PubMed1999

Reconstructive surgery in children after meningococcal purpura fulminans.

BACKGROUND/PURPOSE: Purpura fulminans (PF) is a serious, often life-threatening disease. As more children are surviving their disease, surgeons are presented with increasing numbers of multiple and complicated wounds as sequelae of PF. The purpose of this paper is to review the management of nine cases of PF, and present the reconstruction method in treating bilateral exposed elbow and knee joints. METHODS: All cases of pediatric patients with PF and treated by the division of plastic and reconstructive surgery between 1986 and 1998 were reviewed. RESULTS: Seven children (78%) had meningococcal PF, and one (11%) had PF after Haemophilus influenza septicemia. PF developed in one (11%) but with no growth in either blood or cerebrospinal fluid cultures. Five children (56%) required amputation procedures. Two children (22%) required knee disarticulation. Two patients (22%) had free myocutaneous flap transfers for bone coverage. One (11%) had PF involving the face. CONCLUSIONS: Meningococcal PF is a rare, often life-threatening disease generally of childhood. More children are surviving their diseases but with devastating sequelae. Successful reconstructive treatment outcome of these children requires a multidisciplinary team approach involving multiple specialties. The goal is to preserve function, maintain maximal length, and salvage limbs when possible. Flexibility and innovation are necessary in treating these multiple and complicated wounds.

Amputation, Surgical↗
PubMed2004

[Gait analysis after rotationplasty hip surgery for malignant tumor of the proximal femur].

Rotationplasty of the hip joint is a special surgical technique used for the treatment of malignant tumors of the proximal part of the femur. We report a clinical case and gait analysis results before and after rehabilitation training. Evaluation of joint motion, kinetic moments, and the electromyographic findings enabled us to document progressive adaptation of muscle and joint function to their new role in the motor pattern, demonstrating the exceptional strength of rotationplasty. Active control of two fulcrums in the lower limb, the pseudo hip proximally and the pseudo knee intermedially, makes this type of operation extremely advantageous compared to the alternative of hip disarticulation or hemipelvectomy. Total absence of pain together with the preservation of articular and cutaneous proprioception are important advantages. Rotationplasty is an attractive alternative for treatment of malignant tumors of the proximal part of the femur.

Child↗
PubMed1984

Ollier's disease with multiple sarcomatous transformations.

A 53-year-old man had the monomelic form of Ollier's disease, which resulted in deformity of the left leg. The patient was otherwise well until pain and increasing size of the left thigh led him to seek treatment. Biopsy revealed chondrosarcomatous transformation in the distal left femur. Hip disarticulation was performed. This case is unusual in that multiple foci of chondrosarcomatous transformation at various stages of development were present throughout the left femur, tibia, and fibula.

Amputation, Surgical↗
PubMed1980

Giant cell tumour of the first metacarpal bone.

A rare case of giant cell tumour of first metacarpal bone which was aggressive in its clinical behaviour but histologically benign, is reported in a thirty-one year old male. The tumour was excised en-bloc with disarticulation of the thumb and index finger with a gratifying result. The literature on giant-cell-tumour of the metacarpal bone is reviewed.

Adult↗
PubMed1995

Bone suture anchors in hand surgery.

The recent development of small bone suture anchors has created potential applications in reconstructive surgery of the hand and wrist. A combined laboratory and clinical study was devised to evaluate their use. 16 paired fingers (32 in all) from eight cadaveric hands were disarticulated at the MP joint with a 10 cm tail of FDP tendon. The FDP insertion was released in all specimens. In 16 fingers reinsertion was performed with the classic Bunnell technique; in the paired 16 fingers, the repair utilized Acufex 2 mm anchors. There was no significant difference between the two groups regarding load-to-failure at approximately 40 Newtons. The mean stiffness of the anchor repairs was significantly greater than the Bunnell repairs. 19 consecutive patients were prospectively enrolled with a tendon or ligament repair of the hand or wrist using bone anchors. The average age was 41 years and the average length of follow-up was 24 months. All repairs were stable at the time of follow-up. Bone anchors were simple to insert, required less dissection and surgical time than the Bunnell technique and appeared to be reliable in both laboratory and clinical settings.

Adult↗
PubMed2003

Feasibility of using surface markers for assessing motion of the thumb trapeziometacarpal joint.

OBJECTIVE: The purposes of the present study were to investigate the feasibility of using a skin sensor to represent the first and third metacarpal bone, to verify that there was no significant relative motion between the skin of the third metacarpal bone and trapezium bony segment and to measure thumb metacarpal motion with respect to the hand (third metacarpal). DESIGN: Eight hands from fresh-frozen human cadavers were disarticulated 4 cm proximal to the wrist joint and used in this experiment. BACKGROUND: Recently, magnetic-tracking systems have been developed for the measurement of joint kinematics. Based on the concept of the three-dimensional space within which the thumb metacarpal bone can move, the current study proposes a 3D method for evaluating the relationship between the skin and bony segment. METHODS: An electromagnetic tracking system was used to provide quantitative measurement and evaluation of the relationship between the skin and bony segment while moving the trapeziometacarpal joint. RESULTS: The adjusted coefficient of multiple determination, R(a)(2), values of the kinematic waveforms between the sensors were larger than 0.84. The angular differences and displacements of the center of sensors between the skin and bony sensors were less than 4.9 degrees and 2.8 mm. CONCLUSION: These data revealed that the similarities of the two sensors throughout the motion cycle were high. The differences between the two sensors were also within the clinically allowable range of +/-5 degrees. Therefore, it is feasible to collect motions of the first metacarpal by attaching the skin sensors at the metacarpal head to measure the bony segment.

Aged↗
PubMed2003

Home-birth emergencies in the US and Mexico: the trouble with transport.

Proponents of the global Safe Motherhood Initiative stress that primary keys to safe home birth include transport to the hospital in cases of need and effective care on arrival. In this article, which is based on interviews with American direct-entry midwives and Mexican traditional midwives, I examine what happens when transport occurs, how the outcomes of prior transports affect future decision-making, and how the lessons derived from the transport experiences of birthing women and midwives in the US and Mexico could be translated into improvements in maternity care. My focus is on home birth in urban areas in Mexico and the US. In both countries, biomedicine and home-birth midwifery exist in separate cultural domains and are based on distinctively different knowledge systems. When a midwife transports a client to the hospital, she brings specific prior knowledge that can be vital to the mother's successful treatment by the hospital system. But the culture of biomedicine in general tends not to understand or recognize as valid the knowledge of midwifery. The tensions and dysfunctions that often result are displayed in midwives' transport stories, which I identify as a narrative genre and analyze to show how reproduction can go unnecessarily awry when domains of knowledge conflict and existing power structures ensure that only one kind of knowledge counts. This article describes: (1) disarticulations that occur when there is no correspondence of information or action between the midwife and the hospital staff; and (2) fractured articulations of biomedical and midwifery knowledge systems that result from partial and incomplete correspondences. These two kinds of disjuncture are contrasted with the smooth articulation of systems that results when mutual accommodation characterizes the interactions between midwife and medical personnel. The conclusion links these American and Mexican transport stories to their international context, describing how they index crosscultural markers, and suggest solutions, for "the trouble with transport."

Adult↗
PubMed2002

Survival with an arterial pH of 6.57 following major trauma with exsanguinating haemorrhage associated with traumatic amputation.

We report the survival of a multiply injured patient with exanguinating haemorrhage and an arterial pH of 6.5, following a road vehicle crash. The previously healthy 38 years old male driver veered off the motorway and collided with a tree. The ambulance arrived at the scene 9 min after being called by an eyewitness and, following rapid extrication from the wreckage; the patient arrived in hospital 27 min later (with a GCS of 6), and was immediately intubated. The patient had suffered near-complete amputation of the left leg at upper femoral shaft level, along with multiple distal fractures and open wounds. He also sustained a head injury and closed displaced fractures of left radius and ulna. The patient received 2 l of crystalloids in the pre-hospital phase. Once in hospital the haemorrhage was controlled with a pressure dressing and intra-venous fluids were kept to a minimum until he was taken promptly to theatre. His initial arterial blood sample revealed a pH of 6.57, pCo(2) of 9.18 kPa, a pO(2) of 70.11 kPa and a base excess of -27.5 mmol l(-1). The co-oximeter Hb was 5.8 g dl(-1). Haemorrhage was controlled in theatre where he was transfused a total of 30 U of blood, 1 pack of platelets, 12 U of fresh frozen plasma, 3.5 l of crystalloids and 1.5 l of colloid. Sodium bicarbonate was administered three times. He subsequently remained ventilated in intensive care unit (ICU). Over the following week he survived sepsis, disseminated intravascular coagulation and myoglobinuria (with transient renal failure) attributable to rhabdomyolysis secondary to muscle necrosis. He later underwent diversion colostomy and disarticulating amputation of the left femur after several debridements. After 6 weeks on ICU he made an excellent recovery will full return of his mental abilities. In this case, the serial arterial blood samples obtained were reliable. The lactic acidosis observed was the result of profound tissue hypo-perfusion and its rate of clearance seems to have greater prognostic value than its peak or initial value. Several factors may have contributed to the patient's survival: rapid retrieval from the scene; early intubation with excellent subsequent oxygenation (thus avoiding the dangerous combination of hypoxia and acidosis with synergistic influence on cardiac depression) and limited initial fluid resuscitation in the emergency department with prompt surgical intervention and vigorous restoration of organ perfusion after surgical haemostasis. Immediate operative haemostasis, coupled with restricted fluid administration beforehand and vigorous restoration of organ perfusion afterwards is now replacing the old resuscitation paradigm. Perhaps this shift in practice has helped this patient to survive.

Accidents, Traffic↗
PubMed1979

Reimplantation of the mandibular condyle in cases of intraoral resection and reconstruction of the mandible.

A new technique for the reconstruction of the disarticulated ramus is presented. From an intra-oral approach the mandible is resected, and if the posterior part of the ramus and the neck of the condyle are not involved by the tumour, this part is preserved. It is then fixed to the bone graft from the iliac crest bridging the remaining defect. The procedure is outlined, based on the experience of 4 cases which have been successfully operated on according to this technique. The earliest of them has been followed-up for seven years.

Adult↗
PubMed1986

Transfacial access to the retromaxillary area.

A case of angiofibroma of large proportions is presented which was manifest in various regions difficult of access. Using conventional techniques marked mutilation would have been expected. Consequently the technique of temporary disarticulation of the maxilla attached to the cheek with a transfacial access to the retromaxillary area was applied and will be described.

Adolescent↗
PubMed2000

Abdominoperineal electrical injury involving urogenital organs.

Although the incidence of electrical burns is not very high this incidence is rising in India. The residual effects of electrical burns are sometimes very severe and long lasting, if not managed properly. This case report is of a patient who sustained severe electrical burns over his left arm, lower abdomen and perineal area. The injuries were so severe that life-saving disarticulation of the limb together with excision of the involved pubic bone and genitalia and suprapubic urinary diversion was done. During follow up an unusual finding was noticed. There was a peritubal leak with no drainage from the catheter and on removal of the catheter, a manual examination of the urinary bladder revealed a stone which was removed at the same time. Following removal of the stone two ureteric openings with the trigone were seen and it was concluded that the granulating tissue was actually the posterior wall of the bladder. This was then mobilized and reposited into the abdomen. The deficient lower abdomen was reconstructed with a tensor fascia lata flap. A penile reconstruction for the patient is under consideration.

Abdominal Injuries↗
PubMed2003

Sequential wear patterns of the articular cartilage of the thumb carpometacarpal joint in osteoarthritis.

PURPOSE: The thumb carpometacarpal (CMC) joint is a primary location for osteoarthritis (OA) in the body; however, articular cartilage thickness distribution during progression of OA in the joint has not been reported previously. Determining the cartilage wear patterns within the joint is important in understanding the etiology and treatment of thumb CMC joint OA. This study used cadaveric specimens to investigate the wear patters of the articular surfaces of the trapezium and thumb metacarpal. METHODS: A total of 104 fresh-frozen thumb CMC joints were radiographed, disarticulated, and visually staged for OA. Cartilage thickness maps of the trapezium and metacarpal were determined for each joint by using stereophotogrammetry. Average cartilage thickness maps for the trapezium and metacarpal were generated from all specimens for each of 4 stages of OA, showing the progression of cartilage thickness changes with disease. RESULTS: In normal joints, the surface-wide mean thickness of the articular layers is 0.8 +/- 0.2 mm for the trapezium and 0.7 +/- 0.2 mm for the metacarpal. The average thickness maps were analyzed by anatomic quadrant (dorsal-radial, dorsal-ulnar, volar-radial, volar-ulnar) within the 4 stages of OA. Corresponding quadrants also were compared across the increasing stages of OA. Results show that cartilage degradation is initiated in the radial quadrants of the metacarpal and progresses to the volar quadrants of the articular surface, while significant wear is seen on the dorsal-radial quadrant of the trapezium and progresses to the volar quadrants in late-stage osteoarthritis. CONCLUSIONS: These quantitative results on cartilage thinning agree with previous investigators' reports of high load bearing and low load bearing areas in the CMC joint during functional pinch and grasp positions. Understanding the progression of OA in the thumb CMC joint may aid in the surgical treatment of this disease.

Adolescent↗
PubMed1984

Composite metacarpophalangeal joint reconstruction in great toe-to-hand free tissue transfers.

he recommended technique of skeletal fixation of great toe-to-hand free tissue transfers for thumb reconstruction is related to the length of the first ray present. When the entire first metacarpal is intact, fusion of the disarticulated great toe proximal phalanx to the metacarpal head has been described. Another possibility in this selected situation with cartilage present on the metacarpal head is to reconstruct a new metacarpophalangeal (MP) joint from a cuff of collateral ligaments and plantar plate on the proximal phalanx, anchored to the metacarpal head. In a series of 45 great toe-to-thumb transfers, eight were done with a composite MP joint reconstruction technique. A description of this technique and clinical results are presented. Based on the results in these patients, this technique should be considered as an alternative to joint fusion when the entire first metacarpal is intact.

Adult↗
PubMed1989

Distraction osteogenesis of a congenital amputation at the elbow.

A case is described demonstrating the effectiveness of distraction osteogenesis for the lengthening of a short below elbow congenital amputation. To our knowledge this technique has not been previously used in a patient with a congenital amputation. The surgical technique of corticotomy and postoperative lengthening is detailed. The result converted the level of patient performance from elbow disarticulation to functional below elbow status.

Bone Lengthening↗
PubMed1996

Necrotizing fasciitis of the upper extremity.

Twelve cases of necrotizing fasciitis were identified retrospectively over a 5-year period. All were associated with a history of substance abuse by injection or with diabetes. Eleven of the 12 infections were associated with beta-hemolytic Streptococcus, a mixed anaerobic aerobic infection, or both. Three of five patients tested for human immunodeficiency virus had positive test results. A wide extensile approach was used to debride necrotic fascia. An average of 3 debridements were necessary, with a range of 1-6 debridements. Two patients under-went shoulder disarticulation because of uncontrollable infection. The rapid and destructive nature of this disease makes early recognition, aggressive debridement, and antibiotic therapy necessary to minimize morbidity.

Adult↗
PubMed2000

Limbs found in water: investigation using anthropological analysis and the diatom test.

We report the investigation, using a multi-disciplinary approach, of five cases of dismembered limbs which were recovered from Lake Ontario, Lake Erie and the Niagara River, and examined at the Office of the Chief Coroner for Ontario. In all cases, postmortem examination revealed that the limbs had been disarticulated in the postmortem period, by non-human taphonomic processes. In addition to routine gross examination, the femur and/or tibia were assessed using anthropological methods to give estimates of the sex, age, race and stature of the individual. The anthropologic data facilitated the identification of one of the cases. In all cases, nitric acid extracts of the femoral bone marrow were prepared and examined for the presence of diatoms. In all instances, diatom frustules were recovered from marrow extracts, indicating that drowning was the cause of death or at least a significant contributing factor in the cause of death. The use of the diatom test was helpful in excluding the possibility that the limbs were dismembered from individuals who had died by means other than drowning, and had been subsequently 'dumped' into water. The application of anthropological methods and the diatom test for drowning may significantly enhance the medico-legal investigation of body parts recovered from water, and we present an overview of useful techniques here. Anthropological data may facilitate identification, and the diatom test may establish a cause of death.

Adult↗