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At least 487 records · Page 27Linked to original sources
PubMed2001

Postoperative and amputation-free survival outcomes after femorodistal bypass grafting surgery: findings from the Department of Veterans Affairs National Surgical Quality Improvement Program.

PURPOSE: A noncardiac surgery risk model was used as a means of analyzing variations in postoperative mortality and amputation-free survival for older veterans undergoing femorodistal bypass grafting surgery. METHODS: A prospective cohort study was undertaken in 105 Veterans Affairs (VA) hospitals at the time of index operation from 1991 to 1995. Each patient was linked to subsequent hospitalizations, major amputation surgery, and survival through 1999. Logistic regression and proportional hazards models were used as a means of developing risk indices on the basis of risk factors from the VA National Surgical Quality Improvement Program. A total of 4288 male veterans 40 years or older underwent artificial, vein, or in situ bypass grafting surgery at the femoral to tibial level. The main outcome measures were 30-day postoperative mortality and amputation-free survival. RESULTS: Approximately half of all patients had undergone an earlier revascularization or amputation at any level for vascular disease. The 30-day postoperative mortality rate was 2.1% and varied greatly between mortality risk index quartiles (0.6%-5.2%). In a median 44.3 months of follow-up, surviving patients had 17,694 subsequent VA hospitalizations, 1147 patients (26.7%) underwent subsequent major amputation, and 1913 patients (44.6%) died. The overall survival probability was 88% at 1 year and 63% at 5 years; 1- and 5-year (any sided) limb salvage rates were 87% and 74%, respectively, for patients who underwent a femoropopliteal bypass grafting procedure, compared with 77% and 63%, respectively, for patients who underwent a tibial bypass grafting procedure. When amputation and death were combined as end points, amputation-free survival probability rates at 1, 3, and 7.5 years were 74%, 56%, and 29%, respectively. Patients with the best 20% survival risk scores had observed mean survival probability rates 30% higher than patients in the poorest 20% of survival risk. CONCLUSION: Risk indices derived from the preoperative workup may be of use to clinicians in assessing and communicating risk and prognosis. Risk-adjustment of outcomes is critical for evaluating future disease management initiatives for patients with advanced peripheral arterial disease.

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PubMed2002

Comparative study of the strength of the flexor and extensor muscles of the knee through isokinetic evaluation in normal subjects and patients subjected to trans-tibial amputation.

This study compares the strength of the flexor and extensor muscles of the knee in a group (A) of 25 patients with unilateral trans-tibial amputation, regardless of cause, and a group (B) of 27 normal volunteers. Measured parameters were peak bending moment, total work, maximum power and flexor/extensor relation. The dynamometer used was a Cybex model 6000, set at velocities of 60 degrees/s and 180 degrees/s (4 and 20 repetitions). Exercise type was concentric, both for flexion and extension of the knee joint. Patients were grouped according to stump size, age and time since amputation. These patients were tested with their prosthesis. Mean age in group A was 35.9 +/- 13 years (age range: 12-59 years). Mean age in group B was 34 +/- 8 years (age range: 19-56 years). Comparison according to subject sex was similar. Data analysis between the amputated and the sound limb reveals strength deficit (bigger deficit at 180 degrees/s), which relates to age but not to stump size. When compared to non-amputated subjects in the measured parameters, negative relations both in the amputated side and the non-amputated side were found. The authors' conclusion is that revision of the parameters used until then for rehabilitation of the patients subjected to trans-tibial amputation is needed.

Adult↗
PubMed2003

A case-control study of the risk factors for toe amputation in a diabetic population.

Toe amputations are becoming more prevalent in the diabetic population. To prevent toe amputations, those individuals with the highest risk must be identified prior to developing a precipitating event. There are obvious risk factors for toe amputations, such as digital deformity, diabetic neuropathy, and ischemia. Other, less obvious, systemic comorbidities may be linked to toe amputations. This study also shows that gender plays a significant role as a risk factor for toe amputation. A foot infection, foot abscess, osteomyelitis, diabetic retinopathy, and diabetic nephropathy were also significant risk factors for toe amputations. This suggests a significant relationship between these complications and comorbidities that put these individuals at a higher risk for toe amputations.

Journal Article↗
PubMed1996

The Mangled Extremity: When Should It Be Amputated?

Amputation of a mangled extremity is repugnant to the patient and the surgeon. However, prolonged unsuccessful attempts at salvage are costly, highly morbid, and sometimes lethal. Much discussion has taken place regarding which criteria predict successful salvage, and predictive indices have been proposed in an attempt to identify limbs for which attempted salvage is unlikely to succeed. The Mangled Extremity Severity Score, or MESS, system is the most thoroughly validated of the various classification systems, but at present there is no predictive scale that can be used with confidence to determine whether to amputate or attempt to salvage a mangled lower extremity. Therefore, these systems should serve only as guides to supplement the surgeon's clinical judgment and experience. Although salvage for severe injuries below the knee can be difficult and the functional outcome unpredictable, prosthetic function after transtibial amputation is generally good. Conversely, prosthetic function after transfemoral or transradial amputation is often poor, while salvage of some useful function for injuries above the knee is often successful. When limb loss is inevitable, immediate amputation is desirable. If obvious criteria for primary amputation are not met, however, it is reasonable to consider an initial salvage attempt, observation, and subsequent early secondary amputation.

Journal Article↗
PubMed1986

Staged below-knee amputations for septic peripheral lesions due to ischaemia.

Preservation of the knee joint is of paramount importance in lower limb amputation for ischaemia. Clinical predictors of healing are unreliable in patients with septic peripheral lesions due to ischaemia. Seventy-three patients in whom a below-knee amputation was considered likely to heal, based on the temperature and appearance of the skin and bleeding from skin and muscle flaps, were divided into two groups. Twenty-nine (Group A) had a primary below-knee (BK) amputation at the site of election with delayed primary skin closure, while 44 patients (Group B) initially had a guillotine BK amputation below the site of election, with elective amputation at the appropriate level once infection had been eradicated (4-5 days later). The groups were similarly matched with regard to level of occlusive arterial disease, nature of ischaemic lesions and operative risk factors. There was no significant difference in the overall operative mortality in Group A (6.7 per cent) compared with Group B (11.4 per cent) (P greater than 0.05). There was a significantly higher above-knee revision rate in Group A survivors (33.3 per cent) compared with Group B (7.7 per cent) (P less than 0.01) due to non-viability and uncontrolled sepsis of the BK amputation site. The presence or absence of a palpable femoral or popliteal pulse had no significant influence on healing in either group.

Amputation, Surgical↗
PubMed2006

Effects of anesthesia on pain after lower-limb amputation.

OBJECTIVE: To evaluate the effects of epidural, spinal, and general anesthesia on pain after lower-limb amputation. DESIGN: Cross-sectional survey. SETTING: Postamputation clinic. PATIENTS: 150 patients who were evaluated one to 24 months after their lower-limb amputation. INTERVENTIONS: Patients received epidural, spinal, or general anesthesia for their amputation. MEASUREMENTS: Standardized questions were used to assess stump pain, phantom sensation, or phantom limb pain preoperatively and postoperatively. Pain intensity was assessed on a verbal rating scale of 0 to 10. After the interview, each patient's medical history and anesthetic record were assessed. RESULTS: Patients who had received epidural anesthesia and those who had received spinal anesthesia recalled significantly less pain in the week after their surgery (P < 0.05). After an average of 14 months, there was no difference in stump pain, phantom limb sensation, or phantom limb pain between patients who received epidural anesthesia, those who received spinal anesthesia, and those who received general anesthesia for their amputation. Phantom limb pain continued to be frequent and severe despite patients' use of opioid analgesics, amitriptyline, and gabapentin. CONCLUSIONS: Patients who received epidural anesthesia and those who received spinal anesthesia recalled better analgesia in the first week after their amputation than did patients who received general anesthesia. Anesthetic technique had no effect on stump pain, phantom limb sensation, or phantom limb pain at 14 months after lower-limb amputation.

Aged↗
PubMedDate not supplied

Randomized prospective study comparing preoperative epidural and intraoperative perineural analgesia for the prevention of postoperative stump and phantom limb pain following major amputation.

BACKGROUND AND OBJECTIVES: Acute stump pain and phantom limb pain after amputation is a significant problem among amputees with a reported incidence of phantom limb pain in the first year following amputation as high as 70%. Epidural analgesia before limb amputation is commonly used to reduce postamputation acute stump pain in the immediate postoperative period and phantom pain in the first year. We investigated whether immediate postamputation stump pain and phantom pain in the first year is reduced by preoperative epidural block with bupivacaine and diamorphine compared with intraoperative placement of a perineural catheter infusing bupivacaine. METHODS: In a randomized prospective trial, 30 patients scheduled for lower limb amputation were randomly assigned epidural bupivacaine at the standard rate used in our hospital (0.166%, 2 to 8 mL/h) and diamorphine (0.2 to 0.8 mg/h) for 24 hours before and during operation (14 patients; epidural group) and 3 days postoperatively, or an intraoperatively placed perineural catheter (16 patients; perineural group) for intra and postoperative administration of bupivacaine (0.25%, 10 mL/h). All patients had general anesthesia for the amputation and were asked about stump and phantom pain in the first 3 days and then at 6 and 12 months by an independent examiner. Study endpoints were rate of stump and phantom pain, intensity of stump and phantom pain, and consumption of opioids. The groups were well matched in baseline characteristics. RESULTS: Stump pain scores in the first 3 days were significantly higher in the perineural group compared with the epidural group (P <.01). After 3 days, 4 (29%) patients in the epidural group and 7 (44%) in the perineural group had phantom pain (P =.32). Numbers of patients with phantom pain for epidural versus perineural group were: 5 (63%) versus 7 (88%) (P =.25) at 6 months; 3 (38%) versus 4 (50%) (P =.61) at 12 months. Stump pain and phantom sensation were similar in both groups at 6 and 12 months. CONCLUSIONS: Using our regimen, perioperative epidural block started 24 hours before the amputation is not superior to infusion of local anaesthetic via a perineural catheter in preventing phantom pain, but gives better relief of stump pain in the immediate postoperative period.

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PubMed1985

Gangrene of the immediate postoperative above-knee amputation stump: role of emergency revascularization in preventing death.

Two hundred seventy-five lower extremity amputations were performed over a 4-year interval for end-stage peripheral vascular disease. Fourteen patients (8.5%) of a total of 165 patients undergoing above-knee amputation (AKA) either suffered acute gangrenous ischemia of the AKA stump postoperatively, or were thought to be at high risk for same, and therefore underwent prophylactic inflow revascularization prior to or concomitant with AKA. The overall operative mortality rate was 28.5% in these 14 patients and was related either to inability to revascularize (two of three patients) or to the attempt to revascularize in the presence of a frankly necrotic amputation stump (three of five patients). Lower extremity amputation may be performed with an overall acceptably low mortality rate, which for our series is 0.9% for 113 below-knee amputation (BKA) and 2.8% for 140 AKA levels. Acute postoperative gangrene of the stump carries a high mortality rate and may be prevented by inflow revascularization prior to amputation. Three situations were identified as carrying a high risk for the subsequent development of gangrene: acute thrombosis of a prior combined inflow/outflow procedure, occlusion of the superficial femoral artery with an occluded/stenotic deep femoral artery and no palpable femoral pulse, and flat pulse volume recordings at the high thigh level. Patients who present for AKA with one of these indications should be considered as a candidate for prophylactic inflow revascularization prior to AKA to prevent ascending gangrene.

Acute Disease↗
PubMedDate not supplied

Prosthetic use in patients with burns and associated limb amputations.

A review of 11 patients who sustained burns that were complicated by limb amputation was completed to determine their eventual ability to use prosthesis. Amputations included six below-elbow, four above-elbow, three below-knee, and three above-knee amputations. Ten of the 11 patients (91%) had open wounds on the stump limbs and nine patients (82%) required skin grafting procedures on the amputated limbs. Delays in prosthetic fitting because of continued surgeries, open wounds, skin grafts on the stump limb, and breakdown of the stump were identified. However, eight of these patients (73%) were eventually able to wear prosthetic devices. Fisher's exact test was used to test the influence of the number and site of the amputations and skin grafting on the stump on successful prosthesis use. None of these tested items were found to be significant. The results demonstrate that most patients with burns who require limb amputation can achieve successful prosthesis use.

Adult↗
PubMed1998

Impact of femoro-distal bypass on major lower limb amputation rate.

BACKGROUND: Limb salvage is one of the cardinal aims of vascular surgery, but the influence of distal bypasses on amputation rates has been difficult to demonstrate. METHODS: The incidence and indications for major limb amputations and infrapopliteal bypass during two consecutive 16-month periods were analysed. RESULTS: There was a decrease in the number of major amputations from 34 during the first period to 13 in the second, while the number of bypasses to the infrapopliteal arteries increased from four in the first period to 21 in the second. CONCLUSIONS: An increase in the incidence of bypasses to the infrapopliteal arteries was matched by a decrease in the number of major amputations. Factors that may have contributed to the increase in the incidence of distal bypass and the decrease in the number of amputations include the availability of digital subtraction angiography, and a change in referral patterns within the hospital so that, except for trauma, all patients who were considered to be candidates for major amputation were assessed by a vascular surgeon.

Aged↗
PubMed2000

Major amputations in Nigeria: a plea to educate traditional bone setters.

A study was made of 100 major amputations performed on 96 patients in two regional hospitals in a 10-year period in Nigeria. The objective of the study was to evaluate the outcome of major amputations in Nigeria. The median age of patients was 30 years with male to female ratio 3:1. Ninety of the 100 major amputations involved the lower limbs with the above-the-knee/elbow-the-knee ratio of 0.5. Trauma was the leading indication for 70 amputations, of these 60 were iatrogenic resulting from mismanaged fractures by the traditional bone setters. The non-traumatic indications were: diabetic limb gangrene (20); bone malignancies (9); and vascular insufficiency (1). Provisional amputation was offered in 60 cases, of these 10 had reamputation. There were eight (8.5%) mortalities. The functional outcome for this group was discouraging. Only 25 amputees affording successful prosthetic fitting and social rehabilitation. Major amputation in Nigeria foreshadows a dismal existence and emphasizes the need for health policies which are effective in controlling the risk factors.

Adolescent↗
PubMedDate not supplied

The use of bone bridges in transtibial amputations.

UNLABELLED: We sought to describe the bone bridge technique in adults, and present a variation for use in children, as well as to present its applicability as an option in elective transtibial amputations. This paper presents a prospective study of 15 transtibial amputations performed between 1992 and 1995 in which the bone bridge technique was employed. The patients' ages ranged from 8 to 48 years, with an average of 22.5 years. This technique consisted of the preparation of a cylinder of periosteum extracted from the tibia and with cortical bone fragments attached to it to promote a tibiofibular synostosis on the distal extremity of the amputation stump. We noted that the cortical bone fragments were dispensable when the technique was employed in children, due to the increased osteogenic capacity of the periosteum. This led to a variation of the original technique, a bone bridge without the use of the cortical bone fragments. RESULTS: The average time spent with this procedure, without any significant variation between adults and children, was 171 minutes. The adaptation to the definitive prosthesis was accomplished between 20 and 576 days, with an average of 180 days. Revision of the procedure was necessary in 3 amputations. CONCLUSIONS: This technique may be employed in transtibial amputations in which the final length of the stump lies next to the musculotendinous transition of the gastrocnemius muscle, as well as in the revision of amputation stumps in children, where the procedure has been shown to be effective in the prevention of lesions due to excessive bone growth.

Adolescent↗
PubMed1999

Syme amputation for the treatment of fibular deficiency. An evaluation of long-term physical and psychological functional status.

BACKGROUND: Syme amputation is an accepted treatment for fibular deficiency. With improvement in limb-lengthening procedures, there has been renewed interest in limb salvage for these patients. The purpose of the present study was to evaluate the physical and psychological results in ten young adults who had had a Syme amputation for the treatment of fibular deficiency when they were children. METHODS: The evaluation consisted of physical examination, prosthetic assessment, psychological testing, and physical performance testing of knee extension and flexion with use of a Cybex-II dynamometer. RESULTS: Five patients reported no difficulty with the involved limb since the Syme amputation, four had had minor secondary procedures (three medial distal femoral or proximal tibial hemiepiphyseodeses, one reconstruction with an autologous patellar ligament graft, one revision of the stump, and one tibial osteotomy) on the affected extremity, and one had mild instability of the knee that had been treated nonoperatively. All ten patients had an appropriate, functional Syme prosthesis, and none reported difficulty with walking or running. On psychological testing, this group generally did not differ from the norm with regard to occupational satisfaction, personal growth, relationships with family members and peers, and recreational behavior. The patients' overall assessment of self-reported quality of life and self-esteem was similar to that of normative adult samples. In general, these patients were leading active, productive lives and had always done so. CONCLUSIONS: On the basis of the results of this study, we concluded that young adults who have had a Syme amputation apparently are not limited in their ability to pursue and achieve personal goals. In order to justify recommending limb salvage rather than early Syme amputation for the treatment of fibular deficiency, the results of multistaged lengthening and reconstruction would have to match the functional, psychological, and cost-effective results for the patients whom we studied, who had had a Syme amputation.

Adolescent↗
PubMed1987

Mobility after major limb amputation for arterial occlusive disease.

This study is concerned with the degree of mobility achieved by patients following major amputation for arterial occlusive disease of the legs and its relationship to the level of amputation. Eighty-four out of a possible 85 consecutive amputees form the basis of the study and the degree of mobility was assessed and graded in survivors six months after amputation. Of the 69 survivors 74% were mobile to some degree and 57% walked daily with a prosthesis. Sixty-five per cent of all the amputations were below-knee. Seventeen per cent of below-knee stumps in patients surviving two weeks failed to heal. In amputees who attained a unilateral mobile healed stump 78% with below-knee amputations and 50% with above-knee amputations walked daily with a prosthesis. To obtain maximum mobility the knee should be retained whenever practical even though this results in some unhealed stumps requiring revision.

Aged↗
PubMed1979

The vascularization in the amputation stumps of rabbits. A microangiographic study.

With the aid of microangiography the vascularization in the amputation stumps of 108 rabbits was studied, both in extremities with normal circulation and in those supplied with collaterals. It was found that the vascularization of the normal leg was altered by amputation, with the development of newly-formed, pathological, spirally-twisted vessels. Closure of the stump with myoplasty, however, counteracted this vessel formation, and hypervascularization took place through normal arteries. After amputation of extremities supplied with collaterals, the influence of amputation on collateral function and vascularization in the amputation stump was dependent on the time interval between arterial occlusion and amputation.

Amputation, Surgical↗
PubMedDate not supplied

The role of revascularization in transmetatarsal amputations.

Data from 37 patients who underwent a transmetatarsal amputation from January 1993 to April 1996 were reviewed. The mean age and diabetes duration of the subjects were 54.9 (+/- 13.2) years and 16.6 (+/- 8.9) years, respectively. The follow-up period averaged 42.1 (+/- 11.2) months. At the time of follow-up, 29 (78.4%) of the 37 patients still had foot salvage, 8 (21.6%) had progressed to below-the-knee amputation, and 15 (40.5%) had undergone lower-extremity revascularization. Twelve (80%) of the 15 revascularized patients preserved their transmetatarsal amputation level at a follow-up of 36.4 months. The authors concluded that at a maximum of 3 years follow-up after initial amputation, transmetatarsal amputation was a successful amputation level.

Adult↗
PubMed2004

Modified supracondylar amputation of the femur.

The upper leg can be amputated at many levels starting with the through the knee amputation and ending with the hip disarticulation. The most common above the knee amputation is through the mid-femur, and this procedure is taught in most surgical programs in the United States. A new modification of the supracondylar amputation of the femur is herein described. A 20-year experience of over 200 procedures is reported using a new modification of the supracondylar amputation of the leg. Two deaths occurred, and a primary healing rate of 95 per cent was obtained. Revision to a higher level was required in only three patients. The advantages of the modified amputation procedure include short operative procedure, minimal blood loss, long femur stump, reduced pain, strong fascial closure, high rate of primary healing, and avoidance of a postoperative flexion contracture at the hip.

Amputation, Surgical↗
PubMed1983

A prospective study of lower limb amputations.

Most leg amputations are performed for vascular disease. A mortality of 30% was associated with above-knee amputations in this study. Healing by primary intention took place in 59% of patients, 31% had delayed healing and 10% required a revision. Only 10% of above-knee amputees used a prosthesis and 48% required total bed care. Below-knee amputations in which a rigid dressing was used had slightly better healing than when soft dressings were used but the difference was not significant. The overall reamputation rate was 15%, the mortality was 7.2% and 57% were fully ambulatory with a prosthesis. Amputation at either the transmetatarsal or digital level was carried out in 25% and 80% healed. The mortality was 11%. Clinical observation is still the best determinant of the level of amputation; below-knee amputation should be strived for in every patient who is a candidate for rehabilitation. Use of a rigid dressing is recommended.

Aged↗