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PubMed1994

Revision of failed below knee amputations. Local debridement with gentamicin collagen.

OBJECTIVE: To describe our results with a new technique of revision of failed below knee amputation stumps using gentamicin impregnated collagen sponge. DESIGN: Open study. SETTING: District hospital. SUBJECTS: 31 patients who underwent below knee amputations between 1988 and 1992, compared with 31 historical controls who were operated on between 1984 and 1988. INTERVENTIONS: Two thirds of the stumps that failed to heal underwent excision of necrotic and devitalised tissue; half had shortening of tibia and fibula and a gentamicin impregnated collagen sponge was left in the wound, which was then closed. MAIN OUTCOME MEASURES: Successful wound healing and rehabilitation. RESULTS: 12 Stumps failed to heal, 8 of which were suitable for local treatment with the gentamicin sponge. All 8 healed satisfactorily, though one required revision of the scar 6 months later. Of the remainder, the stumps were converted to above knee amputations (n = 3) and one was disarticulated at the knee. In the control group 5 of the 7 stumps in which healing failed, were converted to above knee amputations and the other two healed after split skin grafting. CONCLUSION: We think that local treatment with the collagen sponge with gentamicin offers a viable alternative to conversion to above knee amputation for below knee amputation stumps that fail to heal. The treatment should now be subjected to a randomised controlled trial.

Adult↗
PubMed1995

[Transgenicular amputation with special reference to partial secondary femoral condyle resection].

During the last five years 54 patients (mean age 69 years) have undergone a unilateral, transgenicular (through-knee) amputation, instead of an impending amputation through the thigh. The indication for surgery was a chronic, or an acute critical ischemia of the leg. In 32 and 22 cases respectively, amputations have been preceded by a multitude of reconstructive measures. Uncomplicated stump healing was observed in 25 of 51 survivors (49%). Disturbances in the wound healing process necessitated further amputation in 26 cases (51%). In 13 of these cases the advantage of the transgenicular amputation could be retained by a partial femoral condylectomy, whereas in the other 13 cases a thigh amputation was inavoidable. Thus, in three out of four of the survivors, a long, strong stump with a good terminal load-carrying capacity could be retained which, when supplied by a prosthesis, led to the recovery of the original walking ability in 90% of these cases.

Aged↗
PubMedDate not supplied

Long-term incidence of lower-extremity amputations in a diabetic population.

OBJECTIVE: To describe the 10-year cumulative incidence of and risk factors for lower-extremity amputations in diabetics. DESIGN: Cohort study. SETTING: Primary care. PARTICIPANTS: Population-based sample (N = 879) of younger-onset diabetic persons (in whom diabetes was diagnosed before 30 years of age and who were taking insulin) and a stratified random sample (N = 956) of older-onset diabetic persons (diagnosis at or after 30 years of age) participating in baseline, 4-year, and 10-year examinations. MAIN OUTCOME MEASURE: Amputations of the lower extremities as reported by the participants. RESULTS: The 10-year cumulative incidence of lower-extremity amputation was 5.4% in younger-onset and 7.3% in older-onset persons. Multivariate analyses were performed by logistic regression. In younger-onset persons, age (odds ratio [OR] for 10 years, 2.0; 95% confidence interval [CI], 1.5-2.8), history of ulcers (OR,4.8; 95% CI, 2.3-9.9), diastolic blood pressure (OR, 2.1 for 10 mm Hg; 95% CI, 1.5-3.0), glycosylated hemoglobin level (OR, 1.4 for 1%; 95% CI, 1.2-1.6), sex (OR, 5.2 for men; 95% CI, 2.2-12.3), and retinopathy (OR, 1.2 for 2 steps; 95% CI, 1.1-1.4) were significantly associated with incidence of lower-extremity amputation. In older-onset persons, history of ulcers (OR, 3.3; 95% CI, 1.6-6.8), glycosylated hemoglobin level (OR, 1.3 for 1%; 95% CI, 1.1-1.5), duration of diabetes (OR, 1.6 for 10 years; 95% CI, 1.1-2.5), sex (OR, 2.6 for men; 95% CI, 1.3-4.9), diastolic blood pressure (OR, 0.7 for 10 mm Hg; 95% CI, 0.5-1.0), and proteinuria (OR, 2.4; 95% CI, 1.0-5.7) were significantly associated with incidence of lower-extremity amputation. CONCLUSION: These data show there are several risk factors for lower-extremity amputation with potential for modification and preventive strategies.

Adolescent↗
PubMed1988

Cost of treating advanced leg ischemia. Bypass graft vs primary amputation.

We compared the hospital costs of 94 patients undergoing femoropopliteal bypass grafts with those of 53 patients undergoing primary amputation. The total cost of uncomplicated bypass surgery averaged +20,300, compared with +14,000 for uncomplicated below-knee amputation. However, including the cost of prosthesis and rehabilitation, the total cost of primary amputation was +20,400, equivalent to that of the bypass operation. Complications requiring revision of a bypass graft increased hospitalization by 4.5 days with the total cost rising to +28,700; complications that ended with major amputation added 15 hospitalization days and had an average cost of +42,200. In contrast, complicated below-knee amputation cost +40,600 and added 12.5 hospitalization days. There is therefore no cost-benefit in primary amputation when compared with arterial reconstruction, and cost should not be used to deny a patient the opportunity for limb salvage.

Amputation, Surgical↗
PubMed2000

Nature, incidence, and cause of work-related amputations in Minnesota.

BACKGROUND: The Minnesota Sentinel Event Notification System for Occupational Risks (SENSOR) has collected data on the nature, incidence, and cause of work-related amputation injuries that have taken place since 1992. METHODS: SENSOR defined an amputation as any finger amputation or the loss of any other body part; 832 workers were identified as having amputation injuries between 1994 and 1995 and 72% of these workers completed telephone interviews. RESULTS: The amputation injury rate for Minnesota workers was 39 per 100,000 workers, with agriculture and manufacturing having the highest rates. Sixty-six percent of the injuries involved one finger; 14% involved two or more fingers. Persons working with machinery reported 73% of the injuries. CONCLUSIONS: A closer examination of the incidence and causes for amputation injuries shows that these were not random events. Reliance on human reactions to prevent injury is inadequate; therefore, additional research needs to be conducted.

Accidents, Occupational↗
PubMed2004

Type of incision for below knee amputation.

BACKGROUND: Below knee amputation (BKA) may be necessary in patients with advanced critical limb ischaemia or diabetic foot sepsis in whom no other treatment option is available. There is no consensus as to which surgical technique achieves the maximum rehabilitation potential. OBJECTIVES: To look at the evidence comparing different surgical techniques for BKA using stump healing, wound infection, reamputation rate and mobility with a prosthetic limb as outcome measures. SEARCH STRATEGY: Publications describing randomised controlled trials comparing different types of incision for below knee amputation were sought using the search strategy described by the Cochrane Review Group on Peripheral Vascular Diseases. This involved searching the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE. Additional searches were made of bibliographies of papers found through these searches, and also by handsearching relevant journals. SELECTION CRITERIA: Randomised controlled trials comparing two or more types of skin incision for BKA were identified. All patients with lower limb ischaemia (acute or chronic) and/or diabetic foot sepsis were considered for inclusion. Patients undergoing below knee amputation for other conditions were excluded. DATA COLLECTION AND ANALYSIS: Three studies were included in the analysis: two-stage versus one-stage BKA; skew flaps BKA versus long posterior flap BKA; sagittal flaps BKA versus long posterior flap BKA. Data were extracted independently by both authors. MAIN RESULTS: BKA using skew flaps or sagittal flaps conferred no advantage over the well established long posterior flap technique. For patients with wet gangrene, a two-stage procedure with a guillotine amputation at the ankle followed by a definitive long posterior flap amputation leads to better primary stump healing than a one-stage procedure. REVIEWER'S CONCLUSIONS: Evidence suggests that the choice of amputation technique has no effect on outcome and can therefore be a simple matter of surgeon preference. Factors which might influence this include previous experience of a particular technique, the extent of non-viable tissue, and the location of pre-existing surgical scars.

Amputation, Surgical↗
PubMedDate not supplied

What is the most effective way to reduce incidence of amputation in the diabetic foot?

Approximately 40-60% of all amputations of the lower extremity are performed in patients with diabetes. More than 85% of these amputations are precipitated by a foot ulcer deteriorating to deep infection or gangrene. The prevalence of diabetic foot ulcers has been estimated to be 3-8%. The complexity of these ulcers necessitates a multifactorial approach in which aggressive management of infection and ischemia is of major importance. For the same reason, a process-oriented approach in the evaluation of prevention and management of the diabetic foot is essential. Healing rates of foot ulcers are unknown with the exception of specialised centres where it is between 80-90%. The negative consequences of diabetic foot ulcers on quality of life include not only morbidity but also disability and premature mortality. Costs for healing ulcers are high and even higher for ulcers resulting in amputation, due to prolonged hospitalisation, rehabilitation, and need for home care and social service for disabled patients. Therefore, one of the most important steps to reduce cost in the management of the diabetic foot is to avoid amputations. A cost-effective management should not only be focused on the short-term cost until healing but also on the long-term cost, since foot ulcer and especially amputation are related to increased re-ulceration rate and lifelong disability. A multidisciplinary approach including preventive strategy, patient and staff education, and multifactorial treatment of foot ulcers has been reported to reduce the amputation rate by more than 50%.

Amputation, Surgical↗
PubMed2004

Work-related upper limb amputations in Taiwan, 1999-2001.

BACKGROUND: Work-related upper limb amputations account for a significant number of occupational injuries. This study analyzes the nationwide incidence of work-related amputations of upper limbs in Taiwan by using the workers' compensation database. METHODS: A total of 2,950 cases were retrieved and analyzed from the database of workers' compensatory disability claims between the years 1999 and 2001. RESULTS: The cases were workers with an average age of 39.1 years, of whom 23.0% were female, the highest percentage of cases was in the 30-49 age group, but the incidence based on insured population was the highest for those under 20 years old. About 96% of the cases involved finger amputation, and 85% of all amputations were related to common powered machines. The average annual incidence of disability claims due to occupational amputation of upper extremities was 12.5 per 100,000 workers. Claims were most prevalent among manufacturing workers and male workers. The male to female risk ratios ranged from 2.62 for manufacturing workers to 9.05 for transport, storage and communication workers by the Poisson regression analysis. CONCLUSIONS: Young male manufacturing workers were at high risk of occupational amputation of upper extremities in Taiwan. These results provide an epidemiological base for developing a prevention strategy.

Accidents, Occupational↗
PubMed1993

Hospitalized occupational finger amputations, New Jersey, 1985 and 1986.

About 19,000 finger amputations occur at work each year in the United States. Twenty percent of these injuries are severe enough to require hospitalization. Hospital discharge data from New Jersey (1985, 1986) were used to describe the demographic characteristics of persons with such injuries and to identify potential subjects for telephone interview. A total of 637 persons hospitalized for finger amputations were sent letters asking for their participation. Of 637 persons, 355 (56%) were contacted and 228 (36%) were interviewed, of whom 134 (59%) said their injury occurred at work. The annual rate of finger amputations at work was 9.3 per 100,000 employed persons. The rate was higher for males (14.7) than females (1.9). The age-adjusted rates were higher for Hispanic (52.8) and black (28.9) males than for white males (9.5). Persons working with machines or maintaining them in the manufacturing industry were at highest risk. Unjamming or repairing machinery (e.g., presses, saws, or slicers) while in operation was particularly hazardous. These data can be used to target occupations and industries for specific worksite intervention to prevent finger amputations. One limitation of this study, however, is that hospitalized occupational finger amputations may not be representative of all finger amputations, the majority of which are less severe and do not require hospitalization.

Accidents, Occupational↗
PubMed1985

Bone healing after amputation of mouse digits and newt limbs: implications for induced regeneration in mammals.

Postamputational healing was compared in nonregenerating and regenerating animals to determine whether bone healing might interfere with a regenerative response in mice. More than 150 mouse toes and 100 newt limbs were examined at the light microscope level. Stages of normal bone healing with approximate times of occurrence were established. Major differences in healing of these two species were seen. The periosteum produced hyaline cartilage, woven bone, and chondroid bone in mice, but only hyaline cartilage in newts. The endosteum produced woven bone in mice but no new growth in newts. Dead bone persisted in mice but was removed in newts. The marrow cavity became sealed in mice but remained open in newts. Despite these differences both animals produced skeletal tissue distal to the amputation plane. Woven bone formed distal to the amputation plane of mice. Cartilage formed distal to the amputation plane of newts, but cartilage was never seen distal to the plane of mice. Results of previous studies reveal that cartilage can be formed distal to the amputation plane of experimentally treated mice. Thus, although it does not regenerate, mouse bone is capable of producing, distal to the amputation plane, the type of skeletal tissue which appears at that location during an epimorphic regenerative response. This observation, in combination with other experimental results, indicates that both skeletal and soft tissues at the amputation site of treated mammals can resemble comparable tissues of newt limbs at an early stage of regeneration.

Amputation, Surgical↗
PubMed1985

Failure of Doppler ankle pressure to predict healing of conservative forefoot amputations.

Fifty minor foot and transmetatarsal amputations were studied to assess the reliability of Doppler ankle blood pressure (DABP) and skin blood flow (SBF) to predict healing. The level of amputation was determined solely on clinical criteria. Thirty-six (72 per cent) of the amputations healed. There was no statistical difference between mean DABP in healed 89 +/- 8 mmHg mean +/- s.e.m.) and non-healed (91 +/- 12 mmHg mean +/- s.e.m.) amputations. SBF was assessed by 125I-iodoantipyrine clearance in 28 patients. There was no correlation between DABP and SBF (r = 0.038). SBF in patients with healed amputations was 14.8 +/- 1.2 (mean +/- s.e.m.) ml 100 g-1 min-1 in contrast to SBF of 5.9 +/- 0.3 (mean +/- s.e.m.) ml 100 g-1 min-1 in the patients with non-healing (P less than 0.01). Where the flow was in excess of 8 ml 100 g-1 min-1 healing was always obtained while a flow of less than 7 ml 100 g-1 min-1 was associated with healing failure. These results suggest that DABP should be interpreted with caution as this technique fails as an accurate means of identifying those patients suitable for forefoot amputations. Skin blood flow assessment appears to provide an absolute value for the prediction of healing potential at this level.

Aged↗
PubMed1988

Amputation for peripheral vascular disease: the case for level selection.

One hundred major lower limb amputations were performed for end stage peripheral vascular disease over a 15-month period. Selection of amputation level was made on the basis of laboratory criteria using skin blood flow and infrared thermography data. Eighty-one amputations were performed at the below-knee level with six failures. This resulted in a final below-knee: above-knee amputation ratio of 3:1. It is clear that there are still many centres in the UK where above-knee amputation is the accepted operation, despite the inherent drawbacks to this procedure. We recommend that more attention is given to achieving higher below-knee amputation rates to improve the chances of amputee mobility and therefore quality of life.

Amputation, Surgical↗
PubMed1990

Through-knee amputation in high-risk patients with vascular disease: indications, complications and rehabilitation.

During a 10-year period 104 patients (mean age 72 years) had 106 through-knee amputations. Indications for surgery were: limb gangrene, 67 (64 per cent); ischaemic ulceration, 22 (21 per cent); rest pain, 9; knee contractures, 6. Thirty patients had had previous unsuccessful vascular reconstructive surgery and five had had a failed femoral embolectomy. The through-knee disarticulation used lateral skin flaps. The mortality was 21 (20 per cent). Of the 83 survivors, 59 (71 per cent) underwent uncomplicated primary wound healing; 36 (43 per cent) of the survivors were unsuitable for rehabilitation on a prosthesis. The remaining 47 (57 per cent) were walking before discharge 30-130 days (mean 68 days) after amputation. Through-knee amputation is a rapid, relatively bloodless, amputation and is a useful debridement procedure. The many surgical and functional advantages, in conjunction with the recent reports of better rehabilitation compared with the above-knee or Gritti-Stokes amputation, suggests that the through-knee amputation deserves greater consideration.

Aged↗
PubMed1992

Factors influencing the healing of distal amputations performed for lower limb ischaemia.

A total of 235 toes were amputated during 125 operations on 100 consecutive patients with lower limb ischaemia. The overall amputation wound healing rate for the series was 58.4 per cent and limb salvage was achieved in 66 patients. Toe amputation was performed under local anaesthesia in 57 cases and 32 (56 per cent) of these healed primarily, not significantly different from the healing rate of 41 (60 per cent) of 68 under general anaesthesia. Reconstructive arterial surgery was performed in conjunction with toe amputation in 39 patients; the healing rate with reconstruction was 32 (82 per cent) of 39, significantly better than the 41 (48 per cent) of 86 patients not undergoing bypass surgery (P less than 0.001). There was no difference in healing rates when comparing diabetic and non-diabetic patients. Multiple regression analysis demonstrated that reconstructive arterial surgery was the only factor which had an independent and significant influence on toe amputation healing. The use of local anaesthesia for distal amputation has no deleterious effects on wound healing.

Adult↗
PubMed1992

Traumatic amputation by explosive blast: pattern of injury in survivors.

Explosive blast causes a pattern of injury including primary blast lung, secondary fragment injury and traumatic amputation of limbs. Major traumatic amputation is rare in survivors of bomb blast but common in those who die. The mechanism of such injury has not been previously determined, but must be established if protective measures are to be developed for members of the armed forces. The nature of 41 traumatic amputations in 29 servicemen who survived to reach medical care after blast injury was investigated to determine the anatomical level of amputation and the pattern of soft tissue damage. Joints were an infrequent site of amputation and the tibial tuberosity was a particularly frequent site of lower-limb severance. Comparison of the pattern of injury was made with that seen in ejecting fast-jet pilots, who frequently suffer major flailing injury; there appears to be a substantially different injury distribution. The accepted mechanism of traumatic amputation, avulsion by the dynamic overpressure, is challenged; it is suggested that the shockwave resulting from an explosion is capable of causing at least bone disruption in a limb.

Amputation, Traumatic↗
PubMed1996

Amputation rates as a measure of vascular surgical results.

Reconstructive surgery for critical leg ischaemia (CLI) increased in both hospital- and population-based patient samples over 12 years. In the referral centre amputation numbers were unchanged over this period, although amputation carried out for patients with CLI decreased from 58 to 35 per cent. In the population sample amputation numbers decreased by 25 per cent and amputations of patients with CLI decreased from 79 to 43 per cent. Patient characteristics and amputation patterns were different in the two settings. Amputation rates as a measure of the efficacy of an arterial reconstruction policy should be used only on a population basis. The analysis is skewed by selection bias in referral centres.

Aged↗
PubMed2005

Temporary ectopic implantation for salvage of amputated lower extremities: case reports.

Two cases of temporary ectopic implantation of a complex amputated foot, followed by replantation to its anatomic position, are reported. Both cases of amputated foot were complicated by devastating soft-tissue injuries in the proximal stump of the amputation, fracture of the femur, and hemorrhagic shock, which ruled out the possibility of primary foot replantation. Both feet were temporarily ectopically implanted onto the contralateral legs, with microvascular anastomoses of the vessels to the recipient posterior tibial artery and saphenous vein. When the patient's general condition allowed, and the soft-tissue defects were repaired, the ectopic implanted feet were replanted to their anatomic positions. Both feet survived the temporary ectopic implantation and second-stage replantation. The length of the injured legs was maintained, and the feet regained their function in 4- and 6-month follow-ups. We conclude that temporary ectopic implantation of amputated parts provides an innovative procedure for the salvage of amputated extremities under special circumstances. A contralateral healthy extremity is an ideal recipient site for temporary ectopic implantation. The temporary ectopic implantation and second-stage replantation of an amputated foot and distal leg with indications can obtain satisfactory results.

Amputation, Traumatic↗
PubMed1982

Adolescent adjustment to amputation.

We investigated the psychological effects of amputation on adolescent patients by interviewing 27 persons who had a limb amputation because of cancer during their adolescence and compared them to data obtained from eight patients with amputations due to trauma at similar ages. In cancer patients, mobility-related activities and social matters including relations with peers and the opposite sex and self-consciousness were of paramount concern. All cancer patients considered themselves functionally independent and 67% had little or no concern for the future. While malignancy and amputation had a significant impact on the patients' lives, the vast majority had a positive view of life and 85% were found to have what we assessed as adequate overall adjustment. Individual variables examined included marital and child-bearing patterns, educational attainments, vocational attainments, perceived parental and peer support, adaptation to prosthesis, and variables relating to general outlook on life and psychological adjustment. Our results suggest that the patients who have had amputations due to malignancy differ from traumatic amputees in their adjustment to amputation, with cancer patients showing, in many instances, evidence of better adaptation to disability. This may in part be due to different backgrounds and social orientation of traumatic amputees. We found the majority of cancer amputees to adjust well to their circumstances and to report leading full and productive lives.

Adolescent↗