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Microvascular surgery has allowed creative primary reconstruction using undamaged parts of amputated limbs as donor sites. We present a case of lower extremity below-knee amputation salvage with a free flap of heel, calcaneus, and soft tissues from the amputated lower leg, ankle, and foot supplied by the posterior tibial neurovascular bundle.
A case of immediate stump reconstruction following proximal leg amputation below the knee is reported. Additional length and sensation are conferred to the stump by free autotransplantation of a composite flap taken from the unsalvageable amputated leg. This flap provided 13 cm of vascularized tibia invested in the skin of the foot. This operative procedure facilitated the fitting of a prosthesis and preserved knee function despite an initial very proximal amputation.
The spinal cord of freshly amputated newt tails was displaced cranially by pushing several paraplast chips into the spinal canal with a glass needle. That part of the canal formerly occupied by the spinal cord was then packed with paraplast. Tails treated in this manner failed to regenerate, forming no more than a millimeter of new tissue with little or no cartilage and muscle. Dedifferentiation and early mitotic activity, however, was normal, indicating that the spinal cord exerts its effect on tail regeneration in the later stages. Amputation through the proximal region of a vertebra led to a significantly lower mitotic rate at four days than did amputation through the distal region, a situation contrary to the principle that during regeneration, elongation rate is gennerally faster from proximal than distal levels.
To cover a large soft-tissue defect and to reconstruct the shoulder contour after forequarter amputation, we used an osteomyocutaneous free flap incorporating an elbow joint from the amputated extremity in two patients. These flaps were well vascularised and reliable. They provided excellent coverage of large soft-tissue defects and they maintained shoulder contours. This procedure is useful for reconstruction after extended forequarter amputation and chest wall resection.
Psychological distress and postamputation pain were investigated in a sample of 582 males with long-term limb amputations (mean time since amputation 639.3 months, standard deviation 166.1; range 240-784 months). Prevalence of significant depressive symptoms (Hospital Anxiety and Depression Scale [HADS]-D score > or = 8) was 32.0%, and 34.0% of respondents met the screening criterion for clinical anxiety (HADS-A score > or = 8). Nearly one quarter (24.6%) of respondents reported significant post-traumatic psychological stress symptoms (Impact of Event Scale scores > or = 35). In total, 87.8% experienced either phantom or residual limb pain. Affective distress scores differed according to the respondents' type of pain experience. Respondents who experienced residual limb pain reported significantly higher affective distress scores than those with no phantom or residual limb pain. Many older individuals with long-term traumatic limb amputations could benefit from interventions to ameliorate affective distress and appropriate residual limb pain treatment.
In this survey, the results of arterial bypass grafting procedures for occlusive disease and after major amputations have been reported. The two series have been evaluated separately and then some comparisons have been made. The bypass graft series covered risk, mortality, and patency of grafts, including patency at 1 year. The amputation series covered risk, mortality, and effect of previous bypass on the level of amputation, and the ability to ambulate.
Part II of this series of articles on diabetic foot amputation represents case studies, along with appropriate metatarsal amputation procedures. Misdiagnosis or delayed treatment of these patients can lead to loss of limb and, in some cases, can be life threatening. Diabetic feet have varying degrees of neurovascular compromise, but this should not result in traditional below-the-knee or above-the-knee amputations.
As our population ages, a potential exists for increase in lower extremity amputation related to diabetes mellitus and peripheral vascular disease. Besides the financial impact, amputations impose serious consequences on those affected. This article discusses the problem, its effects, care of the amputation sites, and offers support for prevention programs.
The results of 111 acute below-knee amputations in war wounded were reviewed. The majority of the patients were wounded by exploding mines. The amputation stumps were not closed primarily but secondarily after an average of 6.4 days. Reamputation above the knee was necessary in only one case of wound sepsis. After delayed primary closure 84% of the stumps healed without problems. The best results were obtained when the stump closure was performed within 1 week after the amputation. No cases of gas gangrene or tetanus were encountered.
This case report describes a patient who had a painful and fungating angiosarcoma of the right buttock. A palliative hindquarter amputation was performed. A large, free flap taken from the amputated leg was used to cover the defect. This technique offers a solution for covering large defects in an unsalvageable traumatic amputation or tumor conditions.
This report describes the use of clear plastic bags on vinyl chloride-vinylidine chloride copolymer (also known as S Film) for the postoperative management of amputation stumps. The bags are shrunk to the stump by the application of heat and act as a primary dressing. Their use has been effective in controlling postoperative oedema and infection as well as giving the surgeon direct visual access to the stump without disturbing the wound. A case of a below-knee amputation managed by this method is described.
A small group of patients is reported in whom amputation or re-amputation of the upper or lower limb has been performed at increasingly higher levels in an unsuccessful attempt to relieve the patients' unrecognized chronic pain syndrome. The possibility of self mutilation should also be considered. The etiological factors and management of this uncommon but difficult problem are discussed. It is hoped that members of an experienced amputee team will recognize this rare problem and help to avoid multiple surgical procedures, which are harmful to the patient and costly to society.
A right-handed 4 1/2-year old boy had a sharp amputation 3 cm proximal to his left wrist joint in a hay-cutting machine accident. In addition, he sustained 5 incisions on the anterior and ulnar aspects of the same forearm, the proximal and deepest including radius, ulna and the deep branch of the radial nerve. In a 19 1/2 hours operation, his left hand was replanted and the mainly cold anoxaemia time was 16 hours. Despite several reoperations, the hand could not be saved but the proximal portion of the amputated part did survive. On the 21st day the hand was reamputated at the radiocarpal joint level and the stump closed with viable skin from the proximal 2/3 of the dorsum of the hand. On a 1 year follow-up, the length growth was found to be close to normal. A myoelectric prosthesis is functioning well not only from impulses in the reinnervated extensor muscles but also from the flexor muscles which have been denervated and anatomically divided at least at two levels. Partial replantation success and perfect revascularization and reinnervation in the forearm was gained, thanks to extensive surgery. These results in an extremely complicated injury like this do show that every surgical effort should be made in pediatric extremity trauma.
The use of "spare part" flaps from a non-replantable limb to cover amputation stumps in the upper extremity preserves limb length, provides durable coverage and sensation and will avoid additional donor site morbidity. We have studied the blood supply of the forearm based on the radial artery. The potential for harvesting different tissues is confirmed. In five clinical cases reliable primary soft tissue reconstruction was achieved, even in the presence of trauma.
Tissue expansion of adjacent intact skin and subcutaneous tissue has in five legs provided high-quality soft-tissue coverage of the distal end in legs amputated at different levels without further shortening of the bone. The sensitivity of slowly expanded flaps is temporarily affected but eventually seems to return to normal. Expanded flaps have endured both sitting and the use of prostheses for 4 to 5 years. In one case the technique made it possible to save the knee joint. Besides being a functional reconstruction, the appearance of the reconstructed parts much improved. A technique of overexpansion and double flap coverage of the bone utilizing deepithelialization is described.
This paper reviews different types of treatment of the amputation stump. Following an examination of the historical development there are sections on bandaging, semi-rigid dressings, rigid cast dressing and controlled environment treatment. The merits and demerits of each type of treatment are discussed.
Congenital limb deficiencies pose quite a number of questions, problems and tasks that go far beyond the surgical and prosthetic-orthotic aspects present. The question of amputation in view of improved function and appearance as well as easier prosthetic provision can be answered only in the context of the orthopaedic-surgical and prosthetic possibilities available. Social, cultural and religious factors are in addition enumerated that have to be taken into account.
Unilateral amputees with second leg ischemia may miss consideration for anything but amputation. Justification for a reconstructive approach for these ischemic second limbs was sought from a retrospective study of 108 patients who underwent lower extremity distal bypass. Risk factors and results were compared for the 12 unilateral amputees and the 96 nonamputees. Age and relative incidence of rest pain, claudication, and tissue loss were not significantly different for the two groups. Diabetes mellitus was present in 41.6 per cent of amputees and 31.3 per cent of nonamputees. Preoperative, average ankle-brachial blood pressure ratios were equal for both groups (0.3). Angiography showed comparable distribution of patients between the two groups with regard to distal run-off vessels. Operative mortality was 8 per cent for amputees and 3 per cent for nonamputees. Cumulative survival at 25 months was 67.5 per cent for amputees and 82.4 per cent for nonamputees. Cumulative patency at 6 months was 71.5 per cent for amputees compared with 63 per cent for nonamputees and at 25 months was 58.5 per cent for amputees and 37.6 per cent for nonamputees (no significant difference). Unilateral amputees appear to have similar risks and results for lower extremity distal bypass as do nonamputees. An independent, aggressive approach for evaluation and surgical revascularization should not be overlooked for the ischemic, remaining lower extremity in the dysvascular unilateral amputee.