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PubMed2001

Common pathways in mental imagery and pain perception: an fMRI study of a subject with an amputated arm.

The present paper reviews data from two previous studies in our laboratory, as well as some additional new data, on the neuronal representation of movement and pain imagery in a subject with an amputated right arm. The subject imagined painful and non-painful finger movements in the amputated stump while being in a MRI scanner, acquiring EPI-images for fMRI analysis. In Study I (Ersland et al., 1996) the Subject alternated tapping with his intact left hand fingers and imagining "tapping" with the fingers of his amputated right arm. The results showed increased neuronal activation in the right motor cortex (precentral gyrus) when tapping with the fingers of the left hand, and a corresponding activation in the left motor cortex when imagining tapping with the fingers of the amputated right arm. Finger tappings of the intact left hand fingers also resulted in a larger activated precentral area than imagery "finger tapping" of the amputated right arm fingers. In Study II (Rosen et al., 2001 in press) the same subject imagining painful and pleasurable finger movements, and still positions of the fingers of the amputated arm. The results showed larger activations over the motor cortex for movement imagining versus imagining the hand being in a still position, and larger activations over the sensory cortex when imagining painful experiences. It can therefore be concluded that not only does imagery activate the same motor areas as real finger movements, but also that adding instructions of pain together with imaging moving the fingers intensified the activation compared with adding instructions about non-painful experiences. From these studies, it is clear that areas activated during actual motor execution to a large extent also are activated during mental imagery of the same motor commands. In this respect the present studies add to studies of visual imagery that have shown a similar correspondence in activation between actual object perception and imagery of the same object.

Adult↗
PubMed1983

Major amputations for melanoma.

Major amputation is an infrequently performed procedure for melanoma. Less than one per cent of patients seen at our unit have had a major amputation for melanoma. Thirty-two patients who had a total of thirty-four amputations have been reviewed in this article. The most frequent indication for amputation has been intractable local recurrences not responding to other forms of treatment. Amputation is only considered in patients with no evidence of systemic disease. Our conclusion, based on survival figures after amputation, is that the procedure has a palliative role in some cases of advanced localized melanoma, with a few long term cures.

Adult↗
PubMed2005

A history of sexual medicine in the United kingdom.

The history of sexual medicine in the United Kingdom since the 19th century is reviewed, with particular reference to masturbation, homosexuality, contraception, and in the past four decades, the treatment of sexual dysfunction. The medical profession's tendency to deal with sexual issues according to the sociopolitical and moral issues of the time is emphasized, and whereas "sex negativism" has prevailed within the medical profession for most of this historical period, there has been a succession of individuals within the profession who have presented a more positive approach to defining and promoting sexual health. Four tracks within sexual medicine over the past 30 years are described: the psychoanalytic approach of the Institute of Psychosexual Medicine, modern "sex therapy," psychophysiological sex research, and the involvement of andrology in the assessment and treatment of erectile dysfunction. The impact of Viagra is seen as the most recent chapter in this history.

History, 19th Century↗
PubMed1994

The reasons for amputations in children (0-18 years) in a developing country.

This study describes 49 young amputees who either have attended or have been operated at the Orthopaedic Department of Dodoma Regional Hospital from 1983 to 1991. Emphasis has been put on the aetiological factors of 56 amputations under review, underlying those that are typical of the Least Developed Countries in Africa and highlighting how they interrelate with the beliefs and traditions of the African society. Apart from 14 amputations performed for trauma of different type, important roles were played by home environment, tumours, wild animal bites and the health system itself. Nine amputations have been carried out for burns, while complications after medical care, particularly operative, have called for 12 amputations. Bone tumours have been responsible for eight and hyena assaults and snake bites have resulted in seven amputations. Special interest has been raised by four amputations performed for the so-called 'idiopathic tropical lower limbs gangrene' whose aetiology is still unknown.

Adolescent↗
PubMed2000

Should the amputations of the great toe be replanted?

Seventeen great toes, amputated at the distal phalangeal to the level of the MTP joint, were replanted between 1990 and 1998, at Izmir Hand and Microsurgery Hospital. Replantation in five out of six complete amputations, and seven out of eleven incomplete amputations were successful, and the overall survival rate was 76.4%. In failed replantations, the base of the proximal phalanx of the great toe was preserved during closing of the stump. Nine of 17 patients were available for review in the follow-up period of mean 3.5 years (range 1-6.5 years). Clinical and biomechanical evaluations of the operated feet were carried out in five patients who had replanted great toe, and in four patients who had amputated one. The uninjured sides were used as control group. The patients in the two groups had no significant subjective symptoms, nearly normal ROM of the MTP joint and protective sensation was achieved in the replanted great toes. With the numbers available, while radiographical parameters of the involved and the control sides demonstrated no significant differences in either groups, pedographical studies revealed consistent changes in weight-bearing distribution of the feet with amputated great toes. Although the great toe amputation causes no disturbance in gait, it alters the load distribution of the foot.

Adolescent↗
PubMed2006

Preservation of residual foot length in partial foot amputation: a biomechanical analysis.

BACKGROUND: Partial foot amputation may be preferred to more proximal amputation because of the perceived improvement in function associated with preserving foot length and the ankle joint complex, thus enabling normal gait and push-off. Clinically, partial foot amputees display significant wasting of the triceps surae musculature, strongly indicative of disuse. This investigation aimed to examine the belief that preserving residual foot length should be the primary operative objective necessary to maintain normal foot and ankle function. METHOD: The gait patterns of eight partial foot amputees and a cohort of matched non-amputee control subjects were analyzed using a peak three-dimensional (3D) motion analysis system incorporating an AMTI force platform (Advanced Mechanical Technology Inc., Waterton, MA). Amputee subjects used their own prostheses for the evaluation. RESULTS: Amputations disarticulating the metatarsophalangeal (MTP) joint had little impact on the normal pattern of ankle power generation. However, amputation proximal to the MTP joint level resulted in virtually negligible power generation across the ankle, regardless of residual foot length. Subjects compensated for the lack of ankle power generation by adopting strategies in which the hip became the primary source of power to advance the body forward. CONCLUSIONS: The primary reason for a partial foot amputation is to preserve the normal function of the foot and ankle complex associated with push-off. As such, surgery should strive to preserve the metatarsal heads to allow amputees to use the ankle's contribution to walking. Given that amputation proximal to the metatarsal heads compromised the normal propulsive function of the foot and ankle, surgery should not strive to preserve residual foot length to maintain function but should instead aim to achieve good distal tissue coverage and healing, particularly given that the hip joint(s), not the ankle, become the primary source of power for walking.

Adult↗
PubMed1996

Benchmark analysis on diabetics at high risk for lower extremity amputation.

After the 1990 establishment of a multidisciplinary foot salvage clinic, 1346 diabetic patients, at high risk for the development of foot ulcers and eventual lower limb amputation, were followed for 4 years. Of the 224 high-risk patients admitted to the hospital, 74 amputations (5.5%) of all or part of a lower limb were performed. Patients undergoing amputation were younger, more severely ill, and required more frequent hospitalizations because of greater organ system involvement. They were also more likely to be institutionalized after discharge. Overall, patients with long-standing adult-onset diabetes, identified as at high risk for foot ulcer development, have a substantially increased risk for lower limb amputation, multiple organ system failure, hospitalization, and institutionalization than do diabetic patients as a whole. Clinical benchmarking facilitates the identification and reduction of unnecessary variations in patient care practices. Here, a formal benchmark analysis provides the current outcome expectations for amputation rates and co-morbidities in patients with diabetes who are classified as at high risk for lower extremity amputation. Management of these patients in a structured, multidisciplinary foot salvage clinic, augmentation of baseline services, and preliminary benchmark data may provide a standard for the measurement of therapeutic interventions that improve patient care.

Adult↗
PubMed2005

Amputation and the diabetic foot: learning from a case study.

Diabetic foot disease causes more amputations than any other lower limb disease. Management of the diabetic foot requires a thorough knowledge of the risk factors for ulceration and amputation, the most common of which are neuropathy, ischaemia and infection. Amputations are not inevitable, however; early detection and appropriate treatment of ulcers can prevent up to 85% of amputations. This has been demonstrated in the formation of multidisciplinary diabetic foot clinics, which have been shown to reduce the number of amputations across the world. Adherence to a systematic regime of organization, education, screening and intervention can improve communication between patients, GPs, community nursing and diabetes sub-specialists to facilitate appropriate treatment and prevention of complications. The case discussed here demonstrates how inadequate and disjointed management through lack of communication, education and knowledge of diabetic foot disease can lead to complications requiring amputation and debridement.

Administration, Oral↗
PubMedDate not supplied

Lower limb amputation. 1: indications and treatment.

Lower limb amputation is performed predominantly to alleviate acute and chronic limb ischaemia caused by vascular disease, poorly controlled diabetes or, occasionally, infection. Atherosclerosis is the primary cause of chronic arterial ischaemia and the most common reason for amputation. The vascular nurse has an important role in reducing the need for amputation, by providing information on health promotion and illness prevention to patients with vascular insufficiency to halt progression to amputation. This is the first of four articles focusing on lower limb amputation. It examines the indications for lower limb amputation in detail, and briefly outlines other treatment options including revascularization techniques.

Algorithms↗
PubMed1988

Traumatic partial foot amputations in adults. A long-term review.

A retrospective study of 260 industrial amputees was undertaken to determine the long-term functional results of partial foot amputations following trauma. Follow-up ranged from 1 to 68 years with a mean of 16 years. Of 113 partial foot amputees (118 amputations) who had retained their original amputation, the functional end-results were 43% good, 38% fair and 19% poor. Lisfranc and Chopart amputations were better than those at transmetatarsal or digital levels. Of 260 initial amputations 49 (19%) were revised to a Syme's or a below-knee amputation.

Adolescent↗
PubMed1996

Continuous postoperative infusion of a regional anesthetic after an amputation of the lower extremity. A randomized clinical trial.

We performed a prospective, randomized clinical trial to determine whether continuous infusion of bupivacaine hydrochloride decreased the use of narcotics for the relief of pain after an amputation. Twenty-one patients who were to have an amputation of the lower extremity because of ischemic necrosis secondary to peripheral vascular disease were divided into two groups with use of a table of random numbers. Group A (the treatment group) included nine patients who were to have a transtibial amputation, one patient who was to have a disarticulation at the knee, and one patient who was to have a transfemoral amputation. Group B (the control group) included seven patients, two patients, and one patient, respectively. After the amputation had been performed, a Teflon catheter was placed adjacent to the transected end of the sciatic or posterior tibial nerve. Postoperatively, the patients received continuous infusion of either bupivacaine (Group A) or normal saline solution (Group B) for seventy-two hours. Intravenous administration of morphine with use of a patient-controlled pump also was permitted during this period. The amount of morphine that was used was recorded meticulously. The patients in Group A used less morphine during the first and second days after the operation than did those in Group B. There was no difference between the groups with regard to the amount of morphine used on the third postoperative day. Over-all, eleven of fourteen patients who completed questionnaires reported a decrease in pain between the three and six-month evaluations. We concluded that continuous perineural infusion of an anesthetic appears to be a safe, effective method for the relief of postoperative pain but that it does not prevent residual or phantom-limb pain in patients who have had an amputation of the lower extremity because of ischemic changes secondary to peripheral vascular disease.

Adult↗
PubMed2005

Function of skin grafts in children following acquired amputation of the lower extremity.

BACKGROUND: Investigators have recommended aggressive use of skin-grafting in order to preserve length and proximal joint function following an acquired amputation in children. However, there is little objective evidence to either support or refute that recommendation. METHODS: We performed a retrospective review of the cases of all children for whom a skin graft had been applied to the residual limb following an acquired lower-extremity amputation at our Limb Deficiency Clinic between 1984 and 2002. Skin graft dysfunction, defined as breakdown, contracture, and/or pain, was considered to be clinically relevant if it required the child to discontinue use of the prosthesis for any period of time or if it required revision surgery to facilitate continued prosthetic fitting. RESULTS: Twenty-three children (mean age at amputation, 4.4 years) with a total of thirty-one acquired lower-extremity amputations had been treated with skin-grafting. At a mean of 6.3 years after the operation, sixteen (52%) of the thirty-one extremities had had no episodes of skin graft dysfunction. The remaining fifteen extremities (48%) had had clinically relevant skin graft dysfunction (breakdown in thirteen and contracture and pain in one extremity each). Nine of the ten extensive skin grafts underwent clinically relevant breakdown, as did thirteen of the twenty-four grafts that were located distally on the residual limb. Subsequent surgical revision of the residual limb because of inadequate function of the skin graft was performed on seven extremities (23%), with revision to a more proximal limb-segment level required in five. CONCLUSIONS: Focal skin-grafting (involving < or = 25% of the surface area) of partial-thickness soft-tissue defects in order to optimize the length of the residual limb at the time of an amputation is an effective option for children with an acquired lower-extremity amputation. Limited skin-grafting (involving 26% to 50% of the surface area) is more likely to result in skin graft breakdown, particularly when it is done distally. Extensive skin-grafting, while technically possible, frequently requires revision and rarely results in an optimally functioning limb. Alternative treatment strategies should be considered for extremities that would require extensive, distal skin-grafting.

Adolescent↗
PubMed1993

Lower-extremity amputations in diabetic and nondiabetic patients. A population-based study in eastern Finland.

OBJECTIVE: To study the incidence of LEAs attributable to PVD in diabetic and nondiabetic patients. The age at first amputation, the level of amputation, the number of reamputations, and survival after amputation also were examined in the study populations. RESEARCH DESIGN AND METHODS: This retrospective study was based on a population of 253,000 inhabitants in eastern Finland. All patients with their first LEA performed during the period from 1 January 1978 to 31 December 1984 were identified from the registers of operation theaters in the study area. Furthermore, patient records and death certificates were reviewed. Amputations attributable to causes other than evident atherosclerotic vascular disease were excluded. RESULTS: Altogether, 477 patients (85 diabetic men, 127 nondiabetic men, 169 diabetic women, and 96 nondiabetic women) were identified. The overall LEA rate was 26.9/100,000 per yr, and the incidence increased strongly with age in both diabetic and nondiabetic patients. The age-adjusted amputation incidence per yr was 349.1/100,000 for diabetic men, 33.9/100,000 for nondiabetic men, 239.4/100,000 for diabetic women, and 17.2/100,000 for nondiabetic women. The proportion of peripheral (toe, leg) amputations was markedly higher in diabetic patients who also tended to have more reamputations during the follow-up than did nondiabetic subjects. The diabetic status per se was a statistically significant risk factor for mortality in women, but not in men. CONCLUSIONS: Diabetic men and women had a 10.3- and 13.8-fold higher risk, respectively, for LEA.

Adult↗
PubMed1994

How does provider and patient awareness of high-risk status for lower-extremity amputation influence foot-care practice?

OBJECTIVE: To assess whether patients with diabetes at high risk for lower extremity amputation received more intensive medical care or self-care instruction and to determine the association between foot care and risk of lower-extremity amputation. RESEARCH DESIGN AND METHODS: Patients with diabetes were seen at he Seattle Veterans Affairs Medical Center (VAMC) between October 1984 and April 1987; 67 patients were seen for initial non-traumatic amputation, and 236 consecutive control subjects were seen for non-traumatic but medically necessary surgery unrelated to diabetes. Data collection included patient interview and medical record review. High-risk status, defined as presence of peripheral neuropathy, peripheral vascular disease, or or prior foot ulcer, was temporally fixed at 2 years before study enrollment. RESULTS: Peripheral neuropathy, peripheral vascular disease, and prior foot ulcer were independently associated with risk of lower-extremity amputation: peripheral neuropathy odds ratio (OR) = 1.4 (95% confidence interval (CI) 0.7-2.7), peripheral vascular disease OR = 2.6 (95% CI 1.5-4.5), and prior foot ulcer OR = 10.9 (95% CI 4.6-25.5). Patients with a prior foot ulcer were significantly more likely to have seen a podiatrist and to have received outpatient diabetes education at the Seattle VAMC; their providers were more likely to prescribe clipping toenails, regular foot washing, and elevating feet during the day (chi 1(2) for proportions P < 0.05). However, for patients with a history of peripheral neuropathy or peripheral vascular disease, there was no statistically significant increase in medical care (podiatry visits, outpatient diabetes education) or self-care instruction (clip nails, elevate feet, or self-monitor blood glucose) compared with patients without either of these two conditions (chi 1(2) for proportions P > 0.20). CONCLUSIONS: When clinicians were aware of a patient's very elevated risk for lower-extremity amputation (evidenced by prior history of foot ulcer), they were more likely to prescribe preventive foot-care behaviors, but awareness of other risk factors (peripheral neuropathy or peripheral vascular disease) did not necessarily increase preventive care. Physicians and patients should receive periodic education and reinforcement of diabetes management skills to modify care delivered to individuals at highest risk for lower-extremity amputation.

Adult↗
PubMed1995

Increased foot pressures after great toe amputation in diabetes.

OBJECTIVE: To compare peak pressures on the sole of the foot in non-insulin-dependent diabetic patients with isolated, unilateral amputations of the great toe and first metatarsal with the patients' contralateral, intact foot. RESEARCH DESIGN AND METHODS: Eleven patients with a unilateral great toe and partial first metatarsal amputation of at least 6 months duration were evaluated with the F-Scan in-shoe pressure measurement system. Patients were studied in the same brand and style of footwear--a thin, rubber-soled, canvas boat shoe. We compared mean peak plantar foot pressures under the first metatarsal, lesser metatarsals, lesser toes, and heel in feet with and without a great toe amputation using the Wilcoxon's matched pairs signed-rank test. RESULTS: Peak foot pressures were significantly higher under the first metatarsal head (P = 0.046), lesser metatarsal heads (P < 0.001), and toes (P < 0.001) in feet with a great toe amputation compared with the contralateral foot without an amputation. Pressure under the heel was higher on the contralateral foot (P < 0.01). CONCLUSIONS: After a great toe amputation, pressure distribution of the foot is significantly altered. Because preamputation risk factors such as peripheral neuropathy, foot deformity, and limited joint mobility for many of these patients remain unchanged, an increase in foot pressures contributes to an increased risk of reulceration and reamputation in these patients.

Adult↗
PubMed1996

The development of foot deformities and ulcers after great toe amputation in diabetes.

OBJECTIVE: Our aim was to compare the prevalence and severity of foot deformities and the development of ulcerations in patients after a great toe amputations. RESEARCH DESIGN AND METHODS: We evaluated the presence of deformities of the toes and metatarsophalangeal joints (MTPJs) in patients with a great toe amputation who had an intact unamputated contralateral foot. The contralateral foot served as the patient's own control. We used a binomial test for paired data to compare the presence of deformity and ulcer formation and Fisher's exact test to compare joint flexibility in toes and MTPJs with foot deformities. RESULTS: There were more deformities of the second (P = 0.012) and third (P = 0.002) toes and lesser MTPJs (P < 0.05) and more rigid deformities of the second (P = 0.002) and third (P = 0.016) toes and second MTPJs (P = 0.035) in feet with great toe amputations. New ulcers were more common in feet that had an amputation (P = 0.002). CONCLUSIONS: We concluded that amputation of the great toe contributes to the development of deformities of the second and third toes and lesser MTPJs and new ulcer formation in patients with diabetes. When deformities were present, the second and third toes and second MTPJ were more severe in feet with a great toe amputation.

Amputation, Surgical↗
PubMed1997

Determination of amputation level in ischemic limbs. Reappraisal of the measurement of TcPo2.

OBJECTIVE: To study the accuracy of the measurement of TcPo2 for the determination of the optimal level of amputation in patients with end-stage vascular disease (i.e., the level at which the reamputation rate and the proportion of too-proximal amputations will be minimized). RESEARCH DESIGN AND METHODS: We used a Medline literature search of all published studies of the past 12 years that fulfilled predefined quality criteria, and we analyzed the data by means of receiver operating characteristic (ROC) curve. RESULTS: Ten studies could be identified with a total of 615 lower-limb amputations (51% of them being performed in diabetic patients) and a reamputation rate of 16.4%. The best performances of the TcPo2 measurement were obtained between 10 and 20 mmHg with an accuracy of approximately 80%. CONCLUSIONS: Preoperative TcPo2 measurement may be of considerable help to predict stump outcome and level of amputation. Our study provides objective prognostic values for the range 0-50 mmHg and suggests that TcP02 should usually be 20 mmHg at the site of amputation, which will predict healing with 80% accuracy and should, therefore, not be used as a sole criteron. Despite this aid in making his decision about the amputation level, the surgeon still has to balance between his goal of achieving primary wound healing and his hope of preserving the maximal limb length and has to consider patient preferences.

Amputation, Surgical↗
PubMed1998

Angiographic evaluation of peripheral arterial occlusive disease and its role as a prognostic determinant for major amputation in diabetic subjects with foot ulcers.

OBJECTIVE: To evaluate in diabetic patients with foot ulcers the angiographic findings of peripheral occlusive arterial disease and their role as a prognostic determinant for major amputation. RESEARCH DESIGN AND METHODS: From 1993 to 1995, 104 diabetic inpatients with foot ulcers underwent arteriography on the ulcerated limb. Stenoses in the iliac trunk, the superficial femoral artery, the profunda femoral artery, the popliteal artery, the anterior tibial artery, the posterior tibial artery, and the peroneal artery were scored on the basis of vessel lumen reduction: 0 if stenoses involved a reduction in the vessel lumen of < 50%, 1 if stenoses involved 50 to < 75% reduction, 2 if stenoses involved 75 to < 100% reduction, and 3 if total occlusion was present. The sum of the points assigned to each of these arteries was called the angiographic score. RESULTS: Stenoses causing a vessel lumen reduction > or = 50% were detected in 103 patients (99%). Stenoses were also detected in subjects with palpable foot pulses, ankle-brachial indexes > or = 1, or transcutaneous oxygen tension > or = 50 mmHg. The risk of major amputation was increased significantly when total occlusion was present in the popliteal and infrapopliteal arteries (chi 2 for trend = 50.57, P < 0.001). No major amputation was carried out in patients with angiographic scores < 10; major amputation was carried out in all the patients with scores > 14. Multivariate analysis indicated a high angiographic score as an independent risk factor for major amputation (odds ratio 2.32, P = 0.001, CI 1.40-3.84). CONCLUSIONS: Angiography permits an exact detection of occlusive arterial disease in subjects with normal results for noninvasive vascular procedures. A score that has a relevant prognostic value for major amputation can be obtained from the evaluation of the extent and diffusion of the stenoses.

Amputation, Surgical↗