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PubMed2001

Geographic variation of lower-extremity major amputation in individuals with and without diabetes in the Medicare population.

OBJECTIVE: To describe geographic variation in rates of lower-limb major amputation in Medicare patients with and without diabetes. RESEARCH DESIGN AND METHODS: This cross-sectional population-based study used national fee-for-service Medicare claims from 1996 through 1997. The unit of analysis was 306 hospital referral regions (HRRs) representing health care markets for their respective tertiary medical centers. Numerators were calculated using nontraumatic major amputations and the diabetes code (250.x) for individuals with diabetes. Denominators for individuals with diabetes were created by multiplying the regional prevalence of diabetes (as determined using a 5% sample of Medicare Part B data identifying at least two visits with a diabetes code for 1995-1996) by the regional Medicare population. Denominators for individuals without diabetes were the remaining Medicare beneficiaries. Rates of major amputations were adjusted for age, sex, and race. RESULTS: Rates of major amputations per year were 3.83 per 1,000 (95% CI 3.60-4.06) individuals with diabetes compared with 0.38 per 1,000 (95% C1 0.35-0.41) individuals without diabetes. Marked geographic variation was observed for individuals with and without diabetes; however, patterns were distinct between the two populations. Rates were high in the Southern and Atlantic states for individuals without diabetes. In contrast, rates for individuals with diabetes were widely varied. Variation across HRRs for individuals with diabetes was 8.6-fold compared with 6.7-fold in individuals without diabetes for major amputations. CONCLUSIONS: Diabetes-related amputation rates exhibit high regional variation, even after age, sex, and race adjustment. Future work should be directed to exploring sources of this variation.

Age Distribution↗
PubMed1997

Palliative major amputation and quality of life in cancer patients.

Limb sparing surgery has replaced the amputation surgery in the treatment of limb sarcomas. Recurrent or persistent disease constitutes a major problem. Local symptoms such as agonizing pain, fractures, tumor fungation, inability to walk and inability to maintain daily activities, further impair the patient's quality of life. In this clinical set-up palliative amputation should be considered. Eighteen patients with soft-tissue or bone sarcomas and 3 patients with metastatic carcinoma underwent palliative major amputation. Hemipelvectomy was performed in 3 patients, hip disarticulation in 10, knee disarticulation or below-knee amputation in 3 patients, shoulder disarticulation in one patient and forequarter amputation in 4 patients. Local control of the disease and pain and improvement of the performance status were observed in 19 evaluable patients. The mobility was restored in 15 patients with lower limb surgery. The median survival following the procedure was 9 months. There was only one case of immediate post-operative death. Severe phantom pain was not reported by any of the patients. Quality of life was reported to be improved by two-thirds of the patients. To conclude, we have, found palliative major amputation surgery worth performing in low-performance status cancer patients with locally advanced disease.

Adolescent↗
PubMed1979

Revascularization or amputation.

The factors which determine the choice, revascularization or amputation of an ischaemic leg are very numerous, variable and sometimes also related. They are concerned with the extent and course of the gangrene, the general condition of the patient and the risk of operation, the technical operability in terms of arterial reconstruction, the skill and judgement of the vascular surgeon, the motivation and life expectancy of the patient, as well as the facilities at the limb-fitting centre. In principle, arterial reconstruction should be the primary consideration in all patients with severe ischaemia of a leg, and threatened with loss of the limb. This implies the need for evaluation by a vascular surgeon. If arterial reconstruction is impossible or undesirable and if lumbar sympathectomy is not indicated either, then if amputation is necessary it must be decided, when is it necessary, and whether a below-knee or an above-knee amputation is possible. The patient with severe arterial circulatory disorders is best served when the vascular surgeon who is responsible for the arterial reconstruction, also assumes responsibility for determining the timing and the level of an amputation, and in some hospitals even for doing the amputation. In other words, the same doctor, preferably the vascular surgeon, has to be responsible for the selection of the patients and the judgement whether the patient is a candidate for revascularization or amputation.

Amputation, Surgical↗
PubMed1983

Amputations for vascular insufficiency.

A study was carried out of 302 major amputations for vascular insufficiency in the lower limb with respect to levels of amputation, postoperative revisions, re-amputations on a higher level and postoperative mortality. This information was related to vascular disease (diabetes mellitus/arteriosclerosis) and to the experience of the surgeon. There was a high incidence of above-knee amputations both of diabetics and arteriosclerotics and the rate of complications was high for "senior" as well as "junior" surgeons. The amputations were performed during 1978 and the study has shown that there is an urgent need to lower the level of amputation without increasing the rate of complications. The study indicates that there is a need for further information about the problems involved in rehabilitation of above-knee amputees.

Aged↗
PubMed1997

Mobility of persons after traumatic lower limb amputation.

The objective of this study was to determine the influence of time span since amputation on mobility of persons experiencing traumatic lower limb amputation. A special questionnaire was sent to such persons and responses were analysed statistically. The subjects comprised 223 persons after traumatic lower limb amputation, residents of Slovenia. We discovered that 186 (74.2%) are using their prosthesis for more than 7 hours per day, 109 (52.2%) are able to walk outdoors without crutches, and 129 (57.8%) climb more than 20 stairs per day. In addition, those who are walking without crutches, walking longer distances, still cycling and driving a care are, on average, 5-10 years younger than the others. However, around one-third of persons who were young at the time of amputation face limitations of mobility later in life. A total of 76 (35.3%) are able to walk only up to 500 m out of doors, 38 (18.2%) can walk only with a pair of crutches, 62 (29.7%) need a cane or one crutch, and 37 (16.6%) cannot climb stairs. We conclude that successful fitting and usage of a prosthesis by persons after lower limb amputation promotes independent walking and mobility in everyday life. The level of independence achieved is related to time span since amputation.

Activities of Daily Living↗
PubMed1982

Mortality after major amputation following gangrene of the lower limb.

Major amputations were performed on 310 patients because of gangrene of the lower limb. The mean age was 70 years and 58 per cent of the patients were males. Females were on average 5 years older. The primary levels of amputation were above-knee (AK) in 33 per cent (103/310), through-knee (TK) in 21 per cent (66/310) and below-knee (BK) in 46 per cent (141/310). Mortality during hospitalization was 18 per cent and the average hospitalization time 68 days. Mortality during hospital stay was primarily dependent on the occurrence of somatic complications, secondarily on the level of the amputation (as an expression of the extent of the gangrene) and finally on the age of the patient. The long-term survival rate was correlated primarily to the level of the amputation and secondarily to age. A high excess mortality was noted during the first few postoperative years, especially among AK amputees, but after this period the survival curve ran parallel to the expected survival rate. Mortality after 1 year was 34 per cent, comprising 17 per cent after BK amputation, 39 per cent after TK and 54 per cent after AK amputation.

Adult↗
PubMed1990

Selection of amputation level in ischemia. Skin blood flow and perfusion pressure equally predictive.

In 33 patients who had major amputation for ischemia of the lower extremity, skin blood flow and perfusion pressure were compared in terms of prediction of amputation level. Skin blood pressure was measured photoelectrically. Only the blood flow was known to the surgeon. The primary amputation was performed below the level of the knee in 15 patients, through-knee in 14, and above the knee in only 4 patients. Primary healing was achieved in 27 patients, 5 patients had delayed healing at the same level, and 1 patient was reamputated. The same amputation level was predicted in 24 patients (primary healing/secondary healing/failure = 20/3/1) and a different one in 9 patients. In 4 patients the perfusion pressure suggested a more proximal amputation (2/2/0) and in 5 patients a more distal amputation (all primary healing). There was no difference between the two methods in predicting wound healing.

Adult↗
PubMed1990

Outcome in 282 lower extremity amputations. Knee salvage and survival.

Lower-extremity amputation for arterial insufficiency was performed in 282 cases ineligible for vascular surgery. In 203 cases (Group I), amputation was elective without previous vascular surgery. In 14 cases (Group II), amputation followed recent vascular reconstruction, and in 12 cases (Group III) amputation was performed after failed thromboembolectomy. In 53 cases (Group IV), amputation was done acutely, i.e., as a life-saving procedure because of septicemia. The results as regards both knee salvage and survival were much better in Groups I and II than in Groups III and IV. We conclude that knee salvage is poor and mortality high after acute amputations and after failed thrombembolectomy. These factors should be taken into account when comparing series from different centers.

Adult↗
PubMed2000

Experimental postoperative adjuvant chemotherapy by UFT using primary tumor amputation model.

We evaluated the postoperative adjuvant chemotherapy by UFT using the primary tumor amputation-pulmonary metastasis model. When Lewis lung carcinoma (LLC) primary tumors on the hind foot pad grew palpable, they were amputated on two different days. In experiment (A) (earlier amputation model), micrometastases were detected on the day of amputation only by the histopathological examination. In the experiment (B) (later amputation model), nodules could be determined even by necropsy. Long-term (60-day) consecutive administration of UFT (22 mg/kg/day), which produced no body weight loss, markedly prolonged the survival period in experiment (A) (ILS: over 118%), 1 of the 15 mice being cured. UFT had a relatively weak but significant effect (67% of ILS) in schedule (B). Using the same model, we examined the inhibitory effect of UFT (2-week administration) on the number of metastatic nodules. A significant decrease of metastatic nodules was observed by UFT with both amputation schedules, but its effect was superior with schedule (A). In the same model using Colon 26 PMF-15, UFT markedly prolonged the survival period of mice (150% of ILS) and significantly decreased the metastatic nodules (86% inhibition). The dose of UFT used was relatively low, and did not significantly inhibit the growth of large tumors. However, the sensitivity to the micrometastases was high. These findings suggest that the postoperative adjuvant chemotherapy by the long-term consecutive administration of UFT would be effective for clinical cancer especially in curatively resected cases.

Amputation, Surgical↗
PubMedDate not supplied

Partial foot amputation in 11 dogs.

Eleven dogs with malignant tumors of the digits and feet were treated with partial foot amputation. Partial foot amputation involved amputation of one or both central weight-bearing digits. Lameness occurred in all dogs but resolved in eight dogs at a median of 37 days postoperatively. In the remaining three dogs, lameness improved but did not resolve. Tumor control was excellent, with no evidence of local recurrence in 10 dogs. One dog underwent limb amputation. Based on these results, partial foot amputation may be recommended in the management of malignant tumors of the canine foot in which more than one digit must be amputated to achieve adequate surgical margins.

Amputation, Surgical↗
PubMed1990

Digital amputations in neuropathic feet.

A retrospective study was performed on 26 patients who had undergone 27 digital amputations. All of the patients in the study had marked neuropathy. Sixty-five percent of the feet developed new ulcerations following initial hallux amputations, with 53% of the ulcerations occurring at distal digital sites. Fifty-three percent of the patients who had undergone hallux amputations required further amputations secondary to new ulcerations. In contrast, only 10% of the feet with initial lesser digit amputations developed new ulcerations. The authors discuss the biomechanics involved and the possible therapy for preventing these ulcerations and amputations.

Alcoholism↗
PubMed1999

Limb salvage with Chopart's amputation and tendon balancing.

For several decades, Chopart's amputation has met with some skepticism owing to reports of significant equinus deformity developing soon after the procedure is performed. However, with appropriate tendon balancing, which generally includes anterior tibial tendon transfer and tendo Achillis lengthening, this level of amputation is often more functional than slightly more distal amputations, such as Lisfranc or short transmetatarsal amputations. The authors offer a rationale for this observation, which includes a discussion of the longitudinal and transverse arch concept of the foot. This concept dictates that the shorter the midfoot-level amputation, the more likely the patient is to develop an equinovarus deformity, thus exposing the fifth metatarsal base and cuboid to weightbearing stress and a high risk of ulceration. Chopart's amputation, in eliminating the cuboid, often obviates the potential varus deformity and thus can have a more acceptable long-term result.

Achilles Tendon↗
PubMed1999

Major limb amputation at a provincial general hospital in Kenya.

OBJECTIVE: To determine the pattern of major limb amputation at a provincial hospital. DESIGN: A retrospective study. SETTING: The surgical department of the Central Provincial General Hospital, Nyeri, Kenya. SUBJECTS: One hundred and two patients who underwent major limb amputation between January 1990 and December 1995. RESULTS: The age range was from one year nine months to 85 years. The highest number of amputees were in the 41-60 year age group. The leading indications were trauma, tumours and complications of diabetes mellitus, each accounting for 26.5% of the amputations done. Ninety four per cent of the amputations were done on the lower limb while eight per cent were on the upper limb. Nine deaths recorded. Only 21.5% of the amputees had prostheses fitted. CONCLUSION: Whereas amputation is a commonly done operation, a low percentage of the amputees in this study were adequately rehabilitated with prostheses. A higher mortality rate (> 55%) was associated with amputation done for complications of diabetes mellitus.

Adolescent↗
PubMed1998

Traditional bone setting: a risk factor in limb amputation.

Over a period of ten years a total of 225 limb amputations were performed at Ahmadu Bello University Teaching Hospital, Zaria, Nigeria. The major pathology leading to amputation was trauma and gangrene due to inappropriate splintage of fractures (63.2%) by traditional bone setters. The male:female ratio was 4.6:1 and the ages ranged from two to 85 years. The commonest level of amputation was above elbow amputation (26.6%) followed by above knee amputation. Most of these amputations are preventable if the traditional bone setters avail themselves for training to recognise the impending features of limb ischaemia as well as the introduction of some refinement into their practice.

Adolescent↗
PubMed1999

[Amputation or reconstruction of a circulatory compromised severely injured extremity?].

18 patients treated with primary or secondary amputations after severe lower limb open fractures were studied. All limbs had clinical signs of a compromised circulation at the primary evaluation. The various injuries are described and discussed with respect to the general guidelines for primary amputation. The Mangled Extremity Severity Score (MESS) and Nerve, Ischemia, Soft tissues, Skeletal, Shock, Age (NISSSA) scores were calculated. In view of the described injuries, primary amputation was indicated in ten patients according to the general recommendations, 11 patients according to NISSSA and 15 patients according to MESS. Delayed amputation leads t a significantly (p = 0.005) higher number of operative procedures than early amputation (9.2 vs. 2.9 treatments). The decision of whether to amputate or not should be based on sound clinical judgement, but injury scores such as MESS and NISSSA may be helpful.

Adolescent↗
PubMed2000

Predictive value of transcutaneous oximetry for selection of the amputation level.

BACKGROUND: Transcutaneous oximetry was studied to select the correct amputation level for limb ischemic necrosis with possible identification of threshold value. METHODS: The method was evaluated in 30 cases (20 patients, 5 males and 15 females, of ages ranging from 61 to 93, average 73.1+/-8.5) where patients underwent amputation because of severe leg ischemia. Surgical operations were: minor amputation (toe or transmetatarsal) in 23 cases, below knee amputation in 7. Oxygen tension was measured at the dorsum foot and at the third superior of the anteromedial calf aspect. RESULTS: Results were classified as success (primary or delayed healing) or failure (necrosis at the surgical wound). Amputation was successful in 17/30 cases with oxygen tension of 0-65 mmHg (mean 32.5+/-16.1) and failed in 13/30 with oxygen tension of 0-57 mmHg (mean 7.8+/-17.3). The difference was statistically significant (p=0.0004). Sensitivity of the method resulted 88.2%, specificity 84.6%, diagnostic accuracy 86.7%, positive predictive value 88.2% and negative predictive value 84.6%. A threshold of 20 mmHg was identified: 15/17 successful cases showed values greater than 20 mmHg, while 11/13 failed cases presented values lower than the threshold. CONCLUSIONS: Following our observations and according to some reported studies, we believe transcutaneous oximetry to be the best method for selection of amputation level This is a simple, noninvasive and accurate method, which has showed itself superior to other techniques (i.e., Doppler and radioisotope).

Aged↗
PubMed2001

Increased preoperative c-reactive protein level as a prognostic factor for postoperative amputation after femoropopliteal bypass surgery for CLI.

BACKGROUND AND AIMS: We evaluated the possible predictive role of C-reactive protein (CRP) on the immediate postoperative outcome after femoropopliteal bypass surgery for critical leg ischaemia (CLI). MATERIAL AND METHODS: 138 patients with CLI who underwent 143 femoropopliteal reconstructions. RESULTS: The immediate postoperative period secondary patency rate was 87%, leg salvage rate was 94%, and survival rate 97%. Nine patients (6.3%) had 30-day postoperative major amputation, three of them despite a patent bypass graft because of progression of foot infection. The preoperative serum concentration of CRP was the only predictor of postoperative major amputation (p = 0.004; for an increase of 10 mg/l: OR, 1.188; CI 95%, 1.059-1.332). The median preoperative serum concentration of CRP among patients who did not have major amputation was 13.0 mg/l (range, 1-185), whereas it was 47.5 mg/l (range, 5-168) among those who had amputation after bypass graft occlusion, and 115.0 mg/l (range, 34-222) among those who had amputation despite a patent bypass graft (p = 0.008). CONCLUSIONS: CRP may be a useful marker in risk stratification for postoperative amputation in patients undergoing femoropopliteal bypass surgery for CLI.

Adult↗
PubMedDate not supplied

Analysis of morphogenetic potential of caudal spinal cord in Triturus carnifex adults (Urodele amphibians) subjected to repeated tail amputations.

The present research was aimed at testing whether the extraordinary morphogenetic and histogenetic potential exhibited in the regenerating new tail remains constant even after repeated amputation or whether it changes as a result of the mechanisms responsible for the regenerative process. Particular attention was focused on regeneration of the spinal cord and ganglia. For this purpose, tail regeneration in adult specimens of Triturus carnifex subjected to repeated amputation (up to 7 times) was compared with that of control animals subjected to a single amputation. Results show that although it slowed down the morphogenetic and differentiative phase, repeated amputation did not significantly alter either the morphogenetic or the histogenetic potential of the ependymal layer of the regenerating spinal cord. The latter result leads to hypothesized that the cells of the ependymal layer of the stump, which are responsible for the formation of the apical ampulla and the ependymal tubule inside the regenerative blastema, do not derive from undifferentiated reserve elements triggered after tail amputation but rather from differentiated ependymal elements that dedifferentiate after the trauma and re-acquire embryonic potential. If this regeneration were actually to take place at the expense of the reserve elements, the continual regenerative processes induced by the repeated amputation would lead to the increasing depletion of these elements and a consequent reduction in regenerative capacity.

Amputation, Surgical↗