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PubMed1999

Phantom limb, residual limb, and back pain after lower extremity amputations.

This study describes the sensations and pain reported by persons with unilateral lower extremity amputations. Participants (n = 92) were recruited from two hospitals to complete the Prosthesis Evaluation Questionnaire which included questions about amputation related sensations and pain. Using a visual analog scale, participants reported the frequency, intensity, and bothersomeness of phantom limb, residual limb, and back pain and nonpainful phantom limb sensations. A survey of medication use for each category of sensations also was included. Statistical analyses revealed that nonpainful phantom limb sensations were common and more frequent than phantom limb pain. Residual limb pain and back pain were also common after amputation. Back pain surprisingly was rated as more bothersome than phantom limb pain or residual limb pain. Back pain was significantly more common in persons with above knee amputations. These results support the importance of looking at pain as a multidimensional rather than a unidimensional construct. They also suggest that back pain after lower extremity amputation may be an overlooked but very important pain problem warranting additional clinical attention and study.

Adult↗

PubMed2006

Below-knee amputation using a medial saphenous artery-based skin flap.

BACKGROUND: A modified below-knee (BK) amputation with the medial saphenous artery-based skin flap coverage was designed to preserve a functional BK stump for those who were unable to receive the conventional long posterior flap or skew-type amputation. METHODS: In designing, the medial skin flap was outlined with the margins beginning 1 to 2 cm medial to the tibial crest to close to the middle of the posterior calf, with the length of the flap being equal to the transverse diameter of the leg at the anticipated level of bone section. The posterior margin of the flap was placed close to the middle of the posterior calf or adjacent to the interrupted posterior skin incision line. After elevation of the medial skin flap and performance of the rest of the procedure with the standard BK amputation methods, the posterior muscle mass was carried anteriorly to cover the bony stump and the medial skin flap was brought laterally to cover the defect. RESULTS: This modified BK amputation was successfully done in a total of nine patients during the period January 1998 to January 2004. There were four females and five males, with ages ranging from 44 to 74 years (average 59.1 years). All the skin flaps survived completely without major complications, except for one patient who developed a wound infection. CONCLUSIONS: With a skin flap that was perfused by a direct cutaneous vessel, saphenous artery, and innerved by the saphenous nerve, the medial saphenous artery-based flap used in the modified BK amputation comprises one valuable alternative when conventional techniques are unsuitable.

Adult↗

PubMed1993

Salvaging the ischemic transmetatarsal amputation through distal arterial reconstruction.

From 1982 to 1991, 17 patients underwent a lower extremity arterial bypass to salvage an ischemic transmetatarsal amputation at the New England Deaconess Hospital. Eleven patients were male, and 16 had diabetes for an average of 29 years. The mean age was 71 years. Twelve patients presented with an ischemic ulcer, one had rest pain, and four underwent bypass for failure to heal a transmetatarsal amputation. Twelve patients presented with findings of secondary infection. All 17 patients underwent successful lower extremity bypass procedures to a variety of outflow vessels. Thirteen bypasses were to infrapopliteal arteries, including four to the dorsalis pedis artery. There were no perioperative deaths and all patients were discharged with patent grafts and healing limbs. Actuarial graft patency of the 14 vein grafts was 90% at 2 years. Actuarial limb salvage for the entire group was 93% at 2 years. Thirteen of the 14 patients who maintained patent grafts and healed their transmetatarsal amputations were ambulatory at their last known follow-up examination. Ischemic complications of previously created transmetatarsal amputations are uncommon. However, limb salvage attempts by lower extremity arterial bypass have a high likelihood of success. Major amputation in these patients should not be done without having first undergone a comprehensive vascular evaluation.

Aged↗

PubMed1999

[Below-knee amputation according to Robb-Persson. Technique and clinical results].

The successful rehabilitation and the quality of life of below-knee amputees depend to a great extent on the load-bearing capacity of the amputation stump. Robb and Persson's operating method, utilizing a sagittal cut was used in 154 be low-knee amputations in the period 1982-1992 that were retrospectively analysed. In 91% of the cases, advanced vascular disorders related to diabetes mellitus were the main cause for the loss of a limb. Postoperative mortality amounted to 31.8%, the re-amputation rate was 4.5%. Rehabilitation up to full walking capability was achieved by 75% of the surviving patients. 46 patients were re-examined between 1 and 6 years after amputation. In 85% of the cases the condition of the stump was found to be good to very good. The functional rehabilitation results are comparable to those of other operating methods. The advantages of the Robb-Persson below-knee amputation method are the simplicity of the technique and a secure and longlasting effective stump cover, resulting in favourable long-term results.

Adult↗

PubMed2003

Diabetes and non-traumatic lower extremity amputation in a region of central Italy.

As stated in the St. Vincent Declaration, the reduction of the number of lower extremity amputations (LEA) is one of the major targets in diabetes care. Little information on the prevalence of this complication is available in Italy at present. The aim of this study was to evaluate the impact of diabetes on LEA in a region of central Italy. The regional database of hospital discharge records was used to identify all the cases of non-traumatic LEA (Nt-LEA) that had occurred in 1997 and 1998. Diagnosis of diabetes and the type of surgical intervention were defined on the basis of the medical records. Amputations were categorised as minor or major according to the level of the surgical procedure. The duration of hospitalisation was used to analyse the impact of diabetes on the health care system. Prevalence of diabetes in people who underwent Nt-LEA was 55.9% and it was similar in patients who underwent minor or major amputation (58.7 and 55.0%, respectively). No difference between diabetic and non-diabetic patients was observed as regards sex, level of amputation and duration of hospitalisation. Age was the only predictor of diabetes in amputees. The lack of specific protocols for diabetes foot care or a non-homogeneous application of these protocols in the health care service could account for a similar prevalence of diabetes among patients who underwent minor or major amputation.

Aged↗

PubMed1990

[When is there an indication for primary femoral amputation in patients with vascular disease?].

Every patient suffering from arterial occlusive disease has to be considered a candidate for a bilateral amputation. Below-knee amputation is preferable if at all possible. Poor wound healing and reamputation at a higher level are factors to be expected in 20-30% of these patients. Therefore primary above-knee amputation is indicated only if a more distal amputation level is not possible, or if lower amputation offers no advantage to the patient. The question must be answered in each individual case.

Amputation, Surgical↗

PubMed1990

[Ray amputation of the hand].

The aim of a ray amputation is to improve the cosmetic appearance and function of the hand after finger amputation. Pain, reasons of appearance and impaired function of amputation stumps are good indications. The patient's occupation, hobbies, handedness and emotional attitude regarding the amputation should be assessed when ray amputation is considered.

Adolescent↗

PubMed1989

[When is primary amputation of the upper leg indicated?].

Every patient suffering from arterial occlusive disease has to be considered a candidate for a bilateral amputation. Infragenual amputation is preferable if at all possible. Poor wound healing and reamputation at a higher level are factors to be expected in 20-30% of these patients. Therefore primary above-knee amputation is indicated only if a more distal amputation level is not possible, or if lower amputation offers no advantage to the patient. The question must be answered in each individual case.

Amputation, Surgical↗

PubMed1985

Syme's amputation in adults: a long-term review.

A retrospective study was undertaken in two patient populations to establish the failure rate of Syme's amputation. Failure was defined as an amputation requiring revision to a more proximal level. For traumatic lesions of the foot the failure rate was 29% and for dysvascular lesions it was 41%. The long-term functional results in 55 patients who underwent Syme's amputation for traumatic, dysvascular or congenital lesions were studied. Overall, 73% had good function. The ideal Syme's stump, where the fat pad is centred securely over the distal tibia, was noted in only 22% of patients. The authors conclude that, in the past, technical details may have been overemphasized, because in this study the functional results of Syme's amputation were more dependent on prosthetic fitting. This type of amputation is not recommended for patients with dysvascular lesions because of the high failure rate.

Adult↗

PubMed1986

[Amputations of the child's foot].

Various partial foot amputations are described in detail, ranging from incomplete or total loss of one or several toes, transverse or longitudinal metatarsal amputation, proper performance of the Lisfranc's amputation (tarsometatarsal disarticulation) to Chopart's tenomyoplastic procedure, a modification of Pirogoff's procedure and an improved form of Syme's amputation (preserving most of the cartilage for better weight-bearing). Appropriate orthopedic footwear and prostheses compensating for the amputated parts of the foot and optimizing the remaining function are also presented. In most incidences, satisfying results can be achieved, especially in children. These consist of total weight-bearing of the stump, combined with minor disability from the functional point of view and an almost invisible handicap with regard to daily activities.

Amputation, Surgical↗

PubMed1985

[Medical and surgical outcome of thigh amputation for arteritis].

Results of a minimum 4 year follow up of 87 cases of thigh amputation are discussed. Postoperative mortality was 40% and 40% of patients had survived after one year. Early mortality factors were age (mean 75 years) and the coronary lesion responsible for more than a half of postoperative deaths. Amputation stump complications were noted in 13% of cases, their onset being dependent on 3 factors: loss of femoral pulse, failure of vascular re-establishment and early amputation after this failure. The remaining limb required major amputation in 21% of cases before the end of the second year, the final major level of amputation being a factor of the lack of distal revascularization in 77% of patients.

Age Factors↗

PubMed1995

Amputation for reflex sympathetic dystrophy.

We have reviewed 28 patients with reflex sympathetic dystrophy (RSD) who had 34 amputations in 31 limbs. The amputations had been performed for untenable pain (5), recurrent infection (14) or to improve residual function (15). Only two patients were relieved of pain by amputation, and this could not be predicted. Ten of 14 patients were cured of infection and 9 of 15 patients had improvement of residual function. In 28 of the amputations, RSD recurred in the stump, especially after amputation at a level which was not free from symptoms. Because of recurrence of RSD in the stump or severe hyperpathia only two patients wear a prosthesis. Despite this 24 patients were satisfied with the results.

Activities of Daily Living↗

PubMed1981

Prospective use of xenon Xe 133 clearance for amputation level selection.

Xenon Xe 133 clearance was used to select the most distal amputation level that would allow sufficient blood flow for healing. Capillary blood flow was first measured at the most distal potential amputation level, then at successive proximal levels until an amputation site was found that had a capillary skin blood flow rate greater than or equal to 2.6 mL/min/100 g of tissue. Xenon Xe 133 in saline (100 to 500 mCi) was injected intracutaneously at each level, and flow rates were determined using a gamma camera interfaced with a computer system programmed for the Ketty-Schmidt formula modified for capillary blood flow. There were 45 cases, including one toes, six transmetatarsal, five Syme's, 25 below-knee, four knee disarticulation, three above-knee, and one hip disarticulation amputation. All amputations in patients with flow rates exceeding 2.4 mL/min/100 g of tissue healed, with two exceptions.

Aged↗

PubMed1990

Objective measurement of limb perfusion by dermal fluorometry. A criterion for healing of below-knee amputation.

Quantitative fluorometry has been recommended as an accurate adjunct to clinical judgment in the preoperative assessment of lower-extremity amputation level. In this prospective study of 56 patients who had below-knee amputation, clinical judgment was used as the sole criterion for site selection. Quantitative fluorometry was compared with clinical judgment in a prospective, blinded study. All patients were studied before amputation with administration of intravenous fluorescein. Fifteen minutes after injection, objective measurement of dye fluorescence was performed at multiple sites with a quantitative fluorometer, and a dye fluorescence index was derived. All limbs undergoing amputation were ischemic, manifested by rest pain, nonhealing ulcers, or gangrene. Five patients (8.7%) failed to heal at the below-knee level. The mean dye fluorescence index for the group that healed was 81 +/- 51 (range, 13 to 259) and for the group that failed to heal, 110 +/- 49 (range, 70 to 195). Objective measurement of fluorescein perfusion did not correlate with amputation healing at the below-knee level in our patient population.

Adult↗

PubMed1999

Alternatives to thumb replantation in three cases of traumatic amputation of the thumb.

Three cases of complete amputation of the thumb are reported in which the amputated distal parts were not suitable for replantation. In all cases there were either complete or incomplete amputations of other digits. Two different techniques were used for thumb reconstruction: 1) pollicization of a partially amputated digit with transposition microsurgery in case 1; and 2) replantation of a less important amputated digit to the thumb stump for cases 2 and 3. These microsurgical efforts successfully restored thumb function in all three patients.

Adult↗

PubMed2006

Prosthetic rehabilitation for older dysvascular people following a unilateral transfemoral amputation.

BACKGROUND: Dysvascularity accounts for 75% of all lower limb amputations in the UK. Around 37% of these are at transfemoral level (mid-thigh), with the majority of people being over the age of 60 and having existing co-morbidities. A significant number of these amputees will be prescribed a lower limb prosthesis for walking. However, many amputees do not achieve a high level of function following prosthetic rehabilitation. OBJECTIVES: We aimed to identify and summarise the evidence from randomised controlled trials evaluating rehabilitation interventions for prosthetic ambulation following unilateral transfemoral amputation in older dysvascular people, whether community dwelling or institutionalised. SEARCH STRATEGY: We searched the Cochrane Peripheral Vascular Diseases Group Specialised Register (July 2006), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2006, Issue 3), MEDLINE (1966 to February 2006), EMBASE (1980 to February 2006), CINAHL (1982 to December 2005), AMED (1985 to December 2005), several more specialised databases and reference lists of articles. We also searched the UK National Research Register (Issue 2, 2005) for ongoing trials and contacted experts in the field. No language restrictions were applied. SELECTION CRITERIA: Randomised and quasi-randomised controlled trials testing prosthetic rehabilitation interventions following a unilateral transfemoral or transgenicular amputation in older (aged 60 years or above) dysvascular people. DATA COLLECTION AND ANALYSIS: Two authors independently scanned the search results for potentially eligible studies and then, on obtaining full reports of these, selected studies for inclusion and exclusion. Two authors independently assessed methodological quality and extracted data. No data pooling was possible. MAIN RESULTS: Of 38 full reports obtained for consideration, one trial was included and four were excluded. The sole included trial was a short-term crossover randomised trial which tested the effects of adding three seemingly identical prosthetic weights (150 g versus 770 g versus 1625 g) to the prostheses of 10 participants with unilateral dysvascular transfemoral amputation. Eight participants were over 60 years of age. The trial found that four participants preferred the lightest weight (150 g), five preferred the middle weight (770 g) and one preferred the addition of the heaviest weight (1625 g). AUTHORS' CONCLUSIONS: There is a lack of evidence from randomised controlled trials to inform the choice of prosthetic rehabilitation, including the optimum weight of prosthesis, after unilateral transfemoral amputation in older dysvascular people. A programme of research, including randomised controlled trials to examine key interventions, is urgently required in this area.

Aged↗

PubMed2003

Major amputation for soft-tissue sarcoma.

BACKGROUND: Advances in oncological practice have reduced the number of major amputations performed for soft-tissue sarcoma, but this remains a valuable, if infrequent, option for both curative and palliative indications. METHODS: A review of patients and case-notes was carried out from the prospective sarcoma database at the Royal Marsden Hospital. RESULTS: Over a 10-year interval, 40 major amputations (18 forequarter, 17 hindquarter and five through hip) were performed, predominantly for disease recurring after previous limb-conserving surgery (31 of 40). A wide variety of soft-tissue sarcoma subtypes was seen; they were often large (more than 10 cm; 18 of 40) or multifocal (six), usually high grade (25), and frequently proximal or involving neurovascular structures such that limb salvage was precluded. Median range age of the patients was 59 (17-87) years. The operative 30-day mortality rate was zero. Hospital stay was a median of 10.5 days for forequarter amputation, and 19 days for hindquarter and through-hip amputation. Local recurrence occurred in ten patients, six of whom had concurrent distant metastases. Twenty-seven patients were alive (20 disease free) at a median follow-up of 12 months, nine of whom were alive without evidence of disease beyond 2 years. Ten patients died after a median of 7.5 months; three survived more than 2 years. CONCLUSION: Major amputation is a useful procedure in carefully selected patients with soft-tissue sarcoma.

Adolescent↗

PubMed1995

Evaluation of vascular compliance and vasoconstrictive reactions in amputated hindlimbs of rats.

The vascular compliance and the contractility of vascular smooth muscle of preserved, amputated hindlimbs of rats were evaluated using a fresh blood extracorporeal circulatory system. Vascular compliance was measured under physiologic circulatory conditions (blood pressure of the amputated limb was maintained at 80-150 mm Hg [10-20 kPa]) and found not to differ significantly from that of freshly amputated limbs after storage at 4 degrees C for 12 hours. However, after more than 24 hours of storage at 4 degrees C, the vascular compliance decreased significantly (p < 0.01). To evaluate the contractility of vascular smooth muscle, the arterial blood pressure in the amputated limbs was transiently increased with injections of norepinephrine. The contractility could be preserved for at least 12 hours at 4 degrees C; however, it decreased markedly after more than 24 hours. The vascular compliance and vasoconstrictive reactions of the amputated limbs were maintained for at least 12 hours at 4 degrees C.

Amputation, Surgical↗