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At least 685 records · Page 38Linked to original sources
PubMed1994

Bilateral thumb amputation.

Seventy-one patients with thumb amputations, 45 complete and 26 incomplete nonviable, have been treated at the Microsurgical Unit of the Department of Orthopaedic Surgery at the University of Ioannina Medical School over the past 15 years. Of these thumb amputations, which included crush, avulsion, and guillotine injuries, three cases involved amputation of both thumbs. The three patients with complete bilateral thumb amputations are presented. Because of the importance of the thumb, microsurgical replantation efforts were made which proved successful for two of the patients. Replantation efforts in the third patient, who had severe crush injuries of both thumbs, were not successful. Bilateral thumb amputation is a serious and disabling injury. When replantation is attempted by a team of surgeons well trained in microsurgery, the final result can be impressive, with exceptionally good function of the replanted thumbs.

Adolescent↗
PubMed1997

Forequarter amputation with fasciocutaneous deltoid flap reconstruction for malignant tumors of the upper extremity.

BACKGROUND: Malignant tumors of the upper extremity involving a considerable portion of the medial axillary wall may require forequarter amputation to achieve gross resection of tumor. These resections frequently leave a large defect, often requiring a split thickness skin graft or free flap to close the wound. To address this problem of wound closure, we have modified our technique and devised a reconstructive component as part of our forequarter amputation procedure. METHODS: The medical records of seven patients who underwent forequarter amputation and fasciocutaneous deltoid flap reconstruction between 1982 and 1994 were reviewed. RESULTS: All the amputation sites were completely closed with a fasciocutaneous deltoid flap without the use of additional skin grafts or free flaps. After a median follow-up of 12 months, there were no local recurrences. Three patients (43%) are alive and disease free 5, 12, and 19 months after their forequarter amputation. One patient is alive with disease after 14 months. The remaining three patients died of their disease. CONCLUSION: The fasciocutaneous deltoid flap is technically easy to perform, provides wound coverage without the use of skin grafts, and is especially useful for tumors involving the media axillary wall and in patients with previous axillary radiation.

Adult↗
PubMed1998

[Amputation or reconstruction of IIIB and IIIC open tibial fracture. Decision criteria in the acute phase and late functional outcome].

In IIIB and IIIC type open tibial fractures (according to Gustilo) the primary decision that has to be made regarding therapy is wether or not the limb can be salvaged. To standardize the criteria for amputation different salvage scores have been established in recent years. In this study the Hannover Fracture Scale (HFS), the Predictive Salvage Index (PSI), the Mangled Extremity Severity Score (MESS) and the NISSSA score were evaluated regarding their clinical relevance. When ROC Analysis was performed for all these scores in our patients the HFS revealed the highest sensitivity (0.91), but low specificity (0.71). The highest specificity was noted for the MESS (0.97), which in parallel showed the lowest sensitivity (0.59). In general it seems to be essential to make the right decision initially in order to avoid secondary amputation. All the scores mentioned here appear to be helpful in decision making. Salvaged limbs in IIIB and IIIC fractures presented a comparable good outcome, whereas salvaged IIIC injuries with a high score presented an outcome which was as bad as in secondary amputations. Secondary amputated patients required not only significant longer hospitalization but also resulted in poor outcome compared with the patients having received reconstruction or primary amputation.

Adult↗
PubMed2001

Prevention of diabetes-related foot ulcers and amputations: a cost-utility analysis based on Markov model simulations.

AIMS/HYPOTHESIS: We analysed the cost-effectiveness of intensified prevention in diabetic patients with different risks for foot ulcers and lower extremity amputations. Specifically, we examined whether the additional prevention costs associated with present recommendations would be offset by reduced costs of future foot ulcers and amputations. METHODS: Markov-based 5-year cost-utility simulations of current versus optimal prevention were done for hypothetical cohorts of diabetic patients older than 24 years. The model included eight possible health states for four risk groups. A population of 1677 diabetes patients provided data on present foot ulcer prevention and general mortality. Optimal prevention was defined according to the International Consensus on the Diabetic Foot. Model assumptions, transition probabilities and other data included in the model were based on published literature. The main outcome measures were cumulative incidences of foot ulcers, amputations and deaths, costs, cost-effectiveness, and quality-adjusted life years. RESULTS: An intensified prevention strategy including patient education, foot care and footwear is cost-effective if the risk for foot ulcers and lower extremity amputations can be reduced by 25 %. This is valid for all patients with diabetes except those with no specific risk factors. CONCLUSION/INTERPRETATION: Providing all diabetic patients at risk or high risk for foot ulcers and amputations with adequate prevention would be a cost-effective or even cost-saving strategy.

Adult↗
PubMed1999

Bone growth is induced by nail transplantation in amputated proximal phalanges.

Mammals are able to regrow the tips of amputated fingers and toes. However, regrowth is limited to regions covered by, and is dependent upon, the presence of the nail organ. If the nail organ is responsible for bone growth in digit-tips, we reasoned that transplanted nail organ might also be able to induce outgrowth from other levels of the digit. Partial nail organ has been transplanted to amputated proximal phalanges of young rats. To date, six transplants have successfully produced outgrowth of nail. New bone growth, not seen in control amputated digits, was documented by x-ray and by alizarin red and calcein injections to be directed toward implanted nail organ. These results support an inductive role for nail organ epithelium in bone growth after amputation and provide encouragement for attempts to enhance a positive outcome after appendage amputation.

Amputation, Surgical↗
PubMed1999

Lower limb amputations during 3 years in Hungary.

We reviewed nationwide hospital data of amputations during 3 years to provide a comparison with similar data gathered about 20 years ago. Data were provided by the National Medical Records Centre and processed by our personally developed programmes. The cause of amputation was most often vascular disease, amputees were usually elderly, and the large majority of amputation surgery was carried out on the lower limb. The rate of transtibial amputation has increased favourably in the last 2 decades, but there are large regional differences within the country. Mortality parameters remarkably exceed those of foreign countries. Although the data accuracy is compromised, there are still ways of exploiting the data in favour of quality improvement of care, e.g. improve transtibial amputation rate, reduce mortality. The publication of data can be of benchmarking importance for hospitals by enabling them to compare their own results with those of other hospitals, as well as to develop and improve performance.

Adult↗
PubMed2003

Major lower extremity amputation in an academic vascular center.

Major lower extremity amputations continue to be performed despite an aggressive policy of revascularization. Factors leading to amputation were analyzed to determine whether a reduction in the limb loss rate is possible. A retrospective analysis of a prospectively maintained vascular registry was performed to identify patients undergoing above-knee amputation (AKA), below-knee amputation (BKA), and lower extremity revascularization (LER) for limb salvage between January 1, 1999 and January 1, 2002. Patient demographics, comorbidities, insurance carriers, and indications for operative intervention were analyzed. Greater than one-half of all major lower extremity amputations are performed in patients who have failed attempts at revascularization or who are not candidates for LER due to anatomic factors. However, one-quarter of eventual amputees present very late to the vascular surgeon with extensive gangrene or infection that precludes limb salvage. Prompt patient referral and treatment may improve outcome in this group of patients. In our study, insurance issues did not appear to affect treatment. Renal failure continues to play a major role in limb loss.

Academic Medical Centers↗
PubMed2003

Methicillin-resistant Staphylococcus aureus infection does not adversely affect clinical outcome of lower extremity amputations.

Methicillin-resistant Staphylococcus aureus was first identified in isolation in Europe during the 1960's. Now widespread throughout the world, infection with this organism has emerged as a major problem in surgical practice. However, it remains debatable whether MRSA is more virulent than methicillin-susceptible strains. We have reviewed our most recent 4-year experience of lower extremity amputations to examine the influence of MRSA and non-MRSA infection on clinical outcome. During the past 4 years, 165 patients underwent lower extremity amputation for SVS/ISCVS category III acute limb ischemia and grades II and III chronic limb ischemia. Forty-five had documented MRSA infection, while 57 patients had documented infection with other flora. All patients were treated with appropriate sensitivity-specific antibiotics and aggressive wound care. No significant differences were noted in the level of primary amputation required by the two groups. Similarly, no significant differences were noted in either number of revisions or revision to higher-level amputation, time to heal, hospital length of stay, or 30-day morbidity and mortality rates. Our results demonstrate that MRSA infection does not adversely affect clinical outcome in patients undergoing lower extremity amputations. Appropriate treatment of infections with sensitivity-specific antibiotics, thorough wound debridement, and aggressive wound monitoring should be routine in all patients, regardless of bacterial flora.

Aged↗
PubMed2005

Timing of pedal bypass failure and its impact on the need for amputation.

Although the utility of dorsalis pedis (DP) bypass for limb ischemia has been well established, the fate of limbs with a failed bypass to the DP artery remains unclear. Data of all patients undergoing DP bypass grafting within a 12-year period from two university hospitals' vascular registries were retrospectively reviewed. Outcomes of early (<30 days) and delayed graft failure (>30 days) were examined. The Student's t-test and chi-squared test were used for univariate analysis; patency rates and patient survival were calculated using the Kaplan-Meier product limit method. Of 1434 DP bypass grafts, 277 (19.3%) failed grafts were identified. Sixty five (4.5%) grafts failed early (within 30 days of surgery) and 212 (14.8%) failed late at a mean time of 15.3 months (range, 1.5-105 months) after initial bypass. Of the 65 limbs with early graft failure, 28 (43.1%) proceeded directly to amputation and 20 underwent additional revascularization attempts, but limb salvage was achieved in only 7 patients; in 45 (69.2%) patients no further revascularizations were attempted. Seventy-four (34.9%) patients with late graft failure underwent redo revascularization. Thirty-nine (52.6%) had their limb saved with graft revision, but 35 patients (47.3%) ultimately lost their limb. In 138 patients with late graft failure (65.1%) no further revascularization attempts were performed. Sixty-two (44.9%) required major amputation. Overall, 49.8% of patients with failed pedal grafts ultimately suffered limb loss. Early graft failure resulted in a significantly higher rate of major amputation that did late graft failure (63.1% vs. 45.8%, respectively; p = 0.015). These results indicate that early occlusion of pedal bypass often leads to immediate major amputation and interventions to maintain graft patency in this setting are often futile. Late failure of pedal bypass is associated with a lower likelihood of amputation because of a higher rate of success of bypass revisions and a lower occurrence of critical ischemia with graft failure.

Aged↗
PubMed1986

Amputation after extremity injury.

Extremity injury is a significant cause of morbidity and mortality in the trauma patient. The decision to amputate is a difficult one to make in a patient population still in the productive years of life. At the University of Louisville Hospital from 1976 to 1984, 37 patients with traumatic extremity injury required amputation. Ninety percent of these injuries were to the lower extremities. A decision for amputation was based on the absence of neurovascular function, the presence of fracture of the involved extremity, the presence of a large soft tissue defect, and the presence of severe contamination. Prompt amputation of such severely damaged limbs may be preferable to attempts at salvage. Early amputation offers the opportunity for prosthetic replacement and good long-term functional recovery.

Adolescent↗
PubMed1989

Open transmetatarsal amputation in the treatment of severe foot infections.

Severe forefoot infections may lead to limb loss, even if addressed aggressively. Infection or gangrene that compromises the plantar skin flap may preclude a standard transmetatarsal or midfoot amputation, thereby culminating in a below-knee amputation. We report a series of forefoot infections with loss of the distal plantar skin. Open or guillotine amputation at the mid-metatarsal level led to a high rate of healing and a durable stump, provided that the level of infection did not extend beyond the metatarsal heads. Wound closure was obtained by wound contracture alone or by use of partial-thickness skin grafting. Rehabilitation was dependable. The association of diabetes mellitus or gangrene did not adversely affect outcome. Open transmetatarsal amputation is a safe surgical option preferable to midfoot or below-knee amputation for the treatment of severe forefoot infection that does not extend proximally beyond the metatarsal heads.

Amputation, Surgical↗
PubMed1996

Regional variation in the incidence of diabetes-related amputations in The Netherlands.

The purpose of this study is to identify the incidence of diabetes-related lower extremity amputations in 27 health regions in the Netherlands. A secondary database was used that contains all hospitalizations for a lower extremity amputation in the Netherlands in 1991 and 1992, recorded separately for 27 health regions. The age-adjusted incidence lower extremity amputations per 10,000 diabetic patients in the Netherlands was 25.05, and among the regions it ranged from 10.15 to 44.64. In the non-diabetic population, the age-adjusted incidence in the Netherlands was 1.24 and ranged by region from 0.77 to 1.77. Overall, diabetic males had higher age-adjusted incidence rates than diabetic females, although in four health regions the situation was reversed. In the Netherlands, there was an increasing incidence of diabetes-related lower extremity amputation as age increased: < 45 years, 11.15; 45-64 years, 33.84; 65-74 years, 61.22; and 75 + years, 107.92 (P < 0.001). This continued to be a significant phenomenon for every health region (P < 0.001). This study found a wide range in the incidence of diabetes related lower extremity amputations in the 27 health regions in the Netherlands. A possible explanation could be differences in the severity of diabetes, in local treatment philosophies or the availability of subspecialties.

Adult↗
PubMed2006

Predictors for mortality after lower-extremity amputations in geriatric patients.

BACKGROUND: The identification of independent predictors for operative and long-term mortality after lower-extremity amputations in the geriatric population would allow targeted management for high-risk patients and appropriate allocation of resources. METHODS: Univariate and multivariate logistic regression analyses were used to identify independent predictors for operative mortality. Life tables and Kaplan-Meier survival curves were generated. Independent predictors for long-term mortality were tested by log-rank test followed by Cox regression analysis. RESULTS: Female gender, congestive heart failure, and high-level amputation were identified as independent predictors for operative mortality (odds ratios 4.14, 4.59, and 4.77, respectively). The logistic regression model showed good calibration and discriminative power. Female gender, high-level amputation, cerebrovascular accident, congestive heart failure, noncommunity ambulation, and institutionalization before amputation were associated with an increased risk for long-term mortality. However, only high-level amputation, congestive heart failure, and noncommunity ambulation remained as independent risk factors after Cox regression analysis (relative risks 1.68, 2.08, and 2.10, respectively). CONCLUSIONS: Extra care should be given to patients identified with independent predictors for operative and long-term mortality.

Aged↗
PubMed2005

Risk of plantar ulceration in diabetic patients with single-leg amputation.

BACKGROUND: There is a disconcerting rate of bilateral limb loss in patients with diabetes. Therefore, this study aimed to explore plantar loading of the surviving foot following unilateral trans-tibial amputation within a wider context of daily walking activity to investigate the precise risk to the surviving limb. METHODS: Twenty-one subjects with diabetic neuropathy and trans-tibial amputation were matched for weight; height; age and gender with 21 control subjects with diabetic neuropathy without history of plantar ulceration. Gait parameters, in-shoe plantar pressure distribution and daily walking (using the step activity monitor) were recorded. Student's t-tests were used to compare groups (alpha-level: 0.05). FINDINGS: The trans-tibial amputations group walked almost 30% slower compared to controls (P < 0.01), with reduced cadence (P < 0.01), and shorter strides (P < 0.01). Despite walking slower, the surviving foot showed higher mean peak plantar pressures in the trans-tibial amputations group over the heel (P < 0.001) however there was no significant difference over the I-II and lateral III-IV-V metatarso-phalangeal regions. Pressure time integral was higher over the heel (P < 0.00), I-II (P < 0.01) and III-IV-V metatarso-phalangeal (P < 0.05) in the trans-tibial amputations group. The amputee group walked less steps per day (P < 0.01). INTERPRETATION: Adaptations in gait and level of walking activity affect plantar pressure distribution and ultimately the risk of ulceration to the surviving foot. Therefore rehabilitation measures should consider implications for plantar loading and the potential risk of ulceration to the surviving foot.

Adult↗
PubMed2005

Indications for amputations.

Amputation may take a psychological toll on a patient. Proper documentation is paramount along with a lucid informed consent. Various pathologies may lead to an amputation. Tools to aid in the decision to amputate, in choosing the levels of amputation, and in the selection of the type of procedure are available. The key to any amputation is to be at a level that is most definitive.

Amputation, Surgical↗
PubMed2005

Perioperative management of pedal amputations.

When performing a pedal amputation, proper preoperative, intraoperative, and postoperative care is essential for a successful outcome. This article outlines proper perioperative management for the amputation patient. All patients require appropriate medical management and testing before any surgical procedure; however, preoperative planning specific for the amputation patient also is required to determine the appropriate level of amputation and to provide an optimal result. The surgeon always must remember that patients with more distal amputations have a decreased energy expenditure and better functional outcome compared with their more proximal counterparts. Appropriate psychological counseling and physical rehabilitation also should be initiated as early as possible for the patient to recover fully in a timely fashion.

Amputation, Surgical↗
PubMed2005

Physician supply, treatment, and amputation rates for peripheral arterial disease.

OBJECTIVE: To test whether the availability of vascular surgeons and interventional radiologists in a region affects revascularization and amputation rates for patients with peripheral arterial disease (PAD). METHODS: We identified all patients with PAD in the Medicare claims database in 1994 and tracked their claims through 1999. We aggregated risk-adjusted data on the 143,202 patients who survived through 1999 by Hospital Referral Region and merged this data with information on local physician supply and other regional characteristics. Instrumental variables analysis was used to account for unobserved illness severity. Main outcome measures were risk-adjusted rates of lower extremity bypass surgery, angioplasty, and amputation by region. RESULTS: Increasing vascular surgeon supply in a region by approximately one standard deviation (.30/10,000 Medicare beneficiaries) is associated with a 0.9 percentage point increase in bypass surgery rates and a 1.6 percentage point reduction in amputation rates. We find weaker evidence that greater availability of interventional radiologists increases angioplasty rates and reduces amputation rates. Factors reflecting regional attractiveness, such as the rating of a region based on climate, recreation, crime, and other attributes, were strong independent predictors of the number of vascular surgeons and interventional radiologists in an area. CONCLUSIONS: Availability of specialists affects outcomes for PAD patients. Regional variability in specialists who treat PAD is influenced by factors other than regional medical needs. Policies aimed at increasing the supply of vascular surgeons and interventional radiologists and their provision of bypass surgery in underserved areas may help to reduce regional disparities in amputation.

Aged↗
PubMed2006

Decrease of thalamic gray matter following limb amputation.

Modern neuroscience has elucidated general mechanisms underlying the functional plasticity of the adult mammalian brain after limb deafferentation. However, little is known about possible structural alterations following amputation and chronic loss of afferent input in humans. Using voxel-based morphometry (VBM), based on high-resolution magnetic resonance images, we investigated the brain structure of 28 volunteers with unilateral limb amputation and compared them to healthy controls. Subjects with limb amputation exhibited a decrease in gray matter of the posterolateral thalamus contralateral to the side of the amputation. The thalamic gray matter differences were positively correlated with the time span after the amputation but not with the frequency or magnitude of coexisting phantom pain. Phantom limb pain was unrelated to thalamic structural variations, but was positively correlated to a decrease in brain areas related to the processing of pain. No gray matter increase was detected. The unilateral thalamic differences may reflect a structural correlate of the loss of afferent input as a secondary change following deafferentation.

Adolescent↗