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PubMed1996

Pediatric amputation injuries: etiology, cost, and outcome.

OBJECTIVE: To provide a comprehensive profile of amputation injuries in children and adolescents. DESIGN: A retrospective case series. MATERIALS AND METHODS: All patients 18 years old or less, admitted to the regional Level I trauma center hospital with a traumatic amputation injury over a 10-year period (74 patients, 77 extremities) were included in the study. Etiology and mechanism of injury, length of hospital stay, number of surgeries and procedures, presence of infection, final outcome of injury (amputation vs. salvage), anatomic location of final outcome, and total charges were recorded for each patient. MEASUREMENTS AND MAIN RESULTS: There were 47 injuries to the upper extremity, and 30 to the lower extremity. The average length of stay was 11.3 days, with a mean of 4.3 procedures in 2.3 surgeries and average charges of $22,015. Twenty-two percent of the injuries were caused by power lawn mowers; all of these patients had amputations. Motor vehicle related crashes accounted for 16% of all injuries; 77% of these ultimately had amputations. Gunshot wounds had the highest mean length of hospital stay, surgery days, number of procedures, and charges. Out of 32 extremities that were revascularized for attempted salvage, 27 were successful (84%), all in the upper extremity, and all but one were digits. CONCLUSIONS: Injuries caused by a sharp mechanism with a smaller area of involvement are more likely to be successfully salvaged with revascularization, regardless of ischemic time. Long-term follow-up is needed to evaluate final functional and psychosocial outcome. Lawn mowers represent a serious hazard to children, and should be addressed through changes in engineering and parent education.

Accidents, Home↗
PubMed1999

Below-knee amputations as a result of land-mine injuries: comparison of primary closure versus delayed primary closure.

BACKGROUND: Antipersonnel land mines are designed to maim by mutilating the lower extremities, and these injuries are at higher risk for infection than injuries from other weapon systems. METHODS: The results of 474 unilateral traumatic below-knee amputations as a result of land-mine injuries were reviewed. If the delay in evacuation between the injury and arrival to the battle field hospital was less than 6 hours, 392 amputation stumps (group I) were closed primarily after meticulous debridement. Open amputation was performed after debridement in the remaining 82 amputation stumps (group II), because there was a suspicion of ineffective debridement, although they were evacuated in less than 6 hours or delay was more than 6 hours. RESULTS: Eleven patients in group I (2.8%) were reoperated because of wound sepsis of the stump. Wound sepsis was not encountered in group II. A total of 87.4% of stumps in group I and 81.2% of stumps in group II had healed without a problem. No gas gangrene or tetanus was encountered in any cases. CONCLUSION: Our results reveal that primary closure may be done in traumatic below-knee amputations caused by land-mine injuries with an acceptable infection rate, if the evacuation time is less than 6 hours, and if there is meticulous debridement.

Adolescent↗
PubMed1996

Successful replantation in 10-digit complete amputations.

We report a case of successful replantation of 10-digit complete amputations. The conditions of the wounds over the ends of the 10 amputated digits are bound to vary; some are too severe to be replanted, while others may be light and easy for replantation. We reported a case of 10-digit complete amputations, with severe avulsion injuries over four fingers. Appropriate measures were taken during surgery, and the replanted digits all survived. The replantation operation was done by a team of surgeons, although the surgeons were physically challenged by the long and difficult procedures. However, it was the great pleasure of the surgeons to work hard and whole-heartedly for the benefit of the patient. Postoperative physiotherapy and exercises were done. After 6 months, the functions of both hands had been largely recovered. Complete amputations of 10 digits as a rule result in multiple complicated wounds. The replantation procedure for these conditions is not an easy endeavor because there are numerous blood vessels that need to be anastomosed, the time of the operation will be dreadfully long, and also there is the danger of the occurrence of vascular crises during the postoperative period. It is difficult to achieve successful survival of all 10 amputated digits after replantation.

Amputation, Traumatic↗
PubMed1989

Amputation of the distal portion of the foot.

For 101 patients, initial amputation of 124 extremities involved some distal portion of the foot. Amputations done for atherosclerosis healed in eight of 21 cases (38%), compared with 40 of 77 extremities (52%) in diabetic patients. Presence of cellulitis (44 cases) and absence of a popliteal pulse (44 cases) had no significant effect on success of amputation, but a palpable foot pulse was significantly associated with a successful outcome (29/35 cases, or 83%) (P less than .005). Serial amputations to preserve the foot were successful for 18 of 31 extremities (58%), a success rate equal to that of the entire series, 72 of 124 (58%). Attempts to preserve viability in the distal portion of the foot were not associated with mortality. Cellulitis and absence of a distal pulse are not contraindications to attempting preservation of the extremity, although the best results occur when distal extremity pulses are palpable. In nearly six of every ten cases, amputation of the distal portion of the foot resulted in a successful outcome.

Adult↗
PubMed1999

Diabetes-related lower-extremity amputations disproportionately affect Blacks and Mexican Americans.

BACKGROUND: We sought to identify the age-adjusted incidence of lower-extremity amputation (LEA) in Mexican Americans, blacks, and non-Hispanic whites with diabetes in south Texas. METHODS: We summarized medical records for hospitalizations for LEAs for 1993 in six metropolitan statistical areas in south Texas. RESULTS: Age-adjusted incidence per 10,000 patients with diabetes was 146.59 in blacks, 60.68 in non-Hispanic whites, and 94.08 in Mexican Americans. Of the patients, 47% of amputees had a history of amputation, and 17.7% were hospitalized more than once during 1993. Mexican Americans had more diabetes-related amputations (85.9%) than blacks (74.7%) or non-Hispanic whites (56.3%). CONCLUSIONS: This study is the first to identify the incidence of diabetes-related lower-extremity amputations in minorities using primary data. Minorities had both a higher incidence and proportion of diabetes-related, LEAs compared with non-Hispanic whites. Public health initiatives and national strategies, such as Healthy People 2000 and 2010, need to specifically focus on high-risk populations and high-risk geographic areas to decrease the frequency of amputation and reamputation.

Black or African American↗
PubMed2004

Segmental amputation for recurrent malignant bone tumors of the distal femur.

We describe an alternative method for lengthening a short femoral stump after wide amputation of a malignant bone tumor of the distal femur in two patients. The method consists of two procedures during the operation. The first procedure is amputation of the affected cylindrical segment of the involved limb. The second procedure is elongation of the amputation stump using the tumor-free segment of the ipsilateral lower leg as a free composite osseous myocutaneous graft. Both patients had good function and were satisfied with the results with no complications or tumor recurrence 4 years postoperatively. We think the segmental amputation is a good procedure that results in a longer functional stump in patients who have above-knee amputation.

Adolescent↗
PubMed2006

Advantage of limb salvage over amputation for proximal lower extremity tumors.

UNLABELLED: Although function after lower extremity amputation and limb salvage has been compared, no study has assessed individual functional variables by surgical level. Our aim was to determine whether risks of long-term psychologic and physical limitations were associated with amputation or limb salvage at four levels: below-knee, above-knee, hip, and pelvis. We included 408 patients with sarcomas and postoperative followup of 2 years or greater who had completed a quality-of-life self-report questionnaire. The mean length of followup was 8.91 +/- 5.15 years (range, 2-27 years). Relative risk analysis was done on 12 dichotomous general health, psychologic, and physical function variables. At the below-knee level, outcomes were similar after both procedures. At the above-knee level, amputation was associated with increased risk of limp (RR = 1.6), walking aid use (RR = 2.1), anxiety (RR = 2.4), and inability to drive (RR = 3), and decreased risk of muscle weakness (RR = 0.57). At the hip and pelvic levels, outcomes were descriptively compared because of the small number of amputations. At these higher levels, limitations were more common after amputation. The difference in results between the below-knee and above-knee levels supports the importance of distinguishing surgical levels. Limb salvage offers a functional advantage at proximal tumor locations. LEVEL OF EVIDENCE: Therapeutic study, Level III (retrospective, comparative study). See the Guidelines for Authors for a complete description of levels of evidence.

Adolescent↗
PubMed1992

A survey of lower limb amputation in diabetic patients.

A retrospective survey of non-traumatic and non-neoplastic lower limb amputations in Newcastle upon Tyne during 1989-91 was performed. Hospital data were cross-checked with the local limb fitting centre to ensure 100% ascertainment. The diabetic patients were found to be 39% of amputees and 42% of operations (all levels). Incidence of diabetes amputation was 5.7 per 100,000 population per year. Fifteen percent of the diabetic patients had diabetes first diagnosed when they were admitted for amputation. For the known diabetes patients, 46% were under diabetes care by general practitioners only. Forty-seven percent of the patients who were under the care of a hospital service for diabetes had incomplete foot examination and assessment. Mortality rate within 30 days after diabetic amputation was 10% and median life expectancy following amputation was 22 months. It seems likely that assessment and management of the diabetic foot remains suboptimal in Newcastle, and that protocols and audit of care could lead to improvements without additional resources.

Aged↗
PubMed2004

Predictors of amputation and survival following lower extremity revascularization in hemodialysis patients.

BACKGROUND: Peripheral vascular disease (PVD) has become increasingly common in end-stage renal disease (ESRD) patients, leading to an increase in the rate of revascularization and amputation. We studied the prognosis of ESRD patients undergoing their first revascularization procedure. METHODS: We conducted a longitudinal cohort study of hemodialysis patients enrolled in special studies of the United States Renal Data System. Cox proportional hazards analysis was used to assess the independent effect of type of initial revascularization procedure on lower extremity amputation and all-cause, cardiac, and infectious mortality over 3 years, after adjustment for sociodemographic, clinical, and biologic baseline characteristics. RESULTS: Eight hundred patients underwent an initial revascularization procedure by surgical bypass or angioplasty. The overall incidence of subsequent amputation was 16.3/100 person-years, 22.6 for bypass, and 5.7 for angioplasty. After adjustment for patient characteristics, the risk of amputation was higher for bypass versus angioplasty [relative hazard (RH) 4.00; 95% CI 2.46 to 6.57], for black versus white patients (RH 1.49; 95% CI 1.04 to 2.15), for uninsured or patients on Medicaid versus patients with private insurance or on Medicare (RH 1.65; 95% CI 1.12 to 2.72), and for patients with diabetes versus no diabetes (RH 2.51; 95% CI 1.67 to 3.76). Compared with patients who underwent angioplasty, the risk of all-cause (RH 1.37; 95% CI 1.10 to 1.70), cardiac (RH 1.50; 95% CI 1.08 to 2.09), and infectious (RH 2.17; 95% CI 1.10 to 4.29) mortality was greater among patients who underwent bypass. CONCLUSION: Risk of amputation following revascularization procedures was positively associated with type of procedure, black race, uninsured/Medicaid, and diabetes status. Risk of death was also higher following bypass. While this might reflect underlying severity of disease, patient education, screening, and optimal care of lower extremities should be emphasized to detect PVD at an early stage of the disease process.

Adult↗
PubMedDate not supplied

Tissue response and Msx1 expression after human fetal digit tip amputation in vitro.

Regeneration of mammalian digit tips is well described; however, associated cellular or molecular events have not been studied in humans. We describe an in vitro human fetal model of response to digit tip amputation, and report expression of the transcription repressor Msx1 in the developing and regrowing human digit tip. Human fetal digits from specimens ranging from 53 to 117 days' estimated gestational age (EGA) were cultured in a defined serum-free medium with supplemented oxygen for time periods from 4 days to 4 weeks. Histology and immunohistochemistry were performed on paired control and tip-amputated digits. Regrowing tissue covered the cut end of the distal phalanx in digits up to 80 days' EGA. Msx1 expression was detected beneath the nail field in control digits to at least 70 days' EGA and at the regrowing tip of 57-day digits at 4 and 7 days post-amputation. Our results show that human fetal digits regrow tissue in vitro in response to tip amputation. This process appears spatially associated with Msx1 expression. Msx1 expression appears increased at the regrowing tip of 57-day digits by 4 days after amputation.

Amputation, Traumatic↗
PubMedDate not supplied

Amputation and cisplatin for treatment of canine osteosarcoma.

Seventy-one dogs with histologically confirmed appendicular osteosarcoma were evaluated. Seventeen dogs were treated with amputation and two postoperative [corrected] doses of IV cisplatin given 21 days apart (group 1). Nineteen dogs were treated with IV cisplatin 21 days before amputation, with a second dose given immediately after amputation (group 2). Thirty-five dogs were treated by amputation of the affected limb with no chemotherapy (group 3). The median disease-free interval for group 1 was 226 days, and 177 days for group 2. This was not significantly different. The median survival time was 262 days for group 1, 282 days for group 2 and 119 days for group 3. Group 1 and 2 dogs had survival times that were significantly longer than for dogs in group 3. Two IV courses of cisplatin given before or after amputation appears to improve the survival of dogs with osteosarcoma.

Amputation, Surgical↗
PubMed2003

Treatment of fingertips amputation using the Hirase technique.

The management of very distal finger amputations when the amputated part is saved is still difficult and controversial. Both re-attachment of the amputated portion as a composite graft and microvascular anastomosis can fail in this distal location. Replantation is, in fact, associated with certain problems, such as technical difficulty, risk of failure because of the poor venous drainage, and costs. With the exception of children, amputations at the level of the lunula poorly survive direct re-attachment. Hirase has described a new replantation model without vascular anastomosis and used ice water and aluminium foil to enhance survival of the composite graft. Cooling the entire recipient site retards cellular degeneration in the graft until neovascularisation occurs. The present authors applied this method to seven cases in which a digit had been amputated between the tip and the lunula. In four cases the method proved to be completely successful, whereas in two an area of tip necrosis was observed. The Hirase method has proven to be a simple and reliable surgical technique for fingertip re-attachment.

Adolescent↗
PubMedDate not supplied

Relationship of cosmetic disfigurement to the severity of posttraumatic stress disorder in burn injury or digital amputation.

BACKGROUND: The purpose of this study was to examine the relationships of physical factors including physical functioning and cosmesis to posttraumatic stress disorder (PTSD) symptoms in patients with burn injury and in patients with digital amputation. METHODS: Subjects were 56 patients with burn injury and 26 patients with digital amputation. In addition to assessments of physical factors, psychiatric interviews were administered to examine mental disorders including PTSD and major depression. RESULTS: The prevalence rates of PTSD and major depression were 33.9 and 7.1% in burn-injured patients and 18.5 and 7.4% in patients with digital amputation respectively. Multivariate analysis of variance (MANOVA) revealed that, regardless of the severity of burn injury such as percentage of total body surface burned, female victims with cosmetic disfigurement (i.e., facial burn) exhibited PTSD symptoms, in particular PTSD symptoms of avoidance and emotional numbing. For subjects with digital amputation, MANOVA indicated that, regardless of the degree of physical functioning after replantation, female victims with cosmetic disfigurement exhibited PTSD symptoms. DISCUSSION: These findings suggest that, in female victims with burn injury and/or digital amputation, the degree of cosmetic disfigurement is related to the manifestation of PTSD symptoms of avoidance and emotional numbing.

Adolescent↗
PubMed1993

Unilateral forelimb amputation affects protein synthesis in ipsilateral and contralateral spinal cord and spinal ganglia neurons of the newt in vivo.

The aim of this investigation was to analyze the effect of urodele limb amputation and blastema growth on the protein synthesis in spinal cord and spinal ganglia neurons corresponding to the 3rd and 4th spinal segment of young, postmetamorphic Triturus vulgaris, in vivo. Protein synthesis was studied on both trunk sides as a function of right forelimb amputation at the distal stylopodium, and blastema development, during a critical period of 22 days post amputation (dpa). Protein synthesis was assessed by counting silver grains on autoradiographs obtained after pulse labeling with tritiated phenylalanine. An electronic image analyzer was used to evaluate the results. During the period of observation, several statistically significant, yet moderate changes were observed in the protein synthesis of motor neurons. In contrast, the studied metabolic parameter exhibited considerable augmentation in sensory neurons and spinal nerve. The main results may be summarized as follows: (a) Limb amputation triggers protein synthesis in both ipsilateral and contralateral neural elements; (b) protein synthesis is higher on the ipsilateral than on the contralateral side; (c) as the aftermath of forelimb amputation, the 4th ipsilateral ganglion responds with an approximately 20% higher protein synthesis in comparison to the 3rd one; (d) peaks in protein synthesis are encountered mainly at two time points: 3 hpa and 14 dpa. Protein synthesis returns to control levels after 22 days of limb regeneration.

Amputation, Surgical↗
PubMedDate not supplied

The influence of electrostimulation on the circulation of the remaining leg in patients with one-sided amputation.

The aim of the authors' study was to investigate, in patients with one leg amputated, the influence of electrostimulation on the arterial circulation of the other lower limb and on the ability of a leg with deteriorated blood flow to perform work. The study encompassed 50 patients who were admitted to the rehabilitation center to obtain a leg prosthesis and learn to walk after amputation of 1 lower limb because of severe circulatory disturbance. The patients were randomly divided into 2 groups. The first group contained 25 patients treated with a standard exercise program for patients with limb amputation (control group, C). In this control group, according to the Fontaine's classification of peripheral arterial occlusive disease (PAOD), 15 patients were in stage I and 10 patients were in stage II. In the second group, the electro stimulated (ES) group, there were also 25 patients that had the same rehabilitation program, to which electrostimulation of the gastrocnemius muscle of the remaining leg was added. In this group, 14 patients were in stage I, 10 patients were in stage II, and 1 patient was in stage III of PAOD. For electrostimulation, biphasic charge-balanced asymmetrical current stimuli with a pulse duration of 0.25 ms were used. The electrostimulation program consisted of 2 hours of electrostimulation per day for 8 weeks. Each patient was examined at the start of the rehabilitation program (examination I), at the end of the 8-week program (examination II) and at the end of a 1-year follow-up period (examination III). The effects of the treatment were followed using clinical examination, determination of the ankle-brachial index (ABI), and by measuring the partial oxygen pressure (TcPO2) on the skin surface of the diseased leg at rest and during exercise. After 8 weeks of treatment, in 3 patients of the ES group, claudication disappeared, and they thus moved from clinical stage II to stage I. In the control group, there were no changes in the clinical stages of PAOD. At the end of the observation period, 6 patients in group C and 5 patients in the ES group registered a progression of PAOD. During the observation period, 3 patients in group C and 1 patient in the ES group had below-knee amputations of the remaining leg (p<0.01). Perfusion pressures and ABI of investigated legs were comparable between groups and did not change during treatment. After 1 year of observation, there was a trend to ABI decrease in both groups. The capability of the diseased leg for performing work increased significantly during treatment only in the ES group. During treatment, TcPO2 at rest on the dorsum of the foot increased nonsignificantly in the ES group but in group C a trend of decrease in its value was indicated. After 8 weeks of treatment, total and partial oxygen drop during exercise significantly decreased in the ES group; whereas, in group C, there was no significant change. During the 1-year observation period, these effects of electrostimulation disappeared; however, fewer amputations in the ES group favor the presumption that this could be a positive effect of electrostimulation. The results of the authors' study showed that electrostimulation improved oxygen delivery to a leg with disturbed arterial circulation and increased its work load capacity. The changes are probably caused by improvement of microcirculation.

Aged↗
PubMed1992

Transcutaneous oxygen as a predictor of wound healing in amputations of the foot and ankle.

Thirty-eight amputations of the foot and ankle were performed in patients with peripheral vascular insufficiency over a 20-month period. Amputation level selection was based on clinical examination, a minimum ankle-brachial index of 0.5 as a measure of vascular supply, serum albumin of 3.0 gm/dl as a measure of tissue nutrition, and a total lymphocyte count of 1500 as a measure of immunocompetence. Transcutaneous oxygen tension was measured at the midfoot and ankle levels prior to surgery. Thirty-two of 38 patients (84.2%) healed their amputation wounds. When the transcutaneous oxygen tension was greater than 30 mm Hg, 24 of 26 patients (92.3%) healed. When the value was below 30 mm Hg, only eight of 12 patients healed. When the propensity to support wound healing is factored out, with patients having the metabolic capacity to heal an amputation wound in the foot and ankle, it appears that transcutaneous oxygen tension is an accurate measure of vascular inflow to support amputation wound healing.

Adult↗
PubMed1994

Achilles tendon tenodesis to prevent heel pad migration in the Syme's amputation.

In an attempt to prevent migration of the heel pad, 11 patients underwent a combined Syme's amputation and Achilles tendon tenodesis between December 1989 and April 1992. Ten patients healed the Syme's amputation, and one patient failed to heal the surgical wounds and required a below-knee amputation. In all 10 successful Syme's cases, the heel pad has remained stable with no migration, and no skin breakdown at an average follow-up of 18.5 months. Published series of Syme's amputations report that the incidence of heel pad migration is between 7.5% and 45%, and occurs primarily in the post-operative or early rehabilitation stage. We believe that tenodesis of the Achilles tendon is a technically easy addition to the Syme's amputation, that it keeps tension off of the incision during healing, and that it prevents migration of the heel pad.

Achilles Tendon↗
PubMed2005

Lower-extremity amputation: a 6-year follow-up study in Brazil.

PURPOSE: To evaluate the 6-year mortality in 50 patients following lower-limb amputation. METHODS: The cumulative survival rate of 50 (28 men, 22 women) amputees aged 54 to 94 years (mean, 67.3; median, 73.5) was retrospectively studied from 1993 to 1998. Indications for above- or below-knee amputation were trauma (n = 2), vasculitis (n = 2), and critical ischaemia of the lower limbs (n = 46). Leg amputation was performed after anamnesis, physical examination, and angiography. All patients were followed up for 6 years by phone or domiciliary visit. A death certificate was verified when a patient was lost to follow-up. Statistical analysis was expressed by the actuarial survival curve. RESULTS: Of 50 amputees, 36 died in the 6 years following leg amputation: 22 in the first year, 3 in the second year, 5 in the third year, 2 in the fourth year, 2 in the fifth year, 2 in the sixth year; 14 remained alive after 6 years. CONCLUSION: Patients who underwent lower-limb amputation had a high 6-year mortality. Most deaths occurred in the first year.

Age Distribution↗