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PubMedDate not supplied

Diabetic foot amputations. Part III: Midfoot.

Recently, the approach in management of diabetic foot disorders has undergone critical re-evaluation. Major foot infections, such as plantar space infections and osteomyelitis do not automatically result in Syme's or below-the-knee amputations. When indicated, midfoot amputations should be attempted because of the functional and psychologic advantages compared with more proximal amputation levels of the lower extremity. In Part III of this series of articles concerning diabetic foot amputations, the authors present case studies along with midfoot amputations and muscle-balancing procedures.

Aged↗
PubMed1989

[Current state of amputation surgery].

Upper extremities: Traumatic amputations should be re-planted whenever possible. Lower extremities: Traumatic amputations must never be replanted! Arterial occlusive diseases cause the majority of amputations (ref. to indication, technique, rehabilitation). Borderline amputations are considered only after arterial reconstruction (profundaplasty) or in diabetics. The major preferential amputation is the knee disarticulation, since it results in less trauma and promotes quick rehabilitation, especially in geriatric patients.

Amputation, Surgical↗
PubMed1988

Noninvasive determination of healing of major lower extremity amputation: the continued role of clinical judgment.

Various tests are used preoperatively to differentiate patients who require an above-knee amputation (AKA) from those whose vascular supply is adequate to heal a below-knee procedure (BKA). This 15-month study of 109 amputations compared four of these methods: segmental Doppler systolic pressure measurements, transcutaneous oxygen measurement (tcPO2), fluorescein angiography, and skin thermometry. There were 66 BKAs (85% healed primarily) and 43 AKAs (93% healed primarily). The actual level of amputation was determined by the operating surgeon without consideration of the preoperative test results, and the incidence of healing was then related to the test parameters. The average skin temperature at the amputation site was higher (93.7 degrees F) in the group that healed primarily compared with those who required operative stump revision (89.9 degrees F) (p less than 0.001). The mean midcalf tcPO2 was also higher in the BKA group that healed (PO2 = 36.6 mm Hg) compared with those who failed (PO2 = 16.4 mm Hg) (p less than 0.001). Qualitative skin fluorescence was less successful in differentiating success from failure. Of the 63 BKAs that fluorescein predicted would heal, eight failed (13%). Doppler pressures at the thigh, popliteal, midcalf, or ankle level were unreliable in predicting healing of a BKA. Formulation of indexes relating absolute pressures to the brachial systolic pressure did not improve the value of this examination. From this review it is concluded that the skin temperature and tcPO2 obtained at the site of proposed amputation were the most reliable prognostic noninvasive examinations.(ABSTRACT TRUNCATED AT 250 WORDS)

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PubMed1988

Limb-threatening ischemia in the medically compromised patient: amputation or revascularization?

The clinical courses of 362 patients with threatened limbs, seen over a 25-year period, were reviewed. Below-knee amputation was elected in 158 patients and infrainguinal revascularization in 204 patients. Patients were excluded from the study if amputation was chosen on the basis of arteriographic findings, diffuse infection, or extensive tissue loss. In an effort to compare the two treatment modalities in a minimally biased fashion, patients were stratified into three classes on the basis of the Goldman Multifactorial Index of Cardiac Risk and the American Society of Anesthesiology classification. Within each class, patients treated with amputation and with bypass were comparable with respect to age, sex, severity of ischemia, and anesthetic technique. Patients who underwent revascularization had a lower perioperative mortality rate (p less than 0.05), a shorter length of hospital stay (p less than 0.05), and an increased long-term survival rate (p less than 0.05) than the medically matched subgroup of patients who underwent amputation. Patients in the revascularization group were more successful in regaining ambulatory abilities than patients in the amputation group (p less than 0.01). These differences were most significant as the degree of medical compromise increased. Although medically compromised patients have frequently been denied revascularization on the basis of presumed increases in surgical risk and decreased long-term survival, the data appear to suggest that it is precisely the patients of this group who appear to benefit the most from attempts at limb salvage.

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PubMed1988

Amputation level and distal bypass salvage of the limb.

The feasibility of revascularization of the lower extremity for salvage of the limb with grafts to the tibial and peroneal arteries has been well established. The results of prior reports have suggested that a failed distal bypass may convert a lower extremity amputation to a higher level than afforded by primary amputation. We reviewed all distal, tibial or peroneal artery bypasses performed at our institution during the period of March 1980 through October 1986. Fifty-three patients with 59 threatened lower extremities underwent distal bypass for salvage of the limb. No patient was excluded from review. Thirty-eight patients in the study group had diabetes, and 41 had a prior smoking history. In the postoperative period, six patients were lost to follow-up study, nine patients died, with follow-up data complete in 47 of the study group. The maximum length of follow-up study was 78 months, and the average length was 24 months. Data were examined by life table analysis with respect to cumulative salvage of the limb and graft patency. During the period of review, 12 major amputations were required (nine below-knee and three above-knee) for a cumulative salvage rate of 59 per cent. Of the distal grafts which failed (n = 27), three of 27 of the limbs required above-knee amputation. We conclude that a failed tibial or peroneal artery bypass does not preclude the possibility of salvage of the limb and does not predispose to a subsequent amputation.

Aged↗
PubMed1988

Management of failed prosthetic grafts at the time of major lower extremity amputation.

During a 2-year period 75 patients underwent 77 major lower extremity amputations for arterial insufficiency deemed untreatable by reconstruction (36 primary and 41 after failed infrainguinal arterial bypass). Patients with nonfunctional prosthetic grafts were randomized prospectively to either partial graft removal or complete graft removal, performed simultaneously with amputation, to determine which technique more effectively reduces delayed wound healing, stump infection, operative revision, and process-related death. Patients with known graft and deep wound infection were excluded from this review, as were patients who had positive graft cultures at the time of amputation. Partial graft removal resulted in an increased rate of delayed wound healing (47.8% vs 7.7%; chi 2 5.9, p less than 0.025) and secondary stump infection (39.1% vs 7.7%; chi 2 4.4, p less than 0.05), when compared with complete graft removal. The operative revision and process-related mortality rates were also higher in limbs that had partial graft removal, although not statistically significant. The operative morbidity and mortality rate was no greater in the group with complete graft removal, although the mean operative time was nearly doubled (1.4 vs 2.6 hours). Therefore we recommend that all nonfunctional prosthetic graft material be removed concomitant with major lower extremity amputation to avoid the excessive number of wound healing and suppurative complications that are encountered when residual graft material is present in the amputation stump.

Amputation, Surgical↗
PubMed1987

Rehabilitation in dual disability of hemiplegia and upper extremity amputation: two case reports.

Dual disability involving amputation and hemiplegia is relatively rare. The vast majority of these cases involve lower extremity amputations. In this report two patients sustained a right-sided hemiplegia complicating an old left upper extremity amputation. Through the comprehensive rehabilitation program these two patients were able to make gains, especially in some activities of daily living and in lower extremity functions. Since some of the upper extremity activities, such as dressing or bathing, could not be accomplished, it appears that patients with upper extremity amputation who have a contralateral hemiplegia have a poorer prognosis for achieving functional independence than patients with lower extremity amputation and similar neurologic loss.

Amputation, Surgical↗
PubMed1987

Hemiplegia and lower extremity amputation: double disability.

A retrospective study of 52 consecutive patients was conducted to determine the influence of certain factors on the ambulatory rehabilitation of patients with hemiplegia and lower extremity amputation. Factors studied included side of hemiplegia, laterality of disability, level of amputation, order of disability (amputation first or hemiplegia first), neuromuscular status, mental status, sex, age. The level of function was defined as independent, limited, or nonambulatory. Of 52 double-disability patients, thirty were fitted with a prosthesis. Eight patients attained independent prosthetic function while 16 patients were limited and six were nonambulatory. Factors such as ipsilateral BK amputation preceding hemiplegia, a good-to-fair neuromuscular status, and an intact mental status have been associated with better functional results. Although producing higher fitting rates, none of these factors has been found in the present study to be associated with statistically higher levels of ambulatory function. A good-to-fair neuromuscular status seemed to be the prime requisite for good ambulation with a prosthesis in a patient with the double disability of amputation and hemiplegia.

Aged↗
PubMed1986

Rehabilitation of patients with end-stage renal failure after lower extremity amputation.

Four patients with end-stage renal failure on maintenance hemodialysis and one patient with near end-stage renal failure received inpatient rehabilitation following lower extremity amputation. All were prosthetically restored. Three of the patients had bilateral below-knee amputations and were ambulatory at the time of discharge, including the patient with near end-stage renal failure who was on maintenance hemodialysis at follow-up. One unilateral below-knee amputee was also ambulatory at discharge. The other unilateral below-knee amputee had an ulcer on the other foot and used a pylon for transfers only. To assess the prevalence of patients on maintenance hemodialysis with lower extremity amputations, a survey of 310 patients at four dialysis units was performed. Of the 310 patients 2.9 percent had at least one amputated lower extremity and 1.0 percent had bilateral lower extremity amputations. Preliminary data and the potential for functional results following prosthetic restoration suggest the need for further research concerning prosthetic restoration in the lower extremity amputee with end-stage renal failure.

Adult↗
PubMed1987

Cardiovascular disease risk factors in combat veterans after traumatic leg amputations.

Traumatic leg amputation, but not arm amputation, in World War II combat veterans has been associated with subsequent increased ischemic heart disease mortality. In a pilot project we examined a group of 19 high-risk Vietnam War veterans with bilateral above-knee amputations in comparison with a control group with unilateral below-elbow amputations. Nine of the 19 above-knee amputees were hypertensive (p = 0.05) and obese by hydrostatic weighing (p less than 0.001). Obesity was strongly associated with hypertension, decreased glucose tolerance, and marked hyperinsulinemia. Cigarette smoking, blood lipid abnormalities, and decreased cardiovascular fitness were not implicated as significant risk factors. Long-term risks of amputation may be related to metabolic and hemodynamic sequelae of excessive maturity-onset weight gain in young men immobilized by loss of lower limbs.

Adult↗
PubMed1987

Nutritional status and wound healing in lower extremity amputations.

This prospective study examines the importance of nutritional status in 41 consecutive patients with lower extremity amputations proximal to the Symes level. The nutritional status of the patients was assessed by evaluating serum albumin levels and total lymphocyte counts, proven indices of nutritional status. Fifteen of 16 patients with normal nutritional parameters healed their amputations uneventfully, whereas 11 of 25 malnourished patients suffered either local or systemic postoperative complications. The difference in the complication rate between the nourished and malnourished groups is statistically significant (p less than 0.05). Malnutrition adversely affects the prognosis for healing lower extremity amputations, but it seems to be less detrimental to wound healing in the more proximal amputations, where blood flow is superior. Based on these findings, it is recommended that patients being admitted for lower extremity amputation should be screened at the time of admission, and those with laboratory parameters indicative of malnutrition should have elective surgery postponed until their malnourished state is corrected. Patients requiring urgent surgical treatment should probably receive supplemental nourishment in the perioperative period.

Adult↗
PubMed1985

Fluorometric prediction of successful amputation level in the ischemic limb.

The present study was undertaken to compare fluorometric documentation of fluorescein dye delivery with the standard means of determining the level at which an amputation should be performed in the dysvascular extremity. Thirty-nine patients underwent lower-extremity amputation at the level determined by the surgeon based upon physical examination, angiography, segmental pressure indices, and/or pulse volume recordings. In addition, fiberoptic fluorometry was performed preoperatively. After intravenous administration of sodium fluorescein (4-8 mg/kg), fluorometric readings were obtained by placing the fluorometer's light guide on 126 reading sites. Fluorometric findings were evaluated retrospectively, and therefore did not influence the surgeon's decision. Of the 39 amputations performed overall, only 26 healed. The accuracy of the standard criteria was lowest for the 20 below-ankle amputations, where only 12 cases healed. Alternatively, fluorometric indices separated healing from nonhealing sites in 36 of the 39 cases and in 18 of the 20 below-ankle amputations. Overall, healing sites averaged 94 percent of the fluorescence of the healthy reference area, while nonhealing sites averaged only 29 percent. We conclude that fluorometry should prove to be a valuable adjunct in the assessment of the dysvascular extremity. It uses a low dose of dye, is easy to perform, and is readily repeatable.

Amputation, Surgical↗
PubMed1974

Saving amputated digits. Current status of replantation of fingers and hands.

Since the advent of microsurgery in the 1960's it has become possible to sucessfully repair vessels as small as 0.5 mm in diameter, which makes the replantation of totally severed digits possible. Some centers have reported 50 to 60 percent survival of completely severed digits and up to 100 percent survival of amputated hands and of partially amputed but otherwise non-viable digits that were reattached. In view of this success, severed members should be considered as potentially replantable.THE RECOMMENDED INDICATIONS FOR REPLANTATION ARE: (1) multiple digital amputations at or proximal to the proximal interphalangeal joint; (2) amputation of the thumb; (3) amputation of the wrist or hand; (4) partially attached digits that are non-viable without reattachment.The surviving replanted digits give functional improvement to the hand and prove cosmetically acceptable.

Amputation, Traumatic↗
PubMed1984

Nutritional status: importance in predicting wound-healing after amputation.

Protein-calorie malnutrition, or both, affects the morbidity and mortality of patients undergoing operations. Laboratory assessments of nutritional status consisting of evaluations of serum albumin levels and total lymphocyte counts are valid tests of a patient's nutritional status. In this study we examined the influence of preoperative nutritional status on morbidity in twenty-three diabetic patients who underwent a Syme amputation. All of the patients met Wagner's criteria for a Syme-level amputation, but in only 43 per cent (ten patients) did the amputation heal at this level, which was chosen by Wagner's criteria alone. Of the seven patients who, in addition to meeting Wagner's criteria, had a serum albumin level of at least 3.5 grams per deciliter and a total lymphocyte count of at least 1500 cubic millimeters, in six (86 per cent) the amputation healed at the Syme level. In contrast, the Syme-level amputation healed in only two of the eleven patients who met the criteria of Wagner but who had a serum albumin level of less than 3.5 grams per deciliter and a total lymphocyte count of less than 1500 cubic millimeters.

Adult↗
PubMed1984

Ankle-level amputation.

Ankle-level amputation for diseases involving the foot can be achieved by the Pirogoff amputation instead of the Syme amputation with very good results. This technique provides a strong end-bearing stump and has the advantage that the amputated leg is essentially the same length as the patient's normal leg. With the use of modern prostheses, the results of rehabilitation are very good. We have used the Pirogoff technique for ankle-level amputations in 12 patients during the past 4 years with good results.

Aged↗
PubMed1983

Amputation of gangrenous toes--effect of sepsis, blood supply and debridement on healing rates.

While 32% of the patients in this series who required amputation in the lower limb presented with infected or gangrenous toes, only 9% had pedal pulses. In a prospective study of 26 phalangectomies and 9 ray or transmetatarsal amputations, the definition of a successful procedure was taken as a healed, painless wound at 1 month. By 1 month, 6 wounds were healed, 5 pain-free and granulating and 8 septic or painful; 16 patients had had further surgery. In the end 14 of 35 feet were salvaged, with 2 patients lost to follow-up and 4 with painful or septic feet. The 15 patients who later required below-knee or above-knee amputations were pain-free, but 7 could not be rehabilitated on prostheses. Blood supply and sepsis affected the healing rate, whereas diabetes was unimportant. The final salvage rate was apparent within 1 month of the initial surgery. In the absence of a pedal pulse, the use of clinical judgement for the selection of patients with dry gangrene gave a 50% salvage rate, but only 8 patients were selected for local surgery out of the total of 24 in this category. Sixteen amputations were performed for sepsis in the absence of a pedal pulse; no wound healed and only 2 patients had a clean, pain-free, granulating wound at the end of the 1-month period. Direct arterial surgery played an important role in restoring the pulse prior to amputation.

Amputation, Surgical↗
PubMed1980

The effect of arterial reconstruction on lower limb amputation rate. An epidemiological survey based on reports from Danish hospitals.

During the period 1 April-31 December 1976, the incidence rates of admission, of amputation and of arterial reconstruction for arteriosclerosis of the lower limbs were calculated from information in the Danish National Patient Register. Admissions increased with age (from 4.3 per 100,000 persons under 40 years of age per year to 1603 per 100.000 persons over 80 years per year). Similarly, lower limb amputations varied with age (from 0.3 to 226 per 100.000 persons per year). Arterial reconstructions, however, did not vary with age, but remained rather constant at about 50 per 100.000 persons per year, in persons over 50 years. The incidence rates of admissions, amputations and arterial reconstructions in men were 1.5 x the incidence rates in women. Both amputation and arterial reconstruction showed a significant regional variation from county to county. However, the rates were not correlated, and the expected amputation-preventing-effect of arterial reconstructions could not be demonstrated. The most probable cause for this was the inadequate capacity for vascular surgery in Denmark. An estimation shows that of the 1100 operated on for severe lower limb ischemia during the period studied, only 290 were offered arterial reconstruction.

Adult↗
PubMed1982

Salvage replantation of lower limb amputations.

Three cases are reported in which the microsurgical salvage of parts of traumatic lower extremity amputations associated with degloved proximal skin loss provided sturdy, sensate skin and soft-tissue coverage and thereby preserved functional below-knee amputation levels. In two instances, a free innervated filletted flap was constructed from the foot of the amputated limb, and in the third case, the amputated lower leg was shortened, successfully replanted, and followed later by elective amputation of a foot at the Syme level. At a mean follow-up of 2 years, all three patients are ambulating well in below-knee prostheses.

Adult↗