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PubMed1982

Amputation for congenital pseudarthrosis of the tibia. Indications and techniques.

The indications for amputation with pseudarthrosis of the tibia are: failure of bony union after three surgical attempts; significant leg-length discrepancy; interference with growth distal to the pseudarthrosis; and a significant period under medical care, such that the patient suffers unduly. The primary problems related to amputating at the level of the pseudarthrosis are poor stump configuration, bony overgrowth, and poor skin coverage. A distal amputation at the ankle is recommended, using the technique for a cartilage-preserving Symes amputation. Methods for realigning the tibia at the time of amputation include the use of an intermedullary rod or a compression plate. The ultimate goal of treatment is always a functional limb.

Amputation, Surgical↗
PubMed1982

Predictive value of preoperative segmental blood pressure measurements in below-knee amputations.

Segmental blood pressure criteria for below-knee amputations were assessed retrospectively. 40 patients underwent 44 below-knee amputations for advanced lower limb ischaemia. Preoperative systolic blood pressure measurements using a Doppler device as a distal sensor were performed on 31 limbs to be amputated. Healing occurred in all limbs with calf systolic pressures of 68 mmHg or more and distal thigh systolic pressures of 100 mmHg or more. With calf pressures below 35 mmHg and distal thigh pressures of 60 mmHg or less, all amputations failed. Diabetes did not affect the pressure criteria except for one obvious case with mediasclerosis. It appeared that pressure data could be used to improve the preoperative assessment of the amputation level.

Aged↗
PubMed1978

Major amputation following vascular reconstructive procedures (including sympathectomy).

To study the effects of vascular reconstruction or sympathectomy, or both, on the level of amputation, the number of revision procedures performed and the mortality following amputation, the authors reviewed the records of 504 patients from three Toronto teaching hospitals who had one or both limbs removed at or above the below-knee level. It appears that (a) previous vascular surgery or sympathectomy, or both, actually increases the number of patients in whom a below-knee amputation is successful, (b) the number of revision procedures necessary is increased after failed vascular surgery or sympathectomy, or both and (c) revision procedures following amputation do not affect the mortality from lower limb amputation.

Amputation, Surgical↗
PubMed1995

Amputations in patients attending a diabetic clinic in Addis Abeba, Ethiopia.

During 18 years, 1976 to 1994, 43(1.9%) of the 2,250 patients registered in the Diabetic Clinic at Yekatit 12 Hospital, Addis Abeba, Ethiopia (six patients) required an amputation at diagnosis or during the course of diabetes mellitus. Male to female ratios was 2:1; eight patients had Type 1 and 35 Type 2 diabetes. Diabetic peripheral neuropathy was the underlying condition in at least 21 of the 43 patients; only five cases of ischaemic gangrene were seen. Mean ge at amputation was 37.4 +/- 8.7 years in Type 1 patients and 58.6 +/- 12.1 in Type 2. Twenty-three of the 43 are now dead, 12 of the deaths having been due to sepsis in patients who refused an amputation in the face of progressing gangrene. Eleven of the 43 still attend regularly up to 11 years after an amputation. Most patients who needed below-knee amputations did not regain independence because of difficulty obtaining prostheses.

Adolescent↗
PubMed1994

[After-care of patients with diabetic foot by general practitioners or special ambulatory care--effects on rate of amputation].

The impact of a diabetic foot clinic on amputations rates was assessed in 55 diabetic patients with foot lesions, consecutively treated in hospital at the medical department of the university of Düsseldorf. After discharge from the hospital, wound care was continued at home by a mobile nursing team, in conjunction with an outpatient diabetic foot clinic, until complete healing of the lesions after 86-91 days on average. About 18-30 months later, the patients were re-assessed: 39 of them had kept in touch with the foot clinic (0.83 visits per month), and 16 had not (0.09 visits of the foot clinic per month) and were cared for by their general practitioners. Both groups did not differ with regard to age, sex, duration of diabetes, prevalence of peripheral ischaemic vessels disease, mortality, and other items. The prevalence of patients with relapsing foot lesions was also similar in both groups. However, there was a significant difference in amputation rates, in that the patients under care of the foot clinical had only 21% amputations per relapsing patient as compared to 68% amputations in relapsing patients under care of general practitioners (p < 0.05). It is concluded that patients with relapsing diabetic foot lesions are less frequently amputated when cared for by a specialised diabetic outpatient footclinic, as compared to the care provided by general practitioners.

Adult↗
PubMed1993

Limb salvage: thrombolysoangioplasty as an alternative to amputation.

OBJECTIVE: This 5-year retrospective study evaluates the results of thrombolysoangioplasty (TLA) used as an alternative to major amputation in patients with severely debilitating, lower extremity, peripheral vascular disease. All patients in this study were originally designated for major amputation to treat their ischemic symptoms after all other surgical options were exhausted. MATERIALS AND METHODS: Twenty-one limbs in 20 patients with complete occlusions of the superficial femoral, popliteal and at least 2 of the 3 major branches below the popliteal trifurcation were attempted for thrombolysoangioplasty for limb salvage. The majority of patients had previous bypass procedures, and all patients had either nonhealing ischemic ulcers, tissue loss, and/or resting pain. RESULTS: There were no primary failures. 17/21 patients were saved from major amputation. 4/21 patients were changed from an AKA to a BKA. 5/21 patients reoccluded within 1 year. 4/5 were successfully retreated via TLA. 1/5 required a major amputation. Life Table analysis demonstrated 63.6% (+/- 3.72)-12 months and 45.4% (+/- 3.78)-15 months primary patency rates. Limb salvage rates, however, were significantly better. Twenty-four month and 31 month rates of 75.5% (+/- 5.57) and 75.5% (+/- 6.44) were seen for complete limb salvage, respectively, while 24 and 40 months partial limb salvage rates of 94.7% (+/- 3.67) and 94.7% (+/- 4.27) were demonstrated. There were 2 complications; they were both retroperitoneal hemorrhages. Both patients recovered without sequelae. DISCUSSION: In conclusion, these preliminary results indicate that TLA is an effective alternative to major amputation for patients with severely debilitating peripheral vascular disease.

Aged↗
PubMed1993

Effect of age on progression through temporary prostheses after below-knee amputation.

Forty six patients that underwent below knee amputation for diabetes, trauma/osteomyelitis or peripheral vascular disease were studied. Healing was estimated by the rate of progression through temporary prostheses as determined weekly by the amputee rehabilitation team (physiatrist, orthopedist, physical therapist, nurse, and prosthetist). For all groups combined, mean days +/- standard error from amputation to above knee cast with pylon and foot (AKPy) were 22.9 +/- 1.9, to below knee cast with pylon and foot (BKPy) 41.6 +/- 2.8 and to laminated temporary prostheses 66.5 +/- 4.5. A regression analysis of these variables on age (range: 29 to 84 yr) showed significant positive correlations for AKPy (r = 0.34, P = 0.0214) and BKPy (r = 0.40, P = 0.0056). An analysis of variance with contrasts (Tukey's protected t) showed significant lower values (P < 0.05) for amputation to BKPy in the trauma/osteomyelitis group when compared to diabetes or peripheral vascular disease and no difference among the last two groups. However, when variables were adjusted for age (analysis of covariance with age as a covariate), the differences among groups disappeared (covariance F(2,44) = 0.9, P > 0.4). In conclusion, age, not the cause of the amputation, correlated with healing after below knee amputation as estimated by the rate of progression through temporary prostheses.

Adult↗
PubMed1993

The interscapulothoracic amputation in the treatment of malignant diseases of the upper extremity with a review of the literature.

The majority of patients with soft tissue sarcoma (STS) or bone sarcomas (BS) of the upper limb can be treated today with limb saving procedures using combined modality therapies. However, for a small group of patients the interscapulothoracic (IST) amputation is the only final surgical treatment with either a curative or a palliative intent. Since 1972, 12 patients seven males and five females, median age 36 years (range 13-82) underwent an interscapulothoracic amputation; five for bone sarcomas, five for soft tissue sarcoma and two for locoregional metastases. There was no post-operative mortality or morbidity. During a median follow-up of 8 years (range 0.25-15), there was no local recurrence. The five-year survival rate for the soft tissue sarcomas was 80% and for the bone sarcomas 30%. The interscapulothoracic amputation is one of the major ablative surgical procedures which should be performed with curative intent, very rarely with a low palliative intent. The prognosis of an interscapulothoracic amputation for shoulder girdle malignancies is not different from extremity soft tissue sarcomas or bone sarcomas located more distally. The morbidity and local recurrence rate after interscapulothoracic amputation should be negligible.

Adolescent↗
PubMed1993

Changes in the number of lower limb amputations during a period of increasing vascular surgical activity. Results of a nation-wide study, Denmark, 1977-1990.

OBJECTIVE: To find out if the number of lower limb amputations for peripheral occlusive arterial disease increased during the period of increased vascular surgical activity 1977-1990. DESIGN: Retrospective review of a database covering all admissions to Danish hospitals. SUBJECTS: All patients admitted to Danish hospitals with peripheral occlusive disease during the period 1977-1990. MAIN OUTCOME MEASURES: Numbers, and age and sex specific incidence rates for admission, arterial reconstruction and amputation. RESULTS: The number of admissions during which arterial reconstruction for OAD was done increased from 963 in 1977 to 2311 in 1990 (p < 0.001). The number of admissions during which a diagnosis of OAD was made and an amputation done increased from 1290 in 1977 to a maximum of 1609 in 1983 (p < 0.001). The number remained nearly constant in the mid-1980s but decreased during last part of the period to 1181 in 1990 (p < 0.001). CONCLUSION: The reduction in the number of amputations may indicate that vascular surgery even on a national scale is effective in preventing amputations for OAD.

Adult↗
PubMed1993

The potential benefit of pre-operative assessment of amputation wound healing potential in peripheral vascular disease.

Choosing the most distal amputation level that will heal is difficult in patients with peripheral vascular disease. From 1984 to 1988, 965 patients underwent 1,563 amputations for lower limb peripheral vascular disease at King Edward VIII Hospital, Durban. The primary amputation revision rate was 51% with a mortality rate of 23.1%. Random pre-operative assessment of amputation wound healing potential using a transcutaneous oxygen pressure index was investigated over the 4-year period, 1987-1990. This was responsible for a reduction in the amputation revision rate to 8.2% in patients tested.

Amputation, Surgical↗
PubMed1993

Congenital longitudinal deficiency of the fibula (fibular hemimelia). Parental refusal of amputation.

Fibular hemimelia with significant limb-length inequality is usually best treated with foot ablation and prosthetic fitting. Parents tend to be reluctant to agree to allow their child's foot to be amputated at an early age, especially when the foot is near normal and the limb length is not grossly abnormal. Experience with some families of children with fibular hemimelia who initially refused amputation of the affected limb prompted a retrospective review of the treatment experience with these children. Twenty-four children with 36 affected limbs were treated during the last three decades. Amputation of the foot was performed for 16 limbs in 12 of the 24 patients. The 12 patients whose limbs were not amputated were reviewed in detail. Six of these children were advised to have an amputation, but their families refused to consent. These children were managed by specially designed prostheses to incorporate their foot deformity and limb-length inequality. Four patients required subsequent corrective surgical procedures in an attempt to stabilize the feet or lengthen the limb. To facilitate treatment decisions for both the clinic team as well as the involved families, the authors propose a more practical classification of fibular hemimelia.

Abnormalities, Multiple↗
PubMed1996

[Forefoot gangrene and infra-crural bypass: sequential amputation].

When revascularizing for gangrene, deciding on amputation depends on the risk of infection due to trophic injury both for the foot and for the bypass and on the requirement to attempt amputation at the correct level at the first operation. In our experience, the importance of infection has led us to propose the following sequence: if the lesions are infected--immediate amputation, differed revascularization after the infection has been controlled; if the lesions are dry early vascularization followed by amputation either during the same operation with strict separation of the two operative fields or a few days later, particularly if the level of the amputation has been determined.

Aged↗
PubMed1997

Lower limb amputation and grade of surgeon.

BACKGROUND: The aim of this study was to identify clinical and operative risk factors that might influence the rate of independent ambulation following major limb amputation. METHODS: Between 1989 and 1993, 172 patients had 193 lower limb amputations for peripheral vascular disease: 98 below-knee, 86 above-knee and nine through-knee. RESULTS: The overall revision rate was 13.5 per cent. Revision was significantly more frequent in those patients who had a previous vascular reconstruction. Only 26 per cent of patients were able to ambulate independently after rehabilitation and limb-fitting. Univariate risk factor analysis suggested that independent ambulation was not affected by age, mode of presentation, the presence of ischaemic heart disease, diabetes, smoking status, previous vascular reconstruction or the level of amputation. However, fewer patients whose amputation was performed by a junior trainee could walk with a prosthetic limb (P = 0.03). CONCLUSION: Patients considered suitable for walking training should have amputation performed by a senior trainee or consultant to optimize independent ambulation with a prosthetic limb.

Aged↗
PubMed1997

Amputation versus limb salvage.

The decision to attempt salvage or to amputate a severely injured leg in among the most difficult that the orthopaedist must face. Even surgeons with tremendous trauma experience cannot agree on standard course of action. In the face of such injuries, physician consultation regarding the treatment decision, including all of those members of the team that are needed for a successful salvage, is necessary. In the best circumstances, the trauma surgeon, vascular surgeon, orthopaedist, and a soft-tissue specialist are all involved. From a psychological perspective, the timing of an amputation is important. Although each patient's case is unique, immediate amputation is often viewed by the patient and family as a result of the injury. Conversely, a delayed amputation may be viewed as a failure of treatment. It is imperative that the surgeon have a detailed discussion with the patient and the family whenever possible before making the decisions. Scoring systems are of some help in estimating the chances of a successful salvage. However, the ultimate decision to amputate or attempt salvage is based on such patient factors as preinjury function and social situation, and of associated injuries, surgeon experience, available resources, projected physical abilities, and the patient's projected physical requirements. These decisions are difficult and tax the judgment and emotions of the patient, family, and physician.

Adult↗
PubMed1997

Transmetatarsal and midfoot amputations.

This article discusses transmetatarsal and midfoot amputations, selection of level, criteria for wound healing, surgical techniques, and functional considerations. Amputations through the middle of the foot include the Lisfranc amputation at the tarsometatarsal joints and the Chopart amputation at the midtarsal joints. Both of these procedures result in the development of equinovarus deformity, and require lengthening of the Achilles tendon. Transmetatarsal amputation preserves foot function, is cosmetically acceptable and does not require a prosthesis. Satisfactory limb salvage can be achieved by the motivated patient and knowledgeable surgeon when these procedures are employed.

Amputation, Surgical↗
PubMed1998

Risk factors for amputation in diabetic patients: a case-control study.

BACKGROUND: The objective was to quantify risk factors for lower extremity amputation in patients with diabetes mellitus in an attempt to prevent amputation. METHODS: This investigation was conducted as a case control study among diabetic males from 30-90 years of age with an average clinical duration of diabetes of 10 years: included were 80 cases which required a supracondyle amputation associated with diabetes mellitus, and 240 controls without injuries in the lower extremities. Measurements included the following: socioeconomic level, psychosocial risk factors, neuropathics, peripheral vascular factors, high blood pressure, smoking; environmental factors, health care, self care, and nutritional and metabolic factors in patients with diabetes mellitus before surgery. Statistically significant risk factors identified from analyses were: absence of lower leg vibratory perception (odds ratio = 14.9, 95% CI: 8.2-27.9); peripheral vascular disease (OR = 8.9, 95% CI: 5.3-15.9); high blood cholesterol > 450 mg (OR = 3.8, 95% CI: 2.9-8.6); low blood albumin < 3.5 g (OR = 7.9, 95% CI: 4.8-14.9); hyperurea blood nitrogen > 3.5 mg (OR = 3.1, 95% CI: 1.7-4.9); obesity (OR = 4.2, 95% CI: 1.51-9.8); time of evolution of diabetes mellitus > 10 years (OR = 3.47, 95% CI: 1.40-8.56); cracks in feet (OR = 3.45, 95% CI: 1.33-8.82); feet soaked in water (OR = 1.8, 95% CI: 1.07-2.93); ingrown toenails (OR = 2.0, 95% CI: 0.6-5.3), and lack of outpatient diabetes education (OR = 3.2, 95% CI: 1.5-6.7). CONCLUSIONS: Different risk factors for lower extremity amputation in diabetes mellitus patients were quantified, identifying certain aspects of preventive impact (patient education, glycemic control, careful daily foot hygiene, and appropriate footwear) which may be applicable in environmental factors and which have the possibility of success in lowering the rate of risk for lower extremity amputation.

Adult↗
PubMed1999

[The diabetic foot. Optimal prevention and treatment can halve the risk of amputation].

Almost half of all lower leg amputations are performed in patients with diabetes. In over 70 per cent of these cases, amputation is precipitated by progression of foot ulceration to deep gangrenous infection. Most foot ulcers are preceded by trauma, usually due to ill-fitting shoes, and are precipitated by sensory motor neuropathy with varying degrees of peripheral vascular disease. The Swedish Medical Research Council and the Swedish Institute for Health Services Development arranged a conference on diabetic foot problems in April 1998, the purpose of which was to arrive at a consensus regarding the prevention and management of diabetic foot. It was concluded that a satisfactory multidisciplinary approach should include regular control of feet and footwear, preventive foot care (education, footwear, chiropody), continuous follow-up of high-risk feet, and early recognition of revascularisation. Continuous registration of amputation, irrespective of type, cause and site, might substantially reduce the amputation rate among diabetics. Were such an approach to reduce the incidence of diabetes-related amputation by 50 per cent, annual costs for the management of diabetic foot in Sweden would be reduce by SEK 400 million (the value of improved quality of life not taken into consideration).

Amputation, Surgical↗
PubMed1991

Regenerative capacity of forelimb buds after amputation in mouse embryos at the early-organogenesis stage.

The ability of mouse forelimb buds at stage 1 (Wanek et al., '89a) of development to regenerate after amputation was investigated. The findings were as follows: 1. Outgrowths in the form of hillocks were found at the sites of amputation in 116 (95%) out of 122 embryos examined 24 hours after amputation. Examination of the amputated region after various intervals of time revealed that the outgrowths were established from flank tissues at the anterior and posterior borders of the wound. 2. Ectodermal thickening was found on the distal margin of the outgrowths in 21 (66%) out of 32 specimens examined. These thickenings were histologically similar to the apical ectodermal ridge (AER) present on the control limb buds. 3. Alkaline phosphatase activity was detected on the ectodermal thickening in 11 (79%) out of 14 experimental limb buds examined. The pattern of expression of alkaline phosphatase activity was similar to that observed in control limb buds. 4. There was no correlation between the size of the outgrowths and the presence of the ectodermal thickening or the enzymatic activity. The outgrowths developed despite the absence of ectodermal thickening and enzymatic activity, suggesting that the thickening and the presence of alkaline phosphatase are not crucial for the initiation and formation of the outgrowths. 5. Explants of the outgrowths, when grafted beneath adult kidney capsules, differentiated extensively into various tissues, which included bones, epiphyseal plates, skeletal muscles, and skin derivatives. Control explants also gave rise to the same spectrum of tissues. Hence, the flank tissues surrounding the site of amputation in E10 mouse embryos can regenerate to form a structure that is morphologically and histochemically similar to a limb bud and the mesenchyme within the structure is histogenetically competent to produce the variety of tissues that is normally found in the adult limb.

Alkaline Phosphatase↗