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PubMed1991

[Transarticular amputation at the knee in peripheral arterial occlusive disease. Very positive experiences after routine use of the Klaes and Eigler technique].

In a retrospective study we compare our experience with the through-knee amputation in peripheral vascular disease. In the first 15 patients we used an amputation technique with circular incision. In about 50% of these patients we observed a delayed wound healing or they needed a reamputation to a higher bony level. In the 17 following patients we used the amputation technique described by Klaes and Eigler, using a posterior myocutaneous flap to cover the condyles. Only one of these patients needed a reamputation and another had a secondary wound healing. We conclude that the technique of through-knee amputation described by Klaes and Eigler is better adapted for patients with peripheral vascular disease.

Aged↗
PubMed1990

[Determining the level of leg amputation in patients with occlusive diseases of peripheral arteries by the method of transcutaneous measurement of oxygen tension].

The method of noninvasive percutaneous measurement of arterial blood pO2 was used to determine the rational level of amputation in 45 patients with occlusive diseases of the arteries of the lower limbs. The measurement was made on different levels of the limb before and after amputation. A marked dependence was revealed between the clinical course of the disease, the optimum level of limb amputation, and the pO2 value determined by the percutaneous method, which allows the noninvasive method of percutaneous pO2 measurement to be recommended for choosing the correct level of amputation in the clinic.

Aged↗
PubMed1977

Elderly patients with lower extremity amputations: three-year study in a rehabilitation setting.

Of the 112 mostly elderly patients with lower extremity amputations who were initially evaluated for this study, 86 were discharged as independent prosthetic ambulators after completion of both phases of a two-phase prosthetic rehabilitation program with a team approach. In four years of outpatient follow-up of the 86 patients who completed phase II, 14 died and contact was lost with 6. Sixty-six remain prosthetic ambulators. Six others who had unilateral amputations underwent amputation of the other limb; the initial procedure was above knee in one and below knee in five. All of the patients included in the study were originally referred to the Helen Hayes Hospital with a multitude of problems. The majority had emotional, social and financial difficulties, as well as medical problems. Many of the patients had undergone multiple surgical procedures prior to the first amputation. Psychological problems, particularly depression, were often severe in that group of patients.

Aged↗
PubMed1999

Diabetes mellitus and nontraumatic lower extremity amputation in black and white Americans: the National Health and Nutrition Examination Survey Epidemiologic Follow-up Study, 1971-1992.

BACKGROUND: The comparative long-term risk of non-traumatic lower extremity amputation (LEA) in black and white Americans, 2 groups with strikingly different rates of diabetes mellitus, is not known. OBJECTIVE: To examine the 20-year incidence of LEA in relation to race and diabetes mellitus. METHODS: The 14 407 subjects in the National Health and Nutrition Examination Survey Epidemiologic Follow-up Study were observed prospectively between 1971 and 1992. Prevalent diabetes mellitus was ascertained at the baseline examination, and incident diabetes mellitus, during follow-up. Lower extremity amputation was ascertained from hospital discharge records. Cox regression analysis was used to estimate associations between race, diabetes mellitus, and risk of first LEA. RESULTS: During the study period, 158 LEAs occurred among 108 subjects. While black subjects constituted 15.2% of the cohort, they represented 27.8% of the subjects with amputation (P = .002). The 20-year age-adjusted rate ratio of first LEAs for black subjects-white subjects was 2.14. Regression analyses confirmed the importance of diabetes mellitus as a key LEA risk factor. The association between prevalent diabetes mellitus and LEA risk was substantially higher (relative risk [RR], 7.19; 95% confidence interval [CI], 4.61-11.22) than that for incident diabetes mellitus (RR, 3.15 [CI, 1.84-5.37]), highlighting the importance of diabetes mellitus duration on LEA risk. While preliminary analyses adjusted for age and diabetes indicated a significant association between race and LEA risk (RR, 1.93 [95% CI, 1.26-2.96]), the effect of race diminished (RR, 1.49 [95% CI, 0.95-2.34]) following adjustment for education, hypertension, and smoking. CONCLUSIONS: Although black subjects experienced higher age- and diabetes mellitus-adjusted rates of amputation than their white counterparts, a combination of social and environmental factors may account for the apparent ethnic difference. More research into nonbiological factors associated with LEA may reduce the occurrence of these procedures in both black and white individuals.

Adult↗
PubMed1979

Predicting success of forefoot amputations in diabetics by noninvasive testing.

Sixty-six diabetic patients underwent needed forefoot amputations when clinical assessment indicated a reasonable chance of healing. All patients underwent noninvasive testing consisting of segmental systolic pressure measurements and pulse volume recordings (PVRs) taken at the thigh, calf, ankle, and forefoot levels. Segmental systolic pressures were falsely high (greater than 200 mm Hg) and therefore not useful in 56%. Ankle systolic pressures predicted failure in 36% of patients who healed and success in 64% who failed to heal. Segmental PVRs were sequentially predictive in only 50%. Forefoot PVR traces predicted failure in 50% of patients whose amputations healed. No patient should be denied a forefoot amputation solely on the basis of unfavorable results of noninvasive tests. Favorable clinical signs and a strongly positive forefoot PVR trace are the best predictors of successful forefoot amputations in diabetic patients.

Amputation, Surgical↗
PubMed1981

Prediction of amputation wound healing. Roles of Doppler ultrasound and digit photoplethysmography.

Segmental limb blood pressures (BPs) measured by Doppler ultrasound and digit photoplethysmography were used to define hemodynamic correlates of wound healing in 122 lower-extremity amputations for ischemia. Healing of digit or transmetatarsal amputations were influenced by the presence of diabetes and correlated better with digit pulsation and BP than with ankle pressure. Healing of below-knee amputation did not correlate with segmental limb BPs. In the absence of an absolute threshold to predict wound healing or failure, caution is urged in using hemodynamic indices to select the level of amputation of arterial insufficiency.

Aged↗
PubMed1985

Prevention of major amputations in the diabetic patient.

Five of six major amputations of the lower extremity involve diabetic patients. It should be possible to reduce the number of major amputations by substituting reconstructive for destructive surgery, by radical local surgical debridement, by achieving healing of chronic foot lesions, by the early diagnosis of spread of infections from foot to leg, by limiting minor amputations, by improving the blood supply, and by providing a continuum of care by experienced personnel who supervise the foot status of the patient on an ongoing basis. In my experience, the application of these principles over the past seven years has precluded major amputation in the treatment of 48 diabetic patients with serious lower extremity lesions.

Adult↗
PubMed1991

Limb salvage vs amputation for critical ischemia. The role of vascular surgery.

Since 1980, 498 patients with 627 critically ischemic legs (rest pain, gangrene, ischemic ulcer, and ankle-brachial pressure index less than 0.40) were treated with revascularization regardless of operative risk or anticipated operative difficulty. Primary amputation was performed only when no graftable distal vessels were present (14 primary amputations [2.8%]) or in neurologically impaired, hopelessly nonambulatory patients. The mortality for revascularization was 2.3%, and the median hospital stay was 11 days. During follow-up, 41 limbs (7%) required amputation, 31 after failure of revascularization and 10 despite patent revascularizations. Renal failure had an adverse influence on limb salvage (67%) because of a significantly increased requirement for amputation despite patent revascularizations. We conclude aggressive limb revascularization in patients with critical lower-extremity ischemia results in low operative morbidity and mortality and excellent long-term limb salvage. Patients with critical leg ischemia and renal failure are at higher risk for limb loss than patients without renal failure.

Adult↗
PubMed1998

Problem of amputations in patients with newly diagnosed diabetes mellitus.

A reduction of 50% or more in diabetes-related amputations is a primary target of the St Vincent Declaration. This is thought to be achievable because both primary and secondary preventative healthcare strategies are effective in reducing the incidence of diabetic foot ulceration and progression to amputation. Unfortunately there is a group who cannot benefit from preventative health care, that is, newly diagnosed diabetic patients with already established severe complications. Using our population-based district diabetes information system we investigated, during the period 1 January 1992 to 31 December 96, the incidence and prevalence of lower extremity amputations (LEAs) and the proportion occurring in patients newly or recently diagnosed as having diabetes. Seventy-nine diabetic patients (59 male, 20 female) were recorded as having had 94 LEAs, the incidence of diabetes-related LEA being 475 per 100,000 diabetic patient-years. Of these LEAs 16 (20.2%) were performed within 1 year of diabetes being diagnosed. This study highlights an appreciable and previously unrecognized problem: patients presenting with established complications of diabetes who cannot benefit from secondary preventative healthcare. These patients pose a potential obstacle to achieving targets for reductions in diabetes-related amputations.

Adult↗
PubMed2000

Medical, personal, and occupational outcomes for work-related amputations in Minnesota.

BACKGROUND: The Minnesota Sentinel Event Notification System for Occupational Risks (SENSOR) surveillance system has collected data on the medical, personal, and occupational outcomes associated with work-related amputations since 1992. METHODS: SENSOR defined amputations as any finger amputation or the loss of any other body part; 832 workers were identified as having amputation injuries between 1994 and 1995 and 72% of these workers completed a telephone interview. RESULTS: Twenty percent of those injured required overnight hospitalization. Ninety-one percent of the cases reported having missed work, with 56% reporting missing ten or more days. Individuals working on their usual jobs at the time of injury were more likely to report less serious medical and occupational outcomes. CONCLUSIONS: Severe injuries were significantly associated with worse medical, personal, and occupational outcomes. Two groups of machines, material handling, and powered handtools were associated with a higher proportion of severe injuries.

Absenteeism↗
PubMed2000

Extent of ossification at the amputation plane is correlated with the decline of blastema formation and regeneration in Xenopus laevis hindlimbs.

Xenopus laevis larvae gradually lose the ability to regenerate lost hindlimb structures as they progress through metamorphosis. Previous studies have suggested that this loss of regenerative capacity occurs in a proximal-to-distal fashion. We assessed the quality of overall regeneration and early bud blastema formation in order to evaluate previous explanations for this loss of regenerative ability in Xenopus. We further examined the extent to which epidermis, basement membrane, dermis, cartilage, bone, periosteum, and accumulated mesenchyme within the blastema are involved in the decline of regenerative abilities during mid-metamorphic stages of development. Each tissue was scored based on its contributions to the regeneration blastema, in accordance with previously reported blastemal descriptions. Tadpoles amputated at the ankle and tarsal-metatarsal joints scored objectively higher within the overall regeneration and blastema quality rating systems. Both joint sites met more criteria associated with regeneration-capable blastemas than tadpoles amputated through the middle of the tarsus, especially at later stages of metamorphosis. The three amputation sites studied began to vary in their ability to regenerate skeletal elements and to generate productive blastemas during the same stages at which we initially observed ossification of the tarsus. These results suggest that the decline of Xenopus hindlimb regeneration does not occur in a strictly proximal-to-distal fashion but rather is dependent at later stages on the state of ossification of the structure through which amputation occurs. Our morphological and cellular observations reveal specific times and places during Xenopus hindlimb development at which further investigations into tissue-specific molecular events during early regeneration should be focused.

Amputation, Surgical↗
PubMedDate not supplied

Never amputate without consultation of a vascular surgeon.

Lower limb ischaemia is one of the determinants in the development of diabetic foot ulcers and the most important factor preventing their healing. There are a number of misleading factors masking the presence of atherosclerotic disease and tissue damage; these are reduced inflammatory response to infection, autosympathectomy and mediasclerosis, which all diminish the clinical suspicion of ischaemia. Therefore, adequate assessment of the lower limb circulation should be routinely performed in complicated diabetic foot. This evaluation can often be made with simple methods. In addition to clinical examination ankle/brachial pressure index, systolic toe pressure, plethysmographic pulse volume recordings and simple hand-held Doppler auscultation are most often sufficient to make a decision as to whether angiography is needed or not. Duplex examination can give more profound information on the severity and extent of arterial occlusive disease, but the method is strongly user-dependent. Early vascular consultation is mandatory in diabetic foot work-up and should be undertaken within 2 weeks if a new skin lesion shows no tendency to heal. Long bypass grafting procedures and microvascular free flap techniques have been shown to achieve excellent results in relieving critical leg ischaemia, even in the presence of large foot lesions, and should be used to prevent major amputation. The timing of various procedures is a controversial issue. Feet with small ulcers or restricted dry gangrena can be revascularised first, with minor amputations and local surgery of the ulcer being done thereafter. In the septic neuroischaemic foot, major amputation may be unavailable but if the infection is not immediately life-threatening the infected part of the foot should be drained and debrided properly and left wide open, sometimes with a guillotine amputation in order not to risk the bypass graft, which can be done a couple of days later.

Amputation, Surgical↗
PubMed2004

Vascular supplies differ in regenerating and nonregenerating amputated rodent digits.

Bone regenerates following amputation through the level of the nail, but bone is capped following amputation through more proximal levels. Because osteogenesis requires an ample blood supply, we postulated that a restricted vascular supply might be correlated with restricted regenerative ability at proximal levels. More than 40 rats and mice were injected with ink or resin to visualize vascular supplies of intact, regenerating, and nonregenerating rat and mouse digits. Ink-injected specimens were viewed as histological sections or cleared whole mounts. Partially digested resin casts were viewed using scanning electron microscopy. Contrary to our hypothesis, prior to amputation, proximal sites are more vascular than distal sites. At both proximal and distal levels, endosteal and periosteal vascular systems are evident. However, in proximal phalanges, additional subcutaneous and dermal layers encircle the bone. Beneath the distal nail, these layers are absent, and a single layer of vessels provides both periosteal and cutaneous supplies. After amputation at both levels, new vessels sprout profusely in osteogenic areas of both endosteum and periosteum. However, at proximal levels, the additional hypodermal and dermal vessels contribute to a vascular plexus that, paradoxically, may impair bone regrowth by contributing to the formation of dermal scar rather than bone.

Acrylic Resins↗
PubMed1994

Epidemiology of leg amputation: the influence of vascular surgery.

The number of amputations performed for vascular disease in Denmark has decreased from 1777 (34.5 per 100,000 population) in 1983 to 1288 (25.0 per 100,000) in 1990, a reduction of 28 per cent. This decline coincided with an increase in vascular surgical activity of up to 100 per cent, including a marked rise in the rate of femorodistal reconstruction. Moreover, regional variation in vascular surgical activity correlated with percentage reduction in amputation rate (rS = 0.65, P < 0.01). The relative number of above-knee amputations also decreased in favour of more distal levels during the period studied. These findings suggest that vascular surgery may be responsible for the lower amputation rate.

Amputation, Surgical↗
PubMed2005

Prevention and treatment of amputation neuroma by an atelocollagen tube in rat sciatic nerves.

To evaluate the potential of the atelocollagen tube as a cap for amputation neuromas, the histological and histochemical characteristics of the neuroma and spinal cord were compared with those following silicone capping. Four weeks after the transection of 18 rat sciatic nerves, the amputated neuroma was resected, and the nerve stump inserted into an atelocollagen or silicone tube. The histological changes in the nerve ends and c-fos expression in the dorsal horn of the fourth lumbar spinal cord were evaluated at 4 weeks postoperatively. The regenerated nerve structure in the atelocollagen or silicone tube was very thin. In contrast, a typical bulbous neuroma was observed in the control group (the nerve stump was left in place). The atelocollagen and silicone tube groups demonstrated fewer c-fos-expressed cells in the spinal cord than the controls. These results suggest that capping by an atelocollagen tube, like that by a silicone tube, might successfully prevent an amputated neuroma from forming, and suppress induced pain. The atelocollagen tube may be a promising biomaterial for the prevention or treatment of a painful amputation neuroma.

Amputation, Surgical↗
PubMed1977

Tail regeneration in the plethodontid salamander, Plethodon cinereus: induced autotomy versus surgical amputation.

Regeneration of the tail in the plethodontid salamander, Plethodon cinereus, occurs following either surgical amputation or induced autotomy. Autotomy may occur along any one of the caudal myosepta which form natural cleavage planes. The distally attached myofibers break away from the myoseptum which then becomes part of the stump surface remaining intact during subsequent regeneration of the distal segments. Under these conditions, therefore, muscle fibers do not normally participate in tail regeneration. If, however, the myofibers of a caudal myotome are interrupted as in mid-segment amputation, the damaged fibers undergo hyaline degeneration and are largely replaced by connective tissue often as far proximally as the next myoseptum. Other tissues at the amputation surface are concurrently engaged in the epimorphic regeneration of the tail, including myogenesis, though at a slower initial rate than that following autotomy. Muscle cells, therefore, appear not to participate in epimorphic tail regeneration in Plethodon cinereus following either surgical amputation or induced autotomy.

Amputation, Surgical↗
PubMed2006

Major extremity amputation for nodal metastasis from squamous cell carcinoma.

The regional lymph node basin is usually the first site of spread in cutaneous squamous cell carcinoma (SCC). Regional metastases are usually treated with comprehensive nodal dissection, sometimes followed by radiation and/or chemotherapy. Occasionally, when disease recurs after these conventional therapies, major extremity amputation may be the only way to render patients free of disease. We present three cases for which major extremity amputation was necessary. One patient underwent forequarter amputation for nodal metastasis, which had invaded the brachial plexus. Another patient underwent hip disarticulation for femoral bony invasion from inguinal nodal metastasis. The third patient underwent a hemipelvectomy for nodal metastasis, which had eroded the femoral artery and pelvic bone. These cases show that major extremity amputation can be both palliative and curative in patients with SCC.

Aged↗
PubMed1991

Major amputations done with palliative intent in the treatment of local bony complications associated with advanced cancer.

Palliative amputations were performed on 11 patients (7 men, 4 women) with disseminated disease to control local bony complications. The average patient age was 54 years (range 14-78 years). The primary diseases were melanoma/sarcoma (seven patients) and carcinoma (four patients). All had pain; eight had intractable pain that could not be controlled by analgesics. All 11 patients had additional severe local complications, which included recurrent pathological fracture (4), sepsis (2), hemorrhage (2), radiation necrosis (2), and iliofemoral thrombosis secondary to tumor (1). Previous attempts of palliation had been made in all 11 patients, and 8 had undergone previous operative procedures (5 had undergone two or more) prior to amputation. Three anterior hemipelvectomies, five posterior hemipelvectomies, two hip disarticulations, and one forequarter amputation were performed. All patients survived the surgery, and there were no intraoperative complications. All patients received dramatic relief of pain. Postoperative complications included two cases of flap necrosis and two infections; all resolved satisfactorily. The six patients who were nonambulatory before surgery ambulated postoperatively, and two eventually ambulated with a prosthesis. Six of 11 patients survived 1 year or longer, with a median postoperative survival period of 13 months (average 16 months). Although major amputations are viewed at times as offering little to already-compromised patients, they can improve dramatically the quality of life in selected patients.

Adolescent↗