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PubMed1977

Transmedullary amputation and resection of metastases in combined therapy of osteosarcoma.

The eradication of microfoci of metastatic osteosarcoma by adjuvant chemotherapy permits the surgeon to take a more conservative approach to amputation and to more aggressively resect metastases. In a series of 59 children with osteosarcoma of an extremity, transmedullary amputation carried no greater risk of stump recurrence than either disarticulation or amputation above the joint. We attribute this to careful selection of the level of amputation by use of preoperative bone scans, intraoperative frozen sections of bone stump and intensive postoperative adjuvant chemotherapy. Immediate application of a prosthetic limb has enhanced the physical and emotional rehabilitation of these patients. Resections of pulmonary metastases in 12 patients who were receiving adjuvant chemotherapy has resulted in a median tumor-free survival of 17 mo, with 3 patients still alive without disease for 13, 25, and 72 mo. A more aggressive approach to the resection of pulmonary metastases may substantially improve current rates of tumor-free survival.

Adolescent↗
PubMed1984

V.A. Cooperative Study on antiplatelet agents in diabetic patients after amputation for gangrene: I. Design, methods, and baseline characteristics.

This report describes the experimental design, methods, and baseline characteristics of patients enrolled in a Veterans Administration Cooperative Study on the effect of aspirin (325 mg t.i.d.) and dipyridamole (75 mg t.i.d.) (110 patients), or placebo (121 patients) on major vascular outcome variables in noninsulin-dependent diabetic patients with either a recent amputation for gangrene (n = 207) or active gangrene (n = 24). It also describes the baseline characteristics of the patients. A total of 231 patients of 563 screened (41%) were enrolled at 11 participating V.A. Medical Centers during a 39 month period. The median age at entry was 60 years, the median duration of diabetes was 10 years, and weight was 110% of desirable. All patients were men. Sixty-eight percent were treated with insulin and 32% with diet alone. Only 42% were smokers at entry, 40% had retinopathy, 61% sensory neuropathy, 42% hypertension, and 29% had a history of myocardial infarction, angina, and/or congestive heart failure. Thirteen percent had a history of cerebrovascular disease. Despite randomization, the treatment group had an increased frequency of a history of cerebrovascular disease (p = 0.01), diagnosed as stroke (p = 0.03), a finding suggesting that the treatment group was at a slightly increased risk for vascular disease upon enrollment in the study. Other baseline variables did not differ significantly between the two groups. This study should provide definitive data on the efficacy of these doses of antiplatelet agents in preventing further vascular disease in diabetic men with gangrene or recent amputation for gangrene, using death due to vascular disease and subsequent amputation of the opposite extremity for gangrene as major outcome variables. It should also give useful information on the effect of antiplatelet therapy on vascular outcome variables such as same side amputations, myocardial infarction, stroke, transient ischemic attack, retinopathy, and renal failure. Finally, the study should provide useful data on the natural history and significance of risk factors in this patient population.

Amputation, Surgical↗
PubMed1984

The need for replantation surgery after traumatic amputations of the upper extremity--an estimate based upon the epidemiology of Sweden.

Reports in the literature give different views of the frequency of serious amputation injuries of the upper extremity. In Sweden the vast majority of work injuries are registered by the Swedish Labour Market Insurance. All registered serious amputation injuries of the upper extremity in Sweden (8 million inhabitants) during 1979 were investigated in this study. For comparison the frequency of all amputation injuries (work and leisure) of the upper extremity in a county of Sweden (0.4 million inhabitants) during five years (1976-1980) were studied. The overall (work and leisure) incidence in Sweden is fourteen serious amputation injuries of the upper extremity per million inhabitants annually, i.e. a total number in the country of 110 cases per year. The frequency is lower in the areas of the largest cities and substantially higher in regions with sawmills, mechanical industry and/or agriculture. Thus, estimation of the total incidence based upon single counties or smaller regions may be misleading. Replantation would have been technically possible in more than 70% of the cases, but attempts at replantation were only carried out in less than 10% of the serious cases. This study emphasizes the importance of a referral of all patients with a suitable injury of the upper extremity to microsurgically trained handsurgeons.

Accidents, Occupational↗
PubMed1983

Phantom limb, phantom pain and stump pain in amputees during the first 6 months following limb amputation.

The incidence and clinical picture of non-painful and painful phantom limb sensations as well as stump pain was studied in 58 patients 8 days and 6 months after limb amputation. The incidence of non-painful phantom limb, phantom pain and stump pain 8 days after surgery was 84, 72 and 57%, respectively. Six months after amputation the corresponding figures were 90, 67 and 22%, respectively. Kinaesthetic sensations (feeling of length, volume or other spatial sensation of the affected limb) were present in 85% of the patients with phantom limb both immediately after surgery and 6 months later. However, 30% noticed a clear shortening of the phantom during the follow-up period; this was usually among patients with no phantom pain. Phantom pain was significantly more frequent in patients with pain in the limb the day before amputation than in those without preoperative limb pain. Of the 67% having some phantom pain at the latest interview 50% reported that pains were decreasing. Four patients (8%), however, reported that phantom pains were worse 6 months after amputation than originally. During the follow-up period the localization of phantom pains shifted from a proximal and distal distribution to a more distal localization. While knifelike, sticking phantom pains were most common immediately after surgery, squeezing or burning types of phantom pain were usually reported later in the course. Possible mechanisms for the present findings either in periphery, spinal cord or in the brain are discussed.

Aged↗
PubMed1991

Phantom-related phenomena after rectal amputation: prevalence and clinical characteristics.

Phantom sensations are well known and almost inevitable sequels to limb amputation, whereas similar phenomena are only rarely described after rectum amputation (phantom rectum). Our study attempted to assess the frequency and character of phantom rectum. All surviving patients (n = 22), who had undergone abdominoperineal surgical resection of the rectum in the period 1980-1986 at our clinic, were interviewed by a standard questionnaire and underwent a physical examination. Sixty-eight per cent of the patients experienced a sensation of a missing rectum (phantom rectum), and in 27% of these or 18% of all patients this sensation was painful (phantom pain). The most common symptoms were sensations of flatus and/or faeces in a normal rectum, phantom flatus or phantom faeces. The phantom pains were described as either pricking and shooting or like haemorrhoids or hard stools that would rupture the rectum. Neither age, sex, preoperative pain, the Duke classification of the tumour nor the healing of the perineal wound seemed related to the likelihood of phantom rectum. The pathophysiological mechanisms underlying phantom-related phenomena following amputation have not yet been elucidated. This study describes a relatively unknown phantom-related clinical entity after amputation and may thus contribute to the understanding of this phenomenon.

Aged↗
PubMed1990

Rehabilitation of burn patients with concomitant limb amputation: case reports.

Burn patients with associated limb amputations present demanding rehabilitation problems, many of which might be expected to lead to chronic difficulties. Therapeutic goals following limb amputation include oedema reduction, prevention of contracture (through positioning and range of motion), stump shaping, both pre- and post-prosthetic fitting strengthening exercises of the limb and trunk, and gait training. Some patients present problems that are associated with both the burn injury and the limb amputation that cause concern among the physical therapy staff. Some of these situations include intolerance of the stump to pressure or manipulation due to remaining open wounds or fragility of newly skin grafted areas on the residual limb or delayed gait or functional training due to wounds on other body surface areas. Delays in stump preparation or other treatment aims due to continued surgical procedures can be worrisome. A review of these patients indicates the possible difficulties that rehabilitation personnel may face when treating burn victims who required amputation. Effective rehabilitation of these patients can be achieved despite the noted concerns.

Adult↗
PubMed1990

Rehabilitation of burned patients with bilateral above-knee amputations.

Bilateral above the knee amputations occur rarely in the seriously burned population. In a 6-month interval, two patients were treated in our Burn Center whose trauma necessitated bilateral above-knee amputations. This led us to review our experience with such cases. A review of 5018 patients treated over a 28-year period identified six patients over a 20-year period who had bilateral above-knee amputations, four of whom survived. These patients were found to have large and deep burns, concomitant injuries and a number of complications. Recovery was time consuming and costly. Physical therapists were challenged to create adaptations of traditional methods to meet the rehabilitation needs of these patients. The patients who survived remain wheelchair bound and unemployed, but are socially active, appear relatively well adjusted and report themselves satisfied with their lives. During a period of time when technological advances in medicine are ensuring survival of victims of massive trauma, questions are raised concerning the advisability of resuscitation. Knowledge gained in the treatment of these patients who are both burned and have had bilateral above-knee amputations can be reassuring to care providers with limited experience with such massive injury.

Adult↗
PubMed1995

Outcome of amputations in patients with major burns.

There is little mention in the literature of the outcome of patients who require amputations for large surface area burns. To determine their outcome, we devised a case-control study. Fifteen patients who underwent amputations between 1984 and 1993 at the University of Louisville Burn Unit were analysed and compared to a similarly injured control group. Both groups represented severely burned patients with high total body surface areas involvement. Apache II scores, and per cent of inhalation injuries. The results showed a 60 per cent survival rate in each group. Unlike previous reports on electrical burns, the amputations in this series of primarily thermal injuries (12 of 15 patients) were performed late in the hospital course (mean, 15 days) and after previous attempts at limb salvage (mean, two procedures). By eliminating either non-viable or infected tissue, amputations served a role in obtaining a respectable survival rate for these severely injured patients that also compared favourably with the control group.

APACHE↗
PubMed1994

Functional outcome following traumatic upper limb amputation and prosthetic limb fitting.

Nineteen consecutive patients underwent traumatic upper limb amputation for nonreconstructible or replantible upper limb injury at a Level I trauma center over a 9-year-period. Eleven amputations were at the transradial level, five were transhumeral, and three were shoulder disarticulation. Eighteen patients underwent prosthetic limb fitting. Fifteen of the 18 initially underwent preparatory prosthetic limb fitting within 30 days following amputation with a body-powered, cable-driven prosthesis. Seventeen of the 18 achieved sufficient proficiency with their prostheses to allow them to return to work. Of these, 15 maintained daily functional prosthetic use of at least 8 hours daily at a followup examination of 12 to 110 months. Use of prosthetic limb following traumatic upper limb amputation carries a high probability for functional rehabilitation if limb fitting and prosthetic training are instituted as soon as the residual limb can tolerate the prosthetic socket as opposed to waiting for the residual limb to "mature".

Adolescent↗
PubMed1996

Phantom limb pain and etiology of amputation in unilateral lower extremity amputees.

The relationships between phantom limb pain and both the etiology of amputation (blood clots, nonclot diabetes, and miscellaneous) and the occurrence of gangrene and/or infection were investigated in 92 unilateral lower extremity (LE) amputees who were seen sequentially. There were 55 above-knee (AK) and 37 below-knee (BK) amputations in 61 men and 31 women. The mean age was 51.4 years. The blood-clot etiology had the highest levels of phantom pain both pre- and postrehabilitation, the longest time interval between amputation and prosthetic fitting, and the greatest number of medical conditions. The nonclot diabetes and miscellaneous etiologies followed in order. A history of gangrene and/or infection was associated with higher levels of pain and longer time interval between amputation and prosthetic fitting.

Adolescent↗
PubMed2004

Primary use of the index finger for reconstruction of amputated thumbs.

Seven cases of primary reconstruction of traumatic amputation of the thumb using the index finger are reported. In six cases, the reconstruction was done using an injured index finger, while in one case where the amputation of the thumb was through the carpometacarpal joint, an intact index finger was primarily pollicised. This reduces cost of treatment, hospitalisation period and allows earlier rehabilitation without a period of a 'no thumb experience'. We have followed all the patients for a minimum period of 2 years and all of them have excellent functional results. We believe that pollicisation of a normal index finger, if thumb amputation is through the carpometacarpal joint or an injured index finger at the time of initial management of a severely traumatised hand with thumb amputation is an excellent technique for thumb reconstruction.

Accidents, Occupational↗
PubMed2005

When is a more proximal amputation needed?

Amputation may be the most appropriate therapy for an ischemic or infected limb, but the level at which to amputate is often difficult to determine. Selecting the appropriate level is crucial when performing an amputation. The goals of surgery are to maintain maximal limb length and ensure successful healing. When more of the foot and limb can be preserved, the chances for rehabilitation are improved. This article reviews how to determine the most appropriate level of amputation.

Amputation, Surgical↗
PubMed2005

Tendon balancing in pedal amputations.

Pedal amputations are necessary procedures performed by a foot and ankle surgeon that may lead to gross positional deformities of the foot. To achieve a plantigrade foot, proper balancing of the foot is required often through the use of tendon transfers and lengthening. This article describes the basic tendon transfers needed to achieve a successful outcome when performing various pedal amputations. A case is presented in which Achilles tendon lengthening was used to heal a forefoot ulcer. A full understanding of tendon function and transfer techniques is paramount for surgeons performing pedal amputations. By rebalancing the foot, patients are able to ambulate with custom shoes or bracing, and more proximal amputations, which can be physically and psychologically devastating, are prevented.

Amputation, Surgical↗
PubMed2005

Lisfranc and Chopart amputations.

The issue of choosing an amputation level can be difficult for physicians. Every attempt should be made to maintain as much pedal length as possible to increase biomechanical function and ambulatory power. When there is excessive soft tissue loss because of trauma, infection, or vascular compromise, a Lisfranc amputation should be considered as a limb-salvage procedure. A more proximal midfoot amputation than Lisfranc is one at Chopart's articulation. This article addresses Lisfranc and Chopart amputations.

Amputation, Surgical↗
PubMed2005

The influence of subintimal angioplasty on level of amputation and limb salvage rates in lower limb critical ischaemia: a 15-year experience.

OBJECTIVES: The aim of this study is to assess the influence of subintimal angioplasty (SIA) on lower limb amputation rate and level in critically ischaemic limbs. METHODS: Between January 1989 and March 2004, 1268 patients were admitted for treatment of lower limb critical ischaemia. Eight hundred and twenty-nine patients underwent revascularisation (bypass 671 and angioplasty 158), while 439 patients had primary amputations. A retrospective analysis of a prospectively maintained vascular registry was performed. Patients were divided into two groups, those who were admitted prior to the availability of subintimal angioplasty and those treated post-introduction of angioplasty. The two groups were compared with regards to age, sex, diabetes mellitus, ASA grade, Rutherford classification and level of disease. Outcome was assessed by the limb salvage rate, 30-day morbidity and mortality, and length of hospital stay. RESULTS: The average number of revascularisation increased with the introduction of subintimal angioplasty, from 53 to 96 per year (p<0.001). The overall limb salvage rate increased significantly from 42 to 70% (p<0.001). The cumulative limb salvage rate following revascularisation rose from 72 to 86% (p<0.001). The level of amputation (AKA:BKA) did not vary significantly. Thirty-day morbidity, mortality and length of hospital stay were significantly lower in the post-angioplasty group. CONCLUSIONS: Technical advances have resulted in a steadying of amputation numbers despite an ageing population.

Aged↗
PubMed2005

Outcome after occlusion of infrainguinal bypasses in the Dutch BOA Study: comparison of amputation rate in venous and prosthetic grafts.

OBJECTIVE: To compare the consequences of occlusion of infrainguinal venous and prosthetic grafts. METHODS: In total, 2690 patients were included in the Dutch BOA study, a multicenter randomised trial that compared the effectiveness of oral anticoagulants with aspirin in the prevention of infrainguinal bypass graft occlusion. Two thousand four hundred and four patients received a femoropopliteal or femorodistal bypass with a venous (64%) or prosthetic (36%) graft. The incidence of occlusion and amputation was calculated according to graft material and the incidence of amputation after occlusion was compared with Cox regression to adjust for differences in prognostic factors. RESULTS: The indication for operation was claudication in 51%, rest pain in 20% and tissue loss in 28% of patients. The mean follow up was 21 months. After venous bypass grafting 171 (15%) femoropopliteal and 96 (24%) femorodistal grafts occluded. After prosthetic bypass grafting 234 (30%) femoropopliteal and 25 (38%) femorodistal grafts occluded. Patients with occlusions in the venous group had more severe ischemia, less runoff vessels and were older than the patients with prosthetic grafts. In the venous occlusion group 54 (20%) amputations were performed compared to 42 (16%) in the prosthetic occlusion group; crude hazard ratio 1.17 (95% CI 0.78-1.75). After adjustment for above mentioned differences in patient characteristics the hazard ratio was 0.86 (95% CI 0.56-1.32). CONCLUSION: The need for amputation after occlusion is not influenced by graft material in infrainguinal bypass surgery.

Aged↗
PubMed2007

Influence of secondary infection on amputation in chronic critical limb ischemia.

OBJECTIVES: To evaluate the influence of secondary infection on major amputation in chronic critical leg ischemia (CLI). DESIGN: Prospective, controlled observational study. MATERIALS AND METHODS: Sixty-seven patients with CLI and ischemic lesions participated in the study. Presence of infection was defined by clinical, laboratory and radiological criteria. Patients were categorized as having no local infection, soft tissue infection or osteomyelitis treated without antibiotics, amoxicillin/clavulanacid for 1 month or ciprofloxacin and clindamycin for 3 months, respectively. Clinical outcome was assessed at 2, 6 and 12 months. Study endpoints were major amputation and mortality. Analyses were performed using the Kaplan-Meier method. RESULTS: Forty-seven of 67 patients had a local infection. Major amputation was lower in patients with successful revascularization as compared to patients unsuitable for or with failed (without) revascularization (0% vs 26%, p<0.01). In patients with successful revascularization the probability of complete healing was lower with secondary infection (23% vs 71%, p=0.03). In patients without revascularization complete healing was rare (<10%), but secondary infection did not influenced major amputation, mortality or serious adverse events. CONCLUSION: Secondary infection reduces the likelihood of successful healing following revascularisation of CLI.

Aged↗
PubMed2005

Nonmicrosurgical replantation using a subcutaneous pocket for salvage of the amputated fingertip.

PURPOSE: The pocket principle suggested by Brent in 1979 is an alternative method for use when microsurgical replantation is not feasible. The application and the amputation level for which the method is available, however, have not been well examined. METHODS: Between 1999 and 2003 we treated 6 patients (7 fingers) by nonmicrosurgical replantation using a subcutaneous pocket (the Brent technique). All patients had sustained complete fingertip amputations across or proximal to the lunula in digits other than the thumb. In every case the amputation was a crush or avulsion-type injury and microsurgical replantation was not feasible; however, cosmetic symmetry was desired strongly by the patient. RESULTS: Of the 7 fingers only one survived completely but became atrophic after 4 months. One finger developed necrosis involving less than half of the replant but a hooked nail deformity developed. Two fingers developed partial necrosis involving more than half of the replant but both fingers were missing the fingernail and the cosmetic results were not acceptable. Three fingers developed total necrosis. In addition a slight flexion contracture not improved with therapy in the digits was noted in 4 patients. CONCLUSIONS: The Brent technique should be performed scrupulously for fingertip amputation across or proximal to the lunula because of the poor survival rate and the possibility of contracture in the digits or other proximal joints.

Adult↗