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PubMed2006

Homodigital antegrade-flow neurovascular pedicle flaps for sensate reconstruction of fingertip amputation injuries.

Fingertip amputations through the distal 50% of the nail matrix usually create a finger that is best served by maintaining length. When the amputation is more proximal than this, revision with ablation of the small residual nail unit may provide greater overall patient satisfaction. When amputations in the distal 50% of the nail matrix are transverse or short oblique in orientation, a flap of some kind is needed to restore the contact surface of the pulp. Many alternative reconstructive strategies are possible but have inherent limitations that detract from the quality of the final result. Inadequate padding, lack of sensibility, excessive tension, hook nail deformity, poor durability, and donor site morbidity are but some of the considerations. Although not a panacea for all distal fingertip amputations, the antegrade-flow homodigital neurovascular pedicle flap offers a good ratio of advantages to disadvantages. As with all flaps, knowledge and execution of the details largely determine the outcome.

Amputation, Traumatic↗
PubMed2004

Major palliative amputations.

The role of major amputations in the palliative care of cancer patients remains controversial. Major amputations result in loss of function, frequently require prolonged recovery, and are associated with major morbidity or mortality. Therefore, it may seem that major amputations should be rarely recommended for the palliation of cancer patients. Hence, we attempt to establish the indications,management, and outcomes of major amputations in the palliative management of cancer patients.

Amputation, Surgical↗
PubMed1998

Cardiovascular disease in patients with dysvascular amputation.

Cardiovascular diseases are the most common causes of morbidity and mortality in individuals with peripheral vascular disease (PVD). Among patients who have undergone lower extremity amputation as a result of PVD, the prevalence of concomitant cardiovascular disease may be as high as 75%. Comorbid heart disease may complicate the postamputation course of recovery, delay initiation of rehabilitation training, and inhibit the achievement of maximal functional independence. A variety of methods have been used to assess cardiac status and risk in amputation patients undergoing physical training; these have included clinical evaluation, resting electrocardiography, and continuous dynamic electrocardiography during either standard physical therapy exercise or adapted ergometry. Several conditioning training programs have been developed to improve the cardiovascular fitness of patients with dysvascular amputation, the results of which have been favorable. These assessment and intervention strategies have extensive applicability in the clinical management of patients with dysvascular amputation.

Amputation, Traumatic↗
PubMed1999

Enabling factors related to prosthetic use by people with transtibial and transfemoral amputation.

OBJECTIVE: To evaluate the frequency and extent of prosthetic use by people with lower limb amputation and identify factors that facilitate prosthetic use. DESIGN AND SETTING: Five-year follow-up survey using the Prosthetic Profile of the Amputee (PPA) questionnaire and Dillman's mailing strategy. SUBJECTS: Adults with unilateral transtibial and transfemoral amputation (n = 396) who had completed a prosthetic training program. MAIN OUTCOME MEASURES: Frequency of prosthetic wear, in hours per week, and active prosthetic use for locomotion indoors and outdoors. RESULTS: Eighty-five percent of the respondents (mean age 62.9+/-15.9yrs) were prosthetic wearers; 53% used their prosthesis for locomotion indoors, and 64% outdoors. Ability to don the prosthesis (p < .001), locomotor capabilities with the prosthesis (p < .001), walking distances (p < .001), automaticity of gait (p < .05), and assistive devices used (p < .001) were the main factors related to the three outcome measures. People with transfemoral amputation reported greater difficulties in donning their prosthesis (p < .01) and a significantly higher rate of falls (p < .001). CONCLUSION: The majority of people with lower limb amputation wear their prosthesis daily. With the exception of resources (prosthetic laboratory and means of transportation), all enabling factors investigated were significantly associated with the outcome measures.

Amputation, Surgical↗
PubMed2005

Negative pressure wound therapy after partial diabetic foot amputation: a multicentre, randomised controlled trial.

BACKGROUND: Diabetic foot wounds, particularly those secondary to amputation, are very complex and difficult to treat. We investigated whether negative pressure wound therapy (NPWT) improves the proportion and rate of wound healing after partial foot amputation in patients with diabetes. METHODS: We enrolled 162 patients into a 16-week, 18-centre, randomised clinical trial in the USA. Inclusion criteria consisted of partial foot amputation wounds up to the transmetatarsal level and evidence of adequate perfusion. Patients who were randomly assigned to NPWT (n=77) received treatment with dressing changes every 48 h. Control patients (n=85) received standard moist wound care according to consensus guidelines. NPWT was delivered through the Vacuum Assisted Closure (VAC) Therapy System. Wounds were treated until healing or completion of the 112-day period of active treatment. Analysis was by intention to treat. This study has been registered with , number NCT00224796. FINDINGS: More patients healed in the NPWT group than in the control group (43 [56%] vs 33 [39%], p=0.040). The rate of wound healing, based on the time to complete closure, was faster in the NPWT group than in controls (p=0.005). The rate of granulation tissue formation, based on the time to 76-100% formation in the wound bed, was faster in the NPWT group than in controls (p=0.002). The frequency and severity of adverse events (of which the most common was wound infection) were similar in both treatment groups. INTERPRETATION: NPWT delivered by the VAC Therapy System seems to be a safe and effective treatment for complex diabetic foot wounds, and could lead to a higher proportion of healed wounds, faster healing rates, and potentially fewer re-amputations than standard care.

Air Pressure↗
PubMed1979

Preoperative haemoglobin as predictor of outcome of diabetic amputations.

Simple factors which may serve as predictors of the success or failure of amputations in the feet were examined in 59 consecutive diabetics. Age, sex, method of diabetic control, smoling, presence of neuropathy or peripheral pulses, preoperative blood-urea, and temperature did not correlate with success of amuptations. The average preoperative white-cell count and blood-sugar were higher in the failure group (p less than 0.01 and p less than 0.05 respectively), but there was considerable overlap between the groups. By contrast, the preoperative haemoglobin level was significantly lower (p less than 0.001) in patients whose amputations healed than in those with failure of healing, both at the digital and metatarsal or transmetatarsal levels; also, there was very little overlap in haemoglobin levels between the success and failure groups. All 18 amputations done in patients with a preoperative haemoglobin less than 12.0 g/dl were successful, whilst all 30 amputations in those with a preoperative level greater than 13.0 g/dl failed.

Aged↗
PubMed1998

Peripheral neuropathy, hypertension, foot ulcers and amputations among Saudi Arabian patients with type 2 diabetes.

Three hundred and seventy-five Saudi Arabian patients with type 2 diabetes were consecutively examined for peripheral neuropathy, foot ulcers, amputations and hypertension. All the 46-69-year-old patients (n = 212) were compared to a corresponding Swedish group seen by the same physician using identical approach and definitions. Vibration sensitivity was examined using a tuning fork. Pin prick sensitivity using a needle on the plantar and dorsal aspects of the foot. Distal neuropathy was defined as complete absence of vibration and/or pin prick sensitivity in an extremity. With a diabetes duration of 10 or more years the prevalence of neuropathy among the 375 Saudi Arabians was 38% (95% confidence intervals 30-45); hypertension 19% (13-25) current and past ulcers 4.7% (1.3-8); amputations below ankle 3.4% (0.5-6). In the selected 46-69-year-old group prevalence of hypertension (17%), ulcers (2.3%) and amputation (1%) was significantly lower in the Saudi Arabian than in the Swedish patients. The frequencies reported here are the first from the Arab Peninsula. The Saudi Arabian patients with type 2 diabetes have the same prevalence of distal neuropathy as other ethnic groups. A low prevalence of hypertension is consistent with findings in expatriate and indigenous Arab groups with type 2 diabetes. The low occurrence of ulcers and amputations may be explained by different styles of footwear.

Aged↗
PubMed1996

Canine osteosarcoma: amputation and chemoimmunotherapy.

Canine osteosarcoma is a highly metastatic cancer commonly seen in large breed dogs. At the time of diagnosis, approximately 90% to 95% of the dogs have established micrometastases. Dogs undergoing amputation alone have a median survival time of 3 to 4 months. Amputation followed by cisplatin chemotherapy increases median survival times to 9 to 11 months. When dogs are treated with amputation and cisplatin, followed by immunotherapy (with liposome-encapsulated muramyl tripeptide phosphatidylethanolamine), median survival times increase to 14.4 months, the longest reported median survival time for dogs with osteosarcoma treated by amputation and any form of adjuvant therapy.

Acetylmuramyl-Alanyl-Isoglutamine↗
PubMed2000

Changes of cortical excitability in patients with upper limb amputation.

In our study we wanted to assess motor excitability in patients with upper limb amputation by means of transcranial magnetic stimulation (TMS). In 12 patients, TMS was applied using a paired pulse paradigm in order to test cortico-cortical excitability. Additional parameters of motor excitability like motor threshold and cortical silent period were also measured. Recordings from the amputated side were compared to the contralateral side and to healthy controls. We found a significant reduction of intracortical inhibition in forearm amputees and an enhancement of intracortical facilitation in upper arm amputees on the affected side. We conclude that after upper limb amputation, changes in the activity of intracortical interneuronal circuits appear in the affected hemisphere. These changes may depend on the level of amputation, and be the base of cortical reorganization.

Adult↗
PubMed1999

Abnormal motor cortex organization contralateral to early upper limb amputation in humans.

We performed both a functional magnetic resonance imaging (fMRI) study using single slice FLASH technique and an investigation with transcranial magnetic stimulation (TMS) in a 21-year-old patient. He had suffered a left upper extremity amputation at age 7. Anteflexion of the amputation stump produced an unusual, broad activation contralateral to the movement. TMS revealed an enlarged cortical motor output area of the deltoid muscle at the amputation stump. Application of paired magnetic stimulation demonstrated decreased intracortical inhibition (ICI). A T1-weighted image indicated a lack of the characteristic shape of the central sulcus contralateral to the amputation. In addition to previous functional studies, these new structural data suggest that maturation of the central sulcus develops in response to daily practice of the contralateral hand, possibly until adolescence.

Adult↗
PubMed1999

Diabetic neuropathic pain in a leg amputated 44 years previously.

The mechanism of neuropathic pain in the diabetic limb is far from clear. Phantom limb pain likewise is of obscure aetiology. The development of typical pain in an absent leg in a patient with diabetes many years after the amputation stimulates thought as to the mechanism, not only of neuropathic pain, but also of phantom limb pain. A 58-year-old man was diagnosed with type 2 diabetes 44 years after having undergone left below knee amputation for congenital AV malformation, at the age of 13. Eight months before the diagnosis of diabetes he began to complain of pain in the leg on the amputated side-pain very similar to that described in typical diabetic neuropathy. This was followed by similar pain in the right leg. MR scan of the spine revealed a small syringohydromyelia of the thoracic cord in addition to a prolapse of disc at L(5)/S(1) level on the left side, which was first noted 5 years previously. There were no other features of S(1) compression. The typical neuropathic character of the pain involving both the amputated and the intact limbs that developed with the diagnosis of type 2 diabetes suggest that the neuropathic pain may originate from centres higher than peripheral nerves.

Amputation, Surgical↗
PubMed1984

Primary microsurgical repair of ring avulsion amputation injuries.

Patients with ring avulsion injuries of the fourth and fifth digits often demand attempts at reconstruction rather than completion of the amputation. In the past, this has led to reconstruction involving a staged series of operations with results that were often less than desirable. Seven patients with ring avulsion amputation injuries that were reconstructed by use of microsurgical reanastomoses are reported. All were classified as either Carroll type IV or Urbaniak type III. Six patients (85%) had a successful replantation leading to a useful finger. The operating time averaged 5.5 hours. On average, 1.9 arteries (range 1 to 2) and 3.3 veins (range 2 to 5) were repaired for each digit. Average hospital stay was 6.7 days (range 4 to 15). Average range of motion was 0(2)/84(2) for metacarpophalangeal joint and 15(2)/90(2) for proximal interphalangeal joint (PIP) with distal interphalangeal joint ankylosis at between 0(2) and 15(2) of flexion. Sensibility was protective in all cases and good in three. If the PIP joint was damaged, completion of amputation was the treatment of choice. If the amputation is distal to the PIP with a functional superficialis tendon, primary microsurgical repair is the treatment of choice in complex ring avulsion injuries.

Adult↗
PubMed1999

Prediction of imminent amputation in patients with non-reconstructible leg ischemia by means of microcirculatory investigations.

PURPOSE: We investigated the usefulness of skin microcirculatory investigations to predict imminent major amputation in patients with non-reconstructible critical limb ischemia. METHODS: One hundred eleven patients with non-reconstructible chronic rest pain or small ulcers and an ankle blood pressure of 50 mm Hg or less or an ankle-to-brachial pressure index of 0.35 or less were included. Nailfold capillary microscopy (CM; big toe, sitting), transcutaneous oxygen pressure (TcpO2; forefoot, supine; 44 degrees C), and laser Doppler perfusion measurements (LD; pulp of big toe, supine) were performed at rest and during reactive hyperemia. Patients were classified according to their skin microcirculatory status just before the start of the treatment in three groups: those with a "good," "intermediate," or "poor" microcirculation, according to a combination of predefined cutoff values (Poor: capillary density less than 20/mm2, absent reactive hyperemia in CM and LD, TcpO2 less than 10 mm Hg; good: capillary density of 20/mm2 or more, present reactive hyperemia in CM and LD, TcpO 2 of 30 mm Hg or more). Subsequently, patients received maximum conservative therapy from the surgeon, who was unaware of the microcirculatory results. After a follow-up period of as long as 36 months, limb survival and disposing factors were analyzed and compared with the initial microcirculatory status. RESULTS: Cox regression analysis showed a significant prognostic value of the microcirculatory classification (hazard ratio = 0.28, P <.0001), but not of the Fontaine stage, ankle blood pressure, or the presence of diabetes mellitus for the occurrence of an amputation. Positive and negative predictive values were 73% and 67%, respectively. The cumulative limb survival at 6 and 12 months was 42% and 17% in the poor microcirculatory group, 80% and 63% in the intermediate microcirculatory group, and 88% and 88% in the good microcirculatory group ( P <.0001, log-rank). CONCLUSION: Microcirculatory screening and classification is useful in detecting non-reconstructible critical ischemia that requires amputation, which is not detectable by means of the clinical stage or blood pressure parameters. Most of the poor patient group will require amputation. In the intermediate and good groups, nonsurgical treatment appears sufficient for limb salvage.

Aged↗
PubMed1996

Amputation and prosthesis.

Amputation of a limb is a drastic therapy in cattle and should be considered as a last resort in the treatment of limb injuries. Even though the surgical technique for amputation is simple, daily limb management, prosthesis manufacture, and adaptation of the animal to the prosthesis are difficult and time consuming. Dedication of the owner to the aftercare required for the rest of the animal's life is extremely important. Amputation of a limb with prosthesis application is a method of saving valuable animals for breeding purposes or animals of sentimental value. The author reviews his experience with partial foreleg amputation and prosthesis application in three heifers.

Amputation, Surgical↗
PubMed1990

[Cross-forearm replantation in bilateral amputation].

We report the case of a 27-year-old patient who sustained a traumatic amputation of his 4 limbs. For the right upper limb, the site of amputation was at the level of the upper third of the forearm. For the left upper limb, the site of amputation was at the level of the Cower third of the forearm. In both cases, the loss of soft tissue was so extensive that hand replantation was impossible in the initial position. In such an unusual case, replantation of the right hand to the left side was attempted in this young patient. Osteosynthesis of the radius to the ulna in supination was performed, and arteries, veins, nerves and tendons were repaired. The other segments of amputated limbs were debrided and cleaned. Within a year, protective sensibility was restored in the replanted hand, but intrinsic muscles were paralysed. Secondarily, transfer of thumb opposition and capsulorrhaphy at the level of the metacarpophalangeal joints of long fingers were performed in order to provide a useful key-grip between the three first fingers.

Adult↗
PubMed2003

Amputation considerations and energy expenditures in the diabetic patient.

Amputations are not procedures of choice but are often necessary and valuable tools for returning a patient to a more active lifestyle. Because of the comorbidities associated with diabetes, this is an important consideration. A return to a more active existence can reduce the effect of vascular disease, hyperglycemic states, and functional limitations. It is an interesting and not uncommon occurrence for the chronic wound patient, when offered an amputation, to have the procedure because the frequency of needed medical care has stripped him of his independence. The frequency of wound care in the nonhealing wound and its personal demands can be compared with the demands placed on the dialysis patient. The greatest obstacle for the uninitiated surgeon is a sense of hesitancy: Am I moving too fast to amputation as an answer? The ability to make this decision comes with experience and with prioritizing the patient's needs. Life-threatening infections and avascular extremities that are not bypassable are the easier decisions to make, as there is little choice at that point. In deciding whether to amputate, the wise surgeon will take into consideration the medical and mobility needs of each patient and determine level and timing based on understanding of the whole person.

Amputation, Surgical↗
PubMed1993

Quality of life following lower limb amputation for peripheral arterial disease.

Lower limb amputations for peripheral arterial disease are performed predominantly on an elderly population with poor social support and concomitant medical problems. The effect of amputations on the quality of life of this population has not been properly assessed. The quality of life of 149 amputees from one hospital was evaluated using the Nottingham Health Profile and compared to that of a control group matched for age and sex. One hundred and thirty (87%) amputees and 115 (77%) controls responded to the questionnaire. Amputees reported significantly more problems with mobility, social isolation, lethargy, pain, sleep and emotional disturbance than controls (p < 0.001). However, mobility was the only significant independent factor after matched logistic regression analysis (p < 0.001). The differences in social isolation and emotional distress lost their significance after adjustment for mobility. The overall quality of life following lower limb amputation for peripheral arterial disease is poor, but much of this is secondary to restricted mobility. Rehabilitation following amputation should therefore focus on attempts to improve mobility.

Activities of Daily Living↗
PubMed1997

Measuring quality and cost of care: evaluation of an amputation clinical pathway.

This study was based on nursing literature supporting the use of clinical pathways in case management systems to improve quality, reduce cost, and increase efficiency. Its purpose was to provide a descriptive analysis of outcomes in lower-extremity amputation caused by arterial occlusive disease. Patients were admitted between Jan. 1, 1989, and Sept. 1, 1995, with arterial occlusive disease for an above- or below-knee amputation and were cared for in three consecutive phases of nursing case management: (1) without a clinical pathway (group I), (2) with a consultation to rehabilitation services in the postoperative stay (group II), and (3) with a rehabilitation-focused clinical pathway (group III). The results of the study indicated more patients were able to return home from acute care and rehabilitation (52%) in group III than in group I and group II (40% and 44%, respectively). In addition, the hospital length of stay was reduced from 11 days to 8 days (geometric mean) once a rehabilitation consultation was included in the plan of care (group II). Although hospital charges rose initially with rehabilitation consultation ($18,627), they were reduced significantly when the pathway was used ($12,629; adjusted for rate increases). When patients were separated by level of amputation, those with below-knee amputations in group III had a significantly shorter length of stay and lower hospital charges than those in the other two groups, but comorbidity remained high. Nurse case managers can use this clinical pathway as a model for care as the findings support its cost effectiveness. They also demonstrate its effectiveness in enhancing the of quality care through a rehabilitation-focused, goal-oriented plan to return patients home.

Amputation, Surgical↗