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PubMed2006

Digital amputation caused by climbing-rope entanglement.

Digital avulsions and amputations are not uncommon in outdoor activities. Rope entanglement is often the cause, though specific descriptions of the mechanism of injury have not been reported. We report a common scenario where entanglement during a fall resulted in an amputation injury. Although any roping activity may cause a loop formation leading to digital entrapment and subsequent amputation injury, activities involving soft and loose ropes may increase the chances of injury. Rope slack is to be avoided to minimize the likelihood of entanglement. This case report describes a digital amputation during an indoor climbing incident and also describes a possible mechanism for such injuries.

Adolescent↗
PubMed1993

Lower-extremity amputation. Incidence, risk factors, and mortality in the Oklahoma Indian Diabetes Study.

Oklahoma Indians with NIDDM (n = 1012) underwent a baseline examination in 1972-1980. The incidence of and risk factors for first lower-extremity amputation were estimated. The mortality rates of amputees using data from 875 patients who had no previous history of amputation and who underwent follow-up examination between 1987 and 1991 are presented. The mean age of the 875 patients was 51.6 +/- 10.8 yr, and the mean duration of diabetes was 6.6 +/- 6.1 yr. After a mean follow-up time of 9.9 +/- 4.3 yr, the incidence rate of first LEA among diabetic Oklahoma Indians was 18.0/1000 person-yr. The incidence rate was two times higher in men than in women. In both sexes, significant risk factors (P < 0.05) were retinopathy and duration of diabetes. Fasting plasma glucose, use of insulin, and systolic blood pressure were significant for men only. For women, plasma cholesterol and diastolic blood pressure were additional risk factors. Compared with the mortality rate of 33.5/1000 person-yr among nonamputees, the rate among amputees was 55.5/1000 person-yr. The 5-yr survival rate after first amputation was 40.4%. For the amputees, the most common causes of death were diabetes (37.3%), cardiovascular disease (29.1%), and renal disease (7.3%). The incidence and mortality rates in diabetic Oklahoma Indians were higher than those reported in Pima Indians and other diabetic populations. To lower the incidence of lower-extremity amputation in this high-risk population, preventive action through education, foot care programs, and early detection of lesions must be intensified.

Adult↗
PubMed1998

Potential economic benefits of lower-extremity amputation prevention strategies in diabetes.

OBJECTIVE: To estimate the potential economic benefits of selected strategies from published literature--educational interventions, multidisciplinary clinics, and insurance coverage for therapeutic shoes--to reduce the incidence of lower-extremity amputation among individuals with diabetes. RESEARCH DESIGN AND METHODS: We developed a model to estimate the expected incidence and associated costs of lower-extremity amputation in a hypothetical cohort of 10,000 people with diabetes. Prevention strategies were assumed to be targeted at individuals with a history of foot ulcer, and benefits were estimated over a period of 3 years. RESULTS: The total potential economic benefits (discounted at 5%) of strategies to reduce amputation risk ranged from $2.0 to $3.0 million ($2,900 to $4,442 per person with a history of foot ulcer) over 3 years. Benefits were highest for educational interventions. Most benefits were found to accrue among individuals aged > or = 70 years. CONCLUSIONS: Strategies to reduce the risk of lower-extremity amputation may generate substantial economic benefits and should be a standard component of routine diabetes care. Benefits may best be achieved through a partnership of government, private payers, health care service providers and producers, and individuals with diabetes.

Age Factors↗
PubMed2005

Reducing amputation rates in patients with diabetes at a military medical center: the limb preservation service model.

OBJECTIVE: To describe and evaluate the Limb Preservation Service (LPS), a multidisciplinary, state-of-the-art, foot care clinic for patients with diabetes at Madigan Army Medical Center (MAMC). Evaluation criteria include the overall incidence of lower-extremity amputation (LEA) and the distribution of the anatomic level of amputation between 1999 and 2003. RESEARCH DESIGN AND METHODS: This is a retrospective study of the incidence and types of LEAs performed in patients with diabetes at MAMC. Patients with diagnosed diabetes and LEA procedures were identified by ICD-9-Clinical Modification (CM) codes. Hospital and clinic characteristics that are integral to the success of the program are described. RESULTS: The number of patients at MAMC with diagnosed diabetes increased 48% from 1999 to 2003; however, the number of LEAs decreased 82% from 33 in 1999 to 9 in 2003. Amputations of the foot, ankle, and toe comprise 71% of amputations among patients with diabetes. CONCLUSIONS: The results of this study provide evidence of the value of a focused multidisciplinary foot care program for patients with diabetes. Associations between the creation of the LPS and LEA rates are discussed.

Amputation, Surgical↗
PubMed2003

Vocational reintegration after a lower limb amputation: a qualitative study.

The objectives of this study were to describe the process of job reintegration, to obtain more detailed information about workplace adjustments, and to assess the positive and negative experiences of amputees (in the Netherlands) who returned to paid work after their lower limb amputation. The study had a retrospective design with semi-structured interviews. The authors used a qualitative methodology to obtain detailed information on the reintegration process. Thirty-two (32) subjects participated with a mean age of 42.6 years. The mean time between amputation and return to work was nearly one year (11.5 months). The most common reasons for delay in return to work were stump problems and problems in wound healing. Fifty percent (50%) of the amputees got different work tasks or another job than before amputation, mainly because of physical restrictions caused by the amputation. The most important motives of the amputees for job reintegration were work as a form of day spending (69%) and social contacts at the workplace (66%). Bad support of the implementing body which takes care of job reintegration and employer (34%) were the most mentioned obstacle to job reintegration. Vocational workers should be regular members in the rehabilitation teams for amputees.

Adult↗
PubMed1983

The healing of through-knee amputations in relation to skin perfusion pressure.

The healing in 20 through-knee amputations was compared with preoperatively measured skin perfusion pressure, determined as the minimal external pressure required to stop the washout of isotopes injected intradermally 10 cm distal to the knee joint. Out of 18 amputations with a skin perfusion pressure of above 20 mmHg only 2 failed to heal, whereas 2 out of 4 cases with skin perfusion pressure below 20 mmHg failed to heal. It is concluded that the through-knee amputation must be considered in cases where the circulation is borderline for healing in below-knee amputation.

Aged↗
PubMed1984

Measurement of skin perfusion pressure by photoelectric technique--an aid to amputation level selection in arteriosclerotic disease.

During a period of 14 months 60 amputations, 41 below-knee and 19 above-knee, were performed on 54 patients with gangrene of the lower limb. Wound healing was evaluated in 59 amputations. A newly introduced standardized photoelectric technique for measurement of the local skin perfusion pressure (SPP) was used preoperatively, the result of which served as a guide to the selection of the proper amputation level. An overall healing rate of 90 per cent was found. Sixty-eight per cent of the amputations were performed below-knee. The healing rates for individual SPP levels were identical to those obtained with the isotope washout technique. The standardized photoelectric technique is simple and rapid and gives only negligible discomfort to the patient allowing repeated measurements at different levels on the leg.

Adult↗
PubMed1986

Below-knee amputation in patients with vascular disease and prosthetic fitting problems.

A study was made of 544 cases with lower limb deficiencies caused by obliterative diseases; 262 cases were below-knee amputees. Of these, 106 (40%) were amputees transferred from other clinics for prosthetic fitting; in 156 cases (60%) the amputations were performed in the Institute. Amputations were carried out using one of two techniques according to the state of arterial and collateral circulation. The posterior flap below-knee amputation (Burgess, 1969) was employed in 94 cases, the other 62 amputations were carried out using a modification of that technique which was characterized by the formation of a musculo-fascia-cutaneous flap. The stump wound healed by first intention in 127 patients (81.4%), by second intention in 18 (11.5%) and in 11 cases (7.1%) the wounds failed to heal. Successful prosthetic fitting and walking training was achieved in 91.3% of amputees and 67.2% were returned to productive work.

Adult↗
PubMed1993

Incidence and prognosis of dysvascular amputations in Okayama Prefecture (Japan).

This survey analysed the clinical characteristics of subjects who first underwent major amputation of lower limbs necessitated by dysvascular disease during the 5 year period from 1984 to 1988. All were residents of Okayama Prefecture, Japan, and have been issued with a Physically Disabled Person's Certificate. In total, 114 dysvascular amputees, representing 58.2% of all lower limb amputations performed in the resident population during the study period, were surveyed. The underlying diagnosis was arteriosclerotic obstruction in 64.9% of the subjects, diabetic gangrene in 22.8%, acute embolism in 7.0% and Buerger's disease in 5.3%. The yearly incidence of new dysvascular amputees per 100,000 people was estimated to be 1.2 among the general population and 5.7 among those aged over 65 years. At three years after primary amputation, the survival rate was 52.3% in arteriosclerotic obstruction, and 66.7% in diabetic gangrene. Secondary amputation was performed in 17.0% of the entire group. The concurrent incidence of hemiplegic stroke was 19.8%. Among 36 amputees due to arteriosclerotic obstruction, who survived 3 years postoperatively, 10 (27.8%) were fitted with prosthetic limbs.

Adult↗
PubMed1994

The biomechanics of trans-femoral amputation.

The biomechanics of trans-femoral amputations has not been previously described. Little attention has been paid to the importance of adductor magnus in holding the femur in its normal anatomical axis. Loss of function of adductor magnus leads to abduction of the residual femur, in a trans-femoral amputation. A cadaver study of the adductor group of thigh muscles has been done and the biomechanical importance of these muscles is documented. The moment arms of the three adductor muscles have been determined, based on muscle attachments and muscle size, relative to each other. Adductor magnus has a major mechanical advantage in holding the thigh in its normal anatomical position. Loss of the distal third of its attachment results in a 70% loss of the effective moment arm of the muscle, which contributes to the abducted femur in standard trans-femoral amputations. A muscle preserving trans-femoral amputation, which keeps adductor magnus intact, prevents abduction of the residual femur and may allow for easier walking with a prosthesis. The conflicting reports about adductor magnus activity during the gait cycle can be explained by this muscle's dual innervation by the sciatic and obturator nerves and its dual function as a hip adductor and extensor.

Amputation, Surgical↗
PubMed1981

Radioisotope washout technique as a routine method for selection of amputation level.

In 36 amputations of the lower extremity the local skin perfusion pressure was measured preoperatively by an isotope washout technique. The result served as a guidance in the selection of amputation level. An overall healing rate of 94 per cent was found with 64 per cent of the amputations being below the knee. Thus, the isotope washout technique, used routinely, gives a reliable preoperative assessment of the chances of wound healing following below-knee and above-knee amputations.

Adult↗
PubMed1983

Age, diabetes and smoking in lower limb amputation for arterial occlusive disease.

The increased number of amputations for arterial occlusive disease noted in western countries is only partly explained by increasing numbers of the elderly. A prospective analysis of the influence of diabetes and smoking habits was therefore carried out. In 1978-81, 188 lower limb amputees in Lund were examined and classified as non-smokers, ex-smokers, light smokers and heavy smokers. These figures were compared with corresponding figures among age-correlated controls and to a group of hip fracture patients. The material was divided into men and women and into non-diabetics and diabetics. Smokers had much lower mean age at amputation. Out of 188 amputees only 23 were not either a diabetic, a smoker or 80 years or more. The population study indicates a correlation between smoking and amputation for ichaemia. The coincident increase in cigarette consumption in Sweden is illustrated and it is suggested that smoking should be noted as routinely as diabetes at amputations.

Adult↗
PubMed1993

Risk factors for failed healing in amputation for vascular disease. A prospective, consecutive study of 177 cases.

We examined factors which may lower the mean amputation age and factors which may serve as predictors of success or failure of amputations in the lower extremities for vascular disease in 177 consecutive amputees. Smoking lowered the mean amputation age by 9 years and diabetes by 3 years. Preoperative absence of gangrene in the ischemic limb predicted a higher risk of failure compared to patients with gangrene. Also preoperative hemoglobin > 120 g/L gave a higher risk of failure. Failure to heal was not correlated with age, sex, diabetes, level of amputation, previous vascular surgery, smoking, preoperative blood pressure, serum creatinine, erythrocyte sedimentation rate, blood glucose or temperature.

Adult↗
PubMed1997

Minor amputations on the feet after revascularization for gangrene. A consecutive series of 95 limbs.

A consecutive series of 89 patients (95 limbs) with gangrene were operated on with amputation of toes or some distal part of the foot after arterial reconstruction. 43 patients had diabetes. Healing was achieved in 81/82 feet when the reconstruction was open. Amputation below or above the knee was required in 4/5 limbs when the reconstruction failed. 8 patients died before healing. The median time to healing was 30 (17-452) days, after a single amputation, and 115 (36-466) days, when more than one procedure had been necessary. We concluded that amputations on the feet for gangrene usually heal after arterial reconstruction, in patients with diabetes as well as in those with arteriosclerosis. No weight bearing and control of infection are important during the early postoperative period.

Adult↗
PubMed1998

Cost of prostheses in patients with unilateral transtibial amputation for vascular disease. A population-based follow-up during 8 years of 112 patients.

We analyzed the cost of prostheses for patients amputated because of vascular disease. During 1 year, 112 patients were treated with a primary unilateral transtibial amputation in Malmöhus county, Sweden, which has 527,000 inhabitants. During the first 6 months after the amputation, 50% (56/112) of the patients had received a prosthesis. At 6 months, 49 patients (7 had died) were examined, 18 had poor and 31 had good prosthetic function. Within 1 year, 71 (63%) patients had been fitted with a prosthesis. During 8 years after the amputation, they received altogether 137 prostheses and 54 exchange sockets; 59% of the prostheses and 26% of the sockets were delivered during the first year. Each patient received a median of 1 prosthesis and 1 extra socket. During the 8-year period, the total cost of prostheses, sockets and maintenance for the 71 patients was USD 228,746, representing a median cost of USD 1,582 per patient. The total cost of maintenance of the prostheses during the same period was USD 37,959, representing 20% of the total cost of all the prostheses and sockets. There was no statistically significant difference in the costs between patients with good or poor function.

Adult↗
PubMed2000

Skin blood flow level and stump healing in ischemic amputations.

Skin blood flow was measured with xenon 133-histamine mixture in 20 lower extremities of 18 patients before performing amputations. The amputation levels were chosen according to clinical criteria; 13 below-knee, 3 distal femoral, 1 midfemoral, 2 transmetatarsal, and 1 Syme's amputations were performed. Fourteen stumps had normal healing, 2 had delayed healing, and 3 had necrosis. All of the stumps with normal healing had a skin blood flow >1.76 ml/100 g tissue/minute. Bleeding from the skin also was a good predictor of healing. Skin blood flow measurement may be helpful for level selection in ischemic amputations.

Adult↗
PubMed2006

Epi-LASIK after amputation of a LASIK flap.

PURPOSE: To demonstrate the feasibility of performing epi-LASIK after amputation of a LASIK flap. METHODS: Three months following complicated primary LASIK and immediate flap amputation, a Lasitome microkeratome (Gebauer, Neuhausen, Germany), equipped with an epi-head and -blade, was used to perform an epi-LASIK surface ablation. RESULTS: Despite uneven stromal contour at the site of the original hinge after amputation of the LASIK flap, the microkeratome passage was uneventful, resulting in a regular epithelial flap. Laser ablation was performed and the epithelial flap was repositioned. CONCLUSIONS: Epi-LASIK was completed with no intraoperative complication in the presence of an irregular stromal surface after amputation of a LASIK flap. This procedure may extend our options in the management of LASIK flap-related complications.

Adult↗
PubMedDate not supplied

Lower-limb deficiencies and amputations in children.

Important differences exist in the management of child and adult amputees. Many factors, including the etiology of childhood limb deficiencies, expected skeletal growth, functional demand on the locomotor system and prosthesis, appositional bone stump overgrowth, and psychological challenges, make caring for these young patients particularly challenging. Adherence to the general principles of childhood amputation surgery will typically guide one to the optimal functional result. These principles can be summarized as follows: (1) Preserve length. (2) Preserve important growth plates. (3) Perform disarticulation rather than transosseous amputation whenever possible. (4) Preserve the knee joint whenever possible. (5) Stabilize and normalize the proximal portion of the limb. (6) Be prepared to deal with issues in addition to limb deficiency in children with other clinically important conditions. A large proportion of young amputees undergo a Syme disarticulation, modified Boyd amputation, or knee disarticulation. A modified Van Nes rotationplasty procedure is also useful in this age group. All these provide the child with a weight-bearing stump with good growth potential and no complications due to bone overgrowth. Appropriate timing of amputation procedures and prosthetic fittings is essential to maximize functional benefit to the patient.

Age Factors↗