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PubMed1992

Risk factors for amputation in patients with diabetes mellitus. A case-control study.

OBJECTIVE: To identify and quantify risk factors for lower extremity amputation in persons with diabetes mellitus. DESIGN: Case-control study. SETTING: A Veterans Affairs medical center. PATIENTS: Eighty patients having amputation associated with diabetes and 236 diabetic controls without limb lesions were enrolled before surgery from the 21,167 inpatient care and outpatient surgical patients seen at the Seattle Veterans Affairs Medical Center during a 30-month period. MEASUREMENTS: Selected vascular, neuropathic, environmental, health care, self care, nutritional, metabolic, lifestyle, and psychosocial risk factors were measured in all patients before surgery. RESULTS: Statistically significant risk factors identified from analysis included insufficient mean below-knee and foot cutaneous circulation (odds ratio, 161; 95% CI, 55.1 to 469); ankle-arm blood pressure index less than 0.45 (odds ratio, 55.8; CI, 14.9 to 209); absence of lower leg vibratory perception (odds ratio, 15.5; CI, 8.3 to 28.7); low levels of high-density lipoprotein (HDL) subfraction 3 less than or equal to 0.7 mumol/L (odds ratio, 4.9; CI, 2.9 to 8.3); and no previous outpatient diabetes education (odds ratio, 3.2; CI, 1.6 to 6.6). A logistic regression analysis done to control for the potentially confounding effects of age; race; socioeconomic status; diabetes duration, type, and severity confirmed these findings and added a statistically significant interaction between foot transcutaneous oxygen tension and peripheral vascular disease history. Clinical interventions to alter these risk factors were identified, including aggressive treatment of infection, diabetes education, protective footwear, and preventive footcare. CONCLUSIONS: Multiple risk factors exist along the continuum of conditions and events leading to lower extremity amputation in diabetes. Modification of certain risk factors by patients and health professionals may reduce the risk for amputation and thus decrease the human and dollar costs that accompany limb loss in this prevalent chronic disease.

Adult↗
PubMed1994

Diabetes mellitus. Prevention of amputation.

Fifteen percent of individuals with diabetes will likely develop foot ulcers in their lifetime, and approximately 15% to 20% of these ulcers are estimated to result in lower extremity amputation. Techniques to prevent lower extremity amputation range from the simple but often neglected foot inspection to complicated vascular and reconstructive foot surgery. Appropriate management can prevent and heal diabetic foot ulcers, thereby greatly decreasing the amputation rate and medical care costs. Prevention is the key to treatment. The author discusses general guidelines for foot screening and identifies three specific goals for prevention of amputation: 1) identification of at risk individuals needing prevention and the specific factors placing them at risk; 2) protection of the foot against the adverse effects of external forces (pressure, friction, and shear); and 3) reduction of the incidence of diabetic foot ulcers through educational programs.

Amputation, Surgical↗
PubMed1999

Effect of podiatric medical care on rates of lower-extremity amputation in a Medicare population.

The purpose of this study was to determine whether Medicare patients at risk for lower-extremity amputation due to complications from diabetes, peripheral vascular disease, and/or gangrene who receive the services classified under Level II code M0101 of the Health Care Financing Administration's Common Procedure Coding System (cutting or removal of corns, calluses, and/or trimming of nails, application of skin creams and other hygienic and preventive maintenance care) have lower rates of lower-extremity amputation than those who do not receive such services. Analysis of the data suggests that those at-risk beneficiaries who received these services were nearly four times less likely to experience lower-extremity amputation than those who did not receive such services. The study has both methodologic limitations (the study considers only one variable, receipt or nonreceipt of certain types of podiatric medical care, while other variables may affect rates of lower-extremity amputation) and technological limitations (attempts to link the 2 years of per case Medicare Part B data were unsuccessful, limiting the length of the study to 1 year). Further research on this topic is encouraged.

Aged↗
PubMedDate not supplied

Healthy limb amputation: ethical and legal aspects.

A surgeon in Scotland has amputated the legs of two consenting, physically healthy patients. Although a handful of medical professionals believe that the desire for healthy limb amputation is symptomatic of a mental disorder that can be treated only by amputation, there is currently no consensus on what causes a person to desire such a disabling intervention. As long as there is no established body of medical opinion as to the diagnosis and treatment of such a condition, performing the surgery may be a criminal act. Given the ethically problematic history of surgery for psychiatric conditions, as well as the absence of sound medical data on this condition, surgeons should exercise great caution before complying with a request to amputate a healthy limb.

Amputation, Surgical↗
PubMedDate not supplied

Myofasciocutaneous expansion in the tegumentary rehabilitation of the amputation stump.

In post-traumatic amputations, in particular in leg amputations, the presence of an unstable scar or of ulcerous areas that are difficult to heal in the site of the amputation stump constitutes a repair problem that is not easily solved. In this specific field of reconstruction skin expansion has earned significant agreement, and is even considered to be a safe and reliable method for the surgical rehabilitation of the amputation stump, allowing us to obtain high-quality tegumentary covering, with no excessive thickness, that adapts well to the prosthesis and to the underlying skeleton, and that is characterized by good sensitivity of protection. Tegumentary amplification may, in some cases, also become myocutaneous, allowing us to obtain more tissue thickness for protection in patients submitted to chronic loading that lasts longer and in those with thin teguments, in which traditional expansion could determine excessive narrowing of the tegumentary covering, following atrophy caused by compression of the subcutaneous adipose tissue.

Accidents, Traffic↗
PubMed1999

Principles of partial foot amputations in the diabetic.

Unfortunately, amputation surgery is still a very important part of the treatment for diabetic foot problems. The decision-making process must be done thoughtfully, remembering that blood flow is not the only issue. Many factors enter into the decision to perform a partial foot amputation or to perform a more proximal level amputation. Adherence to good surgical principle, proven techniques, and gentle soft-tissue handling can make the difference between a successful and durable amputation or continued complications and frustrations.

Amputation, Surgical↗
PubMed1994

Trends in arterial reconstruction, angioplasty and amputation.

Data from operating theatre and X-ray department ledgers, and other sources, for two periods (1983-87 and 1988-91) were compared retrospectively to determine the trend in leg amputation in the defined population of a District Health Authority, following an increase in arterial reconstruction and percutaneous transluminal angioplasty for peripheral arterial disease. There was an eleven-fold increase in arterial reconstructions, and a thirteen-fold increase in angioplasty, in 1988-1991 compared with 1983-1987. A significant reduction occurred in the age- and sex-adjusted mean annual rate for major leg amputation, from 47.5 (95% confidence intervals 41.5-53.6) in 1983-87 to 32 (95% confidence intervals 26.5-37.6) in 1988-91 (Wilcoxon rank sum test, p < 0.05). There was no increase in the ratio of above-knee to below-knee amputations. The introduction of peripheral arterial reconstruction and percutaneous transluminal angioplasty was associated with a reduction in major amputations for peripheral arterial disease of 3.8 per 100,000 population per year.

Amputation, Surgical↗
PubMed1999

Psychosocial adaptation to amputation: the role of sociodemographic variables, disability-related factors and coping strategies.

This study examined the roles of sociodemographic variables, disability-related factors, and coping strategies as predictors of the psychosocial adaptation of 61 persons with amputations. Psychosocial adaptation was conceptualized as a multifaceted outcome criterion and was measured by seven scales from the Reactions to Impairment and Disability Inventory (RIDI) and the Acceptance of Disability (AD) scale. A series of multiple regression analyses indicated that both a set of sociodemographic variables and disability-related factors (age, duration of amputation, type of amputation) and a set of coping strategies (action problem-solving, emotion-focusing, behavioral/problem disengagement, cognitive disengagement) accounted, albeit differentially, for significant portions of the variance in the outcome measures of psychosocial adaptation to amputation. Of the various coping strategies, active problem-solving was negatively associated with the psychosocial reactions of depression and internalized anger (RIDI) but it was positively associated to adjustment (RIDI) and acceptance of disability (AD). Emotion-focusing and cognitive disengagement were positively associated with anxiety, depression, and externalized hostility (RIDI) and negatively associated with acceptance of disability (AD). Measurement and theoretical implications are briefly outlined.

Adaptation, Psychological↗
PubMed1976

Electrolyte concentration in the hypertrophic salivary glands of incisor-amputated rats.

The effect of periodic amputations of the lower incisors of the rat on the electrolyte concentration in the major salivary glands was studied. The incisor amputations caused a hypertrophy of the parotid, submandibular and sublingual glands. The resulting increased weight of the salivary glands was due to a higher dry mass. In general, the electrolyte concentration showed higher values in the salivary gland tissues of the incisor-amputated animals. Considering the parotid, submandibular and sublingual glands respectively, the Na+ concentration was increased by 47%, 50% and 14%; and Mg2+ concentration by 377%, 126+ and 376%. Inorganic phosphorus increased 45% in the parotid, 25% in the subnamdibular and was unchanged in the sublingual gland. K+ concentration increased in the submandibular (12%) and sublingual (100%) glands but decreased in the parotid (24%). The Na+/k+ ratio was higher in the parotid (82%) and submandibular (37%) glands and lower in the sublingual gland (84%). The electrolyte concen-ration changes are discussed in relation to the mechanism and type of stimulation promoted by the incisor-amputations on the major salivary glands of the rat.

Amputation, Surgical↗
PubMed1975

Results of minor foot amputations for ischemia of the lower extremity in diabetics and nondiabetics.

Results of 208 minor amputations were analyzed in 179 patients who had no food pulses. Wound healing was assessed at 3 months in relation to diabetes and previous vascular surgery. The results suggest that simple removal of the toe or toes is not advisable unless the blood supply to the foot can be improved by vascular reconstruction or sympathectomy, or both. Transmetatarsal amputation should be considered more often as a conservative amputation for gangrene of the toes. The absence of a palpable posterior tibial pulse is a contraindication to the Syme's amputation.

Amputation, Surgical↗
PubMed2000

[Long-term survival of elderly amputated vascular patients].

The object of this study was to assess the 10 year outcome of patients over 70 years of age who underwent amputation for vascular diseases. The secondary objective was to determine the prognostic risk factors. One hundred and four consecutive patients having undergone a leg (16 cases) or through-thigh amputation (88 cases) were reviewed. The average age at the time of surgery was 80.7 years (+/- 6.5 years, range 70-98 years). At the time of the enquiry, there were 4 survivors (operated on average 107.7 months previously +/- 14.6 months). The survival rates at one, six, twelve months and two years were 74.1%, 48.1%, 38.5% and 27% respectively. The mean survival time was 19.2 months with a median of 6 months. Univariate analysis showed the following criteria to be statistically correlated with a poor prognosis: female gender (p = 0.008), previous psychiatric disease (p = 0.007), cachexia (p = 0.004), age of 80 or over (p = 0.025), absence of diabetes (p = 0.025). Multivariate analysis showed that men had a lower risk of death (RR: 0.591--95% CI: 0.394-0.888--p = 0.011). The comparison of subjects who died during the first year with the survivors, showed a deleterious effect of proximal amputations (p = 0.032) and absence of diabetes (p = 0.021). These results confirm the very mediocre prognosis of elderly amputated vascular patients during the first postoperative year. Thereafter, the outlook is not as bad. Female gender would seem to be a poor prognostic factor whereas the presence of diabetes could identify a subgroup with a better outlook.

Aged↗
PubMed2002

[Replantation in the complete amputation of the upper extremity].

Trauma of the upper extremity can be a cause of significant morbidity and disability to otherwise productive people. Wounded extremity can be saved by replantation of the amputated parts. Replantation of traumatic amputations can be performed with reasonable success at a regional medical center when experienced surgeons, appropriate and experienced equipment, and skilled ancillary care are available. Successful replantation significantly reduces the morbidity of upper extremity amputations. We presented one case that, 9 year-old, was bridged to our hospital because of total arm amputation after sustained during use of a lawn mover. His arm was saved by urgency surgery.

Amputation, Traumatic↗
PubMed2000

[Experimental study on the extent of injured blood vessels in an avulsion amputation model].

OBJECTIVE: To measure the length and extent of the injured blood vessels in an avulsion amputation model. METHODS: Twenty rabbits were randomly divided into 2 groups. Group A was a sharp amputation group, and group B was an avulsion amputation group. The length and extent of the injured blood vessel was observed with naked eye, operation microscope and electron microscope, and the limbs were replanted. Group A and B were explored at three days and ten days after the replantation respectively. The patency rate and healing process were compared. RESULTS: All the severed ends of vessels in group A were neat with almost the same injured range in the three layers of the vessel wall about 1 mm away from the severed end. The vessels of group B were damaged seriously, the endothelial cells were deleted. The "jumping-like" damage could be observed in the elastic fibers. The injury of 2 to 3 mm away from the normal vessel wall could be observed by operation microscope. CONCLUSION: The damage of avulsion amputation vessels was irregular, 2 to 3 mm or more tissues should be excised under the microscope in the process of operation in order to ensure the healthy intact blood vessel walls.

Amputation, Traumatic↗
PubMed2002

[Reposition flap techniques in fingertip amputations: 6 cases].

PURPOSE OF THE STUDY: The purpose of this study was to evaluate an alternative procedure for amputations distal to the distal interphalangeal joint: the reposition flap. MATERIALS AND METHODS: The reposition flap was used for 6 patients who underwent fingertip amputations in an emergency setting. Pulp was excised on the amputated segment and the remaining bone and nail bed were reattached to the proximal stump with a Kirschner wire. The pulp was reconstructed with a local advancement and sensitive flap. The patients were aged 18 to 44 years and had been victims of work accidents. All refused finger shortening. RESULTS: The fingers showed good scarring and good trophicity. Two-point discrimination was 6 mm. Bony fusion was constant but all distal interphalangeal joints remained stiff. Cosmetic results were correct except for two cases of claw nail formation. DISCUSSION: Fingertip amputations have been widely reported. Methods have varied from directed scarring to partial toe transfer. These situations present two types of challenge: insensitivity of the volar aspect or an overly sensitive pulp; cosmetic presentation and function of the dorsal aspect due to the complex role of the nail. Distal reimplantation remains the best technique, but the reposition flap offers an interesting alternative in case of failure or for patients who do not accept finger shortening. The advantage of the reposition flap is that it preserves finger length and the nail. Work stoppage and intolerance to cold can be an inconvenience due to the long time required for wound healing.

Adolescent↗
PubMed2002

[Reconstruction with vein graft interposition and pedicled muscle flap in a patient with above.elbow partial arm amputation].

It is difficult to decide replantation or revascularization in partial or total amputations proximal to the wrist. Important point is the expected functional result and/ or protection of sensibility. Crush type partial or total amputations have poor prognosis. In addition to the vascular injury there are also broad cutaneous and muscular injury which have a potential risk for necrosis and infection. And this may threat the patient's life. In this case report, as two major nerves seemed intact, arterial reconstruction by a vein graft 22 cm. long and protection of important structures such as vein graft, nerves and bone which were exposed after debridement was performed by pedicled latissimus dorsi muscle flap in an above-elbow partial amputation caused by crush injury, and successful result was obtained. Key Words: Major limb amputation, revascularization, vein graft, pedicled muscle flap.

Adult↗
PubMed1976

Energy cost of walking of amputees: the influence of level of amputation.

A comparison of selected gait parameters and the energy cost of prosthetic walking was made in seventy patients with unilateral traumatic and vascular amputations. Amputations above the knee, below the knee, and at the Syme's level were compared in both groups of amputees, and a control group of forty normal subjects also studied. In both groups of amputees performance was significantly better the lower the level of the amputation. When preservation of function is the chief concern, amputation should be performed at the lowest possible level.

Adult↗
PubMed2003

[Temporary ectopic implantation of amputated foot].

OBJECTIVE: To investigate an effective technique of temporary ectopic implantation for amputated extremity under complex condition. METHODS: Two cases of amputated foot, which could not be implanted primarily, were treated with temporary ectopic implantation. The other leg of patient was chosen as recipient site. The posterotibial artery and saphenous vein were chosen as recipient vessels. When the general condition and the proximal condition of the amputated part were suitable, the ectopic implanted feet were transferred to their anatomic positions. RESULTS: All the feet survived after the replantation. The injured limbs recovered their normal length and sensation. The patients could walk after 4-6 months. CONCLUSION: Temporary ectopic implantation is an ideal technique for the salvage of amputated limb and organ under special condition. Severed foot and lower segment of the leg under complex condition were the best indication for the temporary ectopic implantation.

Adult↗
PubMedDate not supplied

[Study of static transcutaneous oximetry before amputation in patients with arteritis].

Transcutaneous oximetry has been used to define the level of amputation in arteritic patients, with discrepant results. We have studied preoperative statix oximetry in 33 arteritic patients at the Leriche-Fontaine Stage IV, who underwent 36 amputations (thighs = 6, Legs+Symes = 14, transmetatarsal = 7, toes = 9). Oximetry included the measurement, at the level of amputation, of the transcutaneous partial oxygen pressure (tc pO2), of the tissue oxygenation ratio (TOR), preferably with a precordial electrode, of the tc pO2 gain after oxygen inhalation and of the gain ratio with the reference electrode. Two patients died postoperatively, the amputation stump did not heal in another 8 patients. The tc pO2 value was 36.6 +/- 16.2 mm Hg in the healed group and 21.1 +/- 19.9 mm Hg in the non healed group. The TOR respectively was 71.2 +/- 32.7% and 38.6 +/- 29.9% in these two groups. These differences were statistically significant. The difference between the two groups in the measurements made after the oxygenation test was not statistically significant. With a tc pO2 threshold at 26 mm Hg, the sensitivity was 73% and the specificity 75%, the positive predictive value 90%, the negative predictive value 46% and the value of the test 73.5%. The thresholds calculated to be 56% for TOR, 11 mm Hg for the gain and 32% for the gain ratio, did not improve the performances of oximetry. In our study, the tc pO2 was the parameter that best allowed predicting healing was obtained with smaller values than the threshold. Other elements such as the general condition and diabetes have played a role in the prognosis.

Aged↗