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PubMed1995

Phantom-limb pain as a perceptual correlate of cortical reorganization following arm amputation.

Although phantom-limb pain is a frequent consequence of the amputation of an extremity, little is known about its origin. On the basis of the demonstration of substantial plasticity of the somatosensory cortex after amputation or somatosensory deafferentation in adult monkeys, it has been suggested that cortical reorganization could account for some non-painful phantom-limb phenomena in amputees and that cortical reorganization has an adaptive (that is, pain-preventing) function. Theoretical and empirical work on chronic back pain has revealed a positive relationship between the amount of cortical alteration and the magnitude of pain, so we predicted that cortical reorganization and phantom-limb pain should be positively related. Using non-invasive neuromagnetic imaging techniques to determine cortical reorganization in humans, we report a very strong direct relationship (r = 0.93) between the amount of cortical reorganization and the magnitude of phantom limb pain (but not non-painful phantom phenomena) experienced after arm amputation. These data indicate that phantom-limb pain is related to, and may be a consequence of, plastic changes in primary somatosensory cortex.

Adult↗
PubMed2002

Skin grafts for the salvage of degloved below-knee amputation stumps.

We present a series of six patients in whom a traumatic below-knee amputation was associated with significant degloving, such that there was inadequate local skin to achieve primary stump closure. In each case, skin grafts were used to cover the stump muscle flaps. The patients ranged in age from 21 years to 73 years; the mean hospital stay was 72 days and the mean follow-up was 48 months. Despite an average of five procedures to achieve stump healing and an average of 118 days to first limb fitting, all patients have achieved independent mobility with their prosthesis. All have had minor stump problems necessitating periods of time off their prosthesis. Three patients have required minor stump-revision surgery. The advantages of a below-knee amputation over an above-knee amputation compensate for these problems. The forgiving nature of modern prostheses has contributed to acceptable results in these patients, who had what may previously have been considered insufficiently durable stump cover.

Adult↗
PubMed1991

Skewflap versus long posterior flap in below-knee amputations: multicenter trial.

A multicenter trial of alternative techniques for below-knee amputation is described in which surgeons in 11 centers randomized 191 patients with end-stage occlusive vascular disease to two different methods of stump construction. The skewflap technique was performed in 98 and the long posterior flap was performed in 93. The two groups were well matched in respect to age, sex, smoking, diabetes, and indications for amputation. Early outcome was compared in terms of 30-day mortality rate: skew 11 (11%) deaths versus long posterior flap 16 (17%); the state of the wound at 1 week (primary healing 60% in both groups); the need for surgical revision at the same level 7 (7%) versus 7 (8%), and revision to a higher level 10 (10%) versus 7 (8%). Follow-up information at 6 months was available from records or by mailed questionnaire in 188 (98%) at 6 months, 20 died during that interval. It showed that a prosthetic limb was fitted to 64 (84%) of skew flaps and 50 (77%) of long posterior flaps. Walking, alone or with support, was achieved in 59 (78%) and 46 (71%), respectively. None of these differences reached statistical significance. It is concluded that the skew flap is just as effective as the long posterior flap and is an excellent option for below-knee amputation.

Aged↗
PubMed2002

Salvage of major amputation stumps of the lower extremity with latissimus dorsi free flaps.

In some severe lower limb injuries, the level of bone trauma enables preservation of the knee joint or adequate length of the femoral stump only if the soft tissues can be reconstructed over the exposed bone. The options for soft-tissue reconstruction of an amputation stump are to use a flap from the amputated distal part, a local flap possibly after tissue expansion or a free flap. To preserve an adequate length of stump we reconstructed 10 stumps with latissimus dorsi free flaps: above the knee in one patient and below the knee in nine. The reconstructions were done during an acute post-traumatic phase in five and for late problems with the stump in four patients. In one patient the reconstruction was done nine weeks after a below-knee amputation for ischaemic necrosis after septicaemia. All flaps survived, but the venous anastomosis had to be revised in three patients in the early postoperative period. All patients regained adequate ambulation for their daily activities. The flap was secondarily debulked in three patients. Every effort should be made to preserve an adequate stump length, particularly in young patients with crushing injuries of the extremities and when there is severe or recurrent late stump ulceration. A latissimus dorsi musculocutaneous soft-tissue reconstruction is a reliable and durable option for stump defects.

Adolescent↗
PubMed2002

Rates and characteristics of lower limb amputations in Taiwan, 1997.

This study aims to describe the national incidence rate and characteristics of lower limb amputations (LLA) in 1997 from an island-wide database of the national health insurance programme in Taiwan. Some 117,647 discharge records from a sampled database (1 in 20) of the National Health Insurance Research Database were analysed. This study included records (n=171) containing LLA procedures. The LLA procedure rates were obtained by multiplying the number of identified procedures by 20 as the numerator and mid-year total population of Taiwan in 1997 as the denominator. Each procedure was further analysed according to the demographic characteristics of the patients, cause and level of amputation. Summarised gender ratios of LLA procedure rates were obtained by Poisson regression analysis. The crude LLA procedure rate was 18.1 per 100,000 population per year and the crude major LLA procedure rate was 8.8 per 100,000 population per year in Taiwan in 1997. The major cause of LLA procedures was peripheral vascular disease (72%), and the toe was most frequently amputated (48%). The LLA procedure rates, which increased logarithmically with age of patients, were significantly higher in men with a summarised male to female rate ratio of 1.65. The age-standardised LLA procedure rate in Taiwan was lower than that reported in the United States, Finland, the Netherlands, the United Kingdom (Leeds, Middlesborough, and Newcastle), but higher than Spain, Italy, and Japan. The trend of an increasing proportion of PVD-related LLA procedures will prompt the health professionals to develop strategies for LLA prevention.

Adolescent↗
PubMed2005

Skew flap technique in trans-tibial amputation.

The long posterior flap technique is an established technique for trans-tibial amputation in ischaemic limbs. Despite its success, it has a few drawbacks. It may be time-consuming and requires considerable planning, and at times the dog-ears cannot be avoided. The suture line passes over the distal end of the stump, which is usually a problem during prosthetic use. The skew flap technique retains the advantages of the long posterior flap technique and eliminates the difficulties of prosthetic fitting. The equal skin flaps are skewed so that the flaps become anteromedial and posterolateral, whereas the calf muscle flap remains long underneath the skewed skin flaps. The posterior muscles are brought anteriorly covering the cut ends of the bones and are buried in between the tibia and its anterior periosteum, by suturing their margins with the periosteum. The skew flap procedure was perceived in 1980 and was started at the Artificial Limb Centre, Pune in 1983 by the author. This procedure underwent many changes during the initial 5 years and by the end of April 1992, 85 trans-tibial amputations were performed using this technique. A 9-year follow-up of these patients, who had been using prostheses with ease and without any discomfort or problem, had been exceptionally good. Encouraged by the results, this technique is now being practised as routinely. By March 1998, a total of 125 such trans-tibial amputations had been performed in 119 patients, with excellent results.

Adolescent↗
PubMed2005

Stump management after trans-tibial amputation: a systematic review.

In order to achieve stump healing after trans-tibial amputation, various methods are applied, such as soft dressings followed by elastic wrapping of the stump, rigid dressings, semi-rigid dressings, and more recently the application of silicon or gel-liners. A systematic literature search was performed to identify the optimal post-amputation management. The methodological quality of the studies was systematically evaluated by using a predefined list of criteria. Only 11 controlled studies were identified and evaluated for their methodological quality. From these studies, no studies were classified as A-level studies, whereas three were classified as B-level, and 8 were classified as C-level studies. Relevant literature appears heterogeneous with respect to patient selection, intervention and outcome measures. Despite the large variability of included studies, this review reveals a trend in favour of rigid and semi-rigid dressings for achieving stump healing and reduction of stump volume. No conclusions can be drawn with regard to the effect on functional outcome. The literature is not conclusive on the effects of early weight bearing on stump healing, volume reduction, and functional outcome. More research is needed for the development of evidence-based clinical practice guidelines concerning management after transtibial amputation.

Amputation, Surgical↗
PubMedDate not supplied

Osteocutaneous pedicle flap of the foot for salvage of below-knee amputation level after burn injury.

Lower extremity amputations are occasionally required after high-voltage electric and deep thermal burns. The extensive loss of skin and soft tissue after these injuries may make it difficult to fashion below-knee amputation that will readily tolerate a prosthesis. We have found an osteocutaneous pedicle fillet flap of the foot useful in the salvage of below-knee amputation after severe burn injury. Three patients have undergone this procedure after burn injury, 1 with burn secondary to high-voltage electric injury and 2 after deep thermal burns. All became ambulatory with artificial prostheses. There were no postoperative infections and no need for further revisions. The osteocutaneous pedicle fillet flap of the foot has proven to be a reliable form of below-knee stump coverage in patients with extensive soft tissue necrosis after burn injury.

Accidents, Traffic↗
PubMed1983

Neuroma formation following digital amputations.

One hundred consecutive patients with 144 digital amputations performed at the University of Colorado Health Sciences Center between 1978 and 1980 were retrospectively reviewed. In this group, four patients demonstrated painful amputation stumps. Two of these were treated by surgical excision of neuromas and two patients, who had more vague complaints, were treated by desensitization which decreased the sensitivity of their stumps and allowed them to return to work. It is felt that this low incidence of painful neuromas and amputation stumps is due to the positive postoperative effort to send patients back to work as soon as possible, allowing them to perform their own therapy and thereby minimizing their disability and tendency to develop pain problems.

Adult↗
PubMed1991

The role of microvascular free flaps in salvaging below-knee amputation stumps: a review of 22 cases.

Twenty-two cases of traumatic below-knee amputation stumps with inadequate soft-tissue coverage salvaged with microvascular free flaps were reviewed retrospectively. All patients would have required an above-knee amputation for prosthesis fitting had microvascular free flaps not bee utilized. A total of 24 flaps were used in 22 patients; parascapular 11 (46%), foot filet six (25%), latissimus dorsi four (17%), lateral thigh, tensor fascia lata, and groin one (4%). Free flaps were performed immediately after injury in five (21%) cases, within the first week in two (8%), between 1 and 3 months in 12 (50%), and after 3 months in five (21%). Fifty per cent of the patients had significant other injuries. The patients had a total of 107 operations (mean, 4.9) related to their injury: 33 (mean, 1.5) of those operations were after the free flap, 27 (25%) of which were either performed because of a complication of the free flap or for revision of the free flap. Complications included partial necrosis in five (21%), neuroma in three (13%), hematoma in two (8%), donor site complication in two (8%), thrombosis requiring reoperation in one (4%), and flap failure in one (4%). Patient followup ranged from 12 to 116 months. All patients maintained a functional below-knee prosthetic level. The mean time to ambulation was 5.75 months, and was not significantly affected by flap complications. Most patients employed before their injury were employed after their injury. Despite a protracted course in these severe injured trauma patients, a functional below-knee amputation level was preserved in all cases utilizing microvascular free flaps.

Activities of Daily Living↗
PubMed2000

Crossover replantation and fillet flap coverage of the stump after ectopic implantation: a case of bilateral leg amputation.

A successful case of crossover replantation of the left foot to the stump of the right leg and temporary ectopic implantation of the right amputated foot on the forearm is described. The ectopically implanted right foot was used as a free fillet flap for the late reconstruction of the left leg stump. At the latest follow-up examination, 18 months after the accident, the patient was able to walk independently with a prosthesis on the stump of the left leg. Both the cross-replanted foot and the free filleted foot flap, used for the reconstruction of the left leg stump, have maintained adequate protective sensation. The importance of utilization of amputated parts for functional reconstruction is stressed. Crossover replantations and ectopic implantations should be considered in bilateral amputations for the salvage of at least one extremity.

Adolescent↗
PubMed1975

Prosthetic fitting immediately after below-knee amputation.

Frequently surgical amputation of a lower extremity is required when gangrene develops as a result of peripheral vascular disease. This is particularly true in geriatric patients. A below-knee amputation, with refinements in the surgical procedure, and immediate rigid-cast prosthetic fitting are strongly advocated by our group. The progress of two patients treated in this manner is described. Preservation of the knee joint improves the amputee's prognosis for ambulation with a below-knee prosthesis. The rigid-cast dressing on the below-knee amputation reduces edema and postoperative pain, is of psychologic value to the patient, and permits him to stand at from one to two days postoperatively.

Aged↗
PubMedDate not supplied

Outcomes of lengthening short lower-extremity amputation stumps with planar fixators.

Patients with short lower-extremity amputation stumps exhibit poor prosthetic fit and inefficient gait. Often they are fit at the next-higher prosthetic level, increasing energy consumption. This study aimed to characterize the risk/benefit ratio of stump lengthening with planar external fixators. All patients lengthened for functionally short amputation stumps were reviewed. Outcome measures included changes in prosthetic use, soft tissue problems, qualitative gait analysis, and surgical complications. Patients averaged 15.1 years of age at surgery, with 4.1 years of follow-up. The average lengthening index was 9.2 mm/mo. Femoral lengthenings obtained more length (8.7 vs. 6.9 cm). After treatment, prosthetic skin-related complications decreased and qualitative gait parameters improved. Most (85%) wore a standard prosthesis for their amputation level after surgery, whereas none could before. There were 1.4 complications per patient, all successfully surgically treated. Lengthening is time-consuming and associated with frequent complications but results in improved gait and energy consumption.

Adolescent↗
PubMed2006

Falls sustained during inpatient rehabilitation after lower limb amputation: prevalence and predictors.

OBJECTIVE: The purpose of this study is to identify risk factors for falling and fall-related injury among a group of inpatients undergoing rehabilitation after major lower limb amputation. DESIGN: Retrospective cohort. RESULTS: Out of 1267 patients, 260 (20.5%) fell at least once. There were a total of 374 falls, 67 (17.9%) of which resulted in one or more injuries. Adjusted odds ratios (OR) and 95% confidence intervals (CI) were calculated for factors significantly associated with falling, including age of > or =71 yrs (OR = 1.40, 95% CI = 1.02-1.89), lengths of stay of 22-35 days (OR = 2.97, 95% CI = 1.14-7.72) or >5 wks (OR = 6.07, 95% CI = 2.34-15.71), four or more comorbidities (OR = 1.93, 95% CI = 1.09-3.41), cognitive impairment (OR = 1.68, 95% CI = 1.02-2.78), two or more as-needed medications (OR = 1.81, 95% CI = 1.02-3.21), benzodiazepines (OR = 2.22, 95% CI = 1.24-3.96), and opiates (OR = 5.76, 95% CI = 3.29-10.09). Factors significantly associated with fall-related injuries included bilateral amputation (OR = 3.68, 95% CI = 1.49-9.05) and falls during the day shift (OR = 2.63, 95% CI = 1.24-5.57). CONCLUSIONS: One in five patients with lower limb amputation will likely experience at least one fall during inpatient rehabilitation, with 18% sustaining an injury. Ongoing research is required to develop appropriate intervention strategies to ameliorate the risk of falling during inpatient rehabilitation.

Accidental Falls↗
PubMed2000

A case of pyoderma gangrenosum on the stump of an amputated right leg.

We present here a case of pyoderma gangrenosum (PG) on the stump of an amputated leg. The patient was a 69-year-old woman who had both of her legs amputated due to acute arterial occlusion. An ulcer first appeared nine years later, after which point it continued to fluctuate in size. Complications included regional blood flow disorder at the amputated stump, diabetes, and secondary infection. Despite various therapies, the ulcer exacerbated, and hypoproteinemia, increased CRP, and fever were confirmed. The patient was diagnosed as having PG based on her clinical symptoms and because the ulcer did not respond to various therapies. The ulcer improved significantly in response to administration of 40 mg/day of prednisolone, and complete epithelialization was later achieved. Given the presence of multiple complications, it was extremely difficult to confirm PG. Therefore, it is important for physicians to consider PG as one of the causes of intractable ulcers.

Aged↗
PubMed2000

Thalamic and cortical contributions to neural plasticity after limb amputation.

Little is known about the substrates for the large-scale shifts in the cortical representation produced by limb amputation. Subcortical changes likely contribute to the cortical remodeling, yet there is little data regarding the extent and pattern of reorganization in thalamus after such a massive deafferentation. Moreover, the relationship between changes in thalamus and in cortex after injuries of this nature is virtually unexplored. Multiunit microelectrode maps were made in the somatosensory thalamus and cortex of two monkeys that had long-standing, accidental forelimb amputations. In the deprived portion of the ventroposterior nucleus of the thalamus (VP), where stimulation to the hand would normally activate neurons, new receptive fields had emerged. At some recording sites within the deprived zone of VP, neurons responded to stimulation of the remaining stump of the arm and at other sites neurons responded to stimulation of both the stump and the face. This same overall pattern of reorganization was present in the deprived hand representation of cortical area 3b. Thus thalamic changes produced by limb amputation appear to be an important substrate of cortical reorganization. However, a decrease in the frequency of abnormal stump/face fields in area 3b compared with VP and a reduction in the size of the fields suggests that cortical mechanisms of plasticity may refine the information relayed from thalamus.

Amputation, Surgical↗
PubMed2006

Subintimal recanalization of the femoropopliteal segment to promote healing of an ulcerated below-knee amputation stump.

PURPOSE: To describe the use of the subintimal technique to revascularize an ulcerated below-knee amputation stump. CASE REPORT: A 64-year-old man with persistent ulceration of a below-knee amputation stump underwent attempted percutaneous revascularization. Via antegrade puncture, the femoropopliteal occlusion was recanalized subintimally and eventually opened into a large medial geniculate collateral branch, improving the stump flow. The procedure was uneventful, and at 6 months, the patient was pain-free and able to mobilize with his prosthetic limb. CONCLUSION: Subintimal revascularization of a critically-ischemic below-knee amputation stump may be a useful option and should be considered in clinical situations like this.

Amputation, Surgical↗
PubMed1980

A clinical study of amputations of the lower limb.

A retrospective study of 525 cases of lower limb amputation attending the Outpatient Department of the Rehabilitation and Artificial Limb Centre and various rural clinics from January 1976 to March 1978 was carried out. Males outnumbered females and the majority of cases were in the 3rd decade. Trauma was the most common cause of amputation followed by peripheral vascular disease and neoplastic lesions. The stump was considered to be satisfactory in more than half of the cases studied. Proper postoperative care was lacking in most of those amputated at other centres.

Adolescent↗