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PubMed1999

The psychologic assessment and psychosocial recovery of the patient with an amputation.

The purpose of this paper is to introduce the surgical clinician to the importance of psychosocial issues in those patients undergoing amputation. Although fundamental, obtaining a good recovery for the patient means far more than providing a technically superb surgical outcome. This paper reviews the necessity of a thorough preoperative assessment in those psychosocial areas most likely to impact how the patient perceives, reacts to, and, ultimately, accepts the recommendation for amputation. Patients who undergo amputations as a result of chronic illness, of trauma, or of cancer have common concerns and special vulnerabilities that the astute surgeon should recognize. After reading this paper, the clinician should know how to assess patients in many dimensions, how to formulate a comprehensive treatment plan for psychosocial recovery, to be familiar with and to appreciate expected emotional responses in their patients, and to look for and recognize complications and stress points that require interventions either from the clinician or via a consultation. The referring surgeon should be familiar with the aims of psychotherapeutic treatment modalities and be comfortable in asking the goals and progress being made by their patients. They should have continuing input and receive timely updates.

Amputation, Surgical↗
PubMed1999

Transtibial amputations.

The transtibial amputation is one of the most frequently performed major limb amputations in the United States. The long posterior flap technique has become the most frequently recommended technique; however, the surgeon performing amputations needs to be comfortable with the alternative techniques as well. Situations occasionally do arise where the sagittal or skew techniques may be more applicable. With careful surgery and soft tissue handling, wound healing can be expected in the majority of patients. Aggressive rehabilitation is possible in many patients, and with good prosthetic intervention, return to ambulation at or near the preoperative level of function can be expected in most patients.

Activities of Daily Living↗
PubMed2001

Health related quality of life in patients with dysvascular transtibial amputation.

Sixty adults with transtibial amputations completed a validated outcomes instrument assessing their prosthesis related quality of life. All had their amputations because of peripheral vascular disease or nonsalvageable diabetic foot infection. Of the patients, 46 were male and 14 were female. Forty-four had diabetes. All of the subjects used a prosthesis for a minimum of 6 months. The Prosthetic Evaluation Questionnaire measured prosthesis function (usefulness, residual limb health, and appearance), mobility (ambulation and transfers), psychosocial response (perceived responses, frustration, and social burden), well-being, and satisfaction. Scoring was accomplished using a linear analog scale, with poor responses rated as 0 and excellent responses rated as 100. Mobility scores were the lowest (ambulation, 55.3; transfer, 64.6). Functional scores were slightly better (usefulness, 65.7; residual limb health, 79.7; and appearance, 73.3). Psychosocial response scored best (perceived responses, 86.6; frustration, 69.1; and social burden, 66.4). The overall well-being scale graded at 67.0, and overall satisfaction scored at 65.2. Although experts in rehabilitation would expect function and mobility scores to be highest and psychosocial scores to be lowest, this population actually perceived the reverse to be true. These data provide realistic expectations for patients faced with transtibial amputation and a benchmark to measure newer treatment modalities or technical innovations.

Aged↗
PubMed1981

Permanent axotomy by amputation results in loss of motor neurons in man.

Morphometric assessment of the size distribution of cell bodies (cytons) in motor neuron columns from serial sections of lumbar spinal segments reproducibly yields three peaks. Using troughs between peaks as division points, it is possible to determine the number of large (Cl), intermediate (Ci), and small (Cs) cytons per lumbar segment. In a patient with above-knee amputation 4 1/2 years previously, the number of Cl was 42%, Ci 99%, and Cs 129% that of normal. Nine years after total amputation of a lower limb for chondrosarcoma, a second patient exhibited values of 25%, 14%, and 55%, respectively. Normal results were obtained from the non-amputated sides. These results, and our previous studies on the permanent axotomy model, show that loss of target tissue by axotomy leads to atrophy and then loss of motor neurons. Extrapolated to the interpretation of morphologic abnormalities of proximal neuronal alterations in peripheral neuropathy, these results suggest that atrophy and loss of such proximal elements cannot be explained by acute distal pathology, but could be the result of chronic disorders, particularly when severe.

Amputation, Surgical↗
PubMed1976

Amputation as a salvage for patients with incapacitating infected fractures of the lower limbs.

Most serious lower-limb injuries with severe bone and soft tissue damage heal when treated wisely by techniques available today. Unfortunately, a small percentage of patients face prolonged physical and economic disability as a result of extensive damage to bone and soft tissue, nonunion of fractures with infection, nerve and blood-vessel injury, and complications of surgical treatment. Every effort should be made to effect union by established methods but a small percentage of fractures do not heal satisfactorily. Failure of infected lower-limb fractures to unite after prolonged treatment or the prospect of prolonged treatment or the prospect of prolonged morbidity and disability occasionally justify amputation in one lower limb. When a lower-limb prosthesis can provide stability support, and mobility painlessly, and overcome the morbidity and disability of an infected ununited fracture, amputation may be the treatment of choice. In the present review of our experiences in the past 17 years with patients having severly injured and diseased lower limbs where little chance existed for rehabilitation to acceptable levels of function by various methods of treatment, open amputation through infected bone followed by secondary closure was chosen to salvage the unfortunate patient with littlw chance of achieving acceptable function after infected ununited fractures of the lower limbs.

Adult↗
PubMed1990

Objective criteria accurately predict amputation following lower extremity trauma.

MESS (Mangled Extremity Severity Score) is a simple rating scale for lower extremity trauma, based on skeletal/soft-tissue damage, limb ischemia, shock, and age. Retrospective analysis of severe lower extremity injuries in 25 trauma victims demonstrated a significant difference between MESS values for 17 limbs ultimately salvaged (mean, 4.88 +/- 0.27) and nine requiring amputation (mean, 9.11 +/- 0.51) (p less than 0.01). A prospective trial of MESS in lower extremity injuries managed at two trauma centers again demonstrated a significant difference between MESS values of 14 salvaged (mean, 4.00 +/- 0.28) and 12 doomed (mean, 8.83 +/- 0.53) limbs (p less than 0.01). In both the retrospective survey and the prospective trial, a MESS value greater than or equal to 7 predicted amputation with 100% accuracy. MESS may be useful in selecting trauma victims whose irretrievably injured lower extremities warrant primary amputation.

Adult↗
PubMed1994

A technique for simultaneous replantation of multiple amputated digits at Tamai's Zone V.

A technique for simultaneously replanting multiple digits amputated at Tamai's Zone V is described. Since these multiple amputated digits are connected together, they should be replanted as a single unit. The technique includes applying the pneumatic tourniquet first, debridement, bone shortening, and fixation of all the amputated digits, including tendon repairs, application of vascular clamps before releasing the tourniquet, followed by vascular anastomosis in one-by-one fashion for each digit. The disadvantage of this technique is the difficulty in keeping the digit cool. The advantages are it is a less time-consuming operation, there is reduced blood loss and contamination, and there is a better axial arrangement of the bony framework.

Adolescent↗
PubMed1996

Pattern and mechanism of traumatic amputation by explosive blast.

The mechanism of traumatic amputation of limbs by explosion is presented. A survey of blast casualties from Northern Ireland revealed that amputations through joints were very uncommon--the principal site was through the shaft of the long bones. Computer modelling of a bone exposed to blast forces reinforced the hypothesis developed from the casualty survey, that the primary mechanism of the bone injury was the direct coupling of the blast wave into the tissues. The fracture occurs from the resulting axial stresses in the bone, prior to limb flailing from the gas flow over the limb. The gas flow completes the amputation. Field trials employing a goat hind limb model have confirmed the hypothesis. Having identified the mechanism, concepts to develop protective clothing may now be proposed.

Amputation, Traumatic↗
PubMed2002

Factors influencing the decision to amputate or reconstruct after high-energy lower extremity trauma.

BACKGROUND: Factors thought to influence the decision for limb salvage include injury severity, physiologic reserve of the patient, and characteristics of the patient and their support system. METHODS: Eligible patients were between the ages of 16 and 69 with Gustilo type IIIB and IIIC tibial fractures, dysvascular limbs resulting from trauma, type IIIB ankle fractures, or severe open midfoot or hindfoot injuries. Data collected at enrollment relevant to the decision-making process included injury characteristics and its treatment, and the nature and severity of other injuries. Logistic regression and stepwise modeling were used to determine the effect of each covariate on the variable salvage/ amputation. RESULTS: Of 527 patients included in the analysis, 408 left the hospital with a salvaged limb. Of the 119 amputations performed, 55 were immediate and 64 were delayed. The multivariate analysis confirmed the bivariate analysis: all injury characteristics remained significant predictors of limb status with the exception of bone loss; and soft tissue injury and absence of plantar sensation were the most important factors in accounting for model validity. CONCLUSION: Soft tissue injury severity has the greatest impact on decision making regarding limb salvage versus amputation.

Adolescent↗
PubMed1998

Trauma of the external genitalia in children: amputation of the penis and emasculation.

PURPOSE: Amputation of the penis or emasculation in children is rarely reported in the medical literature. This study involves 7 children with these injuries admitted to the University Hospital San Vicente de Paul, Medellin, Colombia, from 1960 to 1995. A new surgical technique is described for penile reconstruction that makes sex reassignment to the female gender unnecessary in most if not all cases. MATERIALS AND METHODS: Clinical histories and photographs of 7 boys 4 months to 8 years old with penile amputation or emasculation were reviewed. Five patients were younger than 1 year. Sex reassignment to the female gender was accepted by 1 family and refused by 4. Three boys were hospitalized at ages 3.5, 4 and 4.5 years, respectively, and underwent phalloplasty using the stumps of the remaining corpora cavernosa. The 2 older patients had been emasculated in accidents. In the 8-year-old patient the penis was reattached and the 7-year-old boy awaits myodermal flap phalloplasty. RESULTS: The boy raised in the female gender requested reassignment as a boy 14 years later. The 3 patients who underwent penile reconstruction were followed for 17, 12 and 8 years, respectively. At the last followup they emptied the bladder, and had normal skin sensitivity and erections. After 3 years the boy with a reattached penis has no problem emptying the bladder but he has lymphedema and decreased skin sensitivity. CONCLUSIONS: Phalloplasty using the remaining stumps of the corpora cavernosa should be first line therapy in children with traumatic loss of the penis. It restore the functional and cosmetic aspects of the organ, and makes sex reassignment to the female gender unnecessary. Replantation of the penis must be attempted when the amputated organ is recovered. A microvascular technique is recommended.

Amputation, Traumatic↗
PubMed1979

Successful replantation of an amputated leg in a child.

We report the successful replantation of an amputated leg in a 4-year-old boy. Four years after the replantation, skeletal growth and nerve regeneration were good and he had an excellent recovery of function and appearance. This result was undoubtedly enhanced by his youth, the ideal conditions for nerve repair, and the good preservation of the amputated leg in ice water. Replantation of an amputated lower extermity should be tried if the conditions mentioned above are fulfilled.

Amputation, Traumatic↗
PubMed1987

Microsurgical reattachment of totally amputated ears.

At a time when microsurgical reattachment of amputated limbs is commonplace, successful reattachment of total ear amputations is rare. Avulsed vessels, small diameters (0.3 to 0.7 mm), and technical difficulties provide primary obstacles. Three clinical cases of ear reattachments are presented which encompass the clinical spectrum of an uncomplicated success, a salvage of an impending failure, and a late failure due to venous thrombosis. In all cases there was difficulty with identification of vessels, with differentiation of arteries from veins, and in the performance of venous anastomoses. Vein grafts were necessary in two of the three patients. Anticoagulation was essential in alleviating venous thrombosis. Medicinal leeches (Hirudo medicinalis) were used to salvage one case with venous thrombosis. Despite the technical difficulties and long operative times, successful microvascular reattachment of an amputated ear is superior to any other means of reattachment or reconstruction.

Adolescent↗
PubMed1999

Toe transplantation for isolated index finger amputations distal to the proximal interphalangeal joint.

Functional deficit following single distal index finger amputations has been considered insignificant, and reconstruction is usually not recommended. Herein, 19 cases of second toe transplantation for reconstruction of isolated index finger amputation distal to the proximal interphalangeal joint are presented with long-term functional results. There are 14 men and 5 women. The average age was 26 years. The toe transplantations were performed either as a primary procedure (5 patients) while the wounds were still open or as a secondary procedure (14 patients) after the wounds healed. In 11 patients, the dominant hand was involved. All toes survived completely, although re-exploration was required in three cases (16 percent). The functional evaluation included (1) sensory recovery, where the average static and moving two-point discrimination were 8 mm (range 4 to 15 mm) and 6 mm (range 2 to 15 mm); (2) motor function, where the average of index-thumb pulp-to-pulp pinch compared with the normal hand was 67.5 percent (range 36 to 96 percent); (3) average range of motion in index finger joints (extension/flexion), where metacarpophalangeal joint was 14/90, proximal interphalangeal joint was 0/94, and distal interphalangeal joint was 19/38; and (4) functional and cosmetic results, where percentage of involvement in daily activities and functional capacity of the reconstructed index were 69 percent and 70.5 in average, respectively, over a total score of 100. Average scores of aesthetic appearance and acceptability of donor-site deformity were 74 and 87.5 over a total score of 100, respectively. Toe transplantation for distal index finger amputations improved hand function when performed in selected patients with specific job requirements or high motivation.

Adolescent↗
PubMed1983

Amputations after vascular trauma in civilians.

In a ten-year retrospective study of 233 patients who sustained a vascular injury to an extremity, eight (3.4%) extremities were amputated. Factors that affect the incidence of amputation after peripheral vascular trauma include early operation, fasciotomy, preoperative antibiotics, appropriate vascular reconstruction with adequate tissue coverage, use of arteriography during and after reconstruction, and early reoperation for postoperative complications. Some patients benefit psychologically and physically from early definitive amputation.

Adolescent↗
PubMed1998

Risk factors for above-knee amputations in diabetes mellitus.

BACKGROUND: Above-knee amputation (AKA) is a common complication in diabetics, mostly after one or more lower level amputations (LEAs) have been done. The aim of this study was to identify risk factors for AKAs among diabetics. METHODS: We abstracted 1,800 medical records of hospitalizations for LEA. Kaplan's comorbidity classification was used to rank disease severity. We used both univariate and multivariate models to identify risk factors for AKA. RESULTS: Of the 1,043 diabetic amputees in this study, 22% had AKA. Variables associated with AKA were locomotor impairment, severe anemia, history of lower extremity bypass surgery, body mass index (BMI) < 20 kg/m2, female sex, cerebrovascular disease, cardiovascular disease, and SGOT > 40 U/L. CONCLUSIONS: Most of these risk factors represent end-stage processes and do not have good treatment alternatives. Perhaps one of the practical applications of these data is not to describe risk of proximal amputations but instead to look more closely at candidates who should be considered for distal procedures.

Activities of Daily Living↗
PubMed2006

Pollicization of the index finger for traumatic thumb amputation.

BACKGROUND: Indications for pollicization of the index finger have decreased since the toe-to-thumb transfer and wraparound flap have been developed for thumb reconstruction. Pollicization, however, remains a useful method of thumb reconstruction depending on the amputation level, age, and patients' requests. The purpose of this study was to evaluate the authors' results and to clarify indications for pollicization. METHODS: Eight patients treated by pollicization of the index finger after thumb amputation were reviewed retrospectively. Five men and three women were included. The age at surgery ranged from 24 to 66 years, with a mean age of 43 years. Amputation levels included the metacarpophalangeal joint in four patients, the first metacarpal in three, and the carpometacarpal joint in one. The period between injury and pollicization ranged from 0 days to 4 years. Postoperative evaluations included thumb range of motion, opposition and pinch function, grasp and pinch strength, sensation, conversion of position sense, a "picking-up" test, and appearance. RESULTS: The follow-up period ranged from 5 to 28 years, with an average of 15 years, excluding one patient who died during the follow-up period. The thenar muscles were retained in four patients, who had excellent postoperative function and satisfactory results. CONCLUSIONS: Pollicization gives excellent results if the thenar muscles can be retained; opposition can be expected after this procedure. However, if the thenar muscles cannot be preserved, the reconstructed thumb may function as a post against the fingers to regain grasping and pinching functions.

Adult↗
PubMed1996

Plasticity of the somatosensory cortical map in macaque monkeys after chronic partial amputation of a digit.

Activity-dependent changes in cortical representational maps have been reported in many studies of adult mammals. Limits in extent of change have been attributed to limited divergence in the thalamocortical projection. However, studies have commonly been restricted to animals surviving less than a year following relatively modest peripheral sensory perturbations. After extensive deafferentation and long-term survival, more extensive changes, seemingly beyond the limits of thalamocortical divergence, have been reported. We report changes in the somatotopic map in area 3b of an adult macaque monkey, in which part of the index finger of one hand had been amputated two years previously. The representation of the remaining stump occupied the whole region of area 3b normally devoted to the representation of the entire digit. The skin surrounding the stump appeared to have been hyperinnervated by axons severed during the amputation. The hyperinnervation of remaining skin may have reactivated neurons of the somatosensory system silenced by the amputation, leading to the recovery of a cortical map but with a modified organization.

Amputation, Surgical↗