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A conservative regime for distal digit amputations allowing healing under vaseline gauze has much to recommend it, being simple and allowing rapid healing with few complications. Secondary distal amputations for gangrene and sepsis also heal rapidly if left open. A consecutive series of 55 amputations treated in this way is described.
The purpose of this paper is to report prosthesis-related issues of importance that were identified by a diverse group of persons living with lower limb amputations (LLA) and prostheses. These perceptions and themes validate some old assumptions and challenge others, report both common and unusual experiences, and indirectly identify the information level of our respondents concerning prostheses. Persons with LLA were identified from computerized rosters at a level one regional trauma center and at the VA Puget Sound Health Care System-Seattle, Division. Inclusion criteria specified that respondents were to: 1) be one or more years post-unilateral amputation at the Syme's level (ankle disarticulation) or higher, 2) use their prosthesis at least 5 days a week, 3) read English, and 4) be able to provide informed consent. Respondents completed the Prosthesis Evaluation Questionnaire-field version (PEQ) and the standard form (SF)-36, a health status measure. Of 114 persons who agreed to participate, 92 (85% male, mean age 55 years) responded to the questionnaire and graded the personal importance of various characteristics and qualities of their prosthesis. The number of years since their last amputation ranged from 1 to 53 years. Four Themes of Interest were identified from responses to open-ended questions about living with a prosthesis. These themes included the fit of the socket with the residual limb, aspects of the mechanical functioning of the prosthesis, other nonmechanical qualities, and advice about adaptation to life with a prosthesis with support from others. Future research is recommended to adjust aspects of the fit of the prosthesis with the residual limb. Implementing periodic check-up visits could uncover problems and eliminate unnecessary suffering.
The lizard tail regenerates after autotomy or amputation. After horseradish peroxidase injections in the regenerate, motoneurons were retrogradely labeled only in the three spinal segments rostral to the amputation, whose spinal nerves are severed by tail loss. The changes in these motoneurons, compared to those of lizards with original intact tails, were investigated 5, 15, and 30 days after caudotomy and at 8 months in lizards with mature regenerates. Morphometric analysis of Nissl-stained motoneurons rostral to the amputation revealed marked hypertrophy, peaking at 15 days, when chromatolysis and nuclear eccentricity were also evident; motoneuron perikarya remained significantly larger than in controls after tail regeneration. The dUTP nick-end labeling (TUNEL) stain for apoptotic neurons did not reveal labeled cells in the spinal cord 5 and 15 days after caudotomy. Nitric oxide synthase (NOS) expression was studied with nicotinamide adenine-dinucleotide phosphate (NADPH)-diaphorase histochemistry and evaluated quantitatively with densitometry. A few caudal spinal motoneurons were lightly stained in lizards with intact tails. Induction of NADPH-diaphorase positivity was evident in the vast majority of these cells 5 days after caudotomy and was very marked at 15 and 30 days, during tail regrowth. These data were confirmed by neuronal NOS immunohistochemistry. After tail regeneration, histochemical positivity was markedly down-regulated in the tail spinal motoneurons but persisted in the majority of these cells. The findings show that in the lizard caudotomy elicits in axotomized caudal spinal motoneurons NOS induction associated with plasticity phenomena and in particular with vigorous regeneration of axons that innervate the regrowing tail.
INTRODUCTION: Joint reconstruction following trauma at the proximal interphalangeal or metacarpophalangeal levels remain a difficult problem in hand surgery. Function of the injured finger depends on the mobility and stability at these joints. In fingers amputated at these levels with joint destruction, the hand surgeon can perform either an arthrodesis or a replacement arthroplasty (either as an emergency or as a secondary procedure). Arthrodesis will give a stable pain-free joint, but at the cost of sacrificing mobility and even cosmesis. CLINICAL PICTURE: We report a case of traumatic amputation through the proximal interphalangeal joint (PIPJ) of the right middle finger. Arthrodesis of the PIPJ in extension using Kirschner wires was performed following replantation due to extensive periarticular soft tissue loss, so as to enable repair and healing of the extensor mechanism. This results in poor cosmesis and stiffness of finger interfering with function three months after surgery. TREATMENT AND OUTCOME: A prosthetic total joint replacement of PIPJ was performed as a secondary procedure. Satisfactory hand function and finger movement ensued two years after the procedure, with no loosening or infection of the implant. CONCLUSION: Total interphalangeal joint arthroplasty is a useful secondary procedure, after the initial replantation, for finger amputation with periarticular soft tissue loss.
Residual limb recovery after a transtibial amputation depends largely on close monitoring of the weight-bearing activities during the early postoperative stage. Although a biofeedback device, in particular audio biofeedback, was recommended to be used, no quantitative studies regarding its effectiveness in monitoring the weight-bearing activity of a person with amputation were available. In this study, six persons with transtibial amputation were asked to replicate a prescribed amount of weight bearing using a bathroom scale method during their early postoperative ambulatory training. Their weight-bearing characteristics with and without using audio biofeedback were continuously monitored using a load monitoring device and compared with the prescribed load. The results showed that the residual limb would be overloaded using the conventional bathroom scale method during early postoperative ambulatory training if no audio biofeedback was provided. It was demonstrated that audio biofeedback was useful in preventing the residual limb from being overloaded beyond the prescribed load particularly when the prescribed load was low.
Success is possible with partial foot amputations even in the diabetic patient population. Many diabetics who in the past would have undergone a major lower extremity amputation now have successful reconstruction of their complex foot wounds. Even though this article presents the levels of amputation and methods of closure for soft tissue defects in a sequential manner, in many instances, different levels and methods are used for different aspects of the same foot defect (i.e., a TMA may require a fillet of toe, STSG, and TAL for successful closure). Familiarity with the principles advocated in this article and the importance of each member of the multispecialty team involved help to ensure that good outcomes in the immediate postoperative period and in the long-term recovery period are achieved.
This study retrospectively reviews an 8-year consecutive series of transmetatarsal amputation (TMA) for forefoot ischaemia in diabetic and non-diabetic patients. Forty-one patients had TMA. Peri-operative mortality was 17% (7/41). A healed stump was achieved in 19 patients (46%) and 18 of these patients were independently mobile, or mobile with sticks. Non-diabetic patients (8/12) healed significantly better than diabetics (11/29). Median time to healing was 7 months (range 3-20 months). All non-healed survivors had a higher amputation (14 below-knee, 1 Syme's). A healed TMA gives good mobility, but prediction of who will heal after operation is unreliable. Time to healing is often lengthy, and failed healing results in higher amputation. These issues need to be fully discussed with the patient who is considered for TMA.
Multiple factors, including peripheral vascular disease and neuropathy, contribute to the development and perpetuation of complications of the lower extremities in diabetes. The main aim of the present study was to assess the peripheral vascular and nerve status of diabetic and non-diabetic subjects that had undergone lower limb amputation. Various non-invasive tests of peripheral vascular and nerve function were carried out on subjects who had undergone unilateral lower limb amputation and were now attending a Rehabilitation Centre. The control group (n=23), the diabetic amputee group (n=64) and the non-diabetic amputee group (n=32) were age-matched. Only the diabetic amputee group had evidence of medial arterial calcification. Transcutaneous oxygen levels were significantly lower in the diabetic amputee group (median 43 mmHg; interquartile range 33-49 mmHg) than in the control (59; 56-74 mmHg) and non-diabetic amputee (57; 43-65 mmHg) groups (control compared with diabetic amputee group, P<0.001; diabetic amputee compared with non-diabetic amputee group, P<0.01). The same trend was found for carbon dioxide levels in the skin [mmHg: diabetic amputees, 25 (21-37); controls, 38 (32-42); non-diabetic amputee, 34 (31-39)] (control compared with diabetic amputee, P<0.01; diabetic amputee compared with non-diabetic amputee, P<0.05). Vibration and pressure perception measurements (which assess Abeta nerve fibre function) showed that both the diabetic amputee and non-diabetic amputee subjects had significantly greater impairment than the controls. However, measures of Aalpha and C nerve fibre function were abnormal only in the diabetic amputee group. Thus the peripheral vascular and nerve functions of age-matched diabetic and non-diabetic subjects having undergone lower limb amputation show specific differences, with non-diabetic amputees exhibiting signs of neuropathy. This indicates that factors characteristic of diabetes (such as hyperglycaemia and non-enzymic glycation) are associated with calcification, lower oxygen and carbon dioxide levels in the skin, and abnormal Aalpha and C nerve fibre function.
Both traumatic forequarter amputation and scapulothoracic dissociation are rare and life-threatening injuries. We present the case of a 31-year old woman who was ejected from a car after a motor vehicle accident and sustained an apparent partial forequarter amputation. Upon examination her injury was found to share many characteristics with a scapulothoracic dissociation injury. With both injuries mortality is high and prompt diagnosis and treatment imperative. By viewing scapulothoracic dissociation and forequarter amputation as a continuum faster recognition and appropriate treatment may be implemented for these devastating injuries.
BACKGROUND: The aim of this prospective study was to assess the effect of an intensive in-patient rehabilitation programme upon the mobility of amputees. METHODS: All major lower limb amputations between 1997 and 1999 received a pre-operative mobility assessment and, where appropriate, were referred for a vigorous rehabilitation programme. RESULTS: 92 lower limb amputations were performed in 87 patients (57 below knee, 33 above knee, two hip disarticulations). Overall, 63% of patients were able to ambulate independently following rehabilitation. Univariate analysis revealed that the only predictor of mobility was the level of amputation, below knee gaining better mobility than above knee (p=0.002). CONCLUSION: Lower limb amputees should participate in an aggressive in-patient physiotherapy regimen since reasonable mobility can be achieved in the majority of patients.
BACKGROUND: When there is doubt about perfusion in the distal part of the leg and around the ankle, an above-knee amputation (AKA) site has been the most commonly selected to assure primary wound healing. METHODS: The Gritti-Stokes amputation (GSA), a modified through-knee amputation, seems to have value for selected patients, according to a literature review and our success in a small group of patients. We have investigated the proportion of patients who have had AKA and who might have been suitable candidates for GSA. RESULTS: In a retrospective study of 66 patients who had had AKA, at least one third could have been considered for a GSA and might have benefitted from this procedure. This suggests that some consideration should be given to the reintroduction of the Gritti-Stokes operation. CONCLUSION: Our expectation is that patients so treated could achieve a high proportion of primary wound healing, an end-bearing stump, and more rapid rehabilitation than found in patients undergoing the classic AKA.
A retrospective review was carried out, of cases of amputation, which were performed between 1985 and 1999 at the Baptist Medical Centre, Ogbomoso with the aims of documenting our experience and complications. The majority of the operations were performed by trainee family practitioners. There was a preponderance of males (M/F ratio of 1.89:1) and over half of the patients were between 21 and 50 years of age. Most of the patients were admitted for trauma and most of them underwent a two stage operation. Slightly less than half of the amputations performed were below knee amputation (BKA). Eleven patients died, 6 of whom were diabetics (55%). It is recommended that medical practitioners be aggressive with wound care, especially in diabetics and that special attention be paid to the foot hygiene of these patients in order to prevent limb loss.
Within the figure of more than 200,000 surgical amputations performed in the United States each year lies another--70% of patients experience phantom limb pain after the procedure, and 50% still experience phantom pain 5 years after surgery. Patients describe burning, stabbing, twisting, cramping, or throbbing pains in the missing part. Adding to the patient's and the anesthesia professional's conundrum has been the lack of a simple model that tissue injury produces pain. The patient with a surgical amputation who experiences phantom limb pain can have several sources for discomfort including problems from the original tissue injury or from pathology, e.g., scarring or continued cellular dysfunction resulting from diabetes, ischemia, or infection. Suboptimal prosthesis fit and tissues and joints connected to the affected part can continue to generate pain long after surgical wound healing. In addition, nonaffected tissues and joints now made to carry extra loads as a result of altered gait and balance can sustain collateral stress and damage and produce nociception. In addition to this series of problems, amputee patients remain susceptible to the pain problems experienced by the general population. There is a positive correlation between a painful limb before amputation and experiencing chronic phantom limb pain. Authors have described patients with preamputation pain who benefited from effective preemptive analgesia and experienced less phantom limb pain. CRNAs can have a significant role in providing anesthesia and analgesia services to these patients and can begin to think in terms of preventing lifelong pain.
There is a real need for a reliable guide to determine the lowest level of successful limb amputation. Factors such as wound edge bleeding and clinical judgment cannot be minimized but, when clinical experience had been the sole index, AK amputation has too often resulted. The availability of a pocket-sized Doppler ultrasound pulse detector has made thigh or ankle systolic pressure recording a simple bedside procedure. Our analysis shows that a thigh pressure of 50 mm Hg correlates well with success of BK amputation. This fact can be added to the clinician's judgment in better rehabilitating the elderly ischemic amputee.
This study describes the methods of anesthesia and analgesia used in 296 limb amputations for vascular disease over a fifteen year period (1986-2000). The main type of anesthesia was general in 55%, epidural in 29% and spinal in 14%: there were no significant differences for ASA grade, age, or amputation level, nor any statistical differences in mortality for each method of anesthesia. The main methods of analgesia in the first 48 hours changed between 1986 and 1998, with decreasing intramuscular and oral opioids (from 42% to 1%, and from 14% to 1% respectively) while epidurals became the commonest method (2% in 1986 and 83% in 2000). Thirty-seven percent of patients were prescribed pethidine for phantom pain. There have been substantial changes in postoperative analgesia following amputation, and epidurals are now common practice, despite the controversy about their role in preventing phantom pain.
The aim of the study was to investigate whether the Swedish version of the Katz Index of ADL (Activities of Daily Living), on days 5-7 after amputation for vascular disease, had predictive value regarding length of hospital stay, discharge to the patient's own home or death within 1 month. Patients who had recently undergone primary unilateral trans-tibial amputation, living in their own homes before the amputation, were included. Fifty-two patients with a median age of 78 years (60-92) were assessed with the Katz Index of ADL. Results revealed that of the 10 (20%) patients discharged to their own homes within 1 month, only 2 belonged to grades A-C, that is, were independent in the majority of functions in personal ADL. Within 6 months 62% were discharged to their own homes. Eighty-four percent of the patients in grades D-G, i.e. most dependent on others, were still at the hospital or dead 1 month post-operatively. All the patients who belonged to grades A-F survived the first month post-operatively. The Katz Index of ADL had predictive value regarding early outcome in terms of length of hospital stay, discharge to the patient's own home or death within 1 month, and positive predictive value regarding survival the first month post-operatively.
OBJECTIVE: To evaluate the function of injured hand after repair of finger stump and reconstruction of digit tendon attachment in finger amputation. METHODS: From 1992 to 1998, 20 cases with amputation of the 2nd to the 5th fingers were investigated, of which reconstruction of digit tendon attachment in 10 cases (group A) and routine operation without reconstruction of digit tendon attachment in other 10 cases (group B). After 6 months of operation, the tension test, fatigue test the sense of stability in motion and the perimeter of forearm in injured hand and the corresponding healthy hand were compared. RESULTS: The differences were remarkable (P < 0.01) between group A and group B in the tension test of injured finger, the fatigue test, the sense of stability in motion and the perimeter of injured arm. CONCLUSION: The digit of injured finger should be reconstructed in finger amputation in order to furthest maintain the function of injured hand.
Amputation, once the mainstay of treatment of malignant bone tumors, now is used selectively and infrequently. Most patients are candidates for limb-sparing procedures because of effective chemotherapeutic agents and regimens, improved imaging modalities, and advances in reconstructive surgery. Patient age as well as tumor location and extent of disease help define the most appropriate surgical alternatives. Options for skeletal reconstruction include modular endoprostheses, osteoarticular or bulk allografts, allograft-prosthetic composites, vascularized bone grafts, arthrodesis, expandable prostheses, rotationplasty, and limb-lengthening techniques. Two key factors must be considered: survival rates should be no worse than those associated with amputation, and the reconstructed limb must provide satisfactory function. Functional outcome studies comparing limb-sparing procedures and amputation have inherent limitations, including the inability to randomize treatment and the subjective nature of important outcome measures.