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PubMed1978

Lower extremity amputation for ischemia.

Three hundred-twenty-four amputations of the lower extremity for ischemia at the University of Oregon Health Sciences Center over the past ten years are presented. Striking differences between the first and second five-year periods are noted in level of amputation. The primary healing rate of all patients in the two periods was similar. Diabetics tended to have more distal amputations but primary healing was lower than that of nondiabetics.

Amputation, Surgical↗
PubMed1982

Peri-operative antibiotic cover in amputations using an amoxycillin-clavulanic acid combination.

In a series of 64 patients requiring amputation for lower limb sepsis, the performance of a new antibiotic combination with beta-lactamase-inhibiting properties, amoxycillin plus clavulanic acid (A-CA) (Augmentin; Beecham) in the prophylaxis of postoperative wound sepsis, was compared with that of a combination of amoxycillin and ampicillin (A-A) (Suprapen; Bencard) and a control group. The sepsis rate following A-CA prophylaxis (12,9%) was significantly less than in the control group (x 2 = 18, 49; P less than 0,001). Although not attaining statistical significance (x 2 = 2, 12),, A-CA compared favourably with A-A (sepsis rate 35.3%) in the prevention of post-amputation wound sepsis. There was no statistically significant difference in the development of sepsis between wounds closed primarily and those left unsatured while under A-CA cover. It is concluded that peri-operative antibiotic cover for amputations in septic lower limb lesions is advisable and that A-CA is a valuable antibiotic in this situation.

Adult↗
PubMed1982

[Characteristics of the rheological properties of the blood, thrombocyte function and hemodynamics in ischemic heart disease after the amputation of the extremities of patients in a state of prolonged hypokinesia].

Ischaemic heart disease (IHD) in patients after amputation of the limbs runs a course with little manifest clinical symptoms, but with high risk of development of myocardial infarction with a lethal outcome. In patients after amputation of limbs there is a decrease of the blood stroke volume, increase of the total peripheral resistance and also marked disorders of the blood rheology and the function of platelets. In patients with IHD after amputation of the limbs for obliterating diseases of the vessels such changes are manifest in disorders of the microrheological properties of the blood (the rate of aggregation of red cell and the stability of red cell aggregates). Physical rehabilitation and prostheses in patients of this groups must be realized under careful cardiological control.

Adolescent↗
PubMed1982

Lower extremity amputation level: selection using noninvasive hemodynamic methods of evaluation.

The superior rehabilitative potential of the below knee amputee versus the above knee amputee is well known. In end-stage occlusive vascular disease, the limiting factor in determining how distal an amputation can be performed is whether or not the stump will heal. The use of clinical judgement to determine the correct amputation level has historically been proven to be too subjective. Therefore, several procedures have been proposed which would hopefully fulfill the need for a reliable, objective method for determining the optimal amputation level. These procedures include the measurement of local and cutaneous blood flow and pressure, blood volume, and skin temperature. After evaluating the studies done on each of these procedures, it is evident that the measurement of skin capillary blood flow is the most accurate parameter for predicting wound healing potential.

Age Factors↗
PubMedDate not supplied

Above vs. below knee amputations: a retrospective analysis.

A review of 99 case histories (57 males and 42 females) involving 117 amputations of the lower limb during a four-year period is presented. Fifty-eight below-the-knee amputations were performed: five were revised to the above-the-knee (AK) level. There were 54 primary AK amputations. Complications associated with peripheral vascular disease constituted the main reason for performing surgery. The overall mortality rate was 20.2%: sepsis was the main cause of death.

Adult↗
PubMed1981

An effective method of skin traction in A-K guillotine amputation.

In modern orthopedic surgery, there are still indications for the guillotine amputation of the thigh. Immediate postoperative management by effective skin traction can promote rapid healing and eliminate the need for revision surgery. Revision surgery necessitates further shortening of the stump; skin grafting likewise can be avoided as a secondary procedure. Most skin tractions for above-the-knee amputations loosen within 24 hours. The suggested method of applying skin traction on A-K amputations, if applied properly, will be effective for periods ranging from five to seven days.

Amputation, Surgical↗
PubMed1981

Surgery of hand and finger amputations.

The management of upper limb amputations is an important part of the practice of surgery of the hand. Reattachment of parts has opened dramatic new potentials, but elective amputation and wound closure after traumatic loss remain frequent and important operations. The negative aura surrounding these unpleasant events favors their quick disposition, but they demand the same measured judgement, technical skill, and concern that any reparative hand operation requires. Many basic surgical principles related to amputation are well established and must be followed. The difference in surgery under war conditions and civilian practice, where careful surveillance is possible, must be appreciated. Secondary procedures must be proposed on the basis of very careful study of the circumstances and the needs of each patient, above all avoiding unrealistic attempts at reconstruction. The aesthetics and the psychological impact cannot be ignored. Success can be measured only by the patient's recovery in a global sense, that is, how well he or she resumes normal life.

Amputation, Surgical↗
PubMed1980

[Amputation of the lower leg with formation of a musculo-cutaneous flap in vascular diseases].

A report is presented on leg amputations with formation of a posterior musculocutaneous flap, as used since 1970 at the authors' clinic for vascular diseases. A total of 87 patients were operated on. In 74.7%, the amputation stump healed per primam; in 88.7%, movements of the knee joint were completely preserved. Rehabilitative walking on the prosthesis is possible very soon after the operation. The described method of amputation may also be recommended for patients with extensive loss of circulation of the lower extremities, including cases complicated by diabetes.

Adult↗
PubMed1995

Alternative methods for below-knee amputation: reappraisal of the Kendrick procedure.

BACKGROUND: In 1956, Kendrick described a technique for below-knee amputation (BKA) using anterior and posterior flaps in a length ratio of 1:2. There has been no review of the utility and safety of this technique over the past four decades. STUDY DESIGN: The Kendrick method was studied in 96 consecutive patients who underwent 100 BKAs from 1982 to 1995. Follow-up examination was continued through the period of rehabilitation and included all revisional surgery. RESULTS: Eighty-one patients had diabetes mellitus, 15 patients were nondiabetic, and the mean age was 67 years (range, 12 to 94 years). Fifty-seven patients underwent BKA for diabetic foot sepsis with healing failure after debridement or nonreconstructable vascular disease, 19 patients underwent BKAs for progressive necrosis despite a patent arterial reconstruction, and 24 patients underwent BKAs for other causes, including microembolism, calciphylaxis-related gangrene, bypass failure, trauma, frostbite, and calf-wound healing failure after coronary revascularization. Preliminary guillotine amputations were performed on three limbs. There was an incision in the calf from previous vascular surgery in 25 limbs. The 30-day mortality rate was 6 percent. Healing of the stump and knee salvage occurred in 93 limbs (93 percent). Four patients had local wound complications develop in the stump, yet they eventually healed. During the follow-up period, conversion to an above-knee amputation was necessary in seven patients, five within 30 days. Only one of these was in a limb with a previous arterial reconstruction in the calf. CONCLUSIONS: The Kendrick procedure for BKA with anterior and posterior flaps is efficacious and safe. This procedure is advantageous for its anatomic basis, the ease with which the flaps can be designed despite leg edema or overall size, and the ability of the surgeon to distance the posterior flap margin from sepsis in the lower one-third of the calf.

Adolescent↗
PubMed1995

[Successful replantation in ten-digit complete amputation: a case report].

We report a case of successful replantation of ten-digit complete amputation. The conditions of the wounds over the ends of the ten amputated digits varied from severe to light and easy for replantation. The amputation included severe avulsion injuries over four fingers. Appropriate measures were taken during surgery and the replanted digits all survived. The replantation operation was done by a team of surgeons. Although the surgeons were physically challenged by the long and difficult procedures, they worked hard for the benefit of the patient. Physiotherapy and exercises six months after operation showed that the functions of both hands were largely recovered.

Adult↗
PubMed1995

[Results of revascularization and amputation of the gangrenous diabetic foot. Importance of a multidisciplinary approach].

A total of 89 diabetic patients with foot lesions were treated using amputation during the past 5 years at Niguarda-Ca' Grande Hospital. All patients suffered from gangrene which in 76% of cases was classified as Wagner's stage IV. The lesion was infected in 67 patients. Emergency surgical cleansing was performed in order to drain abscesses and remove necrotic tissue, taking care not to damage healthy tissue. An accurate multidisciplinary study was performed in all cases which included neurological, oculistic and vascular assessment. 83% of patients presented retinopathy and 62.5% were nephropathic. Angiographic tests revealed the presence of distal vascular lesions in 90% of cases. A femoro-distal by-pass was used in 17 cases and the limb was salvaged in 13 patients; ileal-femoral PTA was performed in 10 cases and the limb was salvaged in 7 patients. Amputations were limited wherever possible to distal segments: toes (55 cases), transmetatarsal (12 case), leg (12 cases), thigh (5 cases), atypical resections or ample cleansing of the foot (5 cases). This approach allowed us to record: 1) a low operative mortality (1 case); 2) higher quality of life; 3) the possibility of reoperating on more proximal portions of the limb in the event of immediate or long-term failure. This was necessary in 19 cases which can be classified as follows: reamputation of toe (11 cases), transmetatarsal (4 cases), amputation of leg (4 cases).

Aged↗
PubMed1994

[Blood vessel transfer allowing avoidance of surgical rotation or amputation in the management of primary malignant tumors of the knee].

PURPOSE OF STUDY: The surgical and clinical outcome of a limb-salvaging technique for tumors about the knee utilizing autogenous vessel transfer is reported. The original indication for these lesions was amputation or Van Nes rotationplasty because of vascular encasement by the tumor. MATERIAL: Twelve patients are reported: seven females and five males with an average age of 16 years. There were nine distal femur and three proximal fibula stage IIB primary malignant tumors. METHOD: All patients underwent a local wide resection of the primary tumor including the main vessels, followed by local reconstruction of the bone and vessels by an ipsilateral vessel transfer. Postoperatively the limbs were immobilized in a cast and the patients were treated with intravenous Heparin, followed by a single low dose Heparin injection for three months. RESULTS: Immediate postoperative arterial occlusion in one patient was successfully treated, but eight weeks later another occlusion occurred and an amputation was necessary. In another patient, arterial thrombi necrotized two toes; they were subsequently amputated. Other local complications were hematoma (two patients), superficial skin necrosis (one patient), and deep infection (one patient). All were successfully revised surgically. All resections obtained negative margins, and there were no local recurrences or distant metastases. In all twelve patients the tumor either encased the artery and vein, or the pseudocapsule of the tumor touched the vascular adventitia. DISCUSSION: The results show that by patients in whom there is attachment of the tumor with major vessels or in whom the vessels are encased by the tumor, wide limb-saving resection can be achieved by en-bloc resection of the primary tumor and the vessels. In this respect a contamination of the vessels is no longer a contra-indication for a limb-saving procedure. CONCLUSION: The described method is safe, has a relatively low complication rate comparable with rotationplasties and allows a limb-saving procedure.

Adolescent↗
PubMed1993

Anatomical and functional changes in the organization of the cuneate nucleus of adult rats after fetal forelimb amputation.

A previous study has shown that fetal forelimb removal in the rat results in an increase in the size of the hindlimb representation in primary somatosensory cortex and suggested that this anomalous cortical organization may have resulted from alterations in the primary afferent innervation of the dorsal column nuclei (Killackey and Dawson, 1989). The present study used both anatomical and electrophysiological techniques to examine the effects of fetal forelimb amputation on the dorsal column nuclei. Rats sustained forelimb removals on embryonic day 16 and were used in terminal experiments when they reached adulthood (> 60 d of age). Analysis of cytochrome oxidase-stained sections demonstrated that the cuneate nucleus ipsilateral to the lesion decreased in volume by an average of 36.7% (N = 7, p < 0.001, paired t test), but there was no corresponding increase in the volume of the gracile fasciculus and nucleus. Bilateral application of HRP to the sciatic nerves demonstrated that axons that innervate only the gracile nucleus on the intact side of the brainstem were present in the cuneate nucleus on the deafferented side. Injection of HRP into the skin overlying the point of the amputation (the stump) indicated that axons innervating this region filled most of the dorsal one-half of the shrunken cuneate nucleus and overlapped with the sciatic nerve afferents innervating the cuneate on this side. Mapping the receptive fields of multiple unit clusters demonstrated that most recording sites in the shrunken cuneate nucleus were activated by inputs from the stump and adjacent skin. In addition, 9.1% (N = 30) of such unit clusters (N = 328) could also be excited by stimulation of the hindlimb. These were observed in only three of the nine experiments. Unit clusters with split receptive fields including the skin overlying the stump and the hindlimb were located throughout the rostrocaudal extent of the cuneate nucleus. These results indicate that fetal forelimb amputation results in anatomical expansion of the central projections of hindlimb afferents into the cuneate nucleus. This anatomical organization appears weakly expressed in the receptive fields of cuneate neurons.

Afferent Pathways↗
PubMed1993

A functional and psychosocial assessment of patients with post-Sudeck atrophy amputation.

Twelve patients with reflex sympathetic dystrophy were referred to a comprehensive orthopaedic rehabilitation center after failure of conservative management. Ten underwent amputation of the affected limb and, although functional improvement occurred in the patients undergoing lower limb amputation, psychosocial dysfunction persisted. All the patients required psychological support. In cases of post-Sudeck amputation, early orthopaedic diagnosis and referral to a comprehensive treatment center are recommended. In the 12 cases described here, apart from the obvious limb pathology, severe psychological inadequacies were found to be present.

Activities of Daily Living↗
PubMedDate not supplied

Anatomic sites of foot lesions resulting in amputation among diabetics and non-diabetics.

OBJECTIVE: To identify and quantify the anatomic sites of foot lesions resulting in amputation among patients suffering from peripheral arterial disease with and without diabetes mellitus. DESIGN: A retrospective study. SETTING: Department of Orthopaedic Rehabilitation. PATIENTS: A total of 212 recent lower limb amputees with diabetes mellitus (158) or peripheral arterial disease only (54) admitted for prosthetic rehabilitation. RESULTS: In 62.2% of all amputees the site of lesion that led to amputation was located in the digits. A lesion under the metatarsal heads was reported in 8.0%, along the mid-foot and heel in 8.5%, on the dorsum of the foot in 3.3%, around the ankle joint and lower leg in 5.7%. Finally, 12.3% reported multiple lesions or were unable to recall the exact anatomic location. CONCLUSIONS: Most foot lesions resulting in amputation are located around the digits. These high-risk sites, therefore, need the patient's and the health care team's special attention. The patient should be trained in self foot examination and meticulous daily care, whereas the role of the health care team is in foot evaluation and provision of protective foot wear.

Adult↗
PubMed1994

[Prosthetic management after amputation injuries of the lower extremities. Orthopedic-technical management].

The primary treatment of a below and above knee amputation consists in replacing the lost extremity with a preliminary prosthesis. This has been of value regarding the medical-social rehabilitation and treatment costs. The final prosthesis in form of a full contact or short stem prosthesis in below knee amputations means extraordinary good comfort to the patient and should be preferred to the "classic" below knee prosthesis with thigh stem. In the last years the final prosthetic design for above knee amputation has changed from the classic transversal-oval form to the longitudinal-oval CAT-CAM-stem. The distinctive advantages of this design is a physiological weight bearing of the hip joint and no risk of compression of the medial vessels.

Amputation, Surgical↗
PubMed1994

Continuous regional analgesia by intraneural block: effect on postoperative opioid requirements and phantom limb pain following amputation.

The objective of this study was to assess the effectiveness of a previously described technique of regional analgesia (continuous infusion of local anesthetic through a catheter placed at the time of amputation within the exposed sciatic or posterior tibial nerve) on relieving the postoperative pain in a heterogeneous group of patients who underwent lower extremity amputations. A second objective was to determine the effect of such treatment on the incidence and characteristics of phantom limb pain 6 months or more after surgery in the same patients. The study design was retrospective, unblinded, controlled (postoperative pain), and unblinded questionnaire and interview (phantom pain) were utilized. Subjects were inpatients at Harborview Medical Center, University of Washington, Seattle, WA. Nineteen bupivacaine-treated and 40 nonbupivacaine-treated patients who underwent lower extremity amputation subsequent to trauma, infection, long-standing injury (poor or no function), congenital deformity, or burns were evaluated in the postoperative pain management assessment. Nine treated and 12 untreated patients were interviewed in the phantom pain assessment. Bupivacaine 0.5% 2-6 ml/h was infused through a polyamide 20-gauge catheter inserted into the sciatic or posterior tibial nerve sheath under direct vision at the time of surgery. All patients, treated and control, received opioid analgesics systemically during the 72-hour period of study. The postoperative opioid analgesic requirement of treated patients was compared with that of control patients who received opioid analgesics alone. A questionnaire was administered to assess presence, severity, and character of phantom pain.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1994

Prevention of phantom pain after major lower limb amputation by epidural infusion of diamorphine, clonidine and bupivacaine.

Phantom limb pain may appear in up to 85% of patients after amputation. There is no effective treatment. Perioperative epidural infusion of morphine and bupivacaine, alone or in combination, is effective in preventing phantom limb pain in patients with pre-existing limb pain. Serious side-effects, however, make them difficult to manage on a general ward. Clonidine has been shown to be an effective postoperative analgesia when applied epidurally. To mitigate the potentially serious side-effects of all these drugs, we have studied their combined efficiency in preventing phantom limb pain in a prospective controlled study of 24 patients undergoing lower limb amputation. In the study group (n = 13), an epidural infusion containing bupivacaine 75 mg, clonidine 150 micrograms and diamorphine 5 mg in 60 ml normal saline was given at 1-4 ml/h 24-48 h preoperatively and maintained for at least 3 days postoperatively. The control group (n = 11) received on-demand opioid analgesia. Pain was assessed by visual analogue scale at 7 days, 6 months and 1 year. At 1 year follow-up, one patient in the study group and eight patients in the control group had phantom pain (P < 0.002) and two patients in the study group versus eight patients in the control group had phantom limb sensation (P < 0.05). There was no significant improvement in stump pain. We conclude that perioperative epidural infusion of diamorphine, clonidine and bupivacaine is safe and effective in reducing the incidence of phantom pain after amputation.

Adult↗