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Primary transposition of digital nerves into muscle in second ray amputation: a possible answer for neuroma formation.

After second ray amputation, neuroma formation is a common cause of postoperative pain localized at the web space due to sectioning and leaving the digital nerve ends. Most of the time the complaints lead to two or more operations, using several described techniques, with some limited success. However, transposition of the digital nerve ends into interosseous muscles should be added to the second ray amputation as a part of procedure, neuroma problems can be solved. The technique is described by detail in this article which is advised for other ray amputations and during revisions.

Journal Article↗

Amputation neuroma of the hepatic hilum after orthotopic liver transplantation.

Amputation neuromas following biliary surgery have been previously reported. There are no descriptions, however, of amputation neuroma following liver transplantation. Serial hilum sections taken from 93 hepatectomy specimens obtained during the clinical course of 262 consecutive orthotopic liver transplantations revealed 26 amputation neuromas (27.9% of the specimens examined). The finding was confirmed by immunohistochemistry with numerous S-100 protein positive cells intermingled with neurofilaments interrupting the perineurial layer of cells testing positive for epithelial membrane antigen. Neuromas were found in liver specimens obtained between 89 and 775 days post-transplant (mean time, 211 days). The incidence of neuroma was higher in specimens resected more than 3 months post-transplant. There was only one symptomatic patient, who died from extrahepatic cholestasis demonstrated at autopsy to be caused by a hilar neuroma obstructing the main bile duct.

Humans↗

Induction of dentin formation on canine amputated pulp by recombinant human bone morphogenetic proteins (BMP)-2 and -4.

Dental pulp cells have the potential to differentiate into odontoblasts. The molecular mechanisms underlying differentiation are not clear. Demineralized dentin matrix is osteoinductive and contains bone morphogenetic protein (BMP) activity. BMPs have been implicated in embryonic odontogenic differentiation and hence may play a role in the differentiation of adult pulp cells into odontoblasts during pulpal healing. This study examined the hypothesis that BMPs induce dentin formation on amputated canine pulp. Recombinant human BMP-2 and BMP-4 were capped with inactivated dentin matrix on amputated pulp. At two months, the amputated pulp was filled with tubular dentin in the lower part and osteodentin in the upper part. The amount of dentin formed was markedly diminished when dentin matrix alone was implanted. These findings imply that recombinant human BMP-2 and BMP-4 induce differentiation of adult pulp cells into odontoblasts. Thus, BMPs may have a role in dentistry as a bioactive pulp-capping agent to induce dentin formation.

Animals↗

Syme's two-stage amputation in insulin-requiring diabetics with gangrene of the forefoot.

Thirty-five insulin-requiring adult diabetic patients underwent 38 Syme's Two-Stage amputations for gangrene of the forefoot with nonreconstructible peripheral vascular insufficiency. All had a minimum Doppler ischemic index of 0.5, serum albumin of 3.0 gm/dl, and total lymphocyte count of 1500. Thirty-one (81.6%) eventually healed and were uneventfully fit with a prosthesis. Regional anesthesia was used in all of the patients, with 22 spinal and 16 ankle block anesthetics. Twenty-seven (71%) returned to their preamputation level of ambulatory function. Six (16%) had major, and fifteen (39%) minor complications following the first stage surgery. The results of this study support the use of the Syme's Two-Stage amputation in adult diabetic patients with gangrene of the forefoot requiring amputation.

Adult↗

Pulp remains viable following vital amputation of the mesio-buccal root of the maxillary fourth premolar in dogs.

Vital amputation of the mesio-buccal root of the maxillary fourth premolar (P4) was performed bilaterally in 8 dogs. Histopathologic evaluation of the tooth structure revealed normal pulp in the remaining mesio-buccal, mesio-palatal, and distal roots and crown during a mean follow-up period of 3.5 +/- 1.9 months. Amputation site healing was characterized by a reparative dentin bridge produced by odontoid cells. Tunnel defects were observed in 13 of 16 (81%) dentin bridges. It is concluded that the pulp of a tri-rooted, periodontal disease-free tooth remains viable during a 6-month period following vital root amputation. These results point to the intriguing possibility that this may also occur in humans, however, this needs to be directly tested in man.

Animals↗

Genital self-amputation and the Klingsor syndrome.

Two psychotic individuals, who performed acts of genital self-amputation, are presented. One of the patients had self-mutilated with the intention of suicide and had also in the past amputated his hand. Psychotic patients with delusions (often religious), sexual conflict associated with guilt, past suicide attempts or other self-destructive behaviour and depression, severe childhood deprivation, and major premorbid personality disorder, are the group at risk for genital self-amputation. It has been proposed that the eponym, the "Klingsor" syndrome, be applied only to acts of genital self-mutation, involving religious delusions. The author suggests that this syndrome should be expanded to include all cases of genital self-mutation resulting from a psychotic illness.

Abdominal Injuries↗

Rehabilitation after amputation for vascular disease: a follow-up study.

Rehabilitation of one hundred and twenty eight patients with lower limb amputation performed for vascular disease from 1979 to 1987 was assessed. Arteriosclerotic occlusive disease was the most frequent cause of amputation (85.9%). Sixty seven patients (52.3%) were diabetic. Early and late results were analysed. For long-term follow-up evaluation, Univariate method of Kaplan-Meyer product limit was employed. Multifactorial analysis was used to assess factors influencing mortality. On immediate evaluation of rehabilitation with a prosthesis 85.2% of patients were successfully fitted. On long term evaluation 47.8% of below-knee and 22.1% of above-knee amputees were alive and using the prosthesis full time at five years of follow-up (p = 0.0026). Opposite limb preservation at five years was 69.5% for diabetics and 90.2% for non-diabetics, respectively (p = 0.0013). Survival rate at five years was 42.4% for diabetics, and 85.0% for non-diabetics (p = 0.0002). On multifactorial analysis diabetic patients showed a risk of late mortality six times greater than non-diabetics. In conclusion rehabilitation after vascular amputation is feasible in a large number of patients, despite a limited life span. Diabetes represents a major risk factor both for life and for the opposite limb. Knee preservation is an important factor for better rehabilitation.

Adolescent↗

Neuronal response properties within subregions of raccoon somatosensory cortex 1 week after digit amputation.

Multiple penetrations in the somatosensory cortex of three anesthetized raccoons 1 week following amputation of the fourth digit provided detailed information about somatotopy and neuronal responsiveness in the deafferented cortex. Recordings in a total of 601 penetrations (292 in deafferented cortex and 309 in the surrounding cortex) were compared with those from intact control animals described previously (Rasmusson et al., 1991). The level of spontaneous activity increased within the deafferented cortex, with 42% of the sites having high or moderate levels of spontaneous activity, in comparison with 18% in control animals. There was also an increase in the incidence of inhibitory responses to stimulation of adjacent digits (26% of the penetrations vs. 10% in control animals), confirming previous findings. These two variables, increased spontaneous activity and the presence of strong lateral inhibition, were highly correlated in individual penetrations. An unexpected finding was that the cortex representing the intact parts of forepaw was also disrupted with respect to these two measures, suggesting that amputation had an effect outside the deafferented region. In contrast, response properties that are more clearly a reflection of information processing in the dorsal column-medial lemniscal pathway (adaptation and threshold) were altered only within the deafferented region. The deafferented region was not homogeneous immediately after amputation, but consisted of a radically affected core region and a slightly affected fringe adjacent to the intact representations. This inhomogeneity had also been apparent with partial digit deafferentation, reported previously. The fringe, approximately 1 mm in width, may reflect overlapping projections from adjacent digits at one or more levels of the somatosensory pathway. Since the size of the fringe is similar to the maximum extent of reorganization found in other models of reorganization, the mechanisms of plasticity within this region may involve an unmasking of pre-existing synapses with slight modification in synaptic strength. However, the plasticity within the core region of the raccoon seen in these experiments, which may be 5 mm from nondeafferented cortex, requires more extensive changes, perhaps via polysynaptic pathways.

Afferent Pathways↗

[Measurement of mandibular angle protrusion and semi-blind amputation of hypertrophied mandibular angle with the help of a pre-made mold].

OBJECTIVE: Mandibular hypertrophy is a subjective diagnosis to some extent. The authors tried to find a way for true objective diagnosis of mandibular hypertrophy. METHODS: Radiographic cephalometry was performed in 39 randomly selected adults. The degree of the mandibular angle was measured and summarized. According to measurement of the mandibular angle and the extent to be amputated, we designed and made various molds. RESULTS: With this pre-made mold, we amputated semi-blindly and exactly the desirable size and shape of the mandibular angle. This technique has been used in 6 patients for mandibular amputation and masseter thinning. In three patients shaving of the out layer of the hypertrophied mandible was also done. CONCLUSION: The new technique using the pre-made operative mold shortens operating time, reduces surgical bleeding and tissue swelling, and can help to remove the bony block precisely.

Adult↗

Rehabilitation after bilateral lower extremity amputation.

Fourty-four men (average age, 61.5 years) who had undergone amputation of both lower extremities were studied at a Veterans Administration hospital. Vascular insufficiency was the most frequent reason for amputation. In 26 of the patients bilateral below-knee amputations had been performed. Although diabetes mellitus was present in 26 of the patients, it severely hampered rehabilitation in only four. Twenty-nine (nearly 65%) of the 44 patients became totally independent in daily functions. However, the average time required for maximum rehabilitation was almost 30 weeks.

Aged↗

Sciatic nerve resection: is that truly an indication for amputation?

En bloc resection of the sciatic nerve with an adjacent bone or soft tissue tumor has been assumed to be associated with a poor functional outcome and, therefore, was considered an indication for amputation. Although many surgical oncologists today challenge this assumption and do limb-sparing resection in these patients, a report of the functional outcome of a series of patients who had this procedure has not been published. Between 1991 and 1999, the authors treated 15 patients who had resection of the sciatic nerve. There were 10 females and five males, ranging in age from 2 to 73 years. Diagnoses included 11 high-grade soft tissue sarcomas, one primary bone sarcoma, and three metastatic bone tumors. Four lesions were located in the pelvis, one in the buttock, and 10 in the posterior thigh. At the most recent followup, 14 patients were ambulatory, seven of whom required a walking aid. Because of peroneal nerve palsy, all patients required a short-leg brace. However, overall function was determined to be good in 11, moderate in three, and poor in one patient. None had a pressure sore of the foot and none required a secondary amputation. Good function is achieved in most patients who have sciatic nerve resection. Therefore, the necessity to resect the sciatic nerve is not an indication for amputation.

Adolescent↗

[The physical work capacity of disabled patients following amputation of the extremities].

The examination was performed of 125 invalids. Fifty-five of them underwent amputation of the upper limbs, seventy--of the lower limbs. Reduction of physical performance turned out dependent on body mass loss that is level of the amputation. The authors developed motor regimens, permissible exercise loads, criteria of the follow-up check-ups for the handicapped with various levels of limb amputation.

Adult↗

Syme's amputation.

Syme's amputation was performed in one stage in 8 and in two stages in 13 patients. Failures were defined as those requiring a more proximal amputation and were present in patients with vascular disease only. The failure rate was 38% in the group with vascular disease and 24% in the total group. Syme's amputation provides the patient with a durable end-bearing stump, even in insensitive feet.

Adolescent↗

[Replantation of traumatically amputated parts of extremities-- indications and nomenclature].

The authors submit a brief report on replantation activities during the past five years and discuss the problem of indications and terminology of traumatic amputations. The paper contains instruction regarding communication by telephone between the attending surgeon and a specialized microsurgical department. There are also instruction how to handle the amputated portion of the limb and how to transport the patient and the amputated portion of the limb. The authors discusses traditional procedures in replantation surgery on the basis of his own experience with 292 replantations or revascularizations.

Arm Injuries↗

[Amputation or circulatory reconstruction in critical chronic ischemia of the lower extremities].

As a rule, leg amputations in the elderly lead to an inability to walk and as a consequence to nursing-home care. The loss of body integrity and of psycho-social roots are responsible for the high mortality of 60% or more during in the first year after amputation. In case of imminent amputation, the crural arteries are almost always involved in the process of vascular occlusion. Only during the last 10 years has vascular surgery in the crural area become possible. Today crural reconstructions have a primary success-rate of over 90%, and in 60% of patients the leg can be saved in the long run. Even better long-term results may be expected through interdisciplinary collaboration and by the integration of microsurgical techniques.

Aged↗

Congenital Chopart amputation. A functional assessment.

Of 11 patients with congenital Chopart-level foot amputations, the average age was 6.75 years. Data collected from each patient included leg-length and calf-circumference measurements, range of motion at the ankle and subtalar joints, and a record of stump appearance. The patients were timed running a 50-m dash and measured in a standing broad-jump performance. Patients with congenital Chopart amputations functioned within normal limits in all of the authors' tests. No patient had a plantar flexion deformity. A slipper-style shoe filler or ankle foot orthosis with a foot plate and shoe filler was used as an easily fabricated and very functional prosthesis. The Chopart foot was found to have many advantages compared to a Symes-level amputation, including maintenance of functional length of the extremity, preservation of a broad weight-bearing surface, and an intact plantar fat pad.

Adolescent↗

[Improvement of perineal wound healing following rectum amputation by omentum flap].

The aim of the presented study was to find whether significant improvement in perineal woundhealing could be achieved by placing pedunculate parts of greater omentum in the sacral cavity after rectal amputation. 70 patients undergoing rectal amputation were evaluated, in 34 patients pedunculate parts of the greater omentum were positioned in the presacral cavity. Results show that an omentum flap improves primary perineal woundhealing and reduces per secundam woundhealing time (p less than 0.025). Since regular placement of pedunculate parts all wounds were closed after 3 months. Sinus formation is reduced (p less than 0.05). Suction drainage must be removed early, otherwise infections aggravate woundhealing going up the tube (p less than 0.001). We conclude from our results that the placement of pedunculate parts of the greater omentum in the sacral cavity after rectal amputation is a useful method to improve perineal woundhealing and should be done as routine procedure.

Aged↗