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We have reviewed 75 amputees, 58 in the lower limb and 18 in the upper. Closed amputation was performed in 69 patients (92%) and an open procedure in six (8%). Wound infection occurred in six (8%) and one patient died from thromboembolism. Wound healing was normal in the remainder. The results of closed amputation in war conditions are very good, if performed within 6 hours of injury.
Amputation for tumours is rarely carried out nowadays and has few specific technical features, apart from the rare cases where ingenuity is required to gain a few centimetres in length of a stump. As far as possible, the decision for amputation should not be imposed; it is better that the patient himself should take the initiative. The prosthesis and its constraints should be described honestly to avoid subsequent disappointment. Prevention of a painful phantom limb must always be undertaken, and based on certain operative and perioperative precautions. The most important factors are treatment by psychotropic agents and the quality of the human relationships between patient and surgeon.
BACKGROUND: Below knee amputation (BKA) is often required in patients with critical limb ischemia. When such a procedure fails, an above knee revision (AKA) is required. This can cause further complications in this group of patients, who already have a high incidence of medical co-morbidities. METHODS: Case records of 47 patients (51 procedures performed) with BKA for peripheral vascular diseases during a 4-year period were reviewed. Clinical factors were analyzed using bi- and multi-variate analysis against the procedure outcome. Degree of social deprivation was evaluated with DEPCAT score in relation to amputation failure. Each arterial segment of the pre-operative arteriograms was scored based on a 3-point scoring system (0=normal, 1=stenosis, and 2=cclusion). With the assignment of an arbitrary weight for each segment, a total arterial score (TAS) was derived for each patient. RESULTS: Eighteen percent of BKA (n=9) failed. Absence of popliteal pulse (failure vs. success: 100% vs. 63%, P=0.04), calf rest pain (67% vs. 20%, P=0.01), combination of calf rest pain and feet tissue loss (CRPFTL; 67% vs. 3%, P=0.00), postoperative stump trauma (44% vs. 10%, P=0.03), and wound infection (WI; 89% vs. 26%, P=0.00) were factors associated with the failure of a BKA in bivariate analysis. Using multiple logistic regression, WI (OR=14) and CRPFTL (OR=47) were found to be independent predictors for the outcome of BKA. No statistical significance was found between the DEPCAT score and the failure rate. TAS was significantly higher in the failure group (median=17 vs. 9; P=0.00). CONCLUSIONS: This study suggests that CRPFTL and postoperative WI are predictor variables for the failure of a BKA. In addition, there is the potential role of arteriogram scoring in predicting the outcome of a BKA.
BACKGROUND: We present a patient with a subtotal traumatic supramalleolar amputation of the leg, which was initially treated by a vascular reconstruction with deliberate bone and soft-tissue shortening. METHODS: To correct the ensuing complex deformity, which consisted of a varus hindfoot, leg length discrepancy and equinus, a staged reconstruction was planned. Initially, the hindfoot varus, in presence of a stiff ankle, was corrected by a supramalleolar osteotomy, followed by a Wagner distraction and finally a correction of the equinus. RESULTS: After a relatively long period of normal functioning, she regained painful minimal ankle function, which necessitated ankle fusion and correction of a pronation deformity. At the most recent follow-up 13 years after the injury, the patient is fully functional and has near normal leg length. CONCLUSION: Although a mangled lower extremity is often a candidate for primary amputation allowing early rehabilitation, in certain cases a good result can be obtained by a creative strategy.
INTRODUCTION: Aim of this retrospective study was to obtain a functional outcome following callus distraction and phalangization of the thumb after traumatic amputation in the middle one-third. MATERIALS AND METHODS: From January 1998 to June 2001, 12 patients were treated in a staged procedure starting with corticotomy and continuous distraction (1 mm/day) of the first metacarpal bone using a unilateral external fixator device. After distraction until day 31 (range 25-35 days), the first metacarpal bone was stabilized with a plate, and phalangization was performed. RESULTS. At follow-up 1 year after surgery, the thumb was lengthened to 25-35 mm (average 28 mm) in all but 1 patient. In 1 patient a bone graft from the iliac crest had to be interposed. Pinch grip improved by 45%; grip strength improved by 55%. The function/symptom score from the DASH questionnaire was 25 points (range 16-38 points). In a 'pick-up test' all patients were able to pick up a pencil, they were able to write and could hold a full cup of water. Nine patients were able to pick up a paper clip, and 8 patients could hold a 1-liter bottle of water. CONCLUSION: Callus distraction can be considered a suitable procedure to reconstruct an amputated thumb levelled at the middle one-third. Additional phalangization proved essential as it deepened the first web space, enabling good motion and grasp. Callus formation was delayed in elderly patients, but adequate lengthening and bone healing also occurred in this age group. The procedure will not be as beneficial in cases of osteoarthritis of the trapezometacarpal joint or when coverage of the stump is insufficient. The DASH questionnaire is very helpful in evaluating the effect of thumb reconstruction on the entire upper limb.
Functional outcome and survival in 253 patients treated for critical leg ischemia (CLI) in Guadeloupe (French West Indies) were analyzed. Analysis included calculation of quality-of-life score (QLS) from telephone survey data, with a median follow-up time of 42 months (range 12-109). A slight but significant benefit was observed in the 140 patients who underwent arterial reconstruction, with 76% autonomous ambulatory function, 51% independent residential status, and a QLS of 6.9 +/- 1.5 in comparison with the 113 patients who underwent amputation: 34%, 17%, and 5.1 +/- 2, respectively (p < 0.0001). Survival was comparable in the two groups. Inadequate medical follow-up that was either totally lacking or performed only in case of recurrent CLI as well as low rates of rehabilitation (50%) and prosthetic fitting (32%) in the amputation group highlight the existence of a double problem involving therapeutic compliance and vascular follow-up care/rehabilitation in Guadeloupe.
Our objective was to assess outcomes for 8696 patients who underwent 9236 above- (AKA) and/or below-knee (BKA) amputations during a 4-year period for disorders of the circulatory system. Veterans Affairs (VA) Patient Treatment File (PTF) data were acquired for all patients in Diagnosis Related Groups (DRGs) 113 and 114 hospitalized in VA medical centers (VAMCs) during fiscal years 1991-1994. Data were further analyzed by Patient Management Category (PMC) software, which measured illness severity, patient complexity, and relative intensity score (RIS), a measure of resource utilization. The results of this analysis showed that mortality and morbidity rates remain high after AKA and BKA. Differing amputation practice patterns found in this study warrant further investigation.
A 66-year-old woman had a recurrent desmoid tumor in the right thoracic apex. The tumor infiltrated the brachial plexus and eventually rendered the upper right extremity functionless. The tumor was removed by aggressive wide resection of the right upper hemithorax with simultaneous amputation of the functionless right arm. Reconstruction of the chest wall was accomplished, utilizing the soft tissues of the remnant arm as a pedicled flap to cover the full-thickness defect. Aggressive wide resection of the chest wall with limb amputation is technically challenging but unavoidable in some cases of recurrent desmoid tumor.
Nonoperative management of fingertip pulp amputations has been employed in eighteen adults. After wound cleansing and debridement, the wound was covered by an occlusive dressing. Healing of the amputated fingertip occurred within four weeks. The healed fingertip had an excellent sensory perception, normal range of motion and an acceptable cosmetic appearance. This satisfactory outcome was realized with less than ten days lost from work.
Ankle pressures were obtained using Doppler ultrasound in fifty-seven patients undergoing forefoot amputations. Contrary to other reports, no amputations healed with a pressure of less than 60 mm Hg.
One hundred consecutive patients undergoing major lower extremity amputations were critically analyzed over a five year period. The results of surgical care and the degree of success of rehabilitation were determined. The number of patients with peripheral vascular occlusive disease who require major lower extremity amputations appears to be increasing and they continue to present a challenge to the surgeon.
Thailand recently experienced an epidemic of penile amputations. These were usually performed by angry wives on philandering husbands. This outbreak appeared to have been fueled by graphic press reports and fortunately seems to have abated. A technique for reanastomosis of the amputated penile segment was first described by McRoberts et al [5] in 1968. It was modified further so that it can be performed in any general hospital with an acceptable result. Experience with this procedure in 18 patients has been described.
Walking is most efficient when the least energy is spent over a certain distance. In six normal male subjects and 11 males with above-knee amputation the comfortable self-selected walking speeds and the most metabolically efficient walking speeds were determined. For that purpose energy expenditure was measured per second and per meter at six incremental walking speeds. Heart and step rate were registrated also at each walking speed. The results showed that in subjects who have not undergone amputation the comfortable walking speed is the same as the most efficient walking speed. However, in the above-knee amputee group, the comfortable walking speed is lower than the most efficient walking speed. When both groups walked at their own efficient walking speed they had the same energy expenditure per second.
A retrospective survey of 100 lower limb amputations performed for ischaemia were analysed to assess the influence of preoperative bacterial isolates and the use of prophylactic antibiotics on wound sepsis. Forty-eight per cent had previously undergone a vascular procedure to attempt limb salvage and 17% were diabetics. Benzylpenicillin was given preoperatively and continued for 5 days; diabetics received metronidazole in addition. A total of 51 isolates were obtained from 30 patients preoperatively; Staphylococcus aureus and Enterobacteriaceae each accounted for over 25%. Postoperatively, 74 isolates (20 multiple) were obtained with an overall sepsis rate of 40%. Those patients with a positive preoperative culture were significantly more likely to develop wound sepsis. There was no significant difference in wound sepsis rates for diabetics. In view of the range of organisms causing postoperative infection, we recommend prophylaxis with a broad spectrum antibiotic for amputations.
For fingers left shorter volarly after finger-tip amputation, a volar V-Y amputation flap designed with the V-Y portion at the middle phalanx level and using the Snow cupping technique for reconstruction of the pulp and tip has provided good sensation, padding and contour. Hypersensitivity and beaking of the nail have not been problems.
The volar V-Y plasty is a well accepted method of management for transverse fingertip amputations. It has been suggested by some authors and assumed by some surgeons that fingertip sensation is nearly normal following the procedure. Sixteen patients with twenty fingertip injuries in our series reported an average estimate of sensitivity of 73% of normal. There was diminished sensation to testing by two-point discrimination and/or von Frey monofilament testing in all fingertips when compared to the contralateral digit. Eight patients (twelve fingertips) reported hypersensitivity, particularly cryalgia. We conclude that sensation is not normal in almost all fingertips treated by V-Y plasty for transverse amputations.
Two cases of painful amputation neuroma treated by a new method are described. A vascularized island transfer from a less important finger was used, but the accompanying nerve was divided and its distal end sutured to the proximal end of the nerve in the recipient finger, after excision of the neuroma. Four years and two years later, no clinical evidence of neuroma was present at either amputation stump or donor site.
We describe a new incision for use in ray amputation. A semi-oval flap of skin from one side of the proximal phalanx of the finger to be amputated is preserved so that when the adjoining finger is transposed to fill the gap, the complete web can also be transposed. This avoids scarring in the web space.