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PubMed2006

Technology insight: Utility of TNF-alpha-based isolated limb perfusion to avoid amputation of irresectable tumors of the extremities.

Isolated limb perfusion (ILP) with melphalan is effective in the treatment of small multiple melanoma intransit metastases and is utilized widely for this indication. The treatment is much less effective against bulky melanoma metastases and has uniformly failed in the treatment of irresectable extremity soft tissue sarcomas. The addition of tumor-necrosis factor-alpha (TNF-alpha) to this treatment approach has changed the situation dramatically. High response rates and limb-salvage rates have been reported in multicenter trials that combined ILP with TNF-alpha plus melphalan; these trials resulted in the approval of TNF-alpha for bulky melanoma metastases and soft tissue sarcomas in Europe in 1998. Subsequently, many doctors working in European centers have been trained, and a series of confirmatory reports from single institutions have now been published regarding the efficacy of the procedure. TNF-alpha has an early and a late effect; it enhances tumor-selective drug uptake during the perfusion, and plays an essential role in the subsequent selective destruction of the tumor vasculature. These effects result in a high response rate in bulky tumors, soft tissue sarcomas, bulky melanomas, and various other tumor types. This induction therapy therefore allows tumor remnants to be resected some 3 months after ILP thus avoiding limb amputation. TNF-alpha-based ILP is a well-established treatment that aims to avoid amputations regardless of the tumor size and type. It represents an important example of combination therapy that modulates the tumor vasculature and should be offered in high-volume tertiary referral centers.

Amputation, Surgical↗
PubMed1985

Self-biting with multiple finger amputations following spinal cord injury.

We have observed mutilative self-biting leading to multiple finger amputations in two patients following C4 complete spinal cord injury (SCI). Both men were of normal intelligence without psychosis and each had a neurotic personality and history of fingernail biting. They related the self-biting to anxiety and depression. We believe these to be the first English language reports of multiple finger amputations due to self-biting following SCI.

Adult↗
PubMed2001

The influence of falling, fear of falling, and balance confidence on prosthetic mobility and social activity among individuals with a lower extremity amputation.

OBJECTIVE: To assess in amputee patients the relationship between having fallen in the past 12 months, fear of falling, and balance confidence on mobility capability, mobility performance, and social activity. DESIGN: Population-based survey and chart review. SETTING: Two university-affiliated outpatient amputee programs in southwestern Ontario. PARTICIPANTS: Community-living individuals (n = 435) with a unilateral lower limb amputation. INTERVENTIONS: Patient chart review and a survey questionnaire. MAIN OUTCOME MEASURES: Self-report assessment of prosthetic capability and performance and social activity participation was assessed with the Prosthetic Evaluation Questionnaire mobility subscale, the Houghton Scale, and the Frenchay Activities Index. RESULTS: Falling experiences in the past 12 months were not significantly associated with any outcomes. Fear of falling was important in univariate relationships in all 3 outcomes, but not when balance confidence was included in multivariable modeling. Balance confidence was statistically significant with each of the outcomes and remained significant with inclusion of the covariates. There was statistical interaction (balance confidence x automatism; balance confidence x medication count) in modeling mobility capability and in modeling mobility performance (balance confidence x pain + balance confidence x amputation level). The final models accounted for 70%, 60%, and 55% of the variation in mobility capability, mobility performance, and social activity, respectively. CONCLUSION: Balance confidence was the only factor associated with mobility capability and performance and social activity in the final adjusted models. Clinicians and researchers should consider this variable in the rehabilitation of amputee patients.

Accidental Falls↗
PubMed2002

Outcome of lower extremity malignancy survivors treated with transfemoral amputation.

OBJECTIVE: To determine outcomes of surviving patients who underwent transfemoral amputation as part of treatment for lower extremity malignancy at a mean 15 years postoperatively, with a minimum 2-year follow-up. DESIGN: Retrospective, case control. SETTING: Tertiary care university medical center. PATIENTS: Thirty-five of 38 consecutively admitted patients free of metastatic disease managed with transfemoral amputation as part of treatment of a lower extremity bone and/or soft tissue malignancy between 1966 and 1997 at 1 institution. The control group included 35 age- and gender-matched subjects recruited from the local driver's license office. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Musculoskeletal Function Assessment (MFA), Short Form-12 General Health Status Survey (SF-12), physical performance battery, cost, and demographic data. RESULTS: Controls showed superior scores as measured by the MFA (P < .0001), the physical component summary of the SF-12 (P = .0002), and the physical performance battery (P < .0001), but had inferior scores on the mental component summary of the SF-12 (P < .0001). With the numbers available, no differences were found between study and control subjects in terms of employment rate (P = .51), education level (P = .66), income level (P =.44), marital status (P = .79), incidence of self-reported health problems (P = .14), and alcohol (P =.42) and tobacco (P = .82) use. Ten patients were included in the cost analysis; the mean cost to obtain and maintain a lower extremity prosthesis was $4225 per year (range, 623 dollars-8517 dollars). CONCLUSIONS: Although the decrease in physical performance was anticipated in the study group, the group differed very little from the control population in terms of employment, education level, income, marital and home status, incidence of self-reported health problems, incidence of self-reported depression, and alcohol and tobacco use. Also, the long-term cost of maintaining a lower extremity prosthesis is noted.

Activities of Daily Living↗
PubMed1999

The localization of the infrapatellar nerves in the anterior knee region with special emphasis on central third patellar tendon harvest: a dissection study on cadaver and amputated specimens.

The aim of this dissection study on cadaver and amputated specimens was to determine the position of the infrapatellar nerves in the anterior knee region, and to investigate whether it would be possible to harvest the patellar tendon through two small vertical incisions, leaving the infrapatellar nerves undamaged and the major part of the paratenon intact. The infrapatellar nerve did not pass through the area between the apex of the patella and the tibial tubercle in 1 of 60 specimens. The nerve passed through this area as one branch in 15 of 60 specimens, as two branches in 37 of 60, as three in 6 of 60, and as four in 1 of 60 specimens. The distance from the apex of the patella to the infrapatellar nerve or the uppermost branch of the nerve was 30 mm (+/- 27 mm [2 SD]). The distance from the tibial tubercle to the infrapatellar nerve or the lowermost branch of the nerve was 27 mm (+/- 27 mm [2 SD]). In one specimen, the infrapatellar nerve passed 10 mm distal to the tibial tubercle. In 4 of 60 specimens, a branch of the infrapatellar nerve passed just above the tibial tubercle, and in 2 of 60 a branch passed just above the apex of the patella. In 19 of 20 specimens in which the harvesting procedure was performed, the infrapatellar nerve or the nerve branches were undamaged. The length of the undamaged paratenon was 27 mm (+/- 23 mm [2 SD]). This study showed that it was possible to harvest consistent bone-patellar tendon-bone autografts through two vertical 25-mm incisions, leaving the infrapatellar nerve undamaged and the paratenon partially intact in the majority of the cadaver and amputated specimens.

Aged↗
PubMed2000

The value of technetium 99 scintigraphy in the prognosis of amputation in severe frostbite injuries of the extremities: A retrospective study of 92 severe frostbite injuries.

We report a retrospective study of the prognostic value of 2-phase technetium 99m bone scanning performed in 92 patients who presented to Chamonix Hospital with severe frostbite of the extremities in the past 12 years. The results of this study show that an initial bone scan (as early as day 3) has excellent specificity in evaluating the severity of frostbite injury. There was a direct correlation between the demarcation zone of uptake in the phalanges and the eventual level of amputation (positive predictive value, 0.84). A second scan on approximately day 7 was even more sensitive and informative. A strong correlation existed between positive uptake and eventual healing (negative predictive value, 0.99). This study showed that (99m)Tc bone scanning in the first few days after frostbite injury indicates the level of amputation in severe frostbite in more than 84% of cases. We propose an algorithm based on the results of this study that can be used to evaluate new medical and surgical management of frostbite injury.

Adult↗
PubMed2001

Restoration of functional prehension after radial hemihand amputation in a three-year-old child: rationale for and long-term result after great toe transfer.

Partial hand amputations are rare injuries among children, causing significant functional impairment. Reports on thumb reconstruction in children and adults are used to develop a reconstruction plan for restoring prehension. While either first or second toe transplantation may be indicated to restore prehension in adults with thumb loss, near universal reluctance to use the great toe in children centers around concern regarding the subsequent function and appearance of the foot. This report details the reconstruction of functional prehension after radial hemihand amputation in a 3-year-old child. Great toe transplantation was used and resulted in neither objective nor subjective donor site morbidity. The rationale for use of the great toe in this child and long-term functional outcome are described.

Amputation, Traumatic↗
PubMed2000

Total hip arthroplasty in patients with below-knee amputations.

We present a unique small group of 5 patients with below-knee amputation who underwent total hip arthroplasty after a displaced subcapital fracture of the femur. Three patients were operated on after failed fixation of the fracture, and 2 were operated on as a primary procedure. All 5 patients resumed their prefracture level of activity and mobilization with no deterioration during follow-up (average, 69 months [range, 22-98]). These encouraging results call for use of total hip arthroplasty or hemiarthroplasty as the primary treatment modalities of patients with displaced subcapital femoral head fracture in an extremity with below-knee amputation.

Aged↗
PubMed2003

Above-knee amputation after recurrent dislocations of total knee arthroplasty.

Amputation after total knee arthroplasty (TKA) is an extremely rare but disastrous complication. Most of the reported cases resulted from refractory deep joint sepsis or perioperative vascular complications. We present a case of above-knee amputation resulting from vascular complications after recurrent dislocations of a TKA in a patient with underlying end-stage renal disease. The possible association between certain metabolic diseases and instability of TKA is discussed. In contrast to the high incidence of vascular complications after traumatic knee dislocation, popliteal artery injury after TKA dislocation is seldom encountered. The importance of careful evaluation and serial physical examinations to exclude the possibility cannot be overemphasized, however. When compromise of the circulation was recognized, emergent exploration of the popliteal fossa for repair of the vascular injury presented the best chance to save the limb.

Amputation, Surgical↗
PubMed2002

Reconstruction of an amputated fingertip by a prefabricated free volar forearm flap.

An amputated fingertip was banked temporarily under the skin of the volar wrist. This prefabricated fingertip was transferred back to the finger 2 months later, together with a free flap from the volar wrist based on the superficial palmar branch of the radial artery. The fingertip pulp showed a little pale pigmentation, but maintained its length well. The dorsal tip of the finger looked normal. This two-stage procedure made it possible to salvage the amputated bone and nail.

Adolescent↗
PubMed1999

Dorsal adipofascial turn-over flap for fingertip amputations.

We designed a dorsal adipofascial pedicled flap to cover amputations of the tip of the same digit. This flap includes all the adipofascial tissues from the dermis to the paratenon of the extensor tendons. After elevation of the skin, the adipofascial tissues are raised as a flap and turned over to resurface the exposed bone or joint and then covered with a split thickness skin graft. Ten digital amputations between the distal phalanx proximal to the nail matrix and the mid portion of the middle phalanx were successfully resurfaced with dorsal adipofascial turn-over flaps. All flaps survived completely and the mean follow-up was 11 months. This one-step procedure would seem to be a relatively simple way of achieving early recovery because it does not require the use of distant flaps immobilization of adjacent digits, or homodigital flaps that might jeopardize an already injured finger.

Adolescent↗
PubMed2001

Indications and selection for digital amputation and replantation.

Even though replantation surgery has now become a routine procedure, it remains delicate and demanding surgery, requiring adequate training and expertise in microsurgical techniques. Well-defined selection criteria for replantation procedures have evolved over the past few years, including definitive guidelines for thumb, single digit, multiple digit and mid-palm amputations. For more complex cases, other techniques, including transpositional microsurgery and various secondary reconstructive procedures, such as toe-to-hand transfer, are now available. Although replantation procedures have been simplified, a second surgical team can save valuable surgical time by debriding and identifying the vessels in the amputated part, harvesting microvenous grafts, and performing bone fixation or tendon repair among other things, while the chief surgeon focuses on revascularization. Overall, the most significant guideline underlining the philosophy of digital replantation today reflects the aim of not only ensuring the survival of a digit, but its functional use as well. Experience dictates that this can be achieved only if the basic principles and indications of replantation surgery are adhered to.

Amputation, Traumatic↗
PubMed2000

[Subcutaneous preservation of an amputated auricle. Morphological changes].

BACKGROUND: Microsurgical replantation of an avulsed auricle remains a challenge in reconstructive surgery. Secondary reconstruction of a traumatic lost auricle is usually performed using a costal cartilage framework according to well documented techniques or with a prosthesis. In order to minimize donor-site morbidity, various efforts can be undertaken to preserve the amputated auricle by implanting the de-epithelialized cartilage framework in a subcutaneous pocket on the surface of the mastoid. Where preservation is successful, this original cartilage could be used for reconstructive treatment. PATIENT AND RESULTS: This study describes the histologic and immunohistologic changes in a complete traumatic avulsion of the auricle with subsequent cartilage conservation for eight months within a skin pocket. Trauma, preparation and preservation were accompanied by morphologic changes that included generation of local ossification centers and infiltration of fibrous tissue. We compared the macroscopic and microscopic morphology of the amputated part to native elastic cartilage following maximal denutrition and temporary heterotopic implantation in conjunction with atypical tension and pressure properties of the retroauricular pocket. CONCLUSION: In this case, the limited success of cartilage conservation in the subcutaneous pocket required conventional auricle reconstruction with autologous costal cartilage.

Adult↗
PubMed2003

Successful replantation of an amputated leg with severe crush and avulsion injury in an elderly patient: case report.

An amputated leg with severe crush and avulsion injury was replanted in a 57-year-old man. Since the skin and soft tissue around the ankle became necrotic 11 days postoperatively, a flow-through forearm free flap was transferred into the defect, preserving the blood circulation to the replanted leg. Seven weeks after the replantation, sural nerve cable grafts were interposed between both amputated edges of the tibial nerve. As the function of the ankle joint did not recover, arthrodesis of the ankle joint was performed 7 months after the replantaion. As a result, the patient could walk 1 year postoperatively.

Amputation, Traumatic↗
PubMed2005

Toe-to-hand transfer from a cross-foot replantation in a traumatic four-extremity amputation.

Treatment of mutilating hand injuries often requires multiple innovative procedures. This report describes a case of multi-limbed amputations from a train injury and the extraordinary microsurgical approaches for a two-hand reconstruction. The first stage of the procedure was a cross replantation of the left foot to the right leg. The second stage was a combined second and third toe transfer from the cross replantation of the left foot to the right hand, and a sensate fibular osteocutaneous flap transfer for left hand reconstruction. Satisfactory function was restored, including good protective sensation. These kinds of extraordinary microsurgical approaches are useful salvage procedures for hand reconstruction, when presented with a case of multi-limb amputation.

Adolescent↗
PubMed1993

Forequarter amputation wound coverage with an ipsilateral, lymphedematous, circumferential forearm fasciocutaneous free flap in patients undergoing palliative shoulder-girdle tumor resection.

Closure of massive soft-tissue defects in patients undergoing forequarter amputation for shoulder-girdle tumors may present a daunting challenge. This report describes two patients whose forequarter amputations were closed using ipsilateral, lymphedematous, circumferential forearm fasciocutaneous free flaps.

Aged↗
PubMed1991

Digital amputation, replantation, and cold intolerance.

In a controlled, retrospective, clinical study, the relationships between traumatic digital amputation, digital replantation, and cold intolerance were investigated. The results of the investigation indicate that cold intolerance is a major reason for disability after digital amputation. They also indicate that the cold intolerance experienced after digital replantation is due to the original injury, and that it is not aggravated by the reconstructive surgery. Cold intolerance, in and of itself, is not a contraindication to digital replantation, regardless of whether the patient lives or works in high- or low-temperature environments.

Adolescent↗