Management of the patient requiring leg amputation for peripheral vascular disease

Most leg amputations are performed because of the effects of peripheral vascular disease. Only 50% of such amputations were performed below the knee in Ontario in 1972, although the knee joint should be preserved in most patients. Careful preoperative evaluation is essential. Postoperative problems include gas gangrene for which prophylactic measures are recommended; failure of the stump to heal, which necessitates early revision of the stump; and defects in stump contour, which necessitate late revision. An enthusiastic team approach to rehabilitation is necessary to overcome the physical and mental problems that result from amputation of a leg.     

A PCR-RFLP method for the detection and species identification of human microsporidia

Amputation in a growing child should be performed through a joint and not above or below a joint, as is commonly the case in an adult. We describe a technique for performing a through-knee amputation in a situation in which a soft-tissue sarcoma involved a leg, reaching up to the knee joint. Soft-tissue dissection was performed above the knee, leaving a safe zone from the tumor. The distal femur was dissected free of all attachments to the tibia and leg, leaving it intact but protruding from the soft-tissue sleeve of the thigh. To be able to close the stump over the protruding distal femur, the femur was shortened in the metaphysodiaphyseal area. Follow-up over 3 years shows a good through-knee stump, tumor free, and a normal distal growth plate.     

Parvovirus B19 quiescence during the course of human immunodeficiency virus infection in persons with hemophilia

One hundred and seventy patients with major lower limb amputation (MLLA) presenting to The National Prosthetic-Orthotic Centre (NPOC) in Khartoum over a 1-year period were studied. There were 141 males and 29 females giving a M:F ratio of 4.9: 1.0, with mean age of 37 years (range 5-72 years). Forty-one patients (24%) underwent amputation of diabetic septic foot, 30 patients (17.6%) underwent amputation as a result of trauma from road traffic accidents and Madura foot, and war injuries accounted for 29 amputations (17%). One hundred and eleven patients had below knee amputation (BKA), 52 had above knee amputation (AKA) and seven patients had Syme's amputation. Diabetic amputees had higher rate of revisional surgery compared with others because of sepsis and/or flap necrosis. Stump pain was reported by amputees with excessive scarring of the stump and those with undue prominence of bony ends. There are two types of prostheses provided by the NPOC for both BKA and AKA: the peg leg and the conventional prostheses. The Syme's amputees were fitted with either simple hoof or articulated prostheses with solid ankle cushion heel (SACH). The peg leg consists of a leather lined side bearing metal socket connected to a rocker base by side steels. It is used by the country natives as it suits different weather and job conditions, particularly farming, and it can be repaired locally. The urban population use the conventional prostheses which is lighter in weight, can be put on and taken off easily and is cosmetically acceptable. However, these prostheses are more expensive and require frequent repair or replacement. The functional outcome of patient's rehabilitation with the prostheses was significantly affected by the level and indication of amputation. Those with BKA and those amputated because of trauma or Madura foot experienced better functional outcome compared with the diabetics, independent of age. 50% of patients with the AKA and 19% of those with BKA reported poor functional outcome. Surgeons should be more involved with the long-term evaluation of functional outcome in such patients, to offer help if feasible and to modify their technique for future procedures.     

Role of emergency reconstruction of fingers by the "reposition-flap" technique. Report of eight cases

Following replantation failure, fingertip reconstruction was performed as an emergency "reposition-flap" procedure in seven patients (eight fingers). This technique was intended for amputations distal to the DIP joint in long fingers, and IP joint in the thumb. Pulp was excised on the amputated segment, and the remaining bone and nail bed were reattached to the proximal stump with Kirschner wires. Pulp was reconstructed with a local advancement and sensitive flap. Trophicity and nail regrowth as well as mobility and strength were satisfactory in five cases. MRI examination showed revascularization of the distal bone fragment in four cases. This procedure is an alternative to amputation after replantation failure when patients do not accept finger shortening. The more distal the amputation, the better is the result.     

Lower-limb deficiencies and amputations in children

Important differences exist in the management of child and adult amputees. Many factors, including the etiology of childhood limb deficiencies, expected skeletal growth, functional demand on the locomotor system and prosthesis, appositional bone stump overgrowth, and psychological challenges, make caring for these young patients particularly challenging. Adherence to the general principles of childhood amputation surgery will typically guide one to the optimal functional result. These principles can be summarized as follows: (1) Preserve length. (2) Preserve important growth plates. (3) Perform disarticulation rather than transosseous amputation whenever possible. (4) Preserve the knee joint whenever possible. (5) Stabilize and normalize the proximal portion of the limb. (6) Be prepared to deal with issues in addition to limb deficiency in children with other clinically important conditions. A large proportion of young amputees undergo a Syme disarticulation, modified Boyd amputation, or knee disarticulation. A modified Van Nes rotationplasty procedure is also useful in this age group. All these provide the child with a weight-bearing stump with good growth potential and no complications due to bone overgrowth. Appropriate timing of amputation procedures and prosthetic fittings is essential to maximize functional benefit to the patient.     

Effect of ribonucleic acid on the function and structure of the pancreas and kidneys of rats with different concentrations of protein in their diets

Amputation on rabbits was found to change the muscle blood flow (MBF) in the limb subjected to surgery as well as in the contralateral extremity, depending on the technique used for amputation and the level at which it was carried out. Amputation was immediately followed by a reduction in MBF in the stump. After amputation of the crus and knee disarticulation, the flow was normalized a few days later and exceeded the preoperative mean flow. After amputation of the femur such an increase in flow was not seen, but when osseous plugging of the medullary cavity was applied, the MBF in the stump was intensified even after amputation of the femur.     

Participation of leukotriene D4 and tumor necrosis factor on lipopolysaccharide-induced airway hyperresponsiveness in guinea pigs

Partial failure of a free flap can create an unusual dilemma, as guidelines suggesting appropriate further intervention are not well defined. The increased complexity of a second free flap attempt is not necessarily contraindicated, but must be minimized if the same fate as the first is to be avoided. For the unique circumstance where the initial failed flap contained a vascular flow-through, the most distal patent vessels can then secondarily serve in an expeditious manner as the recipient vessels for the second or salvage free flap. The efficacy of this concept has been here validated after limited necrosis occurred in the distal portion of a radial forearm free flap. Following the requisite debridement, the residual flap still maintained a satisfactory arterial and venous flowthrough as a "bridge flap" that supported the attachment of a gracilis muscle free flap, and both flaps in turn preserved a sensate transtarsal amputation stump.     

Gritti's amputation in vascular surgery

Gritti's amputation was performed in 35 patients, mean age 71 years, with vascular disease of leg. There was no immediate postoperative mortality. Of twenty patients fitted with an appliance using a specific technique, only one had a poor functional result. The results obtained in this preliminary series were compared with those after amputations and knee disarticulations. They showed that Gritti's amputation should be considered for patients with arteritis when a functional knee is impossible to conserve.     

Hearing impairment, disability and handicap in elderly people living in residential care and in the community

The TFI-musculofasciocutaneous flap has become a standard procedure in recent years. Donor-site problems of this method, especially the biomechanical changes of the hip, the proximal femur and the knee joint are evaluated, employing biomechanical techniques. Harvesting of a TFL-flap leads to functional loss of the M. tensor fasciae latae and the iliotibial tract and band. This might lead to a weakening of active and passive stabilising structures of the hip and the knee joint. Loss of the iliotibial tract causes a loss of the lateral tension-band of the proximal femur and leads to a significant increase of shear forces on the proximal femoral shaft. The functionally important structures of the iliotibial tract for knee biomechanics are not influenced by harvesting of the TFL flap. Loss of the M. tensor fasciae latae leads to a mild reduction of hip flexion and internal rotation. The indication for a TFL-flap should consider the patient's activity to prevent overload damage of the proximal femoral shaft. In childhood, harvesting of the TFL flap is likely to influence the growing axial skeleton due to the loss of the iliotibial tract.     

Salvage of failed amputation about the hip in peripheral vascular disease by open wound care and nutritional support

Five consecutive patients with wound and/or plastic surgical flap failure after hip disarticulation or amputation at the lesser trochanteric transfemoral level were treated with local tissue debridement, open wound management, culture-specific antibiotic therapy, and nutritional supplementation. All of the patients underwent amputation about the hip as a result of ischemic necrosis of the lower extremity. Four of the five patients were able to achieve wound healing by second intention. The fifth patient died 2 months after the surgery. None of the patients required revision surgery. One patient underwent split-thickness skin grafting to minimize the need for continued wound care. Local wound management combined with nutritional support and culture-specific antibiotic therapy is an acceptable alternative to major amputation stump revision in patients with potentially high morbidity who fail to heal after amputation about the hip.     

Preexpansion of the tensor fasciae latae for free-flap transfer

Preexpansion has become an established technique to prefabricate elective free flap transfers. We report the use of the tensor fasciae latae flap as a donor site in two cases for reconstruction of a burn scar neck contracture and an unstable contralateral below-knee amputation stump, of which other donor sites were ruled out either by the patients' condition or by choice. Implantation and transfer were straightforward and the donor sites of very large flaps were minimized by preexpansion. The preexpanded muscle fasciocutaneous flaps were transplanted with microsurgical anastomoses of the vessels. Apart from a small area of necrosis at the distal tip of the flap developing on the sixth postoperative day, which we excised in a second operation, there were no major complications. The advantages of the combination of preexpansion and free flap transfer as well as the unique anatomical and functional qualities of this musculocutaneous unit are emphasized.     

Surgical revision of the problematic transmetatarsal amputation

Recurrent ulcerations may develop following transmetatarsal amputation in patients with diabetes mellitus. In many cases, these ulcerations require surgical intervention to achieve healing, especially in situations where conservative care has not been effective. These procedures range from the local resection of bone to skin grafting and flap techniques to successfully heal the wound. The ultimate goal of any surgical intervention is to prevent a more proximal amputation.     

Glycine-glutamate interactions at the NMDA receptor: role of cysteine residues

The term "centrocentral anastomosis" is used to describe the end-to-end connection across interposed nerve grafts between paired fascicular groups of the proximal stump of a severed nerve. In 22 patients harboring a painful terminal neuroma following amputation of a lower limb (20 neuromas on the sciatic nerve and two on the peroneal nerve), a centrocentral anastomosis was performed on the end of the sectioned nerve to treat pain that had not improved with conventional conservative treatment. Follow-up review at 1 year revealed that the typical neuroma pain had disappeared in all cases, although sporadic diffuse pain persisted in four. Where previous phantom sensation was present, no change was observed. The results presented here are consistent with laboratory findings demonstrating the absence of neuroma formation after centrocentral anastomosis. Therefore, this technique is recommended for the treatment of painful amputation neuroma.     

Squamous cell carcinoma of the skin associated with systemic sclerosis

BACKGROUND: The coexistence of sclerosis and cancer has been recognized with increasing frequency. However, squamous cell carcinoma of the skin associated with systemic sclerosis is relatively rare. OBJECTIVE: The mechanisms of malignancy in systemic sclerosis are discussed. METHODS: An 18-year-old girl with progressive systemic sclerosis is described. RESULTS: The patient had developed squamous cell carcinoma of the skin on the sclerosed skin of her left leg requiring amputation. The tumor recurred on the distal end of the stump. Local radiotherapy was unsuccessful. CONCLUSION: This report suggests that sclerosis of the skin may manifest a greater risk of developing skin cancers unrelated to chronic injury or scarring of the skin.     

The use of physiotherapy and antibacterial preparations in urogenital infections

335 patients with obliterative diseases of arteries of the low extremities were examined. Results of motor rehabilitation depend on the severity of post-amputation defect of the extremity and functional condition of the stump. The lower is the level of the amputation the higher is the effectiveness of the rehabilitational measures. Ischemia of femoral stump springs up rarely but its course is mare severe than ischemia of the stump of the shin, which is confirmed by the data of clinical examination, investigation of biochemical parameters of the blood and mortality rate. For prophylaxis of ischemia of the stump it is suggested simultaneously with the amputation of the extremity to perform reconstructive procedures on the arteries, aimed at restoration of blood flow through the profound femoral artery. This policy provides the possibility to form a long functional stump of the extremity and to improve results of motor rehabilitation.     

Extended and telescoped phantom limbs in unilateral amputees.

The incidence of extended (same length) and telescoped phantom limbs was studied by interview in 239 adult unilateral amputees, above and below elbow and knee (AE, BE, AK, BK). Differences were analyzed by nonparametric statistics. Conclusions were as follows: (a) AEs reported the greatest, and BKs the smallest proportions of shortened phantoms; (b) BE and AK groups were approximately similar; (c) telescoped phantoms of proximal amputations were mainly partly telescoped—of distal amputations, fully telescoped; (d) phantom presence, persistence, strength, shortness, and tactile pressure sensitivity were positively related, paralleling the cephalocaudad principle; (e) limb image (established by cortical and learning factors); and (f) intensity of stump cues (dependent on the cephalocaudad gradient, etiology, and sensitization by amputation), affect perception of phantom length and related sensations. (18 ref.) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Dynamics of the martial arts high front kick

Fast unloaded movements (i.e. striking, throwing and kicking) are typically performed in a proximo-distal sequence, where initially high proximal segments accelerate while distal segments lag behind, after which proximal segments decelerate while distal segments accelerate. The aims of this study were to examine whether proximal segment deceleration is performed actively by antagonist muscles or is a passive consequence of distal segment movement, and whether distal segment acceleration is enhanced by proximal segment deceleration. Seventeen skilled taekwon-do practitioners were filmed using a high-speed camera while performing a high front kick. During kicking, EMG recordings were obtained from five major lower extremity muscles. Based on the kinematic data, inverse dynamics computations were performed yielding muscle moments and motion-dependent moments. The results indicated that thigh deceleration was caused by motion-dependent moments arising from lower leg motion and not by active deceleration. This was supported by the EMG recordings. Lower leg acceleration was caused partly by a knee extensor muscle moment and partly by a motion-dependent moment arising from thigh angular velocity. Thus, lower leg acceleration was not enhanced by thigh deceleration. On the contrary, thigh deceleration, although not desirable, is unavoidable because of lower leg acceleration.     

"Extended and telescoped phantom limbs in unilateral amputees": Erratum.

Reports an error in the original article by Samuel A. Weiss and Sidney Fishman (Journal of Abnormal & Social Psychology, 1963, Vol 66[5], 489-497). A correction is provided to a sentence on page 491, in column 1, paragraph 2, line 3. (The following abstract of this article originally appeared in record 1964-02937-001.)The incidence of extended (same length) and telescoped phantom limbs was studied by interview in 239 adult unilateral amputees, above and below elbow and knee (AE, BE, AK, BK). Differences were analyzed by nonparametric statistics. Conclusions were as follows: (a) AEs reported the greatest, and BKs the smallest proportions of shortened phantoms; (b) BE and AK groups were approximately similar; (c) telescoped phantoms of proximal amputations were mainly partly telescoped--of distal amputations, fully telescoped; (d) phantom presence, persistence, strength, shortness, and tactile pressure sensitivity were positively related, paralleling the cephalocaudad principle; (e) limb image (established by cortical and learning factors); and (f) intensity of stump cues (dependent on the cephalocaudad gradient, etiology, and sensitization by amputation), affect perception of phantom length and related sensations. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Postprostatectomy dysuria: restored voiding function by perineal hot water spray in an old male with a contractile bladder]

This study reports the first case of a subtrochanteric stress fracture of the femur after total knee arthroplasty. A 61-year-old obese woman was treated by right total knee arthroplasty for osteoarthrosis. Four months after the surgery and 1 month after full weight bearing, she complained of tenderness in the right groin and proximal thigh. There was no history of trauma. Radiographs of the right hip and of the right proximal femur were interpreted as unremarkable, and nonsteroid anti-inflammatory drugs were administered. Three months later, she had a sudden onset of increased pain with instability and giving way of the right leg. Radiographs revealed a subtrochanteric transverse fracture of the right femur. Histologic workup of the bone and tissue specimen taken at open reduction, as well as the laboratory data were consistent with the radiologic and clinical diagnosis of a stress fracture. It is most likely that a decrease in the tension band effect of the iliotibial tract in combination with coxa vara and changes in static and dynamic forces of the femur and an increased level of activity after a period of relative inactivity secondary to the knee arthroplasty are responsible for this very uncommon fracture type.