Amputation

The objective of this study was to assess midterm functional status, wound healing, and in-hospital resource use among a prospective cohort of patients treated in a tertiary hospital, multidisciplinary Center for Limb Preservation. Data were prospectively gathered on all consecutive admissions to the Center for Limb Preservation from July 2013 to October 2014 with follow-up data collection through January 2016. Limbs were staged using the Society for Vascular Surgery Wound, Ischemia, and foot Infection (WIfI) threatened limb classification scheme at the time of hospital admission. Patients with nonatherosclerotic vascular disorders, acute limb ischemia, and trauma were excluded. The cohort included 128 patients with 157 threatened limbs; 8 limbs with unstageable disease were excluded. Mean age (±standard deviation [SD]) was 66 (±13) years, and median follow-up duration (interquartile range) was 395 (80-635) days. Fifty percent (n = 64/128) of patients were readmitted at least once, ...

OBJECTIVE-To determine the mortality rate after diabetes-related lower-extremity amputation (LEA) in an African-descent Caribbean population. RESEARCH DESIGN AND METHODS-We conducted a prospective case-control study. We recruited case subjects (with diabetes and LEA) and age-matched control subjects (with diabetes and no LEA) between 1999 and 2001. We followed these groups for 5 years to assess mortality risk and causes. RESULTS-There were 205 amputations (123 minor and 82 major). The 1-year and 5-year survival rates were 69 and 44% among case subjects and 97 and 82% among control subjects (case-control difference, P Ͻ 0.001). The mortality rates (per 1,000 person-years) were 273.9 (95% CI 207.1-362.3) after a major amputation, 113.4 (85.2-150.9) after a minor amputation, and 36.4 (25.6-51.8) among control subjects. Sepsis and cardiac disease were the most common causes of death. CONCLUSIONS-These mortality rates are the highest reported worldwide. Interventions to limit sepsis and complications from cardiac disease offer a huge potential for improving post-LEA survival in this vulnerable group.

Background: To evaluate the immediate and midterm results of hybrid (combined open surgical and endovascular) lower extremity revascularization procedures in patients with critical limb ischemia (CLI). Material and Methods: Thirty-seven consecutive patients (44 limbs) were treated for CLI using hybrid techniques during a single procedure. The CFA was involved in all limbs and was uniformly treated with endarterectomy and patch angioplasty. Hemodynamically significant atherosclerotic lesions proximal to the CFA were present in 13 limbs, distal to the CFA in 23 limbs, and both above and below the CFA in 8 limbs, and all were treated with endovascular techniques. All patients underwent a detailed clinical assessment and color duplex ultrasonography at 1, 6, and 12 months after the procedure and annually thereafter. Results: The technical success rate was 96.6%, and the limb salvage rate was 95.5%. All patients except three remained free of symptoms without the need for any secondary interventions at the time of the last follow-up. Three patients presented with SFA thrombosis during the first 6 months after the procedure, and two of them had to be amputated. The median follow-up period was 17 months (range: 3-32), and the primary and secondary patency rates at 24 months were 93.2% and 95.5%, respectively. Conclusion: Hybrid lower extremity revascularization procedures can be used to treat CLI with low perioperative morbidity and mortality and good immediate and midterm patency and limb salvage, thus providing an attractive alternative to larger open surgical interventions.

Diabetic foot is a common complication of diabetes world over. We conducted this study to determine common microbiological pathogens in Diabetic Foot Infections (DFI) at a tertiary care hospital and their management. In this observational study deep wound swabs of all admitted diabetic patients were taken, pathogens isolated, antibiotic used and its response depending on complete resolution of symptoms and biochemical markers were recorded. Data were analysed on SPSS-11. A total of 114 cases were recorded. Sixty-eight (59%) cases had ulcers on forefoot, 28 (25%) mid-foot and 18 (16%) hind-foot. One hundred and four pathogens were isolated from wound swabs after debridement. Commonest pathogen isolated was Staphylococcus aureus (52, 46%) followed by E. coli (11, 10%), MRSA was found in 10 (9%) cases, streptococcus in 6 (5%) and pseudomonas in 5 (4%) cases. Polymicrobial infection was also seen in a few cases. Surgical intervention included superficial debridement in 88 (77%) cases, t...

Background: Digital toe amputation is a relatively minor surgical procedure but there is a historical view that it is the "first stage in a predictable clinical course" leading to eventual limb loss. There is a paucity of contemporaneous data on the long-term outcomes of patients undergoing toe amputation. We aim to study the experience from our institution, focussing on the risk factors for progression to future limb loss, by conducting a retrospective review of our practice. Methods: Sixty-three patients undergoing toe amputation within our institution were identified and the clinical notes retrospectively reviewed. A database of vascular risk factors and co-morbidity was constructed and correlation with future limb loss was analysed with Chi-squared testing and a logistic regression model. Results: Sixty-three patients with a mean age of 69 (IQR 62-76.5) years were identified. Thirty-five (55.6%) of these patients went on to have a further surgical amputation; 22 major amputations (16 below-knee and 6 above-knee amputations) and 23 minor amputations were performed in total. Forty three (68.3%) patients had diabetes and 31 (49.2%) patients had one or more revascularisation procedures undertaken. There was a significant correlation between patients who did not have diabetes and future limb loss (Chi-squared = 4.31, p = 0.038), however no other identified risk factor predicted the need for major amputation. Conclusion: Toe amputation is a significant predictor of future limb loss. Our study identified that patients with diabetes are significantly less likely to progress to further limb loss than those with the disease. We hypothesise that this difference is due to the more intensive, multi-disciplinary foot care follow-up that diabetic patients receive. These results highlight the significance of toe amputation and contribute to the evidence for a more intensive out-patient service for these high risk patients.

Background: We wanted to know the effect of comorbidity, age, and gender on the outcome after surgical below-knee revascularization for critical chronic limb ischemia. Methods: This is a retrospective study of 624 consecutive patients who underwent below-knee bypass surgery between January 1996 and December 2005 because of chronic peripheral arterial disease (PAD). Patients' characteristics were: diabetes mellitus (DM) n ¼ 445 (71%), coronary artery disease (CAD) n ¼ 310 (49%), dialysis-dependent renal insufficiency (dRI) n ¼ 88 (14%), age >70 years n ¼ 279 (44%), male n ¼ 423 (68%), PAD Fontaine's stage III n ¼ 105 (17%), and PAD stage 4 n ¼519 (83%). All patients had Trans Atlantic Inter-Society Consensus (TASC) C and D lesions, all were treated with a vein bypass to a crural artery n ¼ 354 (57%) and to a pedal artery n ¼ 270 (43%). KaplaneMeier analysis and multivariate analysis were performed. Results: The early results were as follows. The 30-day major amputation rate was n ¼ 43 (7%). CAD, dRI, age, and gender did not influence major amputation rate, whereas patients with diabetes had a lower risk of early amputation than those without diabetes. (hazard ratio: 0.49, 95% confidence interval: 0.25-0.95, p < 0.05). The 30-day mortality rate was n ¼ 31 (5%) and was uninfluenced by DM, CAD, and gender. Patients with dRI and octogenarians had a high risk of early death (dRI: 13.6%, octogenarians 9.4%). The late results were as follows. Follow-up rates were: limb salvage n ¼ 596 (95.5%) and survival n ¼ 622 (99.7%). The limb salvage rates at 1, 3, and 5 years were 79.1%, 72.1%, and 66.4%, respectively, and were uninfluenced by DM, CAD, dRI, age, and gender. The mortality rates at 1-, 3-, and 5-years were 79%, 63.4%, and 47.3%, respectively. Comorbidities such as CAD, dRI, and age of >70 years reduced life expectancy significantly. DM did not influence 1, 3 and 5 years of survival. The 5-year survival rates as estimated by KaplaneMeier analysis after revascularization were: DM, 46%; CAD, 38%; dRI, 19%; and age >70 years, 37%. Conclusion: Advanced age and comorbidities reduce life span but not the chance of avoiding major amputation after below-knee bypass surgery for critical limb ischemia.

The purpose of this paper was to review the literature through a structured literature review and provide a grade of recommendation for patient safety, gait energy efficiency, and cost effectiveness of the C-Leg microprocessor-controlled prosthetic knee for transfemoral amputees. Medline (Ovid) and CINAHL (EBSCO) data bases were searched to identify potentially pertinent studies within the 1995–2009 time range. Studies were screened and sorted. Pertinent studies were rated for methodologic quality and for risk of bias. Following assessment of methodologic quality and bias risk, the level of evidence and a grade of recommendation was determined for each of three categories: Safety, energy efficiency, and cost effectiveness. A total of 18 articles were determined to be pertinent: seven for safety, eight for energy efficiency, and three for cost effectiveness. Methodologic quality was low with a moderate risk of bias in the safety and energy effectiveness categories. Studies in cost ef...

Purpose. While lower limb prosthetic prescription is reliant on many physical indicators, it is clear that psychosocial factors need to be emphasised to a greater extent within this field if the needs of users are to be appropriately addressed. The aim of this study is to explore and identify the outcomes of prosthetic prescription through qualitative inquiry. Method. Six focus groups with prosthetic service users and 10 semi-structured interviews with service providers were conducted and then analysed with inductive thematic analysis. Results. The outcomes identified were: independence, not being in a wheelchair, balance and safety, improved quality of life and reaching potential. Conclusions. These emergent themes challenge the predominating focus on physical functioning that many practitioners have. These findings are important for developing a user-based model of service provision and outcome evaluation.

Objective: To determine the prevalence and factors associated with Diabetic Retinopathy (DR) of type 1 diabetes mellitus in Thailand. Material and Method: A cross-sectional, multicenter, hospital-based study was carried out from April to December 2003. Diabetic patients in diabetic clinics of 11 tertiary centers were registered. Retinopathy was evaluated by the ophthalmologists. Results: Seven thousand one hundred and nineteen diabetic patients received retinal examination. The number of patients with type 1 diabetes was 347. The prevalence of DR in type 1 diabetes was 21.6% (75). This consisted of Non-Proliferative DR (NPDR) 10.9% (38) and Proliferative DR (PDR) 10.7%. Patients with DR were significantly older, predominantly female, longer duration of diabetes, had higher BMI, systolic Blood Pressure (BP), diastolic BP, serum creatinine, and TriGlycerides (TG) levels than those without DR. Both groups of patients were not different in term of plasma glucose and glycosylated hemoglobin levels. Although the patients with DR had a higher percentage of overt proteinuria than those without DR, there was no difference in percentage of patients with positive microalbuminuria in both groups. This may be explained by limitation of data (only 16% had results of microalbuminuria and 19% had results of proteinuria). After adjusted for duration of diabetes, serum creatinine and smoking status, factors (adjusted odds ratio [95% confidence interval]) associated with DR were duration of diabetes 5-9.9 years (4.0 [1.49-10.91]), 10-14.9 years (6.86 [2.45-19.20]), 15-19.9 years (21.13 [7.22-61.78]), ≥ 20 years (22.15 [7.32-66.99]) when compared with duration of diabetes less than 5 years, serum creatinine > 2 mg/dl (6.0 [2.09-17.22]) when compared with creatinine less than 2 mg/dl. From the presented model, age, gender, systolic BP > 140 mmHg, diastolic BP > 90 mmHg, serum TG and smoking status were not factors associated with DR. Conclusion: Diabetic retinopathy affects about one fifth of type 1 diabetic patients in our study. The authors found the factors associated with DR in type 1 DM were duration of diabetes and serum creatinine. Regular screening for DR and more aggressive management of metabolic factors should be done to reduce the prevalence of DR.

RESUMO A definição de amputação mais frequentemente aceita por profissionais da área da saúde é a de que se trata da retirada total ou parcial, de um membro pelo ato cirúrgico, traumatismo ou doenças. As causas mais comuns são: insuficiência vascular periférica, como conseqüência de diabetes, aterosclerose, embolias, tromboses, traumatismo e tumores. O objetivo do presente estudo é identificar as causas de amputação nos indivíduos cadastrados nas ESFs (Estratégias de Saúde da Família) do Município de Santa Fé do Sul. Trata-se de uma pesquisa documental realizada por meio da análise de prontuários nas nove ESFs. Após a aprovação do projeto pelo Comitê de Ética em Pesquisa das Faculdades Integradas de Santa Fé do Sul-Funec, iniciou-se a análise dos dados no período vespertino durante 4 dias. Dos 33 prontuários analisados constatou que a maior incidência em relação à etiologia foram a de indivíduos com doenças vasculares associada ao Diabetes Mellitus, correspondendo a 58% da pesquisa; o maior índice de amputações foi no sexo masculino com 55%; e com maior acometimento em membros inferiores 84%. Estudos mostram que as ulcerações nos pés diabéticos precedem 85% das amputações de extremidades inferiores. A longa duração da doença, a hiperglicemia prolongada, a dislipidemia, o hábito de fumar, a ingestão de bebidas alcoólica e a presença de neuropatia, associadas à doença vascular periférica e de lesões ulcerativas são alguns dos fatores de risco para amputações em pessoas com diabetes mellitus. Ao término deste estudo estes pacientes serão contactados e encaminhados para o projeto de amputados da Clínica de Reabilitação da Funec para a uma futura reabilitação e reinserção deste paciente na comunidade. Descritores: Amputação. Atenção primária à saúde. 1 INTRODUÇÃO Amputação é o termo utilizado para definir a retirada total ou parcial de um membro, sendo este um método de tratamento para diversas doenças. As causas mais comuns são: insuficiência vascular periférica, como conseqüência de diabetes, aterosclerose, embolias, tromboses, traumatismo e tumores. É importante salientar que a amputação deve ser sempre encarada dentro de um contexto geral de tratamento e não como a sua única parte. Consequentemente deve-se considerar a amputação não como o fim

Squamous cell carcinoma (SCC) is a rare but well-documented complication of chronic osteomyelitis. Between February 1991 and March 1999, 13 cases (12 men and one woman) of SCC arising in chronic osteomyelitis were diagnosed and treated in our clinic. Mean age was 56.5 (38–70) years. Twelve patients underwent amputation and one underwent limb salvage. Average follow-up was 56 (24–121) months. Among the 13 patients two died of the disease. Treatment of choice for these tumours has been amputation. Carcinome cellulaire squameux est une complication d'ostéomyélite, peu fréquente, mais bien connue. Entre le février 91–mars 99, dans notre clinique, nous ont constate 13 malades (12 hommes et 1 femme) a qui nous ont vu la maladie développe a la base d'ostéomyélite chronique. L'age moyen était 56.5. (38–70) 12 malades ont subi une amputation et dans l'autre l'extrémité a été gardée. La surveillance a duré à peu près 56 (24–121) mois. Parmi ces 13 malades seulement deux sont morts. Pour ces tumeurs on peut dire que l'amputation est la méthode la plus efficace.

This work presents clinical, microbiological and outcome data collected from 76 patients with mycetomas at the Muñiz Hospital from 1989 to 2004. Forty-nine patients were male and 27 female; the mean age was 43.4 years. The majority of the patients acquired the infection in Argentina: the most affected provinces were Santiago del Estero with 31 cases, and Chaco with 11; 8 cases came from other countries (Bolivia 6 and Paraguay 2). The mean evolution of the disease was 9.2 years. The most frequently observed sites were: feet 63 cases, ankles 3, and knees 2. Forty-eight patients had bone lesions and 5, adenomegalies. The following etiological agents were identified: Madurella grisea 29 cases, Actinomadura madurae 26, Scedosporium apiospermum 5, Nocardia brasiliensis 5, Acremonium spp. 4 (Acremonium falciforme 2, Acremonium kiliense 1, Acremonium recifei 1), Madurella mycetomatis 3, Fusarium solani 2, Nocardia asteroides 1 and Streptomyces somaliensis 1. The main drugs used in the treat...

The effects of Seal-In X5 and Dermo liner (Össur) on suspension and patient's comfort in lower limb amputees are unclear. In this report, we consider the case of a 51-yr-old woman with bilateral transtibial amputation whose lower limbs were amputated because of peripheral vascular disease. The subject had bony and painful residual limbs, especially at the distal ends. Two prostheses that used Seal-In X5 liners and a pair of prostheses with Dermo liners were fabricated, and the subject wore each for a period of 2 wks. Once the 2 wks had passed, the pistoning within the socket was assessed and the patient was questioned as to her satisfaction with both liners. This study revealed that Seal-In X5 liner decreased the residual limb pain experienced by the patient and that 1-2 mm less pistoning occurred within the socket compared with the Dermo liner. However, the patient needed to put in extra effort for donning and doffing the prosthesis. Despite this, it is clear that the Seal-In X5 liner offers a viable alternative for individuals with transtibial amputations who do not have enough soft tissue around the bone, especially at the end of the residual limb. Copyright © 2012 by Lippincott Williams & Wilkins.

http://graphics.tx.ovid.com/ovftpdfs/FPDDNCLBPCEOKH00/fs047/ovft/live/gv024/00002060/00002060-201210000-00011.pdf 
http://www.ncbi.nlm.nih.gov/pubmed/22173083

Objectives: Critical limb ischemia (CLI) patients who are unsuitable for intervention face the dire prospect of primary amputation. Sequential compression biomechanical device (SCBD) therapy provides a limb salvage option for these patients. This study assessed the outcome of SCBD in severe CLI patients who otherwise would face an amputation. Primary end points were limb salvage and 30-day mortality. Secondary end points were hemodynamic outcomes (increase in popliteal artery flow and toe pressure), ulcer healing, quality-adjusted time without symptoms of disease or toxicity of treatment (Q-TwiST), and cost-effectiveness. Methods: From 2004 to 2009, we assessed 4538 patients with peripheral vascular disease (PVD). Of these, 707 had CLI, 518 underwent intervention, and 189 were not suitable for any intervention. A total of 171 patients joined the SCBD program for 3 months. Results: All patients were Rutherford category >4. Median follow-up was 13 months. Mean toe pressure increased from 39.9 to 55.42 mm Hg, with a mean difference in toe pressure of 15.49 mm Hg (P ‫؍‬ .0001). Mean popliteal flow increased from 35.44 to 55.91 cm/s, with mean difference in popliteal flow of 20.47 cm/s (P < .0001). Mortality at 30 days was 0.6%. Median amputation-free survival was 18 months. Limb salvage at 3.5 years was 94%. Freedom from major adverse clinical events (MACE) at 4.5 years was 62.5%. We treated 171 patients with SCBD at a cost of €681,948, with an estimated median per-patient cost of treatment with SCBD of €3988. Conclusion: SCBD therapy is a cost-effective and clinically efficacious solution in CLI patients with no option of revascularization. It provides adequate limb salvage and ameliorated amputation-free survival while providing relief of rest pain without any intervention.

Purpose: Following a lower limb amputation, people may experience limitations in performing sexual activities. However, only little research efforts have been devoted to unravel how people experience their sexuality after such an amputation. Therefore, the purpose of the current study is to describe how people with a lower limb amputation experience (changes in) their sexual functioning and sexual well-being. Methods: A qualitative approach with semi-structured interviews was used. Results: In total 26 interviews with persons with a lower limb amputation were performed. Thematic analysis of the data resulted in eight themes derived from the interviews: importance and description of sexuality; changes in sexual functioning; changes in sexual well-being; practical problems concerning sexuality; self-image; feelings of shame; role of the partner; communication about sexuality with professionals. Conclusions: Participants in this study indicated some problems concerning sexual functioning and/or sexual well-being. Some of these problems were of practical nature, and participants would have appreciated some information about how to handle this kind of practical sexual problems. However, such information should not be given at the beginning of the rehabilitation process, as at that time sexuality is not a priority for all patients.

Vocational reintegration is an important goal in the rehabilitation process. The amputees had to take time to adjust themselves to their new condition after lower limb amputation and that might have an impact on their vocation. As yet, there has been no information regarding vocational reintegration among the lower limb amputees in Thailand. Objectives: To study the rate of vocational reintegration, factors associated with vocational reintegration among the lower limb amputees.

Rehabilitation experts have been addressing the problem of accommodating disabled workers in the workplace for many years. When these disabled workers return to work, accomplishing the tasks they performed prior to their disability can present a serious challenge. Meeting this challenge successfully requires that employers provide accommodations at the workplace so that the disabled workers can continue to contribute efficiently to the operation of the enterprise. Disabilities that are caused by amputations are quite critical. The severity of the injury in terms of loss of a limb and the costs associated with accommodations make this type of disability extremely significant. This paper deals with accommodating &quot;permanent partial&quot; and &quot;permanent total disabilities&quot; due to amputations. The paper is divided into two main parts. The first part focuses on the causes of amputations, types, and difficulties that an amputee faces in the work environment. In this part, an...

Background: Improvements in protection and medical treatments have resulted in increasing numbers of modernwarfare casualties surviving with complex lower-extremity injuries. To our knowledge, there has been no prior analysis of foot and ankle blast injuries as a result of improvised explosive devices (IEDs). The aims of this study were to report the pattern of injury and determine which factors are associated with a poor clinical outcome.

Amputation is one of the oldest surgical procedure and a good amputation results in optimal functional outcome by providing healthy residual limb. Advances in prosthetics has enabled amputee with diverse options and better functionality. There is also decrease in the overall burden of amputation as a result of better treatment of causative disorders and proper limb salvage techniques. Complications, however, pose challenges in regain of necessary functions and include an array of disorders related to the procedure, technique and other factors. An understanding of common and practical complications is helpful in their anticipation and relevant prohibitive measures. Apart from it, a comprehensive study that highlights pattern of amputations and related complications provides database for preventive and management strategy. A total of 69 cases of extremity amputations were included within a defined period of Jan 2011 to June 2016. Relevant demographic data were noted along with other details amputation and complications. An attempt is also made for co-morbidities associated in cases with complications. Males (88.40%) and lower extremity (66.66%) were involved more commonly than females and upper extremity. Below knee was commonest (50.72%) lower and below elbow along with digital amputations were commonest (15.94% each) upper extremity amputations. The significant complication that required increased hospital stay or additional procedures were noted in 34 (49.27%) cases. Delayed wound healing, wound dehiscence, painful neuroma, stiffness, exposed bone and phantom pain were some of major complication noted in the study. A brief notes on patient characteristics has been attributed to the nature of trauma, co-morbidities and substance abuse among the complicated cases. The early recognition of complication and prompt management goes a long way in abetment of agony and discomfort of patient affecting overall outcome. Introduction Amputation is one of the oldest surgical intervention and staged procedure for variety of indications compromising the vitality of limb and at times life [1]. It is to be considered as a reconstructive procedure and is not mere removal of useless body part. The level and underlying culprit causes are of little concern now as advances in prosthetics has given us diversity and functionality that was akin to fiction in the past. Amputation aims to restore function and better results are met with team efforts. Apart from patient, doctor and prosthetist, moral support of family and close ones and at times psychological support is also critical for the optimal outcome [2]. The knowledge of common risk factor and types of amputations as well as complications helps clinician better anticipate and prevent those.

Background: Osteosarcoma is the most common primary bone malignancy in childhood and adolescence. However, it is very rare in children under 5 years of age. Although studies in young children are limited in number, they all underline the high rate of amputation in this population, with conflicting results being recently reported regarding their prognosis. Methods: To enhance knowledge on the clinical characteristics and prognosis of osteosarcoma in young children, we reviewed the medical records and histology of all children diagnosed with osteosarcoma before the age of five years and treated in SFCE (Société Française des Cancers et leucémies de l'Enfant) centers between 1980 and 2007. Results: Fifteen patients from 7 centers were studied. Long bones were involved in 14 cases. Metastases were present at diagnosis in 40% of cases. The histologic type was osteoblastic in 74% of cases. Two patients had a relevant history. One child developed a second malignancy 13 years after osteosarcoma diagnosis. Thirteen children received preoperative chemotherapy including high-dose methotrexate, but only 36% had a good histologic response. Chemotherapy was well tolerated, apart from a case of severe late convulsive encephalopathy in a one-year-old infant. Limb salvage surgery was performed in six cases, with frequent mechanical and infectious complications and variable functional outcomes. Complete remission was obtained in 12 children, six of whom relapsed. With a median follow-up of 5 years, six patients were alive in remission, seven died of their disease (45%), in a broad range of 2 months to 8 years after diagnosis, two were lost to follow-up. Conclusions: Osteosarcoma seems to be more aggressive in children under five years of age, and surgical management remains a challange.

To assess the efficacy and safety of lower extremity arterial reconstruction in diabetic and non-diabetic subjects during a 3-year period. A prospective clinic-based study between 1994-1999 in Area 7, Madrid, with a population of 569 307 and an estimated diabetic population of 37 932 (15 505 men and 22 427 women). The level of arterial reconstruction and associated risk factors were ascertained. Results: A total of 588 peripheral revascularization surgical procedures were performed in 481 patients. The diabetic patients (n=174, 36.2%) underwent 222 surgical procedures (including 48 follow-on operations, 21.6%), and 307 non-diabetic subjects underwent 366 surgical procedures (59 follow-on operations, 16.1%). The numbers of surgical procedures per 100 000 people at risk and year were 18.8 and 1.8 for non-diabetic men and women, respectively, and 145.1 and 29.0 for men and women with diabetes mellitus (7.7-and 16.2-fold, respectively). Age at reconstruction surgery was 2 and 5 years earlier in non-diabetic than in diabetic men and women, respectively. Diabetic patients had a higher neuropathy score (P B0.05) and were less frequently smokers (PB0.05) than non-diabetic subjects. Diabetic subjects more frequently had distal reconstruction while proximal arterial reconstruction was more often performed in non-diabetic subjects. Between 64.6 and 80.4% of people with diabetes and 82.3 and 88.9% of non-diabetic subjects had no complications during their in-hospital stay. Distal amputation simultaneous to arterial reconstruction was the most frequent morbidity of people with diabetes during the study (P B0.05). Despite a graft occlusion rate after femoropopliteal revascularization significantly higher than in non-diabetic people (P B0.05), diabetic people more often required lower extremity amputations (LEAs) for the same level of bypass (PB 0.01). Cumulative limb salvage rates were lower in diabetic patients than in non-diabetic subjects at femoropopliteal (49.2 vs. 89.7%; PB 0.001), femorodistal (73.5 vs. 95.2%; PB 0.01), and distal reverse (77.9 vs. 87.3%; PB 0.05) arterial reconstruction, at the end of the third year, but similar after aorto-iliac reconstruction (93.1 vs. 97.5%). A higher neuropathy score and the presence of foot ulcers were associated to significantly lower limb salvage in diabetic patients (P B0.05), but not in non-diabetic people. Survival rates after 3 years were similar between diabetic and non-diabetic populations after aorto-iliac (93.1 : S 0 1 6 8 -8 2 2 7 ( 0 1 ) 0 0 2 5 4 -6 A.L. Calle-Pascual et al. / Diabetes Research and Clinical Practice 53 (2001) 129-136 130 vs. 97.5%), femoropopliteal (97.2 vs. 90.3%), and distal reverse (93.2 vs. 98.1%) revascularization, and slightly lower in diabetic compared to non-diabetic patients after femorodistal revascularization (82.1 vs. 96.3%; PB 0.05). Conclusion: Although limb salvage after arterial reconstruction is lower in diabetic than in non-diabetic subjects, particularly in those with a higher neuropathy score, this surgical approach can be applied in both diabetic and non-diabetic subjects with otherwise similar outcome.

Advances in robotic technology have recently enabled the development of powered lower-limb prosthetic limbs. A major hurdle in developing commercially successful powered prostheses is the control interface. Myoelectric signals are one way for prosthetic users to provide feedforward volitional control of prosthesis mechanics. The goal of this study was to assess motor learning in people with lower-limb amputation using proportional myoelectric control from residual-limb muscles. We examined individuals with transtibial amputation and nondisabled controls performing tracking tasks of a virtual object. We assessed how quickly the individuals with amputation improved their performance and whether years since amputation correlated with performance. At the beginning of training, subjects with amputation performed much worse than control subjects. By the end of a short training period, tracking error did not significantly differ between subjects with amputation and nondisabled subjects. Initial but not final performance correlated significantly with time since amputation. This study demonstrates that although subjects with amputation may initially have poor volitional control of their residual lower-limb muscles, training can substantially improve their volitional control. These findings are encouraging for the future use of proportional myoelectric control of powered lower-limb prostheses.

MAGNETIC source imaging revealed that the topographic representation in the somatosensory cortex of the face area in upper extremity amputees was shifted an average of t.5 cm toward the area that would normally receive input from the now absent nerves supplying the hand and fingers. Observed alterations provide evidence for extensive plastic reorganization in the adult human cortex following nervous system injury, but they are not a sufficient cause of the phantom phenomenon termed 'facial remapping'.

Background Joint-sparing or physeal-sparing diaphyseal resections are technically challenging when only a small length of bone is available for implant purchase. Questions/purposes We describe a series of cases with the aim of generating some guidelines as to the choice of reconstruction method and the implant used. Methods We retrospectively reviewed 25 patients with diaphyseal resections in which the remaining epiphyseal or metaphyseal segment provided 3 cm or less of purchase. Reconstruction was performed with bone (allograft, extracorporeally radiated autograft, or vascularized fibula) in 19 cases or a custom diaphyseal implant (CDI) in six. The implants used for holding the bone construct varied from standard plates to custom plates. The presence of union, function, complications, and disease status at last followup was recorded. Results Sixteen of the 25 patients are disease-free and alive with the original construct at a median followup of 34 months (range, 12-66 months). Implant-related complications such as plate breakage (four) and angulation (three) happened more frequently when weak plates such as reconstruction plates were used. Local recurrence with pulmonary metastases occurred in two cases. The two deep infections required an amputation or rotationplasty for control. Custom plates were successful in three of four patients.

This paper addresses the assessment of and intervention with pediatric patients undergoing limb amputation. A multicomponent treatment package is advocated including the use of play and cognitive-behavioral strategies to enhance coping and adjustment to the loss of a limb.

This study identified clinical (e.g., etiology) and demographic factors related to prosthesis use in persons with upper-and lower-limb amputation (ULA and LLA, respectively) and the effect of phantom limb pain (PLP) and residual limb pain (RLP) on prosthesis use. A total of 752 respondents with LLA and 107 respondents with ULA completed surveys. Factors related to greater use (hours per day) for persons with LLA included younger age, full-or part-time employment, marriage, a distal amputation, an amputation of traumatic etiology, and an absence of PLP. Less use was associated with reports that prosthesis use worsened RLP, and greater prosthesis use was associated with reports that prosthesis use did not affect PLP. Having a proximal amputation and reporting lower average PLP were related to greater use in hours per day for persons with an ULA, while having a distal amputation and being married were associated with greater use in days per month. Finally, participants with LLA were significantly more likely to wear a prosthesis than those with ULA. These results underscore the importance of examining factors related to prosthesis use and the differential effect that these variables may have when the etiology and location of amputation are considered.

Objective-To characterize biologic behavior, clinical outcome, and effect of histologic grade on prognosis for dogs with appendicular chondrosarcoma treated by amputation alone. Study Design-Case series. Animals-Dogs (n ¼ 25) with appendicular chondrosarcoma. Methods-Medical records were searched to identify dogs with appendicular chondrosarcoma treated by limb amputation alone. Information recorded included signalment, anatomic location, radiographic appearance, and development of metastasis. Histopathologic diagnosis was confirmed and graded (1, 2, or 3). Survival curves were generated by the Kaplan-Meier method and the association between covariates (gender, age, weight, and tumor grade) and survival were evaluated using the univariate proportional hazards model. Results-Histopathology slides were available for 25 dogs. Rates of pulmonary metastasis were as follows: grade 1-0%, grade 2-31%, and grade 3-50%. Overall median survival time (MST) was 979 days. Age, weight, and sex were not significantly associated with survival (P ¼ .16; .33; and .31, respectively). Survival was significantly associated with tumor grade (P ¼ .008), with dogs with tumor grade of 1, 2, and 3 having MSTs of 6, 2.7, and 0.9 years, respectively. Conclusion-Canine appendicular chondrosarcoma can be treated effectively with amputation alone. Low to intermediate grade chondrosarcoma has a good prognosis, whereas high-grade tumors appear to behave aggressively. Clinical Relevance-The overall prognosis for appendicular chondrosarcoma is better than that of appendicular osteosarcoma treated by amputation alone or in combination with chemotherapy. r

Purpose. To systematically examine the state of research on sexuality and amputees. Methods. A total of five publication databases were searched: Pubmed, Cinahl, Embase, Psychinfo and Recall. Results. A total of 11 eligible studies was found. The studies were characterised by a diversity of study populations, sampling methods, gender and age distributions, assessment methods, and outcomes measures. The use of the terminology regarding sexuality was ambiguous. All studies found an impact of the amputation of a limb on some part of sexual functioning (or concerns about) to some degree. Conclusions. Studies on sexuality and amputees are very diverse and terminology is ambiguous. Amputation of a limb has an impact on sexual functioning. Amputees complain that there is little support from professionals. The authors recommend the use of the ICF terminology. Suggestions for future research are given.

En raison de l'allure épidémique que prend le diabète sucré dans le monde entier, la prévalence de ses complications est amenée à s'accroître significativement. Le pied diabétique, responsable d'une grande morbidité et de graves incapacités, pèse lourdement sur la société, devenant un véritable problème de santé publique. Les données épidémiologiques sur la pathologie du pied diabétique sont nombreuses mais difficiles à interpréter du fait des différences dans la méthodologie employée et dans la définition même de la pathologie étudiée dans les différentes études, du manque d'homogénéité dans l'expression de la prévalence ou de l'incidence, des caractéristiques des populations étudiées (origine ethnique, niveau social, accessibilité aux soins,…). Dans les pays occidentalisés, on peut estimer que chaque année deux patients diabétiques sur cent souffrent d'une ulcération de leur pied. Les chiffres concernant les amputations des membres inférieurs sont très variables : ainsi, l'incidence allant de moins de 1 ‰ en dans la région de Madrid ou au Japon pour dépasser 20 ‰ dans certaines tribus indiennes d'Amérique du Nord. En France métropolitaine, elle est estimée aux environ de 2 ‰ mais avec des variations régionales notables, bien inférieure à celle rapportée à La Réunion. Quoi qu'il en soit, le risque d'ulcération du pied et d'amputation des membres inférieurs est beaucoup plus élevé dans la population diabétique : 15 à 25 % des diabétiques présenteront un ulcère du pied au cours de leur vie et de par le monde, une amputation est réalisée toutes les 30 secondes chez un patient diabétique. Comme le souligne cet article, neuropathie, artériopathie et déformations du pied expliquent pour la plus grande partie cet excès de pathologie. Âge, sexe, origine ethnique, niveau socio-culturel y contribuent. L'identification de ces facteurs est fondamentale afin de classer chaque diabétique dans une catégorie de risque et prendre des mesures de prévention adaptées.

The clinician manages trauma patients in the emergency room, operation theatre, intensive care unit and trauma ward with an endeavour to provide best possible treatment for physical injuries. At the same time, it is equally important to give adequate attention to behavioural and psychological aspects associated with the event. Knowledge of the predisposing factors and their management helps the clinician to prevent or manage these psychological problems. Various causes of psychological disturbances in trauma patients have been highlighted. These include pain, the sudden and unexpected nature of events and the procedures and interventions necessary to resuscitate and stabilise the patient. The ICU and trauma ward environment, sleep and sensory deprivation, impact of injury on CNS, medications and associated pre-morbid conditions are also significant factors. Specific problems that concern the traumatised patients are helplessness, humiliation, threat to body image and mental symptoms. The patients react to these stressors by various defence mechanisms like conservation withdrawal, denial, regression, anger, anxiety and depression. Some of them develop delirium or even more severe problems like acute stress disorder or post-traumatic stress disorder. Physical, pharmacological or psychological interventions can be performed to prevent or minimise these problems in trauma patients. These include adequate pain relief, prevention of sensory and sleep deprivation, providing familiar surroundings, careful explanations and reassurance to the patient, psychotherapy and pharmacological treatment whenever required.

Objective: Dual antiplatelet therapy with clopidogrel plus acetylsalicylic acid (ASA) is superior to ASA alone in patients with acute coronary syndromes and in those undergoing percutaneous coronary intervention. We sought to determine whether clopidogrel plus ASA conferred benefit on limb outcomes over ASA alone in patients undergoing below-knee bypass grafting. Methods: Patients undergoing unilateral, below-knee bypass graft for atherosclerotic peripheral arterial disease (PAD) were enrolled 2 to 4 days after surgery and were randomly assigned to clopidogrel 75 mg/day plus ASA 75 to 100 mg/day or placebo plus ASA 75 to 100 mg/day for 6 to 24 months. The primary efficacy endpoint was a composite of index-graft occlusion or revascularization, above-ankle amputation of the affected limb, or death. The primary safety endpoint was severe bleeding Global Utilization of Streptokinase and Tissue plasminogen activator for Occluded coronary arteries [GUSTO] classification). Results: In the overall population, the primary endpoint occurred in 149 of 425 patients in the clopidogrel group vs 151 of 426 patients in the placebo (plus ASA) group (hazard ratio [HR], 0.98; 95% confidence interval [CI], 0.78-1.23). In a prespecified subgroup analysis, the primary endpoint was significantly reduced by clopidogrel in prosthetic graft patients (HR, 0.65; 95% CI, 0.45-0.95; P ‫؍‬ .025) but not in venous graft patients (HR, 1.25; 95% CI, 0.94-1.67, not significant [NS]). A significant statistical interaction between treatment effect and graft type was observed (P interaction ‫؍‬ .008). Although total bleeds were more frequent with clopidogrel, there was no significant difference between the rates of severe bleeding in the clopidogrel and placebo (plus ASA) groups (2.1% vs 1.2%). Conclusion: The combination of clopidogrel plus ASA did not improve limb or systemic outcomes in the overall population of PAD patients requiring below-knee bypass grafting. Subgroup analysis suggests that clopidogrel plus ASA confers benefit in patients receiving prosthetic grafts without significantly increasing major bleeding risk. ( J Vasc Surg 2010;52:825-33.)