Amputation Group Research Articles

High Failure Rates When Avoiding Obstacles During Treadmill Walking in Patients With a Transtibial Amputation

Hofstad CJ, van der Linde H, Nienhuis B, Weerdesteyn V, Duysens J, Geurts AC. High failure rates when avoiding obstacles during treadmill walking in patients with a transtibial amputation. Objective To investigate if and to what extent patients with a transtibial amputation are less successful in avoiding unexpected obstacles while walking than healthy adults. Design Experimental 2-group design. Setting Dutch rehabilitation center. Participants Eleven patients with a transtibial amputation and 14 healthy controls. Interventions Not applicable. Main Outcome Measures Subjects walked on a treadmill at .56m/s. In 2 series of 12 trials each, an obstacle was dropped in front of the prosthetic or the nonprosthetic leg of the amputation group and the left leg of the control group at different phases during the step cycle. It was noted which avoidance strategy was used (a long step strategy [LSS] or a short step strategy [SSS]) and whether the obstacle was avoided successfully or not. These data were expressed as a percentage of the total number of trials completed by each subject. Results With either leg, the amputation group made significantly more errors than the control subjects (prosthetic leg, 24%±17%; nonprosthetic leg, 21%±17% vs 2%±2% for the control group). Highest failure rates were in the amputation group when time pressure was high, requiring an SSS, especially on the prosthetic side. An LSS under time pressure, however, nearly always resulted in failure for both the prosthetic and nonprosthetic legs. Subjects with the longest time since amputation were most successful in avoiding unexpected obstacles. Conclusions Under time pressure, patients with a lower-leg prosthesis perform best when they use their nonprosthetic leg as the lead limb in an SSS. The fact that some subjects with the longest time since amputation made no errors suggests that over many years it is possible to relearn the appropriate avoidance reactions sufficiently fast.

The insensate foot following severe lower extremity trauma: An indication for amputation?

Conclusion: Insensation of the plantar surface of the foot after lower extremity trauma is not prognostic of long-term plantar sensory status or functional outcome. More than half of patients who presented with an insensate foot after lower extremity trauma ultimately regained sensation at 2 years. Assessment of plantar sensation should not be a component of the limb salvage decision algorithm. Summary: Evaluation of plantar sensation is routine in the assessment of the impact of lower extremity trauma. The authors sought to determine long-term outcome after treatment of severe lower extremity trauma in patients who presented with absent plantar sensation. There were 55 subjects with an insensate extremity at the time of presentation, of whom 26 underwent amputation and 29 were treated for limb salvage. Also included was a control group consisting of patients with lower extremity trauma with intact plantar sensation at presentation who underwent limb reconstruction. Injury characteristics and functional and health-related quality-of-life outcomes at 1 and 2years after injury were compared in the three groups. The insensate salvage group did not have a reported or demonstrated worse outcome at 1 or 2 years compared with the insensate amputation or sensate control groups. Approximately 55% of patients in both the insensate salvage and sensate control groups in whom the limb was salvaged had normal plantar sensation at 2 years after injury. This was regardless of whether plantar sensation had been reported to be intact at the time of presentation after injury. No differences were noted in overall physical or psychosocial scores in the three groups. At 2 years after injury, only one patient in the insensate salvage group had absent plantar sensation. Comment: The data suggest assessment of plantar sensation after lower extremity trauma is essentially worthless in predicting the ultimate sensory status of the foot. These study findings do not support the widespread belief that absent initial plantar sensation in patients with a leg-threatening injury correlates with poor long-term outcome if the limb were to be salvaged. This study implies that tibial nerve dysfunction at the time of presentation does not necessarily imply transaction of the tibial nerve. It is important to remember that reversible ischemic injuries to nerves as well as neurapraxic injuries of peripheral nerves may mimic permanent loss of peripheral nerve function.

The Effect of Digit Amputation or Arthrodesis Surgery on Culling and Milk Production in Holstein Dairy Cows

The objectives of the study were to evaluate the effects of digit amputation and arthrodesis surgery performed in the field on culling and milk production during the early postsurgical period. Cows from 3 commercial dairy farms in New York State were recruited for the study. A total of 49 cows on which digit amputation (AMP) was performed were matched with 68 controls (MC-AMP), and 17 cows on which arthrodesis surgery (ARTHRO) was performed were matched with 20 controls (MC-ARTHRO) according to lactation, DIM, and lactation at the time of surgery. Performance was not directly comparable between the AMP and ARTHRO groups because cows were not randomly assigned to the 2 treatment groups. Therefore, each surgical group was evaluated relative to its respective matched control group. Cows with AMP had a significantly lower estimated median survival of 68 d (95% confidence interval; lower = 35 d, upper = 156 d) compared with 585 d (95% confidence interval; lower = 469 d, upper = 699 d) for the MC-AMP group. Total milk production for the first 60 d postsurgery was significantly lower for the AMP (1,533±SE = 101kg) group compared with the MC-AMP (2,121±101kg) group and for the ARTHRO (1,883±86kg) group compared with the MC-ARTHRO (2,250±88kg) group. Septic arthritis of the distal interphalangeal joint was the most common condition treated by surgery, accounting for 70.5% of ARTHRO cases and 73.5% for AMP. Toe necrosis accounted for 14.3% of AMP cases, and retroarticular abscess made up the rest of the AMP (12.2%) cases and 29.5% of the ARTHRO cases. Results suggest that cows that had undergone ARTHRO had a lower culling rate and a faster return to production compared with those that had undergone AMP. Arthrodesis should be considered as a treatment option for deep sepsis of the bovine foot.

Survival and Quality of Life after Arterial Revascularization or Major Amputation for Critical Leg Ischemia in Guadeloupe

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.

The insensate foot following severe lower extremity trauma: An indication for amputation?

Conclusion: Insensation of the plantar surface of the foot after lower extremity trauma is not prognostic of long-term plantar sensory status or functional outcome. More than half of patients who presented with an insensate foot after lower extremity trauma ultimately regained sensation at 2 years. Assessment of plantar sensation should not be a component of the limb salvage decision algorithm. Summary: Evaluation of plantar sensation is routine in the assessment of the impact of lower extremity trauma. The authors sought to determine long-term outcome after treatment of severe lower extremity trauma in patients who presented with absent plantar sensation. There were 55 subjects with an insensate extremity at the time of presentation, of whom 26 underwent amputation and 29 were treated for limb salvage. Also included was a control group consisting of patients with lower extremity trauma with intact plantar sensation at presentation who underwent limb reconstruction. Injury characteristics and functional and health-related quality-of-life outcomes at 1 and 2years after injury were compared in the three groups. The insensate salvage group did not have a reported or demonstrated worse outcome at 1 or 2 years compared with the insensate amputation or sensate control groups. Approximately 55% of patients in both the insensate salvage and sensate control groups in whom the limb was salvaged had normal plantar sensation at 2 years after injury. This was regardless of whether plantar sensation had been reported to be intact at the time of presentation after injury. No differences were noted in overall physical or psychosocial scores in the three groups. At 2 years after injury, only one patient in the insensate salvage group had absent plantar sensation. Comment: The data suggest assessment of plantar sensation after lower extremity trauma is essentially worthless in predicting the ultimate sensory status of the foot. These study findings do not support the widespread belief that absent initial plantar sensation in patients with a leg-threatening injury correlates with poor long-term outcome if the limb were to be salvaged. This study implies that tibial nerve dysfunction at the time of presentation does not necessarily imply transaction of the tibial nerve. It is important to remember that reversible ischemic injuries to nerves as well as neurapraxic injuries of peripheral nerves may mimic permanent loss of peripheral nerve function.

Failed femorocrural reconstruction does not prejudice amputation level

From January 1985 to December 1989, 500 consecutive patients presented to a single vascular unit with limb-threatening acute or critical ischaemia. Vascular reconstruction was attempted unless the patient had insufficient viable tissue to permit weight bearing or complete absence of run-off vessels in the calf. Fifty patients underwent a primary amputation and 450 patients underwent vascular reconstruction, of whom 265 had a femorocrural bypass. Sixty secondary amputations were performed following femorocrural bypass failure. The below-knee amputation to above-knee amputation ratio (BKA:AKA) was 2.0 in the primary amputation group and 1.1 in the secondary amputation group. Direct comparison between the two groups is not valid as they are clinically different. The combined BKA:AKA ratio was 1.4. This compares favourably with the BKA:AKA ratio of recent published series and figures from the National Amputation and Limb Fitting Services. It suggests that an unselective policy of vascular reconstruction for critical ischaemia does not lead to a higher proportion of above-knee amputations.

Peripheral resistance measurement in the assessment of severe peripheral vascular disease.

Thirty-seven patients undergoing femoropopliteal, fifteen undergoing femorodistal reconstruction and seven below knee amputees were subjected to prospective measurement of peripheral resistance. Resistance was significantly higher in the amputation and femorodistal groups than in the femoropopliteal group (P less than 0.03 and P less than 0.005 at 76 ml/min). In the femoropopliteal group patients with three vessel runoff had a significantly lower resistance than those with two or single vessel runoff (P less than 0.01). In the femoropopliteal group resistance of patent grafts at four months was significantly less than thrombosed grafts (P less than 0.006). Patients with a resistance less than 1200 mPRU had a significantly better patency than those in whom the resistance was greater than 1200 mPRU (P less than 0.05). Taking all the failed grafts there was a significant correlation between graft patency and resistance (P less than 0.003). Resistance measurement has been shown to correlate with the severity of the disease, with runoff defined radiographically and with graft patency. In a simplified form it may prove a useful adjunct to other methods of assessment in patients with distal disease.

The Insensate Foot Following Severe Lower Extremity Trauma

Plantar sensation is considered to be a critical factor in the evaluation of limb-threatening lower extremity trauma. The present study was designed to determine the long-term outcomes following the treatment of severe lower extremity injuries in patients who had had absent plantar sensation at the time of the initial presentation. We examined the outcomes for a subset of fifty-five subjects who had had an insensate extremity at the time of presentation. The patients were divided into two groups on the basis of the treatment in the hospital: an insensate amputation group (twenty-six patients) and an insensate salvage group (twenty-nine patients), the latter of which was the group of primary interest. In addition, a control group was constructed from the parent cohort so that the patients in the study groups could be compared with patients in whom plantar sensation was present and in whom the limb was reconstructed. Patient and injury characteristics as well as functional and health-related quality-of-life outcomes at twelve and twenty-four months after the injury were compared between the subjects in the insensate salvage group and those in the other two groups. The patients in the insensate salvage group did not report or demonstrate significantly worse outcomes at twelve or twenty-four months after the injury compared with subjects in the insensate amputation or sensate control groups. Among the patients in whom the limb was salvaged (that is, those in the insensate salvage and sensate control groups), an equal proportion (approximately 55%) had normal plantar sensation at two years after the injury, regardless of whether plantar sensation had been reported to be intact at the time of admission. No significant differences were noted among the three groups with regard to the overall, physical, or psychosocial scores. At two years after the injury, only one patient in the insensate salvage group had absent plantar sensation. Outcome was not adversely affected by limb salvage, despite the presence of an insensate foot at the time of presentation. More than one-half of the patients who had presented with an insensate foot that was treated with limb reconstruction ultimately regained sensation at two years. Initial plantar sensation is not prognostic of long-term plantar sensory status or functional outcomes and should not be a component of a limb-salvage decision algorithm.

Risk factors for major limb amputations in diabetic foot gangrene patients

We analyzed the clinical picture of diabetic foot lesion patients to investigate the risk factors for major limb amputations. The subjects were 210 diabetic foot lesion patients treated at our department over the past 9 years. The mean follow-up period was 604.5 [standard deviation (S.D.) 451.2] days with a median value of 492 days. There were 113 men and 97 women. By the final follow-up day, 18 underwent bypass surgeries (9%) and 13 skin grafts (6%), while 110 patients (52%) finally required limb amputation. The breakdown was 45 major amputations above or below the knee and 65 minor amputations of the toes or metatarsals. The outcomes of the major amputations were retrospectively analyzed by group. The blood glucose control was poor in all 45 major amputees, and their mean HbA1c (8.80%) was higher than that in the minor or non-amputation group (7.79%, P = 0.035). In the major amputation group, two patients had loss of vision due to retinopathy, and 30 patients received long-term hemodialysis due to nephropathy. The rate of arteriosclerosis obliterans (ASO) was higher in the major amputation group than in the minor or non-amputation group, and arteriography showed significantly high rates of multiple stenosis. Multivariate analysis of these results by the proportional hazard model showed that ASO with multiple stenosis (hazard ratio 3.23, 95% CI: 1.12–5.10), hemodialysis (2.14, 95% CI: 1.17–3.44), and HbA1c (1.20, 95% CI: 1.03–1.41) were independent risk factors for major amputation. The 3-year survival rate was 24.1% in the major amputation group and 93.0% in the minor or non-amputation group, and the life expectancy was significantly lower for the major amputees than the minor or non-amputees ( P < 0.0001). Together with early detection and treatment of foot lesions, good blood glucose control and early management of systemic complications such as nephropathy and arteriosclerosis are considered important to avoid major amputations.

Functional Outcome of Bilateral Limb Threatening

To describe the functional outcome of bilateral limb-threatening injuries at 2 years postinjury and to evaluate whether a different decision-making process should be used for these patients as opposed to patients with unilateral limb-threatening injury. This study population of 32 patients is a subset of 601 patients from a study of 8 level I trauma centers. The patients were prospectively followed through 24 months. The principle outcome measure at 2 years was the Sickness Impact Profile, designed to measure physical and psychosocial dimensions. The overall Sickness Impact Profile scores at 2 years demonstrate that all 3 bilateral injury groups (bilateral salvage [n = 14], unilateral salvage/amputation [n = 8], and bilateral amputation [n = 10]) were severely disabled (Sickness Impact Profile >10). The bilateral salvage group had the most dramatic improvement over the 24 months. The 2-year physical subscale Sickness Impact Profile data showed a similar trend. At the 2-year assessment, the bilateral amputation group was recording greater disability (Sickness Impact Profile = 16.3) compared to the bilateral salvage and unilateral amputation/salvage groups (Sickness Impact Profile = 8.5 and 12.6, respectively). The overall Psychosocial Dimension, which started off worst in the bilateral salvage group, ended up similar in all 3 groups (8 to 9). The percent of patients who returned to work was 66.7% in the unilateral salvage/amputation group versus 21.4 and 16% in the bilateral salvage and amputation groups, respectively. The results indicate that treatment judgments should be based upon the results derived from the analysis of the larger unilateral limb cohort data. Patients with severe, bilateral lower extremity injuries should be counseled that regardless of treatment combinations, the function of each limb is similar at 24 months. The unilateral amputation/salvage group had a greater probability of going back to work. This is the major identifiable benefit to undergoing salvage versus amputation.

Histomorphometric Changes in the Vessel Wall at the Site of Amputation in Diabetic Patients—Do They Influence Healing of the Stump?

To predict healing of the stump by assessing the microscopic vascular changes at the amputation site. A cohort study was conducted on 39 patients, 18 of them had below-knee amputation (group A) and 21 had ray amputation of a single toe (group B). Biopsies were taken from the anterior and posterior tibial arteries and the venae comitantes of group A patients. For group B patients, biopsies of the digital artery and dorsal vein of the toe were taken. In group A, 15 patients required no further amputation (group A1) and 3 underwent a further above-knee amputation (group A2). In group B, 16 required no further amputation (group B1) and 5 underwent a below-knee amputation (group B2). Lumen narrowing caused by intimal thickening of the arteries was significantly different between groups A1 and A2 (p<0.05). Lumen narrowing of the dorsal veins between groups B1 and B2 was also significantly different (p<0.05). The proportion of the vessel walls made up of intima and media was significantly different in both A1 and A2 as well as B1 and B2 groups. The proportion of total wall thickness over the total diameter of the vessel was not significantly different between both subgroups of A and B. Intimal thickening and medial thinning in the arteries can be used to predict the stump healing in patients who underwent below-knee amputation. For ray amputation patients, similar changes occurred in the dorsal veins, and this finding can also be used to predict the healing of the stump. However, intimal thickening occurred at the expense of the media; therefore, there is little change in the wall thickness.

Surgical revascularization versus amputation for peripheral vascular disease in dialysis patients: a cohort study

BackgroundSurgical treatment of peripheral vascular disease (PVD) in dialysis patients is controversial.MethodsWe examined the post-operative morbidity and mortality of surgical revascularization or amputation for PVD in a retrospective analysis of United States Renal Data System. Propensity scores for undergoing amputation were derived from a multivariable logistic regression model of amputation.ResultsOf the Medicare patients initiated on dialysis from Jan 1, 1995 to Dec 31, 1999, patients underwent surgical revascularization (n = 1,896) or amputation (n = 2,046) in the first 6 months following initiation of dialysis were studied. In the logistic regression model, compared to claudication, presence of gangrene had a strong association with amputation [odds ratio (OR) 19.0, 95% CI (confidence interval) 13.86–25.95]. The odds of dying within 30 days and within1 year were higher (30 day OR: 1.85, 95% CI: 1.45–2.36; 1 yr OR: 1.46, 95% CI: 1.25–1.71) in the amputation group in logistic regression model adjusted for propensity scores and other baseline factors. Amputation was associated with increased odds of death in patients with low likelihood of amputation (< 33rd percentile of propensity score) and moderate likelihood of amputation (33rd to 66th percentile) but not in high likelihood group (>66th percentile). The number of hospital days in the amputation and revascularization groups was not different.ConclusionAmputation might be associated with higher mortality in dialysis patients. Where feasible, revascularization might be preferable over amputation in dialysis patients.

The Indications for and the Prognostic Significance of Amputation as the Primary Surgical Procedure for Localized Soft Tissue Sarcoma of the Extremity

The indications for primary amputation of a localized soft tissue sarcoma (STS) of the extremity are not well defined in the literature. However, it has been suggested that patients who require an amputation to treat an STS are at increased risk for developing metastases. We categorized the main indications for primary amputation in our patient population and compared their oncological outcome with the outcome of patients who underwent limb-sparing surgery. 413 consecutive patients treated surgically at a single center for primary, nonmetastatic, deep, intermediate-, or high-grade STS of the extremity were reviewed. Indications for primary amputation were identified. Demographics and outcomes were compared between the amputation and limb-salvage groups. Multivariate Cox model analysis was used to identify independent risk factors for systemic relapse. Twenty-five (6%) of 413 patients with STS underwent primary amputation: they were older (P = .05), had larger tumors (P = .001), and had a significantly greater risk of developing metastatic disease than patients who underwent limb-sparing procedures (P = .008). However, multivariate analysis demonstrated that the only independent predictors of systemic relapse were tumor size (P = .0001) and tumor grade (P = .0001). Primary amputation was not an independent risk factor for metastatic disease. The decision to perform a primary amputation for an STS of the extremity is based on the location and local extent of the tumor, and the expected function of the extremity after tumor resection. The higher risk of metastases for patients who require primary amputation is accounted for by independent risk factors associated with their tumors--predominantly large tumor size.

Results of ray resection and amputation for ring avulsion injuries at the proximal interphalangeal joint

We investigated the long-term functional results of ray resection (14 cases) and amputation (nine cases) for ring avulsion injuries of ring finger which could not be replanted or underwent failed replantation. The mean follow-up was 37 (range, 24–63) months in the ray resection group and 32 (range, 24–40) months in the amputation group. Grip strength, key pinch strength, chuck pinch strength, hand circumference and palmar volume were decreased in the ray resection group but only grip strength and pulp pinch strength were significantly decreased in the amputation group. These results suggest that ray resection should be avoided in patients with occupations that need strong key and chuck pinch functions.

Sensitivity and reproducibility of accelerometry and heart rate in physical strain assessment during prosthetic gait.

Accelerometry and heart rate (HR) are frequently used indicators of physical strain during normal daily life. The present study focused on the sensitivity and reproducibility of accelerometry (body motility, the intensity of body movement measured with accelerometry) and HR (percentage maximal heart rate reserve, %HRR(max)) in the assessment of physical strain during walking in persons with a lower leg amputation, using persons without an amputation as reference. Ten patients with an amputation of the leg and ten comparison subjects performed, at an interval of 1 month, the same walking protocol three times. Subjects walked at a preferred speed and at fixed speeds. At their preferred walking speed, speed (0.63 vs 1.31 m s(-1), P=0.001), body motility [0.53 vs 0.91 (arbitrary unit), P=0.001] and %HRR(max) (42.5 vs 27.6, P=0.02) differed between the amputation group and the comparison group. At fixed walking speeds, only %HRR(max) differed between groups ( P</=0.002) and showed a session effect ( P=0.02). The relationship between body motility and %HRR(max) in the patient group was significantly different from that in the comparison group. It can be concluded that accelerometry is strongly related with walking speed, but not sensitive to differences and changes in economy, contrary to %HRR(max). The use of accelerometry as an indicator of the level of physical strain in persons with an amputation is not feasible. The added value of a calibration procedure has to be studied.

Mangled Extremity Severity Score in Children

Treatment of the severely traumatized or mangled lower extremity poses significant challenges. The Mangled Extremity Severity Score (MESS) is a scale that uses objective criteria to assist with acute management decisions. Most research on the MESS has been in adults or combined series with few children. The study was performed to investigate the MESS in children exclusively. The MESS was applied retrospectively to 36 patients with grades IIIB and IIIC open lower extremity fractures collected from two level 1 pediatric trauma centers. Patients were divided into limb salvage and primary amputation groups based on the decision of the treating surgeon. In the salvage group there were 18 grade IIIB fractures and 10 grade IIIC fractures. The MESS prediction was accurate in 93% of the injured limbs. In the amputation group eight limbs met the inclusion criteria; the MESS agreed with the treating surgeon in 63% of cases. These findings suggest the MESS should be considered when managing a child with severe lower extremity trauma.

Pacientes con isquemia crítica de extremidades inferiores: impacto del tratamiento en la calidad de vida

Summary Objective To assess the quality of life (QoL) of patients with critical limb ischaemia (CLI) and its modification after three types of therapies. Patients and methods From January to December 2000, 195 patients were admitted to our department with the diagnosis of CLI. Only patients receiving first therapy for their episode of CLI were selected and they proposed the realization of test QoL (SF-36) to the admission and to the 6 months of follow-up. 52 patients (36 men, 16 women), were recruited, mean age 68 years (r= 38-90). The type of received treatment divided in three groups (group I: revascularization, group II: major amputation, group III: conservative treatment). These groups were compared by Kruskal-Wallis test. Results To admission, patients with CLI present a poor QoL in all the dimensions. There were 30 patients in the group I, 6 in the group II and 16 in the group III without existing significant differences in these three groups as for sex, age, associate pathologies and QoL to the admission. When comparing the QoL in the several groups to 6 months, only there were significant differences in the dimension of physical function. The mean were inferior in the group of major amputation. Conclusion Independently of the received treatment, in all the patients with CLI the therapy improves the QoL, in particular the physical and emotional rol. Only in amputated patients there's no improvement of the physical function.

Hyperbaric-oxygen treatment: An adjunctive therapy in acute renal failure due to crush injury

Objective: Major seismic events leave their survivors trapped under the rubble leading to extensive muscle damage and its devastating sequale of hemodynamic and metabolic disturbances and acute renal failure. Hypoxemia aggravated during each hemodialysis (HD) session is important in acute renal failure patients with massive tissue injury. We retrospectively analyzed the adjunctive role of hyperbaric-oxygen (HBO) therapy in patients treated with HD for acute renal failure due to crush injury in terms of dialysis duration. Patients and Methods: 16 patients admitted after the 1999 Marmara earthquake to Istanbul Faculty of Medicine were treated with HBO. Only 8 (2 M, 6 F, mean age: 24.8 + 7.3 years) of them had required HD treatment. 29 (16 M, 13 F, mean age: 34.6 + 12.9 years) crush syndrome patients treated with HD but not with HBO were taken as controls and the clinical and laboratory data of the two groups were compared. Results: The mean duration time under the rubble for the HBO group was 9.4 + 3.2 hours. Mainly lower extremity fasciotomies were performed at 15.6 + 14.8 hours after extrication. There were no amputations in this group. There were three amputations in the control group. The mean number of HD sessions was 9.2 + 6.7/patient for 10.9 + 9.6 days until renal functions recovered and the patients had 27.4 + 15.6 HBO sessions until the recovery of their lesions. There were no correlations between the number of HBO sessions and any laboratory parameter nor the number of HD sessions. There was no statistical difference in the need for HD between the HBO and control group. Conclusions: Our results could not demonstrate a significant effect of HBO treatment in terms of HD duration; however, the valuable contribution of the HBO treatment was to increase the salvage of crushed limbs.

Successful subintimal angioplasty for leg ischaemia is dependent on length of occlusion, not site of lesion

Abstract Background The development of subintimal angioplasty offers an endovascular approach to the treatment of long occlusions not suitable for conventional transluminal angioplasty; it remains, however, the remit of relatively few radiologists in specialist centres. The authors have adopted the technique in view of promising published results. Methods Between May 1997 and July 2000, 50 patients had attempted subintimal angioplasty (median age 71 (interquartile range (i.q.r.) 61–80) years). Patients were divided into two groups by length of occlusion; 26 patients (group 1) had occlusions greater than 10 cm in length (iliac, one; superficial femory artery (SFA), 24; crural, one) and 24 patients (group 2) had occlusions of less than 10 cm (iliac, five; SFA, five; popliteal, nine; crural, five). The primary technical success rate, ankle: brachial pressure index (ABPI) before and after the procedure, complication rate and symptomatic improvement were recorded for both groups. Results The groups were well matched for age and indication for intervention. Primary technical success was significantly better for occlusions of less than 10 cm than for the longer lesions (83 versus 50 per cent; P &amp;lt; 0·01) with corresponding significantly greater rises in ABPI (P &amp;lt; 0·05). Complications included one death in each group, one amputation in group 2 and six in group 1, all after failed salvage grafts. Conclusion Subintimal angioplasty gives excellent results for occlusions of less than 10 cm in length irrespective of arterial site. Results for longer lesions are poor, with failed subintimal angioplasty often precipitating urgent distal vascular reconstruction and associated high risk of major amputation.

Hemostatic laparoscopic partial nephrectomy: cable-tie compression

Objectives. Laparoscopic partial nephrectomy (LPN) has generally been reserved for small exophytic lesions because of the limited hemostatic capabilities when excising large segments of renal parenchyma. To overcome this problem, we investigated a technique of laparoscopic reversible, regional hypoperfusion using a cable-tie to minimize blood loss and optimize exposure. Methods. Ten domestic pigs underwent LPN after securing a cable-tie around one pole of the kidney and tightening it until the distal parenchymal surface blanched completely. Eight large amputations involving the collecting system and eight smaller amputations excluding the collecting system were performed using laparoscopic scissors. Fibrin glue was applied to seal the cut surface prior to cable-tie removal. Four pigs (4 large and 4 small amputations) were killed immediately and methylene blue was injected retrograde into the ureter to identify collecting system leaks. The remaining 6 pigs (4 large and 4 small amputations) were killed 4 weeks later and retrograde urograms were performed to assess collecting system integrity. Results. Median cable-tie ischemia time was 15 minutes (range 7 to 48) and median blood loss was 30 mL (range 10 to 300). In each case, hemostasis was attained with fibrin glue. In the survival group, all 4 small amputations healed with a fibrotic scar. In the large amputation group, 1 animal died from urinary extravasation on postoperative day 4. The collecting systems of the remaining 3 pigs sealed completely. Conclusions. In the porcine model, cable-tie-assisted LPN provides an almost bloodless surgical field that facilitates rapid resection of large renal segments and hemostasis during a short ischemic period. We anticipate that this technique will broaden the clinical application of LPN.