Arm Amputation Research Articles

Preliminary Investigation of Pain-Related Changes in Cerebral Blood Volume in Patients With Phantom Limb Pain

ObjectiveTo investigate changes in the pain network associated with phantom limb pain, magnetic resonance imaging (MRI) was used to measure cerebral blood volume (CBV) in patients who had undergone unilateral arm amputation after electrical injury. DesignCase-controlled exploratory MRI study of CBV via MRI. SettingUniversity hospital. ParticipantsParticipants (N=26) comprised patients with phantom limb pain after unilateral arm amputation (n=10) and healthy, age-matched persons (n=16). InterventionsNot applicable. Main Outcome MeasuresThe intensity of phantom limb pain was measured using the visual analog scale (VAS). Depressive mood was assessed using the Hamilton Depression Rating Scale, and cognitive function was assessed using the Korean version of the Mini-Mental State Examination. Voxel-wise comparisons of relative CBV maps were made between amputees and controls over the entire brain volume. The relationship between individual participant CBV (measured in voxels) and VAS score was also examined. ResultsCompared with control participants, amputees exhibited greater degrees of depression; significantly higher CBV in the bilateral medial frontal area (orbitofrontal cortex [OFC] and pregenual anterior cingulate cortex [pACC]); and significantly lower CBV in the right midcingulate cortex, posterior cingulate cortex, and primary somatosensory cortex. CBV increased in the contralateral and ipsilateral hemispheres of the amputated arm, regardless of the amputation side. This CBV increase in the OFC and pACC was strongly correlated with pain intensity in all amputees. ConclusionsWe observed increased CBV in regions associated with emotion in the cerebral pain network of patients who had undergone unilateral arm amputation after electrical injury. This study suggests that CBV changes were related to neuroplasticity associated with phantom limb pain.

Merkel cell carcinoma occurring in a black woman: a case report

BackgroundMerkel cell carcinoma is a rare, very aggressive neuroectodermal tumor of the skin. It is typically located on sun-exposed skin and frequently found in white men aged between 70 and 80 years.Case presentationWe report a case of a 58-year-old black woman diagnosed with Merkel cell carcinoma of the posterior face of the right elbow. She had biopsy excision and was lost to follow-up. Four months later, she presented with recurrent disease on the inferior third of the right arm with three ipsilateral axillary lymph node metastases. Amputation of the right arm and ipsilateral axillary lymph node dissection were performed, followed by adjuvant radiotherapy. Six months later, the patient died as a result of respiratory failure caused by lung metastasis. To the best of our knowledge, no specific studies have been done comparing the course and the characteristics of Merkel cell carcinoma in white and black populations, and no similar case has been reported in the literature.ConclusionsThe Merkel cell carcinoma is very rare in black people. As described elsewhere in the literature, our patient had a poor outcome despite radical management. To date, to the best of our knowledge, there has been no comparison of the prognosis of this tumor in white and black populations.

Isolated metastasis of lung cancer to carpal bones

Introduction. Lung cancer often gives metastases in the bone system, of which the wrist accounts for 0.1% and the bones of the wrist are primarily affected in only 17% of cases. We presented a patient with the delayed diagnosis and a rare localization of isolated metastases of lung cancer to carpal bones which ended with upper arm amputation. Case report. A 56-year-old, a laborer, healthy, smoker, coughing for decades with occasional expectoration, hoarseness, during the last 3 months felt pain in his right wrist. He denied trauma. Physical examination led to the diagnosis of tendovaginitis of the hand. He visited a physiatrist and began treatment. After the therapy, symptoms were partially decreased and later began to worsen with symptoms of the median nerve compression. The neurologist diagnosed it as the carpal tunnel syndrome. The patient?s condition worsened and he was sent to the Emergency Center of the Clinical Center of Vojvodina, Novi Sad, Serbia with the diagnosis of arthritis of the wrist. The final diagnosis of lung adenocarcinoma with isolated metastasis to bone tissue was made with a biopsy of the tumor and examination by an oncologist. Primary tumor localization was diagnosed with a computed tomography (CT) scan and skeletal scintigraphy. The patient underwent upper arm amputation and was sent to an oncologist. Conclusion. Carefully taken anamnesis, detailed general and local examination, and frequent monitoring of patients could help make a correct diagnosis of this rare localization of the lung cancer, before the spreading process and the occurrence of severe complications.

Clinical Efficacy of Microvascular Anastomotic Coupler in Upper Limb Replantation

Objective: Microvascular anastomotic coupler has gained popularity in anastomosis surgery over the last 2 decades. However, evaluation of its impact on patency rate in upper limb replantation is barely reported. In this study, we aim to access clinical efficacy of microvascular anastomotic coupler in the application of upper limb replantation. Methods: From March 2013 to August 2015, a retrospective study was conducted in 6 consecutive patients with amputated upper limbs who underwent replantation. Among these patients, replantation was performed in 2 patients with middle upper arm amputation, 1 patient with elbow amputation, 2 with forearm amputation, and 1 with wrist disarticulation. Twenty-seven microvascular anastomotic couplers were applied in anastomosis of 2 brachial arteries, 4 ulnar arteries, 3 radial arteries, 6 cephalic veins, 4 basilic veins, 4 venae comitantes of brachial arteries, and 4 venae comitantes of ulnar arteries. Revascularization time, patency rate, complications, and viability of limbs were evaluated. Results: Patency rate of vessels in all 6 patients was 100%, and average duration of operation was 5 hours, whereas the mean time for anastomoses was 4 minutes, without postoperative vascular crisis. All replanted limbs survived after an average follow-up of 2 to 12 months; blood flow was patent and no thrombosis occurred over the site of anastomosis by Doppler vascular ultrasound. Conclusion: The microvascular anastomotic coupler serves as a powerful instrument in upper limb replantation by achieving high patency rate, high viability, and low complication rate.

Revealing the neural fingerprints of a missing hand.

The hand area of the primary somatosensory cortex contains detailed finger topography, thought to be shaped and maintained by daily life experience. Here we utilise phantom sensations and ultra high-field neuroimaging to uncover preserved, though latent, representation of amputees' missing hand. We show that representation of the missing hand's individual fingers persists in the primary somatosensory cortex even decades after arm amputation. By demonstrating stable topography despite amputation, our finding questions the extent to which continued sensory input is necessary to maintain organisation in sensory cortex, thereby reopening the question what happens to a cortical territory once its main input is lost. The discovery of persistent digit topography of amputees' missing hand could be exploited for the development of intuitive and fine-grained control of neuroprosthetics, requiring neural signals of individual digits.

Anaesthesia for a Patient with Gorham’s Disease A Very Rare Disease to Report

Gorham disease, which is also known as massive osteolysis, vanishing bone disease or lymphangiomatosis, is an extremely rare condition, characterized by proliferation of vascular channels resulting in destruction and resorption of osseous matrix leading to bone loss, which in turn leads to joint instability and problems during airway management and positioning for surgery. Respiratory involvement may further complicate anaesthesia management. We are reporting the anaesthesia care of a 11-year-old boy of known GS with left sided chylothorax who came for amputation of left arm due to closed injury arm resulting from RTA.He was on cyclical Pamidronate therapy and had completed radiotherapy. JBSA 2016; 29(2): 75-77

Tactile feedback for relief of deafferentation pain using virtual reality system: a pilot study.

BackgroundPrevious studies have tried to relieve deafferentation pain (DP) by using virtual reality rehabilitation systems. However, the effectiveness of multimodal sensory feedback was not validated. The objective of this study is to relieve DP by neurorehabilitation using a virtual reality system with multimodal sensory feedback and to validate the efficacy of tactile feedback on immediate pain reduction.MethodsWe have developed a virtual reality rehabilitation system with multimodal sensory feedback and applied it to seven patients with DP caused by brachial plexus avulsion or arm amputation. The patients executed a reaching task using the virtual phantom limb manipulated by their real intact limb. The reaching task was conducted under two conditions: one with tactile feedback on the intact hand and one without. The pain intensity was evaluated through a questionnaire.ResultsWe found that the task with the tactile feedback reduced DP more (41.8 ± 19.8 %) than the task without the tactile feedback (28.2 ± 29.5 %), which was supported by a Wilcoxon signed-rank test result (p < 0.05).ConclusionsOverall, our findings indicate that the tactile feedback improves the immediate pain intensity through rehabilitation using our virtual reality system.Electronic supplementary materialThe online version of this article (doi:10.1186/s12984-016-0161-6) contains supplementary material, which is available to authorized users.

Healthcare-associated necrotizing cutaneous mucormycosis: A case report

Introduction: Mucormycosis is becoming a challenging problem as the number of immunocompromised patients is increasing. Historically, the primary presentation of the disease was rhinocerebral. However, other manifestations are becoming more prevalent. case report: We report a case of healthcare cutaneous mucormycosis in 51-year-old female initially presenting as cellulitis. the patient subsequently had worsening necrotizing infection and required multiple extensive intra- operative debridement procedures along with right arm amputation. Histopathology later confirmed by tissue cultures, revealed evidence of Rhizopus. the patient was then started on lifelong isavuconazole therapy. conclusion: Healthcare associated mucormycosis is a growing problem that requires high index of suspicion to ensure early diagnosis and prompt treatment.

Esophageal Perforation 2 Years After Cervical Hardware Implantation

A 44 year-old man presented to the emergency department with an 8-12 month history of progressive dysphagia to solids and liquids, 80 pound weight loss, odynophagia, and significant dyspepsia. Medical history included type 2 diabetes mellitus and a cerebral vascular accident 3 years prior with residual left-sided extremity motor weakness but no speech or swallowing dysfunction. Surgical history was significant for traumatic right arm amputation and multiple cervical spine surgeries, with most recent anterior fixation of C3-C7 two years prior. Initial plain films and computed tomography (CT) imaging of head and neck showed surgical fixation of C3-C7 with anterior displacement of C6/C7 hardware and screws into the prevertebral soft tissue without frank intrusion in the esophagus. Barium esophagram and flexible laryngoscopy the following day showed no focal abnormalities to the esophagus, nasopharynx, hypopharynx, and larynx. Endoscopy found surgical hardware visualized at the level of the cricopharyngeus. Six days after presentation, the patient underwent removal of cervical hardware and repair of esophageal perforation with placement of percutaneous endoscopic gastrostomy (PEG), tracheostomy, and salivary bypass. Purulent fluid was found surrounding the cervical hardware, and cultures isolated viridans streptococci, Candida albicans and Methicillin-resistant Staphylococcus aureus. He was treated with a total course of four weeks with IV vancomycin and oral fluconazole. Post-operative course was unremarkable and he reported no dysphagia by follow-up. Anterior cervical spinal fixation has become a common management modality for multiple spinal pathologies. While esophageal perforation most often occurring in the early post-operative phase, lateonset cases have been reported occurring more than 10 years after the initial surgery. Common symptoms include neck and throat pain, odynophagia, dysphagia, hoarseness, and aspiration. Less-common presenting symptoms include recurrent pneumonia, fever, cough, and subcutaneous emphysema. Prompt detection and intervention is crucial as mortality and complication rates rise significantly with delayed detection and intervention. Multiple modalities including CT imaging, endoscopy, and even surgical exploration may be required for diagnosis. Negative imaging should not be used as the sole means to rule out esophageal erosion or perforation. Esophageal perforation is most common at the C5/C6 or C6/C7 level. Essential components of therapy include surgical removal of hardware, abscess drainage with culture-directed parental antibiotics, and salivary fluid diversion. Swallowing function has been reported within 10-14 days after the surgical repair.Figure 1Figure 2Figure 3

Reliability of phantom pain relief in neurorehabilitation using a multimodal virtual reality system.

The objective of this study is to demonstrate the reliability of relief from phantom limb pain in neurore-habilitation using a multimodal virtual reality system. We have developed a virtual reality rehabilitation system with multimodal sensory feedback and applied it to six patients with brachial plexus avulsion or arm amputation. In an experiment, patients executed a reaching task using a virtual phantom limb displayed in a three-dimensional computer graphic environment manipulated by their real intact limb. The intensity of the phantom limb pain was evaluated through a short-form McGill pain questionnaire. The experiments were conducted twice on different days at more than four-week intervals for each patient. The reliability of our task's ability to relieve pain was demonstrated by the test-retest method, which checks the degree of the relative similarity between the pain reduction rates in two experiments using Fisher's intraclass correlation coefficient (ICC). The ICC was 0.737, indicating sufficient reproducibility of our task. The average of the reduction rates across participants was 50.2%, and it was significantly different from 0 (p <; 0:001). Overall, our findings indicate that neurorehabilitation using our multimodal virtual reality system reduces the phantom limb pain with sufficient reliability.

Self-repairing symmetry in jellyfish through mechanically driven reorganization

What happens when an animal is injured and loses important structures? Some animals simply heal the wound, whereas others are able to regenerate lost parts. In this study, we report a previously unidentified strategy of self-repair, where moon jellyfish respond to injuries by reorganizing existing parts, and rebuilding essential body symmetry, without regenerating what is lost. Specifically, in response to arm amputation, the young jellyfish of Aurelia aurita rearrange their remaining arms, recenter their manubria, and rebuild their muscular networks, all completed within 12 hours to 4 days. We call this process symmetrization. We find that symmetrization is not driven by external cues, cell proliferation, cell death, and proceeded even when foreign arms were grafted on. Instead, we find that forces generated by the muscular network are essential. Inhibiting pulsation using muscle relaxants completely, and reversibly, blocked symmetrization. Furthermore, we observed that decreasing pulse frequency using muscle relaxants slowed symmetrization, whereas increasing pulse frequency by lowering the magnesium concentration in seawater accelerated symmetrization. A mathematical model that describes the compressive forces from the muscle contraction, within the context of the elastic response from the mesoglea and the ephyra geometry, can recapitulate the recovery of global symmetry. Thus, self-repair in Aurelia proceeds through the reorganization of existing parts, and is driven by forces generated by its own propulsion machinery. We find evidence for symmetrization across species of jellyfish (Chrysaora pacifica, Mastigias sp., and Cotylorhiza tuberculata).

Reassessing cortical reorganization in the primary sensorimotor cortex following arm amputation

The role of cortical activity in generating and abolishing chronic pain is increasingly emphasized in the clinical community. Perhaps the most striking example of this is the maladaptive plasticity theory, according to which phantom pain arises from remapping of cortically neighbouring representations (lower face) into the territory of the missing hand following amputation. This theory has been extended to a wide range of chronic pain conditions, such as complex regional pain syndrome. Yet, despite its growing popularity, the evidence to support the maladaptive plasticity theory is largely based on correlations between pain ratings and oftentimes crude measurements of cortical reorganization, with little consideration of potential contributions of other clinical factors, such as adaptive behaviour, in driving the identified brain plasticity. Here, we used a physiologically meaningful measurement of cortical reorganization to reassess its relationship to phantom pain in upper limb amputees. We identified small yet consistent shifts in lip representation contralateral to the missing hand towards, but not invading, the hand area. However, we were unable to identify any statistical relationship between cortical reorganization and phantom sensations or pain either with this measurement or with the traditional Euclidian distance measurement. Instead, we demonstrate that other factors may contribute to the observed remapping. Further research that reassesses more broadly the relationship between cortical reorganization and chronic pain is warranted.

206. Teriparatide: An Unexpected Adjunct for the Treatment of a Longstanding Infected Elbow Prosthesis Prevented Arm Amputation

A 76-year-old woman with rheumatoid arthritis, osteoporosis and multiple comorbidities presented with septic left elbow prosthesis. Treatment included combination antibiotic therapy and removal of the prosthesis. Weeks later she was started on teriparatide. Her elbow symptoms resolved. In our experience, this is the first case in the literature reporting teriparatide efficacy in the treatment of septic arthritis.

Network-level reorganisation of functional connectivity following arm amputation

One of the most striking demonstrations of plasticity in the adult human brain follows peripheral injury, such as amputation. In the primary sensorimotor cortex, arm amputation results in massive local remapping of the missing hands' cortical territory. However, little is known about the consequences of sensorimotor deprivation on global brain organisation. Here, we used resting-state fMRI to identify large-scale reorganisation beyond the primary sensorimotor cortex in arm amputees, compared with two-handed controls. Specifically, we characterised changes in functional connectivity between the cortical territory of the missing hand in the primary sensorimotor cortex (‘missing hand cortex’) and two networks of interest: the sensorimotor network, which is typically strongly associated with the hand cortex, and the default mode network (DMN), which is normally dissociated from it. Functional connectivity values between the missing hand cortex and the sensorimotor network were reduced in amputees, and connectivity was weaker in individuals amputated for longer periods. Lower levels of functional coupling between the missing hand cortex and the sensorimotor network were also associated with emerged coupling of this cortex with the DMN. Our results demonstrate that plasticity following arm amputation is not restricted to local remapping occurring within the sensorimotor homunculus of the missing hand but rather produces a cascade of cortical reorganisation at a network-level scale. These findings may provide a new framework for understanding how local deprivation following amputation could elicit complex perceptual experiences of phantom sensations, such as phantom pain.

Novel Control Strategies for Arm Prostheses : A Partnership between Man and Machine

The human hand is an exquisite instrument. Most importantly, it is capable of performing a wide range of functions, and is able to switch seamlessly from one function to the next in response to the changing environment. Not surprisingly, the hand’ s loss through amputation is a major disability with drastic impact on quality of life. Prosthetic devices are designed to help alleviate some of the negative consequences of hand and arm amputation. Early prosthetic devices were purely mechanical, as exemplified by the traditional hook-and-cable systems. Later prostheses began to incorporate electrical and mechanical components to perform functions, and could be controlled by muscle signals in an amputee’ s residual limb （Fig. 1） . Termed myoelectric control, the use of muscle signals for control of robotic prostheses has gained increasing popularity since the 1960’ s. 1,2） Recent technological advances in sensor and actuator technology have further enabled the development of sophisticated myoelectric prostheses. These advances include myoelectric hands with multiple functions, or grip patterns, that amputees can select to perform various tasks. 3）

Attitudes in Context

The stereotypical media coverage of persons with physical disabilities (PWDs) has been repeatedly criticized, because biased depictions of PWDs can negatively affect nondisabled recipients’ attitudinal evaluations of PWDs. However, it remains unclear how the superordinate context of disability, which is frequently used by journalists to depict PWDs in the media – or other contexts (e.g., sports) – affect recipients’ attitudes toward those PWDs portrayed in the media. Potential context effects were analyzed with the help of two experiments (between-subjects design). In Study 1, nondisabled participants (N = 97) were randomly assigned to four groups. The context was manipulated by subliminally (30 ms) exposing participants to different textual primes of disability, sports, politics, and no prime (control group). Participants subsequently evaluated a visually depicted PWD (arm amputation). In Study 2, nondisabled participants (N = 63) were randomly assigned to three groups, and they read an illustrated print article (the same picture as in Study 1 was used). The context was manipulated with the help of specific news cues (disability, sports, politics), while the rest of the article remained unchanged. In both studies, the context of disability significantly lowered participants’ evaluations of the PWD. In contrast, sports – in both studies – had a systematically positive impact on participants’ attitudes toward the PWD. Furthermore, the general acceptance of PWDs in society was perceived to be more positive with sports cues in Study 2. Implications for the media coverage of PWDs are discussed.

Neuromuscular reorganization after arm amputation revealed by stump EMG evoked by different phantom movements

Proprioception, the sense of position and movement of body segments, may not be known as much as other senses such as vision or audition. However, since the pioneer work of Sherrington, the critical role of proprioception in motor control has been increasingly highlighted. In particular, studies of human subjects massively deprived of proprioception after a viral infection, have largely demonstrated their inability to coordinate their actions. As this typically results in an inability to stand and walk, we focus here on the ability of deafferented patients to control their upper-limb movements. We will first present studies that provided striking evidence for the role of proprioception in movement coordination before presenting our recent work on the role of proprioception in motor learning and how the loss of large somatosensory fibres may affect visual perception. http://dx. After amputation, the cortical regions of which the neuronal activity was related to the control of the missing limb will gradually be active in relation to another, generally adjacent, part of the body. This reorganization often goes together with a vivid perception of the presence of the missing limb, called "phantom limb". A little known phenomenon, but experienced by many amputees, is that the phantom limb can be moved at will. The patients feel the movements to be made in correspondence with their will and they are able to copy with their intact limb the movement they "performed" with their phantom limb. Results of recent studies suggest that, despite the cortical reorganisation, M1 still can send motor commands to the missing limb. These motor commands, being unable to project on the missing limb muscles, project on the preserved muscles of the stump, resulting in specific muscle activation patterns. We will (1) show the large panel of phantom movements experienced by patients and (2) make a comparison between the EMG patterns evoked by phantom movements and those generated by the patients for the control of myoelectric prostheses. Funding: Project financed by the Region Provence-Alpes-Cote d'Azur (Projet ExplorAmp, 2012) and CNRS (DEFISENS, 2013).

Biophysical Characterization of a Swimmer with a Unilateral Arm Amputation: A Case Study

To examine the effect of swimming speed (v) on the biomechanical and physiological responses of a trained front-crawl swimmer with a unilateral arm amputation. A 13-y-old girl with a unilateral arm amputation (level of the elbow) was tested for stroke length (SL, horizontal displacement cover with each stroke cycle), stroke frequency (SF, inverse of the time to complete each stroke cycle), adapted index of coordination (IdCadapt, lag time between propulsive phases), intracycle velocity variation (IVV, coefficient of variation of the instantaneous velocity-time data), active drag (D, hydrodynamic resistance), and energy cost (C, ratio of metabolic power to speed) during trials of increasing v. Swimmer data showed a positive relationship between v and SF (R² = 1, P < .001), IVV (R² = .98, P = .002), D (R² = .98, P < .001), and C (R² = .95, P = .001) and a negative relationship with the SL (R² = .99, P = .001). No relation was found between v and IdCadapt (R² = .35, P = .22). A quadratic regression best fitted the relationship between v and general kinematical parameters (SL and SF); a cubic relationship fit the IVV best. The relationship between v and D was best expressed by a power regression, and the linear regression fit the C and IdCadapt best. The subject's adaptation to increased v was different from able-bodied swimmers, mainly on interarm coordination, maintaining the lag time between propulsive phases, which influence the magnitude of the other parameters. These results might be useful to develop specific training and enhance swimming performance in swimmers with amputations.

Amputation Neuroma Growing Intravascularly Into a Thrombus

An adult man underwent arm amputation for a sarcoma. Pain and three masses observed radiologically prompted surgical exploration five years later. Microscopically, the masses represented amputation neuromas. One of them was located in the lumen of an artery, in a remote organized thrombus. Intravascular growth of an amputation neuroma has not been described previously.

Updates in Targeted Sensory Reinnervation for Upper Limb Amputation

Advanced robotic devices capable of simulating the dexterous ability of the upper limb with an array of internal sensors have raised the enticing prospect of replacing the lost intricate functions of the arm following upper limb amputation. However, a large gap still exists in the application of this technology to the human user. In particular, the ability to provide physiologically relevant sensory feedback—to have the amputee feel the prosthetic hand as their own—has not yet been achieved. Although a number of different approaches are being investigated, targeted sensory reinnervation, a refinement of the original targeted muscle reinnervation procedure, is the most recent and promising development in the effort to create a functional human–machine interface with a closed loop sensory feedback system. This technique aims to re-establish hand sensation on the skin so that it can be readily accessed non-invasively during functional tasks. Recent efforts are being directed towards distributing hand maps widely on the stump without interference of sensations from the native area. In this article, we will review the surgical approaches that have been used for sensory reinnervation in upper arm amputation and compare the resultant outcomes and potential functional utility of the techniques.