Bilateral Above-knee Amputations Research Articles

Rare presentation of Waldenström’s macroglobulinaemia requiring bilateral above-knee amputations: a case report

BackgroundWaldenström’s macroglobulinaemia is a rarely encountered B-lymphocytic malignancy. Waldenström’s macroglobulinaemia-associated paraproteinaemia is linked to an increase in serum viscosity, which results in a hypercoagulable state. Burning bilateral foot pain in a man with alcohol dependence and controlled atrial fibrillation presenting to the emergency department was attributed to peripheral neuropathy, given satisfactory angiographic evidence of bilateral foot arterial blood supply. Subsequently, his presentation as an emergency with acute bilateral critical lower limb ischemia that was managed by bilateral above-knee amputations, prompted a wider search for other etiologies. We present a hitherto unreported case of Waldenström’s macroglobulinaemia-related acute bilateral lower limb ischemia, which required bilateral above-knee amputations.Case presentationA 50-year-old Caucasian man, who was an alcohol dependent heavy smoker, presented with burning pain in his right foot that was deemed to be related to alcoholic neuropathy. A computerized tomographic angiogram demonstrated an occluded right distal anterior tibial artery but a patent posterior tibial artery supplying the foot arch, findings that were associated with noncritical ischemia. After multiple presentations within a week, he was admitted following sudden clinical deterioration with acute confusion, hyponatremia, and bilateral foot pain. Over the course of 24 hours, the patient deteriorated rapidly, with bilateral lower limb ischemia requiring bilateral above-knee amputations. Subsequent investigations revealed a diagnosis of Waldenström’s macroglobulinaemia.ConclusionsTo the best of our knowledge, this is the only reported case of Waldenström’s macroglobulinaemia-induced bilateral lower limb ischemia requiring major bilateral amputations.

Powered knee and ankle prostheses enable natural ambulation on level ground and stairs for individuals with bilateral above-knee amputation: a case study

Ambulation with existing prostheses is extremely difficult for individuals with bilateral above-knee amputations. Commonly prescribed prostheses are passive devices that cannot replace the biomechanical functions of the missing biological legs. As a result, most individuals with bilateral above-knee amputations can only walk for short distances, have a high risk of falling, and are unable to ascend stairs with a natural gait pattern. Powered prostheses have the potential to address this issue by replicating the movements of the biological leg. Previous studies with individuals with bilateral above-knee amputations have shown that walking with powered prostheses is possible. However, stair ambulation requires different kinematics, kinetics, and power than walking. Therefore, it is not known whether powered prostheses can restore natural ambulation on stairs for bilateral above knee individuals. Here we show a case study with an individual with bilateral above-knee amputations using a pair of lightweight powered knee and ankle prostheses for walking and stair ambulation. The kinematic analysis shows that powered prostheses can restore natural leg movements, enabling the individual to walk and climb stairs using different gait patterns, such as step-over-step or step-by-step, one step or two steps at a time. The kinetic analysis shows that the powered prostheses can restore natural ankle push-off in walking and positive knee power generation in stair ascent, which are fundamental biomechanical functions of the missing biological legs. This case study is a first step towards enhancing functional mobility and quality of life for individuals with bilateral above-knee amputations through powered knee and ankle prostheses.

Military experience in the management of pelvic fractures from OIF/OEF

IntroductionPelvic fractures are a common occurrence in combat trauma. However, the fracture pattern and management within the most recent conflicts, i.e. Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF),...

Symmetrical Peripheral Gangrene of All Four Limbs of Unknown Etiology: a Rare Case Report

Symmetrical peripheral gangrene is a rare entity with high mortality, up to 40%. It is most often caused because of high-dose vasopressors, sepsis, disseminated intravascular coagulation (DIC), drugs, or malignancy. We are reporting a case of 45-year-old male patient, without any comorbidities presenting with dry gangrenous changes in all four limbs of sudden onset, which progressed to wet gangrene of lower limbs. The patient underwent bilateral above-knee amputation and right upper limb below-elbow amputation, and left hand got auto-amputated. However, even after a series of investigations, no etiology could be found.

RETRACTED: Decision making in junctional trauma care

Paul Parker, Decision making in junctional trauma care. Trauma. Published online ahead of print 4 June 2013. DOI: 10.1177/1460408613489088. This article was published in error and is therefore retracted. Improvised explosive devices cause 60% of all UK military fatalities. The signature injury produced is that of a bilateral above-knee amputation, significant perineal trauma and an open-book pelvic fracture. Shorter timelines deliver these patients to hospital at the very edge of the physiological envelope of survivability. The available time period for their haemorrhage control and initial wound surgery is short – often of the order of 75 min. The concepts and practise of ‘right turn resuscitation’, damage control surgery and orthopaedics, on-table ‘ITU’ pause/catch-up and then further resuscitative surgery are now commonplace. In Helmand in 2013, multiple-team operating is now the norm on these casualties with up to seven surgeons and three anaesthetists contemporaneously involved in the operative care of one patient. This usually involves one consultant orthopaedic surgeon and trainee per lower limb, a plastic surgeon on the upper limb or face/eyes and two general surgeons obtaining proximal vascular control or in-cavity haemorrhage control. A series of consensus statements were issued by the UK Military Limb Trauma Working Group and Torso Trauma Working Group of the UK Academic Department of Military Surgery and Trauma. Twenty-five clear and didactic statements were produced to provide advice to the newly qualified consultant team dealing with significant junctional or terrorist-related trauma. The fundamental message is that bleeding is always a surgical problem. Some adjuncts are available; massive transfusion, pressure (direct and indirect), compressive bandaging, haemostatic dressings and tourniquets. However, only formal surgical control, whether by the surgeon’s finger, soft clamp or tie, is definitive. Early proximal control is mandatory: In all cases, we state, ‘rapidly obtain the most distally appropriate proximal control – above the zone of injury.’

Levamisole-induced leukocytoclastic vasculitis and neutropenia in a patient with cocaine use: An extensive case with necrosis of skin, soft tissue, and cartilage

Levamisole-induced vasculitis is a relatively new entity in people who use cocaine. We describe a 44-year-old woman with a history of cocaine use who presented with a complaint of a painful rash of 2-3 month’s duration on her extremities, cheeks, nose, and earlobes. She had not experienced fever, weight loss, alopecia, dry eyes, oral ulcers, photosensitivity, or arthralgia. Examination revealed tender purpuric eruptions with central necrosis on her nose, cheeks, earlobes, and extremities. Laboratory investigations revealed neutropenia, an elevated erythrocyte sedimentation rate (ESR), presence of lupus anticoagulant, low complement component 3 (C3), and presence of perinuclear anti-neutrophil cytoplasmic antibody (p-ANCA). A urine toxicology screen was positive for cocaine, and gas chromatography–mass spectrometry was positive for levamisole. Skin biopsy showed leukocytoclastic vasculitis and small vessel thrombosis. Necrotic lesions of the nose led to its self-amputation. Large bullae on the lower extremities ruptured, leading to wound infection and extensive necrosis that required multiple surgical debridements. When necrosis progressed despite debridement, bilateral above-knee amputation of the legs was performed. Once new lesions stopped appearing, the patient was discharged home. Two months later, she had a recurrence related to cocaine use. To the best of our knowledge, this is only the second reported case of levamisole-induced vasculitis that required above-knee amputation.

A simple technique to position patients with bilateral above-knee amputations for operative fixation of intertrochanteric fractures of the femur: a case report

IntroductionIntertrochanteric fractures of the femur are common fractures in the elderly, and management includes operative fixation after patient positioning on the fracture table. Patients with bilateral above-knee amputations are challenging in terms of positioning on the table. We describe a simple technique to overcome this special problem.Case presentationA 75-year-old wheelchair-bound Caucasian man with bilateral above-knee amputations presented to our hospital after a fall. Plain radiographs showed an intertrochanteric fracture of the femur, and operative fixation with a dynamic hip screw was planned. His positioning on the table posed a particular problem, and therefore we developed a technique to overcome this problem.ConclusionPositioning of patients for fixation of intertrochanteric fractures of the femur poses a particular problem that can be solved by using our simple technique.

“Phantom” restless legs syndrome

A “body image” is an internal construct of a unitary corporeal self that endures in space and time, even after partial amputations of the physical body. A body image provides...

Cardiac Surgery in Patients with Major Lower Extremity Amputation: A Single Institution Experience

Cardiac surgery patients with lower-extremity amputations pose a challenge in terms of medical comorbidities and functional recovery. A retrospective review of all patients (n=10) with preexisting below-knee amputation (BKA) or more proximal amputation level who underwent cardiac surgery between April 1998 and April 2008. Data were analyzed to evaluate outcomes. The median age was 59 y (range, 51-75 y). One patient had bilateral above-knee amputation (AKA), and 9 had BKAs (two bilateral). Comorbidities included diabetes (n=5), peripheral vascular disease (n=7), cerebrovascular disease (n=2), hypertension (n=9), chronic renal insufficiency (n=2), pulmonary hypertension (n=1), and pulmonary fibrosis (n=1). Nine patients underwent coronary artery bypass grafting and one patient underwent aortic valve replacement. There were no operative deaths. The median length of hospital stay (to home discharge) was 12.5 d (range, 5-562 d). Eight patients were transferred to a rehabilitation unit or a chronic care facility before being discharged to home. At follow-up (median, 1.5 y; range, 0.4-3.8 y), all but one patient were alive and had returned to their preoperative ambulatory status. In our experience, patients with lower-extremity amputations require prolonged hospitalization after cardiac surgery but can expect good mid-term outcomes and functional recovery.

Major Polymer Damage of Drug-Eluting Stents

A 67-year-old man presented with stable angina pectoris on exertion. He had a history of type 2 diabetes, severe peripheral vascular disease with bilateral above-knee amputations, renal insufficiency requiring dialysis, and arterial hypertension for more than 20 years. Coronary angiography revealed a long, calcified 90% bifurcation lesion of the left anterior …

The use of artificial dermis (Integra) and topical negative pressure to achieve limb salvage following soft-tissue loss caused by meningococcal septicaemia

Meningococcal sepsis leading to purpura fulminans leaves survivors with extensive areas of skin and soft-tissue necrosis. Soft-tissue loss in the limbs may result in large areas of exposed bone, leaving a choice between free tissue transfer and amputation. We present a case of meningococcal sepsis where the entire medial and lateral surfaces of the tibiae were exposed with loss of anterior muscle compartments on each side. Faced with the possibility of bilateral above-knee amputation, these were instead covered using the dermal replacement Integra (Integra LifeSciences Corp.), in conjunction with an antimicrobial dressing, topical negative pressure dressing and subsequent skin grafting. This management decision achieved rapid wound closure avoiding amputation. Additional secondary reconstruction with microvascular free flaps was performed to preserve joint function.

Bilateral Lower Extremity Gangrene Requiring Amputation Associated With Heparin-Induced Thrombocytopenia

Heparin is a common cause of thrombocytopenia in hospitalized patients. Between 10% and 15% of patients receiving therapeutic doses of heparin develop thrombocytopenia. Heparin-induced thrombocytopenia (HIT) can cause severe bleeding and thrombosis owing to intravascular platelet aggregation. HIT must be distinguished from other causes of thrombocytopenia. Importantly, heparin use is often associated with an early fall in the platelet count that usually occurs within the first 4 days of initiation and recovers without cessation of heparin treatment. This nonimmune heparin-associated thrombocytopenia has not been found to be associated with thrombosis and does not necessitate discontinuation of heparin. The authors present a case report of a 70-year-old man who received heparin therapy following aortic tissue valve replacement and aortic root repair with graft and developed bilateral lower extremity arterial clots 6 days postoperatively in the setting of positive heparin antibody titers. Ultimately the patient required bilateral above-knee amputations.

Above-Knee Replantation Following Traumatic Bilateral Amputation: Sciatic Nerve Transplantation.

A 12-year-old boy who was overrun by a train, sustained traumatic bilateral above-knee amputation and a rupture of the symphysis. The left leg had multiple fractures and soft tissue injuries and amputation was necessary. The right one, although severely crushed, at the amputation site and with a MESS of 9, was replanted accepting some shortening and a soft tissue defect at the amputation site, employing saphenic vein grafts from the amputate (left leg) and an early free latissimus dorsi-flap. Septic complications at the amputation site were managed, and an autologous sciatic nerve graft was performed 8 months after the accident, employing the contralateral above-knee stump as the donor. Protective foot sole sensitivity was noticed after 2 years and 4 months and continued to improve. Further reconstructive procedures included ORIF of a femoral fracture in the contra-lateral stump. On the replanted leg proximal tibia corrective osteotomy and lateral collateral knee ligament reconstruction were performed. A follow-up of 7 years and 9 months demonstrates now a leg capable of full weight bearing and recovery of overall protective sensitivity. The boy made good psycho-social progress after difficulties and feels that the replanted leg is of significantly greater use to him than the hi-tech prosthesis on the other leg.

Preliminary Evaluation of an Automatically Stance-Phase Controlled Pediatric Prosthetic Knee Joint Using Quantitative Gait Analysis

Andrysek J, Redekop S, Naumann S. Preliminary evaluation of an automatically stance-phase controlled pediatric prosthetic knee joint using quantitative gait analysis. Objectives To evaluate the effects on gait of a new pediatric prosthetic knee joint using an automatic stance-phase lock (ASPL), shown previously to help prevent falls, and to propose future design considerations and prosthetic alignments. Design Case series and crossover trial. Setting Human movement laboratory. Participants Three children with unilateral above-knee amputations and 3 children with bilateral above-knee or below-knee amputations. Interventions Not applicable. Main Outcome Measures Spatiotemporal, kinematic, and kinetic gait parameters. Results Spatiotemporal parameters indicated higher gait velocities with the ASPL knee joint for the children with unilateral amputations. The increased speed, as expected, was associated with increased temporal interlimb asymmetry, joint moments and powers, and excessive prosthetic knee range of motion in swing. A trend toward increased pelvic motions was observed with ASPL knee when compared with conventional knees. Conclusions The biomechanic performance of the single-axis ASPL knee joint was shown to be comparable with more complex polycentric pediatric prosthetic knee joint technologies worn by the children in this study.

MultifocalProteus mirabilisosteomyelitis requiring bilateral amputation in an HIV-positive patient

We present a rare case of multifocal Proteus mirabilis osteomyelitis in an HIV-positive patient. Despite the patient's good immune status as assessed by her CD4 cell count and the aggressive treatment, she eventually underwent bilateral above-knee amputations to eradicate the infection. Multifocal Proteus mirabilis osteomyelitis can have an unpredictable clinical course with a severe outcome in HIV-positive patients.

Bilateral Lower Extremity Gangrene Requiring Amputation Associated with Heparin-Induced Thrombocytopenia

Heparin use, both prophylactically and therapeutically, is prevalent among hospitalized patients. Patients on heparin may develop a thrombocytopenia that is self-limited. Fewer patients develop a heparin-induced thrombocytopenia that can cause severe bleeding and thrombosis owing to intravascular platelet aggregation. The authors present a case report of heparin-induced thrombocytopenia in a patient who underwent aortic arch and aortic valve replacement that resulted in bilateral above-knee amputations. The patient developed limb ischemia related to heparin-associated thrombosis, but had a delay in antibody seroconversion. Early and accurate diagnosis of heparin-induced thrombocytopenia requires a high clinical suspicion and may be present despite the absence of serum antibodies.

Missed Bilateral Compartment Syndrome in the Unconscious Polytrauma Patient

Acute compartment syndrome of the leg demands prompt action. Delayed diagnosis leads to increased morbidity and mortality. The diagnosis of compartment syndrome relies heavily on clinical findings in a conscious patient. This presents a diagnostic dilemma in the unconscious polytrauma patient who requires admission to ICU. We report a case where the diagnosis of bilateral lower leg compartment syndrome was missed. Bilateral above-knee amputations were carried out, after irreversible ischemic necrosis of the muscles and nerves was found at fasciotomy. The importance of a high level of suspicion and an early diagnosis of this common yet life-threatening complication is reiterated.

Exercise effect with the wheelchair aerobic fitness trainer on conditioning and metabolic function in disabled persons: A pilot study

Objective: To determine the effect of exercise with the wheelchair aerobic fitness trainer (WAFT) on anthropometric indices, conditioning, and endocrine and metabolic parameters in persons with lower extremity disability. Design: Exercise sessions with the WAFT lasted 20 to 30 minutes for two to three sessions. Setting: Tertiary-care Veterans Administration medical center. Participants: Twelve subjects (3 with quadriplegia, 7 with paraplegia, 1 with cerebrovascular accident, 1 with bilateral above-knee amputation). Main Outcome Measures: Anthropometric indices (heart rate, blood pressure, weight, oxygen utilization, body mass index, upper arm and abdominal circumference, arm power) and endocrine and metabolic parameters (fasting serum glucose, lipids, and thyroid function) were determined before and after 10 weeks of exercise with the WAFT. Results: All patients noted improved feelings of well-being after training. Mean resting heart rate, upper arm fat area, and fasting serum cholesterol level decreased significantly. Peak oxygen consumption, midarm circumference, and free thyroxine index increased significantly with training. Conclusions: WAFT improves quality of life, conditioning, and endocrine-metabolic parameters in disabled persons.

Physiological comparison of walking among bilateral above-knee amputee and able-bodied subjects, and a model to account for the differences in metabolic cost

Objectives: To compare the metabolic cost for prosthetic ambulation among persons with bilateral above-knee amputation with that for able-bodied ambulation, and to test a model that differentiates the metabolic cost of walking into three components. Design: Cross-sectional comparison. Setting: Community-dwelling subjects studied at an academic medical center. Participants: Five bilateral above-knee amputee subjects with mean (±SD) age of 22 ± 3 years, and five able-bodied control subjects matched for gender, height, weight, and age. Intervention: Subjects performed 6-minute bouts of walking at three paced speeds and their chosen walking speed with oxygen uptake being determined during the last 2 minutes of each bout. Main Outcome Measures: Chosen walking speed and oxygen uptake during each walking condition. Results: The chosen walking speed was 21% slower and induced aerobic demands 49% higher for the amputee subjects. Across specified paced speeds, aerobic demands were 55% to 83% higher for the amputee subjects than for the able-bodied subjects. The described model suggests that the higher metabolic costs for the amputee subjects resulted from greater demands for maintenance of balance and posture and for performing the walking movement. Conclusions: Prosthetic ambulation by young healthy persons with bilateral above-knee amputation induces significantly greater metabolic demands than walking by able-bodied individuals. Although the chosen walking speed of persons with bilateral above-knee amputation is slower, the reduction in speed is insufficient to equalize their metabolic cost with that of able-bodied individuals walking at their chosen walking speed.

Infected Abdominal Aortic Grafts

Aortic grafts were inserted in 1711 patients at Ottawa Civic Hospital (OCH) between 1976 and 1986. Aorto-iliac occlusive disease was the indication in 884 while in 827, the graft was inserted for abdominal aortic aneurysms. Graft infection occurred in 12 patients; six presenting with gastrointestinal bleeding due to aorto-enteric fistula (AEF) and the other six presenting with groin abscesses, mostly as a draining sinus. These were treated with graft excision and immediate extra-anatomic bypass. Seven patients died, giving a mortality rate of 58%. Three surviving patients required above-knee amputation. These results are comparable to the results of others in the literature; therefore, continuing assessment of all aspects of graft infection and the search for more effective methods of prevention and management are needed.