Decision For Amputation Research Articles

Wound healing essentials: let there be oxygen.

The state of wound oxygenation is a key determinant of healing outcomes. From a diagnostic standpoint, measurements of wound oxygenation are commonly used to guide treatment planning such as amputation decision. In preventive applications, optimizing wound perfusion and providing supplemental O(2) in the perioperative period reduces the incidence of postoperative infections. Correction of wound pO(2) may, by itself, trigger some healing responses. Importantly, approaches to correct wound pO(2) favorably influence outcomes of other therapies such as responsiveness to growth factors and acceptance of grafts. Chronic ischemic wounds are essentially hypoxic. Primarily based on the tumor literature, hypoxia is generally viewed as being angiogenic. This is true with the condition that hypoxia be acute and mild to modest in magnitude. Extreme near-anoxic hypoxia, as commonly noted in problem wounds, is not compatible with tissue repair. Adequate wound tissue oxygenation is required but may not be sufficient to favorably influence healing outcomes. Success in wound care may be improved by a personalized health care approach. The key lies in our ability to specifically identify the key limitations of a given wound and in developing a multifaceted strategy to specifically address those limitations. In considering approaches to oxygenate the wound tissue it is important to recognize that both too little as well as too much may impede the healing process. Oxygen dosing based on the specific need of a wound therefore seems prudent. Therapeutic approaches targeting the oxygen sensing and redox signaling pathways are promising.

Verletzungsadaptiertes Vorgehen bei Unterschenkelverletzungen des Schwerverletzten

In polytraumatised patients, fracture management depends on the overall injury severity. For decision making, patients are grouped in one of four categories (STABILE, BORDERLINE, INSTABLE and IN EXTREMIS). STABILE patients should and BORDERLINE patients may undergo primary definitive fracture stabilisation; in contrast, this is not recommended for INSTABLE or IN EXTREMIS patients. The marginal soft tissue envelope of the tibia predisposes for open fractures, compartment syndrome, and wound infections. Therefore the management of lower leg injuries is demanding, especially in polytraumatised patients. Bilateral tibia fractures and ipsilateral tibia and femur fractures represent a special entity. For these injuries special algorithms, which consider the soft tissue status of the tibia and the overall injury severity, have been developed. The indication for fasciotomy covers a wide field and may be performed prophylactically. The decision for amputation is based on the patient's general condition and the soft-tissue and neurovascular status. Scoring systems are useful for decision making, however individual decisions should be made.

Amputations in leprosy

Removal of an anatomical segment is not pleasant for anyone; perhaps even more so in leprosy patients because of disease stigma. Amputation has an immediate relation to social dependence and handicap. The loss of a once normal part of the body is regarded by both the person and society as a detrimental event. In contrast, children with some upper limb congenital anomalies do not regard this as ‘abnormal’ until later in life when society, sometimes even parents, impose on them the concept that they are ‘different’. Amputation may have a very negative impact on someone’s life as well as carry many symbolic representations, from pity to repulsion, encompassing guilt and resignation, both from the amputee and their social partners. However, amputations are valuable surgical procedures, life-preserving and, strange as it sounds, a choice for certain rehabilitation processes. Amputation has a place in the management of disability in leprosy. Amazingly, it can be the bridge from dependence and depression to full social integration including economical participation. To have these positive results, it should be properly indicated, carefully performed and, most importantly, adequately managed and supported by competent prosthetic services. Indications for amputation in leprosy are few and very specific. They are mostly restricted to the lower limbs, as in the general population, in whom over 85% of amputations occur in this part of the body. Primary indications for amputation are long-standing consequences of plantar ulcers and severe bone/joint disintegration. Although infrequent, malignant transformation in plantar ulcers is a mandatory indication. It should also be considered in severe bone/joint disorganisation due to neuropathic disintegration associated with plantar ulcers and contractures. The patient should be fully and explicitly involved in the decision for amputation since it is their limb that will be removed. Furthermore, a patient’s participation in the post-surgical fitting period is even more important than the surgeon’s skill in performing the amputation. The indications for amputation vary with the surgeon’s personal preference and the cultural and technological surroundings, the latter in respect of prosthetic services and long-term maintenance of prosthesis. One should remember that fitting a shoe on an insensitive foot is far easier than fitting a prosthesis on an anaesthetic amputated leg and not the reverse as some unmindful

Komplexe Kniegelenkverletzung beim Polytrauma

In polytraumatized patients severe joint injuries represent a special entity because their management is complex and lengthy. The surgeon must decide if limb salvage is indicated and which further surgical steps have to be instituted. The decision for amputation is based on the patient's general condition and the soft-tissue and neurovascular injury. Scoring systems are useful for decision making. Limb salvage is associated with a multistage surgical approach. Priority is given to restoration of sufficient blood supply and soft tissue repair; the indication for fasciotomy covers a wide field. To avoid further compromise to soft tissue and perfusion, temporary joint and fracture stabilization is required. Definitive surgery has to be delayed until the 2 week period, starting between the fifth and tenth day after trauma.

Noninvasive technique using thallium-201 for predicting ischaemic ulcer healing of the foot.

A post-stress imaging study utilizing single intravenous doses of thallium-201 was performed on feet with trophic skin lesions. Forty-two ischaemic ulcers were classified into four basic types according to the presence and degree of the inherent inflammatory response of the ulcer in both the initial and delayed distributions. Both the relationship between ulcer type and prognosis and the effects of therapy within ulcer type were assessed. The results suggest that ulcers of Type I or Type II heal in response to conservative treatment, while ulcers of Type III, although undergoing healing, require surgical treatment to prevent a protracted hospitalization. In Type IV ulcers, healing is not to be expected at all with conservative therapy; therefore an early decision of amputation may be necessary if surgical measures are not indicated. The technique reported may be helpful not only in the prediction of spontaneous ulcer healing but also in the selection of appropriate treatment.

Parameters of multiple organ dysfunction fail to predict secondary amputation following limb salvage in multiply traumatized patients

Objective: the purpose of this retrospective analysis was to evaluate whether systemic parameters that are used to characterize multiple organ dysfunction could also be used to predict the optimal time for amputation in patients failing limb salvage surgery following severe extremity injury. Methods: the principal criterion for the study group was a lower limb amputation following a type IIIb or IIIc open tibial shaft fracture in multiply traumatized patients. This group was then divided into one group of primary amputation (group A) and one group of secondary amputation (group B). Beside these groups a third group of total traumatic lower limb amputation was recruited (group C). Data analysis included demographics, injury severity according to the ISS, evaluation of the limb injury by three different salvage scores (HFS, MESS and NISSSA) and organ function monitoring by the Denver MOD Score over a 14-day period posttrauma or up to 7 days after secondary amputation. Results: within the period 1987–1997 a total of 15 patients were recruited for group A (primary amputation), 10 patients for group B (secondary amputation) and nine patients for group C (traumatic amputation). The MOD score was only positive for pulmonary dysfunction, also reflected by the Horovitz quotient, in those patients that died later in either group. Mortality was higher in group A (three out of 15) compared with group B (one out of 10), which may be due to a higher ISS in group A (mean ISS 28.2 vs. 21.0 of group B). Although the MOD score of all recovered patients revealed no significant difference between group A and B, secondary amputation resulted in significantly longer demand of mechanical ventilation. According to our results secondary amputation may lead to transiently decreased pulmonary function but does not necessarily end in multiple organ dysfunction. The need for amputation in failed limb salvage was not indicated by systemic parameters. Conclusion: the right time for secondary amputation in order to prevent subsequent pulmonary dysfunction cannot be predicted by parameters otherwise indicating organ dysfunction. As the risk of secondary amputation for developing pulmonary dysfunction apparently cannot be estimated the decision for amputation or limb salvage should be made initially after trauma and should be the definite one.

Psychological management, prevention and treatment of phantom pain after amputations for tumours.

Amputation for tumours is rarely carried out nowadays and has few specific technical features, apart from the rare cases where ingenuity is required to gain a few centimetres in length of a stump. As far as possible, the decision for amputation should not be imposed; it is better that the patient himself should take the initiative. The prosthesis and its constraints should be described honestly to avoid subsequent disappointment. Prevention of a painful phantom limb must always be undertaken, and based on certain operative and perioperative precautions. The most important factors are treatment by psychotropic agents and the quality of the human relationships between patient and surgeon.

Adenovirus-mediated gene transfer to lower limb artery of patients with chronic critical leg ischemia.

Arterial gene transfer offers a promising new approach for the treatment of vascular disorders. However, no data are available about the gene transfer efficiency in human arteries in vivo. The aim of this study was to evaluate the safety and feasibility of catheter-mediated adenoviral gene transfer in human peripheral arteries. Ten patients (8 females, 2 males, mean age 80 +/- 8 years) suffering from chronic critical leg ischemia with a prior decision for amputation were recruited in the study. Gene transfer was performed in eight patients in conjunction with a conventional percutaneous transluminal angioplasty, using a perfusion coil balloon catheter. Two patients served as controls. Increasing concentrations of replication-deficient adenoviruses (titers from 1 x 10(8) to 4 x 10(10) PFU) containing a nuclear-targeted beta-galactosidase marker gene were administered into the arteries over 10 min via the catheter. Amputations were performed 20 to 51 hr after the procedures and gene transfer efficiency was evaluated in the transduced arteries using X-Gal staining for beta-galactosidase activity. Beta-galactosidase gene transfer was well tolerated and no adverse tissue responses or systemic complications were observed in any of the patients. Gene transfer was successful in six of the eight patients. Gene transfer efficiency varied between 0.04 and 5.0% of all arterial cells. Transgene expression was detected in smooth muscle cells, endothelial cells, and macrophages and in tunica adventitia. However, transgene activity was not evenly distributed in the arterial wall and no transgene activity was found beneath advanced atherosclerotic lesions. The safety and feasibility of in vivo gene transfer by adenoviral vectors to human peripheral arteries were established. Although improvements are still required in gene transfer efficiency, these findings suggest that adenoviruses can be used to deliver therapeutically active genes into human arteries.

Amputation after extremity injury

Extremity injury is a significant cause of morbidity and mortality in the trauma patient. The decision to amputate is a difficult one to make in a patient population still in the productive years of life. At the University of Louisville Hospital from 1976 to 1984, 37 patients with traumatic extremity injury required amputation. Ninety percent of these injuries were to the lower extremities. A decision for amputation was based on the absence of neurovascular function, the presence of fracture of the involved extremity, the presence of a large soft tissue defect, and the presence of severe contamination. Prompt amputation of such severely damaged limbs may be preferable to attempts at salvage. Early amputation offers the opportunity for prosthetic replacement and good long-term functional recovery.

Salah Eddin external fixation system: a bone slider and compressor.

This study involves 65 patients with severe war injuries to the extremities where all conventional and available lines of treatment have failed or a decision of amputation has been made. Twelve humeri, 45 tibiae and eight femura were studied. The sliding system was used on 39 patients and the compressor system on 26 patients. In the sliding system, gaps ranged from 2 cm to 12 cm. In the compressor system established nonunion, failed bone graft operations, infected pseudarthrosis and gaps less than 2 cm were studied. Salah Eddin external fixation systems, both sliding and compressor, were found to be efficient, biomechanically adequate, easy to apply and remove and able to replace considerable gaps with no risks of open surgery.

Advanced occlusive arterial disease (gangrene) in the aged, and decision-making for amputation.

In aged patients with advanced occlusive arterial disease, organic brain syndrome, other serious disorders (especially diabetes), and spreading gangrene of a lower limb, the decision for amputation may be crucial for the patient's life. For the brain‐damaged patient, decision‐making is influenced by the sometimes conflicting attitudes of the patient's family, the attending physician, and the nursing‐home staff. Four illustrative cases are presented. The presence of gangrene posed overwhelming nursing problems. In the population of patients described, the decision for surgery was based less on objective medical criteria and more on the subjective attitudes of the physician and the families. The physician seemed to be influenced by the wishes of the family and by his attitude toward the aged in general. Serious consideration should be given to the correction of distorted ethical values in the treatment of the mentally ill aged.