Left Below-knee Amputation Research Articles

Neonatal lower limb gangrene

Limb gangrene is a common orthopedic emergency in this part of the world, but neonatal limb gangrene is a rare pathology. Sepsis is a common complication of limb gangrene which can lead to mortality if not managed early. Here is a case of left leg gangrene in a 16-day-old female neonate following the application of local cosmetic agent ("lele") by the mother prior to naming ceremony. The patient presented with features of septicemia; she was resuscitated, and left below-knee amputation was done for her. Harmful and unnecessary cosmetics should be avoided in neonates.

Chronic prosthesis-related residual limb ulcer treated with autologous micro-fragmented adipose tissue.

A 56-year-old male with a past medical history significant for a left below-knee amputation and a left total knee replacement presented with knee pain at a non-healing stage 2 prosthesis-related residual limb ulcer. The ulcer at the weight-bearing surface at the anterior patella had not closed despite three years of conservative management; including offloading and wound clinic follow up. To assist with the healing process, the ulcer was treated with autologous micro-fragmented adipose tissue therapy. He was injected with 8 mLs of minimally manipulated adipose tissue (Lipogems) underneath the ulcer. Upon the four-week follow-up, his pain had resolved, and the wound was significantly reduced in size with new skin appearing. The goal of this case report is to examine if autologous micro-fragmented adipose tissue can represent a feasible and safe treatment option for chronic prosthesis-related residual limb ulcers. To our knowledge, this is the first reported case using micro-fragmented adipose therapy to treat a chronic prosthesis-related residual limb ulcer.

Ultrasound-guided bilateral combined inguinal femoral and subgluteal sciatic nerve blocks for simultaneous bilateral below-knee amputations due to bilateral diabetic foot gangrene unresponsive to peripheral arterial angioplasty and bypass surgery in a coagulopathic patient on antiplatelet therapy with a history of percutaneous coronary intervention for ischemic heart disease: A case report.

Background:Patients on antiplatelet therapy following percutaneous coronary intervention can become coagulopathic due to infection. Performing regional anesthesia for bilateral surgery in such cases is challenging. We report a case of successful combined inguinal femoral and subgluteal sciatic nerve blocks (CFSNBs) for simultaneous bilateral below-knee amputations in a coagulopathic patient on antiplatelet therapy.Methods:A 70-year-old male patient presented with pain in both feet due to diabetic foot syndrome. The condition could not be managed by open amputations of the toes at the metatarsal bones and subsequent antibiotic therapy. Computed tomographic angiography showed significant stenosis in the arteries supplying the lower limbs, indicating atherosclerotic gangrene in both feet. Balloon angioplasty and bypass surgery with subsequent debridements with application of negative-pressure wound therapy and additional open amputations did not improve the patient's clinical condition: his leukocyte counts and C-reactive protein levels were above the normal range, and his prothrombin and activated partial thromboplastin times were increased.Results:Simultaneous bilateral below-knee amputations were performed under ultrasound-guided CFSNBs. Following left CFSNBs using 45 mL of a local anesthetic mixture (1:1 ratio of 1.0% mepivacaine and 0.75% ropivacaine), the left below-knee amputation was performed for 76 minutes. Subsequently, under right CFSNBs using 47 mL of the local anesthetic mixture, the right below-knee amputation proceeded for 85 minutes. Throughout each surgery, dexmedetomidine was continuously administered, and a sensory blockade was well maintained in both limbs. The patient did not complain of pain due to regression of the first CFSNBs during the second surgery. The CFSNBs successfully prevented tourniquet pain. Local anesthetic systemic toxicity (LAST) and hemodynamic instability due to tourniquet deflation and administration of dexmedetomidine did not occur. No additional analgesic was required to supplement insufficient surgical anesthesia. Postoperatively, no neurologic complications related to the CFSNBs were reported.Conclusion:The timely placement of bilateral CFSNBs immediately before the corresponding limb surgery, which lasted for less than 2 hours, provided successful surgical anesthesia in both lower limbs without LAST or pain due to regression of the CFSNBs that were performed during the first surgery.

Breast Metastasis of Extraskeletal Myxoid Chondrosarcoma: A Case Report

Patient: Female, 58Final Diagnosis: Extraskeletal myxoid chondrosarcoma with widespread metastasesSymptoms: —Medication: —Clinical Procedure: Left below knee amputationSpecialty: OncologyObjective:Rare diseaseBackground:Extraskeletal myxoid chondrosarcoma is a unique and distinct clinicopathological entity in terms of its origin, morphology, and biologic behavior. Despite being a slow-growing tumor, it has a high rate of local recurrences and history of metastases to uncommon sites like the mandible, liver, retroperitoneum, right ventricle, pancreas, and central nervous system. Here, we report a very unique case of extraskeletal myxoid chondrosarcoma that metastasized to the breast, which itself is a very rare site for metastases.Case Report:A 58-year-old woman presented with a large, firm, and tender soft-tissue mass (6.0×7.0 cm) underneath the sole of the left foot. A computerized tomography (CT) scan showed a heterogeneous lobulated mass in the plantar aspect of the forefoot, measuring 8.6×8.0×7.1 cm. Punch biopsies revealed histology consistent with extraskeletal myxoid chondrosarcoma. Metastatic work-up was negative. The mass was fully resected with left below-knee amputation. The histology of the resected mass was consistent with extraskeletal myxoid chondrosarcoma. A follow-up CT showed a new right breast nodule along with metastases to lung and bones. The results of the core needle biopsies of the right breast masses seen on mammogram were morphologically identical to extraskeletal myxoid chondrosarcoma.Conclusions:Although rare, metastases to the breast should be considered in the differential diagnosis of a breast mass. A close long-term follow-up is needed due to the unpredictable behavior of extraskeletal myxoid chondrosarcoma and the high frequency of local recurrences, metastases, and death due to disease.

Heterotrophic Ossification in a Patient Suspected of Having Osteomyelitis

A 46-year-old man, with a history of bilateral amputations, presented with a long-standing chronic nonhealing wound at the left below-knee amputation, which was sustained after a crush injury. The patient was referred for a bone scan to exclude osteomyelitis of the left stump. The bone scan showed increased uptake in the left below-knee amputation stump, raising the possibility of an infection. However, SPECT/CT of this area confirmed the uptake to correspond to the heterotrophic ossification of the left below-knee stump and no evidence of osteomyelitis.

Orotracheal intubation facilitated with a GlideScope GVL® video laryngoscope in a patient with a large oronasopharyngeal rhinosporidiosis

To the Editor, Rhinosporidiosis is a chronic granulomatous disease caused by an aquatic protistan parasite, rhinosporidium seeberi. The disease presents as multiple polypoidal granular lesions involving the mucosa of nasal cavity, nasopharynx, and oropharynx. These lesions are friable, bleed profusely, and have a high tendency to recur. Due to systemic involvement of the disease, including bone and skin, patients require multiple surgeries. There is considerable risk of autoinoculation of the spores during airway management, hence all cases require atraumatic tracheal intubation. We report herein airway management in a case of a large pedunculated nasopharyngeal mass extending into the laryngopharynx and completely covering the laryngeal inlet. The patient gave written informed consent for publication of this case report. A 32-yr-old immunocompromised Hepatitis B Surface Antigen (HBsAg) seropositive male patient from northern India presented with nasal stuffiness and a one-year history of granulomatous growth on his left ear. The surgical removal of an aural lesion histologically confirmed rhinosporidiosis. One year earlier, the patient underwent left below-knee amputation under subarachnoid block for rhinosporidiosis-related osteomyelitis. During all examinations and interventions, universal safety precautions were followed. On examination, the patient was conscious, cooperative, hemodynamically stable, and not in respiratory distress. His cell blood count, electrocardiogram, and chest radiograph were normal, and serology for HBsAg was positive with the ELISA test. On inspection of his airway, a large polypoidal mass was observed anteriorly in the left nostril, and an irregular polypoidal nasopharyngeal mass, observed originating from the uvula, became prominent on protrusion of the tongue (Fig. 1) and moved with swallowing. The airway was judged as a Mallampati 4 airway with an Arne’s score of 13. The patient’s vocal cords could not be visualized on indirect laryngoscopy. An oral 70 rigid endoscope (Karl Storz Hopkins, Germany) revealed a 5 x 5 cm pedunculated polypoidal nasopharyngeal mass originating from the uvula, extending into the laryngopharynx, and completely covering the laryngeal inlet (Fig. 2). Visualization of the vocal cords showed normal movement with no lesions. The anesthetic plan for securing the airway included awake orotracheal intubation using a GlideScope GVL video laryngoscope (Saturn Biomedical Systems, Verathon, Burnaby, BC, Canada) and fibreoptic intubation (Fl-10P2, Pentax medical, Montvale, NJ, USA) if required. We also planned for the possibility of an emergency tracheostomy. These procedures were explained to the patient and informed consent was obtained. Overnight fasting with aspiration prophylaxis was planned, and glycopyrrolate 0.2 mg iv was administered 45 min before surgery. On arrival to the operating room, routine monitoring was commenced using an Aestiva S/5 anesthesia delivery system (Datex-Ohmeda Inc., Instrumentarium Corp., Aestiva /5 Compact, Finland), and no transtracheal blocks were given to prevent any foci for autoinoculation. Topical anesthesia of the airway was provided with inhaled 4% nebulized lidocaine for 20 min. Lidocaine jelly (2%) was applied gently on the ventral surface of the patient’s tongue from the tip to the base of the tongue as far as back as the vallecula. The patient was placed in a 15 head-down position to facilitate moving the uvular mass into the V. Ahuja, MD (&) S. Gombar, MD D. Thapa, DNB K. Bagri, MD Government Medical College and Hospital, Chandigarh, India e-mail: vanitaanupam@yahoo.co.in

Does a species of Rickettsia play a role in the pathophysiology of Buerger's disease?

Rickettsia is an intracellular pathogen that attaches to vascular endothelial cell membranes and its genome integrates into the DNA of the host and thereby inhibits apoptosis of the endothelial cells. Rickettsia can infect the body following a flea/louse bite. Rickettsia was suggested as one etiology of Buerger's disease long ago. We report a patient with Buerger's disease for whom a left below-knee amputation was done. Twenty-five biopsies for DNA extraction were obtained from the arteries, veins and microvasculature of the amputated limb. Three samples were positive for Rickettsia. The finding may explain the proliferation of endothelial cells in the pathology of Buerger's disease, segmental nature of the disease, involving small- and medium-sized vessels, and the prevalence of Buerger's disease among the low socioeconomic class of the society. Understanding the infectious etiology of Buerger's disease would be invaluable, since early antibiotic therapy or even vaccination might have prevented the limb loss in the current and other cases of Buerger's disease. The authors suggest that paraffin blocks of Buerger's disease biopsies be investigated for Rickettsia infection, focusing specifically on the area of endothelial cell proliferation for DNA extraction. These results should be compared with other biopsies from a variety of other peripheral vascular diseases.

Chronic ulcers, calcification and calcified fibrous tumours: phenotypic manifestations of a congenital disorder of heterotopic ossification

Calcification is a rarely reported cause for chronic, cutaneous ulceration. Although dystrophic calcification occurs in chronic ulcers, idiopathic calcification and ossification leading to recurrent ulcerations is seldom reported. This report illustrates a challenging case with various non healing wounds, calcification/ossification and calcified fibrous tumours. A 56-year-old woman presented with chronic, painful wounds and calcified deposits in her feet, hands and abdomen, some dating back to childhood. The surgeries she had had for various unrelated conditions healed with hard, calcified deposits, which later ulcerated. Skeletal radiological imaging revealed multiple soft-tissue deposits, with calcification and areas of ossification, along with gross distortion of the bony architecture of her feet. All biochemical investigations were normal apart from raised serum alkaline phosphatase. The management has encompassed a combination of conservative and surgical measures (culminating in a left below-knee amputation) with varying degrees of success. Having ruled out other causes of subcutaneous calcification, three congenital disorders of heterotopic ossification fit this patient's presentation: Albright hereditary osteodystrophy (AHO), fibrodysplasia ossificans progressiva (FOP) and progressive osseous heteroplasia (POH). Although AHO and FOP are possibilities, POH is most likely. In addition to describing the diverse phenotypic manifestations of this disorder, this report discusses the diagnostic dilemmas, difficulties in optimising the management plan and issues relating to health-related quality of life in this patient.

Neglected elbow dislocation in a young man: treatment by open reduction and elbow fixator

A 22-year-old man fell 4 floors during a fire. He had 20% burns and multiple injuries. The Injury Severity Score on admission was 44. The Glasgow Coma Score was 11/15. He had a fractured pelvis and bilateral open fractures of the os calcis and required subsequent left belowknee amputation. He had also a left intracerebral hemorrhage resulting in a right hemiplegia and dysphasia. Several attacks of convulsions occurred. The patient presented to us 1 month after injury because of left elbow pain. The left elbow was posteriorly dislocated and was fixed in full extension. There was no nerve palsy in the left upper limb, particularly the ulnar nerve. Radiographs confirmed posterior dislocation of the left elbow with no fracture (Figure 1). Open reduction was performed by the posterior approach. The operative findings were as follows: dense fibrous tissue in the olecranon fossa, a contracted fibrotic triceps, contracted collateral ligaments, preserved articular cartilage, and a fairly normal-looking ulnar nerve. Reduction was achieved after excision of the fibrous tissue remnants of the capsule, release of both collateral ligaments, and clearance of the olecranon fossa. The reduction was concentric and not particularly difficult but with only fair stability. The ulnar nerve was inspected and decompressed at the cubital tunnel. The continuity of the triceps mechanism was carefully preserved, and there was limited flexion of the reduced elbow. The center of rotation of the elbow through the anteroinferior aspect of the medial epicondyle and the center of the lateral epicondyle was identified.2 A 2-mm Kirschner wire was inserted in the axis of rotation, with the position confirmed by image intensifier. The central connecting unit with the humeral and ulnar frames was slid over the wire, and the fixator used as its own template. Humeral screws (6/5 mm) were inserted from lateral to the mid humerus with care taken to avoid the radial nerve. Ulnar screws (4.5/3.5 mm) were applied from the dorsal side at the subcutaneous border so as to allow maximum forearm rotation. The elbow was then flexed and extended to confirm correct alignment and concentric reduction. The Kirschner wire was removed. The reduction was stable, and passive range was 0° to 70° because of limitation from the tight triceps. The postoperative regimen included active mobilization of the elbow and alternate passive stretching in flexion and extension by the compression-distraction device that accompanied the elbow fixator (Figure 2). This allowed slow stretching of the contracted triceps without the risk of overloading the articular cartilage of the elbow joint. The fixator was removed at 6 weeks, and active range on removal was 40° to 125°. The young man was well motivated and had active mobilization with passive stretching by therapists. He achieved 20° to 135° flexion range after 1 more month. At 1-year follow-up, the patient had full range in flexion/ extension and rotation (Figure 3). Radiographs of the left elbow did not show heterotopic ossification or degenerative changes (Figure 4). The Mayo elbow functional score8 was 100, and he was very satisfied, as he could use his left upper limb to maneuver his wheelchair single-handedly.

The Diagnostic Challenge of Diabetic Hands

A 36-year-old woman with a history of insulindependent diabetes mellitus since the age of 2 years was admitted to the medical intensive care unit in a state of diabetic ketoacidosis. Previous complications of her severe, long-standing diabetes included chronic renal insufficiency, peripheral arterial insufficiency necessitating left below-knee amputation for peripheral gangrene, severe diabetic retinopathy with markedly impaired visual acuity, dense peripheral neuropathy, and necrobiosis lipoidica diabeticorum. Two weeks prior to admission, the patient noted a large crust on her right thumb overlying the dorsal distal phalanx. On the day of admission, she presented for evaluation of the thumb lesion, and a roentgenogram showed that she had lytic changes in the distal phalanx that were consistent with osteomyelitis. Her serum glucose concentration was noted to be 3.33 mmol/L (59 mg/dL) with positive serum ketones at a 1:2 dilution. Insulin was administered by continuous intravenous infusion, and fingerstick blood glucose concentrations were

Case 33-1991

Presentation of Case A 74-year-old man was admitted to the hospital because of a question of acute ischemic optic neuropathy. There was a history of atherosclerotic peripheral vascular disease of many years' duration. A myocardial infarct occurred more than 20 years before admission. Seven years before entry a left below-knee amputation was performed because of assumed gangrene. Five years before admission the patient began to experience bouts of transient monocular blindness that involved the upper or lower visual field in the left eye. Forty-five months before entry noninvasive carotid studies, performed elsewhere, were reported to show bilateral carotid disease that . . .

Fluorescein Discoloration of Eyes, Masking Insidious Onset of Hepatitis

To the Editor.— This case is reported to highlight the possibility that skin and mucous membrane discoloration attributed to fluorescein may in actuality be jaundice. Intravenously administered fluorescein, widely used in plastic surgery and ophthalmology as a diagnostic tool, is considered safe. Nausea and a few allergic reactions are known to occur, but no fatalities have been reported. The dye does, however, leave a greenish yellow discoloration of the eyes, skin, and mucous membrane that clears within 24 to 48 hours. The experience gained from this case suggests cautioning patients to report discoloration noticeable beyond a 48-hour limit. Report of a Case.— A 52-year old white diabetic man underwent a left below-knee amputation for gangrene on Nov 27, 1972. He received three units of blood during the operation. On Dec 12, 1972, he had a revision of his right below-knee stump that had been amputated eighteen months previously because of