Loss Of Limb Function Research Articles

Acute compartment syndrome: reducing the risk

Acute limb compartment syndrome is a surgical emergency characterized by raised pressure within an unyielding tissue compartment. Although there is commonly a history of trauma there are a number of causes of compartment syndrome, which includes iatrogenic insults. The key clinical feature of a compartment syndrome in the conscious patient is severe pain out of proportion to the injury and aggravated by passive muscle stretch. Intracompartmental pressure measurements remain the only objective method of diagnosing an acute compartment syndrome. Although it is subject to false positives, interpreting the pressures in relation to the systemic blood pressure helps confirm the diagnosis when the clinical findings are equivocal and provides essential information in unconscious or uncooperative patients. Successful treatment of an acute compartment syndrome involves prompt, early diagnosis followed by an adequate surgical decompression of all four compartments of the leg by fasciotomies. Delay in diagnosis is almost invariably associated with a poor outcome and loss of limb function. As acute compartment syndromes typically occur in young patients with an average work–life expectancy of up to 30 years, a poor outcome results in severe loss of productivity.

Composite Forearm Free Fillet Flaps to Preserve Stump Length Following Traumatic Amputations of the Upper Extremity

Replantation of traumatic upper arm amputations are usually contraindicated due to patient age, comorbid diseases, ischemia time, and/or avulsion of proximal structures. Stable soft tissue coverage preserving proximal stump length and critical joints is required to prevent loss of limb function and aid in prosthetic fitting and comfort. The use of free fillet flaps from the amputated limb is well documented for lower-extremity amputations but has only recently been reported for upper-arm amputations involving distal humeral or elbow wounds or following radical upper-arm tumor resections. Furthermore, these described free fillet flaps were fasciocutaneous rather than composite flaps. Composite free fillet flaps from the amputated upper arm utilizing the flexor muscles adjacent to the vascular pedicles is not well described or documented. Eight upper-extremity, composite, free fillet flaps were performed to cover proximal humeral and shoulder defects secondary to upper-arm traumatic amputation from July 1995 to May 2005 on 7 males and 1 female. A retrospective chart review was completed, and information collected included the age of patient, gender, date of injury and surgery, amputation site, mechanism of injury, ischemia time, type of fillet flap, donor and recipient vessels, flap sensation, flap survival, and number of complications. All upper-arm amputations were trauma related (100%) and secondary to industrial accidents (4), motor vehicle and motorcycle accidents (2), fall (1), and train (1). Patient age ranged from 16 to 62 years and polytrauma was noted in 50%. Procedures included 6 composite free fillet flaps and 2 radial forearm free fillet flaps, with 4 (50%) sensate. Sensory nerves included the medial (3) and lateral (2) antebrachial cutaneous nerves attached to median proximal nerve stumps. Ischemia time ranged from 280 to 630 minutes. All flaps survived and 2 (25%) complications occurred in 1 patient. Subjective and protective sensation was observed in each neurorrhaphy; however, no confirmatory tested was used. Immediate soft tissue coverage using composite free fillet flaps from amputated limbs can be successful, with few complications, and preserves limb length while maximizing available tissue. Furthermore, including flexor muscle belly adjacent to the vascular pedicles provides additional coverage and a well-vascularized composite flap to aid in prosthetic fitting and comfort.

Conservative surgery for well-differentiated liposarcomas of the extremities adjacent to major neurovascular structures

There is no clear consensus as to the appropriate nomenclature and the best surgical strategy for well-differentiated liposarcomas. A wide surgical excision is recommended over marginal resection for local control of well-differentiated liposarcomas. However, this surgical procedure should be reconsidered for lesions, which come into contact with major neurovascular structures. Between 1998 and 2004, 12 well-differentiated liposarcomas of the extremities were treated at our institute. Among them, nine lesions (75%) adjacent to major nerves or blood vessels were marginally resected with careful dissection of these critical structures. The clinical outcomes were reviewed for a mean follow-up time of 4 years. Seven patients continued to be disease-free without any loss of limb function. One patient developed a local recurrence 30 months postoperatively. The other patient with a foot lesion involving the fourth metatarsal bone has experienced slight difficulty in gait-balancing due to the fourth toe amputation, but remains free of disease. The local control rate was 88.9%, even though seven lesions were resected with positive surgical margins. Our findings suggested that well-differentiated liposarcomas frequently arise in close proximity to major nerves or blood vessels. Marginal resection alone seems to be adequate for these lesions to preserve critical structures.

Abstracts of literature

Abstracts of literature

Correlates of Informant-Rated Cognitive Decline after Stroke

Cognitive impairment is common after stroke, but measurement is problematic. Six tests of mental ability, unaffected by loss of limb function, were administered to 49 subjects of mean age 74.2 years at a median of 4.3 years (range 0.1–16.8) after stroke together with a depression score and the IQCODE, an informant-rated scale of estimated cognitive decline. Over 90% of stroke patients were able to complete most tests. IQCODE correlated significantly with the HADS depression score (r = 0.35, p = 0.040), the 2-year Barthel score (r = –0.60, p = 0.001) and with a general cognitive factor extracted from the mental ability test scores (r = –0.42, p = 0.016). We conclude that informant-rated methods offer a promising approach to measuring cognitive decline after stroke.

Preoperative staging, prognostic factors, and outcome for extremity rhabdomyosarcoma: A preliminary report from the intergroup rhabdomyosarcoma study IV (1991–1997)

Background: During the fourth Intergroup Rhabdomyosarcoma (RMS) Study IRS IV 1991–1997, a preoperative staging system was evaluated prospectively for the first time. The authors evaluated this staging system and the role of surgery in extremity RMS in contemporary multimodal therapy.Methods: A total of 139 patients (71 girls; median age, 6 years) were entered in IRS IV with extremity-site RMS. Stage was assigned by the IRSG Preoperative Staging System. Postsurgical group was determined by tumor status after initial surgical intervention. Multivariate analysis was performed using all pretreatment factors that were significant by univariate analysis, including clinical Group lie, I through IV), tumor invasiveness (T1,T2), nodal status (N0,N1), and tumor size (< or ≥5 cm). Failure-free survival rates (FFS) and survival rates were estimated using the Kaplan and Meier method.Results: Preoperative staging and clinical group distribution were as follows: Stage 2, n = 34; Stage 3, n = 73; Stage 4, n = 32; Group I, n = 31; Group II, n = 21; Group III, n = 54; Group IV, n = 33. Three-year FFS was 55%, and the overall survival rate was 70%. Eighty-seven patients had either unresectable, gross residual disease (Group III) or metastases (Group IV). FFS was significantly worse for these patients with advanced disease, compared with that for patients with complete resection or with only microscopic residual tumor lie, Group I or II; Group I, 3-year FFS, 91%; Group II, 72%; Group III, 50%; Group IV, 23%; P < .001). Lymph nodes were evaluated surgically in 76 patients with positive results in 38. Clinically, 13 additional patients had nodal disease. Both stage and group were highly predictive of outcome and were highly correlated. By multivariate analysis, none of the other variables were predictors of FFS.Conclusions: This review confirms the utility of pretreatment staging for stratification of patients with extremity RMS with widely different risks of relapse, thereby paving the way for development of risk-based therapy. Group (operative staging) remains the most important predictor of FFS, emphasizing the importance of complete gross resection at initial surgical intervention, when feasible without loss of limb function. The high incidence of nodal disease in the patients who had lymph node biopsy confirms the need for surgical evaluation of lymph nodes to ensure accurate staging in children with extremity rhabdomyosarcoma.

Severe injury and fatality in Rugby League football

Method: Retrospective analysis of injuries which received compensation, published in the annual reports of the NSW (Govt.) Sporting Injuries Insurance Scheme. The scheme covered registered male rugby league players, in New South Wales, 1981-97. There was an average annual membership of 81,000 players for the study period. Severe injury was defined as permanent brain, spinal cord, organ injury or orthopaedic/neurological injury leading to 50% or greater loss of limb function.

Outcome following Blunt Vascular Trauma of the Upper Extremity

Blunt trauma to the upper extremity may cause extensive vascular damage in addition to severe musculoskeletal injury. Over a 5.5-year period, 17 patients with a total of 23 arterial injuries were treated. Diagnosis was made in 16 patients before surgery by physical and Doppler ultrasonographic examination. Angiography performed in ten patients assessed the extent of injury. Associated orthopedic injuries were present in 11 patients and neurologic injury in 16. At surgery, 21 of 23 arterial repairs required autologous vein. The initial limb salvage rate was 76%. Four patients underwent above-elbow amputation because of progressive sepsis and myonecrosis. A fifth underwent delayed amputation at 7 months due to loss of limb function. Neurologic impairment was the major long-term morbidity. The data show that outcome following blunt vascular trauma of the upper extremity is governed by the associated injuries.

Temporary Loss of Limb Function Secondary to Soft Tissue Calcification in a Patient With Rhabdomyolysis-Induced Acute Renal Failure

A case of unusually severe soft tissue calcification with temporary loss of limb function in a patient with rhabdomyolysis-induced acute renal failure (ARF) is described. A large dose of intravenous (IV) calcium was administered early in the hospital course to treat hypocalcemia, and hemodialysis, when initiated, was with a 1.75-mmol/L calcium dialysate. This case illustrates the danger of administering calcium supplementation and raises questions about the use of normal to high dialysate calcium concentration in the early stages of rhabdomyolysis-induced oliguric ARF. Calcium supplementation should be reserved for patients with clear clinical signs of hypocalcemia and dialysate calcium should be adjusted to prevent excessive positive calcium balance.

Transponders as Permanent Identification Markers for Domestic Ferrets, Black-Footed Ferrets, and Other Wildlife

A 0.05-g transponder implanted subcutaneously was tested to see if it provided a reliable identification method. In laboratory tests 20 domestic ferrets (Mustela putorius furo) received transponders and were monitored for a minimum of 6 months. None showed signs of inflammation, and necropsies conducted at the end of the study showed no scar tissue or transponder migration. Seven of 23 transponders failed during the test because of leakage through the plastic case, and a glass case is now being manufactured that does not have the leakage problem. During mark-recapture studies in September and October 1985, transponders were implanted in 20 black-footed ferrets (M. nigripes), 11 of which were subsequently recaptured and 9 of which were brought into captivity; none showed signs of inflammation. Transponders provide a reliable new method for identifying hard-to-mark wildlife with a unique, permanent number that can be read with the animal in-hand or by remote equipment. J. WILDL. MANAGE. 51(2):294-297 Finding permanent, individually-identifiable markers for small mammals has generally been difficult. Biologists have used metal fingerling ear tags, ear tattoos, and toeclipping to individually mark animals. These methods have often proven unsatisfactory; some individuals lose the ear tags within a few days or weeks and the majority of ear tattoos are not permanent or, if permanent, are not recognizable as a unique number or letter (Fagerstone et al., Pages 10.110.10 in Proc. Black-footed Ferret Workshop, Univ. Wyoming, 1985). Toeclipping may cause infection or loss of limb function. A more reliable method of identifying individuals is needed for long-term population studies. This study evaluated the effectiveness of subcutaneously implanted transponders as permanent marking devices for domestic ferrets in the laboratory and for wild black-footed ferrets. The transponder is a polypropylene-encased microchip that is preprogrammed during its manufacture with a unique 10-digit identifying code. We thank S. E. Gaddis and K. A. Crane for their assistance in animal care and data collection and A. J. Luedke for conducting the necropsies. P. L. Hegdal and J. L. Oldemeyer critically reviewed the manuscript. We gratefully acknowledge the assistance of personnel from the following agencies and organizations during the capture of black-footed ferrets: U.S. Fish and Wildl. Serv., BIOTA Res. and Consulting, Wyo. Game and Fish Dep., Univ. Wyoming, and Nat. Image Films. E. S. Williams and E. T. Thorne kindly provided necropsy results for black-footed ferrets. This study was conducted under the guidance of the U.S. Fish and Wildl. Serv., Dep. Inter. The Cent. was transferred to the Anim. and Plant Health Inspection Serv. (APHIS) on 3 March 1986. Reference to trade names and companies does not imply U.S. Gov. endorsement.

Demonstration of Cutaneous Doxorubicin Extravasation by Rhodamine-Filtered Fluorescence Microscopy

Accidental extravasation of the widely used antineoplastic anthracycline doxorubicin (adriamycin) is capable of causing serious and on-going skin and soft tissue necrosis leading to loss of limb function. The only effective cure has been the complete surgical excision of drug-contaminated tissue. Surgical excisions preparatory to skin grafting have often underestimated the extent of drug infiltration into tissue. Using an experimental technique utilizing the drug's natural property of red fluorescence, we were able to effect complete surgical excision by rhodamine fluorescence microscopy in frozen sections of resected skin.

Physiatrics for Deforming Linear Scleroderma

When linear scleroderma traverses several joints, severe and mutilating deformities and contractures, with loss of limb function, can result. Drugs and surgical procedures are usually of little benefit in ameliorating the deformities. Physiatrics on the other hand, is a readily available modality than can restore much useful function and reverse the contractures and is probably the most effective means of treating patients with deforming linear scleroderma. This type of therapy should be instituted at the inception of the disease process so that the development and progression of any contraction can be minimized or prevented.