Lower Leg Amputation Research Articles

Amputation versus reconstruction in traumatic defects of the leg: outcome and costs.

This retrospective review covers global aspects of reconstructive efforts to salvage severely injured legs. Eighteen patients with traumatic lower leg amputation were compared to 21 patients who underwent complex microvascular reconstruction. The mean number of interventions was 3.5 for amputation and 8 for reconstruction (p < 0.009). Total rehabilitation time was 12 months for amputation and 30 months for reconstruction (p < 0.009). Changes in lifestyle were consistently more important in the amputee group. The mean annual hospital costs for amputated patients were 15,112 Swiss Francs (SD 7,094 SF) for the first 4 years. The mean annual hospital costs for reconstructed patients were 17,365 Swiss Francs (SD 8,702 SF) for the first 4 years. Fifty-six percent of the amputees and 19% of the reconstructed patients were retrained to a different profession (p < 0.025). Fifty-four percent of the amputees and 16% of the reconstructed patients were drawing an extremely costly and life long invalidity pension (p < 0.02). We conclude that for potentially salvageable legs reconstruction is advisable because the functional outcome was better than for amputation and there was no permanent social disintegration due to the long treatment. Total costs (including pensions) for reconstruction were far lower than for amputation.

Cross-over Replantation after Bilateral Traumatic Lower-Leg Amputation: A Case Report with a Six-Year Follow-Up

A suicidal 66-year-old female patient was run over by a train. The lower extremities were amputated at different levels. On the right side, there was a complete amputation in the distal third of the lower leg. Proximal to the amputation site, there was an extensive soft-tissue and bone defect. On the left side, there was a crush injury of the tarsus and mid-tarsal bones. The left lower leg showed only minimal injuries. An ipsilateral (anatomic) replantation was not possible. In order to save one lower extremity, a cross-over (contralateral) replantation of the right foot to the left lower leg was carried out. After a follow-up of 6 years, the patient is able to walk well with a prosthesis on the right side, and the right foot replanted to the left lower leg. From a psychological point of view, it seemed better for the patient to preserve one extremity, even with a cross-over replanted foot.

Towards less amputations in diabetic patients. Incidence, causes, cost, treatment, and prevention--a review.

Foot problems frequently threaten limb and life in the diabetic individual (Connor 1987, Greenhalgh et al. 1988, Fylling and Knighton 1989, Levin et al. 1993, Boulton et al. 1994). More than half of all amputations in the lower leg are performed in diabetic patients, mainly because of peripheral neuropathy, vascular disease, and infection. Two thirds of the amputations in diabetic patients are precipitated by a traumatic foot ulceration. A major amputation in diabetic patients is associated with a high morbidity, a high risk of further amputation and a mortality of 30-50 percent within 3 years. Annual short-term costs for lower leg amputation in diabetes approach the costs of treatment of patients with hip fracture or knee and hip arthroplasties together.

Decision making and results in subtotal and total lower leg amputations: reconstruction versus amputation.

As a result of modern therapeutic and technological advances, the surgeon has the ability to salvage even the most severely injured lower limbs. However, the success of replantation nowadays is no longer measured simply on the basis of restoration of viability but also on functional outcome compared with primary amputation with early prosthetic fitting, the risk to the patient during and after replantation and the overall time of treatment which should not exceed 2 years. Although every major limb replantation has to be considered individually, the decision-making process for reconstruction (replantation/revascularisation) versus amputation with subsequent early prosthetic fitting should be determined by objective criteria. Based on personal experience and an extensive literature search, an algorithm for treatment of amputation or amputation-like injuries to the lower leg has been developed and tested in a clinical study. A 100% viability success rate was achieved. There was not only a significant increase in the percentage of "functional extremities" but also a doubling in grade I results. Moreover, there was a 50% reduction in patients presenting a "non-functional extremity", and no patient required a secondary re-amputation. The replantation risk (e.g., risk of severe systemic disturbance during and/or after replantation) was about 16.6% (2/12) in our study. There was a significant decrease in the postoperative complication rate and no patient died during or after replantation. Based on our experience, if reconstruction in subtotal or total lower leg amputation is done for a well-selected patient group, good functional results with a reasonable replantation risk and a reasonable time for social re-integration can be achieved.

MIDFOOT REPLANTATION

The replantation of lower extremity amputations is uncommon. Foot replantation is quite rare because of the severity of the primary injury and its rare occurrence compared with lower leg and upper extremity amputations. A successful replantation in a young woman of a foot amputation at the talo-navicular-calcaneal area is reported with a 1-year postoperative follow-up revealing adequate restoration of foot function.

Lumbosacral Agenesis

Three patients with lumbosacral agenesis underwent surgery to lock the lumbopelvic instability. All three patients had an unstable sitting position and a kyphotic bearing that impaired intestinal transit or hampered further colostomy or ureterostomy. Luque instrumentation with iliac fixation performed according to Galveston was used in one patient. Cotrel-Dubousset instrumentation was used for the two other patients. Autografts plus allografts provided sufficient bone for fusion without requiring lower leg amputations. Increased hip flexion was obtained after pelvic stabilization, but knee flexion contracture remained the same. All patients showed improved intestinal transit or decreased urinary infections, and two patients attained a stable sitting position without aid.

Plaster Casts in the Management of Advanced Ischaemic and Neuropathic Diabetic Foot Lesions

The outcome of plaster cast treatment of diabetic ulcerations at different sites of the feet in 33 patients was assessed in a prospective study. They were selected for the study because the previous conservative treatment had been unsuccessful. The mean age was 68 years and Type 1/Type 2 ratio was 4/29. Fifteen patients had lesions of grade 2 severity according to Wagner's classification, 9 patients' lesions were grade 3, and 9 patients had grade 4 lesions. The lesions healed in 19 patients (58%). All 10 patients (100%) with plantar lesions healed, while 7 (44%) of the patients with ischaemic lesions on the toes underwent lower leg amputation (p less than 0.01). Other factors that were important in determining which patients underwent amputation included the presence of local pain (p less than 0.001), and ankle/arm pressure index (less than 0.5 vs greater than or equal to 0.5, p less than 0.001). We conclude that plaster cast treatment is more useful in the treatment of advanced foot lesions than has previously been reported.

Stabilizing effect of the tibiocalcaneal fascicle of the deltoid ligament on hindfoot joint movements: an experimental study.

The tibiocalcaneal fascicle of the deltoid ligament was studied in 10 lower leg amputation specimens to evaluate its stabilizing effect on movement in the tibiotalocalcaneal joint complex and the talocalcaneal joint complex. Cutting of the fascicle resulted in minor numerical increases in movement in all three planes in the tibiotalocalcaneal joint complex as well as in the talocalcaneal joint complex. The maximum median increase in the tibiotalocalcaneal joint complex was 6.1 degrees in abduction, whereas the maximum median increase in the talocalcaneal joint complex was 3.6 degrees in abduction. However, the percentage of increase in the total range of movement in a single plane was large for abduction-addition in both the tibiotalocalcaneal joint complex and the talocalcaneal joint complex, at 28% and 31%, respectively. The largest percentage of increase, 40%, was found in the total range of plantarflexion-dorsiflexion in the talocalcaneal joint complex. Our data suggest that the tibiocalcaneal fascicle is an important stabilizing structure of abduction, external rotation, and plantarflexion movements in the tibiotalocalcaneal joint complex, especially in the talocalcaneal joint complex.

Histiocytome fibreux malin de la jambe consécutif à un traumatisme

Following a skin injury to the left leg, a 62-year-old lady developed a progressively enlarging multinodular mass of the pretibial area of the left leg. Histologic examination revealed a grade II malignant fibrous histiocytoma. An extensive work-up did not show any evidence of disseminated disease. A lower leg amputation was performed. The patient is alive and well 10 months following surgery.

Amputations in diabetic patients in Gotland and Umeå counties 1971-1980.

In two counties of Sweden, Gotland and Umeå, lower leg or thigh amputations were performed during 1971-1980 in 111 and 71 diabetic patients, respectively. These figures correspond to 20.5 and 6.5 per 100 000 inhabitants and year, respectively. The corresponding incidence for Umeå city and the rural area surrounding Umeå was 3.1 and 13.8/100 000 inhabitants and year, respectively. The lower frequency of amputations in Umeå was probably the consequence of a restricted period of systematic search for early signs of gangrene, as a part of a research program, but other factors could also be of importance and these are discussed. The death rate of the patients was high in both series, after 2 years only about one third of the patients were still alive.

A. D. L. for Prosthetics

General statistics were compiled from and the extent of A. D. L. was examined in the records kept by the National Pension Law Office on 60 cases who have undergone various kinds of amputation at limbs and were given the artificial limbs by the Welfare Pension Law. Out of these 60 cases one was the case with amputation at the shoulder joint, 4 with amputation at the upper arm, 16 at the forearm, 6 as the wrist joint, 14 at the thigh, one at the knee joint, and 18 at the lower leg. The criteria for A. D. L. as against the normal are established at 80-60% for the mild disturbance, 60-40% for the moderate, and under 40% for the severe.From the over-all evaluation, it was found that A. D. L. of the cases with the shoulder joint amputation proved to be 56%, with the forearm amputation 77%, and with the thigh or lower leg amputation 87%.From the A. D. L. evaluation it is obvious that in cases of the upper arm amputation it is desirable to leave a stump longer, especially in cases of forearm amputation so as to leave the functions of supination and pronation. In addition it would be better to train these patients in the use of the artificial limb for a work or functional artificial limb rather than the cosmetic artificial limb.On the other hand, in cases of lower limb amputation it is desirable to amputate the thigh at the middle and in the case of lower leg amputation at the routine level.In any case it is necessary that the patients with the amputated limbs should be equipped with the artificial limbs at an early stage and should be given the intensive rehabilitation training. At the same time it is urgently hoped that an artificial upper limb that would function just as efficiently as the natural human hand should be developed soon.

Arteriography in the evaluation of arteriosclerotic vascular insufficiency

1. 1. Arteriography in arteriosclerotic disease of the lower extremities is a safe and easily performed examination. 2. 2. It is of assistance in determining patients unsuitable for local amputation and/or other conservative measures and in selecting patients for lower leg amputation. 3. 3. It may be of assistance in determining more suitable candidates for sympathetic denervation. 4. 4. Its use in large vascular clinics is warranted but the information gained in occasional examinations probably does not justify its routine use.