Post Amputation Research Articles

Handedness change after dominant side amputation: Evaluation from a hand laterality judgment task.

Amputation of the dominant hand forces patients to use their non-dominant hand exclusively. Whether this chronic forced use of the non-dominant hand would affect the handedness preference remains an open question. In this study, the handedness preference in amputees was evaluated using a hand laterality judgment task by comparing recognition speeds of their lost hand and remaining hand. A handedness index was defined as lateralization between response times to the left hand and the right hand. Healthy controls responded faster to the pictures of dominant hand than that of non-dominant hand, while amputees did not show this handedness advantage. The handedness index was significantly correlated to the response time, accuracy, amputation age and the time post amputation. Amputees with poorer performance experienced severer handedness change and new amputees were more likely to suffer handedness change. Our results suggest that handedness is changed after dominant side amputation and the handedness change might not be induced by chronic use of the intact hand.

Establishment of Online education portal: HACMK - Chinese medicine personnel database

Purpose: Phantom limb syndrome (PLSd) is a frequent chronic complication post amputation and is difficult to manage with conventional medicine. Acupuncture has been shown to be effective in the management of other chronic pain conditions but little is known about the effectiveness of acupuncture for themanagement of PLSd. The study is nested in a larger study evaluating the feasibility of acupuncture for treating PLSd and aimed to explore the experience of PLSd and establish the acceptability of acupuncture intervention to treat PLSd. Methods: Study design comprised of a case study approach using multiple cases. One off semi-structured interviews were conducted with a purposive sample of 15 lower limb amputees 1-3months post-surgery, with past or current experience of PLSd. Interviews explored participants’ experience of PLSd and perceived acceptability of acupuncture intervention. Framework analysis was used to analyse data. Results: 6 key themes were identified during analysis; suffering (prior to amputation), acceptance and coping with the loss of a limb, real and physical phantoms, living with a phantom, being informed about PLSd, acupuncture acceptability. Additionally, outcome measures for the feasibility study were substantiated for ease of completion and relevance. Acupuncture was generally considered an acceptable intervention regardless of positive or negative past experience and few concerns were expressed. Local needling of the residual limb was considered acceptable. PLSd was perceived as a real and physical pain and participants used numerous and often metaphorical descriptions. PLSd frequently disrupted sleep and negatively affected wellbeing and mood. Conclusion: The study contributes to existing evidence exploring the experience of PLSd and identified that PLSd is a bothersome and annoying condition which affects quality of life. Findings suggest that amputees suffering from PLSd would be willing to try a complementary medicine (acupuncture) approach to help manage this condition. Contact: Esme Trevelyan, trevelye@lsbu.ac.uk / Nicola Robinson, nicky.robinson@lsbu.ac.uk

Islanded Parascapular Flap: An Above Elbow Stump Cover

Introduction: In the management of amputation stumps, surgical endeavour is to provide an ideal stump, over which a well-fitting prosthesis maybe given. Moving on from the conventional workhorse flap cover of latissimus dorsi muscle or myocutaneous flap, free fasciocutaneous flaps offer several advantages. With the advent of perforator flaps, there seems to be a resurgence of islanded regional flaps providing a better tissue match while reducing the donor site morbidity. Materials and Methods: The successful use of a parascapular fasciocutaneous flap to cover an above-elbow amputation stump with exposed bone is described in a patient with post traumatic above elbow amputation attributable to a long pedicle and its eccentric location. With no further shortening of the bone length, the stump was covered with robust tissue of good match with primary closure of donor site while preserving the latissimus dorsi muscle. This was carried out in Department of Plastic Surgery, Victoria Hospital, Bangalore Medical College and Research Centre, Bangalore. Conclusion: The islanded parascapular flap is a good option for above elbow stump cover reaching up to the distal third of the arm providing robust tissue of excellent match without any donor site morbidity. Also we believe that this application of islanded parascapular flap for above elbow amputation stumps has not been described in the past.

Transcriptomic and proteomic analyses of Amphiura filiformis arm tissue-undergoing regeneration.

This study identified various genes and proteins involved in brittle star arm regeneration based on high throughput transcriptomics and proteomics studies. In this study the genes and proteins associated with regeneration were validated and mapped for biological and molecular pathways involved in regeneration mechanism. This study will lead to discovery of marker associated with tissue or organ regeneration.

Lived experience of persons with an amputation of the upper limb

Summary Background Amputations are done daily over the world in an attempt to save a person's life, treat a disease symptomatically or to improve the functionality of a person. Amputation causes disfiguration, a mutilated body image and physical disability with multiple aspects that the person has to deal with. Objectives This qualitative phenomenological study was designed to explore the lived experience of individuals with an of an upper limb to provide an evidence base to support nursing interventions. Methods A sample of eight participants with of an upper limb, living in the southern sub-district of Tshwane, Gauteng, South Africa, took part in a semi-structured interview. One open-ended central question was used to focus the interview: Please tell me about your lived experience after losing your arm through an upper limb amputation . Data were analysed using content analysis with open coding. Seven themes were identified from the data. Results The themes emerging from the interviews were: Initial reaction post amputation, support from immediate family, support facilitated adaptation and independence, had financial implications, external response to disability, recurrent physical problems and acceptance is a process. Data have shown that effective communication between multidisciplinary team members; discharge information and ongoing support on an outpatient basis are needed to assist with the adaptation process of the individual to amputation. Discussion Individuals with an of an upper limb need an effective multidisciplinary approach to care, clear discharge information and ongoing support on an outpatient basis to accept of an upper limb effectively.

Residual Limb Pain Is Not a Diagnosis

Although postamputation pain (PAP) syndromes have been described since the 16th century, taxonomy of these conditions remains ill-defined. The term "Residual Limb Pain" fails to distinguish between distinct diagnostic entities such as neuroma, complex regional pain syndrome, and somatic pathology. Even phantom limb pain (PLP), although easily distinguished from residual limb pain (RLP), has not been consistently delineated from other PAP syndromes. A systematic review of the literature was conducted to identify the degree of delineation of various post amputation pain states and what diagnostic criteria were utilized if any. Furthermore, papers that involved treatment modalities were reviewed to determine efficacy of treatment. Of the 151 papers reviewed, none further categorized RLP into more specific diagnostic criteria. Furthermore, the literature contains numerous case reports, case series, letters to the editors, and grossly underpowered studies demonstrating significant positive results, yet few high-quality randomized controlled trials. Describing and defining the distinct clinical entities, intuitively, is a prerequisite to developing optimal treatments. The reported variation in the incidence of PAP phenomena may well represent inconsistency in assessment tools and diagnostic categories rather than variation in prevalence of these conditions. In this paper, we review the historical evolution of the current understanding of these syndromes and propose an algorithm for uniform classification.

Sympathetic asymmetry in post amputation pain

Sympathetic asymmetry in post amputation pain

Phantom pains and sensations – how does it feel? Only the patient really knows

In the qualitative study by Berit Bjorkman et al. published in this ssue of the Scandinavian Journal of Pain, some interesting aspects n post amputation pain problems and other phantom sensations re presented [1]. The information comes from the narrative inforation obtained by in-depth interviews from patients that have ndergone amputations of an extremity or a breast, and are sufferng from phantom sensations and phantom pain. The manuscript ay seemodd for readers used to scientific articlesmainly presentng medical research based on quantitative data, but it absolutely eserves publication, because it highlights the patients’ own expeience of a very complex pain phenomenon, notoriously difficult to reat. Quantitative research designs give us answers to many aspects hat can be measured in some way, e.g. that phantom limb pain ccurs in 50–80% of amputees, and that it is usually intermittent ndofhigh intensity [2,3]. Furthermore that inphantompain, imagng studies can demonstrate that cerebral cortical reorganization ccurs [4], and that even loss of brain volume takes place [5] as a onsequence of amputation and phantom pains. However, what oes it really feel like to suffer from phantom pains and phanom sensations, and what meaning and what consequences do hey have for the individual? In order to understand these fundaental questions, the quantitative tools, the common foundation or medical research, will never give full answer. To understand his experience better, we can ask a friend that has undergone mputation what she/he experiences or, in a more systematic scintific way, we can apply qualitative narrative research designs 6]. The aim of this study by Berit Bjorkman et al. [1] was to escribe and discuss how patients experienced and interpreted heir post-limb amputation or post-mastectomy phantom pheomena. Focus was set on how patients evaluated the perceived ualities of the phenomenon itself, how different aspects, physical nd socio-cultural, influenced thephenomenon, andhowit affected he every-day life. The study was prospective, i.e. the patients were recruited to he study before the amputation took place, which is a significant trength of the study. The situation was investigated one month

Role of myofascial trigger points in post-amputation pain

Post-amputation pain is a multifactorial issue and thus necessitates multiple treatment strategies. Myofascial trigger points-related pain remains under diagnosed and hence not addressed. This study investigates causation and management. To identify the presence and role of myofascial trigger points in post amputation pain. Post-amputation pain clinic review and recruitment. Twenty one identified patients in the post-amputation pain clinic with myofascial trigger points were recruited, of which 13 were transtibial and eight transfemoral and all had phantom limb pain and stump pain. The trigger points were identified and injected with long-acting local anaesthetic on a weekly basis and patients were followed up on an ongoing basis. There was significant resolution of pain on the Visual Analogue Scale in the majority of these patients within five weeks, though some of the transtibial cohort needed further eight injections on a weekly basis for resolution of the pain. Identification of myofascial trigger points in amputation stumps and their role in post-amputation pain, followed by appropriate intervention is an important facet of management of this complex chronic pain. Clinical relevance Myofascial trigger points in amputation stumps can lead to ongoing chronic post-amputation pain and our results indicate that identification and intervention of these trigger points does lead to notable resolution of this pain.

Life-long preservation of the regenerative capacity in the fin and heart in zebrafish

SummaryThe zebrafish is a widely used model animal to study the regeneration of organs, such as the fin and heart. Their average lifetime is about 3 years, and recent studies have shown that zebrafish exhibit aging-related degeneration, suggesting the possibility that aging might affect regenerative potential. In order to investigate this possibility, we compared regeneration of the fin and heart after experimental amputation in young (6–12 month old) and old (26–36 month old) fish. Comparison of recovery rate of the caudal fin, measured every two or three days from one day post amputation until 13 days post amputation, show that fins in young and old fish regenerate at a similar rate. In the heart, myocardium regeneration and cardiomyocyte proliferation occurred similarly in the two groups. Moreover, neo-vascularization, as well as activation of fibroblast growth factor signaling, which is required for neo-vascularization, occurred similarly. The epicardial tissue is a thin layer tissue that covers the heart, and starts to express several genes immediately in response to injury. The expression of epicardial genes, such as wt1b and aldh1a2, in response to heart injury was comparable in two groups. Our results demonstrate that zebrafish preserve a life-long regenerative ability of the caudal fin and heart.

A novel approach to wound management and prosthetic use with concurrent vacuum-assisted closure therapy

Stump healing is critical to post amputation management. When healing is not optimal, immobility is prolonged and patients risk hospital acquired deconditioning. Two clinical cases with unhealed trans-femoral stump wounds are described. Vacuum assisted closure (VAC) dressing with concurrent prosthetic utilisation was undertaken successfully in both cases. Fitting of the prosthetic socket included space for VAC dressing with modifications to allow the suction piping to exit the prosthesis. With VAC application, timely rehabilitation and mobility was enabled despite incomplete wound healing. The two clinical cases described made excellent progress. Discharge home was expedited with the provision of portable VAC pumps. Wounds healed fully without infection. Both patients were able to mobilise sooner than if they had to wait for complete wound closure and, importantly, the consequences of prolonged immobility were minimised. No extra costs were incurred using this novel therapy. Guidance for early mobilisation of trans-femoral amputees with open wounds is limited. These cases provide examples utilising VAC dressings with concurrent prosthetic rehabilitation, facilitating prompt ambulatory retraining, minimising deconditioning and optimising outcomes.

Comparison of post amputation outcome in patients with type 2 diabetes from specialized foot care centres in three developing countries

Objective To evaluate post amputation outcome and associated complications in type 2 diabetic patients who had undergone major amputations in developing countries. Patients and Methods A total of 526 (M:F; 369:157) subjects from three centers [India (IND), n = 194, Bangladesh (BAN) n = 177 and Tanzania (TAN) n = 155 who had undergone amputation and subsequently visited the hospital were included in this analysis. Details on foot problems and associated complications were recorded. Results The prevalence of amputations was similar in all centres. The history of minor amputation and foot deformity was high in BAN. Recurrence of foot ulceration was more in TAN (30%) than in IND (9%) and BAN (11%). Re-amputation rate was similar in all groups (3%). The use of artificial limb was most in BAN (97%). Myocardial infarction was more prevalent in IND (15%). In Tanzania, 31% had died during the follow-up period and it was 16% and 5% in IND and BAN. The causes of death were infection due to septicemia and cardiovascular events which finally led to multisystem organ failure. Conclusion The outcome following a major diabetic foot amputation was compared in three developing countries. Recurrence of foot infection was common in Tanzania. The most frequent causes of death were infection and cardiovascular events.

Functional analysis of grimp, a novel gene required for mesodermal cell proliferation at an initial stage of regeneration in Enchytraeus japonensis (Enchytraeidae, Oligochaete)

Enchytraeus japonensis is a small oligochaete species, which has a remarkable regeneration capacity. It has been proposed as a new model animal for the study of regeneration, and some histological studies of this species have been carried out. On the other hand, the molecular biological mechanism of regeneration is almost unknown in this species. To clarify the molecular biological mechanism operating at an initial stage of regeneration in E. japonensis, we isolated by the cDNA subtraction method five genes whose expression levels changed in the regeneration process occurring between growing and early regenerating worms. One of the isolated genes (a novel gene named grimp) was expressed transiently from 3 to 12 h post amputation only in neoblasts and a population of mesodermal cells (the non-neoblast grimp-expressing cells) incorporating BrdU simultaneously showed mitotic activity. We succeeded in inhibiting grimp expression by RNA interference (RNAi), thus applying this technique for the first time in Oligochaeta. In knock-down worms, the number of BrdU-positive neoblasts and the non-neoblast grimp-expressing cells in the coelom drastically decreased. Moreover, the elongation and the segmentation of blastemas were inhibited, while no statistically significant inhibitory effect was observed in epidermal and intestinal cells. These results suggest that grimp is required for initial proliferation of neoblasts and some mesodermal cells for regeneration.

Dynamic interpretation of the Hedgehog gradient drives wing disc patterning in Drosophila

Concurrent session 3: Mechanisms of developmental patterning Program/Abstract # 18 Dynamic interpretation of the Hedgehog gradient drives wing disc patterning in Drosophila Marcos Nahmad, Angela Stathopoulos Department of CDS, Caltech, Pasadena, CA, USA Div. of Biol., Caltech, Pasadena, CA, USA Morphogens are classically defined as molecules that control patterning by acting at a distance to regulate gene expression in a concentration-dependent manner. In the Drosophila wing imaginal disc, secreted Hedgehog (Hh) forms an extracellular gradient that organizes patterning along the anterior–posterior axis by defining at least three different domains of gene expression. However, a direct spatial correspondence between the boundaries of these patterns and Hh-concentration thresholds has not been demonstrated. We have acquired evidence that the interpretation of Hh signaling depends on the history of exposure to Hh and that a single concentration threshold is sufficient to support multiple outputs. Mathematical modeling and computer simulations suggest that a spatial ‘overshoot’ of the Hh gradient occurs, that is, a transient gradient in which the Hh-concentration profile is expanded compared to the steady-state gradient. This overshoot results from the gene network architecture, in particular, it depends on Hh-dependent up-regulation of the Hh receptor, Patched (Ptc). Through a temporal examination of Hh-target gene expression in vivo, we observe that particular borders of expression shift posteriorly, and subsequently refine. Furthermore, when the network structure is altered such that Ptc transcription is no longer activated in response to Hh signaling, we find that the patterns of gene expression, which have distinct borders in wild-type discs, now in fact overlap. Taken together, our results demonstrate that the overshoot of the Hh gradient is necessary to establish different patterns of gene expression. doi:10.1016/j.ydbio.2009.05.025 Program/Abstract # 19 Planarian anterior–posterior axis is established by interaction of voltage-dependent Ca influx and β-catenin signaling at the early stage of regeneration Taisaku Nogi, Dan Zhang, John D. Chan, Jonathan S. Marchant Department of Pharmacology and The Stem Cell Institute, University of Minnesota Medical School, MN, USA Since the classic experiments of Marsh and Beams in the 1950s, it has been suggested that endogenous voltage gradients play an important role in planarian regeneration. Here, we show voltagedependent Ca influx is a key regulator of anterior–posterior (AP) axis specification during planarian regeneration. Using a pharmacological screen of Ca signaling modulators in the planarian D. japonica, we identified that praziquantel (PZQ) – a voltage-operated Ca channel (VOCC) activator – had a robust effect to yield a bipolar (two-headed) phenotype from regenerating trunk fragments. PZQtreated fragments displayed a mirror-imaged pharynx and posterior, rather than ectopic, head. This effect was Ca-dependent and increased by a variety of depolarizing agents known to couple to VOCCs. Time-window experiments and in situ hybridization of marker gene expression demonstrated PZQ treatment impacted the early stages of regeneration (<18 h post amputation) and produced a complete anteriorization. Chemical genetic analysis identified that Ltype voltage-operated Cachannel (VOCC) β subunits were essential for PZQ action as in vivo RNAi for βsubunits counteracted PZQ-evoked bipolarity. Finally, β-catenin RNAi and PZQ co-treatment synergistically caused the bipolar phenotype, suggesting PZQ-evoked Ca signals inhibit Wnt/β-catenin signaling. Taken together, these data suggest voltage-dependent Ca influx is an upstream factor to Wnt/ β-catenin signals that establish AP axis polarity during planarian regeneration. doi:10.1016/j.ydbio.2009.05.026 Program/Abstract # 20 The diverse functions of transcriptional factor AP2 (TFAP2) targets in neural crest development Ting Thalia Luo, Yan Xu, Janaki Rangarajan, Trevor Hoffman, Yoo-Seok Hwang, Thomas Schilling, Thomas Sargent Lab. of Mol. Genet., NICHD/NIH, Bethesda, MD 20892, USA Department of Dev. and Cell. Biol. Univ. of California, Irvine, CA 92697, USA Neural crest (NC) cells are a unique feature of vertebrate embryos, arising from the border of neural and non-neural ectoderm as the result of inductive signals including BMP and Wnt, among others. NC cells migrate extensively to give rise to a wide variety of cell lineages, i.e., the craniofacial bones, pigment cells, neurons and glia of the peripheral nervous system. We showed that the transcription factor AP2 (TFAP2) plays an important role in regulating gene expression in NC cells, and is positively regulated by BMP and Wnt. By the microarray approach, we have identified three predominantly NC expressed genes as TFAP2 targets: PCNS, Myosin X (MyoX) and Inca, were intensively studied in the Xenopus and zebrafish by in vivo and in vitro. PCNS is a novel protocadherin which appears to regulate cadherin mediated cell–cell adhesion. MyoX is a non-muscle myosin known to play important roles in the formation of filopodia and cell Developmental Biology 331 (2009) 390–391

Planarian anterior–posterior axis is established by interaction of voltage-dependent Ca2+ influx and β-catenin signaling at the early stage of regeneration

Concurrent session 3: Mechanisms of developmental patterning Program/Abstract # 18 Dynamic interpretation of the Hedgehog gradient drives wing disc patterning in Drosophila Marcos Nahmad, Angela Stathopoulos Department of CDS, Caltech, Pasadena, CA, USA Div. of Biol., Caltech, Pasadena, CA, USA Morphogens are classically defined as molecules that control patterning by acting at a distance to regulate gene expression in a concentration-dependent manner. In the Drosophila wing imaginal disc, secreted Hedgehog (Hh) forms an extracellular gradient that organizes patterning along the anterior–posterior axis by defining at least three different domains of gene expression. However, a direct spatial correspondence between the boundaries of these patterns and Hh-concentration thresholds has not been demonstrated. We have acquired evidence that the interpretation of Hh signaling depends on the history of exposure to Hh and that a single concentration threshold is sufficient to support multiple outputs. Mathematical modeling and computer simulations suggest that a spatial ‘overshoot’ of the Hh gradient occurs, that is, a transient gradient in which the Hh-concentration profile is expanded compared to the steady-state gradient. This overshoot results from the gene network architecture, in particular, it depends on Hh-dependent up-regulation of the Hh receptor, Patched (Ptc). Through a temporal examination of Hh-target gene expression in vivo, we observe that particular borders of expression shift posteriorly, and subsequently refine. Furthermore, when the network structure is altered such that Ptc transcription is no longer activated in response to Hh signaling, we find that the patterns of gene expression, which have distinct borders in wild-type discs, now in fact overlap. Taken together, our results demonstrate that the overshoot of the Hh gradient is necessary to establish different patterns of gene expression. doi:10.1016/j.ydbio.2009.05.025 Program/Abstract # 19 Planarian anterior–posterior axis is established by interaction of voltage-dependent Ca influx and β-catenin signaling at the early stage of regeneration Taisaku Nogi, Dan Zhang, John D. Chan, Jonathan S. Marchant Department of Pharmacology and The Stem Cell Institute, University of Minnesota Medical School, MN, USA Since the classic experiments of Marsh and Beams in the 1950s, it has been suggested that endogenous voltage gradients play an important role in planarian regeneration. Here, we show voltagedependent Ca influx is a key regulator of anterior–posterior (AP) axis specification during planarian regeneration. Using a pharmacological screen of Ca signaling modulators in the planarian D. japonica, we identified that praziquantel (PZQ) – a voltage-operated Ca channel (VOCC) activator – had a robust effect to yield a bipolar (two-headed) phenotype from regenerating trunk fragments. PZQtreated fragments displayed a mirror-imaged pharynx and posterior, rather than ectopic, head. This effect was Ca-dependent and increased by a variety of depolarizing agents known to couple to VOCCs. Time-window experiments and in situ hybridization of marker gene expression demonstrated PZQ treatment impacted the early stages of regeneration (<18 h post amputation) and produced a complete anteriorization. Chemical genetic analysis identified that Ltype voltage-operated Cachannel (VOCC) β subunits were essential for PZQ action as in vivo RNAi for βsubunits counteracted PZQ-evoked bipolarity. Finally, β-catenin RNAi and PZQ co-treatment synergistically caused the bipolar phenotype, suggesting PZQ-evoked Ca signals inhibit Wnt/β-catenin signaling. Taken together, these data suggest voltage-dependent Ca influx is an upstream factor to Wnt/ β-catenin signals that establish AP axis polarity during planarian regeneration. doi:10.1016/j.ydbio.2009.05.026 Program/Abstract # 20 The diverse functions of transcriptional factor AP2 (TFAP2) targets in neural crest development Ting Thalia Luo, Yan Xu, Janaki Rangarajan, Trevor Hoffman, Yoo-Seok Hwang, Thomas Schilling, Thomas Sargent Lab. of Mol. Genet., NICHD/NIH, Bethesda, MD 20892, USA Department of Dev. and Cell. Biol. Univ. of California, Irvine, CA 92697, USA Neural crest (NC) cells are a unique feature of vertebrate embryos, arising from the border of neural and non-neural ectoderm as the result of inductive signals including BMP and Wnt, among others. NC cells migrate extensively to give rise to a wide variety of cell lineages, i.e., the craniofacial bones, pigment cells, neurons and glia of the peripheral nervous system. We showed that the transcription factor AP2 (TFAP2) plays an important role in regulating gene expression in NC cells, and is positively regulated by BMP and Wnt. By the microarray approach, we have identified three predominantly NC expressed genes as TFAP2 targets: PCNS, Myosin X (MyoX) and Inca, were intensively studied in the Xenopus and zebrafish by in vivo and in vitro. PCNS is a novel protocadherin which appears to regulate cadherin mediated cell–cell adhesion. MyoX is a non-muscle myosin known to play important roles in the formation of filopodia and cell Developmental Biology 331 (2009) 390–391

A UK survey of therapists' perspectives on post-amputation hopping

Aims: There is a lack of evidence to guide therapists on early mobility with patients post-amputation. Guidelines were published in the UK in 2006 to assist therapists with decision making in this area. In light of these guidelines, the author sought to explore UK therapists’ views, experiences and sources of knowledge on hopping with and without aids post amputation, and identify further areas for research. Methods: A survey methodology was adopted. Data were analysed using descriptive statistics and respondents’ written remarks were explored to support the analysis. Findings: Survey responses were returned by 88 therapists; 27 occupational therapists and 61 physiotherapists. Hopping without aids was not recommended by any therapist. 61% of respondents would recommend hopping with aids in some circumstances; 63% felt that some patients have to hop to get around the home; 52% felt that hopping was inadvisable and 40% thought it would delay rehabilitation. 90% of therapists have had amputees report they are hopping. Senior staff and colleagues were the most cited source of knowledge on post-amputation mobility. Conclusions: In the absence of evidence, therapists rely on other colleagues and personal observations to inform their practice in this area. Findings suggest that therapists are following the guidelines which advise that wheelchair mobility is the ideal, but specified reasons may lead therapists to teach amputees to ambulate with aids. Further research is required on the use of hopping post-ambulation.

Functional outcome of hip disarticulation and hemipelvectomy: a cross-sectional national descriptive study in the Netherlands

Objective: To describe characteristics of hip disarticulation and hemipelvectomy amputees, to assess their level of activities, participation and experienced limitations in mobility and to describe the amputation-related problems. Design: A cross-sectional study. Setting: Patients were mainly recruited via orthopaedic workshops in the Netherlands. Subjects: Forty-six patients with an acquired unilateral hip disarticulation or hemipelvectomy at least one year post amputation. Main outcome measures: Sickness Impact Profile 68 (SIP 68) to assess the level of activity and participation and the questionnaire Rising and Sitting Down, Walking and Climbing Stairs to assess perceived limitations in mobility. Results: The 46 patients (31 with hip disarticulation and 15 with hemipelvectomy) had a mean age of 55.8 years (SD 12.1). In 78% of cases the reason for amputation was a tumour. Mean SIP 68 was low, 10.5 (SD 6.9). Hip disarticulation amputees had significantly poorer emotional stability than the hemipelvectomy amputees (P = 0.04). All amputees experienced considerable limitations in their mobility according to the Rising and Sitting Down, Walking and Climbing Stairs scores. Conclusions: Hip disarticulation and hemipelvectomy amputees have a relatively high level of activity and participation (SIP scores) but at the same time experience limitations in walking, rising and sitting down and climbing stairs.

Correlation of Pain Scores, Analgesic Use, and Beck Anxiety Inventory Scores During Hospitalization in Lower Extremity Amputees

Post amputation pain can be debilitating for patients and families. Chronic pain is a common phenomenon after lower extremity amputation, occurring in up to 80% of this population. The purpose of this pilot study was to correlate post amputation pain scores to opioid analgesic consumption and Beck Anxiety Inventory (BAI) scores. Twenty-three patients with lower extremity amputation at an 827-bed acute care inner-city hospital were surveyed pre-operatively and post-operatively to determine if there was a significant correlation between anxiety and pain. A numeric scale was utilized by patients to rate their pain level, while the BAI was utilized to measure their anxiety levels.A significant correlation was found between the pre-operative BAI levels and the BAI levels identified at time of discharge. Patients were found to have a higher than normal level of anxiety pre-operatively. No significant correlations were found between anxiety and pain.

Resource utilization and economic costs of care based on a randomized trial of vacuum-assisted closure therapy in the treatment of diabetic foot wounds

Background To evaluate resource utilization and direct economic costs of care for patients treated with negative-pressure wound therapy (NPWT), using the Vacuum-Assisted Closure (V.A.C.) system, compared to standard moist wound therapy (MWT). Methods A total of 162 diabetic patients with post-amputation wounds (up to the trans-metatarsal level) entered a 16-week, randomized clinical trial. Patients randomized to V.A.C. (n = 77) received therapy with dressing changes every 48 hours. Control patients (n = 85) received standard MWT. Resource utilization, procedures, and direct costs were calculated and analyzed in this post hoc retrospective study. Results There was no difference between groups for in-patient hospital stay (number of admissions or length of stay). More surgical procedures (including debridement) were required in the MWT group (120 vs 43 NPWT, P <.001). The average number of dressing changes performed per patient was 118.0 (range 12–226) for MWT versus 41 (6–140) for NPWT (P = .0001). The MWT group had 11 (range 0–106) outpatient treatment visits during the study versus 4 (range 0–47) in the NPWT group (P <.05). The average direct cost per patient treated for 8 weeks or longer (independent of clinical outcome) was $27,270 and $36,096 in the NPWT and MWT groups, respectively. The average total cost to achieve healing was $25,954 for patients treated with NPWT (n = 43) compared with $38,806 for the MWT group (n = 33). Conclusion Treatment of diabetic patients with post amputation wounds using NPWT resulted in lower resource utilization and a greater proportion of patients obtaining wound healing at a lower overall cost of care when compared to MWT.

A motion‐based angiogenesis analysis to quantify new blood vessel growth

We developed a new method to quantify blood vessel growth using a short video recording of the vascular bed in the regenerated region of the zebrafish caudal fin. After cutting the three most ventral caudal fin bones at the point of branching, each zebrafish, Danio rerio, was exposed to an angiogenic factor for 60 minutes. On day six post amputation, after each fish was anesthetized with 0.2% Tricaine, the newly developed vascular bed in the regenerated area was examined under a Nikon microscope at 40X magnification and a 15 second video clip was recorded. The last 20 frames of the clip were then imported to an imaging software program called Environment for Visualizing Images 3.6 (ENVI 3.6). The only difference among these 20 frames was the movement of blood through all the blood vessels. Consequently, the deviation among the frames highlighted only the blood vessels. When only the newly developed vascular bed in the regenerated area was outlined, a precise, objective and easy comparison could be made between the angiogenic response in control and experimental zebrafish. The same method may be used to quantify angiogenic effects in other models with some modifications.