Stump End Research Articles

Characteristics and outcomes of hip fractures in lower limb amputees.

Lower limb amputees, regardless of age are at an increased risk of developing fragility fractures of the neck of femur. The characteristics and outcomes of the fractures of the neck of femur in lower limb amputees have not been studied in detail. We undertook a retrospective review of a prospectively collected single centre and single surgeon database between March 1996 and January 2017, using a standard proforma to identify patients who required surgical intervention for fracture neck of femur and had sustained a previous lower limb amputation and compared them with a cohort of standard hip fracture patients. Twenty-seven patients, sustaining 28 fractures of the neck of femurs were identified of which 16 were females with mean age of 78 years (50-89). Nineteen fractures were sustained on the ipsilateral side of the amputation. Results showed that seventy percent of amputees returned to their previous level of mobility and prior residence. Mortality in this group is higher as compared to a standard hip fracture patient but pain and mobility were comparable in both groups. The incidence of both hip fractures and amputations in increasing worldwide but no study has compared outcomes of hip fractures in amputees and compared them to a standard hip fracture patient. Amputees exhibit reduced bone density both at the hip and stump end which increases risk for osteoporosis and fragility fractures in the hip. The management of our patients followed orthopaedic principles, well established surgical interventions and rehabilitation. This study reveals that hip fractures in amputees can have comparable results to a standard hip fracture cohort if preoperative optimisation, planning and postoperative rehabilitation is carried out.

Nerve-mediated expression of histone deacetylases regulates limb regeneration in axolotls

Axolotls have amazing abilities to regenerate their lost limbs. Nerve and wound epidermis have great impacts on this regeneration. Histone deacetylases (HDACs) have been shown to play roles in the regeneration of amphibian tails and limbs. In this study, a bi-phasic up-regulation of HDAC1 was noted before early differentiation stage of axolotl limb regeneration. Limb regeneration was delayed in larvae incubated with an HDAC inhibitor MS-275. Local injection of MS-275 or TSA, another HDAC inhibitor, into amputation sites of the juveniles did not interfere with wound healing but more profoundly inhibited local HDAC activities and blastema formation/limb regeneration. Elevation of HDAC1 expression was more apparent in wound epidermis than in mesenchyme. Prior denervation prohibited this elevation and limb regeneration. Supplementation of nerve factors BMP7, FGF2, and FGF8 in the stump ends after amputation on denervated limbs not only enabled HDAC1 up-regulation but also led to more extent of limb regeneration. In conclusion, nerve-mediated HDAC1 expression is required for blastema formation and limb regeneration.

An electroneurography-based assay for identifying injured nerve segment during surgery: design and in vivo application in the rat

Objective. Nerve injury is the main reason for nerve reconstruction surgery, during which the surgeon must determine the location of the injured nerve segment, resect it, and reconnect the remaining healthy nerve stump ends within a limited time. Given this importance, an assay needed to determine the exact location of the injured nerve segment, but no tool has yet fulfilled this need so that a visual inspection of the nerve is still the primary method of identifying the injured segment. Approach. We designed a flexible multi-electrode array sensor that records the electroneurographic signal (ENG) as the action potential elicited by electrical stimulation that propagates along the nerve upon both orthodromic and antidromic stimulation. Its utility was validated by in vivo experiments in injured sciatic nerves of rats. Main results. The results showed that the first post stimulus negative electroneurographic component (N1) is the most valid neural correlate, as its amplitude decreased, and latency increased as the action potential propagated across the injured segment. Gradual recovery of nerve conduction was observed when measured immediately, 7, and 30 d after injury. The locations of the identified injured segments were validated by histological findings. Significance. The sensor and the algorithm developed in this study are breakthroughs in surgical nerve assessment accomplished by determining the specific nerve segment that should be resected, enabling the optimal surgical outcome.

Sequential pictorial account of results of sealant gel-aided cable nerve grafting in a case of iatrogenic facial nerve palsy

The uniqueness of this surgical case report is in the use of a stitchless anastomosis of the harvested greater auricular nerve cable graft with the sealant gel to the stump ends of the facial nerve. A liberal use of the gel was done in the full length of the cable graft and a folded hammock support by the temporalis fascia was used to reinforce the stability of the nerve. The restoration of the grafted facial nerve has been documented in different stages in its course of the recovery. Our review of medical literature in PubMed and Medscape search engines failed to show such a sequential pictorial account of documented nerve grafting with the use of sealant gel in the Indian perspective.

De novo transcriptome sequencing of axolotl blastema for identification of differentially expressed genes during limb regeneration

BackgroundSalamanders are unique among vertebrates in their ability to completely regenerate amputated limbs through the mediation of blastema cells located at the stump ends. This regeneration is nerve-dependent because blastema formation and regeneration does not occur after limb denervation. To obtain the genomic information of blastema tissues, de novo transcriptomes from both blastema tissues and denervated stump ends of Ambystoma mexicanum (axolotls) 14 days post-amputation were sequenced and compared using Solexa DNA sequencing.ResultsThe sequencing done for this study produced 40,688,892 reads that were assembled into 307,345 transcribed sequences. The N50 of transcribed sequence length was 562 bases. A similarity search with known proteins identified 39,200 different genes to be expressed during limb regeneration with a cut-off E-value exceeding 10-5. We annotated assembled sequences by using gene descriptions, gene ontology, and clusters of orthologous group terms. Targeted searches using these annotations showed that the majority of the genes were in the categories of essential metabolic pathways, transcription factors and conserved signaling pathways, and novel candidate genes for regenerative processes. We discovered and confirmed numerous sequences of the candidate genes by using quantitative polymerase chain reaction and in situ hybridization.ConclusionThe results of this study demonstrate that de novo transcriptome sequencing allows gene expression analysis in a species lacking genome information and provides the most comprehensive mRNA sequence resources for axolotls. The characterization of the axolotl transcriptome can help elucidate the molecular mechanisms underlying blastema formation during limb regeneration.

Successfully Seal Pancreatic End After Thermal Distal Pancreatectomy Using Needle Arrays in Alternating Electromagnetic Fields

Pancreatic fistula is still the major postoperative morbidity after distal pancreatectomy (DP). An inductive heat technology via needle arrays in a system of alternating magnetic fields (AMFs) was designed to seal off the pancreatic end. Twenty Lanyu pigs were divided into 2 groups for DP: the conventional group had hand-sewn closure of the pancreatic end (n = 10), and the AMF group received thermal DP by AMF (n = 10). Pathological examinations of the resected and remnant pancreas were studied immediately after resection and on the 14th postoperative day (POD), respectively. The severity and the incidence of pancreatic abscess were compared. The incidence and severity of pancreatic abscess were significantly decreased in the AMF group than those in the conventional group (P = .009). In the immediate postoperative period, microscopic examination of the pancreatic resected end showed prominent coagulative necrosis, loss of NADPH-diaphorase activity, and significant apoptosis at the resected pancreas in the AMF group compared with the control group. Fourteen days after AMF ablation, the pancreatic stump end was covered with thick fibrosis, and histological study of the remnant pancreas showed that the parenchyma had well recovered with positive NADPH-diaphorase activity, and the pancreatic duct was sealed off successfully by prominent periductal fibrosis and intraductal plug. The body weight gain on the 14th POD was significantly increased in the AMF group (from 23.8 ± 1.8 kg to 25.4 ± 5.5 kg) compared with the conventional group (from 25.3 ± 2.1 to 25.4 ± 6.0 kg; P = .003). Inductive heats by the AMF system via needle array can be performed easily and can seal the pancreatic cut surface well during DP.

Knieexartikulation und transgenikuläre Amputation

A knee disarticulation or a through-knee stump is superior compared to a transfemoral stump. The thigh muscles are all preserved, and the muscle balance remains undisturbed. The range of motion of the hip joint is not limited. The bulbous shape of the stump allows full weight bearing at the stump end and can easily be fitted with a prosthesis. An amputee with a bilateral knee disarticulation is able to walk "barefoot". A more distal amputation level, e.g., an ultra-short transtibial amputation, is not possible. Important alternative to transfemoral amputations. Possible for any etiology except for Buerger-Winiwarter's disease. New indications are infected and loosened total knee replacements. Preservation of the knee joint is possible. Knee disarticulation is a very atraumatic procedure, compared to transfemoral amputations. Neither bones nor muscles have to be severed, just skin, ligaments, vessels, and nerves. Even the meniscal cartilages may be left in place to act as axial shock absorbers. The cartilage of the femur is not resected, but only bevelled in case of osteoarthritis. There are no tendon attachments or myoplastic procedures necessary. The patella remains in place and is held in position only by the retinacula. Skin closure must be performed without the slightest tension, and if possible not in the weight-bearing area. Transcondylar amputations across the femoral condyles only are indicated when there are not sufficient soft tissues for wound closure of a knee disarticulation. Alternatives as the techniques of Gritti, Klaes, and Eigler, the shortening of the femur and the Sauerbruch's rotation plasty [14] are presented and discussed. The risk of decubital ulcers is rather high. Correct bandaging of the stump is, therefore, particularly important. Prosthetic fitting is possible 3-6weeks after surgery. The type of prosthesis depends on the amputee's activity level. The superior performance of amputees with knee disarticulations in sports prove the superiority of that amputation level compared to transfemoral amputees. However, because less than 5% of amputations are knee disarticulations, statements about statistical significance cannot be made. On the other hand, one should do everything to preserve an ultra-short transtibial stump.

Pressure characteristics at the stump/socket interface in transtibial amputees using an adaptive prosthetic foot

Background The technological advances that have been made in developing highly functional prostheses are promising for very active patients but we do not yet know whether they cause an increase in biomechanical load along with possibly negative consequences for pressure conditions in the socket. Therefore, this study monitored the socket pressure at specific locations of the stump when using a microprocessor-controlled adaptive prosthetic ankle under different walking conditions. Methods Twelve unilateral transtibial amputees between 43 and 59 years of age were provided with the Proprio-Foot™ (Össur) and underwent an instrumented 3D gait analysis in level, stair, and incline walking, including synchronous data capturing of socket pressure. Peak pressures and pressure time integrals (PTI) at three different locations were compared for five walking conditions with and without using the device’s ankle adaptation mode. Findings Highest peak pressures of 2.4 kPa/kg were found for incline ascent at the calf muscle as compared to 2.1 kPa/kg in level walking with large inter-individual variance. In stair ascent a strong correlation was found between maximum knee moment and socket pressure. The most significant pressure changes relative to level walking were seen in ramp descent anteriorly towards the stump end, with PTI values being almost twice as high as those in level walking. Adapting the angle of the prosthesis on stairs and ramps modified the pressure data such that they were closer to those in level walking. Interpretation Pressure at the stump depends on the knee moments involved in each walking condition. Adapting the prosthetic ankle angle is a valuable means of modifying joint kinetics and thereby the pressure distribution at the stump. However, large inter-individual differences in local pressures underline the importance of individual socket fitting.

Cross-Limb Vascular Shunting for Major Limb Replantation

In the management of traumatic major limb amputation, rapid re-establishment of circulation to the amputated part is imperative so as to prevent complications related to reperfusion injury, especially for those already suffering from prolonged ischemia. A temporary, extra-anatomic cross limb shunting with infusion lines can be used to perfuse the amputated part almost instantaneously. This allows the surgeon to carry out skeletal fixation and other reparative works in an unhurried manner. The cannulation site is targeted at intact vessels far away from the injury zone, obviating the need to explore and handle traumatized vessels at the mangled stump ends, thus greatly simplifying and expediting the revascularization process. Such a method had been successfully applied in 2 young people suffering traumatic arm amputation and thigh amputation, respectively. We suggested that such a procedure could be a useful adjunct in the field of major limb replantation.

Auslösung von Phantomschmerzen und -sensationen durch muskuläre Stumpftriggerpunkte nach Beinamputationen

The aim of the study was to examine whether/how myofascial stump trigger points (TPs) after lower leg amputations are able to produce stump pain (SP), phantom pain (PP), and sensations (PS) in the phantom limb. Palpation of the 5 most striking stump TPs of 30 leg amputees (12 transfemoral, 18 transtibial) was documented in a standardized manner. Patients were asked to localize SP, PP, and PS. Of 150 TPs, 14 produced involuntary stump movements and 10 stump fasciculations. Dorsal PP after ventral TP palpation occurred as well as PP in the toes from TPs near the hip. Of 30 patients, 20 reported PS and 8 PP; 60 of 150 TPs produced PS and 17 PP. Phantom phenomena were localized in 62.8% in the toes (1st toe 19.8%, toes 2-5 about 10% each), 17.9% midfoot, and the rest were more proximal. TPs were localized more in the lateral/dorsal stump than medial/ventral. About 70% of the TPs were found between 3 and 7 cm from the stump end, those with toe projections more distal than those with tibial projections. Myofascial TPs in amputation stumps are common and able to produce sensations and pain in the phantom limb. Most reported experiences were localized in the toes, as phantom pain usually is. There seems to be a "stump representation" and it seems possible that "referred TP pain" and "phantom pain" may develop from similar origin.

Development of Automatic Immediate Fitting Socket (AIFS) System for Artificial Leg Socket Modeling using Fuzzy Set Control

The Automatic Immediate Fitting Socket (AIFS) system was developed to reduce the time consumption for making an artificial leg. The AIFS is composed of an outer shell, a particle containing bag and three air bags. The rigidity of the AIFS can be controlled by the application of negative pressure between the outer shell and the particle bag. The three air bags are used for adjusting the shape of the socket. A fuzzy set theory was utilized for the real-time automatic control of the socket shape based on the subjective evaluation by amputee. Two experiments were conducted for evaluation of this system. One was for measurement of contact pressures between the surface of the stump and the socket during walking. This result revealed that the pressure distribution function of the AFIS was more uniform than conventional artificial legs. Another experiment was conducted for evaluation of a shape-modelling function. The shape-modelling performance was evaluated by measuring the cross-section area ratio of the stump calf to the stump end. This ratio with AIFS was about 1.5 times as large as the conventional artificial leg. This result showed that AIFS system provides a suitable shape for walking. The entire AIFS modeling process including test walking was completed in 40 minutes, which is significantly shorter than the time for the conventional modeling process.

Thumb Metacarpal Lengthening

Over a period of 35 years, 92 patients have been treated: 70 adults and 22 children age 8 to 14. The metacarpal lengthening obtained varied from 2 to 4.5 cm with an average of 3.5 cm, or equal to the length of a thumb proximal phalanx. In one third of the adult patients, due to delayed spontaneous ossification, the interfragmental space was bridged by a bone graft taken from the iliac crest. Late follow-up of 21 patients made 10 to 14 years after the treatment showed good function of the thumb with a normal pattern of skin sensibility. The lack of trophic changes in the distal part of the reconstructed thumb is due to the interposition type of bone lengthening, that is, the new bone structure is placed into the bone middle and not superimposed on the bone stump end, as is done in other methods of thumb reconstruction. The metacarpal lengthening procedure has the following drawbacks: (1) the full treatment course lasts several months; (2) the reconstructed thumb has neither joint nor nail. Advantages of the method are: (1) reconstruction of the thumb is done by using the available stump tissue resources; (2) the reconstructed thumb is covered by its own, normally innervated skin.

能動義手／断端駆動ロック肘（Ｒｏｂｉｎ‐Ａｉｄｓ）処方が効果的であった前腕不良短断端の２症例

In short below-the-elbow stumps with insufficient muscle strength to flex the forearm through the normal range, it is very important to select suitable prosthesis. The wrong prosthesis may result in some clinical problems such as stump pain or abrasion. We reported two cases in which clinical problems were improved when using the Robin-Aids elbow hinge. Both patients had wide scarring around the stump, muscle atrophy of the upper limb, and limited range of motion in the elbow joint. They could perform standard active prosthesis techniques without trouble when using the Robin-Aids elbow hinge. Because the motion of the stump was used only for “locking or unlocking” when using the Robin-Aids elbow hinge, there was no need to burden the stump end with a heavy load. Though, in recent years, modern high-technology devices such as myoelectric hands have attracted people's attention, we should not forget old time-tested techniques which are as useful as modern ones.

Wound Currents Following Amputation of Tail Tip in the Japanese Newt, Cynops pyrrhogaster

Abstract When tail tips of the Japanese newt (Cynops pyrrhogaster pyrrhogaster) were amputated, large ionic currents were detected around the stump using a vibrating probe system. The initial wound currents flowed outwardly through the whole stump, and then localized within 24 hr toward the central region of the stump. Current densities reached a peak of about 450 μA • cm−2 (about 900 times greater than before amputation) within one half of a day after amputation, and returned to levels similar to the intact tail tip by 4 days, i.e., the wound currents were transient. The swelling of the stump end (regenerate or blastema) occurred about 7 days after amputation. The major ion carrying the currents is thought to be Na+, because the currents were strongly inhibited by 0.5 mM ouabain added in the external medium or by Na+-deficient medium. These findings are consistent with those of newt limb stump.

クリッピング困難な椎骨動脈瘤に対する治療選択

Therapeutic occlusion of the vertebral artery (VA) is considered a treatment of choice for unclippable vertebral artery aneurysms and can be achieved with surgical or endovascular intervention. To avoid ischemic complications after treatment, the location and extent of obliteration must be carefully planned. We describe 3 cases of unclippable vertebral artery aneurysms and discuss proper therapeutic options for patients with various vascular structures. Risk of ischemic complications depends on two factors: location of the aneurysm, and the origin of the posterior inferior cerebellar artery (PICA). If an aneurysm is near the vertebral junction and PICA originates at a low position, the perforators probably arise from the long segment between these two structures. VA occlusion above the PICA may cause thrombosis at the stump end of the VA, which would affect the perforators. In this situation, the VA should be occluded below the PICA to avoid subsequent ischemia in the brainstem. The anterior spinal artery, another vital branch from the VA and sometimes visualized on angiogram, should also be preserved. A temporary balloon test occlusion of the VA is a useful adjunct to predict tolerance for ischemia in the basilar artery territory.

Reduction of the Current of Injury Leaving the Amputation Inhibits Limb Regeneration in the Red Spotted Newt

Immediately following amputation of the limb in salamanders, a strong, steady, and polarized flow of ionic current is produced by the injury. Current flows in a proximodistal direction within the limb stump and is associated with a fall in electrical potential of about 50 mV/mm near the stump's end. This current is electrogenically driven by the Na+-dependent, internally positive transcutaneous voltage of the intact skin of the limb stump. Reduction of this EMF, the skin's battery, by topical application of Na+blocking agents leads to inhibition or disruption of normal limb regeneration. This suggests electrical factors are a critical control of limb regeneration. Here we test another means to reduce the injury current and its associated electrical field within the forelimb stump of red spotted newts. A fine (40 gauge), insulated, multistrand wire was inserted beneath the skin of the animal's back, with the uninsulated portion terminating either at the shoulder region or at the base of the tail. When this cathodal (negative) electrode is connected to a regulated current source, sufficient current was pulled into the stump end from an external anode (placed in the water the animal was immersed in) to markedly reduce or null the endogenous current for the first 8 days following amputation. The extent of limb regeneration in sham-treated and experimentally treated animals was determined 1 month following amputation at the elbow. Sham-treated animals regenerated normally, with most producing digits within this time. Limb regeneration was completely arrested, or caused to be strikingly hypomorphic, in half of the experimentally treated animals. This effect was independent of where the subcutaneous electrode was placed and suggests that electrical (physiological) factors are indeed a critical control of limb regeneration in urodeles.

AN OPERATIVE CASE OF CARCINOMA IN ADENOMA OF THE PAPILLA OF VATER

We experienced a successfully operated case of carcinoma in adenoma of the papilla of Vater in an 84-year-old man. The tumor was diagnosed as a carcinoma by preoperative endoscopic biopsy. Radical excision of the papilla of Vater was performed because intraoperative frozen section diagnosis indicated that pancreatoduodenectomy was not necessary. He has been doing well without signs of recurrence during 2 years and 6 months. The carcinoma and adenoma were extremely alike each other in histological findings. This case suggests the a adenoma-carcinoma sequence in the papilla of Vater. Forty-six cases of carcinoma in adenoma of the papilla of Vater have been reported in Japan so far. This 84-year-old case was oldest among them. These cases were clinically reviewed and it is concluded that, in the treatment of carcinoma in adenoma of the papilla of Vater, pancreatoduodenectomy is not always necessary and excision of the papilla of Vater can turn out radical operation, if no residual canser and adenoma in the stump ends is confirmed.

Regenerative outgrowth and distribution of the electroreceptive nerve fibers in the catfish Kryptopterus.

The ampullary electroreceptors on the trunk of Kryptopterus bicirrhis are induced and continuously maintained by a trophic substance released by their afferent nerve fibers. When the fibers are transected and the proximal stumps deflected to a new place, the regenerating fibers grow along new routes to the old electroreceptor sites and again induce organs there. The new routes consist of two sections. The first goes from the deflected stump end to other nearby running intact or degenerated nerves and fibers. In the second section, the regenerating fibers grow along these nerves and fibers to their distal ends, i.e., to the old electroreceptor sites. If the path-guiding nerves and fibers are experimentally removed, the displaced fibers grow to the normal receptor areas directly. Growing out from the displaced stump, they spread out over the trunk in a pattern similar to the pattern displayed formerly by the original nerve fibers at this place. It is concluded that the outgrowing fibers do not possess a specificity for a certain receptor site or skin area, but spread out according to epigenetic factors in the periphery.

Traumatic degeneration of transected myelinated fibers of the mouse sciatic nerve.

Traumatic degeneration of myelinated fibers was studied by electron microscopy over 5 days following transection of mouse sciatic nerve. Special attention was paid to the mechanism which separates the degenerating part, while preserving the viable part of the axon. Immediately after transection, the opened end of the proximal stump revealed extensive subcellular changes including the disorganization of neurofilaments, and disruption of mitochondria and axonal endoplasmic reticulum (SER). Subsequently, vesicles of round and tubular profiles filled up the whole area of the stump end, and proximal to it appeared a neurofilament-predominant area characterized by randomly oriented neurofilaments and normally appearing mitochondria and SER. Characteristic membranous demarcations occurred in early periods at the border between the vesicle accumulation and the neurofilament-predominant areas, and later also within these areas. The demarcation membranes formed both by invagination of the surface plasma membrane and, probably, by fusion of the large vesicles. These became prominent with time, dividing the axoplasm into compartments of varying sizes, which gradually underwent degeneration and were liberated from the parent axon. Occurrence of autophagic vacuoles was characteristic of the degenerating portions of the parent axon. Thus, by the function of demarcation membranes, the parent axon to be preserved could remain membrane-bound, while the degenerating parts were shed off.

Effects of Axotomy on the Cholinesterase and Carbonic Anhydrase Activities of Axons in the Proximal and Distal Stumps of Rabbit Sciatic Nerves

The temporal changes in transected sciatic nerves of rabbits were studied using recently developed histochemical techniques for discriminating between sensory and motor axons. A segment of the nerve was removed to inhibit spontaneous regeneration across the gap. Staining characteristics of the proximal and distal nerve stumps were studied at 1, 2, 3, 4, 9, and 35 days following axotomy and compared with control sciatic nerves. In the control and test nerves, subpopulations of myelinated sensory axons were identified histochemically by carbonic anhydrase (CA) staining, and a subset of alpha motor axons were visualized by cholinesterase (CE) staining. Axon staining patterns were reciprocal; i.e., sensory axons were CA-positive and CE-negative, whereas motor axons were CE-positive and CA-negative. Histochemical activities persisted at day 35 after axotomy in the proximal stump and until day 9 after axotomy in the distal stump. This implies that these techniques may aid in both immediate and delayed primary nerve repair. With time, there is buildup of scar tissue adding to the proximal and distal stumps. Therefore, sections for demonstrating sensory and motor axons must be taken progressively further back from the nerve stump ends. Histochemical axon typing indicated that sensory axons regenerated earlier and to a greater degree than motor axons in the developing neuroma. Use of both the carbonic anhydrase and cholinesterase staining methods is more accurate than either technique alone as an adjunct for examining normal and injured peripheral nerves.