Underwent Limb Amputation Research Articles

Retrospective evaluation of the effectiveness of epsilon aminocaproic acid for the prevention of postamputation bleeding in retired racingGreyhounds with appendicular bone tumors: 46 cases (2003–2008)

To determine the frequency of delayed postoperative bleeding in retired racing Greyhounds with appendicular bone tumors undergoing limb amputations. To identify if administration of epsilon-aminocaproic acid (EACA) was effective on the prevention of postoperative bleeding. Retrospective study from December 2003 to December 2008. Veterinary university teaching hospital. Forty-six retired racing Greyhounds (RRGs) diagnosed with primary appendicular bone tumors that underwent limb amputation were included in the study. None. Thirteen of 46 RRGs (28%) included in the study had delayed postoperative bleeding starting 48-72 h after surgery. Bleeding episodes included cutaneous, subcutaneous, and external bleeding that extended from the area of the surgical site that became widespread within hours, and that required administration of blood components. A paired t-test suggests that there was a significant decrease in PCV postoperatively for both dogs that bled and dogs that did not bleed (P < 0.0001). Forty of 46 RRGs (86%) received either fresh frozen plasma (FFP) or EACA or both, for the prevention of postoperative bleeding. A logistic regression model determined that dogs that did not receive EACA were 5.7 times more likely to bleed than dogs that did receive EACA, when controlling for whether or not they received FFP (95% CI: 1.02-32.15, P = 0.047). This retrospective study suggests that preemptive postoperative administration of EACA appears to be efficacious in decreasing the frequency of bleeding in RRGs undergoing limb amputation; however, a prospective study is warranted to corroborate its effectiveness.

Do We Have the Tools to Prevent Phantom Limb Pain?

Do We Have the Tools to Prevent Phantom Limb Pain?

Injury pattern of suicide bomb attacks in Pakistan

The aim of our study was to analyze the pattern of injuries, hospital care, and outcome of the victims of suicide bomb attacks in Pakistan. This prospective, cohort study was conducted at the Combined Military Hospital Rawalpindi during the last 3years. Seriously injured patients in the "immediate category" were resuscitated in the emergency operation theater adjacent to the emergency room and, after resuscitation, the patients were transferred to the main operation theaters, where consultant surgeons were available. During the study period, 1,296 terrorist victims presented to the emergency department and (86.9%) were admitted, with a mean hospital stay of 8.2±2.1days. The majority of patients arrived by ambulance (91%) and only 38 (3%) were evacuated by air. Penetrating splinter injuries were the most prevalent (87%), and 29% patients also had associated injuries. Open bone fractures were found in 48% and 42% had injured hollow and solid viscous. Overall, 33% of patients had thoracic injuries and neuro-trauma was observed in 16% of the study population. Deafness was a feature in 33% patients, 121 had to undergo limb amputations, and mortality remained in 7% of patients. Most of the problems encountered were logistic in nature. Early evacuation of the victims remains pivotal in saving lives. The major causes of death in peripheral patients was hypovolemic shock, sepsis, and hypothermia. Mortality and morbidity can be enhanced by ample fluid resuscitation, tetanus prophylaxis, and proficient first aid at the site of injury.

Predictors of outcome in dogs treated with adjuvant carboplatin for appendicular osteosarcoma: 65 cases (1996–2006)

To determine outcomes and prognostic factors for those outcomes in dogs with appendicular osteosarcoma treated with curative-intent surgery and adjuvant carboplatin. Retrospective case series. 65 client-owned dogs with appendicular osteosarcoma and no evidence of gross metastatic disease at the time of diagnosis. Medical records of dogs that underwent limb amputation or distal ulnectomy and adjuvant carboplatin treatment for appendicular osteosarcoma were reviewed. Adverse effects of chemotherapy and findings regarding preoperative biopsy specimens and postoperative diagnostic imaging were recorded. Signalment, clinical history, and chemotherapy variables were evaluated for associations with outcome. Histologic grade and other variables were evaluated for association with outcome for 38 tumors that were retrospectively graded. The median disease-free interval was 137 days (95% confidence interval [CI], 112 to 177 days). Median survival time was 277 days (95% CI, 203 to 355 days). The 1-, 2-, and 3-year survival rates were 36%, 22%, and 19%, respectively. None of the chemotherapy variables were associated with outcome. Preoperative proteinuria was the only clinical variable associated with poor outcome. Histologic features of tumors associated with a poor outcome were intravascular invasion, mitotic index > 5 in 3 microscopic hpfs, and grade III classification. Carboplatin administration was well tolerated and resulted in a disease-free interval and median survival time similar to those of other published protocols.

Owners' observations of domestic cats after limb amputation

Questionnaires were distributed to owners of cats that had undergone limb amputation in the UK, through 1000 veterinary clinics or publications relating to companion cats, or online. Between July 2009...

Conditional survival of extremity soft‐tissue sarcoma

With increasing interest in adult cancer survivorship, currently available prognostic estimates for long-term survivors of extremity soft-tissue sarcoma (ESTS) are limited. We assessed determinants of survival in adults surgically treated for nonmetastatic ESTS, conditional on specific survival periods. We identified 6215 persons aged >18 in the Surveillance Epidemiology and End Results program who were surgically treated for nonmetastatic ESTS from 1991 to 2006. We used Cox proportional hazards regression to assess demographic, tumor, and treatment factors associated with 10-year sarcoma-specific survival (SSS) at diagnosis and conditional on surviving 3 and 5 years postdiagnosis. At the time of diagnosis, age, tumor, and treatment factors predicted SSS. Although older age significantly predicted worse SSS for all age groups at diagnosis (HR 3.78 for age >81 vs 18-35; P < .05 for all), the effect of age became nonsignificant as survival time increased, except for the oldest group (>80 years). Tumor size, grade, and histologic subtypes continued to be important predictors of SSS for all periods of conditional survival. Persons who underwent limb amputation were at 3 times the risk of mortality for all conditional survival periods. In this large population-based experience of ESTS survivors, age >80, tumor, and treatment factors continued to affect long-term survival, whereas the effect of age dampened over time. These estimates provide important counseling information for changing risk factors as survival time increases, help to streamline future surveillance programs, and provide insights into the design of adult survivorship care. Cancer 2011. © 2010 American Cancer Society.

Reducing the risk of ulcers and amputations in type 2 diabetes

Although type 2 diabetes is often considered to be ‘mild’ diabetes, it can lead to major complications, such as ulcers and amputations. The number of people with type 2 diabetes who undergo limb amputations has doubled in a decade. Every week 100 people have a limb amputated because of diabetic complications. Simple interventions such as stopping smoking and wearing suitable footwear dramatically reduce the risk of ulcers and amputations and improve quality of life. This article aims to educate the healthcare assistant (HCA) on the reasons why people with diabetes develop foot ulcers, which will enable the HCA to provide appropriate care and support to people with diabetes.

Phantom Limb Phenomena in Cancer Amputees

The objective of this study was to determine the prevalence of phantom pain and correlated conditions such as phantom sensations and stump pain in a population of cancer patients who had undergone limb amputation. A cross-sectional study was carried out in adult patients submitted to limb amputation, who were being followed up at the Physiotherapy Department between April 3 and November 30, 2006. The presence of phantom pain and associated conditions was quantified using a verbal numerical scale. The data obtained were analyzed for means, medians, and proportions with their respective confidence intervals, as appropriate. Seventy-five patients participated in this study, 50 men (66.7%) and 25 women (33.3%). Mean age was 54.4 years (SD +/- 18.5); range 19 to 88 years. The prevalence of phantom pain was 46.7% (95%CI: 35.1 to 58.6), phantom sensation 90.7% (95%CI: 81.7 to 96.2), and surgical stump pain 32.0% (95%CI: 21.7 to 43.8). Phantom pain and phantom sensations are highly prevalent among cancer patients. Further studies should be carried out to determine the main factors associated with their onset.

Adult limb and breast amputees’ experience and descriptions of phantom phenomena—A qualitative study

Background Phantom phenomena – pain or other sensations appearing to come from amputated body parts – are frequent consequences of amputation and can cause considerable suffering. Also, stump pain, located in the residual limb, is in the literature often related to the phantom phenomena. The condition is not specific to amputated limbs and has, to a lesser extent, been reported to be present after radical surgery in other body parts such as breast, rectum and teeth. Multi-causal theories are used when trying to understand these phenomena, which are recognized as the result of complex interaction among various parts of the central nervous system confirmed in studies using functional brain imaging techniques. Functional brain imaging has yielded important results, but without certainty being related to phantom pain as a subjective clinical experience. There is a wide range of treatment methods for the condition but no documented treatment of choice. Aims In this study a qualitative, explorative and prospective design was selected, in the aim to understand the patients’ personal experience of phantom phenomena. The research questions focused at how patients affected by phantom pain and or phantom sensations describe, understand, and live with these phenomena in their daily life. This study expanded ‘phantom phenomena’ to also encompass phantom breast phenomenon. Since the latter phenomenon is not as well investigated as the phantom limb, there is clinical concern that this is an underestimated problem for women who have had breasts removed. Methods The present study forms the first part of a larger, longitudinal study. Only results associated with data from the first interviews with patients, one month after an amputation, are presented here. At this occasion, 28 patients who had undergone limb amputation (20) or mastectomy (8) were interviewed. The focused, semi-structured interviews were recorded, transcribed, and then analyzed using discourse-narrative analysis. Results The interviewees had no conceptual problems in talking about the phenomena or distinguishing between various types of discomfort and discomfort episodes . Their experience originated from a vivid, functioning body that had lost one of its parts. Further, the interviewees reported the importance of rehabilitation and advances in prosthetic technology. Loss of mobility struck older amputees as loss of social functioning, which distressed them more than it did younger amputees. Phantom sensations, kinetic and kinesthetic perceptions, constituted a greater problem than phantom pain experienced from the amputated body parts. The descriptions by patients who had had mastectomies differed from those by patients who had lost limbs in that the phantom breast could be difficult to describe and position spatially. The clinical implication of this study is that when phantom phenomena are described as everyday experience, they become a psychosocial reality that supplements the definition of phantom phenomena in scientific literature and clinical documentation. Conclusions There is a need for clinical dialogues with patients, which besides, providing necessary information about the phenomena to the patients creates possibilities for health professionals to carefully listen to the patients’ own descriptions of which functional losses or life changes patients fear the most. There is a need for more qualitative studies in order to capture the extreme complexity of the pain–control system will be highlighted.

Pattern of limb amputation in a Kenyan rural hospital

Causes of limb amputations vary between and within countries. In Kenya, reports on prevalence of diabetic vascular amputations are conflicting. Kikuyu Hospital has a high incidence of diabetic foot complications whose relationship with amputation is unknown. This study aimed to describe causes of limb amputations in Kikuyu Hospital, Kenya. Records of all patients who underwent limb amputation between October 1998 and September 2008 were examined for cause, age and gender. Data were analysed using the statistical package for Social Sciences (SPSS) for Windows Version 11.50. One hundred and forty patients underwent amputation. Diabetic vasculopathy accounted for 11.4% of the amputations and 69.6% of the dysvascular cases. More prevalent causes were trauma (35.7%), congenital defects (20%), infection (14.3%) and tumours (12.8%). Diabetic vasculopathy, congenital defects and infection are major causes of amputation. Control of blood sugar, foot care education, vigilant infection control and audit of congenital defects are recommended.

Non-painful phantom limb phenomena in amputees: incidence, clinical characteristics and temporal course.

58 patients undergoing limb amputation mainly because of peripheral vascular disease were interviewed by means of a standard questionnaire and examined 8 days, 6 months and 2 years after limb amputation regarding non-painful phantom limb phenomena. During the follow-up period, 41% of patients died. The incidence of phantom limb 8 days, 6 months and 2 years after limb loss was 84%, 90% and 71%, respectively. Phantom limb phenomena changed within the first half year after amputation from a mainly proximal and distal distribution to a mainly distal localized sensation. While approximately 3/4 of patients with phantom limb had kinaesthetic sensations in the limb (i.e. feeling of length, volume or other spatial sensation) during the first 6 months after amputation, less than 50% of patients had this later in the course; 30% of patients noticed a clear shortening of the phantom limb during the follow-up period. While the incidence of phantom limb did not decrease during the follow-up period, both the duration and frequency of phantom limb phenomena declined significantly. The distribution of non-painful and painful phantom limb did not differ significantly from each other. The present findings suggest that mechanisms both in periphery, spinal cord and brain participate in generating the phantom limb percept.

Fondaparinux for the treatment of patients with acute heparininduced thrombocytopenia

Heparin-induced thrombocytopenia (HIT) is a life-threatening immune response to heparin that is associated with a high risk of thromboembolic complications. We prospectively treated seven subjects with acute HIT with fondaparinux and compared the results to a similar historical control population from the same hospital. Six of the seven fondaparinux-treated subjects were transitioned to warfarin, beginning after platelet count recovery occurred. Ten historical controls were treated with a direct thrombin inhibitor (DTI), eight of which were transitioned to warfarin. The primary study outcome was platelet count recovery which was defined as an increase from baseline by at least 30% of nadir to greater than 100,000/mm(3) by day seven. Seven subjects were prospectively treated with fondaparinux for a median of eight days. Six of the seven had HIT with thrombosis at the time of enrollment. All fondaparinux treated subjects had a complete platelet count recovery, and none experienced a new thromboembolic complication, major bleeding or death by week four. One subject underwent limb amputation. Ten historical controls were treated with a DTI for a median duration of eleven days. Platelet count recovery occurred in eight of the ten historical controls. No new thromboembolic complications or major bleeds occurred but limb gangrene occurred in four controls. The development of limb gangrene in the historical controls may have been a result of delayed recognition of HIT and/or inappropriately early institution of warfarin in the historical controls. This pilot study suggests that fondaparinux may be useful in patients with acute HIT.

Lepirudin in patients with heparin-induced thrombocytopenia – results of the third prospective study (HAT-3) and a combined analysis of HAT-1, HAT-2, and HAT-3

To assess efficacy and safety of lepirudin in patients with heparin-induced thrombocytopenia (HIT) in a prospective study (HAT-3) as well as in a combined analysis of all HAT study data. Patients with laboratory-confirmed HIT were treated with lepirudin in three different aPTT-adjusted dose regimen and during cardiopulmonary bypass (CPB). Endpoints were new thromboembolic complications (TEC), limb amputations, and death and major bleeding. A historical control group (n = 120) was used for comparison. After start of lepirudin in 205 patients treated in HAT-3, the combined endpoint occurred in 43 (21.0%). Thirty (14.6%) patients died, 10 (4.9%) underwent limb amputation, and 11 (5.4%) new TECs occurred. Major bleeding occurred in 40 patients (19.5%) (seven during CPB surgery). Combining all prospective HAT trials (n = 403), after start of lepirudin treatment, the combined endpoint occurred in 82 patients (20.3%), with 47 deaths (11.7%), 22 limb amputations (5.5%), 30 new TECs (7.4%), and 71 (17.6%) major bleedings. Compared with the historical control group (log-rank test), the combined endpoint after start of treatment was reduced (29.7% vs. 52.1%, P = 0.0473), primarily because of reduction in new thromboses (11.9% vs. 32.1%, P = 0.0008). Mean lepirudin maintenance doses ranged from 0.07 to 0.11 mg kg(-1) h(-1). Major bleeding was more frequent in the lepirudin-treated patients (29.4% vs. 9.1%, P = 0.0148). The rate of new TECs in HIT patients is low after start of lepirudin treatment. The rate of major bleeding of 17.6% might be reduced by reducing the starting dose to 0.1 mg kg(-1) h(-1).

Partial Foot Amputation in 11 Dogs

Eleven dogs with malignant tumors of the digits and feet were treated with partial foot amputation. Partial foot amputation involved amputation of one or both central weight-bearing digits. Lameness occurred in all dogs but resolved in eight dogs at a median of 37 days postoperatively. In the remaining three dogs, lameness improved but did not resolve. Tumor control was excellent, with no evidence of local recurrence in 10 dogs. One dog underwent limb amputation. Based on these results, partial foot amputation may be recommended in the management of malignant tumors of the canine foot in which more than one digit must be amputated to achieve adequate surgical margins.

VEGF and VEGF Receptor Expression in Human Chronic Critical Limb Ischaemia

Objective This study quantified endogenous VEGF and VEGF receptor expression in limbs of patients with chronic critical limb ischaemia (CLI). Methods Skin and muscle biopsies were obtained from the legs of 25 patients undergoing limb amputation for CLI. Samples were obtained at the amputation level (thigh or calf) and, distally, from the foot and in the vicinity of ischaemic ulcers and gangrene. Control biopsies were obtained from patients undergoing amputation for non-arterial reasons or knee arthroplasty ( n=7). VEGF protein levels in tissue lysates were measured by ELISA, and VEGF and KDR mRNA levels were determined using quantitative PCR. Results At the amputation level, VEGF protein and VEGF and KDR mRNA levels in CLI limbs were similar to those in controls. In the foot VEGF mRNA in skin ( P=0.005) and VEGF protein levels in muscle ( P=0.02) were elevated compared to levels in a proximal biopsy from the same limb. VEGF and KDR mRNA levels in the vicinity of gangrene/ulcers (VEGF P=0.01, KDR P=0.03) also were elevated. Conclusions VEGF expression is not deficient in CLI. Indeed, it is elevated at distal sites in the ischaemic limb. These findings question the rationale for VEGF supplementation in CLI.

Heparin-induced thrombocytopenia with thromboembolic complications: meta-analysis of 2 prospective trials to assess the value of parenteral treatment with lepirudin and its therapeutic aPTT range

AbstractThis meta-analysis focuses on 2 prospective studies in patients with heparin-induced thrombocytopenia (HIT) and thromboembolic complication (TEC) who were treated with lepirudin (n = 113). Data were compared with those of a historical control group (n = 91). The primary endpoint (combined incidence of death, new TEC, and limb amputation) occurred in 25 lepirudin-treated patients (22.1%; 95% CI, 14.5%-29.8%): 11 died (9.7%; 95% CI, 4.9%-16.8%), 7 underwent limb amputation (6.2%; 95% CI, 2.5%-12.3%), and 12 experienced new TEC (10.6%; 95% CI, 5.8%-18.3%). The risk was highest in the period between diagnosis of HIT and the start of lepirudin therapy (combined event rate per patient day 6.1%). It markedly decreased to 1.3% during lepirudin treatment and to 0.7% in the posttreatment period. From the start of lepirudin therapy to the end of follow-up, lepirudin-treated patients had consistently lower incidences of the combined endpoint than the historical control group (P = .004, log-rank test), primarily because of a reduced risk for new TEC (P = .005). Thrombin–antithrombin levels in the pretreatment period (median, 43.9 μg/L) decreased after the initiation of lepirudin (at 24 hours ± 6 hours; median, 9.18 μg/L.) During treatment with lepirudin, aPTT ratios of 1.5 to 2.5 produced optimal clinical efficacy with a moderate risk for bleeding, aPTT ratios lower than 1.5 were subtherapeutic, and aPTT levels greater than 2.5 were associated with high bleeding risk. Bleeding events requiring transfusion were significantly more frequent in patients taking lepirudin than in historical control patients (P = .02). In conclusion, this meta-analysis provides further evidence that lepirudin is an effective and acceptably safe treatment for patients with HIT.

Heparin-induced thrombocytopenia with thromboembolic complications: meta-analysis of 2 prospective trials to assess the value of parenteral treatment with lepirudin and its therapeutic aPTT range

This meta-analysis focuses on 2 prospective studies in patients with heparin-induced thrombocytopenia (HIT) and thromboembolic complication (TEC) who were treated with lepirudin (n = 113). Data were compared with those of a historical control group (n = 91). The primary endpoint (combined incidence of death, new TEC, and limb amputation) occurred in 25 lepirudin-treated patients (22.1%; 95% CI, 14.5%-29.8%): 11 died (9.7%; 95% CI, 4.9%-16.8%), 7 underwent limb amputation (6.2%; 95% CI, 2.5%-12.3%), and 12 experienced new TEC (10.6%; 95% CI, 5.8%-18.3%). The risk was highest in the period between diagnosis of HIT and the start of lepirudin therapy (combined event rate per patient day 6.1%). It markedly decreased to 1.3% during lepirudin treatment and to 0.7% in the posttreatment period. From the start of lepirudin therapy to the end of follow-up, lepirudin-treated patients had consistently lower incidences of the combined endpoint than the historical control group (P = .004, log-rank test), primarily because of a reduced risk for new TEC (P = .005). Thrombin–antithrombin levels in the pretreatment period (median, 43.9 μg/L) decreased after the initiation of lepirudin (at 24 hours ± 6 hours; median, 9.18 μg/L.) During treatment with lepirudin, aPTT ratios of 1.5 to 2.5 produced optimal clinical efficacy with a moderate risk for bleeding, aPTT ratios lower than 1.5 were subtherapeutic, and aPTT levels greater than 2.5 were associated with high bleeding risk. Bleeding events requiring transfusion were significantly more frequent in patients taking lepirudin than in historical control patients (P = .02). In conclusion, this meta-analysis provides further evidence that lepirudin is an effective and acceptably safe treatment for patients with HIT.

Limb amputation on renal replacement therapy.

Ten (10) diabetic and 7 non-diabetic patients on renal replacement therapy have undergone limb amputation in the authors' unit in the 1988 to 1996 period. The article examines the course of illness and survival patterns in this distinct and increasing sub-set in the amputee population. Rehabilitation and survival were significantly better in the diabetic group and it is recommended that it would be helpful for both prognosis and analysis if the sub-set of amputees on treatment for chronic renal failure is further divided into diabetic and non-diabetic sub-sets.

Hyperbaric oxygen therapy in the pediatric patient: the experience of the Israel Naval Medical Institute.

The pediatric patient is to be found in hyperbaric facilities throughout the world, receiving hyperbaric oxygen (HBO) therapy for both life-threatening and chronic diseases. To review the experience accumulated at the Israel Naval Medical Institute in the treatment of pediatric patients. A retrospective analysis and review of all records of patients younger than age 18 years. Between 1980 and 1997, 139 pediatric patients age 2 months to 18 years (mean, 7.7 years) received HBO treatment at the Israel Naval Medical Institute. Of the children, 111 (79%) suffered from acute carbon monoxide (CO) poisoning; 13 (9.2%) were treated after crush injury, traumatic ischemia, or compartment syndrome; 4 (2.8%) had clostridial myonecrosis; 1 (0.7%) had necrotizing fasciitis; 5 (3.6%) had refractory osteomyelitis; 2 (1.4%) had suffered massive air embolism; 2 (1.4%) had purpura fulminans; and 1 (0.7%) suffered from decompression sickness. Outcome, judged by neurologic sequelae, mortality, and extent of soft tissue loss and limb amputation, was favorable in 129 patients (93%). Two patients (1.4%) died, 1 as a result of CO poisoning and the other, gas gangrene; 2 of the patients in the CO group (1.4%) remained with neurologic sequelae, and 6 patients in the acute traumatic ischemia group (4.3%) underwent limb amputation. We had a favorable experience with 129 of a total 139 pediatric patients treated at our facility for the indications listed. A basic knowledge of HBO therapy is needed to refer the pediatric patient for treatment when indicated. The needs of the pediatric patient, especially the critically ill, require specific skills and equipment inside the hyperbaric chamber. Close collaboration between the pediatrician and the hyperbaric medicine physician is essential to ensure adequate care for infants and children.

The prevalence of phantom sensation and pain in pediatric amputees

Phantom sensations and pain occur with an unknown frequency in children. We hypothesized that such experiences are common among children, and occur more often than is recognized by health-care personnel. Children and adolescents, ages 5–19 years, who had undergone limb amputation in the past 10 years, served as subjects for this retrospective study. Subjects were divided into three major groups depending upon the indication for amputation: congenital deformity (CD), trauma/infection (TI), and cancer (Ca). Surveys assessing phantom sensations and phantom pain were mailed to children and their parents/guardians. The incidence of phantom sensations was 100% in each group, and phantom pain occurred in the overwhelming majority. Both types of phantom phenomena began within days of surgery for almost all patients. Seventy-five percent of children and adolescents who had experienced phantom pain also had preoperative limb pain. At the time of the study, phantom pain had resolved in only 35% of the subjects. Phantom pain was documented in the medical records of only 40% of those answering positively to questions regarding phantom pain on the questionnaire. We conclude that phantom pain occurs commonly in children and adolescents. The association of preoperative pain in the diseased extremity and the later occurrence of phantom pain suggests that preoperative regional anesthesia may prevent phantom pain.