Analysis of patient outcome and owner satisfaction with double limb amputations: 14 dogs and four cats.

OBJECTIVE: To evaluate the indications for, complications of, and surgical outcomes of dogs and cats that were treated with double limb amputations. ANIMALS: 14 dogs and 4 cats that underwent double limb amputations. PROCEDURES: Data collected retrospectively included patient-specific (species, age, weight, breed, sex, existing comorbidities) and amputation-specific (indication for amputation, full or partial limb amputation, associated complications, need for revision surgeries) variables. Owner satisfaction scores were also collected. RESULTS: The most common indication for double amputations was trauma (12/18) patients. Eleven patients had both amputations performed simultaneously. Nine patients had double partial limb amputations versus full limb amputations. Twelve patients underwent bilateral pelvic limb amputations, 4 underwent bilateral thoracic limb amputations, and 2 had 1 pelvic and 1 contralateral thoracic limb amputated. Five patients had reported complications over the course of the follow-up period, and complications for 3 patients were considered major. Revision surgery was reported for 2 animals. Owner satisfaction scores were reported as very satisfied/excellent (14/18), mildly satisfied (3/18), and strongly dissatisfied (1/18). Median time to follow-up was 450 days (range, 85 to 4,380 days). CLINICAL RELEVANCE: Double limb amputation may be a viable alternative to advanced limb-sparing procedures or humane euthanasia based on the owner satisfaction data and the relatively low rate of major complications in this study. Future studies should clarify patient selection criteria and differences in function between surgical types.

Comparison of self-reported physical activity levels and quality of life between individuals with dysvascular and non-dysvascular below-knee amputation: A cross-sectional study.

BACKGROUND: Decreased physical ability of individuals with a dysvascular amputation when compared with non-dysvascular counterpart may impact on their ability to participate in regular physical activity and concomitant quality of life. OBJECTIVE: To compare physical activity, quality of life (QoL), and perceptions towards exercise between individuals with dysvascular and individuals with non-dysvascular amputation. METHODS: A random sample of individuals identified from the New Zealand Artificial Limb Service database, aged 18 years and over, with a unilateral below-knee amputation due to a dysvascular condition (n = 61) and trauma (n = 116) completed the self-reported survey. Main constructs measured were: self-reported physical activity levels (MET-hours/day); quality of life (EuroQoL); perceptions towards exercise (Exercise Barriers and Benefits Scale [EBBS]); mobility capability (Locomotor Capability Index [LCI]) and a customized screening questionnaire. RESULTS: Significant differences (p ≤ 0.05) were observed between dysvascular and non-dysvascular groups for total MET-hours/day [13.2 ±â€¯12.7; 27.0 ±â€¯23.2], LCI [36.3 ±â€¯17.7; 49.9 ±â€¯13.7], EuroQoL [72.1 ±â€¯21.7; 80.9 ±â€¯19.3] and EBBS [78.5 ±â€¯10.3; 85.0 ±â€¯14.3]. Cause of amputation, age, experience with the prosthesis, presence of co-morbidities and LCI were significant (p ≤ 0.008) correlates (simple linear regression) of MET-hours/day. Age was the only significant correlate in multivariable model with 0.43 MET-hours/day [F (5,161) = 9.28; p < 0.001], for each 1-year increase in age. CONCLUSION: Physical activity levels and quality of life of individuals with dysvascular amputation were lower when compared with non-dysvascular amputation. Person-centred behavioural interventions to increase physical activity levels are needed to decrease the risk for developing long-term co-morbidities and to lessen the effects of co-morbidities already present in this population.

Living with limb loss: everyday experiences of "good" and "bad" days in people with lower limb amputation.

Purpose: To provide an understanding of the everyday experiences of individuals with a limb amputation. Methods: Twenty-two participants (14 female, 8 male) with a mean-age of 42 years (SD = 10 years) were recruited to take part in two focus groups. The participants reported a range of lower-limb amputations (i.e., congenital, acquired, transfemoral, trantibial, unilateral, and bilateral) and on an average were 5 years post-surgery (SD = 7 years). Each focus group comprised of 11 participants and was moderated by either the first or second author. The moderator asked participants to discuss their everyday experiences of life with an amputation using Charmaz's good day/bad day approach. Focus groups were transcribed verbatim and analyzed using an inductive thematic analysis. Results: Four themes were identified: pain, organization and planning, the embodied experience after amputation, and interactions with others. Conclusions: These themes provide a key resource for understanding daily fluctuations in physical, social, and psychological functioning. Implications for Rehabilitation Lower limb amputation can result in daily fluctuations in physical, social, and psychological functioning. These fluctuations can be illustrated through experiences of pain, planning and organization, embodied experiences, and interactions with others. At a policy level, evaluations of daily living after an amputation should be based on a longitudinal assessment.

Athletes With Versus Without Leg Amputations: Different Biomechanics, Similar Running Economy.

Athletes with transtibial amputations use carbon-fiber prostheses to run. Compared with biological legs, these devices differ in structure and function, and consequently yield affected leg running biomechanics that are theoretically more economical than those of nonamputees. However, experimental data indicate that athletes with unilateral and bilateral transtibial amputations exhibit running economy values that are well within the range of nonamputee values.

High Bilateral Amputations and Dismounted Complex Blast Injury (DCBI).

High, combat-related bilateral lower extremity amputations rarely occur in isolation. Dismounted complex blast injury is a devastating and life-threatening constellation of multisystem injuries most commonly due to dismounted contact with improvised explosive devices. Rapid damage control resuscitation and surgery are essential to improve patient survival and minimize both early complications and late sequelae. A coordinated team approach is essential to provide simultaneous airway management, volume resuscitation (ideally with whole blood or ratio transfusion), and immediate control of life-threatening hemorrhage. Temporary aortic or iliac vessel clamping during concurrent exploratory or vascular control laparotomy is frequently required. Stabilization of unstable pelvic fractures is then performed, followed by debridement and irrigation of all wounds, which should be left open, and subsequent provisional stabilization of long bone fractures. The goal of the initial surgical resuscitative endeavor is rapid concurrent control of all sources of hemorrhage to avoid the lethal triad of acidosis, hypothermia and coagulopathy. To this end, multiple surgeons or surgical teams should be utilized whenever feasible. Patients then require ongoing resuscitation followed by early and frequent return to the operating suite throughout the evacuation chain. Utilizing this approach, a high survival rate with reasonable functional outcomes is achievable despite the extreme severity of the DCBI pattern.

Predict the Medicare Functional Classification Level (K-level) using the Amputee Mobility Predictor in people with unilateral transfemoral and transtibial amputation: A pilot study.

BACKGROUND: While Amputee Mobility Predictor scores differ between Medicare Functional Classification Levels (K-level), this does not demonstrate that the Amputee Mobility Predictor can accurately predict K-level. OBJECTIVES: To determine how accurately K-level could be predicted using the Amputee Mobility Predictor in combination with patient characteristics for persons with transtibial and transfemoral amputation. STUDY DESIGN: Prediction. METHOD: A cumulative odds ordinal logistic regression was built to determine the effect that the Amputee Mobility Predictor, in combination with patient characteristics, had on the odds of being assigned to a particular K-level in 198 people with transtibial or transfemoral amputation. RESULTS: For people assigned to the K2 or K3 level by their clinician, the Amputee Mobility Predictor predicted the clinician-assigned K-level more than 80% of the time. For people assigned to the K1 or K4 level by their clinician, the prediction of clinician-assigned K-level was less accurate. The odds of being in a higher K-level improved with younger age and transfemoral amputation. CONCLUSION: Ordinal logistic regression can be used to predict the odds of being assigned to a particular K-level using the Amputee Mobility Predictor and patient characteristics. This pilot study highlighted critical method design issues, such as potential predictor variables and sample size requirements for future prospective research. Clinical relevance This pilot study demonstrated that the odds of being assigned a particular K-level could be predicted using the Amputee Mobility Predictor score and patient characteristics. While the model seemed sufficiently accurate to predict clinician assignment to the K2 or K3 level, further work is needed in larger and more representative samples, particularly for people with low (K1) and high (K4) levels of mobility, to be confident in the model's predictive value prior to use in clinical practice.

The use of the International Classification of Functioning, Disability and Health to classify the factors influencing mobility reported by persons with an amputation: An international study.

BACKGROUND: Amputation of lower limb results in limitations in mobility which are amenable to multiple rehabilitation interventions. The challenges faced by the persons with lower limb amputation vary internationally. The International Classification of Functioning, Disability and Health provides a common language to describe the function of persons with lower limb amputation across various countries. OBJECTIVES: This article reports the concepts in mobility important to persons with lower limb amputation across six countries using the International Classification of Functioning, Disability and Health. STUDY DESIGN: Qualitative study using focus groups and individual interviews. METHODS: Focus groups and individual interviews of persons with lower limb amputation were organised across six countries to identify the issues faced by patients with an amputation during and after their amputation, subsequent rehabilitation and on an ongoing basis in their daily life. Meaningful concepts were extracted from the responses and linked to suitable second-level and where applicable third-level International Classification of Functioning, Disability and Health categories. International Classification of Functioning, Disability and Health categorical frequencies were analysed to represent the prevalence and spread of International Classification of Functioning, Disability and Health categories by location. RESULTS: A total of 133 patients were interviewed. A large percentage (93%) of the identified concepts could be matched to International Classification of Functioning, Disability and Health categories for quantitative analysis. CONCLUSION: The important concepts in mobility were similar across different countries. The comprehensiveness of International Classification of Functioning, Disability and Health as a classification system for human function and its universality across the globe is demonstrated by the large proportion of the concepts contained in the interviews from across the study centres that could be matched to International Classification of Functioning, Disability and Health categories. Clinical relevance The activity and participation restrictions faced by a person with lower limb amputation vary internationally and are amenable to multiple rehabilitation interventions. The International Classification of Functioning, Disability and Health may provide a common language to report and quantify the various concepts important to the patient in their rehabilitation journey.

Forequarter amputation: a safe rescue procedure in a curative and palliative setting in high-grade malignoma of the shoulder girdle.

BACKGROUND: Forequarter amputation (FQA) is a surgical treatment of tumors in the upper extremity and shoulder girdle that infiltrate the neurovascular bundles. In both curative and palliative settings, FQA can serve as an effective oncological treatment. METHODS: This study presents the FQA-related data of 30 patients (mean age 50 years) treated between 2000 and 2012. Their medical condition was high-grade bone or soft tissue sarcoma in 26 and high-grade carcinoma in four cases. RESULTS: Mean operation time was 119 min. One major and five minor complications occurred in the postoperative period. Resection margins were wide in 91 % of patients. Local recurrence was observed in four patients after 19 months on average. Patients treated with curative intention had a 5-year survival chance of 39 %. Average survival after palliative amputation was 11 months. CONCLUSIONS: FQA provides an opportunity for adequate oncological margins in large tumors, while offering relief from tumor-induced distress in palliative situations.

Primer simulacro de amputación traumática de miembro superior de necesidad y rescate en un escenario inhóspito. Base Marambio, Antártida Argentina. 9 de diciembre de 2011 / First simulacrum of traumatic upper limb amputation of necessity and rescue a bleak scenario. Bse Marambio, Antarctica Argentina. December 9, 2011

Se efectuó un simulacro de amputación de necesidad y rescate en dependencias de la Base Marambio (Antártida Argentina). La amputación de una extremidad constituye un dilema al cual está sujeto un médico en determinadas situaciones críticas. Además, los intentos infructuosos para salvar una extremidad irrecuperable están asociados a una alta morbilidad y muchas veces son letales para el paciente. Existen innumerables discusiones en relación con los criterios de predicción para conservar un miembro lesionado, por lo que se han propuesto varios índices de valoración para determinar qué extremidad puede ser conservada o cuál amputada. Por ello en el presente trabajo se efectúa una revisión bibliográfica sobre el uso de tablas y/o criterios para la toma de tal decisión. Se efectuó un ejercicio simulado en el cual se consideró la escena (situación de aislamiento geográfico, características inhóspitas y recursos limitados en la Antártida) y el estado de atrapamiento de la víctima, más la irrecuperabilidad de la porción distal del miembro superior, en donde debía priorizarse la vida del paciente, respecto a la pérdida de la extremidad que ya se encontraba mutilada en forma irreversible, con el fin de ser estabilizado y extricado del lugar para ser trasladado a otro espacio para completar con mejores medios su tratamiento definitivo. Dicho ejercicio se realizó como parte de la capacitación continua del personal que se desempeña en las Bases Antárticas, que dadas las características del escenario antártico, hacen necesaria tal preparación para afrontar situaciones de extrema gravedad en un lugar inhóspito y alejado del continente.

We conducted a mock amputation and rescue agencies need the Marambio Base (Antarctica Argentina). The amputation of a limb is a dilemma which is subject to a doctor in certain critical situations. In addition, unsuccessful attempts to save a limb unrecoverable are associated with high morbidity and are often lethal to the patient. There are countIess discussions regarding prediction criteria to retain an injured limb, so that several indices have been proposed assessment to determine what can be preserved limb amputated or what, why in the present study the authors reviewed the literature on use of tables and/or criteria for making such a decision. We conducted a simulation exercise, which was considered the scene (geographical isolation, limited resources and inhospitable features in Antarctica) and the state of entrapment of the victim, plus the irrecoverable from the distal upper limb, where needed to prioritize the patient's life, about the loss of the limb that was already irreversibly mutilated, in order to be stabilized and extricated the place to be moved to a place with better ways to complete definitive treatment. This exercise was conducted as part of the continuous training of personnel working in the Antarctic Bases, that given the characteristics of the Antarctic scenario necessitates such a preparation to deal with situations of extreme gravity in an inhospitable place and away from the continent.

[Intra-operative histochemical detection of vitalized muscular tissue during lower limb amputation for chronic critical ischemia].

Direct results of 747 lower limb amputations for chronic critical lower limb ischemia were analyzed. Early postoperative complications were observed in 45,1% of cases. Among them 45,4% were caused by tissue ischemia. Basing on detection of lactate dehydrogenase activity in muscular tissue method of intra-operative evaluation of tissue ischemia at the level of amputation is proposed. Relationship between this index and frequency of early postoperative complications is proved.

Differences in function and safety between Medicare Functional Classification Level-2 and -3 transfemoral amputees and influence of prosthetic knee joint control.

The functional differences between persons with amputation who are classified as Medicare Functional Classification Level (MFCL)-2 and -3 include the abilities to walk at various cadences and to negotiate environmental barriers outside the home. This study compared the effect of active microprocessor control and passive mechanical control of the prosthetic knee on function and safety in 17 subjects with transfemoral amputation (8 MFCL-2 and 9 MFCL-3). Assessed functional tasks included hill and stair descent, an attentional demand task, and an obstacle course. Self-reported measures included concentration, multitasking ability, and numbers of stumbles and falls. Active knee control was associated with significant improvements (p < 0.05) in hill and stair gait, speed (hills, obstacle course, and attentional demand task), and ability to multitask while walking for both cohorts. MFCL-2 subjects also reported a significant reduction (p < 0.01) in uncontrolled falls. Over the study, 50% of MFCL-2 subjects and 33% of MFCL-3 subjects transitioned to a higher MFCL. Results suggest that active knee control improves function and reduces the frequency of adverse events in a population that is at risk for falls. Use of active knee control may allow persons with amputation to expand their functional domain, transition to a higher MFCL, and access additional prosthetic options.

Four-fold increase in foot ulcers in type 2 diabetic subjects without an increase in major amputations by a multidisciplinary setting.

AIMS: We observed a large increase in type 2 diabetic subjects with foot ulcers in our diabetic outpatient foot clinic and wanted to identify the amputations rate and individuals at risk of amputations by comparing those who had had a regular control in the multidisciplinary foot clinic prior to the amputations and those who had not. METHODS: We examined all clinical records from the orthopaedic surgery department and the diabetic outpatient foot clinic of diabetic patients who underwent amputations for 6 years. RESULTS: Eighty-eight patients with type 2 diabetes underwent 142 amputations; 42 major and 100 minor amputations. There was no increase in the number of major amputations in this period. In the group not followed in the foot clinic prior to amputations we showed a greater major amputations rate (p<0.05), although this group had a shorter duration of diabetes and less retinopathy, nephropathy and AMI/stroke. Everyone in both groups had severe neuropathy and ischemia. CONCLUSION: A multidisciplinary diabetic foot clinic may decrease the risk of major amputations in type 2 diabetic subjects with foot ulcers. Severe neuropathy and ischemia were the most important risk factors.

All-cause mortality after diabetes-related amputation in Barbados: a prospective case-control study.

OBJECTIVE: To determine the mortality rate after diabetes-related lower-extremity amputation (LEA) in an African-descent Caribbean population. RESEARCH DESIGN AND METHODS: We conducted a prospective case-control study. We recruited case subjects (with diabetes and LEA) and age-matched control subjects (with diabetes and no LEA) between 1999 and 2001. We followed these groups for 5 years to assess mortality risk and causes. RESULTS: There were 205 amputations (123 minor and 82 major). The 1-year and 5-year survival rates were 69 and 44% among case subjects and 97 and 82% among control subjects (case-control difference, P < 0.001). The mortality rates (per 1,000 person-years) were 273.9 (95% CI 207.1-362.3) after a major amputation, 113.4 (85.2-150.9) after a minor amputation, and 36.4 (25.6-51.8) among control subjects. Sepsis and cardiac disease were the most common causes of death. CONCLUSIONS: These mortality rates are the highest reported worldwide. Interventions to limit sepsis and complications from cardiac disease offer a huge potential for improving post-LEA survival in this vulnerable group.

[Walking activity in prosthesis-bearing lower-limb amputees]. / Capacité de marche en milieu extra-hospitalier des amputés appareillés.

PURPOSE OF THE STUDY: A large body of literature has been devoted to gait analysis in amputees. Most studies have been conducted in the laboratory setting where numerous variables are analyzed: gait efficiency, energy cost, walking velocity. At the present time however, data are lacking on the real-life use of walking prostheses. Little is known about how long patients wear their prosthesis or how difficult it is for them to walk during different periods of the day. Currently, such information depends on the quality of the interview and the patient-physician relationship. A precise assessment of walking activity in amputees and use of prostheses would be a valuable source of information for therapists and would provide complimentary information to that collected from laboratory gait analysis. The purpose of this study was to study walking activity in home-dwelling prosthesis-bearing lower-limb amputees and to determine variables affecting walking performance. To our knowledge, this is the first published study on this topic. MATERIAL AND METHODS: The series included home-dwelling prosthesis-wearing lower-limb amputees (Syme amputation or more proximal) who were able to get up and go without assistance. A StepWatch3 recorder was implanted on the prosthesis for 15 consecutive days. Variables recorded were number of steps, total walking time, and walking velocity. Variables which might affect walking in prosthesis-wearing amputees were also recorded: body mass index, use of a walking aid, level and reason for amputation, age at amputation and at recording, time between amputation and recording. RESULTS: From June 2004 to May 2005, 43 patients wore the StepWatch3 for the scheduled 15 days during their daily activities. Mean age at amputation was 42 years (range 13-78 years) and at recording 52 years (range 25-85 years). Considered separately, gait parameters showed that all of the patients wore their prosthesis daily and that the best walking performance was significantly observed among below-knee amputees who did not use a walking aid and who underwent amputation for a non-vascular cause. Multivariate analysis revealed that above-knee amputees lost 93 minutes of walking time per day (21% loss), and that amputees who used a walking aid lost 58 minutes per day (13% loss). Daily walking time declined 2.5 minutes per year of age. Body mass index was not correlated with total daily walking time but had a direct significant effect on walking velocity.

Validation of a diabetic foot surgery classification.

The purpose of this project was to evaluate associations of increasing diabetic foot surgery stage with postoperative outcome. This project, designed as a retrospective cohort model, was conducted at three large, urban referral-based diabetic foot clinics. The investigators abstracted medical records from 180 patients with diabetes, 76.1% male, aged 57.8 +/- 11.2 years, falling equally into four classes of a previously reported diabetic foot surgery classification system. These classes included class 1 (elective), class 2 (prophylactic), class 3 (curative) and class 4 (emergency). There was a significant trend towards increasing risk of ulceration/reulceration (chi2(trend) = 17.8, P = 0.0001), peri-postoperative infection (chi2(trend) = 96.9, P = 0.0001), all-level amputation (chi2(trend) = 41.7, P = 0.001) and major amputation (chi2(trend) = 8.6, P = 0.003), with increasing class of foot surgery. The results of this study suggest that a non vascular foot surgery classification system including variables such as the presence or absence of neuropathy, an open wound and acute infection may be predictive of peri- and postoperative complications. This may assist the surgeon in better identifying risk when determining a rationale for and type of surgery in persons with diabetes.

Prevalência de amputação em membros inferiores de causa vascular: análise de prontuários / Prevalence amputation on inferior members from vascular cause: analyses of promptuary

A amputação é o procedimento cirúrgico mais antigo e significa retirada, geralmente, cirúrgica, total ou parcial de um membro. A amputação não deve ser considerada como fim, e sim como o início de uma nova fase, que tem como principal objetivo manter e/ou devolver a dignidade e funcionalidade do paciente. Acredita-se em que, dentre todas as amputações, as de membros inferiores ocorrem em 85 por cento dos casos, sendo suas causas mais comuns: insuficiência vascular periférica como conseqüência de diabetes, aterosclerose, embolias, tromboses arteriais, traumatismos e tumores malignos. Das causas vasculares que levam a amputação, o diabetes corresponde a 80 por cento, e as taxas de mortalidade associada à amputação variam de 6 a 17 por cento. Acredita-se em que o prognóstico é pios em pacientes idosos, pois está associado a uma habilidade física desfavorável e uma maior dependência social. As amputações podem levar a complicações como: hematoma, infecções, necrose, contraturas, neuromas, sensação fantasma e dor fantasma, além das complicações psicológicas. Foi realizado um levantamento de dados dos prontuários dos anos de 2002 e 2003 do Hospital Regional da cidade de Cascavel-PR, e coletados dados referentes à idade do paciente, sexo, motivo vascular da amputação, nível glicêmico e número de amputações sofridas pelo mesmo paciente

The healing of amputation wounds.

This article discusses the anticipated healing of amputation wounds and highlights potential problems and actions in the pre- and post-amputation phases.

Care of the elderly patient with lower extremity amputation.

BACKGROUND: The elderly patient with a lower extremity amputation (LEA) remains relatively common in most family medicine practices. LEA can be categorized into three major types: partial foot, transtibial amputation, and transfemoral amputation. Family physicians have not been well trained to provide care to these patients. METHODS: A literature review was performed using the key words "lower extremity amputation," "aged" and "rehabilitation." RESULTS AND CONCLUSIONS: Appropriate medical, surgical, and rehabilitative care can have a positive effect on the functional outcome for an elderly patient with a lower extremity amputation. The family physician can be instrumental in preparing the patient and family for surgery, providing psychological support, preventing and treating complications, managing comorbid illness, and assisting in rehabilitation. In addition, the family physician is primarily responsible for the daily care needs of these patients.