Comparison of quality of life and functionality in patients with traumatic unilateral below knee amputation and salvage surgery.

The aim of this study was to compare the functionality during daily activities and quality of life of patients with transtibial amputation vs. salvage surgery after severe lower limb trauma. Ten patients with unilateral below knee amputation and nine patients with salvage surgery after severe lower limb trauma were enrolled. Functional Ambulation Scale (FAS), Visual Analogue Scale (VAS), Short Form 36 (SF-36) Energy Expenditure Index (EEI), 6-Minute Walking Test (6MWT) and 10-Meter Walking Test (10MWT) were used for the evaluation of subjects. Patients in the salvage group were also evaluated radiologically with Graves' radiological assessment method and Freiburg ankle scoring system. All patients were classified as grade 5 according to FAS. All SF-36 subgroup values were higher in the amputation group whereas only those of general health and vitality reached statistical significance (p < 0.05). The visual analogue scale (VAS) has been used to assess the efficacy of pain management. Mean VAS scores were found to be statistically higher in the salvage group (p < 0.005). Reoperation rates were one in 10 amputee and six in nine salvage patients. Mean Freiburg ankle scores of the patients in the salvage group were 55.33 +/- 15.51 which was consistent with moderate functionality. According to Graves' radiological assessment; four patients had grade 3 degeneration, four had grade 2 and one had grade 1 degeneration in the ankle joints. Mean EEI values, 6-MWT and 10-MWT results were not significantly different between the groups (p values > 0.05). Although amputation still remains as the last resort both for patients and the physicians, our results demonstrated that reoperation rates, quality of life (general health and vitality) and pain scores were better in amputee patients.

Painful neuroma requiring surgical excision after lower limb amputation caused by landmine explosions.

This article reports an analysis of 75 consecutive lower limb amputees who developed painful neuroma requiring surgical excision after lower limb amputation following landmine explosions. This retrospective study analyses the results of 75 patients who were treated for painful neuroma after lower limb amputation following landmine explosions between the years 2000 and 2006. The average time period from use of prosthesis to start of symptoms suggesting neuroma was 9.6 months. The average time period from start of pain symptoms to neuroma surgery was 7.8 months. All clinically proven neuromas were surgically resected. In the mean follow-up of 2.8 years, all patients were satisfied with the end results and all were free of any pain symptoms. Painful stump with clinical diagnostic findings of neuroma described above may be regarded as neuroma without requiring any further imaging modalities and is an indication for surgery if conservative measures fail.

Does standing protect bone density in patients with chronic spinal cord injury?

BACKGROUND/OBJECTIVE: To compare the t-scores of proximal femur and lumbar spine of patients with spinal cord injury (SCI) with different levels of weight bearing. METHODS: Cross-sectional study comparing 3 groups of patients with SCI: patients with daily standing times of more than 1 hour, patients with daily standing times of less than 1 hour, and nonstanding patients. Seventy-one patients with chronic SCI were recruited. They were assigned to 1 of 3 groups according to their reported daily standing time. The bone density of lumbar and proximal femoral regions was measured with dual-energy x-ray absorptiometry. RESULTS: The 3 groups were similar in terms of demographics and clinical variables. No significant difference was found among the mean t-scores of lumbar and proximal femoral regions of the groups. However, the patients in the group that stood more than 1 hour daily had a slight tendency to have higher t-scores than those in the control group. CONCLUSIONS: There was no significant difference among the 3 groups. However, standing might be partially helpful in protecting the bone density in SCI by opposing the effects of immobilization.

Osteoporosis: A factor on residual limb pain in traumatic trans-tibial amputations.

Residual limb pain is defined as a painful sensation or feeling from the remaining part of the leg. Aggressive bone edge, bone spur formation, neuroma, abscess or bursitis are common causes of residual limb pain. On the other hand, regional osteoporosis on femur and tibia is an inevitable consequence in patients with lower limb amputations. The etiology of bone loss is uncertain but it is likely to be a local phenomenon in lower limb amputees. Altered gait pattern, decreased weight load, disuse atrophy and lack of muscular action at the limb seem to be important causal factors in the development of both local and generalized osteoporosis. The aims of this study are: (i) To determine if there is significant bone mineral density (BMD) difference at proximal tibias and femurs between intact and amputated limbs, (ii) to investigate the factors affecting bone loss in these areas and (iii) to investigate the possible relationship between residual limb pain and local bone loss. The 36 men who participated in this study had amputations due to land-mine injuries. Dual energy X-ray absorptiometry was used to determine BMD of the proximal femur and proximal tibia. The non-amputated limb was used as a control for the amputated side. BMD values on the amputated side were significantly lower than non-amputated side. In addition, BMD values on the amputated limbs with residual limb pain were significantly less than in those without residual limb pain. Insufficient mechanical loading leads to bone loss in patients with trans-tibial amputations. Furthermore, bone loss at tibia may be a cause of residual limb pain. However, this needs to be confirmed with more specific studies in the future.

Sectional neuroanatomy of the middle thoracic spine (t5-t8) and chest.

This is the third in a series of articles on the spine. The first reviewed the anatomy of the neck. The second reviewed the upper thoracic spine and chest (T1-T4). A fourth article is planned for the lower thoracic spine. Procedures in the midthoracic spine include chest tube placement, trigger point injections, chemodenervation with botulinum toxin, video-assisted thoroscopic surgery, and spinal injections. Complications include pneumothorax, hemothorax, diaphragmatic irritation, sympathetic trunk irritation, postthoracotomy pain, and intradural abscesses. This article provides anatomically accurate schematics of innervations of the middle thoracic chest and spine (T5-T8) that can be used to interpret magnetic resonance images of the muscles and nerves. Cross-sectional schematics of the middle thoracic chest and spine were drawn as they appear on imaging projections. The relevant nerves were color coded. The muscles and skin surfaces were labeled and assigned the color of the appropriate nerves. An organized comprehensive map of the motor innervation of the middle thoracic chest and spine allows the physician to increase the accuracy and efficacy of interventional procedures. This could also assist the electromyographer in correlating the clinical and electrophysiologic findings with magnetic resonance images.