Increased cardiovascular disease mortality rates in traumatic lower limb amputees.

We evaluated the 24-year mortality rates of male traumatic lower limb amputees (n = 201) of the Israeli army, wounded between 1948 and 1974 compared with a cohort sample representing the general population (n = 1,832). Mortality rates were significantly higher (21.9% vs 12.1%, p <0.001) in amputees than in controls. Cardiovascular disease (CVD) mortality was the main cause for this difference. The prevalence of selected risk factors for CVD was determined in 101 surviving amputees (aged 50 to 65 years) and a sample of the controls (n = 96) matched by age and ethnic origin. Amputees had higher plasma insulin levels (during fasting and in response to oral glucose loading) and increased blood coagulation activity. No differences were found in rates of current symptoms of ischemic heart disease or of cerebrovascular disease, obesity, hypertension, altered plasma lipoprotein profile, impaired physical activity, smoking, or nutritional habits. Traumatic lower limb amputees had increased mortality rates due to CVD. Surviving amputees had hyperinsulinemia, increased coagulability, and increased sympathetic and parasympathetic responses (described previously). These established CVD risk factors may explain the excess mortality due to CVD in traumatic amputees.

Silicone suspension of external prostheses. A new era in artificial limb usage.

The use of silicone inner sockets, with or without the incorporation of shuttle locks, has greatly improved the function of artificial limbs. They cushion and protect the stump and provide a means for prosthetic suspension, allowing more comfortable use, especially in patients with ischaemic stumps. They also allow greater movement at the proximal joint.

The design of two-dimensional gradient estimators based on one-dimensional operators.

Two-dimensional (2-D) gradient estimators are some of the most useful tools in image processing. A computational procedure for the extension of one-dimensional (1-D) gradient estimators to two dimensions (2-D) is presented. The procedure is equivalent to the surface fitting method. It is, however, simpler in design, as the design is 1-D rather than 2-D. Higher order derivative estimators can also be constructed by the same procedure.

The changing needs of patients after primary rehabilitation: an overlooked entity.

PURPOSE: The need for rehabilitation should not be viewed as a single event that may occur during a lifetime. This theme is explored. METHOD: A case of a man who lost the distal portions of all four limbs, is reported. RESULTS: He was rehabilitated and spent many years as an active member of the community. The physical changes, owing to advancing age, were overlooked. CONCLUSIONS: Attention is drawn to the fact that long term re-evaluation of function is periodically required.

Why did the patient choose an inappropriate orthosis?

PURPOSE/METHOD: A 70-year-old engineer, suffering from drop foot, designed and produced a strange orthosis. Although on ambulation the orthotic device elevated his foot, an abnormally strange walking pattern was required. Of his own volition the patient attended an orthotic clinic requesting that a local manufacturer produce a replica of the orthosis. The patient received an explanation pertaining to the range of regular orthotics available and in what way they would improve his functional ability. RESULTS/CONCLUSION: The patient saw all the options available and physically tried several. The patient was afforded the opportunity of free choice and chose his own, self-designed orthotic. From a professional point of view this was the most inappropriate option. The rehabilitation team erred in its psychological management of the case, for it overlooked the question of the patient's motivation and commitment to change.

The will to walk--a partnership involving dual dynamics.

A case report is used as an example of how the will of a patient convinced an entire rehabilitation team to alter its assessment of the patient's ambulatory potential. The question of dual dynamics is discussed in the light of the realities of the honest desire and motivation to walk and regain independence.

Why should a deformed, anaesthetic, functionless hand be wanted?

A 58-year-old woman presented at a disability assessment tribunal with a severely deformed left forearm. She had broken the arm 25 years previously and the infected open fracture had not healed. There were no sensory or motor functions in the hand, which the patient kept constantly hidden in her garments. The question of an amputation was raised and the advantages of modern prosthetics with respect to cosmesis and function failed to convince the patient that she might benefit from such surgery. One questions why a patient should want to retain this cumbersome, obviously embarrassing, burden and whether the question of surgery should have been raised.

Successful fitting of a prosthesis for a child amputee suffering from scleroderma.

A few anecdotal cases of limb amputations owing to scleroderma have been described in the literature. This article outlines the salient problematic features of a residual stump and provides the prosthetic considerations and appropriate design that eventually facilitated ambulation.

Rehabilitation considerations of prosthetic fittings for Kaposi's sarcoma amputees.

PURPOSE: We report on cutaneous limb manifestations of Kaposi's sarcoma and the secondary infection of these lesions that necessitated five lower-limb amputations. METHOD: The cases are briefly described and prosthetic adaptations in respect to pressure, traction and sweating on the skin are considered. RESULTS: All four patients ambulated initially; one lady died, the double amputee stopped walking owing to the excessive physical demand, and two patients ambulate freely. CONCLUSION: Special considerations to the cutaneous/prosthesis interface are necessary in order to provide these patients with optimal ambulatory ability.

Utility of 24 hour bone scan in evaluation of bone involvement by soft tissue sarcoma.

Accumulation of Tc-99m MDP in soft tissue malignancies occurs frequently. When tumor overlaps adjacent bone structures, the bone margins can be indiscernible on a regular bone scan. Additional views should be taken to differentiate bone from tumor, however, separation is sometimes difficult and not always successful. This report presents a patient in whom accumulation of Tc-99m MDP in a liposarcoma of the thigh disappeared on a 24 hour scan and bone margins were seen clearly. A possible mechanism for this phenomenon and its utility are discussed.

Criteria for prosthetic provision: "he who pays the piper calls the tune".

Previously instituted policies regarding prosthetic limb provision had been deemed dependable. A follow-up home visit study showed that 18 of 60 patients that had been provided with prostheses, did not make use of them. Analysis showed that three categories of patients made up the large majority of the non-users; double amputees, blind persons and those with psychiatric disorders. In order to attempt to eliminate the wastage of prosthetic provision to non-ambulators a new policy decision was made. Doubtful ambulators and those from the three aforementioned categories will be initially provided with temporary prostheses. Only after a period of months of temporary prosthetic usage at home will a decision be made as to whether a permanent prosthesis will be issued.

[Two stage Syme amputation].

In 1843 James Syme described the amputation which bears his name. It is done in two stages and can be accomplished in the presence of wounds and infections or gangrene of the feet. The operation is of great value especially in the elderly. Patients with a Syme stump can be fitted with a strong, light, plastic prosthesis, they develop an excellent gait and the entire body weight can be borne without pain. The advantages of the Syme amputation are that the knee joint is retained and the long lever allows an almost normal gait with an energy cost only 10% above normal. The stump has a large interface for proprioceptive feed-back and the prosthesis is easy to put on.

Paraplegia following surgical correction of scoliosis with Cotrel-Dubousset instrumentation.

Three patients with paraplegia following corrective surgery for idiopathic scoliosis, using the Cotrel-Dubousset (CD) instrumentation, were admitted to our department over a period of 22 months. They were operated on by three different surgeons and they were the first serious neurological complications in these surgeons' careers. The monitoring method was the "wake-up" test, applied at the end of the correction maneuver with the instrument. One patient presented paraplegia at the "wake-up" test and the other two were paraplegic shortly after ceasing anesthesia. Electrophysiological spinal cord monitoring during surgery may reduce the risks of complications.