Aims.
Aims. The aim of this study was to describe implant and patient-reported outcome in patients with a unilateral transfemoral amputation (TFA) treated with a bone-anchored, transcutaneous prosthesis. Methods. In this cohort study, all patients with a unilateral TFA treated with the Osseointegrated Prostheses for the Rehabilitation of Amputees (OPRA) implant system in Sahlgrenska University Hospital, Gothenburg, Sweden, between January 1999 and December 2017 were included. The cohort comprised 111 patients (78 male (70%)), with a mean age 45 years (17 to 70). The main reason for amputation was trauma in 75 (68%) and tumours in 23 (21%). Patients answered the Questionnaire for Persons with Transfemoral
Aims. The Intraosseous Transcutaneous
Patients with transfemoral amputation (TFA) often
experience problems related to the use of socket-suspended prostheses.
The clinical development of osseointegrated percutaneous prostheses
for patients with a TFA started in 1990, based on the long-term
successful results of osseointegrated dental implants. Between1999 and 2007, 51 patients with 55 TFAs were consecutively
enrolled in a prospective, single-centre non-randomised study and
followed for two years. The indication for amputation was trauma
in 33 patients (65%) and tumour in 12 (24%). A two-stage surgical
procedure was used to introduce a percutaneous implant to which
an external amputation prosthesis was attached. The assessment of
outcome included the use of two self-report questionnaires, the
Questionnaire for Persons with a Transfemoral
Clinical management of open fractures is challenging and frequently requires complex reconstruction procedures. The Gustilo-Anderson classification lacks uniform interpretation, has poor interobserver reliability, and fails to account for injuries to musculotendinous units and bone. The Ganga Hospital Open Injury Severity Score (GHOISS) was designed to address these concerns. The major aim of this review was to ascertain the evidence available on accuracy of the GHOISS in predicting successful limb salvage in patients with mangled limbs. We searched electronic data bases including PubMed, CENTRAL, EMBASE, CINAHL, Scopus, and Web of Science to identify studies that employed the GHOISS risk tool in managing complex limb injuries published from April 2006, when the score was introduced, until April 2021. Primary outcome was the measured sensitivity and specificity of the GHOISS risk tool for predicting amputation at a specified threshold score. Secondary outcomes included length of stay, need for plastic surgery, deep infection rate, time to fracture union, and functional outcome measures. Diagnostic test accuracy meta-analysis was performed using a random effects bivariate binomial model.Aims
Methods
We have reviewed 28 patients with reflex sympathetic dystrophy (RSD) who had 34 amputations in 31 limbs. The amputations had been performed for untenable pain (5), recurrent infection (14) or to improve residual function (15). Only two patients were relieved of pain by amputation, and this could not be predicted. Ten of 14 patients were cured of infection and 9 of 15 patients had improvement of residual function. In 28 of the amputations, RSD recurred in the stump, especially after amputation at a level which was not free from symptoms. Because of recurrence of RSD in the stump or severe hyperpathia only two patients wear a prosthesis. Despite this 24 patients were satisfied with the results.
1. The question whether amputation for lower femoral osteosarcoma should be by disarticulation of the hip or through the upper femur to leave a stump is discussed. 2. Sixty-eight such patients are reviewed. Thirty were treated by disarticulation and thirty-eight by through-femur amputation. 3. There was a 16 per cent incidence of stump recurrence after through-femur amputation, but none after disarticulation. Comparison of survival was not conclusive. 4. Disarticulation of the hip is advised.
1. All traceable Syme amputees attending the Edinburgh limb centre have been seen and reviewed. They number sixty-seven. Forty had amputations twenty-five or more years before. 2. There are seventy-one surviving stumps. One has failed. 3. Records of all the below-knee amputees reveal five further failures of Syme stumps. The causes of failure are discussed. 4. Problems in the Syme stump are rare after the first year. The early difficulties are discussed. 5. We conclude that a patient with Syme's amputation can expect his stump to give a lifetime of service.
1. The conservative school of treatment of fractures of the tibia, which bases part of its criticism of internal fixation on the ultimate risk of amputation, does not often publish its own rates of amputation. 2. Statistics from a hospital that treats one-third of closed fractured tibiae and two-thirds of compound fractures by internal fixation are therefore put up as a basis for criticism. 3. Comparisons are made with the few available statistics in the literature of conservative treatment. 4. Almost all of the causes for secondary amputation are now curable and in recent years the number of limbs being saved is increasing.
1. The indications for amputation of all the toes for severe toe deformity in rheumatoid arthritis, hallux valgus and pes cavus are discussed. 2. The results of forty-seven amputations in twenty-eight patients are analysed: 93 per cent were found to be very satisfied with the operation. 3. The technique of the operation and the subsequent management are described. The importance of retaining full-length shoes fitted with metatarsal insoles and toe blocks to preserve a good gait and balance is emphasised.
The details in technique which are most essential to ensure a perfect Syme's stump are the provision of a broad area of support for the heel flap by transecting the tibia and fibula as low as possible; the maintaining intact of the specialised weight-bearing qualities of the heel flap; and the proper placement of the heel flap under the cut ends of the tibia and fibula. If these aims are achieved a good and useful stump is assured; if they are neglected the stump will be imperfect and may be unsatisfactory and no further operation can restore the qualities of the heel flap which are lacking. It must be recorded, however, that Syme's stumps which are not technically perfect often function so well that there has been no need to consider re-amputation. A loose heel pad can be held beneath the end of the bone by firm lacing of the corset of the prosthesis.If its area of bony support is reasonably large it may serve well, though not perfectly, as an end-bearing stump. Syme's stumps so completely unsatisfactory as to necessitate re-amputation have been those in which the plane of transection of the tibia is so high that the area supporting the heel flap is too small; or the weight-bearing qualities of the heel flap have been damaged; or there is instability of the heel flap which cannot be controlled; or there is impairment of nutrition of the heel flap.
We assessed 46 Syme’s amputees attending our prosthetic clinics in terms of the clinical and radiological condition of their stumps, their level of function and problems with the prosthesis. Twenty-five were compared with a matching group of 25 transtibial amputees in regard to activity, function and prosthetic behaviour. Function was similar in the two groups, but Syme’s amputees had a higher incidence of prosthetic failure. Overall, Syme’s amputees were pleased with their prostheses and their function. Childhood amputations were associated with fewer long-term problems in terms of function and stump problems Syme’s amputation is indicated for congenital foot deformities, fibular hemimelia and severe injury to the foot as long as the heel pad remains viable.
Skin cover after below-knee amputation has been extensively discussed. We describe the flaps which are commonly used and discuss their vascular basis in the context of the current knowledge of the fasciocutaneous system. An understanding of this vascular system will enable surgeons to plan and shape flaps for surgical exposure and coverage.
The aims of the study were to analyze differences in surgical and oncological outcomes, as well as quality of life (QoL) and function in patients with ankle sarcomas undergoing three forms of surgical treatment, minor or major limb salvage surgery (LSS), or amputation. A total of 69 patients with ankle sarcomas, treated between 1981 and 2017 at two tumour centres, were retrospectively reviewed (mean age at surgery: 46.3 years (SD 22.0); 31 females (45%)). Among these 69 patients 25 were analyzed prospectively (mean age at latest follow-up: 61.2 years (SD 20.7); 11 females (44%)), and assessed for mobility using the Prosthetic Limb Users Survey of Mobility (PLUS-M; for amputees only), the Toronto Extremity Salvage Score (TESS), and the University of California, Los Angeles (UCLA) Activity Score. Individual QoL was evaluated in these 25 patients using the five-level EuroQol five-dimension (EQ-5D-5L) and Fragebogen zur Lebenszufriedenheit/Questions on Life Satisfaction (FLZ).Aims
Methods
Upper limb amputations, ranging from transhumeral to partial hand, can be devastating for patients, their families, and society. Modern paradigm shifts have focused on reconstructive options after upper extremity limb loss, rather than considering the amputation an ablative procedure. Surgical advancements such as targeted muscle reinnervation and regenerative peripheral nerve interface, in combination with technological development of modern prosthetics, have expanded options for patients after amputation. In the near future, advances such as osseointegration, implantable myoelectric sensors, and implantable nerve cuffs may become more widely used and may expand the options for prosthetic integration, myoelectric signal detection, and restoration of sensation. This review summarizes the current advancements in surgical techniques and prosthetics for upper limb amputees. Cite this article:
We reviewed 20 patients after forequarter amputation performed for high-grade malignant tumours of the shoulder girdle (Enneking grades IIB to III). The operations were classified as palliative or curative according to the resection margins and the presence of disseminated disease at the time of the surgery. There were five palliative and 15 curative procedures. Two patients died from unrelated causes, septicaemia and suicide. Eight died in the first two years, four of whom had had a palliative operation. Four died between two and five years after surgery, one after a palliative operation. Five patients are alive, at a mean of 89.4 months after surgery, four of whom are free from disease. The median survival after a palliative amputation was 20.6 months. Our overall five-year survival (palliative and curative cases) was 21.2%, for curative cases it was 30.2%. None of the patients use an artificial prosthesis. Despite the disfigurement which results from this operation, it still has a useful role to play in the management of high-grade malignant tumours of the upper limb.
In nine patients of median age 34 years who had sustained an amputation of the thumb at a median 24 (5 to 131) months previously, we lengthened the first metacarpal by 30 (17 to 36) mm. Seven amputations had been through the proximal phalanx and two through the metacarpal. The first two patients had autogenous grafting at a second stage, but the other seven had callotasis alone. In these patients the external fixators were removed at a median 189 (115 to 271) days after osteotomy. In six cases the adductor pollicis tendon was transferred proximally and the first web deepened. There was late fracture or palmar flexion of the callus in five patients, but this required further surgery in only one. Treatment was complete at 326 (140 to 489) days after osteotomy. The extended thumb retained its sensitivity; both grasp and key-pinch strength were satisfactory and only one patient felt that the result did not warrant the long course of treatment. Metacarpal lengthening by this method is a prolonged procedure, but provides a valuable alternative to more complex reconstructions.
1. A sagittal technique for below-knee amputation for ischaemic gangrene based on mediolateral musculo-cutaneous flaps is described, similar to the one independently presented by Tracy (1966). 2. The results with this method are illustrated by the evolution of the below-knee healing rate over six years in 172 patients with ischaemic gangrene. 3. A comparison between sagittal and conventional flap techniques shows a reamputation rate of six out of fifty-eight in the former and sixteen out of forty-one in the latter. 4. The overall relative knee joint preservation during 1971 was 82 per cent, and the frequency of attempted below-knee amputation was 93 per cent. 5. It is concluded that the sagittal technique has several advantages in comparison to the posterior flap technique, and that the potential for healing is on the same high level. 6. A fully controlled comparison between different techniques is proposed.
1. A case of congenital bowing of the tibia is described in which pseudarthrosis developed and recurred after nine operations performed by the age of ten years. 2. Union was finally secured by a procedure based on deep impaction of the trimmed upper fragment into the reamed-out lower fragment. This was followed by a Boyd type of partial amputation of the foot with calcaneo-tibial arthrodesis. 3. The end-bearing stump four years later is entirely satisfactory and the simple prosthesis gives equality of leg lengths.
1. An attempt has been made to rationalise the selection of the site of amputation for gangrene in primary peripheral vascular disease. 2. There is a good chance of the survival of a below-knee stump if the circulation in the skin of the proposed flaps appears adequate clinically, and if the blood supply to the muscles is obviously good at amputation. 3. If the popliteal pulse is present before operation, below-knee amputation should succeed. The absence of a popliteal pulse, however, does not exclude below-knee amputation. 4. Below-knee stumps should be about four inches long in amputations for peripheral vascular disease. 5. Tests for determining the state of the circulation are also necessary before choosing the level for above-knee amputations.
A patient with Paget's sarcoma of the femur, alive and well seven years after amputation, is reported. Long survival in two previously reported cases is also mentioned.
Osseointegrated prosthetic limbs allow better mobility than socket-mounted prosthetics for lower limb amputees. Fractures, however, can occur in the residual limb, but they have rarely been reported. Approximately 2% to 3% of amputees with socket-mounted prostheses may fracture within five years. This is the first study which directly addresses the risks and management of periprosthetic osseointegration fractures in amputees. A retrospective review identified 518 osseointegration procedures which were undertaken in 458 patients between 2010 and 2018 for whom complete medical records were available. Potential risk factors including time since amputation, age at osseointegration, bone density, weight, uni/bilateral implantation and sex were evaluated with multiple logistic regression. The mechanism of injury, technique and implant that was used for fixation of the fracture, pre-osseointegration and post fracture mobility (assessed using the K-level) and the time that the prosthesis was worn for in hours/day were also assessed.Aims
Methods
This is a case series of prospectively gathered
data characterising the injuries, surgical treatment and outcomes
of consecutive British service personnel who underwent a unilateral
lower limb amputation following combat injury. Patients with primary,
unilateral loss of the lower limb sustained between March 2004 and
March 2010 were identified from the United Kingdom Military Trauma
Registry. Patients were asked to complete a Short-Form (SF)-36 questionnaire.
A total of 48 patients were identified: 21 had a trans-tibial amputation,
nine had a knee disarticulation and 18 had an amputation at the
trans-femoral level. The median New Injury Severity Score was 24 (mean
27.4 (9 to 75)) and the median number of procedures per residual
limb was 4 (mean 5 (2 to 11)). Minimum two-year SF-36 scores were
completed by 39 patients (81%) at a mean follow-up of 40 months
(25 to 75). The physical component of the SF-36 varied significantly
between different levels of amputation (p = 0.01). Mental component
scores did not vary between amputation levels (p = 0.114). Pain
(p = 0.332), use of prosthesis (p = 0.503), rate of re-admission
(p = 0.228) and mobility (p = 0.087) did not vary between amputation
levels. These findings illustrate the significant impact of these injuries
and the considerable surgical burden associated with their treatment.
Quality of life is improved with a longer residual limb, and these
results support surgical attempts to maximise residual limb length. Cite this article:
Currently, there is no animal model in which
to evaluate the underlying physiological processes leading to the heterotopic
ossification (HO) which forms in most combat-related and blast wounds.
We sought to reproduce the ossification that forms under these circumstances
in a rat by emulating patterns of injury seen in patients with severe
injuries resulting from blasts. We investigated whether exposure
to blast overpressure increased the prevalence of HO after transfemoral
amputation performed within the zone of injury. We exposed rats
to a blast overpressure alone (BOP-CTL), crush injury and femoral
fracture followed by amputation through the zone of injury (AMP-CTL)
or a combination of these (BOP-AMP). The presence of HO was evaluated
using radiographs, micro-CT and histology. HO developed in none
of nine BOP-CTL, six of nine AMP-CTL, and in all 20 BOP-AMP rats.
Exposure to blast overpressure increased the prevalence of HO. This model may thus be used to elucidate cellular and molecular
pathways of HO, the effect of varying intensities of blast overpressure,
and to evaluate new means of prophylaxis and treatment of heterotopic
ossification. Cite this article:
Limited forefoot amputation in diabetic patients
with osteomyelitis is frequently required. We retrospectively reviewed
diabetic patients with osteomyelitis, an unhealed ulcer and blood
pressure in the toe of >
45 mmHg who underwent limited amputation
of the foot with primary wound closure. Between 2006 and 2012, 74
consecutive patients with a mean age of 67 years (29 to 93), and
a median follow-up of 31 months, were included. All the wounds healed
primarily at a median of 37 days (13 to 210; mean 48). At a median
of 6 months (1.5 to 18; mean 353 days), 23 patients (31%) suffered
a further ulceration. Of these, 12 patients (16% of the total) required
a further amputation. We conclude that primary wound closure following limited amputation
of the foot in patients with diabetes is a safe and effective technique
when associated with appropriate antibiotic treatment. Cite this article:
Opinion remains divided as to whether the development
of pathological fracture affects the prognosis of patients with
an osteosarcoma of the extremities. We conducted a comprehensive systematic review and meta-analysis
of papers which reported the outcomes of osteosarcoma patients with
and without a pathological fracture. There were eight eligible papers
for final analysis which reported on 1713 patients, of whom 303
(17.7%) had a pathological fracture. The mean age for 1464 patients in
six studies was 23.2 years old (2 to 82). The mean follow-up for
1481 patients in seven studies was 90.1 months (6 to 240). The pooled estimates of local recurrence rates in osteosarcoma
patients with and without pathological fractures were 14.4% (8.7
to 20.0) The development of a pathological fracture is a negative prognostic
indicator in osteosarcoma and is associated with a reduced five-year
event-free survival and a possibly higher rate of local recurrence.
Our findings suggest that there is no absolute indication for amputation,
as similar rates of local recurrence can be achieved in patients
who are carefully selected for limb salvage. Cite this article:
A total of 157 hindquarter amputations were carried
out in our institution during the last 30 years. We have investigated
the reasons why this procedure is still required and the outcome.
This operation was used as treatment for 13% of all pelvic bone
sarcomas. It was curative in 140 and palliative in 17, usually to
relieve pain. There were 90 primary procedures (57%) with the remaining
67 following the failure of previous operations to control the disease
locally. The indication for amputation in primary disease was for
large tumours for which limb-salvage surgery was no longer feasible.
The peri-operative mortality was 1.3% (n = 2) and major complications
of wound healing or infection arose in 71 (45%) patients. The survival
at five years after hindquarter amputation with the intent to cure
was 45%, and at ten years 38%. Local recurrence occurred in 23 patients
(15%). Phantom pain was a significant problem, and only 20% used
their prosthesis regularly. Functional scores were a mean of 57%.
With careful patient selection the oncological results and functional outcomes
of hindquarter amputation justify its continued use. Cite this article:
Aims. Current literature suggests that survival outcomes and local recurrence rates of primary soft-tissue sarcoma diagnosed in the very elderly age range, (over 90 years), are comparable with those in patients diagnosed under the age of 75 years. Our aim is to quantify these outcomes with a view to rationalizing management and follow-up for very elderly patients. Methods. Retrospective access to our prospectively maintained oncology database yielded a cohort of 48 patients across 23 years with a median follow-up of 12 months (0 to 78) and mean age at diagnosis of 92 years (90 to 99). Overall, 42 of 48 of 48 patients (87.5%) were managed surgically with either limb salvage or amputation. Results. A lower overall local recurrence rate (LRR) was seen with primary amputations compared with limb salvage (p > 0.050). The LRR was comparable between free (R0), microscopically (R1), and macroscopically positive (R2) resection margins in the limb salvage group.
Aims. This study describes the Osseointegration Group of Australia’s
Accelerated Protocol two-stage strategy (OGAAP-1) for the osseointegrated
reconstruction of amputated limbs. Patients and Methods. We report clinical outcomes in 50 unilateral trans-femoral amputees
with a mean age of 49.4 years (24 to 73), with a minimum one-year
follow-up. Outcome measures included the Questionnaire for persons
with a Trans-Femoral
Aims. The treatment of tibial aplasia is controversial.
Aims. The aim of this study was to determine the risk of local recurrence and survival in patients with osteosarcoma based on the proximity of the tumour to the major vessels. Patients and Methods. A total of 226 patients with high-grade non-metastatic osteosarcoma in the limbs were investigated. Median age at diagnosis was 15 years (4 to 67) with the ratio of male to female patients being 1.5:1. The most common site of the tumour was the femur (n = 103) followed by tibia (n = 66). The vascular proximity was categorized based on the preoperative MRI after neoadjuvant chemotherapy into four types: type 1 > 5 mm; type 2 ≤ 5 mm, > 0 mm; type 3 attached; type 4 surrounded. Results. Limb salvage rate based on the proximity type was 92%, 88%, 51%, and 0% for types 1 to 4, respectively, and the overall survival at five years was 82%, 77%, 57%, and 67%, respectively (p < 0.001). Local recurrence rate in patients with limb-salvage surgery was 7%, 8%, and 22% for the types 1 to 3, respectively (p = 0.041), and local recurrence at the perivascular area was observed in 1% and 4% for type 2 and 3, respectively. The mean microscopic margin to the major vessels was 6.9 mm, 3.0 mm, and 1.4 mm for types 1 to 3, respectively. In type 3, local recurrence-free survival with limb salvage was significantly poorer compared with amputation (p = 0.025), while the latter offered no overall survival benefit. In this group of patients, factors such as good response to chemotherapy or limited vascular attachment to less than half circumference or longitudinal 10 mm reduced the risk of local recurrence. Conclusion. The proximity of osteosarcoma to major blood vessels is a poor prognostic factor for local control and survival.
We reviewed our initial seven-year experience
with a non-invasive extendible prosthesis in 34 children with primary bone
tumours. The distal femur was replaced in 25 cases, total femur
in five, proximal femur in one and proximal tibia in three. The
mean follow-up was 44 months (15 to 86) and 27 patients (79%) remain
alive. The prostheses were lengthened by an electromagnetic induction
mechanism in an outpatient setting and a mean extension of 32 mm
(4 to 80) was achieved without anaesthesia. There were lengthening
complications in two children: failed lengthening in one and the
formation of scar tissue in the other. Deep infection developed
in six patients (18%) and local recurrence in three. A total of
11 patients required further surgery to the leg.
Most patients with advanced malignancy suffer bone metastases, which pose a significant challenge to orthopaedic services and burden to the health economy. This study aimed to assess adherence to the British Orthopaedic Oncology Society (BOOS)/British Orthopaedic Association (BOA) guidelines on patients with metastatic bone disease (MBD) in the UK. A prospective, multicentre, national collaborative audit was designed and delivered by a trainee-led collaborative group. Data were collected over three months (1 April 2021 to 30 June 2021) for all patients presenting with MBD. A data collection tool allowed investigators at each hospital to compare practice against guidelines. Data were collated and analyzed centrally to quantify compliance from 84 hospitals in the UK for a total of 1,137 patients who were eligible for inclusion.Aims
Methods
1. We have described what happens to patients a number of years after injury of the sciatic nerve or of its divisions; there were 329 who had been under observation for periods ranging from three to eighteen years. The neurological recovery was recorded in every case and, more important, the behaviour of the limb as appreciated by the patient. 2. Although it was generally true that good neurological recovery and good function went together there were remarkable discrepancies. Isolated paralysis of the medial popliteal or of the lateral popliteal nerve was often compatible with good function, though patients with lateral popliteal paralysis usually needed toe-raising apparatus. Even total sciatic paralysis sometimes gave little trouble. 3. Of the various types of injury, clean wounds and traction lesions led to rather better than average return of function. 4. Some degree of pain was present in about half the cases, and over-response–exaggerated and painful response to an ordinary stimulus–was present in one-third of the cases. 5. Repair of the posterior tibial nerve was rarely worth while; no less than eight out of twelve patients with this type of injury exhibited over-response. 6. One-third of the patients showed vasomotor and trophic disorders: coldness of the affected limb, erythema, thinness or pigmentation of the skin, changes in the nails or oedema. 7. Pressure sores were the most serious consequence of sciatic nerve injury and at some time or other were present in 14 per cent of our patients. The cause was deformity rather than insensibility of the sole. 8. Of the various palliative operations Lambrinudi's tarsal arthrodesis gave such disappointing results that we doubt whether the operation is worth doing. Tenodesis, revived as a time-saving expedient during the war, was a failure. For lateral popliteal paralysis anterior transplantation of tibialis posterior is excellent. 9.
Periprosthetic joint infection represents a devastating complication after total elbow arthroplasty. Several measures can be implemented before, during, and after surgery to decrease infection rates, which exceed 5%. Debridement with antibiotics and implant retention has been reported to be successful in less than one-third of acute infections, but still plays a role. For elbows with well-fixed implants, staged retention seems to be equally successful as the more commonly performed two-stage reimplantation, both with a success rate of 70% to 80%. Permanent resection or even amputation are occasionally considered. Not uncommonly, a second-stage reimplantation requires complex reconstruction of the skeleton with allografts, and the extensor mechanism may also be deficient. Further developments are needed to improve our management of infection after elbow arthroplasty. Cite this article: