Knee disarticulation vs. transfemoral amputation after failed transtibial amputation: Surgical outcome and prosthetic fitting in patients with peripheral vascular disease.

OBJECTIVE: Our aim was to compare transfemoral amputation (TFA) to knee disarticulation (KD) as a reamputation level after failed transtibial amputation (TTA) in patients with peripheral vascular disease and/or diabetes. METHODS: We studied 152 patients undergoing reamputation, 86 TFA and 66 KD, after a failed TTA. The primary outcome was reamputation and reoperation, and secondary outcomes were prosthetic fitting and mortality. Logistic regression analyses were performed to identify factors associated with the outcome. RESULTS: The reamputation rate was 36% after KD and 15% after TFA ( p = 0.004). The multivariable analysis showed that TFA was associated with a significantly reduced risk of reamputation, odds ratio (OR) = 0.31 (95% confidence interval [95% CI], 0.1-0.7). The overall reoperation rate was 38% after KD and 22% after TFA ( p = 0.03). This reduction of risk for TFA was not significant in the multivariable analysis, OR = 0.49 (95% CI, 0.2-1.0). Prosthetic limb fitting was possible in 30% after KD and 19% after TFA ( p = 0.1). Previous amputation in the contralateral leg was the only factor associated with reduced ability for prosthetic fitting in the multivariable analysis, OR = 0.15 (95% CI, 0.03-0.7). Mortality at 30 d was 17% and 53% at 1 year. No independent factors affected 30-d mortality in the multivariable analysis. CONCLUSIONS: In this study, we found a significantly lower risk of reamputation after TFA compared with KD after a failed TTA. We consider TFA to be the reamputation level of choice, especially when there is a need of reducing risk of further reamputations.

Assessing Resident Impact on Surgical Outcomes in Below-the-Knee Amputations Based on Operative Autonomy.

BACKGROUND: Gradual increases in resident autonomy with attending physician oversight is crucial to developing safe and competent surgeons1. The Veterans Affairs Surgical Quality Improvement Program (VASQIP) follows surgical outcomes within the VA. We set forth to examine the VASQIP database to compare outcomes between resident independent cases and nonindependent cases during below-the-knee amputations (BKA). METHODS: All VASQIP records for BKA from 2000 to 2020 were examined and categorized based on whether the attending was scrubbed during the case. Case matching was performed based on preoperative comorbidities; 30-day postoperative outcomes, including a return to the operating room, wound infection, and mortality, were assessed in addition to operative time, hospital length of stay, and transfusion requirements. Student's t-test and Fisher's Exact Test were utilized. RESULTS: A total of 13,208 BKA VASQIP records were obtained. After case control matching, 2,688 cases remained. Cases were identified with the attending surgeon noted as being scrubbed during the case (n = 1,344), or not scrubbed (n = 1,344). Patients were similar in comorbidities across both groups. No statistically significant difference in operative time (1.52 hr ± 0.78 vs. 1.47 hr ± 0.75, P = 0.08), 30-day mortality (3.3% vs. 4.8%, P = 0.05), or complication rate (19.5% vs. 21.3%, P = 0.25). Resident independent cases were noted to have slightly longer postop length of stay (12.47 days ± 12.69 vs. 15.33 days ± 20.56, P < 0.01) and operative bleeding requiring more than 4 units transfused (0.3% vs. 1.3%, P ≤ 0.01). CONCLUSIONS: Resident independent operating during below-the-knee amputation at VA hospitals is associated with an increased length of stay and blood transfusion. There was no statistically significant increase in operative time, 30-day mortality, or total complication rate. Further research is required to assess the risks associated with surgical training, resident supervision, and resident preparedness for independent practice.

Compartment Syndrome and Wrist Disarticulation After a Catfish Sting.

Catfish have the ability to inflict stings on their victims through spines located on their dorsal and pectoral fins. The stings of catfish can release toxins that have dermonecrotic, edemogenic, and vasospastic factors. In this case, a 56-year-old man suffered a catfish sting to his right thumb, which resulted in acute hand compartment syndrome and resultant hand fasciotomies. His hospital course was complicated by multiple irrigation and debridements, finger amputations, hand fluid cultures positive for Vibrio damsela, and eventual wrist disarticulation. The combination of envenomation, infection, and delayed presentation for treatment ultimately led to a hand amputation.

Reviving the debate: Articular cartilage preservation during disarticulation at the lower limb? A systematic review.

BACKGROUND: The need for preservation(P) or removal(R) of articular cartilage during disarticulations remains unanswered. METHODS: Medline database was used to conduct a systematic review regarding all types of minor disarticulations and some types of major disarticulations in patients with diabetes mellitus, peripheral arterial disease or trauma related disarticulations. Fisher-exact statistical test was used to perform calculations for the entire group as for subgroups. RESULTS: A total of 444 disarticulations at the Chopart joint, ankle and knee were included (P = 255 vs. R = 189). There was no difference in wound healing, functionality and mortality. Reamputation rate was lower in the P-group (9.4% vs. 16.9%). Infection rate was not significantly different. Differences in reamputations (R = 10.6% vs. P = 1.0%) and infections (R = 4.4% vs. P = 22.6%) were only present for the ankle subgroup. CONCLUSIONS: There is no difference in wound healing, functionality and mortality between the preservation and removal of articular cartilage in the lower limb.

Extra-articular resection of shoulder joint for bone sarcomas: Oncologic and limb-salvage outcomes of 32 cases compared with shoulder disarticulation and forequarter amputation.

BACKGROUND AND OBJECTIVES: We aimed to identify the overall survival (OS), surgical complications, survival of reconstruction, and functional outcome of patients who underwent extra-articular resection of the shoulder joint for primary bone sarcomas. The OS and local recurrence rates in patients who underwent an amputation were also evaluated for comparison. METHODS: Thirty-two patients treated between 1988 and 2017 were studied. The tumours were located in the humerus in 22 (69%) and scapula in 10 patients (31%). The resection types were Malawer type IV in 6 (19%), type V in 21 (66%), and type VI in 5 patients (15%). Reconstruction was performed with endoprosthesis in 23 patients (72%) while excision arthroplasty with the suspension of the humerus to the clavicle was performed in 9 patients (28%). Surgical margins were wide in 16, marginal in 8, intralesional in 3, and not available in 5 patients. During the study period, 40 patients underwent a forequarter amputation and 11 patients underwent a shoulder disarticulation. RESULTS: The 5-year OS for patients who underwent extra-articular resection of the shoulder joint was 42% which was not statistically different compared with that of patients who underwent amputation (5-year OS = 30%; P = .091). The 5-year survival of the reconstruction was 94%, similar for endoprosthesis and excision arthroplasty. Local recurrence and complications developed in 6 (19%) and 10 patients (31%), respectively. Failures of the reconstruction requiring revision surgery occurred in two patients (6%). Limb salvage was achieved in 30 patients (94%). The median Musculoskeletal Tumour Society functional score was 61% (interquartile range, 57%-70%) and was similar in the endoprosthesis and excision arthroplasty group. CONCLUSIONS: Extra-articular resection of the shoulder joint for bone sarcomas is an effective limb-salvage method. However, local recurrence remains a principal concern.

Disarticulation of the knee: Analysis of an extended database on survival, wound healing, and ambulation.

OBJECTIVE: This study analyzed survival of the amputee patients, wound healing, and ambulation after knee disarticulation (KD). METHODS: Between July 1989 and October 2015, 153 KDs in 138 patients were performed at Nij Smellinghe Hospital, Drachten. Data were retrieved from hospital medical records. Wound healing was analyzed using nonparametric tests. Ambulation was recorded according to the Special Interest Group Amputation Medicine Workgroup Amputation and Prosthetics mobility scale. RESULTS: Survival at 1, 6, and 12 months was 86%, 65%, and 55%, respectively. Wounds healed in 91% of patients. Wounds healed primarily in 57% of residual limbs, and healing was delayed in 33%. A transfemoral amputation (TFA) was performed in 10%. Patients with sagittal flaps had significantly poorer primary wound healing and delayed wound healing more often than patients with a dorsal-myocutaneous (dorsomyocutaneous) flap (P < .027). In total, 62% of patients were provided with a prosthesis. Preoperatively, 71% of the patients had intention to ambulate with prosthesis, of which 91% received prosthesis. Of these, 35% walked without the help of others. KD amputee patients who underwent a reamputation at the transfemoral level were significantly less ambulant than amputee patients who did not (P < .021). CONCLUSIONS: If feasible, the dorsomyocutaneous flap technique seems to be the treatment of choice in KD. Because the wound complication rate of the group with a dorsomyocutaneous flap and the percentage of amputee patients who received prosthesis after KD fell within the same range as TFA amputee patients, KD may be an appropriate alternative when surgeons consider a TFA.

The complications after open hip dislocation in hip surgery.

Our purpose is to evaluate the complications of open hip dislocation, which is used as a helpful technique in hip surgery. We have retrospectively reviewed 45 hips of 44 cases who applied open hip dislocation with various indications in our institute between the years 2006-2013. There were 27 males and 17 females whose mean age was 31,9 (range, 11-58) years with mean follow-up time of 56,9 months (range, 13-106). The number of cases with at least one complication related to open hip dislocation was 27. Within our series 14 hips have developed only 1 complication, 1 hip have 2, 10 hips have 3 and 2 hips have 4 different complications. Regarding Dindo-Clavien classification 17 hips were evaluated as Grade I (38%), 3 hips were Grade IIa (7%), 2 hips were Grade IIb (4%) and 5 hips were Grade III (11%). In conclusion, the absence of major complications after open hip dislocation does not make it absolutely safe. Open hip dislocations can only be indicated when trochanteric complications are considered. The patients need to be well informed on potential issues and risks.

Ultrasound-Guided Cryoablation of a Traumatic Hip Disarticulation Neuroma.

OBJECTIVE: Traumatic amputation at the pelvic level is a rare procedure with few studies addressing long-term complications. Painful neuroma formation may form at the site of nerve transection and cause significant impairments in daily living. Ultrasound-guided cryoablation therapy has grown in popularity and should be considered in patients with painful neuromas. This is a case report of complete pain relief in a patient with rare traumatic hip disarticulation with neuroma formation, treated with ultrasound-guided cryoablation. The patient gave consent for publication. DESIGN: Single case report. SETTING: Mount Sinai Medical Center. PATIENT: A 57-year-old man with traumatic hip disarticulation over 30 years ago with a 10-year history of severe residual limb pain from neuroma formation. INTERVENTIONS: Ultrasound-guided cryoablative injection therapy. OUTCOME MEASURES: Pain reduction. RESULTS: Ultrasound-guided cryoablation of a traumatic hip disarticulation neuroma resulting in complete pain relief and improved functionality and independence. CONCLUSIONS: This case illustrates a rare incidence of painful neuroma formation in a patient with traumatic hip disarticulation. Cryoablation with ultrasound guidance resulted in resolution of all pain. We report, to the best of our knowledge, the first occasion of an ultrasound-guided cryoablation resulting in complete pain relief in a traumatic hip disarticulation neuroma.

Does Prolonged Reconstruction of Disarticulation Defect With Bone Plate Affect the Electromyography Records of Masticatory Muscles?

OBJECTIVES: For medical or socioeconomic reasons, the primary reconstruction of disarticulation defects with bone plates stays for many years. This study was performed to assess the effect of this delay on electromyography (EMG) records of masticatory muscles. MATERIALS AND METHODS: Twenty-five patients treated by insertion of reconstruction plates in disarticulation defects were prospectively included in this study. Electromyography records for masticatory muscles were obtained before surgery and 3 months, 6 months, 1 year, 2 years, and 3 years afterward. Paired t-test was used to determine whether there was significant difference between the EMG values. RESULTS: At 3 years after surgery, the amplitude values of the masseter and temporalis muscles, on the resected side, have decreased by 39% and 60%, respectively, whereas on the nonoperated side, they have increased by 35% and 29%. The peak decrease, on the resected sides, has occurred at 3 months for the temporalis and 2 years for the masseter. On the nonoperated side, the peak increase has occurred at 6 months for both the temporalis and the masseter. CONCLUSIONS: A prolonged use of bone plates to reconstruct disarticulation defects leads to alterations in EMG values of masticatory muscles. These alterations present clinically as muscle atrophy on the operated side and hypertrophy on the nonoperated side.

Phantom limb pain from spinal sarcoma: a case report.

Phantom limb pain is a frequent sequela of amputation. A high prevalence of residual limb pain and back pain also exists among amputees. We present a case of a new-onset severe phantom limb pain resulting from a metastatic spinal mass in an 81-year-old patient with a history of malignant sarcoma and an old hip disarticulation amputation. The metastatic lesion, upon imaging, was found to involve the L3 vertebra and caused moderate compression of the thecal sac on the right and severe right lateral recess stenosis. After the mass was resected, the patient's phantom limb pain resolved. Our case report demonstrates that spinal metastatic pathologies may be a cause of phantom limb pain and should be included in the differential diagnosis of new-onset phantom limb pain or a change in phantom limb pain.

Syme's ankle disarticulation.

The Syme's ankle disarticulation is an end-bearing amputation level that provides stable walking, requires minimal physical therapy gait training, and rarely requires hospitalization on a rehabilitation unit. This article discusses patient selection, surgical technique, and rehabilitation of an underused rehabilitation amputation level.

Habitual dislocation of patella in knee disarticulation stump in a patient of congenital type I deficiency of tibia: a case report.

The objective of this case report was to describe a patient who developed habitual dislocation of patella after knee disarticulation. Congenital deficiency of the tibia (tibial hemimelia, aplasia or dysplasia) is very rare, with an incidence of approximately 1 per 1 million live births. Knee disarticulation is preferred over transfemoral amputation for type I tibial deficiency. Most of the surgical techniques describe preservation of the patella and suturing of patellar tendon with cruciate ligaments. We present a case of a 14-year-old girl, who underwent disarticulation through the right knee as a primary procedure at age of 5 months for congenital type I tibia deficiency. At 13 years after the primary procedure, the patient developed painful flicking of the patella, which was diagnosed clinically as habitual (spontaneous) dislocation of the patella. In conclusion, type I tibia deficiency is associated with marked hypoplasia of the distal femur along with retardation of ossification of distal femoral epiphysis. This can later result in patellar dislocation. This could delay the rehabilitation of young amputees with knee disarticulation. It would be debatable and would need further evidence as to whether excision of the patella at the initial amputation may be more appropriate to prevent later incidence of dislocation.

Pain and pain-related interference in adults with lower-limb amputation: comparison of knee-disarticulation, transtibial, and transfemoral surgical sites.

Pain and pain-related interference with physical function have not been thoroughly studied in individuals who have undergone knee-disarticulation amputations. The principal aim of this study was to determine whether individuals with knee-disarticulation amputations have worse pain and pain-related interference with physical function than do individuals with transtibial or transfemoral amputations. We analyzed cross-sectional survey data provided by 42 adults with lower-limb amputations. These individuals consisted of 14 adults reporting knee-disarticulation amputation in one limb and best-matched cases (14 reporting transfemoral amputation and 14 reporting transtibial amputation) from a larger cross-sectional sample of 472 individuals. Participants were rigorously matched based on time since amputation, reason for amputation, age, sex, diabetes diagnosis, and pain before amputation. Continuous outcome variables were analyzed by one-way analysis of variance. Categorical outcomes were analyzed by Pearson chi-square statistic. Given the relatively small sample size and power concerns, mean differences were also described by estimated effect size (Cohen's d). Of the 42 participants, 83% were male. They ranged in age from 36 to 85 (median = 55.1, standard deviation = 11.0). Most amputations were of traumatic origin (74%), and participants were on average 12.4 years from their amputations at the time of the survey. Individuals with transtibial amputation reported significantly more prosthesis use than did individuals with knee-disarticulation amputation. Amputation levels did not significantly differ in phantom limb pain, residual limb pain, back pain, and pain-related interference with physical function. Estimates of effect size, however, indicated that participants with knee-disarticulation amputation reported less phantom limb pain, phantom limb pain-related interference with physical function, residual limb pain, residual limb pain-related interference with physical function, and back pain-related interference with physical function than did participants with transtibial or transfemoral amputations. This study demonstrated that patients with knee-disarticulation amputation used prostheses significantly less than did patients with transtibial amputation. However, no evidence was found that patients with knee-disarticulation amputation have worse outcomes in terms of pain and pain-related interference with physical function; in fact, they may have more favorable long-term outcomes.

Anterior flap for coverage following hip disarticulation for osteomyelitis.

The use of a posterior myocutaneous flap is the most common method of coverage following hip disarticulation. Other options for coverage following hemipelvectomy have been described mainly when the conventional flap is unavailable owing to tumor involvement. We report a case of hip disarticulation for a decubitus ulcer with underlying osteomyelitis of the proximal femur; coverage was obtained using an anterior myocutaneous flap. In this case, two previous unsuccessful attempts at wound coverage prior to the hip disarticulation using a lateral and a posterior flap made the anterior flap the best available option for closure. Complete healing was achieved within two months.

Salvage of failed amputation about the hip in peripheral vascular disease by open wound care and nutritional support.

Five consecutive patients with wound and/or plastic surgical flap failure after hip disarticulation or amputation at the lesser trochanteric transfemoral level were treated with local tissue debridement, open wound management, culture-specific antibiotic therapy, and nutritional supplementation. All of the patients underwent amputation about the hip as a result of ischemic necrosis of the lower extremity. Four of the five patients were able to achieve wound healing by second intention. The fifth patient died 2 months after the surgery. None of the patients required revision surgery. One patient underwent split-thickness skin grafting to minimize the need for continued wound care. Local wound management combined with nutritional support and culture-specific antibiotic therapy is an acceptable alternative to major amputation stump revision in patients with potentially high morbidity who fail to heal after amputation about the hip.