Bilateral Below-Knee Amputation Surgery at the Scene: Case Report

European Journal of Trauma and Emergency Surgery, 2011

Introduction The purpose of this study was to analyze the epidemiology and outcomes after traumatic amputation of the upper (UEA) and lower (LEA) extremities. Methods The Los Angeles County ? University of Southern California Medical Center trauma registry was utilized to identify all patients sustaining traumatic amputation during the years 1996-2007. The demographics, mechanism of injury, clinical characteristics, associated injuries, surgical procedures, complications, and outcomes were obtained for these patients. Results During the 12-year study period, 130 patients suffered limb amputation, accounting for 0.25% of all trauma admissions. Thirteen patients (10%) were excluded because they were transferred from another facility after amputation or died in the emergency department. Of the remaining 117 patients, mean age was 38.1 ± 16.4 years and 77.8% were male. The predominant mechanism of injury was automobile versus pedestrian (27.4%), followed by work-related accidents (23.9%). Patients struck by vehicles were more likely to suffer LEA (93.8% versus 6.2%, p \ 0.001), while patients with work-related accidents were more likely to sustain UEA (81.5% versus 18.5%, p \ 0.001). Only nine patients underwent reattachment, all of which were for UEA and unsuccessful. Overall, 24.8% developed a complication during their hospital course, 55.2% of which were extremity related. Overall mortality was 3.4%, primarily attributed to associated severe traumatic brain injuries and thoracic injuries. Patients with LEA had longer hospital and intensive care unit (ICU) length of stay; however, after adjusting for confounders, this difference did not reach statistical significance (adjusted mean difference: 2.1 and 1.2 days, p = 0.69 and 0.79, respectively). A higher percentage of patients with LEA required discharge to a skilled nursing facility or rehabilitation center when compared with patients with UEA (29.6% versus 4.8%, p = 0.001). Conclusions Traumatic limb amputation is a rare consequence of civilian trauma. Amputation is rarely the primary cause of death; however, these devastating injuries are associated with significant intensive care unit and hospital lengths of stay. Although no mortality difference was detected, when compared with patients with upper extremity amputations, patients with lower extremity amputations were more severely injured, required revision extremity surgery more often, had a higher complication rate, and more frequently required discharge to a long-term facility.

ORTHOPAEDICS, TRAUMATOLOGY and PROSTHETICS, 2017

Foot and ankle clinics, 2010

Blast-related extremity trauma represents a serious challenge because of the extent of bone and soft tissue damage. Fragmentation and blast injuries account for 56% of all injuries produced within the Iraqi and Afghan theaters where, as of July 2009, 723 combatants have sustained lower extremity limb loss. If limb salvage is not practical, or fails, then amputation should be considered. Amputation can be a reliable means toward pain relief and improvement of function. Optimizing functional outcome is paramount when deciding on definitive amputation level. Preservation of joint function improves limb biomechanics in many cases. Increased limb length also allows for the benefits associated with articular and distal limb proprioception. Amputees with improved lower extremity function also usually exhibit less energy consumption. Function and length are generally directly correlated, whereas energy consumption and length are inversely related. This article discusses the surgical princip...

JAMA, 2012

This book is designed to meet the continued need to re-learn the principles of treatment of complex war injuries to the extremities in order to minimize posttraumatic and post-treatment complications and optimize functional recovery. Most of the chapters are based on the unique experience gained in the treatment of military personnel who have suffered modern combat trauma and civilian victims of terror attacks at a single, large level 1 trauma center. The remaining chapters present the experience of leading international authorities in trauma and reconstructive surgery. A staged treatment protocol is presented, ranging from primary damage control through to definitive functional limb reconstruction. The organization of medical aid, anesthesiology, diagnostic imaging, infection prophylaxis, and management of complications are reviewed, and a special chapter is devoted to the challenging dilemma of limb salvage versus amputation in the treatment of limbs at risk.

Journal of Surgical Orthopaedic Advances, 2011

Instructional Course Lectures, 2013

The mangled lower extremity is a challenging injury to treat. Orthopaedic surgeons treating patients with these severe injuries must have a clear understanding of contemporary advantages and disadvantages of limb salvage versus amputation. It is helpful to review the acute management of mangled extremity injuries in the civilian and military populations, to be familiar with current postoperative protocols, and to recognize recent advances in prosthetic devices.

Polski przeglad chirurgiczny, 2012

Journal of Orthopaedic Trauma, 2014

Objectives: Much attention has been given to lower extremity amputations that occur more than 90 days after injury, but little focus has been given to analogous upper extremity amputations. The purpose of this study was to determine the reason(s) for desired amputation and the common complications after amputation for those combat-wounded service members who underwent late upper extremity amputation.

Injury, 2014

Amputation is one of the oldest surgical procedure and a good amputation results in optimal functional outcome by providing healthy residual limb. Advances in prosthetics has enabled amputee with diverse options and better functionality. There is also decrease in the overall burden of amputation as a result of better treatment of causative disorders and proper limb salvage techniques. Complications, however, pose challenges in regain of necessary functions and include an array of disorders related to the procedure, technique and other factors. An understanding of common and practical complications is helpful in their anticipation and relevant prohibitive measures. Apart from it, a comprehensive study that highlights pattern of amputations and related complications provides database for preventive and management strategy. A total of 69 cases of extremity amputations were included within a defined period of Jan 2011 to June 2016. Relevant demographic data were noted along with other details amputation and complications. An attempt is also made for co-morbidities associated in cases with complications. Males (88.40%) and lower extremity (66.66%) were involved more commonly than females and upper extremity. Below knee was commonest (50.72%) lower and below elbow along with digital amputations were commonest (15.94% each) upper extremity amputations. The significant complication that required increased hospital stay or additional procedures were noted in 34 (49.27%) cases. Delayed wound healing, wound dehiscence, painful neuroma, stiffness, exposed bone and phantom pain were some of major complication noted in the study. A brief notes on patient characteristics has been attributed to the nature of trauma, co-morbidities and substance abuse among the complicated cases. The early recognition of complication and prompt management goes a long way in abetment of agony and discomfort of patient affecting overall outcome.

Foot and ankle clinics, 2010

Determining whether to perform limb salvage or amputation in the traumatized lower extremity continues to be a difficult problem in the military and civilian sectors. Numerous predictive scores and models have failed to provide definitive criteria for prediction of limb-salvage success. Excellent support is available in the military health care system for soldiers electing to undergo either limb salvage or amputation. Recent experience with soldiers who sustained limb-threatening injuries has shown that delayed amputation after limb-salvage attempts is a viable option for soldiers wounded in combat.

Lo Scalpello - Otodi Educational

The main purpose of amputation is to bring a specific patient, regardless of the initial scenario, to a new normality, characterized by the absence of pain and functional potential of the stump in terms of wearability and power. It is therefore implicit that the strategy is played on the choice of the level, using both analysis of the scenario of the patient and the perspective of the prosthetic project. Hence the delicacy of the choice of the moment and the level of amputation, considering multiple possibilities arising from evolution of surgical techniques, interdigitation of skills between traumatologist and plastic surgeon, translation of some techniques initially used for amputations of the upper limb to amputations of the lower limb, to substantial innovations in limb prostheses.

American Journal of Surgery, 2003

Background: This study was made to evaluate the experience at a Department of Veterans Affairs (VA) hospital with consecutive major lower extremity amputations over a period of 7 years. Methods: The records of 229 patients (221 male and 8 female) who underwent 296 consecutive major lower extremity amputations (119 above-knee amputations [AKA] and 177 below-knee amputations [BKA]) over a period of 86 months (September 1994 to October 2001 were retrospectively analyzed. All amputations were performed by members of the vascular surgery department. Results: Forty of the 229 patients (17%) eventually required a contralateral amputation, 27 patients (12%) had BKAs that eventually necessitated conversion to AKA, and 44 amputations (15%) required an initial guillotine amputation. The 30-day mortalities for BKA, AKA, and BKA to AKA operations were 12%, 17%, and 7%, respectively. Eighty-eight of the amputations (30%) developed wound complications, and required 137 revisions. Seventy-seven of the amputations (26%) had undergone prior revascularization, of which 31 (48%) had an early failed bypass. The average preoperative ankle/brachial index (ABI) was 0.57. Of the patients undergoing amputation, 97 (42%) complained of rest pain, 91 (40%) complained of claudication, and 158 (69%) had tissue loss or gangrene at the time of their operation. One hundred and forty-six patients (64%) were diabetic. Twenty-two patients (9%) were dialysis dependent and 81 patients (35%) admitted to smoking. Of the known causes of death, 21 resulted from myocardial infarction, 22 from congestive heart failure, 14 from respiratory failure, 13 from disseminated cancer, 10 from sepsis, 7 from stroke, and 6 from renal failure. Preoperative functional status determinations revealed that of 272 patients with enough information to assess functional status, 43 were totally dependent, 97 were partially independent, and 132 were independent. Of the 229 patients, 168 (73%) were ambulatory prior to their amputation, and at the completion of this review only 53 patients (23%) were ambulatory. Conclusions: Most patients undergoing major lower extremity amputations have many comorbidities; hence morbidity and mortality rates are high, with the most common causes of death being cardiac and respiratory in nature. These data suggest that major lower extremity amputations highlight a very high-risk population with only 39% survival at 7 years, as well as a costly subset secondary to prolonged hospitalization times (average 15 days, range 3 to 105), in addition to the extraordinary cost associated with diminished functional status.

Journal of Bone and Joint Surgery - Series B, 2012

The types of explosive devices used in warfare and the pattern of war wounds have changed in recent years. There has, for instance, been a considerable increase in high amputation of the lower limb and unsalvageable leg injuries combined with pelvic trauma. The conflicts in Iraq and Afghanistan prompted the Department of Military Surgery and Trauma in the United Kingdom to establish working groups to promote the development of best practice and act as a focus for research. In this review, we present lessons learnt in the initial care of military personnel sustaining major orthopaedic trauma in the Middle East. War wounds range from simple low-energy fragmentation wounds to highly complex injuries. The latter have been more recently encountered in Afghanistan and are well-described by Crabtree. 1 In Iraq and Afghanistan, improvised explosive devices (IEDs) have become the insurgents' preferred weapon and were the most common cause of coalition deaths in 2009 and 2010. 2 There has also been a notable increase in very high, lower extremity amputations or unsalvageable leg injuries with pelvic trauma. 3-5 The conflicts in the Middle East prompted the Academic Department of Military Surgery and Trauma to establish working groups to promote the development of best practice and to act as a focus for research. In this review, we present lessons learnt in the initial care of military personnel sustaining major orthopaedic trauma in the Middle East. Speedier evacuation from the point of wounding can deliver patients to the Emergency Department at the very edge of survival, and the trauma care delivered by the Defence Medical Services on operations equals that available in the NHS in the United Kingdom. 6,7 A recent report by the Healthcare Commission described the military trauma system as 'exemplary'. 8 Between April 2006 and July 2008, 1474 patients were recorded on the United Kingdom's Joint Theatre Trauma Registry. Of these, 530 had an Injury Severity Score 9 > 16 and 296 survived, including unexpected survivors. 10 The Joint Theatre Trauma Registry is the United Kingdom database of all the prospectively collected data for service personnel injured on operational tour. It was started in December 2003.

Prosthetics and orthotics international, 1999

Landmine explosions cause most of the war injuries in the battlefield. Amputations resulting from severe injuries reveal serious problems despite the improvements in surgery. Bilateral lower limb amputations have more impact than unilateral on social life. Some 29 cases with lower limb amputations due to landmine injuries were treated in the Department of Orthopaedics and Traumatology, Gülhane Military Medical Academy between January 1992 and December 1996. Amputation levels were as follows: 1 case had hip disarticulation and a trans-femoral amputation, 6 had bilateral trans-femoral amputations, 6 had trans-femoral and trans-tibial amputations, 12 had bilateral trans-tibial amputations, 1 had trans-femoral and Chopart amputations and the remaining 3 cases had trans-tibial and Chopart amputations. The initial treatment was done for all cases in the first 6-8 hours after injury at the field hospitals. Aggressive debridement, excision and primary closure were performed. None of the stu...