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Introduction: Field amputation can be life-saving for entrapped patients requiring surgical extrication. Under these austere conditions, the procedure must be performed as rapidly as possible with limited equipment, often in a confined space, while minimizing provider risk. The aim of this study was to determine the ideal saw, and optimal approach, through bone or joint, for a field amputation., Methods: This was a prospective cadaver-based study. Four saws (Gigli, manual pruning, electric oscillating and electric reciprocating) were tested in human cadavers. Each saw was used to transect four separate long bones (humerus, ulna/radius, femur and tibia/fibula), previously exposed at a standardized location. The time required for each saw to cut through the bone, the number of attempts required to seat the saw when transecting the bone, slippage, quality of proximal bone cut and extent of body fluid splatter as well as the physical space required by each device during the amputation were recorded. Additionally, the most effective saw in the through bone assessment was compared to limb amputation using scalpel and scissors for a through joint amputation at the elbow, wrist, knee and ankle. Univariate analysis was used to compare the outcomes between the different saws., Results: The fastest saw for the through bone amputation was the reciprocating followed by oscillating (2.1 [1.4-3.7] seconds vs 3.0 [1.6-4.9] seconds). The manual pruning (58.8 [25-121] seconds) was the slowest (p = 0.007). Overall, the oscillating saw was superior or equivalent to the other devices in number of attempts (1), slippage (0), quality of bone cut (100% good) and physical space requirements (4500 cm 3 ), and was the second fastest. In comparison, a through joint amputation (125.0 [50-147] seconds for scalpel and scissor; 125.5 [86-217] seconds for the oscillating saw) was significantly slower than through bone with the Gigli (p = 0.029), the oscillating (p = 0.029) and the reciprocal saw (p = 0.029)., Conclusions: The speed, precision, safety, space required, as well as the adjustable blade of the oscillating saw make it ideal for a field amputation. A Gigli saw is an excellent backup for when electrical tools cannot be used. Through bone amputation is faster than a through joint amputation., Competing Interests: Declaration of Competing Interest All authors declare no potential conflict of interest., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: Lower limb amputation is common in war combat and armed conflict as well as in traumatic settings and presents a challenge for health care providers. The incorporation of advanced technologies, particularly virtual reality, presents an opportunity to address the main consequences of amputation, principally balance and gait. The aim of this study was to investigate the additional effect of virtual reality with a traditional rehabilitation exercise program on balance and gait in unilateral, traumatic lower limb amputees. Materials and Methods: Thirty-two traumatic lower limb amputees, fulfilling a postfitting rehabilitation program at least 6 months ago, were recruited and randomly assigned into two identically sized groups; group C (control group) experiencing the traditional exercise program and group VR (virtual reality group) experiencing an addition of a virtual reality training. The intervention was conducted over 6 weeks at a rate of three sessions per week. Outcome measures assessed before and after 6 weeks were the Berg Balance Scale (BBS), Timed Up and Go (TUG) test, Dynamic Gait Index (DGI), and 6-minute walk test (6 MWT). Results: Both interventions induced improvement in all measured parameters ( P  < 0.05); however, virtual reality demonstrated significant superior effects only on the balance markers, TUG test, DGI, and BBS ( P  < 0.05), but not on the 6 MWT ( P  > 0.05). Conclusion: Virtual reality is a promising, amusing, and safe intervention for addressing balance and gait in unilateral, traumatic lower limb amputees.

Objective: Prehospital limb amputation is a rare but potentially life-saving intervention. When patients cannot be extricated due to limb entrapment or have hemodynamic compromise that precludes a prolonged extrication, they may benefit from an emergent prehospital amputation. The objective was to experimentally compare three prehospital amputation techniques on porcine legs., Methods: The three techniques studied were a scalpel with a Gigli saw, a hacksaw, and a reciprocating saw. For the first technique, a scalpel was used to make a circumferential incision in the soft tissue and a Gigli wire saw to cut through the bone. The second and third techniques only used a saw and did not require soft tissue incision with a scalpel. Three providers including an emergency medicine physician, a paramedic, and a medical student performed three amputations of each technique, resulting in twenty-seven total amputations. The primary outcome was amputation time. Secondary outcomes were rate of instrument malfunction and cleanliness of cut., Results: The primary outcome of amputation time was different between techniques. The Gigli saw technique took 32.86 ± 16.53 s (mean ± SD), hacksaw technique 6.28 ± 0.76 s, and reciprocating saw technique 2.84 ± 0.40 s. There were no differences in amputation time between participants for a given amputation technique. The Gigli saw technique had an instrument malfunction on 3/9 trials which was distinct from the other techniques. Differences in cleanliness of cut were nonsignificant., Conclusions: Prehospital limb amputation with a hacksaw or reciprocating saw may result in faster completion of the time-sensitive procedure with fewer instrument malfunctions., Competing Interests: Declaration of Competing Interest None., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: The purpose of this study was to investigate residual rotation of patients with forearm amputation and the contribution of involved muscle to residual rotation., Methods: Testing was performed using five fresh-frozen cadaveric specimens prepared by isolating muscles involved in forearm rotation. Amputation was implemented at 25 cm (wrist disarticulation), 18 cm, or 10 cm from the tip of olecranon. Supination and pronation in the amputation stump were simulated with traction of involved muscle (supinator, biceps brachii, pronator teres, pronator quadratus) using an electric actuator. The degree of rotation was examined at 30°, 60°, 90°, and 120° in flexion of elbow., Results: Average rotation of 25 cm forearm stump was 148° (SD: 23.1). The rotation was decreased to 117.5° (SD: 26.6) at 18 cm forearm stump. It was further decreased to 63° (SD 31.5) at 10 cm forearm stump. Tendency of disorganized rotation was observed in close proximity of the amputation site to the elbow. Full residual pronation was achieved with traction of each pronator teres and pronator quadratus. Although traction of supinator could implement residual supination, the contribution of biceps brachii ranged from 4 to 88% according to the degree of flexion., Conclusions: Close proximity of the amputation site to the elbow decreased the residual rotation significantly compared to residual rotation of wrist disarticulation. The preservation of pronosupination was 80% at 18 cm forearm stump. Although the pronator teres and the pronator quadratus could make a full residual pronation separately, the supinator was essential to a residual supination.

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 Amputation (Q-TFA) before treatment and at two, five, seven, ten, and 15 years' follow-up. A prosthetic activity grade was assigned to each patient at each timepoint. All mechanical complications, defined as fracture, bending, or wear to any part of the implant system resulting in removal or change, were recorded., Results: The Q-TFA scores at two, five, seven, and ten years showed significantly more prosthetic use, better mobility, fewer problems, and an improved global situation, compared with baseline. The survival rate of the osseointegrated implant part (the fixture) was 89% and 72% after seven and 15 years, respectively. A total of 61 patients (55%) had mechanical complications (mean 3.3 (SD 5.76)), resulting in exchange of the percutaneous implant parts. There was a positive relationship between a higher activity grade and the number of mechanical complications., Conclusion: Compared with before treatment, the patient-reported outcome was significantly better and remained so over time. Although osseointegration and the ability to transfer loads over a 15-year period have been demonstrated, a large number of mechanical failures in the external implant parts were found. Since these were related to higher activity, restrictions in activity and improvements to the mechanical properties of the implant system are required. Cite this article: Bone Joint J 2020;102-B(1):55-63.

Background: Osseointegration, an approach for direct skeletal attachment of a prosthesis to an amputated limb, may address many of the problems associated with socket prostheses. The safety of osseointegration remains uncertain. The aim of this study was to summarize evidence on functional and clinical outcomes, as well as adverse effects of osseointegration for patients with a limb amputation., Methods: MEDLINE, Embase, Web of Science and the Cochrane Library were searched to April 2018. Eligible studies were observational, case and qualitative studies, and RCTs conducted in patients with a limb amputation, who were managed with osseointegrated prostheses and had follow-up data., Results: Twenty-two eligible articles comprising 13 unique studies were included. No RCT was identified. Apart from three case reports that comprised one to five patients, the sample size of studies ranged from 11 to 100 participants. All relevant studies reported improvement in functional outcomes (walking ability, prosthetic use and mobility), satisfaction and quality of life following osseointegration, compared with their preoperative status or when using a conventional socket prosthesis. Infection rates ranged from 1 (95 per cent c.i. 0 to 5) to 77 (59 to 88) per cent. The majority of infections were described as low-grade soft tissue or superficial infections related to the skin-implant interface, and were treated effectively with antibiotics. None of the studies reported additional amputation or death as a result of osseointegration., Conclusion: Osseointegration after limb amputation improves prosthetic use, comfort when sitting, walking ability, mobility, gait and quality of life. However, it is associated with an increased risk of soft tissue infection., (© 2018 BJS Society Ltd Published by John Wiley & Sons Ltd.)

Transfemoral amputation is considered the last treatment option for severe infection, vascular disease, trauma, and malignant tumors of the lower extremity that have failed limb salvage. Unopposed pull of the hip abductors causes a flexion-abduction thigh deformity that results in abnormal biomechanics and increased oxygen consumption during ambulation. Myodesis of the adductor tendons is a critical component of transfemoral amputation that creates dynamic muscle balance, enhances prosthetic fitting and function, and improves clinical outcomes. Traditional adductor myodesis uses locking sutures passed through cortical drill holes along the anterolateral aspect of the distal femur that are tensioned and tied by hand. In this report we describe a novel technique for adductor myodesis using FiberTape suture and knotless anchors that we have found to be quick, easy, and reproducible with strong tendon-bone fixation., Level of Evidence: Level V, expert opinion.

Ischial containment sockets are the current standard of care for military service members with transfemoral amputation. However, they fit intimately with the ischium, which may limit hip motion and contribute to proximal socket discomfort, a common complaint among prosthesis users. Subischial sockets, such as the newly described Northwestern University Flexible Subischial Vacuum (NU-FlexSIV) Socket technique, do not interact with the ischium, potentially increasing hip motion and improving comfort., Purpose: To transfer the NU-FlexSIV Socket technique to military prosthetists and evaluate performance among military service members with transfemoral amputation., Study Design: case series., Methods: Four of the 11 enrolled subjects completed the study protocol comparing the NU-FlexSIV Socket to the ischial containment socket. Gait kinematics (over ground and on stairs), physical performance measures (Four-Square Step Test, T-test of Agility, and an obstacle course), limb-socket motion, and socket comfort were assessed after accommodation time in each socket., Results: While wearing the NU-FlexSIV Socket, sagittal plane hip motion generally increased while coronal plane trunk motion and walking speed remained largely unaffected during over ground walking. During stair ascent, sagittal plane hip motion increased while wearing the NU-FlexSIV Socket, with minimal changes in walking speed for all subjects. Pre- and post-walking fluoroscopy measures suggest fit of the NU-FlexSIV Socket was less affected by activity. Most subjects reported that the NU-FlexSIV Socket was more comfortable for sitting but some found it less comfortable for walking and running. Performance measure results were mixed. Although attempts were made to consistently implement the NU-FlexSIV Socket technique, some challenges were experienced., Conclusions: The NU-FlexSIV Socket provided greater hip motion across a variety of tasks without adversely affecting other movement mechanics but did not consistently improve socket comfort. Variability in the liners and socket materials used may have contributed to variability in results. Overall, the design was a viable alternative to traditional ischial containment sockets for some individuals with transfemoral amputation.

Objective: To evaluate the efficacy of oral meloxicam, topical anaesthetic cream and cautery iron in mitigating acute nociceptive responses of pigs to tail docking., Study Design: A prospective, randomized, controlled experimental study., Animals: A total of 40 healthy Large WhitexLandrace pigs aged 21±1 days, weighing 6.1±0.9 kg., Methods: Pigs were randomly assigned to one of four treatments (n=10 per treatment): CONTROL: docked using clippers without analgesia; MEL: docked using clippers after administration of oral meloxicam; EMLA: docked using clippers after application of topical anaesthetic cream; and CAUT: docked using a cautery iron without analgesia. Anaesthesia was induced and maintained with halothane in oxygen. Following induction, end-tidal halothane was stabilized at 0.95-1.05% and electroencephalograph (EEG) recording commenced. After 5 minutes of baseline data collection, tail docking was performed and recording continued for a further 10 minutes. The EEG summary variables median frequency (F50), 95% spectral edge frequency (F95) and total power (P TOT ) were calculated for the baseline period and for consecutive 30-second intervals following docking., Results: Following docking, F50 increased and P TOT decreased significantly in CONTROL and MEL pigs. EMLA pigs exhibited no change in any variable, whilst CAUT pigs exhibited a reduction in P TOT but no change in F50. F50 was higher in control pigs than in EMLA pigs 30-60 seconds after docking (p≤0.01). P TOT was lower in CONTROL than in EMLA pigs 30-90 seconds after docking (p<0.03) and in CAUT pigs 60 seconds after docking (p=0.01)., Conclusions and Clinical Relevance: Prior application of EMLA cream abolished EEG indicators of nociception in pigs docked using clippers. Docking using a cautery iron without analgesia ameliorated EEG indicators of nociception, relative to using clippers without analgesia. Prior administration of EMLA cream or the use of cautery instead of clippers may reduce the acute pain experienced by pigs undergoing tail docking., (Copyright © 2017 Association of Veterinary Anaesthetists and American College of Veterinary Anesthesia and Analgesia. Published by Elsevier Ltd. All rights reserved.)

Objective: To compare electroencephalographic (EEG) responses of pigs to tail docking using clippers or cautery iron, performed at 2 or 20 days of age., Study Design: Prospective, randomised controlled experimental study., Animals: A total of 40 Large White x Landrace entire male pigs aged 2 (n=20) or 20 (n=20) days were randomly assigned to undergo tail docking using clippers or cautery iron., Methods: Anaesthesia was induced and maintained with halothane delivered in oxygen. Following instrumentation, end-tidal halothane concentration was stabilised at 1.0±0.05%, and EEG recording commenced. After a 5 minute baseline period, tail docking was performed and recording continued for additional 10 minutes. EEG data were subjected to Fast Fourier transformation, yielding the summary variables median frequency (F50), 95% spectral edge frequency (F95) and total power (P TOT ). Variables recorded during the baseline period were compared with those calculated at consecutive 15 second intervals following tail docking., Results: Following tail docking, F50 decreased briefly but significantly in 2-day-olds, whereas 20-day-olds exhibited a sustained increase in F50 (p<0.05). Immediately after tail docking, F50 was overall lower in 2-day-olds than in 20-day-olds (p<0.05). F95 increased after docking in 20-day-olds docked using clippers (p<0.05) but did not change in 20-day-olds docked using cautery iron or in 2-day-olds docked using either method. Overall, F95 was lower in 2-day-olds than in 20-day-olds from 30 to 60 seconds after docking (p<0.05). P TOT decreased after docking in 20-day-olds (p<0.05) but did not change in 2-day-olds. Overall, P TOT was lower in 2- than in 20-day-olds during baseline and after tail docking (p<0.05)., Conclusions and Clinical Relevance: These data suggest that tail docking using clippers is more acutely painful than docking using cautery iron and that docking within the first days of birth may be less acutely painful than docking at a later age., (Copyright © 2017 Association of Veterinary Anaesthetists and American College of Veterinary Anesthesia and Analgesia. Published by Elsevier Ltd. All rights reserved.)

The majority of transfemoral and transtibial amputees can be functionally fitted with conventional suspension sockets; however, due to socket problems using conventional stump care, 60% of the patients have limited function and even in younger patients approximately one sixth are unable to wear the prosthesis daily. After the introduction of transcutaneous osseointegrated prostheses (TOP) the inherent problems of socket-stump care can be avoided for these patients. Against this background this article reviews the recent clinical development of TOP in Sweden, Germany, the Netherlands, Australia and USA currently in nine centers. Unanimously, all groups show that TOP enables physiological weight bearing, improved range of motion in the proximal joint, as well as osseoperceptive sensory feedback and better control of the artificial limb. Likewise, there is agreement that as a rule that there is a clinically less relevant superficial contamination of the stoma. Furthermore, TOP is nowadays also used for transhumeral amputees and after thumb amputation and the development of the indications for this technique are increasing. Future aspects include novel treatment options using implanted intramedullary electrodes allowing permanent and unlimited bidirectional communication with the human body (osseointegrated human-machine gateway). This could possibly realize an innovative form of prosthesis control as well as the combination of TOP and targeted muscle reinnervation (TMR) surgery to create more advanced prosthesis systems for upper and lower extremity amputees.

Background: Bone anchorage of an artificial limb has been proven to be an alternative intervention for amputees when prosthesis use is seriously reduced because of stump problems. Little is known about how prosthesis components interact with bone and joints and which potential the optimum use provides with respect to quality of treatment of leg amputees., Objective: Does osseointegration influence the motor activity of residual limbs differently compared with socket prostheses? How should prosthesis components be aligned? What type of prosthetic knee joints should be preferred in transfemoral amputees?, Material and Methods: Transfer of biomechanical knowledge of socket prosthetics to bone-anchored prostheses. Pilot studies with a limited number of amputees., Results: Force transmission at the interface between the prosthesis and residual limb stump is completely different for osseointegrated fixation and socket design; however, the number of muscles available for control remains unchanged. Because the iliotibial tract is missing, bending moments of the femur are expected to be greater. Prosthetic alignment is very critical for gait pattern and the basic rules seem to be the same as for socket design. The foot position determines the knee function for below-knee amputees. The position of the femur influences the gait pattern of above-knee amputees. The lowest risk of falls and best functional properties are shown by microprocessor controlled knee joints., Conclusion: Osseointegrated leg prostheses have some biomechanical advantages over the socket design. Since rehabilitation quality is clearly affected the prosthetic alignment has to be done carefully and precisely. As a rule microprocessor controlled knee joints are indicated.

Objective: Prehospital emergency amputation is a rare procedure, which may be necessary to free a time-critical patient from entrapment. This study aimed to evaluate four techniques of cadaveric lower limb prehospital emergency amputation., Method: A guillotine amputation of the distal femur was undertaken in fresh frozen self-donated cadavers. A prehospital doctor conducted a surgical amputation with Gigli saw or hacksaw for bone cuts and firefighters carried out the procedure using the reciprocating saw and Holmatro device. The primary outcome measures were time to full amputation and the number of attempts required. The secondary outcomes were observed quality of skin cut, soft tissue cut and CT assessment of the proximal bone. Observers also noted the potential risks to the rescuer or patient during the procedure., Results: All techniques completed amputation within 91 s. The reciprocating saw was the quickest technique (22 s) but there was significant blood spattering and continuation of the cut to the surface under the leg. The Holmatro device took less than a minute. The quality of the proximal femur was acceptable with all methods, but 5 cm more proximal soft tissue damage was made by the Holmatro device., Conclusions: Emergency prehospital guillotine amputation of the distal femur can effectively be performed using scalpel and paramedic shears with bone cuts by the Gigli saw or fire service hacksaw. The reciprocating saw could be used to cut bone if no other equipment was available but carried some risks. The Holmatro cutting device is a viable option for a life-threatening entrapment where only firefighters can safely access the patient, but would not be a recommended primary technique for medical staff., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Transfemoral amputations with more proximal amputation levels have the problem of secondary development into flexion and abduction contractures. This is induced by muscle imbalance, especially the loss of adductor muscle insertions when abductor muscle insertions are preserved. This causes considerable problems when fitting prosthetics. Myodesis with insertion of the distally detached adductor magnus muscle to the lateral femoral cortex, introduced here, results in a stronger stump with good muscle balance, and prosthetics fitting is significantly improved.

Unlabelled: Surgical site infection is a major potential complication of all operative interventions, and the diabetic foot is particularly at risk for bacterial recontamination and infectious sequelae. The objective of this study was to identify whether the sagittal saw blade used during partial foot amputations and diabetic foot debridements carries the potential to serve as a bacterial fomite. We physically cultured the sagittal saw blade during 20 foot debridements involving the resection of bone in patients diagnosed with a diabetic foot infection. The culture was taken after the initial debridement and during the irrigation phase of the procedure. We observed 16 positive routine intraoperative culture results, with positive saw blade culture results in 15 (93.8%; 15/16) of these cases. In 14 (93.3%; 14/15) of these cases, the saw blade culture grew at least one of the same bacteria as our other routine intraoperative cultures. We observed 4 negative routine intraoperative culture results, with negative saw blade culture results in 3 (75.0%; 3/4) of these cases. This results in agreement between routine intraoperative cultures and saw blade culture of 85.0% (17/20). The results of this investigation demonstrate that the sagittal saw blade used for osseous resection during diabetic foot debridements and partial foot amputations carries the potential for intraoperative bacterial transmission. We recommend changing at least the sagittal saw blade if more bone is resected following irrigation, particularly if it is used to obtain a "clean margin" for microbiological or histological examination., Levels of Evidence: Therapeutic, Level IV: Case series., (© 2014 The Author(s).)

Background: We report an unusual case of a 38-year-old physically active patient, who suffered a Ewing sarcoma during adolescence and was therefore treated with a tumor endoprostheses ex domo (replacement of distal femur and proximal tibia). Since then he had undergone a couple of surgical interventions for revision and is currently suffering from persistent pain in the leg concerned. An aseptic loosening of the tibial component was evident after radiologic examinations. Because he had suffered for so long our patient refused further surgery to retain the affected limb and he preferred amputation., Objectives: We would have taken the risk of a femoral residual limb that is much too short compared with a classical above-knee amputation. In this regard we saw difficulties in exoprosthetic treatment with functional limitations that could easily have influenced the outcome negatively., Method: Consequently, we decoupled the tibial component from the femoral one within the knee joint and thus performed a knee disarticulation leaving the femoral component., Results: Postoperatively, we found a mostly harmonious gait pattern with a pure mechanical interim prosthesis regarding time-distance parameters, which may be even further improved with the final prosthesis. Sagittal joint angles are comparable to conventionally knee exarticulated ones., Discussion: To date, no comparable case of such an alloarthroplasty, which could regain mobility with an exoprosthetic treatment has been highlighted in the literature. In the result, a knee disarticulation within the area of a knee arthroplasty leaving the femoral component is not inferior to"ordinary" knee disarticulation.

Background: In Germany around 70,000 amputations are carried out on extremities each year. Modern prosthetic functional components have become more and more sophisticated and must be understood and applied by their users to be of beneficial use in everyday life. The prosthetic socket is the most important component of modern extremity prosthetics., Objectives: Which demands have to be met by a modern prosthetic socket so that innovative function-improving components in prosthetics can be successfully applied?, Materials and Methods: Complex prosthetic technologies are rarely compatible with a lower overall weight of the prosthesis. The increase in functionality also produces differentiated force effects on the human body. Modern socket technologies, therefore, have to compensate for the increased strain and counteract the increasing dynamics between the stump and the prosthesis. This can be achieved through the application of adhesive socket materials and through new adhesive mechanisms. Form variants can also improve the connection between stump and prosthetic socket., Results: The improvements in prosthetic socket technology presented here have a lasting positive effect on the daily routine of many amputees. Not only do they improve the control and application of modern prosthetic components, but also clearly enhance the wearing comfort., Conclusion: The prosthetic socket is crucial for the success of exoskeletal prosthetic management. The better we succeed in making the human body and the prosthetic socket an entity, the more usefully and comfortably innovative prosthetic methods can be applied.

The Duke of Wellington's polyglot army assembled for the Waterloo campaign was hastily aggregated and the Army Medical Department was somewhat short of staff and not entirely of the calibre of the department serving latterly in the Peninsular campaigns. The casualty rates during the battles of this campaign were high and the regimental and hospital staff struggled with the large number of casualties. Lack of stretcher bearers and transport were significant problems, which were compounded by the high density of the casualties. Three quarters of the surviving wounded rejoined their units., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

We report outcomes of 28 patients after stump-lengthening procedures (SLPs) with modular tumor endoprostheses following high-thigh amputation and hip disarticulation over 11years. Mean follow up was 41.3months (range 7.4 to 133.6months). Mean Musculoskeletal Tumour Society Score was 56% (n=11); ten out of eleven patients alive used an exoprosthesis regularly. Complications occurred in 15 patients with infection being most common. In 2 cases, the prostheses had to be explanted. Our data suggest that SLP facilitates post-operative rehabilitation and prosthesis usage. Modular endoprostheses for stump-lengthening allow optimization of remnant soft-tissue envelope, reducing the risk of stump perforation., (Copyright © 2014 Elsevier Inc. All rights reserved.)

On-scene invasive emergency procedures, such as Cricothyroidotomy, chest drain, intraosseous puncture or even in-field-amputation, are often unavoidable, when indicated, and present a major challenge for the emergency physician. Personal, temporal or local conditions are often unsuitable. Even with regular intervention by the Emergency Medical Service, "last resort" measures occur very infrequently, particularly in relation to paediatric emergencies. As well as theoretical training, practice-oriented course concepts are essential in order to achieve high quality in these procedures. This article presents the use of in-field-amputation, with reference to indication, implementation, problems and risks. It is part of a series of four articles on the subject of invasive emergency techniques., (© Georg Thieme Verlag Stuttgart · New York.)

Background: Stair ascent can be difficult for individuals with transfemoral amputation because of the loss of knee function. Most individuals with transfemoral amputation use either a step-to-step (nonreciprocal, advancing one stair at a time) or skip-step strategy (nonreciprocal, advancing two stairs at a time), rather than a step-over-step (reciprocal) strategy, because step-to-step and skip-step allow the leading intact limb to do the majority of work. A new microprocessor-controlled knee (Ottobock X2(®)) uses flexion/extension resistance to allow step-over-step stair ascent., Questions/purposes: We compared self-selected stair ascent strategies between conventional and X2(®) prosthetic knees, examined between-limb differences, and differentiated stair ascent mechanics between X2(®) users and individuals without amputation. We also determined which factors are associated with differences in knee position during initial contact and swing within X2(®) users., Methods: Fourteen individuals with transfemoral amputation participated in stair ascent sessions while using conventional and X2(®) knees. Ten individuals without amputation also completed a stair ascent session. Lower-extremity stair ascent joint angles, moment, and powers and ground reaction forces were calculated using inverse dynamics during self-selected strategy and cadence and controlled cadence using a step-over-step strategy., Results: One individual with amputation self-selected a step-over-step strategy while using a conventional knee, while 10 individuals self-selected a step-over-step strategy while using X2(®) knees. Individuals with amputation used greater prosthetic knee flexion during initial contact (32.5°, p = 0.003) and swing (68.2°, p = 0.001) with higher intersubject variability while using X2(®) knees compared to conventional knees (initial contact: 1.6°, swing: 6.2°). The increased prosthetic knee flexion while using X2(®) knees normalized knee kinematics to individuals without amputation during swing (88.4°, p = 0.179) but not during initial contact (65.7°, p = 0.002). Prosthetic knee flexion during initial contact and swing were positively correlated with prosthetic limb hip power during pull-up (r = 0.641, p = 0.046) and push-up/early swing (r = 0.993, p < 0.001), respectively., Conclusions: Participants with transfemoral amputation were more likely to self-select a step-over-step strategy similar to individuals without amputation while using X2(®) knees than conventional prostheses. Additionally, the increased prosthetic knee flexion used with X2(®) knees placed large power demands on the hip during pull-up and push-up/early swing. A modified strategy that uses less knee flexion can be used to allow step-over-step ascent in individuals with less hip strength.

Background: Persons with amputation and residual limb wounds would benefit from the ability to continue wearing a prosthesis while healing. Sockets with vacuum-assisted suspension may reduce intra-socket motion and be less disruptive to wound healing. The purpose of this case series was to measure residual limb wound size over time in persons with transtibial amputation while using prostheses with vacuum-assisted suspension., Case Description and Methods: Six subjects with residual limb wounds were fit with vacuum-assisted suspension sockets. Wound surface area was calculated using ImageJ software at the time of fit and each subsequent visit until closure. FINDINGS AND OUTCOME: Average wound surface area at initial measurement was 2.17 ± 0.65 cm(2). All subjects were instructed to continue their normal activity level while wounds healed, with a mean of 177.6 ± 113 days to wound closure., Conclusion: Results suggest that well-fitting sockets with vacuum-assisted suspension in compliant individuals did not preclude wound healing. Further research is required to substantiate these case-based observations., Clinical Relevance: Residual limb wounds are typically treated by suspension of prosthetic use until healing occurs, increasing the risk of long-term prosthesis nonuse. Our results suggest that vacuum-assisted suspension sockets may be used while healing occurs.

In this paper, we analyze the use of the body-powered split-hook prosthetic terminal device, which is the most commonly used upper-limb prosthesis. We developed two taxonomies of split-hook use, one on grasp shape and one on force exertion, illustrating the functional capabilities and use cases of the device. Video captured from an amputee using a body-powered split-hook during a number of common activities was used to lend weight to the completeness of the classifications. These taxonomies serve to establish a common language and means of comparing the types of grasps achievable by simple terminal devices to those of advanced myoelectric terminal devices or even human hands. The first taxonomy categorizes the grasp type based on the contacts with the environment while the second is categorized by the method and limitation of force exertion. We discuss the difference between grasps capable of holding objects compared to those that are capable of acquiring objects and the importance of non-prehensile uses of the split-hook. The classification schemes lay the groundwork for further detailed study of split-hook use, and the discussion of the use cases described may help guide terminal device developers to create improved prostheses.

Purpose: To identify and gain agreement on successful outcomes of and important factors to consider in rehabilitation following upper limb absence (ULA)., Method: Fifty-three participants consisting of multi-disciplinary rehabilitation professionals, and individuals with ULA were invited to complete a three-round modified Delphi iterative survey. Following three Delphi questionnaire rounds, participants clarified the definitions of success in three areas (prosthesis use, activities and participation and self-image). In addition, participants identified and agreed the important factors to consider in rehabilitation after ULA., Results: Results showed that participants reached agreement (having a SD <1) over the three rounds on 78 out of 81 rated items. Of these, 54 rated items were "accepted" as important by panel members (mean score of 4 on a five-point Likert scale). Twenty-four items were rejected. Only three rated items had not reached agreement by the third round., Conclusions: Clarification of successful outcomes and factors that should be taken into consideration in a patient's rehabilitation allows a clearer evaluation of what should be the focus of rehabilitation. The findings from the Delphi study can help form the basis for a screening tool for clinicians to be able to identify areas of concern and subsequent treatment for a patient in their care. Implications for Rehabilitation To date, there has been no definitive guidance on which outcomes should be assessed in amputation rehabilitation. This study identified the seven core domains of importance regarding the rehabilitation of individuals with ULA and created a starting point for developing a new portfolio of research that aims to address all relevant aspects of patients' rehabilitation. This study reached a consensus and enabled an insight into what defines successful prosthesis use, self-image and activities and participation, and provided evidence that the current definition of prosthesis use in the literature does not sufficiently capture what RPs and individuals with ULA consider important, such as specific use of the prosthesis, as often as an individual wishes, while using it as intended. This study provided RPs and individuals with ULA an opportunity to communicate their opinions and knowledge anonymously regarding the important areas to consider in rehabilitation.

Infected nonunions are potentially difficult complications to treat in the context of complex tibial fractures. Often, such complications necessitate amputation to prevent further sequelae, such as fulminant sepsis and complete loss of the limb. As such, the eradication of infection, the decision regarding when to amputate, and the length of the residual stump are important factors to optimize patient outcome. The authors present a unique scenario whereby an Ilizarov external fixation device was used to treat an infected tibial nonunion while simultaneously salvaging stump length to enable fitting for a below-knee prostheses. The use of the Ilizarov device can prevent abrupt dissemination of infection, stabilize the fracture, and bridge nonunion gaps. This is augmented by the unique ability of the construct to be periodically readjusted and realigned where needed to permit osteogenesis and proper alignment. The result in this case was complete eradication of infection, with the use of continuous antibiotics as a pharmacological adjunct, union of the tibial fragments, and a below-knee amputation with adequate stump length and prosthetic fit. The success of this treatment strategy was predicated on the above factors, with an emphasis on amputation level and its effect on function. The Ilizarov external fixator is a device that has been widely used to treat limb-length discrepancies, correct deformities, and induce osseous growth in bony nonunion. The authors present the Ilizarov device as a viable option for the treatment of infected tibial nonunions and stump length salvage., (Copyright 2013, SLACK Incorporated.)

After the introduction of firearms, which became increasingly efficient over time, the number of seriously injured soldiers increased considerably during the nineteenth century. As a consequence, surgeons were called upon to broaden their activity, performing operations which had hitherto been considered too hazardous, since they were deemed to be too extensive, or were contraindicated by the risk of complications during surgery (haemorrhage, heart and circulatory failure). From 1846 onwards, the introduction of anaesthetic techniques carried out with ether had expanded surgical perspectives in anatomical districts like the abdomen, which were previously considered a sort of taboo, such that few surgeons ventured into the realm of this internal surgery. In the mid nineteenth century the possibility of suffering from severe infections, as an immediate complication after a firearm injury or after surgical intervention, was very high, ranging between 23% in London, up to 80% in Munich, according to the available records; in Zurich a 46% mortality is reported, and a similar 43% rate came from Edinburgh. The situation worsened during war time, since injured soldiers were recovered in extremely precarious conditions, ad hoc hospitals were located in dilapidated old buildings, and the physicians and health care providers were unaware of the minimum hygiene conditions required, and performed both operations and medications without taking sterility measures into consideration. The author reports and comments on the most significant parts on the documents written by Agostino Bertani, who described in full detail the clinical evolution of the wound suffered by Goffredo Mameli, the poet and patriot of the Italian Risorgimento who wrote the Italian national anthem. The clinical evolution of Mameli's disease was unfavourable: he underwent amputation of the left lower limb after the firearm injury suffered during the defence of the Roman Republic, since a gangrenous complication had become apparent. The poet died of septicaemia on July 6, 1849, 17 days after the surgical operation.

Background and Purpose: Rehabilitation of patients with transfemoral amputations is particularly difficult due to problems in using standard socket prostheses. We wanted to assess long-term fixation of the osseointegrated implant system (OPRA) using radiostereometric analysis (RSA) and periprosthetic bone remodeling., Methods: 51 patients with transfemoral amputations (55 implants) were enrolled in an RSA study. RSA and plain radiographs were scheduled at 6 months and at 1, 2, 5, 7, and 10 years after surgery. RSA films were analyzed using UmRSA software. Plain radiographs were graded for bone resorption, cancellization, cortical thinning, and trabecular streaming or buttressing in specifically defined zones around the implant., Results: At 5 years, the median (SE) migration of the implant was -0.02 (0.06) mm distally. The rotational movement was 0.42 (0.32) degrees around the longitudinal axis. There was no statistically significant difference in median rotation or migration at any follow-up time. Cancellization of the cortex (plain radiographic grading) appeared in at least 1 zone in over half of the patients at 2 years. However, the prevalence of cancellization had decreased by the 5-year follow-up., Interpretation: The RSA analysis for the OPRA system indicated stable fixation of the implant. The periprosthetic bone remodeling showed similarities with changes seen around uncemented hip stems. The OPRA system is a new and promising approach for addressing the challenges faced by patients with transfemoral amputations.

The epidemiological features and management practices associated with amputation in low-income countries, generally synonymous with the tropics, are different from those observed in Western countries. Unlike developed countries, amputation most frequently involves traumatic injury in young active people. However, Westernization of the lifestyle is leading to an increasing number of cases involving diabetes and atherosclerotic disease. In the developing world, leprosy and Buruli ulcer are still significant etiologic factors for amputation. In war-torn countries, use of antipersonnel landmines is another major cause of amputation with characteristic features. Management of amputees in the developing world is hindered by the lack of facilities for rehabilitation and prosthetic fitting. Many international organizations are supporting national programs to develop such facilities. In addition to being affordable, prosthetics and orthotics must be adapted to the living conditions of a mostly rural amputee population, i.e., heat, humidity, and farm work. The rehabilitation process must be part of a global handicap policy aimed at changing attitudes about disability and reintegrating amputees both socially and professionally.

Introduction: Entrapped trauma victims require extrication, which, on rare occasions, may involve amputation of a limb. Standard extrication techniques sometimes fail or may be impossible, leading to the death of the entrapped victim. We propose that the use of fire service hydraulic cutting equipment can be used effectively to urgently amputate a limb, where conventional techniques are unusable., Method: The study aims to determine: (i) the potential use of this equipment to achieve expeditious life-saving amputations and (ii) the effect the fire service hydraulic cutting equipment has on the bony and surrounding soft tissues. Initially a porcine limb was used followed by fresh-frozen cadaveric lower limbs. We recorded the time, number of cuts, proximal fracture propagation and quality of bone cut when performing amputations at five levels., Results: The experiment confirms that faster guillotine amputations in human cadaveric lower limb specimens can be achieved by using fire service hydraulic cutting equipment. Overall, the average time to complete an amputation in these ideal experimental circumstances at all five levels was quicker using the hydraulic cutting equipment. Either one or two cutting actions were required to achieve the amputation using fire service hydraulic cutting equipment. The degree and proximal extent of the comminution were greater using the fire service hydraulic cutting equipment., Conclusion: If circumstances and time constrains allow, a conventional amputation technique carried out by a trained medical practitioner would be preferable to the use of the fire service hydraulic cutting equipment. However, we feel that this technique could be used to perform emergent amputation under trained medical supervision, if it is felt that a standard amputation technique would take too long or the environment is too restrictive to perform a standard amputation safely., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Objective: Serious lower extremity injuries sometimes warrant emergency amputation. The goal of amputation in polytrauma patients is to increase chances of survival, while the goal of amputation in a single limb injury is to prevent further complications, e.g., infection, septic shock., Indications: Rescue from life-threatening lower extremity bleeding in a critically injured patient. Severe injury of a lower extremity: crushed, burned, frozen, advanced infection., Contraindications: Patient refusal., Surgical Technique: Supine position, determination of resection border, skin incision, identification of nerves and blood vessels, osteotomy, vessel ligation, separation of blood vessels and nerves, final removal of tissue with amputation knife, disposal of amputated extremity, skin closure., Postoperative Management: Wound care, careful compression wraps beginning on postoperative day 7, early prosthesis fitting, mental health care consultation., Results: From January 2008 until October 2010, 115 lower extremities were amputated at the BG Trauma Clinic in Ludwigshafen, Germany. A total of 42 amputations were posttraumatic and were performed in the clinic for trauma surgery and orthopedics. There were a total of 18 foot and toe amputations, 16 lower leg amputations, 5 knee amputations, and 3 above knee amputations. Comparison of the groups is difficult due to the varying mechanisms of injury and locations of amputation. Therapeutic decisions regarding emergency amputation are made with careful consideration of the patient.

Objective. Amputation through the diaphysis of the femur at the most peripheral level possible. The stump, covered with soft tissue flaps, is free from pain. It can be fitted with a total contact prosthetic socket. The hip joint is preserved with its full range of motion.Indications. When no possibility to amputate at a more distal level through the tibia or the knee joint exists.Contraindications. When it is possible to amputate at a more distal level.Surgical technique. Symmetrical flaps in the frontal plane are recommended. Asymmetrical flaps and flaps in the sagittal plane can also be made. Their muscles are fixed to each other (myodesis) or the bone end by means of transosseous sutures (myopexy). The ischial nerve has to be shortened about 2 inches proximal to the end of the femur.In peripheral vascular diseases, this procedure is not suitable. An alternative technique is suggested.In chronic osteomyelitis (e.g., after intramedullary nailing), the ventral half of the femur can be removed and the medullary cavity cleansed and filled with a muscular flap in order to maintain length. Lengthening procedures of the femur are discussed.Postoperative management. Avoid active or passive movement of the stump for the first 2 weeks in order not to disturb healing of the muscle sutures. Physical therapy, prosthetic fitting after 4–6 weeks, according to the expected functional level 0–4. Aids: crutches, wheel chair, adjustable bed, modified hand-controlled automobile.The walking ability of a patient with a double amputation above the knee is severely limited and in patients with peripheral artery disease remains the exception.

Degloving injury is the avulsion of the skin off the underlying muscle and bone, which may also involve the latter structures in high-energy trauma. This study reports the case of a 33-year-old male patient who sustained a motorcycle accident and presented with hypovolemic shock, multiple fractures, and multiplanar degloving injury of the leg. The foot and distal leg was not salvageable, and a transtibial amputation with anterior transposition of the posterior compartment muscles was performed; however, a circumferential skin necrosis involving the stump and the knee joint occurred. The wound granulated rapidly using circumferential vacuum-assisted closure therapy and subsequently repaired with split thickness skin grafts. The authors found the topical negative pressure using the Vacuum Assisted Closure (VAC) technique Trademark KCI, Texas, USA, method to be helpful in the care of lower extremity degloving injury, enabling less frequent dressing changes and facilitating formation of granulation tissue with rapid preparation of the wound bed for salvage of the knee joint.

Treatment of severe lower extremity trauma, diabetic complications, infections, dysvascular limbs, neoplasia, developmental pathology, or other conditions often involves amputation of the involved extremity. However, techniques of lower extremity amputation have largely remained stagnant over decades. This article reports a reproducible technique for transtibial osteomyoplastic amputation.

Orthopaedic surgeons use a variety of instruments to help correct, treat, and heal bone disease. The development of these instruments mirrors the history of orthopaedic surgery. The history of bonesetting, the treatment and replacement of joints, and of those who performed these techniques, appears to originate deep in antiquity. Changing ideas within medicine and surgery over the last 200 years have shaped the discovery and evolution of orthopaedic instruments and of the bonesetters themselves. Advances have led to the use of computers as instruments in the navigational guidance of arthroplasty surgery, the use of robotics, the development of cordless drills and improvements in the design of blades to cut bone. Yet some of the old instruments remain; plaster of Paris bandages, the Thomas Splint, Liston's bonecutter, Gigli's saw, bone nibblers and Macewan's osteotomes are still in use. This paper presents a historical review of bonesetters and examines how orthopaedic instruments have evolved from antiquity to the 21st century.

Prehospital surgical amputations are rarely necessary. This paper gives a historical perspective, the indications and contraindications for limb amputations, and details a simple technique for both surgeons and non-surgically qualified medical personnel.

Because of insufficient soft-tissue conditions and variability in the size and mechanical friction of the stump treatment of upper leg amputees with an ordinary prosthesis might be difficult or even impossible. Alternatively, for such patients an endo-exo femoral prosthesis (EEFP) is sometimes the best treatment option. The use of EEFPs will be demonstrated as exemplified by the clinical course in a patient with a primary EEFP implantation including all relevant side-effects and associated problems.

Minor amputations are frequently performed for neuroischemic or neuropathic lesions of the diabetic foot. Depending on the definition used, minor amputations can range from toe to Syme amputations. Minor amputations are often combined with necrosectomy and débridement. For early and optimal rehabilitation, as much vital tissue as possible should be conserved, especially considering the skeletal structures of the foot (borderline amputation). Minor amputations are of utmost importance for the prevention of ascending infections and reduce the duration of clinical and outpatient treatment. Minor amputations should be performed only by experienced surgeons and only if arterial perfusion is sufficient. They should be as tissue-conserving as possible and structured interdisciplinary postoperative care is mandatory. Metabolic control should be optimized. Controversial opinions exist with respect to the use of tourniquets, conservation or resection of cartilage and sesamoid bones, open amputation or primary closure of the wound, interdigital spacer function of toes, aseptic proximal transection of tendons, postoperative wound care, negative-pressure wound treatment and antibiotic therapy. In view of these controversies the most important minor amputation techniques are described and discussed.

Unlabelled: Because of skeletal muscle's density and vascularity, its transection with standard electrocautery can be tedious. In a pilot study we asked whether a linear cutting stapling device decreased surgical time, blood loss, transfusion rates, and complications in patients undergoing above-knee amputation when compared to traditional electrocautery. We retrospectively reviewed 11 patients with above-knee amputation cases using a linear cutting stapling device over a 10-year period and compared those to 13 patients in whom we used electrocautery. The patients treated with the linear cutting stapling device had an average of 97 minutes of surgical time, 302 cc blood loss, and 1.55 units transfusion, compared to an average 119 minutes, 510 cc, and 2.15 units, respectively, with the electrocautery cases. Despite the trends, these parameters, as well as major complications, were similar in these two small groups. In skeletal muscle transection, we believe the linear cutting stapler is a reasonable and potentially cost-effective technical alternative to electrocautery, possibly resulting in less blood loss and shorter surgical time with similar rates of complications., Level of Evidence: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Objective: In human subjects, leg amputation impairs upright quiet-stance control. The inability to exert appropriate force reactions under the amputated leg and a slight weight-bearing asymmetry cause the amputee to develop compensatory mechanisms through the sound leg. This study is aimed at assessing these mechanisms and the influence of the level of amputation., Design: The postural strategies of transtibial and transfemoral amputees for maintaining quiet stance were investigated using a dual-force platform. With this device, mean body weight distribution and plantar and resultant center of pressure trajectories can be measured and used to assess the likely compensatory mechanisms., Results: Compensatory strategies were found in both transtibial and transfemoral groups, with a forward shift of the mean positions of the center of pressure under the amputated leg and greater resultant center of pressure displacements appearing along the anteroposterior axis, respectively. The transfemoral group presents a larger center of pressure displacements under the amputated leg than the transtibial group., Conclusion: These data emphasize the role played by the differences between the center-of-pressure magnitudes intervening under the sound and amputated legs and the size of the prosthesis-stump contact area in these postural strategies.

Background: The creation of a bone bridge between the residual tibia and fibula is a controversial surgical technique used in the performance of transtibial amputation., Methods: Twenty consecutive patients who underwent a unilateral transtibial amputation, as a consequence of traumatic injury, had distal tibiofibular bone-bridging performed by a single surgeon. Eight completed the Prosthesis Evaluation Questionnaire (PEQ), a validated outcomes instrument designed to measure patient self-reported health-related quality of life after a lower-extremity amputation. Their responses were compared with those of a previously reported control group of nondiabetic patients who had undergone transtibial amputation with the use of a traditional technique and with those of a previously reported consecutive group of Brazilian patients, including twelve who were diabetic, who had undergone a similar bone-bridge procedure., Results: The scores in the American bone-bridge group were similar to those in the control group and not as good as those in the Brazilian bone-bridge group. The American bone-bridge and control groups scored lower in the Social Burden, Ambulation, Frustration, Sounds, Utility, and Well-Being domains of the PEQ., Conclusions: While many experts in the care of amputees believe that the distal tibiofibular bone-bridge technique improves patient functional outcomes, our small group of patients treated with this procedure did not appear to have better outcomes than a group of patients treated successfully with a standard surgical technique. More information is needed before the bone-bridge technique can be recommended as an important component of standard transtibial amputation surgery.

The literature on lower extremity prostheses from 1989 to 2006 has been reviewed in this article. New technologies, such as the microprocessor-controlled prosthetic knees and energy-storing/return prosthetic feet, are recent advances in the prosthetic field. Despite the extensive research to date in the areas of socket design and manufacturing, and alignment of prostheses for optimum gait analyses, problems persist in the field. Difficulties in obtaining a comfortable socket fit, prostheses weight and alignment guidelines, and the ability to rapidly manufacture a prosthetic socket that can accommodate the changing sizes of the residual limb persist. Furthermore, no prosthetic device can adjust to the typical movements of the human gait. These areas provide opportunities for further research and development.