Biomedical subjects
Publications and source records attributed to H Osterman.
Four diabetic patients with gangrene of the forefoot and infection ascending above the ankle were treated with open amputation of the foot combined with open fasciotomy and debridement of the involved proximal muscle compartments. All four patients healed their wounds and returned to their premorbid community ambulation status. The management and indications in these unusual patients are discussed.
Ten patients with infected or apparently failing below-knee amputations were treated with total contact casting and continued weight bearing ambulation with a commercially available temporary prosthesis. Amputation was performed for peripheral vascular insufficiency in all patients. Seven of the patients were diabetic, five being insulin dependent. All ten were treated as outpatients and proceeded to heal their wounds and continued to function as independent community ambulators during treatment. None of the patients required surgical revision and each was successfully fit with a permanent below-knee prosthesis.
Two consecutive series of patients undergoing below-knee amputation for peripheral vascular insufficiency were compared relative to the length of acute-care hospitalization and rehabilitation. The residual limb control group was treated with soft-surgical dressings and non-weight bearing ambulation with referral to the amputee clinic when the residual limb wound was "ready." The residual limb experimental group was treated with rigid plaster (cast) dressings with early post-surgical prosthetic limb fitting and progressive weight bearing ambulation. Acute-care hospitalization following amputation surgery averaged 27.7 days in the control group, and 23.7 days in the treated group. Patients were either re-admitted or transferred to a rehabilitation unit where hospitalization averaged 42.9 days in the control group and 14.1 days in the treated group. This resulted in a cost savings of almost $15,000 per patient based on present hospital fees. The results of this study suggest that early post-surgical prosthetic limb fitting not only hastens recovery amputation, but can be safe and cost effective.
Sixty adult patients had psychologic testing following successful below- or above-knee amputation surgery. All were considered to be prosthetic candidates based on the evaluation of an experienced multidisciplinary rehabilitation team. Objective psychologic testing revealed that six (10%) had severe deficits in cognitive ability, eight (13%) had covert psychiatric illness, and three (5%) had both. A vigorous attempt at prosthetic limb fitting and gait training was made in every patient in an inpatient rehabilitation unit. Of the 17 patients (28%) who were determined to be poor candidates for prosthetic limb fitting and gait training based on objective psychologic testing, only four (6%) were capable of even minimal use of the prosthesis, and none approached their preamputation level of ambulation. Psychologic testing may play an important role in determining the rehabilitation potential of the dysvascular amputee.
Forty-six adult patients had a through-the-knee amputation (disarticulation of the knee) in a four-year period. Thirty-four of the patients had peripheral vascular insufficiency and were judged to lack the potential for using a prosthesis functionally, although the evaluation indicated that they had the potential for healing of the wound at the below-the-knee level of amputation. At a minimum follow-up of one year, the amputation wound had healed in thirty of these patients, and no joint contracture had developed. Two patients died in the first postoperative month, and two had failure to heal and needed revision to an above-the-knee amputation. The remaining twelve patients who had a through-the-knee amputation were judged to be potentially able to use a prosthesis functionally, but they did not have the capacity for wound-healing at the below-the-knee level. Therefore, in these patients, a through-the-knee amputation was performed as an alternative to an above-the-knee amputation. The amputation wound healed in eight of these patients, but four (33 per cent) had failure to heal and needed subsequent revision to an above-the-knee amputation. All twelve patients were able to use a prosthesis. The through-the-knee amputation provides good muscular balance and has a low risk for the late development of joint contracture. The residual limb (stump) provides an excellent surface area for sitting balance and a lever-arm for transfer. In a patient who has the potential to use a prosthesis functionally, the residual limb allows direct load-transfer (end weight-bearing).(ABSTRACT TRUNCATED AT 250 WORDS)
Early prosthetic fitting and independent ambulation are major goals in the rehabilitation of amputees with early walking being extremely valuable in the physical and psychosocial rehabilitation of the amputee. With early resumption of weight bearing and ambulation, deterioration of postural reflexes can be prevented and the residual limb (stump) can be shaped for definitive prosthetic fitting. A new temporary prosthesis was evaluated in its use on new below-knee amputees. The prosthesis is a plastic, hollow form which fits over the conventional rigid, plaster postoperative dressing. It comes in one size and is cut to fit the patient. The prosthesis is readily available, needs little training for its application, can be re-used, and is inexpensive. Twenty-two consecutive patients treated at Hines Veteran's Administration Hospital and Loyola University Medical Center underwent below-knee amputations. All were determined to be potential walkers. The average age at surgery was 61 years with a range of 17 to 74 years. Amputation was performed for trauma in two patients and gangrene in the other 20. All wounds were dressed with conventional rigid, plaster dressings with cast changes five days postoperatively. The prefabricated temporary prosthesis was applied at the second cast application at an average of 8.1 days postoperatively with permanent prosthetic fitting at 7.7 weeks. There were no complications related to the use of the plastic temporary prosthesis. The use of a new plastic temporary prosthesis has been found to be advantageous in the early rehabilitation of below-knee amputees.
Recent trends in amputation surgery favor amputation at the most distal level to preserve the patient's ability to walk. This paper reports the results of sixty-four amputations performed at the level of the middle of the foot in fifty-eight patients. All were performed in patients with peripheral vascular disease who had a diagnosis of either gangrene or resistant, nonhealing ulcers. Forty-three patients (74 per cent) had diabetes. Nutritional evaluation of the patient was used to improve the potential for healing. In the initial forty-six patients, a retrospective review of the serum albumin level, the blood total-lymphocyte count, and the Doppler ischemic index was performed. A prospective study was performed in the final twelve patients, in whom a minimum level in each of these three factors was required before the distal amputation was done. The healing rate for all sixty-four amputations was 81 per cent. When all three factors were above the minimum level, the healing rate was increased to 92.2 per cent. When one or two of the factors was below the minimum level, the rate of healing decreased to 38.5 per cent. Aggressive distal amputation can be performed with a high rate of success when the factors influencing the decision on the amputation level include non-invasive vascular testing and nutritional evaluation.