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The Krukenberg operation--creating a sensory forceps--is indicated principally in bilateral below elbow amputation with blindness. Other indications are proposed, in particular in children. The limitations to this procedure are essentially aesthetic problems and should not be minimized. The operative technique is described in details.
Phantom pain refers to pain in a body part that has been amputated or deafferented. It has often been viewed as a type of mental disorder or has been assumed to stem from pathological alterations in the region of the amputation stump. In the past decade, evidence has accumulated that phantom pain might be a phenomenon of the CNS that is related to plastic changes at several levels of the neuraxis and especially the cortex. Here, we discuss the evidence for putative pathophysiological mechanisms with an emphasis on central, and in particular cortical, changes. We cite both animal and human studies and derive suggestions for innovative interventions aimed at alleviating phantom pain.
The extent of the cortical somatotopic map and its relationship to phantom phenomena was tested in five subjects with congenital absence of an upper limb, four traumatic amputees with phantom limb pain and five healthy controls. Cortical maps of the first and fifth digit of the intact hand, the lower lip and the first toe (bilaterally) were obtained using neuroelectric source imaging. The subjects with congenital upper limb atrophy showed symmetric positions of the left and right side of the lower lip and the first toe, whereas the traumatic amputees with pain showed a significant shift (about 2.4 cm) of the cortical representation of the lower lip towards the hand region contralateral to the amputation side but no shift for the toe representation. In healthy controls, no significant hemispheric differences between the cortical representation of the digits, lower lip or first toe were found. Phantom phenomena were absent in the congenital but extensive in the traumatic amputees. These data confirm the assumption that congenital absence of a limb does not lead to cortical reorganization or phantom limbs whereas traumatic amputations that are accompanied by phantom limb pain show shifts of the cortical areas adjacent to the amputation zone towards the representation of the deafferented body part.
Diagnostic imaging has played a major role in the evaluation of patients with cancers of the bone and soft tissue. The imaging modalities have included radiography, computed tomography, magnetic resonance imaging, and bone scintigraphy. Current experience suggests that functional imaging with positron emission tomography (PET) and [F-18]fluorodeoxyglucose (FDG) may also have an important role in the imaging evaluation of patients with bone and soft tissue sarcoma, including guiding biopsy, detecting local recurrence in amputation stumps, detecting metastatic disease, predicting and monitoring response to therapy, and assessing for prognosis. Prospective studies with large patient groups will be essential to define the exact diagnostic role of FDG PET in this clinical setting, which should also include an evaluation of the cost-effectiveness and the short-term and long-term benefits in clinical decision making and management. In this article, we review the diagnostic utility of dedicated PET and PET combined with computed tomography imaging system in the evaluation of patients with bone and soft tissue malignancies.
Severe crush injuries with avulsion require specific treatment strategies. Usually we find complete loss of soft tissue, nerves and vessels, where only tendons and parts of the phalanges are preserved. Primary reconstructive procedures are usually not possible due to the complexity of the injury with severely destroyed structures. Bone shortening should be avoided in order to maintain finger length and motion. Therefore, emergency soft-tissue coverage represents the first step. Later, sensibility and mechanical stability of the skin should be restored. In our clinic, seven patients with this injury pattern were treated. Three cases involved four finger crush-avulsion injuries. In all cases, we performed a primary soft-tissue coverage with a pedicled flap. In a second session, the skin areas of the first web space of both feet were transplanted as neurovascular flaps. With this strategy, a useful hand function could be restored. The functional results are described and advantages and disadvantages of various techniques discussed.
This article presents the authors' experience with the anterolateral thigh free flap for lower extremity reconstruction. Twenty-one consecutive anterolateral thigh flaps were transferred for reconstruction of soft-tissue defects of the lower extremity from March 2000 to May 2002. Total flap survival was 90.5 percent, with two partial failures. Venous congestion was observed in one flap (4.7 percent) and the venous anastomosis was revised immediately in the postoperative second hour. The mean follow-up time was 13.4 months (range: 5 to 26 months). The cutaneous perforators were consistently found and presented as musculocutaneous in 19 patients (90.5 percent) or septocutaneous in two other patients (9.5 percent). A thinned anterolateral thigh flap was used in 11 patients. Sensate flaps were used in four patients (19.05 percent) for the reconstruction of amputation stumps. Five flaps (23.8 percent) were used also as flow-through flaps. All patients were satisfied with the cosmetic and functional results. The anterolateral thigh flap has many advantages over other free flap donors in lower extremity reconstruction. These include a long and large caliber vascular pedicle, large and pliable skin paddle, good color and texture matching, and minimal donor-site morbidity. Moreover, the flap can be used successfully and safely as a sensate, thin, or flow-through flap. The anterolateral thigh flap can be accepted as an ideal free flap choice for lower extremity reconstruction because it has maximal reconstructive capacity and produces minimal donor-site morbidity.
The advantage of the medial sural (GASTROCNEMIUS) muscle perforator free flap is that it is relatively thin, even in most obese individuals, and the donor site can be acceptable, if morbidity must preferably be restricted to the lower extremities. Unfortunately, anatomic anomalies of both the arterial and venous circulation are not infrequent, making this a somewhat less than perfect donor site in the author's total experience using this flap. Nevertheless, the contralateral calf skin was successfully used, as shown in a clinical example, to cover a transmetatarsal amputation stump. This allows the conclusion that, at least as a technical exercise, the medial sural (GASTROCNEMIUS) muscle perforator free flap as a microsurgical transfer can be used as an "immediate" cross-leg flap. This is reminiscent of bygone eras, where such a feat required multiple stages over many weeks.
Almost everyone who has amputated a limb will experience a phantom limb. They have the vivid impression, that the limb is still present. 60 to 70% of these amputees will suffer from phantom limb pain. The present paper gives an overview of the incidence and the characteristics of the so called "post amputation syndrome". Possible mechanism of this phenomena are presented, including peripheral, spinal, and central theories. Treatment of phantom limb pain is sometimes very difficult. It includes drug therapy, psychological therapy, physiotherapy as well as the prevention of phantom limb pain with regional analgesia techniques.
Free-tissue transfers enable surgeons to reconstruct or salvage limbs injured or amputated in high-energy traumas which result in extensive damage to soft tissue, bone, tendons, vessels and nerves. Primary free-tissue transfer is performed following debridement, bone fixation, and repair of injured structures within 24 hr after injury. Between 1987 and 1996, 57 patients who had complex extremity traumas were treated with primary free-tissue transfer, or free flaps. Long-term follow-up ranged from 4 months to 9 years (median: 4.5 years). No flap failure or serious wound-healing complication occurred using the protocol. Radical debridement and primary free-flap coverage in extensive extremity injuries can salvage limbs, provide improved functional and aesthetic results, and psychologically benefit patients through lowered morbidity. Other benefits include reduced incidence of free-flap failure, postoperative infection, secondary operative procedures, and invalidity, as well as shorter hospital stays, and lowered medical expenses.
The authors report eight microsurgical operations to repair soft tissue defects of the fingers using free neurovascular autografts taken from the lateral surfaces of digits 3 and 4. In seven cases, the transferred flaps survived, and one case resulted in necrosis of the transplant. Follow-ups were from one to 12 months. Good cosmetic and functional results were recorded including restoration of sensory discrimination. The procedure described is regarded as an alternative for repairing terminal and other soft-tissue defects of the fingers.
Since 1991 seven children aged between 5-17 years have been treated at the University Children's Hospital in Basel for 10 traumatically partially amputated phalanges with a newly developed external fixator and distractor. Through continual distraction of the osteotomy a phalanx lengthening of 3-10 mm has been achieved (on average 55% of the rest phalanx). The results of this method in distal phalanx amputation with resulting nail dystrophy (claw nail) has shown functional and cosmetic improvements. The average distraction and consolidation phases lasted 5 weeks. The after care lasted 2-12 months. As children have good distraction-histogenesis bone grafting is not necessary. A prerequisite would be, however, an intact or appropriately prepared integument. The advantage of this external fixator and distractor system is that it is suitable for the delicate anatomical structures of a child's hand. The distractor component is only necessary for a distraction step to be carried out. A further advantage of this system is the relatively light but stable construction.
A 47-year-old man with an angiosarcoma of the right lower extremity was cured with mainly surgery and radiotherapy despite an inguinal metastasis. Histologically, the amputation stump of the metastatic tumour showed invasion by tumour. Radiotherapy, chemotherapy, and treatment with interleukin-2 was added. Ten years later he has had no recurrence.
This study analyses the motion of the residual femur within a trans-femoral socket during gait using ultrasound data from two simultaneously transmitting transducers connected to two ultrasound scanners. Calibration tests accurately established the orientation of the two transducers mounted on the lateral wall of the socket. Relative positions of the ultrasound image of the femur were measured on video playback. Motion of the residual femur, relative to the lateral wall of the socket, at any instant during gait may be estimated, if the relative positions of the two transducers and the motion of the ultrasound image are known. A consistent pattern of femoral motion during 10 gait cycles is displayed graphically. The femoral motion in this paper is expressed as abduction/adduction or flexion/extension relative to the socket. However, without a full gait analysis study, the orientation of the socket relative to the ground or relative to the pelvis cannot be determined. Only one ultrasound scanner may be available for clinical use. Hence data collection may be restricted to only one transducer during gait. In order to simulate the single transducer mode, the ultrasound data recorded during the 10 previous gait cycles, was averaged at any instant of the gait cycle. The angular orientation of the femur was calculated based on the averaged data. Similar patterns of femoral motion were obtained irrespective of the technique adopted.
Rehabilitation of trans-humeral amputees represents a challenge. One of the difficulties to overcome is prosthetic suspension. In the case of elbow disarticulation the presence of humeral condyles permits better suspension, but there is no room for elbow joints, particularly electronic ones, and the only available mechanisms are provided by external hinges. The purpose of this report is to present a case of a primarily elbow disarticulated patient, with indication for surgical revision due to bad skin coverage, neuroma and the wish to improve prosthetic fitting. The surgical plan outlined was to produce a shortening of the humerus, by means of an osteotomy just above the humeral condyles, preserving them for prosthetic suspension. This bone reduction was carried out with complementary shaping of bone segments with an indentation to enhance fixation. The operation was completed with neuroma resection, myodesis and removal of the skin grafted area. Preservation of the humeral condyles actually produced effective suspension. For final fitting a Utah Arm II was used, with wrist rotator, and interchangeable hand and Greifer for terminal devices. Good initial results and at nine months follow-up suggest this procedure should be considered in other elective situations.
This study analyses the residual femur motion of a single amputee within a transfemoral socket during a series of daily living activities. Two simultaneously transmitting, socket mounted transducers were connected to two ultrasound scanners. Displacement measurements of the ultrasound image of the femur were video recorded and measured on "paused" playback. Abduction/adduction and flexion/extension of the residual femur within the socket at any instant during these activities were estimated, knowing the relative positions of the two transducers and the position of the residual femur on the ultrasound image. Consistent motion patterns of the residual femur within the trans-femoral socket were noted throughout each monitored daily living activity of the single amputee studied. Convery and Murray (2000) reported that during level walking, relative to the socket, the residual femur extends 6 degrees and abducts 9 degrees by mid-stance while flexing 6 degrees and adducting 2 degrees by toe-off. Uphill/downhill, turning to the right and stepping up/down altered this reported pattern of femoral motion by approximately 1 degree. During the standing activity from a seated position the femur initially flexed 4 degrees before moving to 7 degrees extension, while simultaneously adducting 6 degrees. During the sitting activity from a standing position the femur moved from 7 degrees extension and 6 degrees adduction to 3 degrees flexion and 1 degree abduction. The activity of single prosthetic support to double support introduced only minor femoral motion whereas during the activity of prosthetic suspension the femur flexed 8 degrees while simultaneously adducting 9 degrees. Additional studies of more amputees are required to validate the motion patterns presented in this investigation.
The use of arm prosthesis in trans-humeral amputees is limited; due to the cone form of the amputation stump. A Humerus-T-Prosthesis was implanted in three patients to create artificial humerus condyles. Two of the patients were successfully rehabilitated with the application of a new type trans-humeral arm prosthesis. This arm prosthesis had a socket which is suspended and stabilized by the humerus and implant only. Traction and rotational stability were secured by adjustable pressure adaptation around the artificial condyles. The third patient developed a pressure wound over the lateral part of the artificial condyle that later healed. He also was subject to a new trauma with a fracture of the ipsilateral scapula and until now has had limited the use of his new arm prosthesis. It was concluded that this new concept for prosthesis fitting of trans-humeral amputees looks promising, but alternative designs of the implant should be tested.
The dominant model of cortical plasticity induced by peripheral denervation suggests that a physiologically-reorganized cortical area can acquire new perceptual meaning, including a change in the peripheral referral of sensation. An alternative view is that such an area may retain its former perceptual significance, even though it becomes responsive to new peripheral inputs. To examine evidence related to this issue, a clinical case is presented documenting the time course of changes in phantom limb sensation in a patient with accidental amputation of a hand. About 24 h after injury, a vivid phantom hand was present; tactile stimulation revealed cutaneous trigger zones on the arm, stimulation of which elicited sensation referred to specific fingers of the phantom. While the phantom hand percept remained fairly stable over time, the trigger zones expanded progressively in size during the next 1-8 weeks but had contracted and changed location considerably about one year later. At all times studied, the trigger zones were topographically related to specific fingers and other parts of the phantom hand. The implications of these and other recent clinical findings for cortical reorganization are discussed, and the following tentative conclusions are drawn. (1) A phantom percept is mediated by central neural networks which remain functionally intact after amputation. (2) Cutaneous trigger-zones mapped in humans correspond to novel receptive fields of cortical neurons mapped in animals following peripheral denervation. (3) Cortical reorganization induced by denervation does not produce a major change in perceptual meaning or peripheral reference. In the present case, stimulation of new trigger zones (receptive fields) on the patient's arm presumably activated a reorganized cortical hand area but evoked sensation still referred to the (now missing) hand. Hence, physiological cortical remapping is not necessarily accompanied by functional respecification.
This case report presents a 51 year old female patient who had a train accident in 1999. She suffered bilateral trans-tibial and bilateral trans-radial amputations. In this paper, the evolution of the right transradial amputation where eventually a Krukenberg procedure was performed, is described as is its good functional outcome after rehabilitation treatment. After this first procedure the patient also asked for the Krukenberg procedure for her left arm.