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At least 19 recordsLinked to original sources

PubMed1979

Extended deep femoral angioplasty and lumbar sympathectomy as a limb salvage procedure.

Limb salvage in 27 limbs (26 patients) using the combined operations of extended deep femoral angioplasty and lumbar sympathectomy is described. A successful result was obtained in 14 cases (52%) at 6 months falling to 12 (45%) at 16 months. Prediction of outcome and postoperative progress was monitored by the measurement of the leg: arm pressure ratio using the Doppler ultrasound apparatus. No patient with a preoperative ratio of less than 0.3 had a successful result. It is proposed that lumbar sympathectomy is a logical adjunct to surgery in these patients in order to enhance the development of the collateral circulation.

Aged↗

PubMed1991

The nursing role in limb salvage surgery.

Limb salvage surgery has proven itself as a valuable option for sarcoma patients. The reconstruction options are vast and include metallic implants, allografts, and a combination of both. The nursing implications for these patients are unlimited. The patient needs to be educated and assessed closely for complications such as infections, nonunion of the allograft, and limited mobility. Although the nursing care is more complicated, the rewards with working with these patients are great.

Bone Neoplasms↗

PubMed1985

Psychological outcome of extremity sarcoma survivors undergoing amputation or limb salvage.

When compared to amputation, limb salvage procedures for extremity sarcomas have been advocated because of potential functional benefits and presumed psychological-outcome advantages. The purpose of this study was to compare psychological outcomes between survivors who underwent either amputation or limb salvage procedures for extremity sarcomas. Fifteen amputees and 20 patients with salvaged limbs (mean age, 37.9 years; range, 15 to 71 years) were evaluated 1 to 5 years after surgery for extremity sarcomas. Demographic and medical information was obtained and cognitive functioning, affect, mood, body image, physical functioning, global psychological adjustment to illness and surgery, and lifetime prevalence of psychiatric disorders before and after surgery were assessed. Two patients were excluded because of the presence of an incapacitating organic mental syndrome. The remaining patients, 14 amputees and 19 patients with salvaged limbs, had a variety of soft-tissue and bone sarcomas. No significant differences were found between the groups in age, sex, marital status, surgically involved extremity, chemotherapy status, and social class at the time of surgery and interviews. There were no significant differences between the groups in scores of cognitive capacity, symptoms, mood, body image changes, global physical functioning, global adjustment to illness and surgery, and lifetime prevalence of psychiatric disorders before or after surgery. Most patients revealed only mild psychological symptoms and 55% demonstrated good to excellent adjustment to their surgeries and diseases. There were no significant differences in measures of psychological outcome for patients with extremity sarcomas who underwent limb salvage procedures compared to those who underwent amputation. A psychological-outcome advantage of limb-salvage surgery compared to amputation has yet to be demonstrated.

Adaptation, Psychological↗

PubMed1986

Staged infrainguinal revascularization: initial prosthetic above-knee bypass followed by a distal vein bypass for recurrent ischemia. A valid concept for extending limb salvage?

Optimal infrainguinal revascularization should provide limb salvage for the longest duration of time. It is not known whether limb salvage is longer with an initial below-knee popliteal or tibial in situ saphenous vein graft or with staged bypasses; that is, an initial above-knee popliteal prosthetic bypass if feasible, followed by a more distal vein graft should the above-knee prosthetic graft fail. A retrospective review of 197 lower extremity vascular reconstructions performed since 1976 utilizing polytetrafluoroethylene (PTFE), umbilical vein, or in situ saphenous vein was completed. The data were analyzed for differences in limb salvage and prevention of limb threatening ischemia among three subgroups: above-knee prosthetic bypass, below-knee or tibial in situ saphenous vein bypass, and staged reconstructions (above-knee prosthetic bypass with subsequent in situ bypass). The groups were similar with respect to severity of limb threatening ischemia as indicated by mean preoperative ankle-brachial indices. Cumulative secondary limb salvage at 36 months was 73 percent for prosthetic grafts in the above-knee position, 78 percent for in situ saphenous vein grafts in the below-knee or tibial position, and 87 percent for staged reconstruction with an initial prosthetic graft to the above-knee position followed by a distal in situ vein bypass when the prosthetic graft fails.

Arteriosclerosis↗

PubMed1990

Results of infrainguinal bypass for limb salvage in patients with end-stage renal disease.

Limb salvage in patients with end-stage renal disease (ESRD) is complicated by the diffuse, obstructive, calcific arteriopathy that makes anastomotic technique especially critical. Furthermore, decreased resistance to infection and impaired wound healing produced by host-factor deficiencies such as diabetes mellitus, hypoalbuminemia, uremia, and immunosuppression produce additional obstacles to successful limb salvage. This report summarizes our experience with distal arterial bypass procedures in these patients. A total of 32 bypass procedures were performed for limb salvage in 24 patients (17 diabetic) during a period of 5 years. The operative mortality rate was 6%. During the same period, 635 infrainguinal bypass procedures were performed by the in situ technique in patients without ESRD. Primary bypass patency was comparable in both groups at 24 months (92% vs 90%). In the group with ESRD, overall limb salvage was 83% at 2 years. Life-table analysis of bypass patency and limb salvage was thought not to be appropriate in the population with ESRD beyond 2 years because of the increased mortality rate (38%; 9/24) during this interval. It is important that limb salvage was achieved in diabetic patients with ESRD in the presence of extensive foot gangrene or ischemic ulceration. Revascularization should be considered strongly for limb salvage in all patients in this difficult population.

Adult↗

PubMed1990

Limb salvage versus amputation. Preliminary results of the Mangled Extremity Severity Score.

Objective criteria can predict amputation after lower-extremity trauma. The authors examined the hypothesis that objective data, available early in the evaluation of patients with severe skeletal/soft-tissue injuries of the lower extremity with vascular compromise, might discriminate the salvageable from the unsalvageable limbs. The Mangled Extremity Severity Score (MESS) was developed by reviewing 25 trauma victims with 26 severe lower-extremity open fractures with vascular compromise. The four significant criteria (with increasing points for worsening prognosis) were skeletal/soft-tissue injury, limb ischemia, shock, and patient age. (There was a significant difference in the mean MESS scores; 4.88 in 17 limbs salvaged and 9.11 in nine limbs amputated; p less than 0.01). This scoring system was then prospectively evaluated in 26 lower-extremity open fractures with vascular injury over a 12-month period at two trauma centers. Again, there was a significant difference in the mean MESS scores; 4.00 for the 14 salvaged limbs and 8.83 for the 12 amputated limbs (p less than 0.01). In both the prospective and retrospective studies, a MESS score of greater than or equal to 7 had a 100% predictable value for amputation. This relatively simple, readily available scoring system of objective criteria was highly accurate in acutely discriminating between limbs that were salvageable and those that were unsalvageable and better managed by primary amputation.

Adult↗

PubMedDate not supplied

Five year experience with axillopopliteal bypasses for limb salvage.

Over the last 5 years, we have performed 34 axillopopliteal bypasses to salvage threatened limbs of patients in whom standard anatomic or extra-anatomic bypasses had either failed or were not feasible. The indications for these axillopopliteal bypasses, all of which were performed with 6 mm polytetrafluoroethylene grafts, were: (1) severe atherosclerotic disease of the common, superficial and deep femoral arteries which precluded use of these vessels for inflow or outflow for a standard vascular procedure (15 cases); (2) failed aortofemoral bypass with sufficient fibrosis or disease progression in the profunda femoris artery to prevent its use in a reoperation (7 cases); (3) insufficient hemodynamic improvement and failure to heal a foot lesion after an axillofemoral bypass (9 cases); and (4) sepsis in the groin from a previously infected bypass (3 cases). Graft patency was determined by objective measures. Cumulative life table graft patency rates were 77% at 1 year, 51% at 3 years, and 45% at 5 years. Although these rates are not as good as those for our axillofemoral bypasses (75% at 5 years), 22 limbs revascularized by axillopopliteal bypasses were salvaged with function for 1 year and 9 were salvaged with function for 2 years or longer in situations in which no option other than amputation was available. This justifies the continuing use of axillopopliteal bypass in an effort to salvage those limbs imminently threatened with amputation and in which no standard reconstruction is feasible because of disease or infection.

Aged↗

PubMed1985

Limb salvage for malignant tumors of bone.

With the use of preoperative therapy of chemotherapy and radiation, limb salvage has been possible in more than 95% of patients with highly malignant bone tumors. Without preoperative treatment, limb salvage is possible in only 40% of the patients. In our experience, improved limb salvage is a direct result of the preoperative therapy. We are not sure this preoperative therapy is the ideal one, or whether the intraarterial Adriamycin is superior to intravenous administration, or whether the dose of radiation is the proper one, or even whether radiation is necessary at all. These questions remain unanswered at this time. However, the pathologist's evaluation of the excised specimens shows that the preoperative treatment has definite beneficial effect for more than 80% of the patients on this program. Local control is equal with either amputation or limb salvage. Additionally, the overall survival rate is identical for either limb salvage or primary amputation. The major factor for patient survival appears to be the systemic adjuvant chemotherapy. Limb salvage as practiced at UCLA is as effective as amputation for control of malignant bone tumors. The selection of patients for our limb salvage program has not adversely affected the rate of disease progression or ultimate survival. The cosmetic and functional results of limb-salvage surgery is at least comparable to if not better than external prostheses. Finally, the only factor that appears to influence long-term survival in a positive manner is participation in a polydrug postoperative adjuvant chemotherapy program.

Amputation, Surgical↗

PubMed1979

The elderly patient with severe arterial insufficiency of the lower extremity: limb salvage by femoro-popliteal reconstruction.

To determine the feasibility of limb salvage in elderly patients in whom severe ischemia of the lower extremity is present, the results of femoro-popliteal reconstruction done primarily for limb salvage were reviewed. Of 310 femoro-popliteal bypasses, 72 were performed on patients 70 years of age or older. In the over-70 group, ischemic necrosis was present in 70.8% rest pain in 22.2%, and claudication in 7.0%. Initial limb salvage patients 70 years of age or older was 71.4%. Cumulative limb salvage at 5 years was 51.1% and at 10 years was 44.8%. Operative mortality, including mortality of subsequent amputation, when required, was 8.3%. Appreciable limb salvage can be achieved by femoro-popliteal arterial reconstruction in lieu of primary amputation in elderly patients in whom severe arterial insufficiency of the lower extremity is present.

Age Factors↗

PubMed1985

Isolated profundaplasty for limb salvage.

Fifty-four patients underwent 56 profundaplasties for limb salvage. All had stenosis greater than 50% in diameter of the deep femoral artery and associated superficial femoral artery occlusive disease. After profundaplasty, ischemic ulcers healed in 9 of 17 (53%) patients. Rest pain was relieved in 6 of 19 (32%) and areas of ischemic necrosis healed in 7 of 20 (35%). Cumulative patency of the deep femoral artery was 49% at 3 years but fell to 21% at 5 years, whereas cumulative limb salvage was 49% and 36%, respectively. Eleven of the required 28 amputations were performed in the immediate postoperative period. Profundaplasty was used to lower the amputation level and preserve the knee joint in six patients. The other five early amputations occurred in severely ischemic limbs without distal vessels suitable for bypass. The profundaplasty remained patent in all 19 patients who underwent below-knee amputation and 16 (84%) became ambulatory with a prosthesis. Hemodynamic data provided by determination of the profundapopliteal collateral index predicted limb salvage in 10 of 11 (91%) of limbs when the index value was less than or equal to 0.19. Other clinical criteria, such as preoperative ankle-brachial index and the presence of diabetes mellitus, had no predictive value. Isolated profundaplasty for limb salvage is an effective first procedure for selected patients and provides a reasonable alternative to primary amputation or high-risk distal bypass. When amputation is inevitable, effective perfusion of the profunda femoris artery is essential for preservation of the knee joint and results in a high degree of functional rehabilitation.

Aged↗

PubMed1991

Infrainguinal revascularization for limb salvage in patients with end-stage renal disease.

We studied the efficacy of infrainguinal bypass for limb salvage in patients with end-stage renal disease. The patency of 42 femoropopliteal and femorodistal bypasses, performed for limb salvage in 37 patients with end-stage renal disease, was assessed with Doppler ultrasonography and dye tests. Patency rates and limb salvage were determined by life-table analysis. Average age was 45 years (range, 28 to 61 years); 23 of the 37 were men. Twenty-three patients had diabetes mellitus, and 16 were smokers. Bypass procedures were done in 32 instances while the patients were maintained with chronic hemodialysis and in five instances with peritoneal dialysis; in five instances the patients had had successful renal transplantation. Indications for revascularization included pain at rest, nonhealing ulcer, or distal gangrene. Femoropopliteal bypass was done in 32 limbs; 10 were more distal procedures. Reversed saphenous vein was the conduit in 30 cases; prosthetic material was used in the remainder. Autogenous material was used in all distal bypasses. Four patients required graft revision during the initial hospitalization, but none thereafter. Two patients died within the operative period, nine within 18 months of operation. Nine major operations were required. Three-month cumulative graft patency was achieved in 41 cases and corresponding limb salvage in 33 cases; 18-month patency was achieved in 34 cases and overall limb salvage in 33 cases. Success of limb salvage most closely correlated with preoperative ankle-brachial ratio and level of bypass required.

Adult↗

PubMedDate not supplied

Limb salvage surgery in end stage renal disease: is it worthwhile?

The role of limb salvage surgery in patients with end stage renal disease (ESRD) is controversial. In view of this debate, we reviewed our experience with 54 primary and 15 secondary revascularizations for limb salvage in patients with ESRD over the past decade. Thirty-seven patients required dialysis and 10 had functioning renal transplants. Severe limb threatening ischemia was the indication for all revascularizations. The 2-year cumulative secondary graft patency rate was 56.2% with an associated limb salvage rate of 71.4%. There was no significant difference in graft patency or limb salvage rates between patients requiring dialysis and those with functioning renal allografts (p = 0.5). The 30-day operative mortality for the 99 surgical procedures (69 arterial bypasses and 30 additional operations) was 13% and the 2-year patient survival was 45.6%. Six of the 15 amputations were performed despite a patent graft on limbs which had extensive infection and gangrene. We conclude that limb salvage surgery should only be undertaken with recognition of these risks in patients with ESRD or functioning renal transplants. Surgery should be performed before gangrene and infection become extensive. Patients with unrelenting infection or mid-forefoot gangrene should be considered for primary amputation.

Adult↗

PubMed1986

Limb salvage in octogenarians and nonagenarians.

Although advanced age has often been a relative contraindication to attempts at limb salvage, we have not regarded it as an important deterrent to arterial reconstruction. Our 6-year experience with 168 consecutive patients over 80 years of age who underwent arterial reconstruction or percutaneous transluminal angioplasty represented 18% of all patients treated with limb-threatening ischemia during this period. The average age was 84 years, with 14 patients over 90 years of age. Sixty-eight patients were men (41%) and 100 were women (59%). Indications for treatment in 189 limbs were restricted to limb salvage. One hundred eighty-two operative procedures were performed consisting of 84 femoropopliteal, 72 femorotibial, 12 axillofemoral, 11 femorofemoral, two axillopopliteal and one iliofemoral bypass. Percutaneous transluminal angioplasty was performed in 12 iliac and 14 femoral or popliteal arteries as an alternative (seven) or adjunct (19) to vascular reconstruction. The 30-day procedural mortality rate was 6%. The cumulative life table survival rate of all patients who underwent an attempt at limb salvage was 78% at 1 year, 65% at 2 years, and 54% at 3 years. Cumulative life table limb salvage rates were 84% at 1 year, 74% at 2 years, and 71% at 3 years. Overall graft patency for 182 arterial reconstructive operations was 80% at 1 year and 62% at 3 years. Of patients in whom limb salvage was attempted, 65% lived more than 1 year and 51% more than 2 years with a functional limb. Of patients who died within 5 years of treatment, 76% did so with their previously threatened limb intact. These data support an aggressive approach to arterial reconstruction in elderly patients and indicate that advanced age alone should not be considered a contraindication to attempts at limb salvage.

Actuarial Analysis↗

PubMed1991

Limb salvage versus traumatic amputation. A decision based on a seven-part predictive index.

In severe traumatic injuries to the lower extremity, it is often a difficult decision to attempt heroic efforts aimed at limb salvage or to amputate primarily. To answer this question, the authors performed a 5-year review of 70 limbs in 67 patients. Patients were identified as presenting with major lower extremity trauma and an associated arterial injury. Nineteen (27%) of the 70 limbs were amputated. Limb salvage was not related to the presence or absence of shock and order of repair (orthopedic or vascular). No statistical difference was noted between the time of injury to operative repair in either the amputated or limb salvage group. Limb salvage was related to warm ischemia time and the quantitative degree of arterial, nerve, bone, muscle, skin, and venous injury. A limb salvage index (LSI) was formulated based on the degree of injury to these systems. All 51 patients with an LSI score of less than 6 had successful limb salvage (p less than 0.001). All 19 patients with an LSI score of 6 or greater had amputations (p less than 0.001). Although statistics cannot replace clinical judgment, this index can be a valuable objective tool in the evaluation of the patient with a severely traumatized extremity.

Adolescent↗

PubMed1989

Intermediate results and functional evaluation of limb-salvage surgery for osteosarcoma: an intergroup study in Japan.

This is a 2-7-year follow-up report by 21 institutes in Japan concerning limb-salvage surgery for osteosarcoma. Between 1980 and 1985, 248 patients with osteosarcoma were treated, and 105 patients had limb-salvage surgery. The percentage of cases treated by limb-salvage surgery increased with each year. The cumulative survival rate was 71% at 5 years in the limb-salvage group, and in the amputation group it was 46%; this indicates that cases for limb-salvage patients, tumor resection was classified this procedure. In limb-salvage patients, tumor resection was classified according to the surgical margin as intralesional excision, marginal excision, wide-with-marginal resection, wide resection, and radical resection. Wide resection was performed in most cases as the method of choice. Local recurrence was seen in 13 cases (12%). The overall functional evaluations by Enneking's system showed that the number of results rated excellent or good was relatively high in the early follow-up period, but this decreased later on, and cases rated fair or poor increased as the years passed. This was mainly due to postsurgical complications (44 cases). We identify a few problems in the functional evaluation system used now and suggest a reform of the system, so that physical and mental factors would be evaluated separately.

Adolescent↗

PubMed1991

Limb salvage for osteosarcoma in the 1980s.

The incidence of local recurrences following limb salvage performed by experienced surgeons with wide surgical margins and with the use of neoadjuvant chemotherapy is sufficiently low (5%-10%) so as not to have a biologically statistically significant impact on the long-term survival rate. Following limb salvage, the incidence of morbidity increases with a few patients occasionally requiring prolonged or repeated hospitalizations and further surgical procedures, even amputation. The durability of the reconstructions is variable, and many of the mobile knee reconstructions may need to be revised if the patients become long-term survivors. The function of salvaged limbs is better than that after the alternative amputation, but none of the reconstructions will give normal function. Finally, no matter which type of surgery on the lower extremity is selected, patients will have a good early psychosocial adjustment if no premorbid psychosocial disorder is present.

Bone Neoplasms↗

PubMed1992

Infrapopliteal arterial injury: prompt revascularization affords optimal limb salvage.

Sixty-nine limbs with infrapopliteal arterial injuries were evaluated in 68 patients. Thirty-five (50%) cases were complicated by acute limb-threatening ischemia. Management consisted of revascularization (26 limbs), ligation (15 limbs), fasciotomy only (2 limbs), observation (18 limbs), and primary amputation (8 limbs). Penetrating injuries (n = 35) had a 33% incidence of ischemia and a reduced frequency of associated injury. One delayed amputation (3%) was required. In contrast, blunt injuries (n = 34) had a 68% incidence of ischemia and a greater frequency of associated injury. There were 20 amputations in the blunt group, including eight primary amputations performed in limbs with profound ischemia, complex open fractures, severe soft-tissue damage, and neural injury. Observation or ligation of single arterial injuries resulted in no early amputations. Associated local injuries in both groups included fracture or ligamentous disruption (64%), severe soft-tissue damage (32%), and nerve dysfunction (36%). In both groups, 15 of 35 ischemic limbs were salvaged by prompt revascularization (11 penetrating and four blunt injuries). Aggressive revascularization with autogenous repair or bypass is recommended for management of penetrating trauma. Though a good outcome will be achieved in some patients with combined blunt trauma and infrapopliteal arterial injury, the probability of delayed amputation and prolonged disability must be consciously integrated into the decision to pursue limb salvage. The prognosis for blunt injury complicated by arterial ischemia is poor; thus the severity of associated local and remote injuries will affect the results of revascularization program.

Adult↗

PubMed1990

Increased limb salvage. Distal tibial/peroneal artery thrombectomy/embolectomy in acute lower extremity ischemia.

Fifty-five acutely ischemic lower extremities, in 35 patients, which remained ischemic after standard thrombectomy/embolectomy techniques were further treated with distal tibial/peroneal thrombectomy/embolectomy by ankle level arteriotomy to increase limb salvage. A total of 84 infrapopliteal arteries were explored and thromboembolectomy performed in 79. The precipitating ischemic event was arterial embolus in 38 per cent, arterial thrombus in 60 per cent, and trauma in 2 per cent of the cases. There were 16 female and 19 male patients. Additional bypass grafting was used in 18 per cent of extremities. The limb salvage rate was 91 per cent in this select "tibial/peroneal" group. This technique salvaged 50 limbs that otherwise would have required major amputation. The addition of this technique changed the potential limb salvage rate from 76 per cent of the entire 199 lower extremities treated during this period to an actual limb salvage rate of 97 per cent. Operative mortality was 16 per cent in this selected group with an overall mortality of 6 per cent for all patients with acutely ischemic lower limbs. A mean patient follow-up of 32 months (range 12 to 72 months) identified only three late amputations, demonstrating that distal tibial/peroneal thrombectomy/embolectomy is a durable procedure. It is a technically easy means of promoting limb salvage in the acutely ischemic limb which either 1) remains ischemic after standard transinguinal iliofemoral thromboembolectomy, or 2) is secondary to infrapopliteal artery occlusion. It allows successful thromboembolectomy of acutely occluded infrapopliteal arteries without distal popliteal arteriotomy. These techniques should be within the armamentarium of all surgeons dealing with acute lower extremity ischemia.

Adult↗