Amputation prevention by vascular surgery and podiatry collaboration in high-risk diabetic and nondiabetic patients. The Operation Desert Foot experience.

OBJECTIVE: To describe a unique multidisciplinary outpatient intervention for patients at high risk for lower-extremity amputation. RESEARCH DESIGN AND METHODS: Patients with foot ulcers and considered to be high risk for lower-extremity amputation were referred to the High Risk Foot Clinic of Operation Desert Foot at the Carl T. Hayden Veterans Affairs' Medical Center in Phoenix, Arizona, where patients received simultaneous vascular surgery and podiatric triage and treatment. Some 124 patients, consisting of 90 diabetic patients and 34 nondiabetic patients, were initially seen between 1 October 1991 and 30 September 1992 and followed for subsequent rate of lower-extremity amputation. RESULTS: In a mean follow-up period of 55 months (range 3-77), only 18 of 124 patients (15%) required amputation at the level of the thigh or leg. Of the 18 amputees, 17 (94%) had type 2 diabetes. The rate of avoiding limb loss was 86.5% after 3 years and 83% after 5 years or more. Furthermore, of the 15 amputees surviving longer than 2 months, only one (7%) had to undergo amputation of the contralateral limb over the following 12-65 months (mean 35 months). Compared with nondiabetic patients, patients with diabetes had a 7.68 odds ratio for amputation (95% CI 5.63-9.74) (P < 0.01). CONCLUSIONS: A specialized clinic for prevention of lower-extremity amputation is described. Initial and contralateral amputation rates appear to be far lower in this population than in previously published reports for similar populations. Relative to patients without diabetes, patients with diabetes were more than seven times as likely to have a lower-extremity amputation. These data suggest that aggressive collaboration of vascular surgery and podiatry can be effective in preventing lower-extremity amputation in the high-risk population.     

雷帕霉素对大鼠糖尿病神经痛作用的研究

目的：研究链脲佐菌素（streptozotoccin ,STZ）诱导的糖尿病神经痛（DNP）大鼠脊髓哺乳动物雷帕霉素靶蛋白（mam‐malian target of rapamycin ,mTOR）的变化,及其特异性阻断剂雷帕霉素的干预作用。方法痛阈正常的健康成年雄性SD大鼠40只,随机取30只,尾静脉注射STZ（60 mg／kg）,一周后尾静脉采血血糖大于16．7 mmol／L者视为糖尿病造模成功。测定后足缩足反射阈值,将痛觉过敏者随机分为DNP组和RAP组,其中RAP组每日腹腔注射雷帕霉素5 mg／kg。给药14 d后,测定各组血糖及后足缩足反射阈值,并取L4／5段脊髓检测mTOR及S6K蛋白表达。结果糖尿病神经痛大鼠脊髓mTOR和S6K磷酸化水平升高,给予雷帕霉素14 d后,两者磷酸化水平明显降低,同时痛觉过敏得到显著改善。结论脊髓mTOR可能参与了大鼠糖尿病神经痛的发病,其特异性阻断剂雷帕霉素可以减轻其症状。     

The health care costs of diabetic peripheral neuropathy in the US

OBJECTIVE: Peripheral neuropathy is common among people with diabetes and can result in foot ulceration and amputation. The aim of this study was to quantify the annual medical costs of peripheral neuropathy and its complications among people with type 1 and type 2 diabetes in the U.S. RESEARCH DESIGN AND METHODS: A cost-of-illness model was used to estimate the numbers of diabetic individuals in the U.S. who have diabetic peripheral neuropathy (DPN) and/or neuropathic foot ulcers (both those with no deep infection and those accompanied by cellulitis or osteomyelitis) at a given point in time, and/or a toe, foot, or leg amputation during a year. Prevalence and incidence rates were estimated from published studies and applied to the general U.S. population. All costs were estimated in 2001 U.S. dollars. In a sensitivity analysis, we varied the rates of complications to assess the robustness of the cost estimates. RESULTS: The annual costs of DPN and its complications in the U.S. were 0.8 billion US dollars (type 1 diabetes), 10.1 billion US dollars (type 2 diabetes), and 10.9 billion US dollars (total). After allowing for uncertainty in the point estimates of complication rates, the range of costs were between 0.3 and 1.0 billion US dollars (type 1 diabetes), 4.3b and 12.7 billion US dollars (type 2 diabetes), and 4.6 and 13.7 billion US dollars (type 1 and type 2 diabetes). CONCLUSIONS: The total annual cost of DPN and its complications in the U.S. was estimated to be between 4.6 and 13.7 billion US dollars. Up to 27% of the direct medical cost of diabetes may be attributed to DPN.     

截肢后替代刺激对截肢后大鼠行为学的影响

目的:观察截肢后替代刺激维持外周神经的传入对截肢后大鼠行为学的影响。方法:雄性SD大鼠40只,随机分为单纯截肢组(A组,n=16)、截肢刺激组(S组,n=16),空白对照组(N组,n=8)。观察3组大鼠12 h饮水、12 h饮食量、左足或左残端热痛阈值、右足热痛阈值的改变。结果:截肢术后1~12天A组和S组的12 h饮食量、饮水量、左足热痛阈值无差别,均小于N组。术后14~16天和21天,S组12 h饮水量、饮食量高于A组(P<0.05),与N组没有差别(P>0.05);术后13~15天,S组左残端热痛阈值高于A组(P<0.05),低于N组(P<0.05);术后21~26天,A组和S组右足热痛阈值明显低于N组(P<0.05)。术后27~28天,S组右足热痛阈值高于A组(P<0.05),与N组没有差别(P>0.05)。结论:替代刺激维持残端外周神经的传入可以缓解截肢术后的残端疼痛及对侧肢体的镜像痛,并有效改善截肢术后的饮水,饮食。截肢术后替代性神经刺激可以作为截肢术后残肢痛一种有效的治疗措施。     

Phantom limb pain: relief by application of TENS to contralateral extremity

Three adult patients with below-knee amputation of various etiologies were treated at Norristown's Sacred Heart Hospital and Rehabilitation Center in the fall of 1983. The patients ranged in age from 48 to 64 years and two were men. All three had complaints of phantom limb pain originating from various anatomic sites of the amputated extremity. In all three cases the phantom limb pain was severe and hampered prosthetic training. The patients were treated solely by application of the TENS unit to the contralateral extremity at the sites where the phantom pain originated on the amputated limb. All three patients responded to treatment and were able to continue their prosthetic training. A six-month follow-up showed no pain recurrence of phantom limb pain in all three cases.     

Immediate and long-term phantom limb pain in amputees: incidence, clinical characteristics and relationship to pre-amputation limb pain

In a prospective study 58 patients undergoing limb amputation were interviewed the day before operation about their pre-amputation limb pain and 8 days, 6 months and 2 years after limb loss about their stump and phantom limb pain. All but one patient had experienced pain in the limb prior to amputation. Pre-amputation limb pain lasted less than 1 month in 25% of patients and more than 1 month in the remaining 75% of patients. At the first examination the day before amputation 29% had no limb pain. The incidence of phantom pain 8 days, 6 months and 2 years after amputation was 72, 65 and 59%, respectively. Within the first half year after limb loss phantom pain was significantly more frequent in patients with long-lasting pre-amputation limb pain and in patients with pain in the limb immediately prior to amputation. Phantom pain and pre-amputation pain were similar in both localization and character in 36% of patients immediately after amputation but in only 10% of patients later in the course. Both the localization and character of phantom pain changed within the first half year; no further change occurred later in the course. The incidence of stump pain 8 days, 6 months and 2 years after limb loss was 57, 22 and 21%, respectively. It is suggested that preoperative limb pain plays a role in phantom pain immediately after amputation, but probably not in late persistent phantom pain.     

腘动脉以远血管腔内成形术治疗糖尿病足:附65例报告

目的 探讨腘动脉以远血管腔内成型术对糖尿病足的救肢疗效.方法 总结65例(69条肢体)糖尿病足患者行腘以下闭塞动脉血管腔内长球囊扩张成形术的救肢治疗经验.结果 全组无死亡.即时成功60例64条肢体,失败5例5条肢体,即时技术成功率92.75%.成功的60例64条肢体术后肢温明显改善、疼痛缓解,踝肱指数(ABI)增加至0.84±0.11以上,有39条肢体术后即可触到再通动脉(胫前或胫后动脉)搏动.足、趾感染经清创换药等愈合21条肢体,皮肤软组织小面积坏疽自行脱落愈合10条肢体,清除坏疽愈合6条肢体,截趾后Ⅰ期愈合22条肢体,半足截除1条肢体.无一例截肢.成功病例出院后每月复查彩超1次,随访率100%.术后再阻塞6例6条肢体(3个月1例,6月1例,12个月2例,18个月2例),此6例均进行了二次扩张再通.结论 腘以下动脉腔内长球囊扩张成形对动脉闭塞的搪尿病足是一种有效的救肢方法 ,具有微创、安全、并发症少、可重复扩张等优点,可作为首选治疗方法 . 39条肢体术后即可触到再通动脉(胫前或胫后动脉)搏动.足、趾感染经清创换药等愈合21条肢体,皮肤软组织小面积坏疽自行脱落愈合10条肢体,清除坏疽愈合6条肢体,截趾后Ⅰ期 合22条肢体,半足截除1条肢体.无一例截肢.成功病例出院后每月复查彩超1次,随访率100%.术后再阻塞6例6条肢体(3个月1例,6月1例,12个月2例,18个月2例),此6例均进行了二次扩张再通.结论 腘以下动脉腔内长球囊扩张成形对动脉闭塞的糖尿病足是一种有效的救肢方法 ,具有微创、安全、并发症少、可重复扩张等优点,可作为首选治疗方法 . 39条肢体术后即可触到再通动脉(胫前或胫后动脉)搏动.足、趾感染经清创换药等愈合21条肢体,皮肤软组织小面积坏疽自行脱落愈合10条肢体,清除坏疽     

Outcome After Trans-tibial Amputation for Vascular Disease

All 112 patients (55 females and 57 males) with a primary unilateral trans-tibial amputation for vascular disease performed in one year at all five hospitals in Malmöhus county, Sweden were examined at 6 months according to the prosthetic function and prospectively followed-up 8 years after the amputation for survival, and prosthetic fitting. The prosthetic function was re-examined among the survivors 8 years postoperatively. At 6 months 50% were fitted with a prosthesis and later (up to 8 years) a further 13%, in total 32 females and 39 males. The mortality at 6 months was 33%, at 2 years 47% and at 8 years 92%. Age at amputation (p = 0.015), to be amputated on the left leg (p = 0.0004), to be able to walk alone outdoors before the amputation (p = 0.007) and not using a wheelchair (p = 0.02) were all found to be statistically significant predictors for receiving a prosthesis. Predictors for good function with the prosthesis 6 months postoperatively was male sex (23 of 57 vs 8 of 55 females) (p = 0.006) and greater ability to walk alone outdoors before the amputation (p = 0.01). There was no significant age difference in this comparison. The finding that it is more favourable to be amputated on the left leg merits further study.     

Compound fractures of the lower leg: clinical experiences and concept of treatment in multiple injury patients

From 1980 to 1986 in 15 patients (16 lower leg fractures) with crush fractures of the lower limb, five had to be amputated primarily under emergency conditions, and four had successful reconstruction but required medical treatment for an average of one year. Seven secondary amputations were carried out because of infection of the bone, soft tissue and vascular occlusion. The level of amputation was at the proximal third of the tibia according to Dederich and Burgess. One leg was amputated 'through the knee'. The indication for amputation was based mainly on clinical findings, supplemented by bone X-rays, arteriography or arterial DSA. Doppler sonography was used for monitoring short intervals of blood flow in the emergency case unit, in cases of doubt.     

Biomechanical compensations of the trunk and lower extremities during stepping tasks after unilateral transtibial amputation

BackgroundLower extremity movement compensations following transtibial amputation are well-documented and are likely influenced by trunk posture and movement. However, the biomechanical compensations of the trunk and lower extremities, especially during high-demand tasks such as step ascent and descent, remain unclear.MethodsKinematic and kinetic data were collected during step ascent and descent tasks for three groups of individuals: diabetic/transtibial amputation, diabetic, and healthy. An ANCOVA was used to compare peak trunk, hip and knee joint angles and moments in the sagittal and frontal planes between groups. Paired t-tests were used to compare peak joint angles and moments between amputated and intact limbs of the diabetic/transtibial amputation group.FindingsDuring step ascent and descent, the transtibial amputation group exhibited greater trunk forward flexion and lateral flexion compared to the other two groups (P < 0.016), which resulted in greater low back moments and asymmetric loading patterns in the lower extremity joints. The diabetic group exhibited similar knee joint loading patterns compared to the amputation group (P < 0.016), during step descent.InterpretationThis study highlights the biomechanical compensations of the trunk and lower extremities in individuals with dysvascular transtibial amputation, by identifying low back, hip, and knee joint moment patterns unique to transtibial amputation during stepping tasks. In addition, the results suggest that some movement compensations may be confounded by the presence of diabetes and precede limb amputation. The increased and asymmetrical loading patterns identified may predispose individuals with transtibial amputation to the development of secondary pain conditions, such as low back pain or osteoarthritis.     

Fewer Major Amputations Among Individuals With Diabetes in Finland in 1997�C2007: A population-based study

OBJECTIVE

Complications occur in diabetes despite rigorous efforts to control risk factors. Since 2000, the National Development Programme for the Prevention and Care of Diabetes has worked to halve the incidence of amputations in 10 years. Here we evaluate the impact of the efforts undertaken by analyzing the major amputations done in 1997–2007.

RESEARCH DESIGN AND METHODS

All individuals with diabetes (n = 396,317) were identified from comprehensive national databases. Data on the first major amputations (n = 9,481) performed for diabetic and nondiabetic individuals were obtained from the National Hospital Discharge Register.

RESULTS

The relative risk for the first major amputation was 7.4 (95% CI 7.2–7.7) among the diabetic versus the nondiabetic population. The standardized incidence of the first major amputation decreased among the diabetic and nondiabetic populations (48.8 and 25.2% relative risk reduction, respectively) over 11 years, and the time from the registration of diabetes to the first major amputation was significantly longer, on average 1.2 years more. The cumulative five-year postamputation mortality among diabetic individuals was 78.7%.

CONCLUSIONS

In our nationwide diabetes database, the duration from the registration of diabetes to the first major amputation increased, and the incidence of major amputations decreased almost 50% in 11 years. Approximately half of this change was due to the increasing size of the diabetic population. The risk for major amputation is more than sevenfold that among the nondiabetic population. These results pose a continuous challenge to improve diabetes care.Diabetes is increasing rapidly in Finland (1). For this reason, the National Development Programme for the Prevention and Care of Diabetes (DEHKO) was established for the years 2000–2010 (2). The program has specific goals that aim to reduce the complications of diabetes; one of them is to halve the incidence of lower limb amputations.The majority of amputations are performed for diabetic individuals. In Germany, 66% of lower limb amputations were performed for patients with diabetes; the relative risk was 8.8 for men and 5.7 for women compared with that for the nondiabetic population (3). The incidence of lower limb amputations among diabetic populations has varied from 2.1 to 13.7 per 1,000 person-years (4). In Suffolk, U.K., the incidence of major amputations was as low as 1.62 (5), and, in Sweden, the incidence of the first above-transmetatarsal-level amputation was 1.92 for women and 1.97 for men with diabetes (6). The amputation risk was eightfold (6).Falling amputation trends are described. Among type 1 diabetic patients in Sweden, the relative risk of lower limb amputation was 0.6 during the most recent 5-year period compared against the 5-year period before the year 2000 (7). In Scotland, the incidence of major amputations decreased from 5.1 to 2.9 per 1,000 patients with diabetes in 7 years (8). In Suffolk, U.K., major amputations decreased 82% from 1995 to 2005 (9).A great deal of the improvement in amputation trends is attributed to diabetes control programs. In the U.K., a control program led to a drop in the amputation incidence from 5.6 to 1.76 (10). In South Carolina, an education program brought about a decrease in lower limb amputations that was faster than that in other parts of the U.S. (11). Vascular surgery has an impact: in Denmark, a sevenfold increase in vascular surgical activity was associated with a 75% decrease in major amputations from 1981 to 1995 (12).It is still unclear whether the impact of programs is related to earlier diagnosis of diabetes or reflects a true effect of improved care. Multidisciplinary teamwork focusing on foot care and a continuous prospective audit has been shown to be beneficial (9). A thorough analysis of comprehensive register data may widen the perspective given by figures on amputation incidence among the diabetic population.The aim of our study was to analyze the first major amputations among diabetic individuals identified from comprehensive national databases during 1997–2007 and to evaluate the impact of efforts to improve diabetes care in Finland. Trends in amputation rates, time from the registration of diabetes to the first major amputation, and mortality were compared by sex and age-groups within and between diabetic and nondiabetic populations.     

Foot ulceration and lower limb amputation in type 2 diabetic patients in dutch primary health care

OBJECTIVE: To determine the incidence of foot ulceration and lower limb amputation in type 2 diabetic patients in primary health care. RESEARCH DESIGN AND METHODS: Data on type 2 diabetes were collected by the Nijmegen Monitoring Project between 1993 and 1998 as part of a study of chronic diseases. The records of all patients recorded as having diabetic foot problems and those who died, moved to a nursing home, or were under specialist care were included. The annual incidence of foot ulceration was defined as the number of type 2 diabetic patients per patient-year who developed a new foot ulcer. Incidence of lower limb amputation was similarly defined. Additional information was collected on treatment of foot ulcers. RESULTS: The study population of type 2 diabetic patients increased from 511 patient-years in 1993 to 665 in 1998. The annual incidence of foot ulceration varied between 1.2 and 3.0% (mean 2.1) per year; 25% of the patients had recurrent episodes. The annual incidence of lower limb amputation varied between 0.5 and 0.8% (mean 0.6). Ten of the 15 amputees died, and 12 of 52 (23%) patients with ulceration had a subsequent amputation or a previous history of amputation. In 35 of the 73 (48%) episodes of ulceration, only the family physician provided treatment. Patients with foot problems were older and had more cardiovascular disease, retinopathy, and absent peripheral pulses. CONCLUSIONS: The incidence of foot ulceration and lower limb amputation in type 2 diabetes is low; nevertheless, recurrence rates of ulceration and risk of amputation are high, with high mortality.     

Pain Management in Four‐Limb Amputation: A Case Report

Acute pain following amputation can be challenging to treat due to multiple underlying mechanisms and variable clinical responses to treatment. Furthermore, poorly controlled preoperative pain is a risk factor for developing chronic pain. Evidence suggests that epidural analgesia and peripheral nerve blockade may decrease the severity of residual limb pain and the prevalence of phantom pain after lower extremity amputation. We present the perioperative analgesic management of a patient with gangrene of the bilateral upper and lower extremities as a result of septic shock and prolonged vasopressor administration who underwent four‐limb amputation in a single procedure. A multimodal analgesic regimen was utilized, including titration of preoperative opioid and neuropathic pain agents, perioperative intravenous, epidural and peripheral nerve catheter infusions, and postoperative oral medication titration. More than 8 months postoperatively, the patient has satisfactory pain control with no evidence for phantom limb pain. To our knowledge, there have been no publications to date concerning analgesic regimens in four‐limb amputation.     

A Retrospective Trial Comparing the Effects of Different Anesthetic Techniques on Phantom Pain After Lower Limb Amputation

Background

Pain and other sensations from an amputated or absent limb, called phantom pain and phantom sensations, are well-known phenomena.

Objective

The aim of this retrospective study was to evaluate the effects of anesthetic techniques on phantom pain, phantom sensations, and stump pain after lower limb amputation.

Methods

Ninety-two patients with American Society of Anesthesiologists physical status I to III were analyzed for 1 to 24 months after lower limb amputation in this retrospective study. Patients received general, spinal, or epidural anesthesia or peripheral nerve block for their amputations. Standardized questions were used to assess phantom limb pain, phantom sensation, and stump pain postoperatively. Pain intensity was assessed on a numeric rating scale (NRS) of 0 to 10. Patients' medical histories were determined from hospital records.

Results

Patients who received epidural anesthesia and peripheral nerve block perceived significantly less pain in the week after surgery compared with patients who received general anesthesia and spinal anesthesia (NRS [SD] values, 2.68 [1.0] and 2.70 [1.0], respectively). After approximately 14 to 17 months, there was no difference in phantom limb pain, phantom sensation, or stump pain among the anesthetic techniques for amputation.

Conclusions

In patients undergoing lower limb amputation, performing epidural anesthesia or peripheral nerve block, instead of general anesthesia or spinal anesthesia, might attenuate phantom and stump pain in the first week after operation. Anesthetic technique might not have an effect on phantom limb pain, phantom sensation, or stump pain at 14 to 17 months after lower limb amputation.     

Up-regulation of spinal muscarinic receptors and increased antinociceptive effect of intrathecal muscarine in diabetic rats

Spinally administered muscarinic receptor agonists or acetylcholinesterase inhibitors produce effective pain relief. Intrathecal injection of a small dose of neostigmine produces a profound antiallodynic effect in rats with diabetic neuropathy. However, the mechanisms of increased antinociceptive effect of cholinergic agents on diabetic neuropathic pain are not clear. In the present study, we tested the hypothesis that spinal muscarinic receptors are up-regulated in diabetes. The withdrawal threshold of the hindpaw in response to noxious heat and pressure stimuli was determined in streptozotocin-induced diabetic and age-matched normal rats. Muscarine-stimulated guanosine 5'-O-(3-[35S]thio)triphosphate ([35S]GTPgammaS) binding was used to assess the change of functional muscarinic receptors in the spinal cord in diabetes. The [3H]AF-DX 384 membrane binding was performed to determine the number and affinity of spinal cord M2 muscarinic receptors in normal and diabetic rats. We found that the antinociceptive effect of intrathecal 2 to 12 mug muscarine in diabetic animals was potentiated significantly compared with that in normal animals. The maximal muscarine-stimulated [35S]GTPgammaS binding was 112.5 +/- 8.3% in normal rats and 168.8 +/- 12.1% (P < 0.05) in diabetic rats. Although the KD value (2.9 nM) was similar in both groups, the Bmax of [3H]AF-DX 384 membrane binding was significantly higher in diabetic than in normal rats (255.2 +/- 5.9 versus 165.9 +/- 3.5 fmol/mg protein, P < 0.05). Collectively, these data strongly suggest that the muscarinic receptor is up-regulated in the dorsal spinal cord in diabetic rats. This finding probably accounts for the increased efficacy of the antinociceptive effect of intrathecal muscarinic agonists in diabetic neuropathic pain.     

Treatment of chronic painful diabetic neuropathy with isosorbide dinitrate spray: a double-blind placebo-controlled cross-over study

OBJECTIVE: Considerable evidence implicates impaired nitric oxide (NO) generation in the pathogenesis of diabetic neuropathic pain. We therefore conducted a pilot study to examine the effects of isosorbide dinitrate (ISDN), a NO donor with local vasodilating properties, in spray form in the management of chronic neuropathic pain. RESEARCH DESIGN AND METHODS: The study was of double-blind, randomized, placebo-controlled, and two-period cross-over design. After a 2-week run-in period, 22 diabetic patients (13 men, 20 with type 2 diabetes, age [mean +/- SE] 63.7 +/- 1.8 years, duration of diabetes 9.1 +/- 1.5 years, duration of painful neuropathy 2.6 +/- 0.4 years) were randomized to receive ISDN or placebo sprays for 4 weeks, exchanging their treatment for a further 4 weeks after a 2-week wash-out period. The patients administered the spray to both feet before bedtime. Biweekly pain and other sensory symptoms were assessed using a visual analog scale (VAS) and the Lickert scale, respectively. RESULTS: ISDN spray reduced overall neuropathic pain (P = 0.02) and burning sensation (P = 0.006). No treatment difference was observed with other sensory modalities (hot/cold sensation, tingling, numbness, hyperesthesia, and jabbing-like sensation). At study completion, 11 patients (50%) reported benefit and wished to continue using the ISDN spray, 4 (18%) preferred the placebo spray, and the remaining 7 (32%) were undecided. CONCLUSIONS: ISDN spray offers an alternative and effective pharmacological option in relieving overall pain and burning sensation in the management of painful diabetic neuropathy. The potential of ISDN spray in alleviating other specific sensory symptoms associated with diabetic peripheral neuropathy merits further study.     

Diabetic muscle infarction

Diabetic muscle infarction (DMI) is a rare complication of longstanding, poorly controlled diabetes. Only a few cases have been reported in the literature. The case of a 34-year-old man with a 7-year history of type 2 diabetes mellitus, with sudden onset of left thigh pain, is described here. A final diagnosis of DMI was made, the pathophysiology of which remains unclear. MRI findings were diagnostic and characteristic. The management of this condition is usually symptomatic. Short-term prognosis is very good; however, the recurrence rate is high. Long-term prognosis is poor, with most patients dying from cardiovascular complications of diabetes within 5 years of diagnosis. This case supports the need for a high index of suspicion, when a poorly controlled patient with diabetes presents with non-traumatic limb pain.     

Herpes zoster reactivation of phantom limb pain

A case is reported in which a herpes zoster infection caused recurrence of phantom limb pain in a man whose left arm had been amputated 7 years previously. It is, to our knowledge, the first such case reported, and it shows the importance of peripheral mechanisms in the generation of phantom limb pain.     

Rehabilitation Outcome in Patients With Lower Limb Amputations Because of Arterial Occlusive Disease: Is it Worth Trying for the Lowest Possible Amputation Level? A Prospective Study

A policy of maximizing the ratio of below-knee to above-knee amputations in patients with severe nonsalvageable limb ischemia is followed. The value of this policy is examined. All the patients that were amputated in our department between 1995 and 1997 were followed up for 2 years after the operation. We correlated the amputation level with 6 different parameters: primary or secondary amputation, perioperative mortality, 2-years mortality, amputation stump healing, artificial limb fitment, and rehabilitation outcome. The results were analyzed statistically. A total of 64 patients were included in the study. The revision rate was 38% in below-knee amputees and 4% in above-knee amputees. The perioperative mortality was 22%. Two years after operation, the limb fitment rate in below-knee amputees was 95% and in above-knee amputees was 64%. The overall artificial limb fitment rate was 50%. A total of 47.6% of the living patients were capable to walk out of their house. Artificial limb fitment and rehabilitation status are greater after a below-knee than an above-knee amputation. Although the morbidity may be higher in below knee procedures, it is worth trying for the lowest level of amputation because of the better rehabilitation results in these patients.