Amputation

Amputation
An amputee, seen here running with a blade prosthetic.
SpecialtySurgery

Physical medicine and rehabilitation

Emergency medicine

Amputation is the removal of a limb by trauma, medical illness, or surgery. As a surgical measure, it is used to control pain or a disease process in the affected limb, such as malignancy or gangrene. In some cases, it is carried out on individuals as a preventive surgery for such problems. A special case is that of congenital amputation, a congenital disorder, where fetal limbs have been cut off by constrictive bands. In some countries, such as Afghanistan, Brunei, Iran, Saudi Arabia and the United Arab Emirates, amputation is currently used to punish people who commit crimes.[1][2][3][4] Amputation has also been used as a tactic in war and acts of terrorism; it may also occur as a war injury. In some cultures and religions, minor amputations or mutilations are considered a ritual accomplishment.[5][6][7] When done by a person, the person executing the amputation is an amputator.[8][9]

In the US, the majority of new amputations occur due to complications of the vascular system (the blood vessels), especially from diabetes. Between 1988 and 1996, there were an average of 133,735 hospital discharges for amputation per year in the US.[10] In 2005, just in the US, there were 1.6 million amputees.[11] In 2013, the US had 2.1 million amputees. Approximately 185,000 amputations occur in the United States each year. In 2009, hospital costs associated with amputation totaled more than $8.3 billion.[12] There will be an estimated 3.6 million people in the US living with limb loss by 2050.[11]

Types

Leg

Lower limb amputations can be divided into two broad categories: minor and major amputations. Minor amputations generally refer to the amputation of digits. Major amputations are commonly below-knee- or above-knee amputations. Common partial foot amputations include the Chopart, Lisfranc, and ray amputations.

Common forms of ankle disarticulations include Pyrogoff, Boyd, and Syme amputations.[13] A less common major amputation is the Van Nes rotation, or rotationplasty, i.e. the turning around and reattachment of the foot to allow the ankle joint to take over the function of the knee.

Types of amputations include:

An above-knee amputation
partial foot amputation
amputation of the lower limb distal to the ankle joint
ankle disarticulation
amputation of the lower limb at the ankle joint
trans-tibial amputation
amputation of the lower limb between the knee joint and the ankle joint, commonly referred to as a below-knee amputation
knee disarticulation
amputation of the lower limb at the knee joint
trans-femoral amputation
amputation of the lower limb between the hip joint and the knee joint, commonly referred to an above-knee amputation
hip disarticulation
amputation of the lower limb at the hip joint
trans-pelvic disarticulation
amputation of the whole lower limb together with all or part of the pelvis, also known as a hemipelvectomy or hindquarter amputation

Arm

The 18th century guide to amputations

Types of upper extremity amputations include:

  • partial hand amputation
  • wrist disarticulation
  • trans-radial amputation, commonly referred to as below-elbow or forearm amputation
  • elbow disarticulation
  • trans-humeral amputation, commonly referred to as above-elbow amputation
  • shoulder disarticulation
  • forequarter amputation

A variant of the trans-radial amputation is the Krukenberg procedure in which the radius and ulna are used to create a stump capable of a pincer action.

Other

Partial amputation of index finger.
  • Facial amputations include but are not limited to:
    • amputation of the ears
    • amputation of the nose (rhinotomy)
    • amputation of the tongue (glossectomy).
    • amputation of the eyes (enucleation).
    • amputation of the teeth (dental avulsion). Removal of teeth, mainly incisors, is or was practiced by some cultures for ritual purposes (for instance in the Iberomaurusian culture of Neolithic North Africa).
  • Breasts:
  • Genitals:

Hemicorporectomy, or amputation at the waist, and decapitation, or amputation at the neck, are the most radical amputations.

Genital modification and mutilation may involve amputating tissue, although not necessarily as a result of injury or disease.

Nails are typically trimmed with nail clippers, but this is not typically considered amputation.

Self-amputation

In some rare cases when a person has become trapped in a deserted place, with no means of communication or hope of rescue, the victim has amputated his or her own limb. The most notable case of this is Aron Ralston, a hiker who amputated his own right forearm after it was pinned by a boulder in a hiking accident and he was unable to free himself for over five days.[14]

Body integrity identity disorder is a psychological condition in which an individual feels compelled to remove one or more of their body parts, usually a limb. In some cases, that individual may take drastic measures to remove the offending appendages, either by causing irreparable damage to the limb so that medical intervention cannot save the limb, or by causing the limb to be severed.

Causes

Circulatory disorders

Neoplasm

Transfemoral amputation due to liposarcoma

Trauma

Three fingers from a soldier's right hand were traumatically amputated during World War I.
  • Severe limb injuries in which the limb cannot be saved or efforts to save the limb fail.
  • Traumatic amputation (an unexpected amputation that occurs at the scene of an accident, where the limb is partially or entirely severed as a direct result of the accident, for example, a finger that is severed from the blade of a table saw)
  • Amputation in utero (Amniotic band)

Congenital anomalies

Infection

Frostbite

Frostbite, also known as frostnip, happens when the individual's skin is exposed to cold weather for too long. The fluid in the pale skin solidifies, creating ice crystals, leading to swelling and severe pain. Other symptoms can include numbness, confusion, dizziness, fatigue, nausea, stiffness in the muscles or joints as well as difficulty walking. If the frostbite doesn't get treated soon, this process results in hypothermia, death or poisoning of the bloodstream.

This can affect the hands, feet, toes, fingers, eyes, and face. Once the frostbite shuts the eyelids, this is known as snow blindness. The only way to stop it from spreading is through skin grafts or amputation.

Athletic performance

Sometimes professional athletes may choose to have a non-essential digit amputated to relieve chronic pain and impaired performance.

  • Australian Rules footballer Daniel Chick elected to have his left ring finger amputated as chronic pain and injury was limiting his performance.[16]
  • Rugby union player Jone Tawake also had a finger removed.[17]
  • National Football League safety Ronnie Lott had the tip of his little finger removed after it was damaged in the 1985 NFL season.

Criminal penalty

  • According to Quran 5:38, the punishment for stealing is the amputation of the hand. Under Sharia law, after repeated offense, the foot may also be cut off. This is still in practice today in countries like Brunei, the United Arab Emirates,[18] Iran,[19][20] Saudi Arabia,[21] Yemen,[22] and 11 states of Northern Nigeria.[23][24]
  • The United States considers amputation to be more severe than other punishments but less than death penalty, expressed in the double jeopardy clause: "nor shall any person be subject for the same offence to be twice put in jeopardy of life or limb...".[25] Thomas Jefferson proposed a bill penalizing various crimes with amputation, such as "if a man, by castration, if a woman, by cutting thro' the cartilage of her nose a hole of one half inch diameter at the least" and "cutting out or disabling the tongue, slitting or cutting off a nose, lip or ear, branding, or otherwise, shall be maimed or disfigured in like sort: or if that cannot be for want of the same part, then as nearly as may be in some other part of at least equal value and estimation in the opinion of a jury".[26] That bill is not a current law, so it either did not gain enough approval to become law, or it has since been repealed.
  • As of 2021, this form of punishment is controversial, as most modern cultures consider it to be morally abhorrent, as it has the effect of permanently disabling a person and constitutes torture. It is thus seen as a grossly disproportional for crimes less than those such as murder.[27]

Surgery

Method

Curved knives such as this one were used, in the past, for some kinds of amputations.

The first step is ligating the supplying artery and vein, to prevent hemorrhage (bleeding). The muscles are transected, and finally, the bone is sawed through with an oscillating saw. Sharp and rough edges of bones are filed, skin and muscle flaps are then transposed over the stump, occasionally with the insertion of elements to attach a prosthesis.

Distal stabilisation of muscles is recommended. This allows effective muscle contraction which reduces atrophy, allows functional use of the stump and maintains soft tissue coverage of the remnant bone. The preferred stabilisation technique is myodesis where the muscle is attached to the bone or its periosteum. In joint disarticulation amputations tenodesis may be used where the muscle tendon is attached to the bone. Muscles should be attached under similar tension to normal physiological conditions.[28]

An experimental technique known as the "Ewing amputation" aims to improve post-amputation proprioception.[29][30]

In 1920,  Dr. Janos Ertl, Sr. of Hungary, developed the Ertl procedure in order to return a high number of amputees to the work force.[31] The Ertl technique, an osteomyoplastic procedure for transtibial amputation, can be used to create a highly functional residual limb. Creation of a tibiofibular bone bridge provides a stable, broad tibiofibular articulation that may be capable of some distal weight bearing. Several different modified techniques and fibular bridge fixation methods have been used; however, no current evidence exists regarding comparison of the different techniques.[32]

Post-operative management

A 2019 Cochrane systematic review aimed to determine whether rigid dressings were more effective than soft dressings in helping wounds heal following transtibial (below the knee) amputations. Due to the limited and very low certainty evidence available, the authors concluded that it was uncertain what the benefits and harms were for each dressing type. They recommended that clinicians consider the pros and cons of each dressing type on a case-by-case basis e.g. rigid dressings may potentially benefit patients who have a high risk of falls and soft dressings may potentially benefit patients who have poor skin integrity.[33]

A 2017 review found that the use of rigid removable dressings (RRD's) in trans-tibial amputations, rather than soft bandaging, improved healing time, reduced edema, prevented knee flexion contractures and reduced complications, including further amputation, from external trauma such as falls onto the stump.[34]

Post-operative management, in addition to wound healing, should consider maintenance of limb strength, joint range, edema management, preservation of the intact limb (if applicable) and stump desensitization.

Trauma

Traumatic amputation is the partial or total avulsion of a part of a body during a serious accident, like traffic, labor, or combat.[35][36]

Traumatic amputation of a human limb, either partial or total, creates the immediate danger of death from blood loss.[37]

Orthopedic surgeons often assess the severity of different injuries using the Mangled Extremity Severity Score. Given different clinical and situational factors, they can predict the likelihood of amputation. This is especially useful for emergency physicians to quickly evaluate patients and decide on consultations.[38]

Causes

Private Lewis Francis was wounded July 21, 1861, at the First Battle of Bull Run by a bayonet to the knee.

Traumatic amputation is uncommon in humans (1 per 20,804 population per year). Loss of limb usually happens immediately during the accident, but sometimes a few days later after medical complications. Statistically, the most common causes of traumatic amputations are:

  • Traffic collisions (cars, motorcycles, bicycles, trains, etc.)
  • Labor accidents (equipment, instruments, cylinders, chainsaws, press machines, meat machines, wood machines, etc.)
  • Agricultural accidents, with machines and mower equipment
  • Electric shock hazards
  • Firearms, bladed weapons, explosives
  • Violent rupture of ship rope or industry wire rope
  • Ring traction (ring amputation, de-gloving injuries)
  • Building doors and car doors
  • Animal attacks
  • Gas cylinder explosions[39]
  • Other rare accidents

Treatment

The development of the science of microsurgery over the last 40 years has provided several treatment options for a traumatic amputation, depending on the patient's specific trauma and clinical situation:

  • 1st choice: Surgical amputation - break - prosthesis
  • 2nd choice: Surgical amputation - transplantation of other tissue - plastic reconstruction.
  • 3rd choice: Replantation - reconnection - revascularisation of amputated limb, by microscope (after 1969)
  • 4th choice: Transplantation of cadaveric hand (after 2000)[36]

Epidemiology

  • In the United States in 1999, there were 14,420 non-fatal traumatic amputations according to the American Statistical Association. Of these, 4,435 occurred as a result of traffic and transportation accidents and 9,985 were due to labor accidents. Of all traumatic amputations, the distribution percentage is 30.75% for traffic accidents and 69.24% for labor accidents.[40]
  • The population of the United States in 1999 was about 300,000,000, so the conclusion is that there is one amputation per 20,804 persons per year. In the group of labor amputations, 53% occurred in laborers and technicians, 30% in production and service workers, 16% in silviculture and fishery workers.[40]
  • A study found that in 2010, 22.8% of patients undergoing amputation of a lower extremity in the United States were readmitted to the hospital within 30 days.[41]

Prevention

Methods in preventing amputation, limb-sparing techniques, depend on the problems that might cause amputations to be necessary. Chronic infections, often caused by diabetes or decubitus ulcers in bedridden patients, are common causes of infections that lead to gangrene, which would then necessitate amputation.

There are two key challenges: first, many patients have impaired circulation in their extremities, and second, they have difficulty curing infections in limbs with poor blood circulation.

Crush injuries where there is extensive tissue damage and poor circulation also benefit from hyperbaric oxygen therapy (HBOT). The high level of oxygenation and revascularization speed up recovery times and prevent infections.

A study found that the patented method called Circulator Boot achieved significant results in prevention of amputation in patients with diabetes and arteriosclerosis.[42][43] Another study found it also effective for healing limb ulcers caused by peripheral vascular disease.[44] The boot checks the heart rhythm and compresses the limb between heartbeats; the compression helps cure the wounds in the walls of veins and arteries, and helps to push the blood back to the heart.[45]

For victims of trauma, advances in microsurgery in the 1970s have made replantations of severed body parts possible.

The establishment of laws, rules, and guidelines, and employment of modern equipment help protect people from traumatic amputations.

Prognosis

The individual may experience psychological trauma and emotional discomfort. The stump will remain an area of reduced mechanical stability. Limb loss can present significant or even drastic practical limitations.

A large proportion of amputees (50–80%) experience the phenomenon of phantom limbs;[46] they feel body parts that are no longer there. These limbs can itch, ache, burn, feel tense, dry or wet, locked in or trapped or they can feel as if they are moving. Some scientists believe it has to do with a kind of neural map that the brain has of the body, which sends information to the rest of the brain about limbs regardless of their existence. Phantom sensations and phantom pain may also occur after the removal of body parts other than the limbs, e.g. after amputation of the breast, extraction of a tooth (phantom tooth pain) or removal of an eye (phantom eye syndrome).

A similar phenomenon is unexplained sensation in a body part unrelated to the amputated limb. It has been hypothesized that the portion of the brain responsible for processing stimulation from amputated limbs, being deprived of input, expands into the surrounding brain, (Phantoms in the Brain: V.S. Ramachandran and Sandra Blakeslee) such that an individual who has had an arm amputated will experience unexplained pressure or movement on his face or head.

In many cases, the phantom limb aids in adaptation to a prosthesis, as it permits the person to experience proprioception of the prosthetic limb. To support improved resistance or usability, comfort or healing, some type of stump socks may be worn instead of or as part of wearing a prosthesis.

Another side effect can be heterotopic ossification, especially when a bone injury is combined with a head injury. The brain signals the bone to grow instead of scar tissue to form, and nodules and other growth can interfere with prosthetics and sometimes require further operations. This type of injury has been especially common among soldiers wounded by improvised explosive devices in the Iraq War.[47]

Due to technological advances in prosthetics, many amputees live active lives with little restriction. Organizations such as the Challenged Athletes Foundation have been developed to give amputees the opportunity to be involved in athletics and adaptive sports such as amputee soccer.

Nearly half of the individuals who have an amputation due to vascular disease will die within 5 years, usually secondary to the extensive co-morbidities rather than due to direct consequences of amputation. This is higher than the five year mortality rates for breast cancer, colon cancer, and prostate cancer.[48] Of persons with diabetes who have a lower extremity amputation, up to 55% will require amputation of the second leg within two to three years.[49]

Etymology

The word amputation is derived from the Latin amputare, "to cut away", from ambi- ("about", "around") and putare ("to prune"). The English word “Poes” was first applied to surgery in the 17th century, possibly first in Peter Lowe's A discourse of the Whole Art of Chirurgerie (published in either 1597 or 1612); his work was derived from 16th-century French texts and early English writers also used the words "extirpation" (16th-century French texts tended to use extirper), "disarticulation", and "dismemberment" (from the Old French desmembrer and a more common term before the 17th century for limb loss or removal), or simply "cutting", but by the end of the 17th century "amputation" had come to dominate as the accepted medical term.

Notable cases

  • Patch Adams
  • Rick Allen
  • Douglas Bader
  • Carl Brashear
  • Lisa Bufano
  • Tammy Duckworth
  • Terry Fox
  • Pete Gray
  • Shaquem Griffin
  • Robert David Hall
  • Bethany Hamilton
  • Hugh Herr
  • Frida Kahlo
  • Aimee Mullins
  • Oscar Pistorius
  • Amy Purdy
  • Aron Ralston
  • Hans-Ulrich Rudel
  • Alex Zanardi
  • Ronnie Lott
  • Hari Budha Magar
  • Kalamandalam Sankaran Embranthiri

See also

  • Acrotomophilia
  • Adapted automobile
  • Flail limb
  • Robotic prosthesis control

References

  1. ↑ Fathi, Nazila (2008-01-11). "Spate of Executions and Amputations in Iran". The New York Times. Retrieved 2021-06-27.
  2. ↑ Chuback, Jennifer E. (March 2005). Whitelaw, W.A. (ed.). The history of rhinoplasty. 14th Annual History of Medicine Days. Calgary, Alberta, Canada: University of Calgary. pp. 10–15 – via ResearchGate.
  3. ↑ Kocharkarn W (Summer 2000). "Traumatic amputation of the penis" (PDF). Brazilian Journal of Urology. 26: 385–389 – via Official Journal of the Brazilian Society of Urology.
  4. ↑ Peters R (2005). Crime and Punishment in Islamic Law: Theory and Practice from the Sixteenth to the Twenty-First Century. Cambridge University Press. ISBN 9780521792264.
  5. ↑ Bosmia AN, Griessenauer CJ, Tubbs RS (July 2014). "Yubitsume: ritualistic self-amputation of proximal digits among the Yakuza". Journal of Injury and Violence Research. 6 (2): 54–6. doi:10.5249/jivr.v6i2.489. PMC 4009169. PMID 24284812.
  6. ↑ Kepe T (March 2010). "'Secrets' that kill: crisis, custodianship and responsibility in ritual male circumcision in the Eastern Cape Province, South Africa". Social Science & Medicine. 70 (5): 729–35. doi:10.1016/j.socscimed.2009.11.016. PMID 20053494.
  7. ↑ Grisaru N, Lezer S, Belmaker RH (April 1997). "Ritual female genital surgery among Ethiopian Jews". Archives of Sexual Behavior. 26 (2): 211–5. doi:10.1023/a:1024562512475. PMID 9101034. S2CID 32053425.
  8. ↑ "Amputator". Merriam-Webster. Retrieved 28 June 2021.
  9. ↑ "Amputee". Merriam-Webster. Retrieved 28 June 2021.
  10. ↑ National Limb Loss Information Center (23 July 2012). "Amputee Coalition Factsheet". Amputee Coalition. Archived from the original on 21 April 2013. Retrieved 22 April 2013.
  11. 1 2 Ziegler-Graham K, MacKenzie EJ, Ephraim PL, Travison TG, Brookmeyer R (March 2008). "Estimating the prevalence of limb loss in the United States: 2005 to 2050". Archives of Physical Medicine and Rehabilitation. 89 (3): 422–9. doi:10.1016/j.apmr.2007.11.005. PMID 18295618.
  12. ↑ United States Department of Health and Human Services; Centers for Disease Control and Prevention; National Center for Health Statistics (8 March 2010). "National Survey of Ambulatory Surgery: 1994, 1995, 1996, and 2006". Ann Arbor, Michigan: Inter-university Consortium for Political and Social Research. doi:10.3886/icpsr27461.v2. {{cite journal}}: Cite journal requires |journal= (help)
  13. ↑ Pinzur MS, Stuck RM, Sage R, Hunt N, Rabinovich Z (September 2003). "Syme ankle disarticulation in patients with diabetes". The Journal of Bone and Joint Surgery. American Volume. 85 (9): 1667–72. doi:10.2106/00004623-200309000-00003. PMID 12954823.
  14. ↑ Ransom, Cliff (24 July 2003). "Did Climber Have to Cut Off Arm to Save Life?". National Geographic. Retrieved 5 January 2019.
  15. ↑ Abdul W, Hickey B, Wilson C (April 2016). "Lower extremity compartment syndrome in the setting of iliofemoral deep vein thrombosis, phlegmasia cerulea dolens and factor VII deficiency". BMJ Case Reports. 2016: bcr2016215078. doi:10.1136/bcr-2016-215078. PMC 4854131. PMID 27113791.
  16. ↑ Murray, Shane (2002-01-22). "RTE: Aussie Rules star has finger removed". RTÉ.ie. Archived from the original on 2007-12-14. Retrieved 2007-10-19.
  17. ↑ Australian Rugby Union (2006-10-17). "Tawake undergoes surgery to remove finger". SportsAustralia.com. Archived from the original on 2013-05-01. Retrieved 2013-04-22.
  18. ↑ "Burglar's hand to be amputated". gulfnews.com. Retrieved 2021-11-03.
  19. ↑ "Iranian chocolate thief faces hand amputation". BBC News Online. 2010-10-17. Retrieved 2021-06-28.
  20. ↑ Dovan, Fiona (2008-02-09). "Iran envoy defends amputation". The Telegraph. Retrieved 2021-06-28.
  21. ↑ "Saudi Arabia chops off hand of Egyptian for theft". Monsters and Critics. 2007-11-05. Archived from the original on 2010-08-11. Retrieved 2021-06-27.
  22. ↑ "Yemeni man sentenced to hand and foot amputation for armed robbery". Amnesty International. 2013-09-16. Retrieved 2021-11-03.
  23. ↑ Bamford, David (2001-07-01). "Hand amputation in Nigeria". BBC News Online. Retrieved 2021-06-28.
  24. ↑ Bello, Ademola (2010-06-11). "Who Will Save Amputees of Sharia Law in Nigeria?". Huffington Post. Retrieved 2021-06-28.
  25. ↑ Harper, Timothy (2 October 2007). The Complete Idiot's Guide to the U.S. Constitution. Penguin Group. p. 109. ISBN 978-1-59257-627-2.
  26. ↑ Jefferson, Thomas (1778). Kurland, Philip B.; Lerner, Ralph (eds.). A Bill for Proportioning Crimes and Punishments. Founders' Constitution. University of Chicago Press (published 1986).
  27. ↑ "Archived copy". Archived from the original on 2013-10-03. Retrieved 2021-01-08.{{cite web}}: CS1 maint: archived copy as title (link)
  28. ↑ Smith DG (2004). "Chapter 2. General principles of amputation surgery.". Atlas of Amputations and Limb Deficiencies: Surgical, Prosthetic and Rehabilitation Principles. American Academy of Orthopaedic Surgeons. pp. 21–30. ISBN 978-0892033133.
  29. ↑ Springer, Shira (2018-04-13). "How The Marathon Bombing Helped Bring Innovation To Amputation". WBUR. Retrieved 2021-06-28.
  30. ↑ "Jim Ewing, Dynamic-Model Amputation Patient". Brigham and Women's Faulkner Hospital. 2016-11-21. Retrieved 2021-06-28.
  31. ↑ "Ertl Reconstruction - amputation". www.ertlreconstruction.com. Retrieved 2018-11-24.
  32. ↑ Fischgrund JS (June 2016). "JAAOS Research". The Journal of the American Academy of Orthopaedic Surgeons. 24 (6): 392. doi:10.5435/jaaos-d-16-00309. PMID 27213622.
  33. ↑ Kwah LK, Webb MT, Goh L, Harvey LA (June 2019). "Rigid dressings versus soft dressings for transtibial amputations". The Cochrane Database of Systematic Reviews. 6: CD012427. doi:10.1002/14651858.cd012427.pub2. PMC 6573094. PMID 31204792.
  34. ↑ Reichmann JP, Stevens PM, Rheinstein J, Kreulen CD (May 2018). "Removable Rigid Dressings for Postoperative Management of Transtibial Amputations: A Review of Published Evidence". PM&R. 10 (5): 516–523. doi:10.1016/j.pmrj.2017.10.002. PMID 29054690. S2CID 21732925.
  35. ↑ Smith DG, Skinner HB (2014). "Amputations". In Skinner HB, McMahon PJ (eds.). Current Diagnosis & Treatment in Orthopedics (5th ed.). McGraw-Hill Education. ISBN 978-0-07-159075-4.
  36. 1 2 Watson N (1986). Hand Injuries and Infections. London: Gower Medical. ISBN 0906923808.
  37. ↑ Ramirez C, Menaker J (2017-05-01). "Traumatic Amputations". Trauma Reports. 18 (3).
  38. ↑ Johansen K, Daines M, Howey T, Helfet D, Hansen ST (May 1990). "Objective criteria accurately predict amputation following lower extremity trauma". The Journal of Trauma. 30 (5): 568–72, discussion 572–3. doi:10.1097/00005373-199005000-00007. PMID 2342140.
  39. ↑ Davison, Ben, ed. (February 2011). "Scuba Tanks as Lethal Weapons". Undercurrent. Vol. 26, no. 2. Sausalito, California. pp. 8–9. Archived from the original on 2021-04-28. Retrieved 28 June 2021.
  40. 1 2 "American Statistical Association (ASA)". www.amstat.org.
  41. ↑ Weiss AJ, Elixhauser A, Steiner C (April 2013). "Readmissions to U.S. Hospitals by Procedure, 2010". HCUP Statistical Brief #154. Rockville, Maryland: U.S. Agency for Healthcare Research and Quality.
  42. ↑ Bouskela E, Donyo KA (May 1997). "Effects of oral administration of purified micronized flavonoid fraction on increased microvascular permeability induced by various agents and on ischemia/reperfusion in the hamster cheek pouch". Angiology. 48 (5): 391–9. doi:10.1177/000331979704800503. PMID 9158383. S2CID 28978927. Archived from the original on 2010-11-25. Retrieved 2010-06-24.
  43. ↑ Dillon RS (May 1997). "Patient assessment and examples of a method of treatment. Use of the circulator boot in peripheral vascular disease". Angiology. 48 (5 Pt 2): S35–58. doi:10.1177/000331979704800504. PMID 9158380. S2CID 23512929. Archived from the original on 2010-11-25. Retrieved 2010-06-24.
  44. ↑ Vella A, Carlson LA, Blier B, Felty C, Kuiper JD, Rooke TW (2000). "Circulator boot therapy alters the natural history of ischemic limb ulceration". Vascular Medicine. 5 (1): 21–5. doi:10.1191/135886300671427847. PMID 10737152.
  45. ↑ Williams, Vivien (2008-07-11). Circulator Boot (video). Mayo Clinic News Network. Event occurs at 1:08–1:32. Retrieved 2021-06-27.
  46. ↑ Schultz H (January 2005). "The Science of Things". National Geographic Magazine. Archived from the original on September 6, 2008.
  47. ↑ Ryan J (March 25, 2006). "War without end / Damaged soldiers start their agonizing recoveries". The San Francisco Chronicle. Archived from the original on February 8, 2011. Retrieved June 4, 2017.
  48. ↑ Robbins JM, Strauss G, Aron D, Long J, Kuba J, Kaplan Y (November 2008). "Mortality rates and diabetic foot ulcers: is it time to communicate mortality risk to patients with diabetic foot ulceration?". Journal of the American Podiatric Medical Association. 98 (6): 489–93. doi:10.7547/0980489. PMID 19017860. S2CID 38232703.
  49. ↑ Savage PE (1983). "The diabetic foot". Problems in Peripheral Vascular Disease. Springer Netherlands. pp. 69–73. doi:10.1007/978-94-011-6648-5_12. ISBN 9789401166508.

Further reading

  • Miller, Brian Craig. Empty Sleeves: Amputation in the Civil War South (University of Georgia Press, 2015). xviii, 257 pp.
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