Lower-limb deficiencies and amputations in children

Lived experience of children and adolescents with lower-limb loss who used a prosthesis: A qualitative study

PURPOSE

Children's and adolescents' level of activity, the type of activity, and other features are special to them and can result in unique experiences with lower-limb prosthesis. The specific objective of this study was to explore the lived experience of children and adolescents with lower-limb loss (LLL) who used a prosthesis.

METHODS

We used a descriptive qualitative study design and in-depth, semistructured, face-to-face interviews. Accordingly, 35 participants, including children and adolescents with LLL who used a prosthesis, their parents, and prosthetists, were interviewed. The collected data were analyzed thematically.

RESULTS

One hundred sixty-eight codes about the experiences of children, parent(s), and prosthetists were extracted from the transcripts and categorized into 32 subthemes. Finally, 7 broad themes including suitability, provoke reactions, intrinsic nature, infrastructures, the school, availability, and parenting role were extracted.

CONCLUSION

The experiences of children and adolescents with lower-limb prosthesis are specific as each may face unique challenges and deal with different difficulties. In this study that has been conducted in a developing country, the main challenges faced by children using lower-limb prosthesis and their parents are the prosthetic components, social reactions, long distance, and costs of services. Moreover, designing a more natural prosthesis and gait training for children with LLL were the most important issues faced by prosthetists. However, close relationships with friends and family members, and children's amazing ability to adapt can aid in facilitating prosthetic management.

Surgical Technique for Varus Deformity Correction of Below-Knee Stump in a Paediatric Patient

Paediatric amputation is one of the treatment options for various indications, namely, trauma, infection, tumour and congenital problems, and some may be born with congenital problems. It differs from adult amputation as they have higher physical demands, and special complications may arise. Stump overgrowth by far is the commonest complication in paediatric transosseous amputation, while varus deformity of the tibia stump was reported sparsely in the literature. The growth discrepancy of the proximal tibia and fibula physis coupled with distal tibiofibular synostosis may have resulted in proximal migration of the fibula, which later resulted in varus deformity of the stump. This will cause difficulty in prosthesis fitting and lead to painful stumps due to the pressure at the abnormal bony prominence. We report a case of congenital limb deficiencies in a 12-year-old male who was treated with below-knee amputation (BKA) and experienced progressive varus deformity of the stump that caused pain during prosthetic wear, which interfered with his gait. He had a varus deformity of 15 degrees of the stump, distal tibiofibular synostosis and proximal migration of the fibula head. As the conservative management by modification of the prosthesis had failed, he underwent open wedge proximal tibia corrective osteotomy, division of the synostosis and reduction of the fibula head. The surgical intervention was successful in alleviating his problem. All efforts must be made to ensure optimum prosthetic fitting in paediatric amputation patients to maintain the patient's daily lifestyle and activities.

Exercise training program in children with lower-limb amputation

OBJECTIVE

Few physical exercise programs for children with limb loss have been described in detail recently. We provided information regarding the characteristics and effectiveness of an alternative rehabilitation exercise developed for children with lower-limb amputation.

METHODS

An 8-year-old boy with a below-knee amputation and a 9-year-old bilateral amputee girl performed an exercise program of one 2-h session per week for 20 weeks, aimed at developing muscular strength and coordination. Walking ability and walking speed were assessed by using the L-test of functional mobility and 10-m walk test, respectively. Mechanical and neuromuscular muscle function was assessed by using tensiomyography.

RESULTS

In case 1, a decrement of 9.5% and 10.5% was found in the L-test (42 s vs. 38 s) and in the 10-m test (19 s vs. 17 s) scores, respectively. In case 2, walking ability remained unchanged (L-test score: 38 s), while a 5.2% reduction in walking speed was observed (10-m test score: 19 s vs. 18 s). No relevant changes were observed in the muscular tone in both cases.

CONCLUSIONS

Practitioners should be aware that, contrary to what could be expected, a multidisciplinary training program held once per week for 5 months had a minimal impact on the gait pattern and neuromuscular function of two children with lower-limb amputation.

Effect of Amputation Level on Quality of Life and Subjective Function in Children

BACKGROUND

Our aim was to discern whether children with amputations have differences in subjective function based on amputation level. We hypothesized that children with more proximal amputations would report poorer function and quality of life.

METHODS

An IRB-approved, retrospective chart review of patients aged 0 to 21 years old with lower extremity amputations was performed. Demographic information, type of amputation, type of prosthesis, and the Pediatric Outcomes Data Collection Instrument (PODCI) was collected from parents and children (above 10 y old). Patients were divided into 4 groups based on the level of amputation (ankle; transtibial; knee; transfemoral), and PODCI scores were compared between groups. PODCI subscores were also compared between unilateral versus bilateral amputations, high-demand versus low-demand prostheses, and congenital versus acquired amputations.

RESULTS

We identified 96 patients for analysis (39 ankle, 21 transtibial, 27 knee, and 9 transfemoral amputations). The sports/physical functioning subscale of the PODCI showed the only statistically significant difference between amputation level and outcome with ankle-level amputations reporting higher scores than knee-level amputations (parent: 78.3±16.4 vs. 60.0±25.3, P=0.006; child: 87.4±15.3 vs. 65.4±31.5, P=0.03). Although not significantly different from either the ankle, knee, or transfemoral groups, patients with transtibial amputations reported intermediate scores (parent: 68.5±27.5; child: 78.9±25.5). There were no significant differences among amputation level for PODCI transfers, pain/comfort, global function, or happiness subscales. In subgroup analysis, same-level congenital amputees had similar scores to acquired amputees (P>0.05). When compared with unilateral knee amputations patients, patients with bilateral knee amputations had significantly worse transfer (62.4 vs. 88.3; P=0.02), sports/physical functioning (34.2 vs. 66.2; P=0.01), and global domains (58.4 vs. 80.5; P=0.02).

CONCLUSIONS

Subjective sports and physical functioning of pediatric amputees were significantly worse after knee amputation when compared with ankle-level amputations. Although not statistically significant at all levels, our data suggest a graded decline in sports/physical functioning with higher level amputations. Amputation level did not affect pain, happiness, or basic mobility.

LEVEL OF EVIDENCE

Level III.

Acute femoral shortening for reconstruction of a complex lower extremity crush injury

Traumatic through-knee or transfemoral amputations with concomitant ipsilateral femoral fractures are extremely rare injuries. The initial goal of management is patient resuscitation and stabilization. Subsequent interventions focus on limb salvage and the creation of a residual limb that can be fitted successfully for a functional lower extremity prosthesis. We present the case of a patient who sustained a traumatic through-knee amputation ipsilateral to an open comminuted femoral fracture. Soft tissue injury prohibited initial primary closure over the distal femoral condyles. A functional residual limb was achieved with acute femoral shortening, maintenance of the femoral condyles and fracture stabilization with a short retrograde intramedullary nail. This approach allowed maintenance of muscular attachments to the femur, soft tissue closure and resulted in a residual limb of acceptable length with a broad weight-bearing surface that was fitted with a prosthesis successfully.

Amputation and rotationplasty in children with limb deficiencies: current concepts

PURPOSE

Amputations and fitting surgery have a long history in children with limb deficiencies. With the current developments in limb reconstruction and new techniques in prosthetics, the indications for amputation and fitting surgery might have shifted, but still have a very important role in creating high functional performance, optimal participation and quality of life. The purpose of this current concepts article is to give an overview of the indications, dilemmas and technical considerations in the decision-making for amputation and fitting surgery. A special part of this overview is dedicated to the indications, variations and outcomes in rotationplasties.

METHODS

The article is based on the experience of a multidisciplinary reconstruction team for children with complex limb deficiencies, as well as research of the literature on the various aspects that cover this multidisciplinary topic.

RESULTS

For those children with a more severe limb deficiency, reconstruction is not always feasible for every patient. In those cases, amputation with prosthetic fitting can lead to a good result. Outcomes in quality of life and function do not significantly differ from the children that had reconstruction. For children with a postaxial deficiency with a femur that is too short for lengthening, and with a stable ankle and foot with good function, rotationplasty offers the best functional outcome. However, the decision-making between the different options will depend on different individual factors.

CONCLUSIONS

Amputations and rotationplasties combined with optimal prosthesis fitting in children with more severe limb deficiencies may lead to excellent short- and long-term results. An experienced multidisciplinary team for children with complex limb deficiencies should guide the patient and parents in the decision-making between the different options without or with prosthesis.

Amputation and prosthesis fitting in paediatric patients

Amputation of a limb is always perceived as a catastrophe. The principles underlying creation of a stump adapted to modern prosthetic fittings must be fully understood and the patient managed by a multidisciplinary team. In paediatric patients, preserving residual limb length is a crucial point that should be assessed according to the expected growth potential. Advances in prosthetic fittings have led to changes in the overall concept of socket design, which seeks to achieve three objectives: to maximise the weight-bearing surface area, to eliminate friction of the skin on the socket, and to eliminate lever-arm effects. The introduction on the market of new materials has contributed substantially to advances in prosthetic fittings. These advances require the use of new criteria for stump quality and optimisation, which exert a considerable influence on prosthesis function. Prosthetic fitting and specific management of psychological and social problems are provided during an inpatient stay in a physical medicine department, by a team of physicians, other healthcare professionals, social workers, and educators. Three-dimensional imaging and gait analysis provide valuable information.

Massage therapy effects in a long-term prosthetic user with fibular hemimelia

BACKGROUND

Individuals with lower limb amputation (LLA) commonly experience low back pain (LBP). Although massage effects on LBP are well-documented, research regarding massage for individuals with LLA is scarce.

OBJECTIVES

This study evaluated the effectiveness of massage therapy to promote activity level, decrease LBP, and improve health-related quality of life (HRQOL) in a long-term prosthetic user.

METHODS

The 50-day study consisted of two baseline sessions, seven treatment sessions that included a 50-min massage applied to major gait muscles, and two follow-up sessions. Pedometer-measured ambulatory activity level, visual analog scale-measured pain level, and RAND-36 Health Survey 1.0-determined HRQOL were assessed.

RESULTS

Pain level decreased, HRQOL increased, and no change occurred in ambulatory activity level.

CONCLUSION

For the participant, therapeutic massage intervention lead to successful LBP symptom management.

Through knee amputation: technique modifications and surgical outcomes

Background

Knee disarticulations (KD) are most commonly employed following trauma or tumor resection but represent less than 2% of all lower extremity amputations performed in the United States annually. KDs provide enhanced proprioception, a long lever arm, preservation of adductor muscle insertion, decreased metabolic cost of ambulation, and an end weight-bearing stump. The role for KDs in the setting of arterial insufficiency or overwhelming infection is less clear. The purpose of this study is to describe technique modifications and report surgical outcomes following KDs at a high-volume Limb Salvage Center.

Methods

A retrospective study of medical records for all patients who underwent a through-knee amputation performed by the senior author (C.E.A.) between 2004 and 2012 was completed. Medical records were reviewed to collect demographic, operative, and postoperative information for each of the patients identified.

Results

Between 2004 and 2012, 46 through-knee amputations for 41 patients were performed. The mean patient age was 68 and indications for surgery included infection (56%), arterial thrombosis (35%), and trauma (9%). Postoperative complications included superficial cellulitis (13%), soft tissue infection (4%), and flap ischemia (4%) necessitating one case of surgical debridement (4%) and four trans-femoral amputations (9%). 9 (22%) patients went on to ambulate. Postoperative ambulation was greatest in the traumatic cohort and for patients less than 50 years of age, P<0.05. Alternatively, diabetes mellitus and infection reduced the likelihood of postoperative ambulation, P<0.01.

Conclusions

Knee disarticulations are a safe and effective alternative to other lower extremity amputations when clinically feasible. For patient unlikely to ambulate, a through-knee amputation maximizes ease of transfers, promotes mobility by providing a counterbalance, and eliminates the potential for knee flexion contracture with subsequent skin breakdown.

Congenital fibular deficiency

Congenital fibular deficiency (CFD) is characterized by a wide spectrum of manifestations ranging from mild limb length inequality (LLI) to severe shortening, with foot and ankle deformities and associated anomalies. The etiology of CFD remains unclear. Treatment goals are to achieve normal weight bearing, a functional plantigrade foot, and equal limb length. The recent Birch classification system has been proposed to provide a treatment guide: the functionality of the foot, LLI, and associated anomalies should be taken into account for decision-making. Treatment options include orthosis or epiphysiodesis, Syme or Boyd amputation and prosthetic rehabilitation, limb lengthening procedures, and foot and ankle reconstruction. The outcome of amputation for severe forms of CFD has shown favorable results and fewer complications compared with those of limb lengthening. Nevertheless, advances in the limb lengthening techniques may change our approach to treating patients with CFD and might extend the indications for reconstructive procedures to the treatment of severe LLI and foot deformities.

The Boyd amputation in children: indications and outcomes

BACKGROUND

The level of amputation in the pediatric population requires appropriate planning to provide an optimal residual limb for prosthetic fitting and must include long-term strategies to accommodate future growth of the extremity.

METHODS

A retrospective review over a 15-year period was performed of all Boyd procedures (calcaneotibial fusion) in the pediatric limb deficiency population at a single institution. A chart review and radiographic analysis was performed to identify the indications, surgical outcomes, complications, need for additional surgical intervention, and nature of the postoperative prosthetic management. Optimal positioning of the calcaneotibial fusion and the growth-dependent changes in the morphology of the fusion site were determined by radiographic analysis.

RESULTS

A total of 109 children (117 limbs) were identified for inclusion in the study. The average age at the time of the Boyd procedure was 2.8 years. The most common indication for the Boyd procedure was a diagnosis of postaxial limb bud deficiency, which accounted for 66% of cases. Concomitant procedures were performed in 24% of cases and included proximal tibial epiphyseodesis, tibial osteotomy, or knee fusion in the majority of cases. Additional procedures were required in 33% of cases either for treatment of complication (9%) or optimization of the residual limb (24%). For the entire cohort, the complication rate was 14%. Complications were most common when the Boyd procedure was used as a treatment strategy for congenital pseudoarthrosis of the tibia. Prosthetic management utilizing supramalleolar suspension with complete end-bearing through the residual limb was possible for the majority of cases.

CONCLUSIONS

The Boyd procedure is an effective treatment for various conditions of the lower extremity. Concomitant or additional procedures after the initial intervention may be required for complete optimization of the residual limb.

LEVEL OF EVIDENCE

Level IV.

Effect of alignment changes on socket reaction moments during gait in transfemoral and knee-disarticulation prostheses: case series

The alignment of a lower-limb prosthesis is critical to the successful prosthetic fitting and utilization by the wearer. Loads generated by the socket applied to the residual limb while walking are thought to be different in transfemoral and knee-disarticulation prostheses. The aim of this case series was to compare the socket reaction moments between transfemoral and knee-disarticulation prostheses and to investigate the effect of alignment changes on them. Two amputees, one with a transfemoral prosthesis and another with a knee-disarticulation prosthesis, participated in this study. A Smart Pyramid™ was used to measure socket reaction moments while walking under 9 selected alignment conditions; including nominally aligned, angle malalignments of 6° (flexion, extension, abduction and adduction) and translation malalignments of 15 mm (anterior, posterior, medial and lateral) of the socket relative to the foot. This study found that the pattern of the socket reaction moments was similar between transfemoral and knee-disarticulation prostheses. An extension moment in the sagittal plane and a varus moment in the coronal plane were dominant during stance under the nominally aligned condition. This study also demonstrated that alignment changes might have consistent effects on the socket reaction moments in transfemoral and knee-disarticulation prostheses. Extension and posterior translation of the socket resulted in increases in an extension moment, while abduction and lateral translation of the socket resulted in increases in a varus moment. The socket reaction moments may potentially serve as useful biomechanical parameters to evaluate alignment in transfemoral and knee-disarticulation prostheses.

Transtibial Ertl amputation for children and adolescents: a case series and literature review

PURPOSE

Despite advances in limb reconstruction, there are still a number of young patients who require trans-tibial amputation. Amputation osteoplasty is a technique first described by Ertl to enhance rehabilitation after trans-tibial amputation. The purpose of the study reported here was to evaluate the results of the original Ertl procedure in skeletally immature patients and to assess whether use of this procedure would result in a diminished incidence of bony overgrowth.

METHODS

The cases of four consecutive patients (five amputations) treated between January 2005 and June 2008 were reviewed. Clinical evaluation consisted of the completion of the prosthesis evaluation questionnaire (PEQ) and physical examination. Radiographic analysis was performed to evaluate bone-bridge healing, bone overgrowth, and the development of genu varum as measured by the medial proximal tibial angle (MPTA).

RESULTS

The best mean PEQ score in the question section was 91.8 (range 74-100) for 'well being' and the worst mean score was 66.6 (range 50-78) for 'residual limb health'. Examination of the residual limbs revealed no bursae, and all knees were stable with full range of movement. All bony bridges united at an average age of 1.7 (range 1-2) months. One case required stump revision for bony overgrowth, and one case developed asymptomatic mild genu varum.

CONCLUSIONS

The original Ertl osteomyoplasty may serve as one of the options for treatment of trans-tibial amputation in older children.

CLINICAL RELEVANCE

Our results suggest that the Ertl osteomyoplasty is a feasible option in this challenging patient population.

Evolving techniques in foot and ankle amputation

Multiple clinical pathways lead to lower extremity amputation, including trauma, dysvascular disease, congenital defects, and malignancy. However, the principles of successful amputation-careful preoperative planning, coordination of a multidisciplinary team, and good surgical technique-remain the same. Organized rehabilitation and properly selected prostheses are integral components of amputee care. In the civilian setting, amputation is usually performed as a planned therapy for an unsalvageable extremity, not as an emergency procedure. The partial loss of a lower limb often represents a major change in a person's life, but patients should be encouraged to approach amputation as the beginning of a new phase of life and not as the culmination of previous treatment failures.

Functional, psychosocial and professional outcomes in long-term survivors of lower-extremity osteosarcomas: amputation versus limb salvage

As the number of osteosarcoma survivors increases, the impact of quality of life and function needs to be addressed. Limb salvage is the preferred treatment when patients have treatment options; yet, the questionable long-term durability and complications of prostheses, combined with ambiguous function, leave some doubt regarding the best clinical and surgical options. Comparisons between limb salvage patients, amputees and controls also require further investigation. Amputation would leave the patients with a lifelong requirement for an external prosthetic leg associated with an overall limited walking distance. While artificial limbs are much more sophisticated than those used in the past, phantom limb sensations remain a substantial and unpredictable problem in the amputee. Complications such as stump overgrowth, bleeding, and infection, also require further elucidation. Limb salvage surgery using endoprosthesis, allografts or reconstruction is performed in approximately 85% of patients affected by osteosarcoma located in the middle and/or distal femur. One drawback in limb-salvage surgery in the long-term survivor is that endoprostheses have a limited life span with long-term prosthetic failure. The inherent high rate of reoperation remains a serious problem. Replacing a damaged, infected or severely worn-out arthroplastic joint or its intramedullary stem is difficult, especially in the long-stem cemented endoprostheses used in the 1980s. Limb lengthening procedures in patients who have not reached maturity must also be addressed. Periprosthetic infections, compared to other indications for joint reconstruction, were found to be more frequent in patients treated for neoplastic conditions and their outcome can be devastating, resulting in total loss of joint function, amputation, and systemic complications. Quality of life in terms of function, psychological outcome and endpoint achievements such as marriage and employment apparently do not differ significantly between amputee and nonamputee osteosarcoma survivors. Amputee patients nonetheless appear to have made satisfactory adjustments to their deficits with or without a functional external prosthesis. It also appeared that amputee patients had a similar psychological and quality of life outcome as limb salvage patients. There was no evidence of excessive anxiety or depression or deficits in self-esteem compared with the normal population or matched controls. A number of long-term survivors also achieved high ranking in the professional and commercial work place. These positive aspects should be recognized and emphasized to patients and their parents when discussing the outcome.

Rotationplasty--a unique surgical procedure with a functional outcome

ROTATIONPLASTY is a surgical procedure that may be appropriate for children with severe congenital femoral deficiency or children with malignant tumors of the femur or proximal tibia. OSTEOTOMIES AND RESECTION of the femur and tibia are performed, allowing the patient's foot to be rotated 180 degrees and reattached while preserving the nerves, muscles, and blood supply. THE POSTERIOR-FACING FOOT functions as the patient's knee joint in a specially fitted prosthesis. Although the outcome is visually unusual, for some children, regaining function and physical capabilities outweighs cosmetic concerns. The surgical procedure is technically challenging and requires a multidisciplinary approach.

Hand trauma in shop class

The environment and equipment used in shop class are potential sources of serious injury. There has been little published to date on injuries sustained in shop class, with no reports examining injuries to the hand. The authors report a case series collected from a health records database at a pediatric and hand surgery referral center. Fifteen patients who sustained injuries to their wrist or hand in shop class were identified. Sixty percent of the injuries were caused by table saws. Eighty percent required treatment from a hand surgeon. Sixty-seven percent of patients sustained a serious injury in the form of amputation or tendon or neurovascular injury. Most of the patients had functional deficits at final follow-up. Shop class is a setting where serious hand trauma can occur. School administrators and educators should direct efforts at preventing these injuries. Parents and students must recognize the risks associated with shop class. Physicians should be prepared for severe injuries and the frequent need for hand surgical consultation.

Rehabilitation of a child with meningococcal septicemia and quadrilateral limb loss: a case report

Acquired quadrilateral limb loss is a rare occurrence in children. One cause of this condition is severe meningococcal septicemia. We present the case of a boy who, at 14 months of age, required extensive amputation after an episode of meningococcal septicemia. We review his medical recovery and rehabilitation, including upper- and lower-limb prosthetic prescription and training, and adaptation to his altered body. A multidisciplinary approach led to effective management of his complex clinical and psychologic needs. This case illustrates the need to address a range of medical, prosthetic, and family issues central to successful clinical outcome.

Bone Overgrowth in the Adult Traumatic Amputee

Bone overgrowth of the residual limb after an amputation is a well documented complication in the pediatric amputee population. Bone overgrowth can cause pain, problems with skin breakdown, and poor prosthetic fit. There have been few reports of bone overgrowth in the adult amputee. Two cases of traumatic transfemoral amputations after extensive tissue damage are presented. Both patients successfully completed an in-patient amputee rehabilitation program and achieved functional ambulation with their prostheses. However, each developed distal residual limb pain within a year after their amputations that significantly limited the amount of time they could wear their prostheses and the distance they could walk. Radiographs demonstrated additional bone growth from the residual femur into adjacent soft tissues in both patients. These case examples demonstrate that bone overgrowth should be considered in the differential diagnosis of residual limb pain in the adult amputee.

Factors associated with bone regrowth following diabetes-related partial amputation of the foot

BACKGROUND

The formation of hypertrophic bone after partial resection of metatarsal bone has the potential to cause abnormal foci of high pressure in people who have diabetes mellitus; this may increase the risk of reulceration and reamputation. However, we are not aware of previous studies evaluating the risk factors for this entity.

METHODS

The records of ninety-two adults (mean age, 54+/-10.1 years; range, thirty to seventy-four years) with diabetes who had had an isolated partial amputation of a ray were abstracted. Repeat radiographs were made for all of these subjects at a mean of 22+/-6.1 months (range, thirteen to thirty-five months) after the initial procedure. The formation of hypertrophic bone was defined as more than three millimeters of regrowth.

RESULTS

A total of forty-one (45 percent) of the subjects had formation of hypertrophic bone at the time of radiographic analysis after isolated partial amputation of a ray. On multivariate analysis, the factors that were significantly associated with this regrowth of bone were male gender (88 percent [thirty-six] of the forty-one patients who had bone regrowth were male compared with 51 percent [twenty-six] of the fifty-one patients who did not have bone regrowth; p<0.01, odds ratio = 5.7, 95 percent confidence interval = 1.8 to 18.9), the use of manual bone-cutting instruments (used in 56 percent [twenty-three] of the forty-one patients who had bone regrowth compared with 16 percent [eight] of the fifty-one who did not; p<0.01, odds ratio = 4.7, 95 percent confidence interval = 1.6 to 13.8), and a resection made distal to the surgical neck of the metatarsal (used in 34 percent [fourteen] of the forty-one patients who had bone regrowth compared with 12 percent [six] of the fifty-one who did not; p<0.03, odds ratio = 4.5, 95 percent confidence interval = 1.2 to 16.9). The patients who had regrowth of bone were approximately eight times more likely to have reulceration at the site of the amputation than were those who did not have regrowth (24 percent [ten] of the patients with regrowth had reulceration compared with 4 percent [two] of the patients without regrowth; p<0.01, chi square = 8.4, odds ratio = 7.9, 95 percent confidence interval = 1.6 to 38.5).

CONCLUSIONS

Overgrowth of the bone of a transected metatarsal predisposes patients to ulceration. Male gender, the use of manual bone-cutting instruments, and metaphyseal amputation may be associated with long-term regrowth of bone following isolated partial amputation of a ray. The use of power instruments during these procedures may lead to a lower prevalence of this reaction, thereby potentially reducing the risk of ulceration, infection, and reamputation.