MEASUREMENT
OF
TRANSCUTANEOUS
NORMAL
AND
ISCHAEMIC
G. S. E. DOWD,
From
the University
Department
OXYGEN
K. LINGE,
ofOrthopaedic
PRESSURE
IN
SKIN
G. BENTLEY
and Accident
Surgery,
Royal
Liverpool
Hospital
The transcutaneous
oxygen pressure (tcPo2) was measured
by a polarographic
technique in the legs of
and compared
with the levels found in 62 patients with ischaemic
skin due to peripheral
The results show that the tcPO2 was related to the degree of ischaemia
and, in many cases,
was a more accurate
guide to the viability
of the skin than clinical
assessment.
Measurement
of the
transcutaneous
oxygen
pressure
in the leg at the site of amputation
in 24 patients with peripheral
vascular
disease showed that a preoperative
level greater than 40 millimetres
of mercury at an electrode
temperature
of 44 degrees Celsius was necessary
for the skin of the stump to heal. The technique is simple, non-invasive
and reliable. The tcPo2 accurately
reflects the physiological
and pathological
changes in the circulation
of the
skin. It has potential
in many fields of surgery where careful assessment
of the viability
of the skin is
necessary.
161 volunteers
vascular disease.
An
accurate
method
be
invaluable
would
including
associated
of assessing
in
many
the
peripheral
vascular
with cutaneous
damage
At present,
no satisfactory
non-invasive,
accurate
methods
of investigating
included
the measurement
using
a photo-electric
viability
ischaemic
disease
and
of
and vascular
injury.
method
is available
which
is
and
simple
to use.
Previous
the viability
of the skin have
of cutaneous
blood pressure
probe
(Nielsen,
Poulsen
and
1973), the measurement
of cutaneous
by a thermal
conductance
method
(Challoner
blood
1975),
Gyntelberg
flow
intradermal
measurement
Walker
1976),
isotope
tracers
pressure
these
ofoxygen
and more
recently
measure
to
skin
conditions
limb trauma
tension
(Spence
the application
blood
flow
and
and
of radiodistal
blood
et al. 1976;
(Kostuik
have
techniques
Holstein
et al. 1978). All
applied
to clinical
situations
been
measured
by a polarographic
displayed
on
pressure
(tcPo2).
heated
to produce
lanes,
the
oxygen
with
technique
a monitor
increase
in blood
through
as a non-invasive
ofthe
arterial
oxygen
developed
monitoring
Lubbers
oxygen
and
Huch
1972).
It
electrode
which
is attached
a self-adhesive
ring. Oxygen
monitor
method
pressure
in particular,
factors,
Eickhoff,
the tcPo2
They
the
Ishihara
is directly
have
perfusion
consists
continuous
(Pa,o2) (Huch,
of
a Clark-type
to the surface
of the skin by
diffusing
through
the skin is
G. S. E. Dowd,
MChOrth,
FRCS,
Senior
Lecturer
and
Honorary
Consultant
K. Linge,
Research
Assistant
University
Department
of Orthopaedic
and Accident
Surgery,
Royal
Liverpool
Hospital,
Prescot
Street,
Liverpool
L7 8XP,
England.
Professor
G. Bentley,
ChM,
Royal
National
Orthopaedic
London
WiN
6AD,
England.
FRCS
Hospital,
Requests
be sent
for reprints
should
©
1983 British
Editorial
0301-620X/83/1046--0079
VOL.
65-B,
No.
I, JANUARY
Society
$2.00
1983
to Mr
of Bone
234
Great
Portland
G. S. E. Dowd.
and
Joint
Surgery
Street,
results
the
is
electrode
is
of the capil-
in an increase
It has been
shown
capillaries
the
in
that
Pa,o2
also
blood
shown
that
of blood
is reduced
ischaemic
oxygen
pressure
and the tcPo2
degree
of
In
order
to
the electrode.
tcPo2
depends
the electrode.
there
is a fall in cutaneous
Walker
1976).
The
Lassen
in the
transcu-
should
therefore
reflect
all these
measurement
should
relate
to the
thereby
viability
test
that
skin.
on the
Gothgen
pressure
(Holstein
and
and the oxygen
pressure
and
ischaemia,
of the
the
under
states
(Spence
taneous
changes
assessment
under
similarly
observed
that
the
to the mean
arterial
blood
blood flow and perfusion
1973 ; Kostuik
et a!. 1976)
skin
flow
and Jacobsen
(1979)
have shown
related
to blood flow in normal
pressure
In chronic
has been
of
flow
of the
pressure.
discomfort.
level
oxygen
closely
with the tcPo2
in adults
(Rooth
et a!.
1976; Gothgen
and Jacobsen
1978).
The Pa,o2
and tcPo2
are physiologically
different
and the relationship
between
the two depends
on many
or cause
a transcutaneous
skin below
vasodilatation
vasodilatation
the
correlates
and Jacobsen
(1978)
have
tcPo2
is directly
related
the patient
and
transcutaneous
the skin.
but have limitations
in their routine
use ; several
methods
are invasive
and the others
are technically
difficult
to use
Recently,
the
When
the
maximal
diffusion
maximal
as
of the
this
allowing
an
accurate
skin.
hypothesis,
the
tcPo2
was
measured
compared
degrees
in a group of normal
volunteers
and the results
with those
in a series of patients
with varying
of ischaemia
resulting
from peripheral
vascular
disease.
patients
The technique
undergoing
disease
orthopaedic
and
has subsequently
been
amputation
for peripheral
to patients
conditions
and
undergoing
trauma
where
applied
to
vascular
operations
the viability
for
of
79
80
G.
the
skin
was
in question.
By measuring
the site of the incision
before
identify the tcPo2 above which
MATERIALS
transcutaneous
TCM1TC
was
solution
the
lying
on
for
patients
20 minutes
to
with
their
severe
patients
had
by a self-adhesive
to produce
air
tcPo,
recording
of the
electrode.
of oxygen
volunteers
32
30.
before
the
application
of44
was
The
and
heater
the
degrees
the
Celsius
floor.
The
asked
subjects
None
of
the
was
set
attached
electrode
temperature
degree
20 minutes
18
16
14
.
12
10
SD=
70mm
Hg
±9
6
4
2
to
I,
40
45
50
55
60
65
70
TcPO2
(mm Hg)
of the
Celsius).
after
mean=
electrode
the
was
in the
( ± one
approximately
with
electrode
Celsius.
and
of the
taken
to
disease.
22 degrees
stabilised
were
buffer
.
C
to standardise
rested
n=161
.
20
1). The
in a bisulphite
were
horizontal
ring
(Fig.
BENTLEY
34
a Radiometer
In order
and
legs
respiratory
a temperature
surrounding
using
recorder
pressure.
G.
28
26
24
22
measured
Measurements
the
skin
to
to a chart
level
oxygen
measurement.
a bed
was
to a zero
the
silent
during
near
it was hoped
might
confidently
LINGE,
METHODS
connected
to atmospheric
measurements,
and
pressure
Monitor
calibrated
and
to remain
AND
oxygen
Oxygen
electrode
the tcPo2
operation,
the skin
K.
to heal.
be expected
The
S. E. DOWD,
The
Fig.
application
Histogram
of the
tcPo2
recorded
75
80
85
90
95
2
in the
legs
of 16 1 normal
volunteers.
RESULTS
Normal
volunteers.
of the foot
dorsum
range
of 45 to 95 millimetres
70 millimetres
millimetres
ments
were
-
same
Fig.
apparatus:
A, electrode:
volunteers.
foot
(mean
The
45
years).
skin
skin
with
C, calibration
measured
on the
with
chest
line.
at points
an age
over
the
In 25 volunteers,
vascular
skin
range
were
wall
and
D,
of the
patients
were
ischaemia
of the
intermittent
with
divided
skin
made
in
second
rib
above
disease.
and
Sixty-two
of gangrene:
foot
tcPo,
(the
because
directly
onto
Patients
91
for
gangrene
on
the
of
were
below
the
by the
examination
healing
of the
difficulty
in maintaining
the
knee.
with
Site
67 years)
of the
the
near
after
skin,
foot
the
tcPo2
and
sites
regarding
reference
on
the
of routine
the
of
but
without
of the
skin
to the
gangrenous
measured
skin
amputations.
and
classified
healing
or failure
range
before
amputation
10 centimetres
The
The
oxygen
pressures
at
various
of measurement
Number
of
volunteers
tcPo2
(mmHg)
Chest
Range
Mean
SD
91
50-95
69
±11
10 centimetres
45-88
69
±
9
55-86
70
±
9
45-93
67
± 11
53-95
74
±
9
57-87
72
±
8
46-90
68
± 12
45-93
68
± 11
below-
knee
10 centimetres
knee
below-
25
of the
an age
Readings
site of amputation
tcPo,.
transcutaneous
Dorsum
of foot
of the electrode
with
disease.
to the
operation
delayed
was
vascular
a closer
anatomi-
; patients
adjacent
adhesion
was
were
of
symptoms
skin
foot
there
which
an
gangrene
skin
In 24 patients
to peripheral
surgeon
with
the
of the
that
of skin
similar.
In other words,
measurements
taken
on the
of both feet, or on the skin 10 centimetres
below
knee
were
more
closely
related
than
a chest
also
tissue).
amputation.
without
examined
dorsum
on
of the
knee
the
patients
due
made
on
and
necrotic
dorsum
skin
with
of ischaemic
found
areas
these
on the degree
: patients
measured
(mean
below
were
of
nine
interspace,
patients,
depending
evidence
was
undergoing
to 85 years
groups
clinically
without
of ischaemic
evidence
three
assessed
claudication
signs
tissue
into
dorsum
it was
between
Table I. Comparison
of
sites in normal
volunteers
age range
of 44 to 85 years (mean
66 years),
suffering
from peripheral
vascular
disease
had readings
taken
on the dorsum
of the affected
foot.
The
±
dorsum
of 12 to 94 years
measurements
10 centimetres
peripheral
unit;
each
measurements
of the
in the left midclavicular
on the
was
volunteers,
Further
on the
Patients
a mean
of mercury
(Fig.
2). When
these
measurerelated
to age, the age-dependent
deviations
volunteer
cally
I
B, monitor:
chart
recorder.
tcPo,
in 161 normal
volunteers
taken
with
deviation
not
correlation
Normal
standard
measurements
A
ofthe
of mercury
of mercury,
significant.
A similar
range
of transcutaneous
was
found
on the chest
wall
and
10
centimetres
above
and below
the knee (Table
I). When
measurements
at various
sites
were
compared
in the
.
.
The
of the tcPo2
on the
volunteers
showed
a
-
were
-\
Measurements
in 161 normal
of 50
were
taken
above
decision
and
25
Right
leg 10 centimetres
below-knee
was
based
on clinical
amputation
stumps
in relation
Left leg 10 centimetres
below-knee
to primary
Dorsum
ofthe
left
Dorsum
of the
right
foot
52
foot
to heal.
THE
JOURNAL
OF BONE
AND
JOINT
SURGERY
MEASUREMENT
measurement
OF
compared
Presumably
measurement.
TRANSCUTANEOUS
OXYGEN
with
a below-knee
the reason
for
or
this
foot
was
in thicknessofthe
skin and other physiological
affecting
the skin on the chest and leg.
Comparison
of the
measurements
taken
at
various
sites in the legs and on the chest
wall failed
factors
the
to
an oxygen
pressure
gradient
from proximal
to distal
parts of the body in normal
volunteers.
Patients
with peripheral
vascular
disease.
The tcPo2
on
the dorsum
of the foot in patients
with intermittent
claudication
but without
skin changes
ranged from 26 to
72 millimetres
of mercury
with a mean of 52 millimetres
show
Patients
with
signs
of Ischaemic
skin
had
IN NORMAL
AND
ISCHAEMIC
81
SKIN
of the patients
with clinical
signs of ischaemic
skin
had a tcPo2
below
the lower
limits
of normal ; the
remaining
seven per cent were within five millimetres
of
mercury
of the lower normal
limit. Measurements
taken
adjacent
to gangrenous
tissue
approached
zero millimetres
of mercury
in 52 per cent of patients,
whilst
all
readings
were below the lower limits of normal.
It should
cent
differences
of mercury.
PRESSURE
a
range
of tcPo2 of 19 to 49 millimetres
of mercury
with a
mean
of 33 millimetres
of mercury,
whilst measurements
adjacent
to gangrenous
tissue were in the range of 0 to 38
millimetres
of mercury
with a mean of 10 millimetres
of
be stressed
adjacent
that
readings
in the
to gangrenous
of viability.
When
individual
from
latter
on skin
patients
readings
from the
they
all showed
gradient
tissue
were
thigh,
leg and
a transcutaneous
the
proximal
group
were
taken
of varying
degrees
examined
and
foot
to distal
the
were compared,
oxygen
pressure
part
This gradient
was not apparent
in normal
was related
to the degree of ischaemia.
of the
volunteers
limb.
and
mercury.
When
the
histograms
relating
the
percentage
of
Table
related
in each group to the tcPo2 on the dorsum
of the
compared
to the histogram
of the normal
volunteers
within
the same age range,
the abnormal
groups
clearly showed
a shift to the left of normal
(Fig.
II. Transcutaneous
to subsequent
oxygen
pressure
healing
of the stump
at the
level
of amputation
patients
were
foot
3). The
degree
of shift
ischaemia.
claudication
but
measurements
with
I
.J
signs
of patients
millimetres
Normal
to the
symptoms
without
cent
(45
:
related
with
encompassing
24 per
normal
was
Patients
severity
of
of the
of ischaemia
had tcPo2
the lower range
of normal,
below
the lower
limits
of
of mercury).
Ninety-three
40
(
Claudicatlon
30
1
71
F
Above-knee
74
Healed
2
74
M
Above-knee
64
Healed
n
Result
3
52
M
Above-knee
63
Healed
4
65
M
Above-knee
62
Healed
5
52
M
Above-knee
57
Healed
6
80
F
Above-knee
56
Healed
7
53
M
Above-knee
55
Healed
8
61
M
Midtarsal
54
Healed
9
71
M
Below-knee
53
Healed
10
77
M
Below-knee
49
per
S
I,
Sex
.__.r__rrrrrLi__.,
(n73)
of
Age
Case
intermittent
tcPo2 at site
amputation
(mmHg)
Type of
amputation
15)
S
Delayed
healing
20
nr
G
m
50
Oangr.n.
11
48
M
Below-knee
48
Healed
12
65
M
Above-knee
48
Healed
13
71
M
Above-knee
48
Healed
14
78
M
Above-knee
48
Healed
15
73
M
Above-knee
45
Healed
16
85
M
Above-knee
45
Healed
17
78
M
Above-knee
41
Healed
18
56
M
Above-knee
40
Healed
19
75
M
Midtarsal
40
Failed
20
58
F
Toe
36*
Failed
21
61
F
Midtarsal
36
Failed
22
50
F
Below-knee
35
Failed
23
67
M
Below-knee
34
Failed
24
61
M
Toe
0
Failed
tcPo,
on the
dorsum
(.=33)
40
S
30
C
:
I
20
10
0
10
20
30
40
Fig.
Histograms
relating
the
VOL.
65-B,
No.
50
60
70
80
90
(mmHg)
TcPO2
3
of the four
groups
of volunteers
and
patients,
percentage
of individuals
in each group
to the tcPo2
measurement
on the dorsum
of the foot.
1, JANUARY
1983
*
of the
foot
82
G.
Amputees.
disease
require
Twenty-four
patients
with
of the lower
limb judged
amputation
for gangrene
on the
dorsum
above
quently
of the
and
below
underwent
knee,
three
foot
and
peripheral
on clinical
skin
millimetres
Two
7
6
primary
5
subsebelow-
amputation
>,
of a
C.,
C
without
reading
of the
diffiof 40
The
heal
and
two
below-knee
required
amputations
a more
proximal
of the foot
underwent
which
amputation
They
had readings
the dorsum
a more
When
correlated
in an area
of 0 and
of the foot,
skin appeared
and
of 54 millimetres
amputation
of
of
failed
had
despite
proximal
the
with
amputation
tcPo2
in which
healing,
the tcPo2
of mercury
that
clinically
Both failed
was
the
at
skin
site
toe.
on
the
to heal
necessary.
of
amputation
all amputations
was
Two
a gangrenous
the fact
less than
was
performed
40 millimetres
of mercury
amputation
millimetres
failed
to heal irrespective
of the site of
(Fig. 4). Providing
the tcPo2 was above 40
of mercury
the amputation
stump
healed.
In two patients
the tcPo2 at the level of amputation
(one midtarsal
and the other
above
the knee)
was 40
millimetres
of mercury;
the midtarsal
stump
failed
to
heal
and
the above-knee
stump
healed.
a.
colour,
presence
capillary
return,
or absence
of the skin is usually
made on
into account
such factors
as
alteration
in temperature
and
ofperipheral
pulses.
There
situations,
however,
where
clinical
examination
skin is inadequate
and where a more objective
ment would
be invaluable.
0Inn1
of the
measure-
Radioactive
isotope
tracers
have
been used to
the pressure
of blood perfusion
in the cutaneous
(Holstein
et a!. 1978), but the method
requires
special
expertise
and,
indicated
in ischaemic
measured
blood
flow
to heal
35
by its invasive
nature,
states.
Kostuik
et
in the skin by measuring
40
45
is contraa!. (1976)
the rate of
50
relating
the
operation
clearance
that
tcPo2 at the
to subsequent
of xenon-133
a blood
60
65
70
75
4
site ofamputation
healing
of the
gas from
measured
skin.
the tissue.
before
They
stated
of less than
1 .5 millilitres
per minute
of tissue would result in failure of the skin
amputation
; however,
in our experience
flow
per 100 grams
to heal after
of results
consistency
55
Tc P02 ( mm Hg) at site of amputation
Fig.
Histogram
is a problem
with
this
method.
Theoretical
considerations
suggested
that the measurement
of the tcPo2 was related to changes in the blood
circulation
present
ofthe
study.
skin and this has been confirmed
by the
A series
of normal
values
has been
established
which can be compared
ischaemic
states.
Values
obtained
in this study show that the tcPo2,
with
values
for normal
for practical
found
in
volunteers
purposes,
is not affected
by age. Moreover,
there was no observable
pressure
gradient
from the proximal
to distal end of the
limb in normal
individuals.
The measurements
ofthe
tcPo2 in groups
of patients
with increasingly
severe
peripheral
ischaemia
of the
lower
limbs
of the skin,
than normal
in the local
examination.
When
are many
Arteriography
will demonstrate
the patency
of large
or medium-sized
vessels but will not provide
information
on the local cutaneous
blood supply.
The use of Doppler
ultrasound
has little
value
in investigating
the small
calibre,
distal segments
of the vascular
tree (Harris
et a!.
1974).
measure
vessels
failed
LI1
5,
show
state of the skin.
tent claudication
DISCUSSION
Assessment
of the viability
clinical
grounds,
taking
LII
to
tcPo2
mercury.
36 millimetres
to be well vascularised.
4
healing
below-knee
readings
of 34 and
35 millimetres
of mercury
before
operation.
Two of the three
midtarsal
amputations
with
a tcPo2 on the dorsum
of the foot of 36 and 40 millimetres
of mercury
failed
to heal. The midtarsal
amputation
which
healed
had a preoperative
reading
taken
on the
dorsum
patients
secondary
la
amputations
healed primarily
with a further
one healing
after a delay of several weeks. All three had a tcPO2 of 48
millimetres
of mercury
or more 10 centimetres
above the
knee.
healing
5,
healed
tcPo2
or above.
BENTLEY
to
measured
Fourteen
patients
amputation
: five
amputations
a preoperative
of mercury
vascular
0.
10 centimetres
midtarsal
and two had local
toe (Table II).
gangrenous
All above-knee
culty and all had had
K. LINGE,
grounds
had the tcPo2
on the
the knee.
above-knee
S. E. DOWD,
amputation
to skin
that
they
accurately
reflect
the clinical
In patients
with symptoms
of intermitwithout
clinically
observable
changes
the transcutaneous
oxygen
in 24 per cent, presumably
circulation
which
the preoperative
for peripheral
healing,
the skin
level was lower
due to a decrease
was not apparent
oxygen
pressure
on clinical
at the site of
vascular
disease was compared
of the stump healed
providing
that the tcPo2
was above
40 millimetres
of mercury;
pressure
below
40 millimetres
of mercury
resulted
in
breakdown
of the wound
and failure
to heal.
A tcPo2
of
45 millimetres
of mercury
was the lower limit of normal
volunteers.
millimetres
Thus
of
it appears
that
mercury
is always
disturbance
In patients
with
circulatory
of
amputation
a tcPo2
below
40
related
to a severe
in the cutaneous
peripheral
vascular
is usually
a compromise
tissues.
disease
the site
between
the
desire
to amputate
at the most
distal
level
and the
expectation
of the stump
to heal;
it is well known
that
failure
of the stump
to heal is more likely
with
distal
THE
JOURNAL
OF BONE
AND
JOINT
SURGERY
MEASUREMENT
Review
amputations.
pressures
in
amputation
that
the
TRANSCUTANEOUS
the
of
this series
was decided
higher
OF
OXYGEN
transcutaneous
of patients
on clinical
transcutaneous
oxygen
where
the
grounds
oxygen
PRESSURE
site
alone,
were
with above-knee
amputations
and lower levels
with below-knee
and more distal
amputations.
It should
be stressed
that the levels of tcPo2 must
always be related
to the temperature
of the electrode.
In
with
is not solely
dependent
flow.
We wish
Surgeon,
other
to thank
our colleagues
for permission
Royal
Liverpool
Hospital
and Miss
many
factors
It is known
to use their
J. Doyle,
who
before
operation
plating
So far,
amputation.
Patients
admitted
for
with
a
on the great
oftibial
wound
fractures
breakdown
preoperative
and
skin
can be realistically
are
oxygen
necessary
in this study and,
the manuscript.
10 to 14 days
has only
of mercury.
that
patients
prepared
than
toe with skin of dubious
viability
have been measured.
One patient
with a tcPo2
of 38 millimetres
of mercury
has failed to heal. Measurements have also been taken at the site of the skin incision
a Keller’s
millimetres
on blood
83
SKIN
of blood
operations
clinical
practice,
the temperature
should
be set at a level
at which
maximal
vasodilatation
ofthe cutaneous
vessels
will occur,
but which
will not damage
the skin,
thus
allowing
continuous
monitoring.
By experimentation
it
was found
that 44 degrees
Celsius was the most suitable
for the electrode.
healing
is associated
ISCHAEMIC
consideration.
infection
and
associated
temperature
Wound
AND
to the edges of the skin is a primary
This may be deleteriously
affected
by
wound haematoma.
The technique
of measuring
transcutaneous
oxygen
pressure
has been used to a limited
extent on skin before
circulation
of
shows
pressures
IN NORMAL
pressure
Further
however,
after
occurred
of
studies
before
injury.
in patients
below
40
on traumatised
such
measurements
evaluated.
in particular,
Mr G. A. McLoughlin,
Consultant
Vascular
REFERENCES
Challoner
AVJ.
Eickhoff
Accurate
J, Ishihara
G#{246}thgenI, Jacobsen
66-70.
measurement
5, Jacobsen.
PaO,
E. Transcutaneous
of skin
blood
flow
by skin
electrode.
oxygen
tension
by a thermal
Lancet
conductance
1979;ii
measurement.
I : age variation
Hams
PL, Taylor
LA, Cave FD, Charlesworth
D. The relationship
between
disease
of the lower
limbs.
Surg Gynecol
Obstet
1974; 138 :91 1-4.
Holstein
P, Lassen
NA. Radioisotope
clearance
technique
for measurement
1973:31, Suppl 128: 143-7.
Holstein
the
R, Lubbers
DW,
Huch
Pfluegers Arch 1972:337
A. Quantitative
:185-98.
Kostuik
JP, Wood
D, Hornby
application
of Xenon’
.
R, Feingold
J Bone Joint
Nielsen
PE, Poulsen
Invest 1973;31,
Rooth
G, Hedstrand
Spence
VOL.
VA,
65-B,
Walker
No.
continuous
S, Mathews
Surg [Am]
HL, Gyntelberg
F. Skin
Suppl 128: 137-41.
U, Tyd#{233}nH, Ogren
WF.
1, JANUARY
Measurement
1983
C. The
ofoxygen
blood
measurement
V. The
1976;58-A
pressure
validity
tension
measurement
: 833-7.
blood
in severe
in vascular
Biol
Eng
Comput
by a photoelectric
skin.
oxygen
Med
Biol
pressure
tension
Eng
insufficiency
New York
flow
probe
Comput
and
in skin
pressure
blood
Acta
assessment
arterial
surgery.
oxygen
of skin
transcutaneous
in human
ultrasound
of distal
of partial
measured
of the
Med
and reproducibility.
Doppler
P, Noer 1, Tonnesen
KH, Sager
P, Lassen
NA. Distal
blood pressure
lower
extremities.
In : Bergan
JJ, Yao JST, eds. Operative
techniques
Huch
method.
1975 ; 13 : 196-20
1.
: 1188-9.
on
the
and
skin
method
1976;
external
in adults.
14: 159-65.
Scand
angiography
muscles.
in gangrene
: Grune
and
in peripheral
and
Anaesthesiol
of adults
vascular
Scand
J C/in
67:
arterial
Lab
Invest
and severe
ischaemia
Stratton
1978 ; 265-77.
and
disease
Care
: Suppl
in occlusive
counterpressure.
Crit
1978
Med
new-born
of
babies.
by epicutaneous
Scand
J C/in
1976;4:
162-5.
Lab