Amputations

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Amputation is the removal of an extremity by trauma, prolonged constriction, 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 preventative 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, amputation of the hands, feet or other body parts is, or was used as a form of punishment for people who committed crimes. Amputation has also been used as a tactic in war and acts of terrorism; it may also occur as a war injury.

causes

There are many reasons an amputation may be necessary. The most common is poor circulation because of damage or narrowing of the arteries, called peripheral arterial disease. Without adequate blood flow, the body’s cells cannot get oxygen and nutrients they need from the bloodstream. As a result, the affected tissue begins to die and infection may set in.

Other causes for amputation may include:

• Severe injury (from a vehicle accident or serious burn, for example)
• Cancerous tumor in the bone or muscle of the limb
• Serious infection that does not get better with antibiotics or other treatment
• Thickening of nerve tissue, called a neuroma
• Frostbite

Congenital

• Congenical limb deficiency 
• Phocomelia: “a congenital deformity in which the limbs are extremely shortened so that the feet and hands arise close to the trunk”

Acquired

• Vascular
  • Ischaemia
  • Diabetes
  • Frostbite
  • Arterial insufficiency leading to death or decay of body tissue (gangrene)
  • Chronic leg ulcer leading to septicemia.
• Infection e.g. Bone infection (Osteomyelitis)
• Malignant tumours e.g. sarcoma (cancer of the connective tissue)
• Trauma (limb buried under / crushed by heavy object, limb damaged by car accident, stabbing, gunshot, animal bite etc.); in some cases leading to
  • Traumatic amputation: a physical (non-surgical) separation of the limb in the course of the traumatic event

The Amputation Procedure

An amputation usually requires a hospital stay of five to 14 days or more, depending on the surgery and complications. The procedure itself may vary, depending on the limb or extremity being amputated and the patient’s general health.

Amputation may be done under general anesthesia (meaning the patient is asleep) or with spinal anesthesia, which numbs the body from the waist down.

When performing an amputation, the surgeon removes all damaged tissue while leaving as much healthy tissue as possible.

A doctor may use several methods to determine where to cut and how much tissue to remove. These include:

• Checking for a pulse close to where the surgeon is planning to cut
• Comparing skin temperatures of the affected limb with those of a healthy limb
• Looking for areas of reddened skin
• Checking to see if the skin near the site where the surgeon is planning to cut is still sensitive to touch

During the procedure itself, the surgeon will:

• Remove the diseased tissue and any crushed bone
• Smooth uneven areas of bone
• Seal off blood vessels and nerves
• Cut and shape muscles so that the stump, or end of the limb, will be able to have an artificial limb (prosthesis) attached to it.

The surgeon may choose to close the wound right away by sewing the skin flaps (called a closed amputation). Or the surgeon may leave the site open for several days in case there’s a need to remove additional tissue.

The surgical team then places a sterile dressing on the wound and may place a stocking over the stump to hold drainage tubes or bandages. The doctor may place the limb in traction, in which a device holds it in position, or may use a splint.

Initially, the arterial and venous supply are ligated to prevent hemorrhage (bleeding). The muscles are transected and the bone is sawed through with an oscillating saw. Sharp and rough edges of the bone are filed down, skin and muscle flaps are then transposed over the stump.

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Distal stabilisation of the muscles is recommended, allowing for effective muscle contraction and reduced atrophy. This in turn allows for a greater functional use of the stump and maintains soft tissue coverage of the remnant bone. Muscles should be attached under similar tension to normal physiological conditions.

• myodesis: the muscles and fascia are sutered directly to the distal residual bone for better prosthetic control
• myoplastic: suture to opposite muscle in the residual limb to to each other and to the periosteum or to the distal end of the cut bone for weight bearing purposes

Ideal Stump

1. Skin flaps: skin should be mobile, sensation intact, no scars
2. Muscles are divided 3 to 5 cm distal to the level of bone resection
3. Nerves are gently pulled and cut cleanly, so that they retract well proximal to the bone level to reduce the complication of neuroma

Levels of Amputation

Transfemoral AmputationUpper Limb

• Forequarter
• Shoulder Disarticulation (SD)
• Transhumeral (Above Elbow AE)
• Elbow Disarticulation (ED)
• Transradial (Below Elbow BE)
• Hand/ Wrist Disarticulation
• Transcarpal (Partial Hand PH)

Lower Limb

• Hemipelvectomy
• Hip Disarticulation (HP)
• Transfemoral TF (Above Knee AKA)
• Knee Disarticulation (KD)
• Transtibial TT (Below Knee BKA)
• Ankle Disarticulation
• Symes
• Partial Foot PF (Chopart)
• Toe amputation

Special Investigations

Doppler Ultrasound

• X-rays
• CT scan
• Angiogram (outlines blood vessels)
• Doppler ultrasound (occlusion of vessels)
• Venogram and arteriogram
• Radioactive dye injected into the blood
  

Arterial Insufficiency

• Surgery to improve circulation
• Bypass grafts (autogenous graft uses a vein to bypass the obstructed area)
• Synthetic grafts

Management

Please find below links to more detailed pages on the management of amputees

• Pain Management
• Pre-Fitting Management of the Patient with a Lower Limb Amputation
• Post-fitting Management
• Prosthetic Rehab
• High level Rehab
• Clinical Guidelines: Mental Health Amputees

Buerger’s Exercises

• Stimulates collateral blood flow in the patient’s leg
• It is performed for 20 min.
• The leg is elevated until the toes go white, then lowered, then level
• Repeat 2-3 times to improve collateral circulation

Connective Tissue Massage

Dynamic Stump Exercises

Balance and Gait Retraining

• Improve static and dynamic balance
• Use parallel bars, walking frame then Crutches (in that order)
• Therapist stands on the amputation side, using a belt around the patient’s waist to support
• Rest if the patient feels tired

Short Wave Diathermy (SWD)

Through the pelvis to warm the arteries (contraindicated in patients with arterial insufficiency because the warmth leads to increased metabolism, causing a greater demand for nutrients, which are not available)

Post-operative Care

• Maintain function in the remaining leg and stump to maintain peripheral circulation
• Maintain respiratory function (important with smokers and those patients under general anaesthesia)
• Prepare for mobility rehabilitation

Stump care

• For hygiene and skin care see handout on amputations
• A hip flexion contracture may develop because of elevation to reduce swelling
• Stump bandaging is done to ‘cone’ the stump, thereby preventing oedema, which occurs because there is no muscle pump and the stump hangs
• Swelling must be prevented to allow proper attachment of the prosthesis, and the prevention of pressure sores
• The stump sock is put on first, then the prosthesis
• The prosthesis must be cleaned and maintained (children who are still growing, grow out of their prostheses)

Mobility Aids

• The choice of mobility aids depends on the level of fitness, strength, balance skills of the individual:
  • Walking frame
  • Axillary crutches
  • Elbow crutches
  • Walking stick 
• For bilateral lower limb amputees a wheelchair is often indicated (high energy expenditure during gait with prostheses)

Complications

Some of the most common complications associated with amputation include;

• Oedema
• Wounds and infection
• Pain (phantom limb)
• Muscle weakness and contractures
• Joint Instability
• Autonomic dysfunction

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