amputation

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Amputation

 

Definition

Amputation is the intentional surgical removal of a limb or body part. It is performed to remove diseased tissue or relieve pain.

Purpose

Arms, legs, hands, feet, fingers, and toes can be amputated. Most amputations involve small body parts such as a finger, rather than an entire limb. About 65,000 amputations are performed in the United States each year.
Amputation is performed for the following reasons:
  • to remove tissue that no longer has an adequate blood supply
  • to remove malignant tumors
  • because of severe trauma to the body part
The blood supply to an extremity can be cut off because of injury to the blood vessel, hardening of the arteries, arterial embolism, impaired circulation as a complication of diabetes mellitus, repeated severe infection that leads to gangrene, severe frostbite, Raynaud's disease, or Buerger's disease.
More than 90% of amputations performed in the United States are due to circulatory complications of diabetes. Sixty to eighty percent of these operations involve the legs or feet. Although attempts have been made in the United States to better manage diabetes and the foot ulcers that can be complications of the disease, the number of resulting amputations has not decreased.

Precautions

Amputations cannot be performed on patients with uncontrolled diabetes mellitus, heart failure, or infection. Patients with blood clotting disorders are also not good candidates for amputation.

Description

Amputations can be either planned or emergency procedures. Injury and arterial embolisms are the main reasons for emergency amputations. The operation is performed under regional or general anesthesia by a general or orthopedic surgeon in a hospital operating room.
Details of the operation vary slightly depending on what part is to be removed. The goal of all
Amputation of leg. Figure A: After the surgeon creates two flaps of skin and tissue, the muscle is cut and the main artery and veins of the femur bone are exposed. Figure B: The surgeon severs the main artery and veins. New connections are formed between them, restoring blood circulation. The sciatic nerve is then pulled down, clamped and tied, and severed. Figure C: The surgeon saws through the exposed femur bone. Figure D: The muscles are closed and sutured over the bone. The remaining skin flaps are then sutured together, creating a stump.
Amputation of leg. Figure A: After the surgeon creates two flaps of skin and tissue, the muscle is cut and the main artery and veins of the femur bone are exposed. Figure B: The surgeon severs the main artery and veins. New connections are formed between them, restoring blood circulation. The sciatic nerve is then pulled down, clamped and tied, and severed. Figure C: The surgeon saws through the exposed femur bone. Figure D: The muscles are closed and sutured over the bone. The remaining skin flaps are then sutured together, creating a stump.
(Illustration by Electronic Illustrators Group.)
amputations is twofold: to remove diseased tissue so that the wound will heal cleanly, and to construct a stump that will allow the attachment of a prosthesis or artificial replacement part.
The surgeon makes an incision around the part to be amputated. The part is removed, and the bone is smoothed. A flap is constructed of muscle, connective tissue, and skin to cover the raw end of the bone. The flap is closed over the bone with sutures (surgical stitches) that remain in place for about one month. Often, a rigid dressing or cast is applied that stays in place for about two weeks.

Preparation

Before an amputation is performed, extensive testing is done to determine the proper level of amputation. The goal of the surgeon is to find the place where healing is most likely to be complete, while allowing the maximum amount of limb to remain for effective rehabilitation.
The greater the blood flow through an area, the more likely healing is to occur. These tests are designed to measure blood flow through the limb. Several or all of them can be done to help choose the proper level of amputation.
  • measurement of blood pressure in different parts of the limb
  • xenon 133 studies, which use a radiopharmaceutical to measure blood flow
  • oxygen tension measurements in which an oxygen electrode is used to measure oxygen pressure under the skin. If the pressure is 0, the healing will not occur. If the pressure reads higher than 40mm Hg (40 milliliters of mercury), healing of the area is likely to be satisfactory.
  • laser Doppler measurements of the microcirculation of the skin
  • skin fluorescent studies that also measure skin microcirculation
  • skin perfusion measurements using a blood pressure cuff and photoelectric detector
  • infrared measurements of skin temperature
No single test is highly predictive of healing, but taken together, the results give the surgeon an excellent idea of the best place to amputate.

Aftercare

After amputation, medication is prescribed for pain, and patients are treated with antibiotics to discourage infection. The stump is moved often to encourage good circulation. Physical therapy and rehabilitation are started as soon as possible, usually within 48 hours. Studies have shown that there is a positive relationship between early rehabilitation and effective functioning of the stump and prosthesis. Length of stay in the hospital depends on the severity of the amputation and the general health of the amputee, but ranges from several days to two weeks.
Rehabilitation is a long, arduous process, especially for above the knee amputees. Twice daily physical therapy is not uncommon. In addition, psychological counseling is an important part of rehabilitation. Many people feel a sense of loss and grief when they lose a body part. Others are bothered by phantom limb syndrome, where they feel as if the amputated part is still in place. They may even feel pain in the limb that does not exist. Many amputees benefit from joining self-help groups and meeting others who are also living with amputation. Addressing the emotional aspects of amputation often speeds the physical rehabilitation process.

Risks

Amputation is major surgery. All the risks associated with the administration of anesthesia exist, along with the possibility of heavy blood loss and the development of blood clots. Infection is of special concern to amputees. Infection rates in amputations average 15%. If the stump becomes infected, it is necessary to remove the prosthesis and sometimes to amputate a second time at a higher level.
Failure of the stump to heal is another major complication. Nonhealing is usually due to an inadequate blood supply. The rate of nonhealing varies from 5-30% depending on the facility. Centers that specialize in amputation usually have the lowest rates of complication.
Persistent pain in the stump or pain in the phantom limb is experienced by most amputees to some degree. Treatment of phantom limb pain is difficult. Finally, many amputees give up on the rehabilitation process and discard their prosthesis. Better fitting prosthetics and earlier rehabilitation have decreased the incidence of this problem. Researchers and prosthetic manufacturers continue to refine the materials and methods used to try to improve the comfort and function of prosthetic devices for amputees. For example, a 2004 study showed that a technique called the bone bridge amputation technique helped improve comfort and stability for transtibial amputees.

Key terms

Arterial embolism — A blood clot arising from another location that blocks an artery.
Buerger's disease — An episodic disease that causes inflammation and blockage of the veins and arteries of the limbs. It tends to be present almost exclusively on men under age 40 who smoke, and may require amputation of the hand or foot.
Diabetes mellitus — A disease in which insufficient insulin is made by the body to metabolize sugars.
Raynaud's disease — A disease found mainly in young women that causes decreased circulation to the hands and feet. Its cause is unknown.

Normal results

The five-year survival rate for all lower extremity amputees is less than 50%. For diabetic amputees, the rate is less than 40%. Up to 50% of people who have one leg amputated because of diabetes will lose the other within five years. Amputees who walk using a prosthesis have a less stable gait. Three to five percent of these people fall and break bones because of this instability. Although the fractures can be treated, about one-half of amputees who suffer them then remain wheelchair bound.

Resources

Periodicals

Edwards, Anthony R. "Study Helps Build Functional Bridges for Amputee Patients." Biomechanics (May 1, 2004): 17.
Jeffcoat, William. "Incidence of Amputation is a Poor Measure of the Quality of Ulcer Care." The Diabetic Foot Summer (2004): 70-74.

Organizations

American Diabetes Association. 1701 North Beauregard Street, Alexandria, VA 22311. (800) 342-2383. http://www.diabetes.org.

Other

Amputation Prevention Global Resource Center Page. February 2001. http://www.diabetesresource.com.

amputation

 [am″pu-ta´shun]
the removal of a limb or other appendage or outgrowth of the body. The most common indication for amputation of an upper limb is severe trauma. Blood vessel disorders such as atherosclerosis, often secondary to diabetes mellitus, account for the greatest percentage of amputations of the lower limb. Other indications may include malignancy, infection, and gangrene.

There are two general types of surgical procedure for amputation: (1) the closed or “flap” amputation and (2) the open or “guillotine” amputation. The latter is often required when infection is present and there is a need for free drainage from the operative site. A second surgical procedure involving stump (or residual limb) revision or closure is needed after the guillotine procedure. This is done only after the infection has been eliminated.
 Amputation. Bandaging on above-knee amputation stump. A, Use 6" elastic bandage. Enclose medial, distal end of stump. Apply pressure via bandage to end of stump. Use diagonal, not circular turns. B, Turn No. 3 must be high in groin and then turn made around waist to hold No. 3 in place. Do not pull hip into flexion. (A second 6" roll may be needed.) C, Turn No. 5 must be high in groin and a loop made around waist again. D, See diagram. E, Enclose lateral, distal end of stump. (A 4" roll may be needed.) Continue diagonal and figure-of-8 turns around stump. F, Continue turns to shape end of stump. (Courtesy of University of Washington Department of Prosthetics, from booklet Prosthetics-Orthotics.)
Patient Care. The goal of patient care for the amputee is total rehabilitation with attainment of full function and normal active life. Such total rehabilitation is not always possible because of physical and mental limitations of the patient. It requires that the patient be physically and psychologically able to accept and adapt to a prosthesis and that each member of the health care team fulfill his or her responsibilities in preventing complications and in preparing the patient for optimum use of an artificial limb. Some patients, because of age or disease, do not have the necessary energy, muscular coordination, or mental capacity to undertake prosthetic training.
Preoperative Care. Unless time is a factor, as in emergency cases demanding immediate surgery, the preoperative care of the potential amputee should include emotional and vocational aspects as well as the physical. If patients are fully involved in plans for their rehabilitation, understand what is expected of them, and know the regimen of exercise and skills they will need to develop, their chances of full recovery and achievement of independence will be greatly enhanced. Much emotional support and encouragement can be offered by other amputees who are successfully mastering their prosthesis and making progress toward their goal of total rehabilitation.

Patients undergoing amputation will need help in dealing with the changes in body image as they adjust to the loss of a limb. They should be encouraged and given the opportunity to express feelings of anxiety, grief, anger, and depression, and given guidance in working toward a healthy acceptance of their handicap.

In general, physical preparation of the patient undergoing surgical amputation includes measures to promote optimum health and well-being, to establish nutritional and fluid balances, and to increase muscular strength and endurance levels. A program of exercises may be started to help the patient develop skill in using an overhead trapeze, crutches, and a walker and transferring from wheelchair to bed.
Postoperative Care. The residual limb is watched for hemorrhage, edema, infection, and ischemia. Some bleeding is not unusual but should rarely be more than a modest red stain on the dressing. Ischemia may be caused by a constricting dressing or the development of edema. Ischemia is recognized by the presence of excessive pain.

Traction was formerly commonly used after guillotine amputations but is rarely used nowadays. Generally such stumps are closed by delayed primary closure on the fourth or fifth day after amputation to save time in the hospital and accelerate rehabilitation.

Fitting of a prosthesis may be delayed or immediate depending on the condition of the patient and the reason for the amputation. Immediate fitting of a prosthesis involves the application of a rigid plastic dressing which serves to protect the stump and prevent edema. The dressing is similar to a cast and the patient will require cast care. The temporary prosthetic device is applied at the time of surgery and includes a pylon and foot-ankle assembly.

Early ambulation is a major advantage of immediate fitting of a prosthesis. Other benefits arise from the local compression exerted by the dressing. This serves to inhibit bleeding, to mold and help shrink the stump, and to reduce phantom sensations, pain, and contractures. Unfortunately, not all amputees are candidates for immediate fitting. The technique is not advised for amputations above the knee or above the elbow, for weak and debilitated patients, or for those who are mentally or emotionally unable to cooperate with efforts at rehabilitation. The procedure also requires the services of prosthetic experts.

The more conventional, and probably more frequently chosen, technique of delayed prosthetic fitting requires special care of the stump and a gradual preparation of the patient for weight-bearing and ambulation. During the immediate postoperative period the stump dressings are changed or reinforced as ordered. The stump usually is wrapped with elastic bandages or covered with stump socks. The bandages are checked frequently for signs of bleeding and for slippage, which may lead to a tourniquet effect and the occlusion of blood supply. Exercises are started as soon as possible, regardless of the surgical approach, in order to strengthen the muscles and prevent contractures.

The patient with amputation of an upper limb also may receive immediate or delayed fitting of a prosthesis. When the surgeon has chosen the delayed fitting technique, the patient requires stump care similar to that for the lower limb except that an upper limb stump is bandaged more loosely, especially when amputation was the result of trauma. Exercises are begun the day after surgery and within ten to fourteen days the patient is fitted with a temporary prosthesis.
above-elbow (A-E) amputation amputation of the upper limb between the elbow and the shoulder.
above-knee (A-K) amputation transfemoral amputation.
below-elbow (B-E) amputation amputation of the upper limb between the wrist and the elbow.
below-knee (B-K) amputation transtibial amputation
Chopart's amputation amputation of the foot, with the calcaneus, talus, and other parts of the tarsus being retained.
cineplastic amputation kineplasty.
closed amputation one in which flaps are made from skin and subcutaneous tissue and sutured over the bone end of the stump; called also flap amputation.
congenital amputation absence of a limb at birth, attributed to constriction of the part by an encircling band during intrauterine development.
amputation in contiguity amputation at a joint.
amputation in continuity amputation of a limb elsewhere than at a joint.
Dupuytren's amputation amputation of the upper limb at the shoulder joint.
flap amputation closed amputation.
flapless amputation guillotine amputation.
Gritti-Stokes amputation amputation of the lower limb at the knee through condyles of the femur.
guillotine amputation one in which the entire cross-section is left open (flapless) for dressing; called also flapless or open amputation.
Hey's amputation amputation of the foot between the tarsus and metatarsus.
interpelviabdominal amputation amputation of the lower limb with excision of the lateral portion of the pelvic girdle.
interscapulothoracic amputation amputation of the upper limb with excision of the lateral portion of the shoulder girdle.
kineplastic amputation kineplasty.
Lisfranc's amputation amputation of the foot between the metatarsus and tarsus.
major amputation amputation of the lower limb above the ankle or of the upper limb above the wrist.
minor amputation amputation of a hand or foot, or of a part thereof.
open amputation guillotine amputation.
pulp amputation pulpotomy.
racket amputation one in which there is a single longitudinal incision continuous below with a spiral incision on either side of the limb.
root amputation excision of the root of a tooth; amputation of the root of a single-rooted tooth is called apicoectomy, and that of one root of a two-rooted mandibular tooth is hemisectomy. Called also radectomy and radiectomy.
spontaneous amputation loss of a part without surgical intervention, as in leprosy, ainhum, and certain other conditions.
Syme's amputation disarticulation of the foot with removal of both malleoli.
transfemoral amputation amputation of the lower leg between the knee and the hip. Called also above-knee (A-K) amputation.
transtibial amputation amputation of the lower leg between the ankle and the knee. Called also below-knee (B-K) amputation
traumatic amputation the sudden, accidental removal of a limb or appendage. A limb that is properly cared for may be reimplanted. It should be placed in a plastic bag, and if ice is available the bag containing the limb should be placed in a larger one that contains ice and water.
Tripier's amputation amputation of the foot through the calcaneus.

am·pu·ta·tion

(am'pyū-tā'shŭn),
1. The severing of a limb or part of a limb, the breast, or other projecting part.
2. In dentistry, removal of the root of a tooth, or of the pulp, or of a nerve root or ganglion; a modifying adjective is therefore used (pulp amputation; root amputation).
[L. amputatio, fr. am-puto, pp. -atus, to cut around, prune]

amputation

/am·pu·ta·tion/ (am″pu-ta´shun) removal of a limb or other appendage of the body.
above-elbow (A-E) amputation  amputation of the upper limb between the elbow and the shoulder.
above-knee (A-K) amputation  transfemoral a.
below-elbow (B-E) amputation  amputation of the upper limb between the wrist and the elbow.
below-knee (B-K) amputation  transtibial a.
Chopart's amputation  amputation of the foot by a midtarsal disarticulation.
closed amputation  one in which flaps are made from the skin and subcutaneous tissue and sutured over the end of the bone.
amputation in contiguity  amputation at a joint.
amputation in continuity  amputation of a limb elsewhere than at a joint.
double-flap amputation  one in which two flaps are formed.
Dupuytren's amputation  amputation of the arm at the shoulder joint.
elliptic amputation  one in which the cut has an elliptical outline.
flap amputation  closed a.
flapless amputation  guillotine a.
Gritti-Stokes amputation  amputation of the leg through the knee, using an oval anterior flap.
guillotine amputation  one performed rapidly by a circular sweep of the knife and a cut of the saw, the entire cross-section being left open for dressing.
Hey's amputation  amputation of the foot between the tarsus and metatarsus.
interpelviabdominal amputation  amputation of the thigh with excision of the lateral half of the pelvis.
interscapulothoracic amputation  amputation of the arm with excision of the lateral portion of the shoulder girdle.
Larrey's amputation  amputation at the shoulder joint.
Lisfranc's amputation 
2. amputation of the foot between the metatarsus and tarsus.
oblique amputation  oval a.
open amputation  guillotine a.
oval amputation  one in which the incision consists of two reversed spirals.
Pirogoff's amputation  amputation of the foot at the ankle, part of the calcaneus being left in the stump.
pulp amputation  pulpotomy.
racket amputation  one in which there is a single longitudinal incision continuous below with a spiral incision on either side of the limb.
root amputation  removal of one or more roots from a multirooted tooth, leaving at least one root to support the crown; when only the apex of a root is involved, it is called apicoectomy.
spontaneous amputation  loss of a part without surgical intervention, as in diabetes mellitus.
Stokes' amputation  Gritti-Stokes a.
subperiosteal amputation  one in which the cut end of the bone is covered by periosteal flaps.
Syme's amputation  disarticulation of the foot with removal of both malleoli.
Teale's amputation  amputation with short and long rectangular flaps.
transfemoral amputation  amputation of the lower limb between the knee and the hip; called also above-knee (A-A) a.
transtibial amputation  amputation of the lower limb between the ankle and the knee. Called also below-knee a.

amputation

[am′pyo̅o̅tā′shən]
Etymology: L, amputare, to excise
the surgical removal of a part of the body, a limb, or part of a limb to treat recurrent infection or gangrene in peripheral vascular disease; to remove malignant tumors; and to treat severe trauma. The part is removed, and a shaped amputation flap is cut from muscular and cutaneous tissue to cover the end of the bone. A section may be left open for drainage if infection is present. After surgery, a lower leg amputation is elevated on a pillow for no more than 24 to 48 hours and, if necessary, protected with plastic from urinary and fecal contamination. Vital signs are monitored carefully. If a dressing is used, it is watched for excessive bleeding. The residual limb is moved frequently to prevent circulatory complications, contractures, and tissue necrosis. If a cast is used, it must remain in place for 8 to 14 days. If the cast comes off accidentally, the residual limb must be wrapped tightly at once with an amputation-stump bandage, and plans must be made to replace the cast. The patient is fit for a prosthesis, either delayed or immediately. Medication may relieve incisional pain and phantom limb syndrome. Kinds of amputation include closed amputation, congenital amputation, open amputation, primary amputation, and secondary amputation.

amputation

Surgery The partial or total surgical excision of a limb, appendage or digit. See Above-the-knee amputation, Below-the-knee amputation, Forequarter amputation, Guillotine amputation, Hemipelvectomy, Translumbar amputation.

am·pu·ta·tion

(amp'yū-tā'shŭn)
1. The surgical or traumatic removal of a limb or part of a limb, the breast, or other projecting part.
See also: congenital amputation
2. dentistry Removal of the root of a tooth, or of the pulp, or of a nerve root or ganglion; a modifying adjective is therefore used (e.g., pulp amputation; root amputation).
[L. amputatio, fr. am-puto, pp. -atus, to cut around, prune]

amputation

Removal, by surgical operation or injury, or rarely by disease, of part of the body. From the Latin ambi , around and putare , to prune.

amputation

surgical removal of part of a limb at a level determined by the tissue viability and healing potential of the created stump, and biomechanical function of the postamputation prosthesis; 50% of all lower-limb amputations in the UK occur as a complication of diabetes mellitus
  • below-knee amputation whole-foot amputation and distal one-third of the lower leg

  • Chopart's amputation forefoot amputation through the metatarsal bases

  • digital amputation digital amputation through the metatarsophalangeal joint

  • midtarsal amputation forefoot amputation through the metatarsal shafts

  • midthigh amputation foot and lower-leg amputation at the midfemur

  • ray amputation amputation of a metatarsal and its associated digit

  • Syme's amputation foot amputation through the midtarsal joint

  • terminal Syme's amputation amputation of the terminal phalanx of the hallux or a lesser toe through the distal or proximal interphalangeal joint

amputation,

n the removal of all or part of a limb through surgical means.

am·pu·ta·tion

(amp'yū-tā'shŭn)
1. In dentistry, removal of the root of a tooth, or of the pulp, or of a nerve root or ganglion; a modifying adjective is therefore used (pulp amputation; root amputation).
2. The severing of a limb or part of a limb, the breast, or other projecting part.
[L. amputatio, fr. am-puto, pp. -atus, to cut around, prune]

amputation

the removal of a limb or other appendage or outgrowth of the body. The most common indication for amputation of an upper limb is severe trauma. Other indications may include malignancy, infection and gangrene.

closed amputation
flap amputation; one in which flaps are made from skin and subcutaneous tissue and sutured over the bone end of the stump.
congenital amputation
absence of a limb at birth, attributed to constriction of the part by an encircling band during intrauterine development.
amputation in contiguity
amputation at a joint.
amputation in continuity
amputation of a limb elsewhere than at a joint.
diaclastic amputation
amputation in which the bone is broken by an osteoclast and the soft tissues divided by an écraseur.
flap amputation
closed amputation.
forequarter amputation
amputation of the forelimb including the scapula.
guillotine amputation
open amputation; one in which the entire cross-section is left open (flapless) for dressing.
interpelviabdominal amputation
amputation of the thigh with excision of the lateral portion of the pelvic girdle.
interscapulothoracic amputation
amputation of the forelimb with excision of the lateral portion of the shoulder girdle.
open amputation
guillotine amputation.
spontaneous amputation
loss of a part without surgical intervention, as in leprosy, etc.

Patient discussion about amputation

Q. Why do you have to amputate legs in Diabetic patients? And how can I avoid that? I’ll appreciate an honest answer.

A. Here is a very detailed information about that, it has even some videos that gives an idea about how it happens:
http://yourtotalhealth.ivillage.com/foot-leg-amputation-diabetes.html
there’s a link there to prevention too.

More discussions about amputation