AMPUTATION

INTRODUCTION

Amputation is the surgical removal of all or part of a limb or extremity such as an arm, leg, foot, hand, toe, or finger. It is done by trauma, prolonged constriction, 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, wherefetal 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 of the leg — either above or below the knee — is the most common amputation surgery.

 

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.

Circulatory disorders

Diabetic foot infection or gangrene (the most frequent reason for infection-related amputations)
Sepsis with peripheral necrosis

Neoplasm

Transfemoral amputation due to liposarcoma
Cancerous bone or soft tissue tumors (e.g. osteosarcoma, chondrosarcoma, fibrosarcoma, epithelioid sarcoma, Ewing’s sarcoma, synovial sarcoma)
Melanoma

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)

Deformities

Deformities of digits and/or limbs (e.g., proximal femoral focal deficiency, Fibular hemimelia)
Extra digits and/or limbs (e.g., polydactyly)

Infection

Bone infection (osteomyelitis)
Diabetes
Frostbite

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. Rugby union player Jone Tawake also had a finger removed. National Football League safety Ronnie Lott had the tip of his little finger removed after it was damaged in the 1985 NFL season.

Legal punishment

Amputation is used as a legal punishment in a number of countries, among them Saudi Arabia, Yemen, United Arab Emirates, Iran, Sudan, and Islamic regions of Nigeria.

LEVEL OF AMPUTATION

Level of amputation

Upper Limb

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

Lower Limb

  • Hemipelvectomy
  • Hip Disarticulation HP
  • Transfemoral TF (Above Knee AK)
  • Knee Disarticulation KD
  • Transtibial TT (Below Knee BK)
  • Ankle Disarticulation
  • Symes
  • Partial Foot PF (Chopart)

 

 

 

PROCEDURE

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 the bone are filed down, 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 periostium. 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.

Ideal stump

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

Location of pulses

  1. Femoral Triangle
  2. Foot pulse (Medial malleolus or dorsum of the foot)
  3. Popliteal (behind the knee)
  4. Femoral (within the femoral triangle)
  5. If a leg has been amputated because of gangrene, the remaining leg is examined for a pulse

The surgeon may choose to close the wound right away by sewing the skin flaps which called as 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.

SPECIAL INVESTIGATION

Doppler ultrasound

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

 

MANAGEMENT

Pre-Oparative Management

If the patient has problems with phantom pain (a sense of pain in the amputated limb) or grief over the lost limb, the doctor will prescribe medication and/or counseling, as necessary.

Physiotherapy, beginning with gentle stretching exercises, often begins soon after surgery. Practice with the artificial limb may begin as soon as 10 to 14 days after surgery.

Physiotherapy Management

Burger’s Exercise

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

Burger’s exercise

 

Post-Oparative Management

  • Connective tissue massage
    – Efflurage
    – Rolling
    – It relieves tighteness and loosen the mucles
  • Dynamic stump exercises
Stump exercise

 

 

 

 

 

 

 

 

 

 

 

 

exercise

 

  • Balance and gait retraining
    – Improve static and dynamic balance
    – Use Parallel bars, walking frame then Crutches (in that order)
    – Therapist stands on the amp side, using a belt around the patient’s waist to support
    – Rest if the patient feels tired
  • Maintain function in the remaining leg and stump to maintain peripheral circulation
  • Maintain respiratory function (important with smokers and those patients under general anaesthesia)

Stump Care

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
Walking Stick
  • For bilateral lower limb amputees a wheelchair is indicated (high energy expenditure during gait with prostheses)
ARTIFICIAL LIMB(Prosthesis)

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