Complications Post Amputation

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Original Editor - Lauren Newcombe

Top Contributors - Sheik Abdul Khadir, Admin, Tarina van der Stockt, Tony Lowe, Kim Jackson, Aicha Benyaich, Lauren Lopez, Rachael Lowe, Naomi O'Reilly, Andeela Hafeez and Olajumoke Ogunleye  

Introduction

As with any surgery, having an amputation carries a risk of complications. Surgeons will aim to reconstruct the limb to the best of their ability, taking into account soft tissue viability, bone length and other anatomical considerations. However, underlying disease state and post-operative management can result in complications, the most common of which are:

• Oedema
• Wounds and infection
• Pain
• Muscle weakness and contractures
• Joint instability
• Autonomic dysfunction
  

Oedema

Stump oedema occurs as a result of trauma and the handling of tissues during surgery . After amputation, there is an imbalance between fluid transfer across the capillary membranes and lymphatic reabsorption  . This, in combination with reduced muscle tone and inactivity, can lead to stump oedema.
The complications that can arise from stump oedema include wound breakdown, pain, reduced mobility and difficulties with prosthetic fitting .

Numerous interventions are used across the country to manage and prevent stump oedema, including,compression socks, rigid removable dressings, exercise and PPAM aiding. The BACPAR post operative oedema guidance(2012) details the evidence behind these interventions and recommends the use of rigid removable dressings where expertise, time and resources allow.

The following video by Ossur shows an example of the application of a rigid removable dressing.

Wounds and Infection

Surgical site infection after amputation is common and as well as increasing patient morbidity, can have negative effects on healing, phantom pain and time to prosthetic fitting . Risk factors for a stump infection include diabetes mellitus, old age and smoking, which are all common denominators amongst the amputee population . The decision to insert a drain and use clips instead of sutures is also associated with an increased infection risk.
Literature suggests a post-operative infection rate ranging from 12-70% in the UK  but this is widely due to the variation in the classification of stump wounds. The Centre for Disease Control (CDC) Surgical Site Infection (SSI) Criteria (2008) aims to make this classification more standardised:

The potential consequences of infection include vac therapy, wound debridement and revision surgery. This can increase hospital length of stay and the risk of secondary morbidities such as pneumonia or reduced function. Wounds should be inspected regularly so that any signs of infection can be detected.

The following types of wounds may be encountered:

Tissue Necrosis

Poor tissue perfusion leads to ischaemia and necrosis. Dusky skin changes, mottled discolouration and slough can be observed. This can lead to subsequent wound breakdown and dehiscence . Depending on the extent of non viable tissue, wound debridement or revision surgery is often necessary

Skin Blisters

Wound oedema, reduced elasticity and tight stump dressings can all increase friction of the epidermis and cause blistering of the skin.

Sinus/Osteomyelitis

A deep, infected sinus can often mask osteomyelitis and delay healing. The sinus can extend from the skin to the subcutaneous tissues and management often includes aggressive antibiotic therapy. Sometimes, surgery is an option, however, this can impact on the shape of the stump and rehabilitation outcomes 

Wound management depends on the extent of non viable tissue. The following videos discuss wound classificationand common tissue viability techniques.