Amputations

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Definition

Amputation is defined as surgical removal or loss of body part such as arms or limbs in part or full. It is usually distinguished from disarticulation where a part is removed through a joint

Prevalence

The most recent Global Burden of Disease study reveals that approximately 552.45 million people worldwide are living with traumatic amputations as of 2019, with 13.23 million new cases occurring annually at an age-standardised incidence rate of 171.23 per 100,000 population, representing a 49.2% increase from 1990 levels . Traumatic causes account for 57.7 million cases globally, with falls being the leading cause at 36.2%, followed by road injuries (15.7%), other transportation injuries (11.2%), and mechanical forces (10.4%). Conflict and terrorism rank among the top five causes of years lived with disability from traumatic amputation globally, with military conflicts demonstrating particularly severe patterns of injury. While finger amputations have the highest global incidence, unilateral lower limb amputations cause the greatest disability burden with 1.60 million years lived with disability, and despite increasing absolute numbers due to population growth and aging, age-standardised rates for most amputation types have declined between 1990 and 2019, indicating improvements in prevention and medical care globally . The highest prevalence of traumatic amputations is found in East Asia and South Asia, followed by Western Europe, North Africa, and the Middle East.

Causes of Amputations

There are several conditions that can lead to amputation.

• Severe infection with extensive tissue damage
• Gangrene
• Trauma resulting from accident or injury, such as crush or blast wound
• Congenital/ Paediatric limb deficiency undergoing conversion amputation
• Congenital deformities of digits or limbs
• Congenital extra digits or limbs
• Necrosis or Necrotizing Fasciitis
• Cellulitis
• Peripheral Arterial Disease
• Frostbite
• Malignant/ cancerous tumor in bone or muscle of the limb e.g. Osteosarcoma
• Conditions that affect blood flow for example Diabetes

Levels of Amputation

Upper Limb

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

Forequarter amputation- In this type of amputation, scapula, lateral 2/3rd of clavicle and whole of upper limb are removed.

Shoulder disarticulation- Removal through shoulder joint. Disarticulation is generally not so popular in the upper limb except at shoulder. Even in disarticulation of the shoulder, the head of humerus is preserved wherever possible to maintain the contour of the shoulder for cosmosis.

Above elbow amputation- Amputation above elbow through the arm.

Elbow disarticulation- Removal through elbow joint

Below elbow amputation- Amputation through the forearm bones

Wrist disarticulation- Amputation through radiocarpal joint

Ray amputation- Removal of a finger with respective  metacarpal from carpo-metacarpal joint  

Krukenburg's amputation- This is a below elbow amputation done usually on both sides. The forearm is split between radius and ulna. This can be used as a fork and it provides a pincer grip. Making 'forceps' with two forearm bones amputation

Lower Limb

• Hemicorporectomy
• Hemipelvectomy/ Hindquarter amputation
• Hip Disarticulation
• Short transfemoral(above knee)
• Transfemoral (above Knee)
• Long transfemoral (above knee)
• Knee Disarticulation
• Short transtibial (below knee)
• Transtibial (below knee)
• Long transtibial (below knee)
• Ankle Disarticulation (Symes)
• Tansmetatarsal
• Partial Foot/ray resection
• Toe disarticulation
• Partial Toe

Hind quarter amputation- In this amputation, part of the pelvis is removed along with lower extremity.

Hip disarticulation-Amputation through the hip joint

Above knee amputation- Amputation through the femur

Knee disarticulation- Amputation through the knee

Below knee amputation-Most commonly performed amputation, severe trauma to foot and leg. Amputation is performed through the leg bones

Syme’s amputation- Amputation through the ankle joint. Intact skin over the heel is attached back to the end of the stump with or without a part of calcaneum. Because of the intact heel, it becomes an end bearing stump and the patients generally manage very well walking even bare foot after this type of amputation

Chopart's amputation- Through talo-navicular joint amputation

Lisfranc's amputation- Through inter-tarsal joints amputation

Pre-Surgical Evaluation

1. General system review- Cardiovascular & Respiratory
2. Nutritional status
3. Diabetes Control if appropriate
4. Bowel & Bladder Function
5. Past medical history
6. Social history
7. Pre-morbid mobility
8. Strength & Condition of Healthy limb
9. Psychological assessment to access emotion impact of amputation
10. Home & work place assessment to make sure, everything is in accordance for patients maximal self reliance
11. Explanation of post-operative regimen.

Surgery for Amputation

Anesthesia is the first step to any surgery. During amputation, choice of anesthesia depends on the type of amputation, described above on levels of amputation. Two option of anesthesia for amputation are general anesthesia or epidural anesthesia.

While performing amputation, special care is to be taken to make sure the procedure does not hamper the functioning of remaining limb. It is vital to condition, shorten & smoothen the remaining bone, so there is a healthy stump that in future can take the load of a prosthetic limb and reduce complication risk.

Muscle is sutured to the bone at the distal residual bone so maximal strength of the remaining limb can be retained. This procedure is known as myodesis.

Distal stabilization of the muscles is always 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. As the procedure for amputation is completed, the wound us sealed by performing myoplasty: 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; and is covered with a bandage. A drainage tube might be placed to drain all excess fluid. Hence, every possible measure is taken to reduce risk of infection.

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

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)

Complications of Amputation

• Edema & Swelling
• Wounds Infection
• Pain (phantom limb)
• Muscle weakness
• Muscle Tightness & contractures
• Joint Instability
• Autonomic dysfunction
• Somatosensory impairment

See here, for more detailed information on post-operative complications following an amputation.

Post Surgical Evaluation

• General system review- Cardiovascular & Respiratory
• Nutritional status
• Diabetes Control if appropriate
• Bowel & Bladder Function
• Strength & Condition of Healthy limb
• Psychological assessment to access emotion impact of amputation
• Signs of Infection
• Type of pain(Incisional, phantom, other)
• Level of Pain(VAS 1 - 10)
• Functional status (Bed mobility, transfers, sitting, standing, walking, balance)
• Strength and/or pain of the un-amputated limb

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

Pain in Amputation

Residual Limb pain and phantom limb pain are the two essential types of pain, post amputation.

Residual Limb Pain

Residual limb pain has three main cause:

1. Very likely post operative pain
2. Peripheral nerve neuroma formation at the end of cut peripheral nerve
3. Prosthetic pain caused by ill fitting prosthesis

Phantom Limb Pain

Phantom limb pain is defined as "pain that is localized in the region of the removed body part." Cause of Phantom limb pain is not fully understood , but it is distressing and has a significant impact on patients life.

Psychological Implications of Amputation

• Loss of limb has a huge psychological impact on ones mental health, as if the person has lost a loved one. It is difficult to cope with loss of sensation and function from the amputated limb. It also changes your (patients) and other peoples perception of your (patients) body image, which can lead to depression and anxiety as negative thoughts are very common.

• Psychological well being of the patient is vital to a good rehabilitation process. Hence, it is the duty of a physiotherapist/ physical therapist to acknowledge patients concerns with good knowledge of natural grieving process.

Fall Risk Post Amputation

• Patient undergone amputation is at a higher risk of fall especially when they try to get up from the bed or chair and they have forgotten about the absence of the limb. These falls can cause injury to the surgical site, leading to prolonged healing.

• To deal with the risk of fall, it is mandatory to place a walker besides the patient. This reminds the patient to use assistance for transfers.

Goals of Post-operative Physiotherapy Management

1. Patient education on amputation and rehabilitation post amputation.
2. Maintenance of respiratory & cardiovascular status both pre- & post- surgery
3. Proper positioning of amputated limb to maintain the limb in right anatomical position.
4. Maintaining/improving strength of unamputated limb
5. Residual Limb care
6. Balance training
7. Transfer Training
8. Mobility Training
9. Prosthetic training

Post-operative Physiotherapy Management

1. Start with respiratory maintenance with pain control for amputated limb. Also start strengthening the unamputated limb to maintain its strength.
2. Teach the patient to wrap the residual limb correctly.
3. Prevent hip flexion contracture by avoiding prolonged sitting & guiding patient to spend more time in prone position.
4. For proper positioning avoid side lying position, maintain the residual limb in extension at hip & knee.
5. Start balance training
6. Procced to mobility training initially with a walker followed by crutches.
7. Start strengthening of the residual limb before proceeding to prosthetic training

Pre- Prosthetic Evaluation

1. Social History of patient
2. Financial status
3. Cause of amputation
4. Cardiopulmonary status examination
5. Scar healing assessment
6. Sensory assessment
7. Residual limb length & shape
8. Emotional status of patient for acceptance of amputation and body image
9. Vascularity (pulse, color of limb, temperature, edema/swelling, pain & tropic changes
10. Range of motion
11. Muscle strength
12. Pain (residual & phantom)
13. Functional status ( transfers, mobility, activities of daily living)

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

More to do with patients with amputation

1. 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

2. Connective Tissue Massage

3. Dynamic Stump Exercises

4. 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

5. 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)

Walking Again Post Amputation/ 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)
  

Prosthetic Training

Prosthetic training is vital for smooth and energy efficient living, while performing all of daily living activities.

Below is step by step guidance to prosthetic training:

• Accepting weight of the body on each leg is vital to prosthetic training
• work on strengthening unamputated limb along with residual limb
• Teach the patient to balance on both legs and than on one leg
• Teach walking with prosthetic first with use of walker followed by crutches and stick
• Further proceed to independent prosthetic training.
• Teach the patient to adapt to environmental demands while walking