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Amputation

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Toe Amputation.jpg

Amputation is the process by which a body part such as an arm, hand, leg, or foot is removed. A vast majority of amputation procedures are because of arteriosclerosis or the hardening of the arteries, such as when blockages occur because there is not an adequate blood supply running throughout a portion of the body. When the arteries of the appendage become blocked, amputations occur. Older men who are prone to smoking are more susceptible to hardened arteries and thus have a higher amputation risk. When these arteries harden, gangrene begins to develop and/or an intense pain may also develop. If an operation were not to happen the infection will get more and more severe and end up becoming life-threatening to the patient. On the other hand, 30-40% of the patients that undergo an amputation are those greatly suffering from diabetes. Foot or toe amputations are common among diabetics because ulcers appear. Five to Fifteen percent of patients who have an ulcer will have to undergo an operation. A less common cause of amputations are severe accidents, and tumors or cancer in the limb. Younger patients are also less likely to require the procedure. [1]

Procedure

Amputation operation of a foot.

The amputation procedure begins with patient preparation. The first step allows the patient to remove their personal effects and step into a gown before being placed on the operating table. An intravenous line will then be administered into either the patient's hand or arm. There are several key factors that are monitored before the actual surgical procedure begins including the heart rate, blood pressure, breathing, and blood oxygen levels. While being monitored, a urinary catheter may be inserted if the surgeon believes the bladder may need to drain. Preparing to cut, the incision area on the skin will be wiped clean by using an antiseptic. The pulse is then rechecked along with the temperature, color, and pain sensation of the skin around the incision area. By looking at these different factors it can tell the surgeon how much tissue can be removed during the operation. For the best results the surgeons work to save as much of the functional stump and healthy skin as possible. If amputation is a result of a serious accident where the bone had been crushed, the broken bone fragments are removed first. Once the bone is cut away and smoothed out a temporary drain will be inserted in order to release blood and fluids. Once the operation is complete a sterile bandage will be used to cover the open or closed wound. Depending on each separate amputation procedure another application may be applied such as a stocking or a traction or a splint. [2]

Following the procedure the patient will be placed in a recovery room to be monitored until he or she has fully regained consciousness and stabilized. Once a few hours have passed the patient will then be moved into a separate hospital room where they will spend the remainder of their recovery time. While hospitalized the patient will receive pain medication and antibiotics. For most patients it is pertinent that physical therapy begin as soon as possible after the surgery to ensure a better and faster recovery. Each form of rehabilitation will vary depending on the specific amputation and individual. It will include things such as stretching and specific exercises. After 10-14 days the assistance of prosthetics become an option to the patient. The patient will be fitted with a prosthetic depending on the location of the amputation and the physical needs of each person. As there are many physical and emotional changes that take place because of this operation, the person will have to adapt to their new living conditions. Upon returning home it will be difficult for a person to change with things such as health care, dressing the wound, activities, and therapy. Some of the side effects that must be monitored closely are fever, chills, swelling, bleeding, drainage from the incision site, increased pain, numbness, and tingling. [2]

Risks

Amputation operations have become more and more common throughout the years with advancements in technology and medical procedures. As much as the conditions have improved, there are still many risks and complications that may arise. If an elderly person were to undertake it, the operation would be very trying on their body. Hardening of the arteries is also a significant factor when weighing the risks of an amputation. These patients have between a 10-20% possibility of dying if continuing. Only when amputations become a last resort is it deemed pertinent to proceed with the operation despite the high risks. If the patient is young and vital with good health the risks decrease. If they are amputating due to an injury or tumor the risks are significantly lessened. [1]

Some of the general complications from the surgery include chest infections, angina, heart attacks, strokes, and pressure sores. Local complications include infections in the newly formed stump from the wound. The cure for the wound infection is simply antibiotics. The stump itself may produce its own set of complications apart from an infection. If the patient were to fall and land on the stump, the harsh impact could cause it to break down by not receiving the proper blood supply throughout the area, and/or have difficulty healing correctly. If any of these complications were to arise, another operation could be necessary to fix the problem. In a second operation, if the damage is too extensive, more of the appendage may need to be removed.[1]

A serious complication in the body joints, such as the knee or hip, is the formation of a contracture (an abnormal and usually permanent contraction of a muscle). A contracture results in a permanent, improper alignment of the ligament. In such cases, the patient would not be a suitable candidate for prosthetics. Deep vein thrombosis is the formation of a blood clot within the tied veins of the legs. If left untreated a blood clot can cause serious damage to a person, thus blood thinners are used to reduce them. The phantom limb pain is also a particular product of amputations. It is when an amputee patient feels the pain or discomfort in the already amputated limb. The pain levels vary for each individual; sometimes the pain can be intense or sometimes the feeling can be mild or simply uncomfortable. Because the pain they are feeling is no longer a part of their body, if the pain intensifies to an excruciating point, which is a rare occasion, it is difficult for doctors to properly treat.[1]

Rehabilitation

Patient with a prosthetic leg during physiotherapy post amputation surgery.

Discussion over the rehabilitation process beings before the actual procedure. Because rehabilitation is both physically and emotionally burdening, the physicians make it extremely clear to the patient that the recovery road will be long and arduous. Many times psychological counseling is suggested because of the mental and emotional wave the loss of a limb may bring about. The patient and the doctor must also decide on the patient's mobility and whether or not a wheelchair or prosthetic is going to be necessary or beneficial to them. [3]

The rehabilitation program is a way in which the patient can regain his or her mobility and daily functions despite the loss of an appendage. It is pertinent that patients begin rehab immediately following their stability after the procedure because it will prevent secondary disabilities from building in the meantime. The elderly, especially, are directed to beginning exercises by standing and balancing with the parallel bars quickly because their bodies are already weak enough as it is. Flexion contractures that may build can be prevented by using extension braces. Rehabilitation begins with exercises for basic conditioning after a long, difficult surgery and balance which is especially needed for leg amputations.

Leg amputations require a lot of training as there is for any sort of ambulation. Hip and knee stretching and overall strengthening of the lower extremities help greatly in the recovery process. These drills and exercises are also needed when using a prosthetic. For below-knee amputations the patients have to endure a 10-40% increase of energy in order to get around. Those that suffer from above-knee amputations must use 60-100% more energy to stay mobile. Because more energy is required to simply get around, exercises that work with endurance is important in rehab. During recovery the physical therapist will instruct the patient on how to take care of the stump properly and how to acknowledge the signs of any breakdown of the skin. Stump conditioning is also helpful as it will hasten the shrinkage of the stump. With adequate care and attention the stump should shrink within the first few days. To advance the process doctors use shrinkers or elastic bandages to taper the stump. These wraps are also used to prevent edema from occurring. With the help of a temporary prosthesis and quick mobility after the procedure activity, stump shrinkage, prevention of flexion contractures, and the reduction of phantom limb pain can all be reduced. [3]

Taking good care of the stump in the recovery process is also important. Once a prosthesis is made for the patient it is only to be used for ambulation and must be taken off during sleep. While removing the device the stump should be inspected, washed with soap and warm water, dried, and dusted with talcum powder so that it remains healthy. Problems that may occur are dry skin, excessive sweating, inflamed skin, and broken skin. These problems should be treated promptly to prevent other, more serious complications. [3]

Prosthetics

Main Article: Prosthetics
Staff sergeant was able to return as a drill sergeant after receiving a prosthetic devices and a special robotic bionic hand.

Following an amputation procedure it is normal for the patient to begin fitting for a prosthetic limb during rehabilitation. These artificial devices can be extremely beneficial to someone who has lost a significant body part, such as an arm or leg. They are found to provide greater and more efficient mobility to its owners especially for those who want to remain physically active. There are various types of prosthetic devices that differ depending on the specific types of activities one does and other lifestyle choices. Some are made for functionality and efficiency while others are made to simply look nice and realistic. Others provide a whole range of motion for the lost limb. For each individual they can be customized to suit his or her own personal wants and needs. For example, a normal prosthetic leg may be more robotic-looking, but provide a great sense of balance to its patient. Some may also be used to provide better functionality in walking or running. By customizing one’s own prosthetic not only can they be made specifically for one’s own needs but it will also be more comfortable, easier to operate and control, and overall provide better service to the user. [4]

Since the invention of prosthetics there have been many great advances within the technology and even more are being implemented and experimented with today. Prosthetic legs are being used with power sources and many contain sensors allowing the patient to have direct communication with their devices, enabling it to have a more realistic and natural feel as well as having better control. Newer devices have even shown hand models that allow the fingers to have a wider range of motion and capabilities. It even gives them the opportunity to grip an object. If the entire leg must be replaced the prosthetics for it contain a hydraulic system which allows the knee joint within the device to bend and the artificial foot to balance the body. Recently a covering was created that gives the artificial device a life-like appearance. It has the same look and feel of natural skin. [4]

The cost for a prosthetic ranges greatly depending on how specifically individualized it is, how advanced, what type of prosthetic, and what model. Another factor in the price range is the patient’s insurance. It is normal for an amputee to own several different prosthetics for different occasions such as social engagements, athletics, etc. [4]

When fitting for a prosthetic device the patient is fitted with a socket of pylon created from calcium sulfate hemihydrate, or more commonly referred to as plaster of paris. The socket of pylon is the prosthetic skeleton which is formed to perfectly fit the wearer comfortably. While temporary prosthetics can be adjusted easily, the permanent ones are not as easily changed. They still have the capability to do so if the patient’s stump shrinks and the prosthetic no longer fits properly. The ability to easily change sizes allows the patient to use the temporary prosthetic as soon as rehabilitation begins. By using them one is able to begin exercises and even walking with the help of a cane or crutch of some sort. As soon as the stump has completed shrinking, the patient will be qualified to be fitted for a permanent prosthetic. For leg prosthetics specifically a patellar tendon-bearing device is good for below knee amputations, especially for those elderly amputees who benefit greatly from extra support. This particular model contains a solid ankle, cushion-heeled foot, and a suprapatellar cuff-suspension. Because prosthetics are best if kept lightweight, those with a high corset and a waist belt are not ideal because of all the extra weight it adds. For those with above knee amputations the model differs depending on the patients activity level and range they want. Unless specifically made, prosthetics are generally not waterproof or water resistant. If they ever get wet it is important that they be dried as soon as possible, although the sockets can be cleaned out with a mild soap. Also heat should never be applied to the device. [3]

Causes

Diabetes

Diabetes is one of the major causes for amputations in today’s society. Because this disease deals particularly with blood levels, it impairs the flow of blood throughout the body and can cause important nerve damage. The most affected areas of the body by diabetes are the lower extremities, specifically the feet and possibly the legs if treatment continues to worsen. The nerve damage and improper blood flow turns what appears to be minor injuries into massive problems with deeper consequences. For example an ulcer (open sore) may develop on the foot and if left untreated it may become infected and thus cascade into more problems. This would occur if the person ignored it and did not treat it properly or because of the nerve damage they may not even have been able to feel it. Nerve damage due to diabetes is commonly referred to as diabetic neuropathy. The nerve damage affects the extensive network of nerves in the feet by damaging it to the point that any feeling sensation on the foot is weakened. When feeling in the foot is reduced, pain can no longer be noticed as easily as previously, which is how a small laceration on the foot or the formation of a blister can go untreated and become infected. The reduced blood flow through the legs and down to the feet causes the arteries to decrease in size and become narrow. This makes the healing process for a cut or injury slower because the body tissues that repair the damage are no longer provided with a sufficient amount of blood to quickly heal the wound. This is how minor cuts grow into major problems when they become infected and how they can possibly result in gangrene (tissue death). [5]

If an infection in the foot caused by diabetic problems becomes too severe, generally an amputation of a toe or toes is the first step. If the infection persists or refuses to recover, the damage to the body spreads to the foot and then the entire leg, making it necessary for it to be amputated in order to maintain one’s health. Because the amputation is the result of a severe diabetic case, the management of one’s diabetes is very important. Diabetic patients must carefully monitor their health by eating the right foods, engage in the appropriate amount of physical exercise, control their blood sugar, and take special care of their feet. Foot care is important because diabetes causes nerve damage in the feet and makes feeling difficult. Ways to prevent infection that may lead to amputation are to wash feet daily, inspect feet daily, trim toenails carefully, always keep feet covered - no bare feet, wear clean, dry socks, be wary about foot products, avoid smoking or other tobacco use, take regular foot checkups, and take all and any foot injuries seriously. If however the foot does become infected and amputation is necessary, the surgeon will proceed to remove all the damaged tissue while trying to preserve as much healthy tissue as possible. The healing process will take between 4-8 weeks and several of those days will be spent within the hospital following the procedure. During rehabilitation the patient will meet with a physical therapist, occupational therapist, social worker, and health professional as well as procuring an artificial prosthetic limb. Exercise is a main part of the recovery process for any amputation patient, but it is very important that a diabetic amputee adhere to their strict diabetic plan to ensure a better recovery period. [6]

History

World War I amputee victim wearing temporary pylons before getting permanent artificial limbs.

Amputations have been in use since ancient times. Unlike how they are used in various aspects today, back then it was only used when necessary to remove dead tissue. One of the major complications during an amputation procedure during that time was excessive hemorrhaging, or blood loss. Because they lacked the advancements we now hold, blood loss was difficult to maintain. It was in Ancient Greece and Rome that hemorrhaging became somewhat preventable. They devised a way of ligating, or tying off, the blood vessels. After discovering the use of ligating, cauterization developed for surgical use. For cauterizing blood vessels surgeons would use hot irons or boiling oil to prevent the vessels from leaking. [7]

Amputation was a significant consequence of war, resulting in important advancements and discoveries regarding the process. In 1529, a French military surgeon by the name of Ambroise Pare worked more with ligating blood vessels for the soldiers. In 1674 the tourniquet was developed to better control the blood flow during the procedure. One important discovery of the time that is even used in surgeries today, is that of anesthesia in 1840. [7]

Wars of any kind result in many casualties, some minor and others more significant or deadly. The American Civil War is a prime example of the massive amounts of amputations coming out of a war because of its approximate 50,000 amputees. Amputations were so common in the war that around 75% of all surgeries resulted in an amputation of some sort. Due to the war a sanitary operating environment was not guaranteed in the least. Many of the surgical instruments were reused one after the other without being cleaned, operating hands would go unwashed, and the sterility of the environment was not a top priority. It was because of the massive amount of patients that the surgeons could not maintain a suitable working and operating environment for their patients. Each procedure averaged around 10-15 minutes so that the doctors could quickly and efficiently move on to the next wounded soldier. Amputations became the only resort for many injured due to the new type of ammunition being used in the time. Mini ball bullets, made from lead, were shot at once and tore through the air piercing through the tissue of its victims. The severity of the scattered bullet wounds would damage the body part to a point where it could not be saved.[7]

When the injured soldiers went to the surgeon a rag would be soaked in chloroform and be used as an anesthetic for the patient. Once the patient was knocked unconscious a tourniquet would be put in place directly above the injury site. A sharp knife was then used to carefully cut through the tissue and muscle of the injured. Once the knife hit the bone the surgeon then used a saw to cut through the bone. This process gave surgeons the nickname “sawbones” because of the way they sawed through bone. After separating the dead and healthy body part the blood vessels were tied together with sutures. Once the procedure was complete the skin would fold over the wound, except for a portion that was used to drain fluid. Once the dead limbs were detached it was thrown into a pile in a tent where it would remain. The popularity of amputations during the Civil War and the less advanced conditions led to one death out of every four lives. The unsanitary conditions made bacterial infection all the more common and deadly. If a soldier had not received immediate attention within the first 24 hours, the chances of his death doubled. It is only because of a British surgeon named Joseph Lister that the importance of a sterile surgical environment was advanced.[7]

A knife and saw used to be the main instruments for amputation operations.

When prosthetic usage was first invented they were much less advanced and efficient than today. The earliest ones were formed out of wood or other such compounds. Most of the time the people who used prosthetics would be the soldiers or warriors who had not completely lost their mobility. They would manufacture a type of peg leg kind of structure to attach to the knee or hip joint. This gave the injured the ability to continue to walk around with the aid of a cane or staff. [4]

Paralympics

The paralympic games provide disabled athletes the chance to compete at the same intensive and rewarding levels as an able bodied person. It all began in 1948 when a man named Sir Ludwig Guttmann had a vision where World War II veterans, who suffered from injuries, specifically of the spinal cord, could compete against each other in fair and equally difficult athletic games. This first competition was held in Stoke Mandeville, but it only took a few years before other countries wanted to join in. The first internationally organized event was held in Rome in 1960. 16 years later more people with different disabilities were welcomed into the games. Over the years the participation in the event has grown to around 3,951 athletes all coming from 146 different countries. Coinciding with the summer olympic and the winter olympic games, the paralympics are always held at the same locations. [8]

"To Enable Paralympic Athletes to Achieve Sporting Excellence and Inspire and Excite the World". Vision

This vision of the IPC states what exactly their purpose is in establishing and continuing with the games. They want to enable the athletes with disabilities, and to provide them with the opportunity for motivation and pride in their accomplishments through empowerment. They create an environment where athletes of all different abilities and skill ranges are welcome to join. Just like any other sporting event they strive to see each person attain their highest athletic ability. More over they want to 'inspire and excite the world'. They want to shed light on people with disabilities and provide them with more opportunities. [9]

Amputee Coalition of America

The Amputee Coalition of America is a national not for profit organization. Incorporated in 1989, the board of directors work to provide the best care and service to amputees, their friends and families. They specialize is educating people on surviving the vast ordeal that comes with receiving an amputation. They teach people how to go through the operation process and how to live with the aftermath. Not only do they help people who must receive an amputation sometime in their life, but also those who were born with limb defects. As well as embodying a group of amputees themselves they serve to provide education, support groups, and professionals for the victims themselves. They also provide support for the friends and families of people who live with these disabilities. They also support various agencies and other like organizations. One of their main objectives is "to develop accurate information about the U.S. population of amputees to allow us to best represent our constituents to government, industry, and the world." [10]

"Our Mission to reach out to and empower people affected by limb loss to achieve their full potential through education, support and advocacy, and to promote limb loss prevention." Mission

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References

  1. 1.0 1.1 1.2 1.3 Amputation and Amputation Surgery www.vascular.co.nz. D Mosquera Ltd
  2. 2.0 2.1 Amputation MUSC Health
  3. 3.0 3.1 3.2 3.3 Leg amputation Rehabilitation February 2009 by Mathew H.M. Lee, MD; Alex Moroz, MD. MERCK
  4. 4.0 4.1 4.2 4.3 What are Prosthetic Limbs? by Malcolm Tatum wiseGeek.
  5. Amputation and diabetes: How to protect your feet By Mayo Clinic staff. MayoClinic.com
  6. Amputation and diabetes: How to protect your feet (continue) By Mayo Clinic staff. MayoClinic.com
  7. 7.0 7.1 7.2 7.3 History of Surgical Amputation How Amputation Works. Howstuffworks
  8. Paralympic Games Paralympic Movement
  9. Vision, Mission & Values Paralympic Movement
  10. About the Amputee Coalition of America Amputee Coalition of America

Additional Information