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Amputation (Surgical) - A Guide

An amputation is the surgical removal of part of the body,
usually a leg or an arm causing disability

Introduction
Why amputation is necessary
How amputation is performed
Recovering from an amputation
Risks of an amputation
Complications of amputation

Introduction

There are three main reasons why an amputation is performed:

  • The limb has been affected by gangrene (when the body’s tissue begins to decay and die as a result of loss of blood supply).
  • The limb poses a life-threatening danger to the person’s health, for example because it has been affected by cancer or a serious infection.
  • The limb has experienced serious trauma, such as a crush or blast wound.

How common are amputations?

Approximately 5,000 amputations are carried out in the UK every year. The most common reason for an amputation is a loss of blood supply to the affected limb (dysvascularity), which accounts for 70% of all amputations.

People with either type 1 diabetes or type 2 diabetes are particularly at risk and are 15 times more likely to need an amputation than the general population. This is because the high blood glucose levels associated with diabetes can damage the blood vessels, leading to a restriction in blood supply.

Half of all amputations are performed in people aged 65 or over and men are twice as likely to need an amputation as women.

Prosthetics

After the amputation, it may be possible to fit a prosthetic (artificial) limb onto the remaining stump. Prosthetic limbs have become increasingly sophisticated and can reproduce many functions of the hands, arms and legs.

For example, many people with a transtibial amputation (removing the foot and lower section of the leg from beneath the knee) can walk or ride a bike using a prosthetic limb.

However, adjusting to life with a prosthetic limb often requires an extensive course of physiotherapy and rehabilitation. Also, you need a lot more physical energy to use a prosthetic limb as the rest of your body has to compensate for the missing muscle and bone that has been removed during the amputation. This is why frail people or those with a serious health condition, such as heart disease, may not be suitable for a prosthetic limb.

Psychological impact

The loss of a limb can have a considerable psychological impact. Many people who have had an amputation reported feeling emotions such as grief and bereavement, similar to experiencing the death of a loved one.

Coming to terms with the psychological impact of an amputation is therefore often as important as coping with the physical demands.

People who have had an amputation due to trauma (especially members of the armed forces who were injured while serving in Iraq or Afghanistan) have an increased risk of developing post-traumatic stress disorder (PTSD).

PTSD is when a person experiences a number of unpleasant symptoms after a traumatic event, such as ‘reliving’ the event and feeling anxious all the time.

Outlook

The outlook for people with an amputation often depends on a number of factors, such as:

  • their age (younger people tend to cope better with the physical demands of adjusting to life with an amputation)
  • how much of the limb was removed (if less of the limb is removed, there will be a greater range of movement in the prosthetic limb)
  • how well they cope with the emotional and psychological impact of amputation

A common complication that can occur after an amputation is phantom limb pain. This is when a person experiences a sensation that their limb is still attached to their body and is causing them pain (see Amputation – complications for more information). Phantom limb pain can be treated with a range of medications.

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Why amputation is necessary

Three of the most common reasons for carrying out an amputation are:

  • gangrene resulting from an infected diabetic foot ulcer
  • atherosclerosis, where the arteries become narrowed and hardened
  • trauma, which is a serious injury to a limb or part of a limb

These are explained below.

Gangrene from a diabetic foot ulcer

A diabetic foot ulcer is an open sore that develops on the skin of the feet in people with diabetes.

The high blood sugar associated with diabetes can cause damage to the nerves (called peripheral neuropathy), particularly in your feet. Once damaged, the nerves are unable to transmit sensations of pain to your brain.

Therefore, it is easy to damage your foot by treading on something sharp or to develop a blister due to ill-fitting shoes, without realising it. Due to the lack of pain, you may continue walking without protecting the wound. This can make the wound worse and it may develop into an ulcer.

High blood sugar can also damage your blood vessels, causing the blood supply to your feet to become restricted. If the skin on your feet receives less blood, it will also receive fewer infection-fighting cells, which means that wounds will take longer to heal.

Therefore, the reduced sensation means you are more likely to develop an ulcer, and the reduced blood supply means that the ulcer is more likely to become infected. The infection is likely to restrict the blood supply further, leading to gangrene (decay and death of the body tissues).

Once gangrene has developed, it is sometimes necessary to amputate the affected limb to prevent the spread of infection and prevent further damage to healthy tissue.



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Alive & Whole Amputation
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Living with Physical Disability
and Amputation

Atherosclerosis

Atherosclerosis is a potentially serious and progressive condition (gets worse over time) where the body’s arteries become clogged by fatty substances such as cholesterol. These substances are called plaques or atheromas.

Factors that increase the risk of atherosclerosis include:

  • smoking
  • obesity
  • high-fat diet that leads to high levels of cholesterol in the blood
  • high blood pressure

Many people with atherosclerosis go on to develop a related condition called peripheral arterial disease. Peripheral arterial disease (also known as peripheral vascular disease) occurs when there is a blockage in the arteries of your limbs (in most cases, your legs).

The most common symptom of peripheral arterial disease is pain in your legs. This is usually in one or both of your thighs, hips or calves.

In the most severe cases of peripheral arterial disease, the supply of blood to the lower limbs can become blocked, leading to the development of gangrene, which will then require amputation.

Trauma

If a limb has been so severely damaged by a traumatic injury that you can no longer use that limb, it may be necessary to amputate part of it so you can use a prosthetic limb.

Types of injury that can make amputation necessary include:

  • crush injuries, such as your arm or leg being severely crushed in a car crash or industrial accident
  • blast injuries, such as those experienced by soldiers who have been wounded by improvised explosive devices
  • avulsion injuries, where a body part is torn away from the body, such as a dog biting your finger off
  • guillotine injuries, where a limb or part of a limb is cut entirely or almost entirely away from the body, such as accidentally cutting off your thumb with a power saw
  • severe burns
  • damage caused by exposure to harmful chemicals, such as acid

Less common reasons

Less common reasons for amputation include:

  • cancers that develop inside the skin or bone of a limb, such as osteosarcoma (a type of bone cancer) or malignant melanoma (a type of skin cancer)
  • infections, such as an infection of the bone (osteomyelitis) or necrotising fasciitis (a serious type of bacterial skin infection that is sometimes referred to as flesh-eating bacteria)
  • Buerger's disease, a rare condition where the blood vessels supplying the hands, arms, feet and legs become swollen and blocked, which can sometimes lead to gangrene and infection

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How amputation is performed

Types of amputation

There are two main types of amputation:

  • lower limb amputation, where the foot and part of the leg are removed
  • upper limb amputation, where the hand and part of the arm are removed

An amputation can be:

  • minor, where only a toe, finger or part of the foot or hand is removed
  • major, where a large part of the limb is removed

Lower limb amputations

The most common type of amputation, accounting for half of all cases in the UK, is a type of lower limb amputation known as transtibial amputation. This is where the bottom section of a leg is amputated beneath the knee.

A transtibial amputation is usually needed because of a lack of blood supply in cases of diabetic foot ulcers or peripheral arterial disease related to atherosclerosis. A transtibial amputation is also known as a below-knee amputation.

Other types of lower limb amputation, listed in order of how commonly they are performed in the UK, are:

  • transfemoral, where both the bottom half of the leg and part of the thigh above the knee are amputated (a transfemoral amputation is also known as an above-knee amputation)
  • double lower amputation, where both legs are amputated, usually below the knee
  • knee disarticulation, where the amputation is performed through the middle of the knee joint
  • partial foot amputation, where the toes and lower half of the foot are amputated
  • hip disarticulation, where the amputation takes place through the hip joint, removing the entire leg
  • lower digit amputation, where one or more of the toes are amputated
  • hemipelvectomy, where an entire leg and a section of the pelvis are amputated (a hemipelvectomy is the rarest type of lower limb amputation, usually only reserved for the most serious and extensive cases of damage to the limb)

Upper limb amputations

Most upper limb amputations are needed because the hand and arm have been damaged by a traumatic injury.

The main types of upper limb amputation, listed in order of how commonly they are performed in the UK, are:

  • upper digit amputation, where the thumb or one or more of the fingers are amputated
  • transhumeral, where the hand and a section of the arm are amputated above the elbow
  • transradial, where the hand and a section of the arm are amputated below the elbow
  • partial hand amputation, where a section of the hand is amputated
  • shoulder disarticulation, where the amputation occurs through the shoulder joint, removing the entire arm
  • double upper amputations, where both hands and some of the arms are amputated
  • forequarter amputation, where the entire arm is amputated along with a section of the shoulder blade and collar bone
  • wrist disarticulation, where the amputation occurs through the wrist joint, removing the hand
  • elbow disarticulation, where the amputation occurs through the elbow joint, removing the hand, wrist and forearm

Pre-operative assessment

Unless your amputation has to be performed as an emergency, you will probably go through a number of tests and procedures before the amputation takes place. These are designed to assess a range of factors that may affect your post-operative rehabilitation and influence the type of amputation that is recommended for you.

These tests and procedures may include:

  • a thorough medical examination, including assessing your physical condition, nutritional status, bowel and bladder function and the various systems of your body, such as your cardiovascular system (your heart, blood and blood vessels) and your respiratory system (your lungs and airways)
  • an assessment of the condition and function of the healthy limb. Removing one limb can place extra strain on the remaining limb, so it is important to reduce any potential risk of amputation of the remaining limb at a later date
  • a psychological assessment to determine how well you will be able to cope with the psychological and emotional impact of amputation and whether you will require any additional support
  • an assessment of your home, work and social environments to determine whether any additional provisions will need to be made to help you cope

After the pre-operative assessment, the surgeon should be able to tell you exactly what type of amputation you need.

You will also be introduced to a physiotherapist, who will be involved in your post-operative rehabilitation.

You may be introduced to a prosthetist (a specialist in prosthetic limbs) who will be able to tell you more about the type of prosthetic limbs (or other devices) that are available and how well a particular prosthetic limb will function.

Factors that will influence the type of prosthetic limb recommended for you include:

  • the type of amputation
  • the amount of muscle strength in the remaining section of the limb
  • your general state of health
  • tasks the prosthetic limb will be expected to perform, such as whether you have a desk or manual job and what type of hobbies you do
  • whether you want the limb to look as physically real as possible or whether you are more concerned with being able to use the limb for a wide range of activities

You may have to decide between having a prosthetic that is physically realistic or one that is functionally useful. However, it is possible to have a prosthetic limb that is both physically realistic and fully (or mostly) functional.

Many people planning to have an amputation find it both reassuring and useful to talk to somebody who has gone through a similar type of amputation. A member of your care team may be able to put you in touch with someone.

Surgery

An amputation is carried out under a general anaesthetic (where you are put to sleep) or an epidural anaesthetic, so you will feel no pain during surgery.

Ideally, as much of the limb as possible should be spared as this will mean you will probably have a greater range of movement and functional ability in your prosthetic limb.

But it is also important that the remainder of the limb has a good blood supply, as without such a supply a further amputation may be necessary.

A number of additional techniques can be used during surgery to help improve the remaining limb function and reduce the risk of complications. These include:

  • shortening and smoothing the bone in your remaining limb so it is covered by an adequate amount of soft tissue and muscle
  • stitching the remaining muscle to the bones to help strengthen your remaining limb

After the amputation, the remaining stump wound is sealed with stitches or staples.

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Recovering from an amputation

After surgery, you will be transferred back to a ward.

You will normally be given oxygen through a mask and nutrients and fluids through a drip for the first few days after surgery.

Your amputation wound will be covered with a bandage or plaster dressing and a tube may be placed under the skin next to the wound to drain away any excess fluid from the site of the surgery. This will help prevent excessive bruising and swelling at the wound. It is usually recommended that the bandage remains in place for the first five days to reduce the risk of infection.

A small flexible tube, known as an urinary catheter, may be placed in your bladder during your surgery to drain away urine. This means you will not need to worry about going to the toilet for the first few days after surgery.

It is likely that you will experience considerable pain at the site of the operation, so painkillers will be supplied as required. Let your pain nurse know if the painkillers are not working as you may need a larger dose or a stronger type of painkiller.

Preparing for discharge

As you gradually recover from the effects of surgery, you will meet a number of different health professionals, such as a social worker, occupational therapist and physiotherapist, to help plan for your discharge.

Your physiotherapist will also teach you a number of exercises to help prevent blood clots and improve blood supply.

Going home

How long it will take before you are ready to go home will depend on the type of amputation you have and your general state of health.

In many parts of the country it is common to be transferred to another hospital or ward for a period of rehabilitation following a leg amputation. This is usually done when you no longer require the facilities of the surgical ward.

Before you leave home, it is likely that an occupational therapist will arrange a visit to your home to see if any aids are needed to make your home environment more accessible, such as a wheelchair ramp or a stairlift. If these kinds of modifications are required, the issue can be referred to your local social services department.

It can take several months before you are fitted with a prosthetic limb, or a prosthetic limb may not be suitable for you (see below for more information on prosthetics), so you may be given a wheelchair if you had a lower limb amputation.

You may also have meetings with a social worker to see if you need any additional support at home, such as meals on wheels. Also, a dietitian can provide advice on changes you can make to your diet to cope with the extra energy requirements you may have if you are using a prosthetic limb.

You will probably be asked to attend a follow-up appointment two weeks after leaving hospital to discuss how well you are coping at home and whether you require any additional help, support or equipment.

You may also be given details of your nearest amputee support group, which is made up of both health professionals and people who are living with an amputation. Most amputee support groups meet once a month.

Fitting the prosthetic

A prosthetic limb is not suitable for everyone, especially a lower prosthetic limb. Using a prosthetic limb takes a considerable amount of energy because you have to compensate for the loss of muscle and bone in the amputated limb.

For example, a person fitted with a prosthetic limb after a transfemoral (above-knee) amputation has to use 80% more energy to walk than a person with two legs. So if is thought that your body would not be able to withstand the strain of using a prosthetic limb – for example, if you had a heart condition – then a purely cosmetic limb may be recommended instead (a limb that looks like a real limb but cannot be used).

If you are a suitable candidate for a prosthetic limb, you will begin a programme of activities while still in hospital to prepare the remainder of the limb for the prosthetic.

Before a prosthetic is fitted, the skin covering your stump may be made less sensitive (known as desensitisation). This will make the prosthetic more comfortable to wear.

Skin desensitisation consists of the following steps:

  • gently tapping the skin with a face cloth
  • using compression bandages to help reduce swelling and prevent a build-up of fluid inside and around your stump
  • rubbing and pulling the skin around your bone to prevent excessive scarring

Your physiotherapist will teach you a range of exercises designed to strengthen the muscles in the remainder of your limb while also improving your general energy levels, so you can cope better with the demands of an artificial limb.

Depending on the level of provision in your local primary care trust, it can take several months before you get your first appointment with a prosthetist (specialist in prosthetic limbs).

Lower limb prosthetic

There is a large range of lower limb prosthetics. Most lower limb prosthetics consist of the components listed below:

  • The socket is the interface between your prosthetic limb and the remainder of your real limb. The most common type of socket used in lower limb prosthetics is known as a patellar tendon-bearing socket, which is a plaster mould designed to fit around the knee joint.
  • A suspension system keeps the prosthetic limb in place. Examples of suspension systems include strapping systems and suction cups.
  • Artificial joints are a type of metal hinge designed to replicate the function and range of movement of real joints, such as the knee or ankle joints.
  • A pylon is a metal rod designed to replicate the function of the main bones of the leg.
  • A prosthetic foot is made out of metal, plastic or a combination of both and is designed to replicate the main functions of the real foot, such as bearing the weight of the limb and aiding balance and stability.

Upper limb prosthetics

Again, there is a wide range of upper limb prosthetics, which generally consist of the components listed below.

  • The socket is usually made from lightweight plastic or graphite (a type of lightweight mineral) designed to fit around the remaining limb, which in most cases is a section of the arm just below the elbow joint.
  • A suspension system, either a strapping or suction system, keeps the limb in place.
  • A control mechanism is designed to replicate the movements of the arm and hand. One commonly used type of control system is to attach cables to muscles in other parts of your body, such as your shoulder or upper arm. You learn a range of movements that allow you to control the prosthetic limb. Alternatively, the control mechanism can be electric and controlled by electrodes implanted in your arm, which respond to the electrical activity generated by certain muscles.
  • A terminal device serves as the ‘hand’ of the prosthetic limb. Terminal devices have tended to either be physically realistic and cosmetically pleasing but with little practical function, or look very artificial (such as a hook or a claw) but with a wide range of potential functions. More sophisticated terminal devices are now being developed that are both cosmetically pleasing and functional.

Stump care

It is important to keep the skin on the surface of your stump clean to reduce the risk of the skin becoming irritated or infected.

Wash your stump at least once a day (more frequently in hot weather) with a mild antibacterial soap and warm water, and dry it carefully.

If you regularly take baths, do not leave your stump submerged in water for long periods of time. This is because the water will soften the skin on the stump, making it more vulnerable to injury.

Using unmedicated talcum powder, such as baby talcum powder, is an effective way to help reduce perspiration (sweat) around your stump.

Some people find that wearing a sock around their stump can also help absorb perspiration and reduce skin irritation. However, it is important to change the sock every day.

If you have a prosthetic limb, clean the socket regularly with soap and warm water.

Check your stump carefully every day for any sign of infection such as:

  • warm, red and tender skin
  • discharge of fluid or pus
  • swelling of the skin

If you think you may be developing a skin infection, contact your care team for advice.

Care of your remaining limb

After losing a leg, it is very important to avoid injury and damage to your remaining 'good' leg, particularly if you are diabetic, as the conditions that led to the need for amputation may also be present in the remaining leg.

You should ensure that you avoid poorly fitting footwear, and that an appropriately trained individual (such as a chiropodist) is involved in nail care and other aspects of the care of your remaining foot.

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Risks of an amputation

The risk of serious complications is higher in planned amputations than in emergency amputations.

This is because most planned amputations involve the leg and are carried out in older people with a restricted blood supply, who are in a poor state of health and who usually have a chronic (long-term) health condition, such as diabetes. Most emergency amputations involve the arm and are usually carried out in younger people who are often in a good state of health.

A recent study looked at lower limb amputations carried out in people with a restricted blood supply due to a condition such as diabetes or atherosclerosis. The study found that around 1 in 11 people died in the first 30 days after surgery.

The risk of death was higher for above-knee amputations (1 in 6) than below-knee amputations (1 in 17).

Other complications recorded were:

  • heart complications, such as heart attack or heart failure (when the heart has difficulty pumping blood around the body), which occurred in 1 in 10 cases
  • infection at the site of the surgery, which occurred in 1 in 20 cases
  • pneumonia (infection of the lungs), which occurred in 1 in 22 cases

The blood supply was not sufficiently restored in around 1 in 10 below-knee amputations, so a further above-knee amputation was required.

Due to the relatively high risk of complications, a planned amputation is seen as a ‘treatment of last resort’. It is only used when there is no other way of preventing life-threatening and serious symptoms, such as gangrene, from developing.

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Complications of amputation

Phantom limb pain

One of the most common complications to affect people after amputation is phantom limb pain. This is when a person experiences sensations of pain that seem to be coming from the limb that has been amputated.

It is estimated that 50-80% of people develop phantom limb pain after an amputation. The condition is more common in women then men. Phantom limb pain also appears to be more widespread in people who have had an upper limb amputation than in people who have had a lower limb amputation.

The term ‘phantom’ does not mean that the symptoms of pain are imaginary and all in your head. Phantom limb pain is a very real phenomenon which has been confirmed using brain imaging scans to study how nerve signals are transmitted to the brain.

The symptoms of phantom limb pain can range from mild to severe. Some people have described brief ‘flashes’ of mild pain, similar to an electric shock, that last for a few seconds. Other people have described constant severe pain.

The causes of phantom limb pain are unclear. There are three main theories:

  • The peripheral theory argues that phantom limb pain may be the result of nerve endings around the stump forming into little clusters, known as neuromas. These may generate abnormal electrical impulses that the brain interprets as pain.
  • The spinal theory suggests that the lack of sensory input from the amputated limb causes chemical changes in the central nervous system. This leads to ‘confusion’ in certain regions of the brain, triggering symptoms of pain.
  • The central theory proposes that the brain has a ‘memory’ of the amputated limb and its associated nerve signals. Therefore, the symptoms of pain are due to the brain trying to recreate this memory but failing because it is not receiving the feedback it was expecting.

A step-wise approach to treatment for phantom limb pain is usually recommended. This means that standard painkillers are used first and, if you fail to respond to treatment, you can ‘step up’ to additional medications and treatments.

Amitriptyline

Amitriptyline was originally designed to treat depression, but has subsequently proved effective in treating some cases of phantom limb pain.

You will usually be prescribed the lowest dose that is thought necessary to control your symptoms, to lower the risk of side effects. If the medication then proves ineffective, the dose can be gradually increased.

Common side effects of amitriptyline include:

  • dry mouth
  • constipation
  • sweating
  • problems passing urine
  • slight blurring of vision
  • drowsiness

If you experience drowsiness or blurred vision, avoid driving or operating machinery.

The side effects should ease after 7-10 days as your body begins to get used to the medication. However, if the side effects continue or become troublesome, tell your GP because it may be possible to switch to a different medication that may suit you better.

There have been reports of people suddenly having thoughts of hurting or killing themselves when taking amitriptyline. If this happens to you, contact your GP or go to your nearest hospital straight away.

It may be helpful to tell a close friend or relative that you are taking amitriptyline and ask them to tell you if they notice changes in your behaviour or are worried about the way you are acting.

Do not drink alcohol when you are taking amitriptyline because the combined effects can make you feel very drowsy.

Carbamazepine

Another medication that can be used is carbamazepine, which was originally designed to treat epilepsy. It is thought that carbamazepine can help reduce nervous system activity, which leads to a reduction in pain signals.

Common side effects of carbamazepine include:

  • dizziness
  • tiredness
  • feeling unsteady or finding it difficult to control movements
  • nausea
  • vomiting
  • headache
  • blurred vision

As with amitriptyline, there have been reports of people suddenly having thoughts of hurting or killing themselves once they begin treatment. Again, it is important to contact your GP or go to your nearest hospital straight away.

Carbamazepine can make the contraceptive pill or implant less effective, so use an alternative method of contraception, such as a condom, when taking this medication.

Transcutaneous electrical nerve stimulation (TENS)

TENS involves using a small electric device that is connected to a series of electrodes. The electrodes deliver small electrical impulses to the site of your stump. TENS is thought to work in two ways:

  • The electrical impulses help disrupt the passage of pain signals to the brain.
  • The electrical impulses stimulate the release of natural painkilling chemicals known as endorphins.

Mental imagery

Research carried out in Liverpool in 2008 found that if people spent 40 minutes imagining using their phantom limb, such as stretching out their ‘fingers’ or bunching up their ‘toes’, they experienced a reduction in pain symptoms.

This may be related to the central theory of phantom limb pain (that the brain is looking to receive feedback from the amputated limb) and these mental exercises may provide an effective substitution for this missing feedback.

Psychological impact of amputation

Having an amputation can have an intense psychological impact for three main reasons:

  • You have to cope with the loss of sensation from your amputated limb.
  • You have to cope with the loss of function from your amputated limb.
  • Your sense of body image, and other people’s perception of your body image, has changed.

It is common to experience negative thoughts and emotions after an amputation. This is especially true in people who had an emergency amputation, as they did not have the time to mentally prepare themselves for the effects of surgery.

Common negative emotions and thoughts experienced by people after an amputation include:

  • depression
  • anxiety
  • denial (refusing to accept that they need to make changes, such as having physiotherapy, to adapt to life with an amputation)
  • grief (a profound sense of loss and bereavement)
  • feeling suicidal

Talk to your care team about your thoughts and feelings, especially if you are feeling depressed or suicidal. You may require additional treatment, such as antidepressants or counselling, to improve your ability to cope with living with an amputation.

Resources

Limbcare - Charity offering hope, advice and peer support to amputee/limb impaired individuals, communities, families and others impacted around them.

Amputation - From Wikipedia, the free encyclopedia

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