Amputation

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Amputation
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Sgt. Jerrod Fields, an athlete and amputee.
Specialty Surgery

Physical medicine and rehabilitation

Emergency medicine

Amputation is the removal of a limb by trauma, medical illness, 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 preventive surgery for such problems. A special case is that of congenital amputation, a congenital disorder, where fetal limbs have been cut off by constrictive bands. In some countries, such as the United States [1] [2] and Iran, [3] amputation was proposed, was formerly used, or is currently used to punish people who committed crimes. [4] [5] [6] Amputation has also been used as a tactic in war and acts of terrorism; it may also occur as a war injury. In some cultures and religions, minor amputations or mutilations are considered a ritual accomplishment. [7] [8] [9]

Contents

When done by a person, the person executing the amputation is an amputator. [10] The amputated person is called an amputee. [11]

In the US, the majority of new amputations occur due to complications of the vascular system (the blood vessels), especially from diabetes. Between 1988 and 1996, there were an average of 133,735 hospital discharges for amputation per year in the US. [12] In 2005, just in the US, there were 1.6 million amputees. [13] In 2013, the US has 2.1 million amputees. Approximately 185,000 amputations occur in the United States each year. In 2009, hospital costs associated with amputation totaled more than $8.3 billion. [14] There will be an estimated 3.6 million people in the US living with limb loss by 2050. [15] African Americans are up to four times more likely to have an amputation than European Americans. [16]

Types

Leg

Lower limb amputations can be divided into two broad categories: minor and major amputations. Minor amputations generally refer to the amputation of digits. Major amputations are commonly below-knee- or above-knee amputations. Common partial foot amputations include the Chopart, Lisfranc, and ray amputations.

Common forms of ankle disarticulations include Pyrogoff, Boyd, and Syme amputations. [17] A less common major amputation is the Van Nes rotation, or rotationplasty, i.e. the turning around and reattachment of the foot to allow the ankle joint to take over the function of the knee.

Types of amputations include:

An above-knee amputation Diagram showing an above knee amputation CRUK 094.svg
An above-knee amputation
partial foot amputation
amputation of the lower limb distal to the ankle joint
ankle disarticulation
amputation of the lower limb at the ankle joint
trans-tibial amputation
amputation of the lower limb between the knee joint and the ankle joint, commonly referred to as a below-knee amputation
knee disarticulation
amputation of the lower limb at the knee joint
trans-femoral amputation
amputation of the lower limb between the hip joint and the knee joint, commonly referred to an above-knee amputation
hip disarticulation
amputation of the lower limb at the hip joint
trans-pelvic disarticulation
amputation of the whole lower limb together with all or part of the pelvis, also known as a hemipelvectomy or hindquarter amputation

Arm

The 18th century guide to amputations Amputations 18c.jpg
The 18th century guide to amputations

Types of upper extremity amputations include:

A variant of the trans-radial amputation is the Krukenberg procedure in which the radius and ulna are used to create a stump capable of a pincer action.

Other

Partial amputation of index finger. Index finger amputation.jpg
Partial amputation of index finger.

Hemicorporectomy, or amputation at the waist, and decapitation, or amputation at the neck, are the most radical amputations.

Genital modification and mutilation may involve amputating tissue, although not necessarily as a result of injury or disease.

Nails are typically trimmed with nail clippers, but this is not typically considered amputation.

Self-amputation

In some rare cases when a person has become trapped in a deserted place, with no means of communication or hope of rescue, the victim has amputated his or her own limb. The most notable case of this is Aron Ralston, a hiker who amputated his own right forearm after it was pinned by a boulder in a hiking accident and he was unable to free himself for over five days. [18]

Body integrity identity disorder is a psychological condition in which an individual feels compelled to remove one or more of their body parts, usually a limb. In some cases, that individual may take drastic measures to remove the offending appendages, either by causing irreparable damage to the limb so that medical intervention cannot save the limb, or by causing the limb to be severed.

Causes

Circulatory disorders

Neoplasm

Transfemoral amputation due to liposarcoma 1daypost.jpg
Transfemoral amputation due to liposarcoma

Trauma

Three fingers from a soldier's right hand were traumatically amputated during World War I. World War I radiography amputee.jpg
Three fingers from a soldier's right hand were traumatically amputated during World War I.

Congenital anomalies

Infection

Frostbite

Frostbite, also known as frostnip, happens when the individual's skin is exposed to cold weather for too long. The fluid in the pale skin solidifies, creating ice crystals, leading to swelling and severe pain. Other symptoms can include numbness, confusion, dizziness, fatigue, nausea, stiffness in the muscles or joints as well as difficulty walking. If the frostbite doesn't get treated soon, this process results in hypothermia, death or poisoning of the bloodstream.

This can affect the hands, feet, toes, fingers, eyes, and face. Once the frostbite shuts the eyelids, this is known as snow blindness. The only way to stop it from spreading is through skin grafts or amputation.

Athletic performance

Sometimes professional athletes may choose to have a non-essential digit amputated to relieve chronic pain and impaired performance.

Criminal penalty

Surgery

Method

Curved knives such as this one were used, in the past, for some kinds of amputations. Curvy amputation knife DSC09451.jpg
Curved knives such as this one were used, in the past, for some kinds of amputations.

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 bones are filed, 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 periosteum. 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. [28]

An experimental technique known as the "Ewing amputation" aims to improve post-amputation proprioception. [29] [30]

In 1920,  Professor Janos Ertl Sr., MD, of Hungary, developed the Ertl procedure in order to return a high number of amputees to the work force. [31] The Ertl technique, an osteomyoplastic procedure for transtibial amputation, can be used to create a highly functional residual limb. Creation of a tibiofibular bone bridge provides a stable, broad tibiofibular articulation that may be capable of some distal weight bearing. Several different modified techniques and fibular bridge fixation methods have been used; however, no current evidence exists regarding comparison of the different techniques. [32]

Post-operative management

A 2019 Cochrane systematic review aimed to determine whether rigid dressings were more effective than soft dressings in helping wounds heal following transtibial (below the knee) amputations. Due to the limited and very low certainty evidence available, the authors concluded that it was uncertain what the benefits and harms were for each dressing type. They recommended that clinicians consider the pros and cons of each dressing type on a case-by-case basis e.g. rigid dressings may potentially benefit patients who have a high risk of falls and soft dressings may potentially benefit patients who have poor skin integrity. [33]

A 2017 review found that the use of rigid removable dressings (RRD's) in trans-tibial amputations, rather than soft bandaging, improved healing time, reduced edema, prevented knee flexion contractures and reduced complications, including further amputation, from external trauma such as falls onto the stump. [34]

Post-operative management, in addition to wound healing, should consider maintenance of limb strength, joint range, edema management, preservation of the intact limb (if applicable) and stump desensitisation.

Trauma

Traumatic amputation is the partial or total avulsion of a part of a body during a serious accident, like traffic, labor, or combat. [35] [36]

Traumatic amputation of a human limb, either partial or total, creates the immediate danger of death from blood loss. [37]

Orthopedic surgeons often assess the severity of different injuries using the Mangled Extremity Severity Score. Given different clinical and situational factors, they can predict the likelihood of amputation. This is especially useful for emergency physicians to quickly evaluate patients and decide on consultations. [38]

Causes

Private Lewis Francis was wounded July 21, 1861, at the First Battle of Bull Run by a bayonet to the knee. 3372709503 10dc75d783 oSequelleAmputation.jpg
Private Lewis Francis was wounded July 21, 1861, at the First Battle of Bull Run by a bayonet to the knee.

Traumatic amputation is uncommon in humans (1 per 20,804 population per year). Loss of limb usually happens immediately during the accident, but sometimes a few days later after medical complications. Statistically, the most common causes of traumatic amputations are:[ citation needed ]

Treatment

The development of the science of microsurgery over the last 40 years has provided several treatment options for a traumatic amputation, depending on the patient's specific trauma and clinical situation:

Epidemiology

Prevention

Methods in preventing amputation, limb-sparing techniques, depend on the problems that might cause amputations to be necessary. Chronic infections, often caused by diabetes or decubitus ulcers in bedridden patients, are common causes of infections that lead to gangrene, which would then necessitate amputation.

There are two key challenges: first, many patients have impaired circulation in their extremities, and second, they have difficulty curing infections in limbs with poor vasculation (blood circulation).

Crush injuries where there is extensive tissue damage and poor circulation also benefit from hyperbaric oxygen therapy (HBOT). The high level of oxygenation and revascularization speed up recovery times and prevent infections.

A study found that the patented method called Circulator Boot achieved significant results in prevention of amputation in patients with diabetes and arteriosclerosis. [43] [44] Another study found it also effective for healing limb ulcers caused by peripheral vascular disease. [45] The boot checks the heart rhythm and compresses the limb between heartbeats; the compression helps cure the wounds in the walls of veins and arteries, and helps to push the blood back to the heart. [46]

For victims of trauma, advances in microsurgery in the 1970s have made replantations of severed body parts possible.

The establishment of laws, rules, and guidelines, and employment of modern equipment help protect people from traumatic amputations.[ citation needed ]

Prognosis

The individual may experience psychological trauma and emotional discomfort. The stump will remain an area of reduced mechanical stability. Limb loss can present significant or even drastic practical limitations.

A large proportion of amputees (50–80%) experience the phenomenon of phantom limbs; [47] they feel body parts that are no longer there. These limbs can itch, ache, burn, feel tense, dry or wet, locked in or trapped or they can feel as if they are moving. Some scientists believe it has to do with a kind of neural map that the brain has of the body, which sends information to the rest of the brain about limbs regardless of their existence. Phantom sensations and phantom pain may also occur after the removal of body parts other than the limbs, e.g. after amputation of the breast, extraction of a tooth (phantom tooth pain) or removal of an eye (phantom eye syndrome).

A similar phenomenon is unexplained sensation in a body part unrelated to the amputated limb. It has been hypothesized that the portion of the brain responsible for processing stimulation from amputated limbs, being deprived of input, expands into the surrounding brain, ( Phantoms in the Brain : V.S. Ramachandran and Sandra Blakeslee) such that an individual who has had an arm amputated will experience unexplained pressure or movement on his face or head[ citation needed ].

In many cases, the phantom limb aids in adaptation to a prosthesis, as it permits the person to experience proprioception of the prosthetic limb. To support improved resistance or usability, comfort or healing, some type of stump socks may be worn instead of or as part of wearing a prosthesis.

Another side effect can be heterotopic ossification, especially when a bone injury is combined with a head injury. The brain signals the bone to grow instead of scar tissue to form, and nodules and other growth can interfere with prosthetics and sometimes require further operations. This type of injury has been especially common among soldiers wounded by improvised explosive devices in the Iraq War. [48]

Due to technologic advances in prosthetics, many amputees live active lives with little restriction. Organizations such as the Challenged Athletes Foundation have been developed to give amputees the opportunity to be involved in athletics and adaptive sports such as Amputee Soccer.

Nearly half of the individuals who have an amputation due to vascular disease will die within 5 years, usually secondary to the extensive co-morbidities rather than due to direct consequences of amputation. This is higher than the five year mortality rates for breast cancer, colon cancer, and prostate cancer. [49] Of persons with diabetes who have a lower extremity amputation, up to 55% will require amputation of the second leg within two to three years. [50]

Etymology

The word amputation is derived from the Latin amputare, "to cut away", from ambi- ("about", "around") and putare ("to prune"). The English word “Poes” was first applied to surgery in the 17th century, possibly first in Peter Lowe's A discourse of the Whole Art of Chirurgerie (published in either 1597 or 1612); his work was derived from 16th-century French texts and early English writers also used the words "extirpation" (16th-century French texts tended to use extirper), "disarticulation", and "dismemberment" (from the Old French desmembrer and a more common term before the 17th century for limb loss or removal), or simply "cutting", but by the end of the 17th century "amputation" had come to dominate as the accepted medical term.[ citation needed ]

Notable cases

See also

Related Research Articles

Prosthesis Artificial device that replaces a missing body part

In medicine, a prosthesis or prosthetic implant is an artificial device that replaces a missing body part, which may be lost through trauma, disease, or a condition present at birth. Prostheses are intended to restore the normal functions of the missing body part. Amputee rehabilitation is primarily coordinated by a physiatrist as part of an inter-disciplinary team consisting of physiatrists, prosthetists, nurses, physical therapists, and occupational therapists. Prostheses can be created by hand or with computer-aided design (CAD), a software interface that helps creators design and analyze the creation with computer-generated 2-D and 3-D graphics as well as analysis and optimization tools.

Bone tumor

A bone tumor is a neoplastic growth of tissue in bone. Abnormal growths found in the bone can be either benign (noncancerous) or malignant (cancerous).

Sprain Damage to one or more ligaments in a joint

A sprain, also known as a torn ligament, is the stretching or tearing of ligaments within a joint, often caused by an injury abruptly forcing the joint beyond its functional range of motion. Ligaments are tough, inelastic fibers made of collagen that connect two or more bones to form a joint and are important for joint stability and proprioception, which is the body's sense of limb position and movement. Sprains can occur at any joint but most commonly occur in the ankle, knee, or wrist. An equivalent injury to a muscle or tendon is known as a strain.

Hemicorporectomy is a radical surgery in which the body below the waist is amputated, transecting the lumbar spine. This removes the legs, the genitalia, urinary system, pelvic bones, anus, and rectum. It is an extremely mutilating procedure recommended only as a last resort for people with severe and potentially fatal illnesses such as osteomyelitis, tumors, severe traumas and intractable decubiti in, or around, the pelvis. Till 2009, 66 cases have been reported in medical literature. The most recent documented operation was in September 2019.

Genu varum Varus deformity marked by (outward) bowing at the knee

Genu varum is a varus deformity marked by (outward) bowing at the knee, which means that the lower leg is angled inward (medially) in relation to the thigh's axis, giving the limb overall the appearance of an archer's bow. Usually medial angulation of both lower limb bones is involved.

Joint dislocation Medical injury

A joint dislocation, also called luxation, occurs when there is an abnormal separation in the joint, where two or more bones meet. A partial dislocation is referred to as a subluxation. Dislocations are often caused by sudden trauma on the joint like an impact or fall. A joint dislocation can cause damage to the surrounding ligaments, tendons, muscles, and nerves. Dislocations can occur in any joint major or minor. The most common joint dislocation is a shoulder dislocation.

Hemipelvectomy Surgical removal of half of the pelvis and one of the legs

Hemipelvectomy, also known as a pelvic resection, is a surgical procedure that involves the removal of portion of the pelvic girdle. This procedure is most commonly performed to treat oncologic conditions of the pelvis. Hemipelvectomy can be further classified as internal and external hemipelvectomy. An internal hemipelvectomy is a limb-sparing procedure where the innominate bone is resected while preserving the ipsilateral limb. An external hemipelvectomy involves the resection of the innominate bone plus amputation of the ipsilateral limb.

A pegleg is a prosthesis, or artificial limb, fitted to the remaining stump of a human leg. Its use dates to antiquity.

Phantom pain is a perception that an individual experiences relating to a limb or an organ that is not physically part of the body. Limb loss is a result of either removal by amputation or congenital limb deficiency. However, phantom limb sensations can also occur following nerve avulsion or spinal cord injury.

Proximal femoral focal deficiency

Proximal femoral focal deficiency (PFFD), also known as Congenital Femoral Deficiency (CFD), is a rare, non-hereditary birth defect that affects the pelvis, particularly the hip bone, and the proximal femur. The disorder may affect one side or both, with the hip being deformed and the leg shortened.

Joint replacement

Replacement arthroplasty, or joint replacement surgery, is a procedure of orthopedic surgery in which an arthritic or dysfunctional joint surface is replaced with an orthopedic prosthesis. Joint replacement is considered as a treatment when severe joint pain or dysfunction is not alleviated by less-invasive therapies. It is a form of arthroplasty, and is often indicated from various joint diseases, including osteoarthritis and rheumatoid arthritis.

Heterotopic ossification

Heterotopic ossification (HO) is the process by which bone tissue forms outside of the skeleton.

Rotationplasty, commonly known as a Van Nes rotation or Borggreve rotation, is a type of autograft wherein a portion of a limb is removed, while the remaining limb below the involved portion is rotated and reattached. This procedure is used when a portion of an extremity is injured or involved with a disease, such as cancer.

Open fracture

An open fracture, also called a compound fracture, is a type of bone fracture in orthopedics that is frequently caused by high energy trauma. It is a bone fracture associated with a break in the skin continuity which can cause complications such as infection, malunion, and nonunion. Gustilo open fracture classification is the most commonly used method to classify open fractures, to guide treatment and to predict clinical outcomes. Advanced trauma life support is the first line of action in dealing with open fractures and to rule out other life-threatening condition in cases of trauma. Cephalosporins are generally the first line of antibiotics. The antibiotics are continued for 24 hours to minimize the risk of infections. Therapeutic irrigation, wound debridement, early wound closure and bone fixation are the main management of open fractures. All these actions aimed to reduce the risk of infections.

Congenital amputation is birth without a limb or limbs, or without a part of a limb or limbs.

Krukenberg procedure

The Krukenberg procedure, also known as the Krukenberg operation, is a surgical technique that converts a forearm stump into a pincer. It was first described in 1917 by the German army surgeon Hermann Krukenberg. It remains in use today for certain special cases but is considered controversial and some surgeons refuse to perform it.

Targeted reinnervation enables amputees to control motorized prosthetic devices and to regain sensory feedback. The method was developed by Dr. Todd Kuiken at Northwestern University and Rehabilitation Institute of Chicago and Dr. Gregory Dumanian at Northwestern University Division of Plastic Surgery.

Stump socks are tubular medical or clothing accessories with a blind end that are fashioned similar to socks, usually without a heel. They are worn on amputation stumps for a number of reasons. As stump socks are typically worn on body parts that do not contain a foot, their definition is distinct from the average sock type garment.

Limb-sparing techniques, also known as limb-saving or limb-salvage techniques, are performed in order to give patients an alternative to amputation. There are many different types of limb-sparing techniques, including arthrodesis, arthroplasty, alloprosthetic composite, endoprosthetic reconstruction, prosthetic implants, and rotationplasty.

Gait deviations

Gait deviations are nominally referred to as any variation of standard human gait, typically manifesting as a coping mechanism in response to an anatomical impairment. Lower-limb amputees are unable to maintain the characteristic walking patterns of an able-bodied individual due to the removal of some portion of the impaired leg. Without the anatomical structure and neuromechanical control of the removed leg segment, amputees must use alternative compensatory strategies to walk efficiently. Prosthetic limbs provide support to the user and more advanced models attempt to mimic the function of the missing anatomy, including biomechanically controlled ankle and knee joints. However, amputees still display quantifiable differences in many measures of ambulation when compared to able-bodied individuals. Several common observations are whole-body movements, slower and wider steps, shorter strides, and increased sway.

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Further reading

Classification
D