Amputation and Its Risk Factors

Amputation

• Amputation is the removal or cutting of a body extremity or part.
• It can be congenital or acquired (traumatic, ischemic, or surgical).
• It's used to relieve symptoms, improve function, and improve the patient's quality of life.

Individuals at Risk

• Individuals with peripheral arterial disease (PAD)
• Individuals with diabetes mellitus
• Inactive individuals
• Individuals with hypertension
• Individuals with hyperlipidemia
• Smokers

Factors Leading to Amputation

• Diabetic foot infection or gangrene
• Cancerous bone or soft tissue tumors
• Severe limb injuries that cannot be spared or attempts to spare have failed
• Circulation problems
• Congenital deformities of digits or limbs
• Extra digits or limbs
• Advanced cancers
• Bone infection (osteomyelitis)
• Traumatic amputation
• Utero amputation (amniotic band)
• Punishment/torture
• Sometimes professional athletes may choose amputation to relieve chronic pain and impaired performance

Diabetes and Vascular Disease

• Chronic elevation of blood glucose levels leads to blood vessel damage.
• Endothelial cells in blood vessels take in more glucose than normal.
• This causes the basement membrane to thicken and weaken, leading to more surface glycoproteins than normal
• This results in micro and macrovascular disease.

Peripheral Arterial Disease (PAD)

• Progressive atherosclerotic disease characterized by occlusion and stenosis of arteries (mostly in the lower extremities).
• Risk factors include advancing age, hypertension, dyslipidemia (high cholesterol), and a sedentary lifestyle.
• Results in decreased blood flow to the legs and feet. This leads to pain, functional impairments, tissue loss, gangrene, and amputation.

Aim of Amputation

• Return patient to maximum level of independent function.
• Ablation of diseased tissue (tumor or infection).
• Reduce morbidity and mortality related to the condition.

Levels of Amputation

• Factors considered include circulation and functional usefulness.
• Specific levels of amputation are detailed with descriptions of the optimum, shortest, and longest section for various limb locations.

Types of Amputation Procedures

• Procedures such as Intrascaquiothoracis, Shoulder Disarticulation, Proximal Amputation, Elbow Amputations are described and outlined
• Detailed procedures for Elbow, and Below Elbow Amputations are described.

Aftercare

• Good bandaging for stump moulding into a conical shape for prosthetic fit.
• Avoid proximal compression of limb.
• Prevent contracture issues by splinting or muscle exercises.
• Early prosthetic fitting as possible.

Children

• Usually for congenital limb deficiencies.
• Try to retain the limb if possible to preserve length for growth potential.
• Disarticulate if possible to prevent bone overgrowth from trans-diaphyseal amputation.

Complications

• Haematoma
• Infection
• Necrosis of the stump end
• Muscle imbalance leading to contractures
• Neuroma at nerve ending
• Phantom pain
• Terminal overgrowth (children)

Pain

• Distinguish between normal postoperative pain and phantom limb pain.
• Surgical pain often responds well to opioids.
• Phantom limb pain usually described as burning, stinging, electric pain and is often worsened by stress and anxiety.
• If phantom pain persists at six months post-surgery, prognosis is generally unfavorable.

Phantom Limb Sensation

• This is distinct from pain.
• Patients describe sensations of an amputated limb, such as itching, tingling or movement.
• They often don't produce painful sensations.

Phantom Limb Pain Theories

• There are three main theories about phantom limb pain
• Continued impulse generation by remaining nerves
• Excessive spinal cord nerve firing in absence of sensory stimuli from the limb.
• Altered signal transmission and modulation in the somatosensory cortex.

Pain Management (Mx)

• First-line treatment involves antidepressants and anticonvulsants.
• N-methyl-D-asparate antagonists, gabapentin, calcitonin, mexiletine, and opiates are some other effective options in some cases.

Telescoping

• Sensation that the distal part of the amputated limb has moved proximally.
• Often a normal part of the nerve healing process that fades with time.

Prosthetics

• Prosthesis replaces the function or appearance of a missing limb.
• Orthosis supplements or augments function of an existing limb.

Pre-operative Evaluation

• Tissue evaluation: clinical check of pulses, skin temperature, level of dependent redness, blood vessel circulation assessment with Doppler ultrasound (potentially inaccurate if vessels are calcified).
• Arteriogram (imaging of arteries).

Pre-operative Considerations

• Control for diabetes and other conditions such as cardiac and renal issues.
• Evaluate the patient's nutritional status pre-operatively and make any required adjustments for calorie intake and blood sugar management.
• Plan a return to function plan.
• Preoperative counselling and amputee support groups.
• Pain clinic review
• Spinal anaesthesia.

Medical Management

• Goal is to promote healing to create a non-tender and healthy residual limb to prepare for prosthetic use.
• This includes carefully handling the limb, managing edema, and preventing infection.

Types of Dressings

• Closed rigid dressing
• Removable rigid dressing
• Soft dressing

Psychological Support

• Allow time for grief related to loss and body image changes.
• Help patients cope with potential feelings such as anger, hostility, denial, withdrawal, depression, and anxiety.
• Support groups and multidisciplinary teams provide assistance through these initial phases.
• Help clients achieve optimal functioning in the long-term.

Plan for Success

• Relief of pain
• Absence of altered sensory perceptions
• Acceptance and adjustment to altered body image
• Independent self-care
• Absence of complications
• Restoration of physical mobility
• Wound healing process needs to be monitored and addressed.

This quiz explores the concept of amputation, its causes, and the individuals at risk. It covers congenital and acquired reasons for amputation, as well as conditions that predispose patients to this surgical procedure. Test your knowledge on how amputation can impact quality of life.