Amputation and Risk Factors

Amputation

• Amputation is the removal/cutting of a body extremity or other 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

• Peripheral arterial disease (PAD)
• Diabetes mellitus
• Inactive individuals
• Hypertension
• Hyperlipidemia
• Smokers

Factors leading to amputation

• Diabetic foot infection or gangrene
• Cancerous bone or soft tissue tumors
• Severe limb injuries
• Circulation problems
• Congenital deformities of digits and/or limbs
• Extra digits and/or limbs
• Advanced cancers
• Bone infection (osteomyelitis)
• Traumatic amputation (vehicular accidents)
• Amputation in utero (amniotic band)
• Punishment/Torture
• Non-essential digit amputation in athletes for pain relief

Diabetes and Vascular Disease

• Chronic elevation of blood glucose levels damages blood vessels.
• Endothelial cells lining blood vessels don't depend on insulin, taking in more glucose, than normal.
• This thickens and weakens the basement membrane.
• More surface glycoproteins form.
• Microvascular disease (damage to small blood vessels) and macrovascular disease (damage to arteries) result.

Peripheral Arterial Disease (PAD)

• PAD is a progressive, atherosclerotic disease characterized by occlusion and stenosis.
• It mainly affects the lower extremities.
• Risk factors include advancing age, hypertension, dyslipidemia, and a sedentary lifestyle.
• Results in decreased blood flow, pain, functional impairments, tissue loss, gangrene, and amputation.

Aim of Amputation

• Return patients to maximum levels of independent function
• Ablation of diseased tissue (tumor or infection)
• Reduce morbidity and mortality (tumor or infection)
• Part of a reconstruction to produce a physiological end organ

Levels of Amputation

• Two factors are considered; circulation and functional usefulness.
• Different levels of amputation are categorized from shortest to longest.
• Detailed measurements are available for specific levels.

Aftercare

• Good bandaging to mold the stump into a conical shape for prosthesis acceptance.
• Avoid proximal compression of the limb.
• Prevent contracture (by splinting and/or muscle exercises).
• Early prosthetic fitting when the limb is healed.

Amputation in Children

• Usually for congenital limb deficiencies.
• Try to retain the limb if possible.
• Preserve length.
• Disarticulate, if possible, to prevent bony overgrowth (preserving growth potential).

Complications

• Hematoma (bruising)
• Infection
• Necrosis of stump end
• Contractures
• Neuroma (tumor-like growth on a nerve)
• Phantom pain (pain felt in the missing limb)
• Terminal overgrowth (children)

Pain

• Postoperative pain can be normal or phantom limb pain (burning, stinging, electric pain that increases with anxiety and stress).
• If pain persists six months after surgery, prognosis is unfavorable.
• Phantom limb sensation is the feeling that the absent limb is still present (itching, tickling, moving).

Phantom Limb Pain Theories

• Remaining nerves still generate impulses.
• Spinal nerves fire excessively without sensory input.
• Signal transmission and modulation in the somatosensory cortex is altered.

Pain Management

• First-line treatment: antidepressants and anticonvulsants.
• Other choices include N-methyl-D-aspartate antagonists, gabapentin, calcitonin, mexiletine, and opiates.

Telescoping

• Sensation that the distal part of the amputated extremity has moved proximally up the limb.
• Usually part of the nerve healing process and fades with time.

Prosthesis/Orthosis Terms

• Residual limb: the remaining part of the amputated limb.
• Terminal Device: The most distal part of the prosthesis.
• Myodesis: Direct suturing of muscle or tendon to bone.
• Myolplasty: Suturing muscles to the periosteum.
• Prehensile: Ability to grasp

Forequarter Amputations

• Removal of the upper limb with the scapula, mainly for malignancy.
• Shoulder disarticulation and proximal amputations are techniques used.

Above Elbow Amputations

• Equal anterior and posterior flaps are used.
• Muscles are divided 5 cm below the bony resection.
• Triceps muscle is sutured to anterior muscles.

Elbow Disarticulation

• Articular surface is left intact
• Flexor tendons are sutured to extensors.
• Flaps are closed over drains.

Below Elbow Amputations

• Length is preserved.
• Myoplastic closure or suturing of flexors to extensors is done.

Krukenberg Procedure

• Separation of radial and ulna rays to create pincers for strong prehension and manipulation.

Wrist Disarticulation

• Preserves forearm rotation.
• Flaps are created for length and prosthetic fitting.

Hand Amputations

• Preserve length, function, and sensation.
• Amputation can either be done from distal to PIPJ or from proximal to base MC (whole ray).

Pre-op Evaluation

• Tissue evaluation: feel pulses, skin temperature, level of dependent redness
• Doppler Ultrasound to check circulation (sometimes inaccurate with calcified blood vessels).
• Arteriogram

Preperative Care

• Control diabetes, evaluate cardiac, renal, cerebral circulation, and preoperative calorie control in malnourished patients.
• Counseling for pain management, return to function, and support groups.
• Pain clinic review (pain control/spinal anesthetic).

Medical Management

• Goal: non-tender & healthy residual limb for use with prosthesis
• Promote healing by preventing infection, careful handling, and control of edema.

Dressings

• Closed rigid dressing
• Removable rigid dressing
• Soft dressing (gauze bandages)

Psychological Support

• Need to grieve loss with support for permanent body image changes.
• This may involve anger, bitterness, hostility, denial, withdrawal, depression, and anxiety.
• Multidisciplinary rehabilitation teams are helpful for optimal functioning.

Plan/Goals

• Relief of pain
• Absence of sensory alteration
• Acceptance of altered body image
• Self-care independence
• Absence of complications
• Restoration / regaining physical mobility
• Healing of wounds

This quiz explores the causes and factors leading to amputation, including congenital and acquired conditions. It focuses on high-risk individuals and the relationship between diabetes and vascular disease. Test your knowledge on how various conditions can affect limb health and the rationale behind surgical interventions.