Key Terms: Arterial embolism, Buerger's disease, Diabetes mellitus.
Definition
Amputation is the intentional surgical removal of a limb or body part. It is performed to remove diseased tissue or relieve pain.
Purpose
Arms, legs, hands, feet, fingers, and toes can all be amputated. Most amputations involve small body parts such as a finger, rather than an entire limb. More than 60,000 amputations are performed in the United States each year.
Amputation is performed for the following reasons:
- to remove tissue that no longer has an adequate blood supply
- to remove malignant cancers (almost exclusively in the case of osteogenic sarcoma or other sarcomas)
- as a result of severe trauma to the body part
The blood supply to an extremity can be cut off because of injury to the blood vessel, hardening of the arteries, arterial embolism, impaired circulation as a complication of diabetes mellitus, repeated severe infection that leads to gangrene, severe frostbite, Raynaud's disease, or Buerger's disease.
More than 90% of amputations performed in the United States are due to circulatory complications of diabetes, the most common cause of non-traumatic leg and foot amputations.
Precautions
Amputation cannot be performed on patients with uncontrolled diabetes mellitus, heart failure, or infection, and is also inadvisable for patients with blood clotting disorders.
Description
Amputations can be either planned or emergency procedures. Injury and arterial embolisms are the main reasons for emergency amputations. The operation is performed under regional or general anesthesia by a general or orthopedic surgeon in a hospital operating room.
Details of the operation vary slightly depending on what is to be removed. The goal of all amputations is twofold: to remove diseased tissue so that the wound will heal cleanly, and to construct a stump that will allow the attachment of a prosthesis or artificial replacement part.
The surgeon makes an incision around the part to be amputated. The part is removed, and the bone is smoothed. A flap is constructed of muscle, connective tissue, and skin to cover the raw end of the bone. The flap is then closed over the bone with sutures (surgical stitches) that remain in place for 3 to 4 weeks. Often, a rigid dressing or cast is applied that stays in place for about two weeks.
Preparation
Before an amputation is performed, extensive testing is done to determine the proper level of amputation. The goal of the surgeon is to find the place where healing is most likely to be complete, while allowing the maximum amount of limb to remain for effective rehabilitation.
The greater the blood flow through an area, the more likely healing is to occur. These tests are designed to measure blood flow through the limb. Several or all of the following can be done to help choose the proper level of amputation:
- measurement of blood pressure in different parts of the limb
- Xenon 133 studies, which use a radiopharmaceutical to measure blood flow
- Oxygen tension measurements in which an oxygen electrode is used to measure oxygen pressure under the skin. If the pressure is 0, healing will not occur. If the pressure reads higher than 40ml Hg (40 milliliters of mercury), healing of the area is likely to be satisfactory.
- laser Doppler measurements of the microcirculation of the skin
- skin fluorescent studies that also measure skin microcirculation
- skin perfusion measurements using a blood pressure cuff and photoelectric detector
- infrared measurements of skin temperature
No one test is highly predictive of healing, but taken together, the results can give the surgeon a detailed idea of the best place to amputate.
Aftercare
After amputation, medication is prescribed for pain, and patients are treated with antibiotics to discourage infection. The stump is moved often to encourage good circulation. Physical therapy and rehabilitation are started as soon after surgery as possible. Studies have shown that there is apositive relationship between early rehabilitation and effective functioning of the stump and prosthesis. Length of stay in the hospital depends on the severity of the amputation and the general health of the amputee, but is usually less than one week.
Recovery from surgery takes about six weeks. Rehabilitation, however, is a long and arduous process, especially for above-the-knee amputees. The doctor and physical therapist decide how soon after surgery the patient can begin to exercise, and several sessions each day may be recommended. In addition, psychological counseling is an important part of rehabilitation. Many patients experience a sense of loss and grief when they lose a body part. Others are bothered by phantom limb syndrome, where they feel as if the amputated part is still in place. They may even feel pain in the limb that has been removed. Many amputees benefit from joining self-help groups and meeting others who are also living with amputation. Addressing the emotional aspects of amputation often speeds the physical rehabilitation process.
Risks
Amputation is a major surgery. All the risks associated with the administration of anesthesia exist, along with the possibility of heavy blood loss and the development of blood clots. Infection is of special concern to amputees. If the stump becomes infected, it is necessary to remove the prosthesis and sometimes to amputate a second time at a higher level.
Failure of the stump to heal is another major complication. Nonhealing is usually due to an inadequate blood supply. The rate of complications is generally lowest in centers that specialize in amputation.
As many as 80% of amputees experience some degree of sensation in the stump or phantom limb, and 5% to 10% seek medical attention for the pain. Although phantom pain is most common in the year following amputation, it can be a long-term problem that persists in spite of therapy. One final complication is that many amputees give upon the rehabilitation process and discard their prosthesis. Better fitting prosthetics and earlier rehabilitation have decreased the incidence of this problem. Researchers and prosthetic manufacturers continue to refine the materials and methods used to try to improve the comfort and function of prosthetic devices for amputees. For example, a 2004 study showed that a technique called the bone bridge amputation technique helped improve comfort and stability for transtibial amputees.
Normal Results
The wound should heal fully within four to eight weeks and the patient will have no surgery-associated complications. Some patients may begin practicing with artificial limbs as soon as 10 to 14 days following surgery.
Abnormal Results
The most common complications of amputation are:
- massive hemorrhage that occurs when a suture becomes loose
- infection
- rash, blisters, and skin breakdown caused by immobility, pressure, and other sources of irritation
- pneumonia, blood clots, and breathing problems associated with immobility
- formation of nerve cell tumors (neuromas) at severed nerve endings
Complications can develop immediately after surgery or after the patient has left the hospital. The doctor should be notified if a patient who has had an amputation experiences:
- increased pain, swelling, or drainage at the site of the surgery
- headache, muscle aches, dizziness, a general ill feeling, fever, or other signs of infection
- nausea
- vomiting
- chest pain
- constipation
- coughing
- shortness of breath
- changes in skin quality (certain areas become chalky or blackened)
- any new symptoms
Resources
Books
Ignatavicius, Donna D., et al. Medical-Surgical Nursing Across the Health Care Continuum. 3rd ed. Philadelphia: W.B. Saunders Company, 1999.
Smertzer, Suzanne C., and Brenda G Bare. Brunner & Budarth's Textbook of Medical-Surgical Nursing. Philadelphia: Lippincott Williams & Wilkins, 2000.
Periodicals
Edwards, Anthony R. "Study Helps Build Functional Bridges for Amputee Patients." Biomechanics May 1, 2004: 17.
Organizations
American Diabetes Association. 1660 Duke St., Alexandria, VA 22314. .
Amputation Information Resource Center. 6480 Wayzata Blvd., Minneapolis, MN 55426.
Amputation Prevention Global Resource Center. .
Cherub Association of Families and Friends of Limb Disordered Children, Inc. 8401 Powers Rd., Batavia, NY 14020.(716) 662-9997.
National Amputation Foundation. 73 Church St., Malverne, NY 11565. (516) 887-3600. .
National Cancer Institute. (301) 435-3848. .
Other
Amputation. [cited May 14, 2001 and July 6, 2001]. .
Diabetes Facts and Figures. [cited May 11, 2001 and July 6, 2001]. .
—Tish Davidson, A.M.; Teresa G. Odle
