Amputation

Definition

Amputation is the 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. In the United States, there are approximately 350,000 amputees, with some 135,000 new amputations occurring each year. The number of amputees worldwide is not currently known.

Here in the United States, the most common causes of amputation of the lower extremity are: disease (70%), trauma (22%), congenital or birth defects (4%), and tumors (4%). As for upper extremity amputation, it is usually performed because of trauma or birth defect. Seldom is disease as great a contributing factor. The causes of amputation differ significantly in various countries. For example, countries with a recent history of warfare and civil unrest will have a higher incidence of amputations, due to war itself or its technology (landmines, uncontrolled ordnance, etc).

Among the diseases and conditions that may lead to amputation of an extremity, the most prevalent are:

• hardening of the arteries
• arterial embolism
• impaired circulation as a complication of diabetes mellitus
• gangrene
• severe frostbite
• Raynaud's disease
• Buerger's disease

More than 90% of amputations performed in the United States are due to circulatory complications of diabetes. Sixty to eighty percent of these operations involve the legs.

Demographics

Most amputations involve small body parts such as a finger, rather than an entire limb. About 65,000 amputations are performed in the United States each year.

In the United States, there are approximately 350,000 amputees, with some 135,000 new amputations occurring each year. The number of amputees worldwide is not currently known.

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 part is to be removed. All amputations consist of a two-fold surgical procedure: 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 closed over the bone with sutures (surgical stitches) that remain in place for about one month. Often, a rigid dressing or cast is applied that stays in place for about two weeks.

Diagnosis/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 them 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, the healing will not occur. If the pressure reads higher than 40mm 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 give the surgeon an excellent 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 as possible, usually within 48 hours. Studies have shown that there is a positive 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 ranges from several days to two weeks.

Rehabilitation is a long, arduous process, especially for above the knee amputees. Twice daily physical therapy is not uncommon. In addition, psychological counseling is an important part of rehabilitation. Many people feel 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 this limb that does not exist. 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 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. Infection rates in amputations average 15%. 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 nonhealing varies from 5–30% depending on the facility. Centers that specialize in amputation usually have the lowest rates of complication.

Persistent pain in the stump or pain in the phantom limb is experienced by most amputees to some degree. Treatment of phantom limb pain is difficult. One final complication is that many amputees give up on the rehabilitation process and discard their prosthesis. Better fitting prosthetics and earlier rehabilitation have decreased the incidence of this problem.

Normal results

The five year survival rate for all lower extremity amputees is less than 50%. For diabetic amputees, the rate is less than 40%. Up to 50% of people who have one leg amputated because of diabetes will lose the other within five years. Amputees who walk using a prosthesis have a less stable gait. Three to five percent of these people fall and break bones because of this instability. Although the fractures can be treated, about half the amputees who suffer them then remain wheelchair bound.

Alternatives

Alternatives to amputation depend on the medical cause underlying the decision to amputate and the degree of medical urgency. In some cases, drug therapy may be considered as an alternative.

For example, one serious complication of diabetes is the development of foot ulcers that often lead to amputation. Some studies have suggested non-surgical treatment of diabetic foot ulcers with a new, recombinant drug (Becaplermin/Regranex). Combined with competent ulcer nursing, the drug leads to fewer amputations compared to the alternative of ulcer nursing on its own.

Resources

books

Meier, R. H. Functional Restoration of Adults and Children With Upper Extremity Amputation. New York: Demos Medical Publishing, 2003.

Murdoch, G. and A. Bennett Wilson. A Primer on Amputations and Artificial Limbs. Springfield: Charles C. Thomas Pub. Ltd., 1998.

Watts, H. and M. Williams. Who Is Amelia?: Caring for Children With Limb Difference. Rosemont, IL: American Academy of Orthopaedic Surgeons, 1998.

periodicals

Buzato, M. A., E. C. Tribulatto, S. M. Costa, W G. Zorn, and B. van Bellen. "Major amputations of the lower leg. The patients two years later." Acta Chirurgica Belgica 102 (August 2002): 248–252.

Cull, D. L., S. M. Taylor, S. E. Hamontree, E. M. Langan, B. A. Snyder, T. M. Sullivan, and J. R. Youkey. "A reappraisal of a modified through-knee amputation in patients with peripheral vascular disease." American Journal of Surgery 182 (July 2001): 44–48.

Gerstein, H. and D. Hunt. "Foot ulcers and amputations in diabetes." Clinical Evidence 7 (June 2002): 521–528.

Hagberg, K. and R. Branemark. "Consequences of non-vascular trans-femoral amputation: a survey of quality of life, prosthetic use and problems." Prosthetic Orthotherapy International 25 (December 2001): 186–194.

Kazmers, A., A. J. Perkins and L. A. Jacobs. "Major lower extremity amputation in Veterans Affairs medical centers." Annals of Vascular Surgery 14 (May 2000): 216–222.

Oyibo, S. O., E. B. Jude, I. Tarawneh, H. C. Nguyen, D. G. Armstrong, L. B. Harkless, and A. J. Boulton. "The effects of ulcer size and site, patient's age, sex and type and duration of diabetes on the outcome of diabetic foot ulcers." Diabetic Medicine 18 (February 2001): 133–138.

organizations

American Academy of Orthopaedic Surgeons. 6300 North River Road, Rosemont, Illinois 60018-4262. Phone (847) 823-7186. <www.aaos.org>.

American College of Surgeons. 633 N. Saint Clar st., Chicago, IL 60611-3211. (312) 202-5000. <www.facs.org>.

American Diabetes Association. 1701 North Beauregard Street, Alexandria, VA 22311. (800) 342-2383. <www.diabetes.org>.

National Amputation Foundation. 40 Church Street, Malverne, NY 11565. (516) 887-3600. <www.nationalamputation.org/>.

other

The Amputee Newswire. <http://www.amputee-online.com/amputation/>.

Amputation Prevention Global Resource Center Page. <www.diabetesresource.com>.

Cripworld Guide to Amputation. <http://www.cripworld.com/amputee/ampinfo.htm>.

Tish Davidson, A.M. Monique Laberge, Ph.D.

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

Amputations are performed in a hospital, usually by an orthopaedic surgeon. Orthopedics is a medical specialty that focuses on the diagnosis, care and treatment of patients with disorders of the bones, joints, muscles, ligaments, tendons, nerves, and skin. These elements make up the musculoskeletal system. The physicians who specialize in this area are called orthopedic surgeons or orthopedists. Orthopedic surgery is a specialty of immense variety, and includes amputation surgery.

QUESTIONS TO ASK THE DOCTOR

• Is amputation the best solution?
• How long is the procedure?
• How long will it take to recover from the amputation?
• What are the major risks of the surgery?
• What kind of pain will I have after the amputation and for how long?
• What steps will you take to minimize those risks?
• How long will I have to remain in bed?
• When will I be fitted with my first prosthesis?

Amputation

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 micro-circulation
• 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 a positive 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 up on the rehabilitation process and discard their prosthesis. Better-fitting prosthetics and earlier rehabilitation have decreased the incidence of this problem.

Normal results

Up to 50% of people who have one leg amputated because of diabetes will lose the other within five years. Amputees who walk using a prosthesis are likely to fall and break bones because of their unstable gait. Although the fractures can be treated, many of the amputees who suffer them remain wheelchair-bound.

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

Smertzer, Suzanne C., and Brenda G Bare. Brunner & Budarth's Textbook of Medical-Surgical Nursing. Philadelphia: Lippincott Williams & Wilkins, 2000.

Ignatavicius, Donna D., et al. Medical-Surgical Nursing Across the Health Care Continuum, 3rd ed. Philadelphia: W.B. Saunders Company, 1999.

Thompson, June M., et al. Mosby's Clinical Nursing, 4th ed. St. Louis: C.V. Mosby Company, 1997.

ORGANIZATIONS

American Diabetes Association. 1660 Duke St., Alexandria, VA 22314. <http://www.diabetes.org>

Amputation Information Resource Center. 6480 Wayzata Blvd., Minneapolis, MN 55426.

Amputation Prevention Global Resource Center. <http://www.diabetesresource.com>.

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. <http://www.nationalamputation.org>

National Cancer Institute. (301) 435-3848. <http://www.nci.nih.gov>.

OTHER

Amputation. 14 May 2001. 6 July 2001 <http://community.healthgate.com>

Diabetes Facts and Figures. 11 May 2001. 6 July 2001 <http://www.diabetes.org>.

Tish Davidson, A.M.

KEY TERMS

Arterial embolism

—A blood clot arising from another location that blocks an artery.

Buerger's disease

—An episodic disease that causes inflammation and blockage of the veins and arteries of the limbs. It tends to be present almost exclusively on men under age of 40 who smoke, and may require amputation of the hand or foot.

Diabetes mellitus

—A disease in which insufficient insulin is made by the body to metabolize sugars.

Raynaud's disease

—A disease found mainly in young women that causes decreased circulation to the hands and feet. Its cause is unknown.

Amputation

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 be amputated. Most amputations involve small body parts such as a finger, rather than an entire limb. About 65,000 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 tumors
• because 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. Sixty to eighty percent of these operations involve the legs or feet. Although attempts have been made in the United States to better manage diabetes and the foot ulcers that can be complications of the disease, the number of resulting amputations has not decreased.

Precautions

Amputations cannot be performed on patients with uncontrolled diabetes mellitus, heart failure, or infection. Patients with blood clotting disorders are also not good candidates for amputation.

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 part 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 closed over the bone with sutures (surgical stitches) that remain in place for about one month. 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 them 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, the healing will not occur. If the pressure reads higher than 40mm 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 single test is highly predictive of healing, but taken together, the results give the surgeon an excellent 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 as possible, usually within 48 hours. Studies have shown that there is a positive 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 ranges from several days to two weeks.

Rehabilitation is a long, arduous process, especially for above the knee amputees. Twice daily physical therapy is not uncommon. In addition, psychological counseling is an important part of rehabilitation. Many people feel 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 does not exist. 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 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. Infection rates in amputations average 15%. 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 nonhealing varies from 5-30% depending on the facility. Centers that specialize in amputation usually have the lowest rates of complication.

Persistent pain in the stump or pain in the phantom limb is experienced by most amputees to some degree. Treatment of phantom limb pain is difficult. Finally, many amputees give up on 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.

KEY TERMS

Arterial embolism— A blood clot arising from another location that blocks an artery.

Buerger's disease— An episodic disease that causes inflammation and blockage of the veins and arteries of the limbs. It tends to be present almost exclusively on men under age 40 who smoke, and may require amputation of the hand or foot.

Diabetes mellitus— A disease in which insufficient insulin is made by the body to metabolize sugars.

Raynaud's disease— A disease found mainly in young women that causes decreased circulation to the hands and feet. Its cause is unknown.

Normal results

The five-year survival rate for all lower extremity amputees is less than 50%. For diabetic amputees, the rate is less than 40%. Up to 50% of people who have one leg amputated because of diabetes will lose the other within five years. Amputees who walk using a prosthesis have a less stable gait. Three to five percent of these people fall and break bones because of this instability. Although the fractures can be treated, about one-half of amputees who suffer them then remain wheelchair bound.

Resources

PERIODICALS

Edwards, Anthony R. "Study Helps Build Functional Bridges for Amputee Patients." Biomechanics (May 1, 2004): 17.

Jeffcoat, William. "Incidence of Amputation is a Poor Measure of the Quality of Ulcer Care." The Diabetic Foot Summer (2004): 70-74.

ORGANIZATIONS

American Diabetes Association. 1701 North Beauregard Street, Alexandria, VA 22311. (800) 342-2383. 〈http://www.diabetes.org〉.

OTHER

Amputation Prevention Global Resource Center Page. February 2001. 〈http://www.diabetesresource.com〉.

amputation The word ‘amputation’ derives from the Latin ambi — around — and putare — to prune or lop. The word can be applied to the removal of any part of the body, but it is usually restricted to removal of part of a limb, unless the word is qualified, as in ‘amputation of the nose’. Children born with an absent part of a limb are often said to have a congenital amputation.

The amputation of a limb represents one of the earliest forms of surgery and was performed for severely damaged arms and legs in both war and peace over many centuries. In the days before anaesthesia, speed was of the essence; the surgeon would cut through the flesh of the limb with a single sweep of the knife and then divide the bone with a few strokes of the saw. Haemorrhage was dealt with by the crude technique of cauterization of the stump, using boiling oil or a red-hot iron, until Ambroise Paré (1510–90), a French military surgeon, showed that tying of the blood vessels was a far safer and much kinder method. In modern surgical amputations, skin flaps are raised, the soft tissues carefully divided, blood vessels tied, the bone divided, the soft tissues and then skin carefully sutured, and the stump bandaged to produce a relatively aesthetic appearance.

The indications for amputation of a limb include severe injury, where the blood supply to the limb has been hopelessly damaged; severe infection following injury (particularly gas gangrene); malignant tumours of bone or of the adjacent soft tissues; and occasionally the removal of a hopelessly deformed arm or leg. In peacetime, however, by far the commonest indication is gangrene due to severe arterial disease, usually arteriosclerotic or diabetic in origin, and not infrequently from a combination of these two conditions.

With modern surgical techniques, the limb that was once doomed to amputation can often be saved. Whereas at one time damage to the main limb artery in a fracture or a missile injury usually meant loss of the arm or leg, reconstructive arterial surgery can now often repair the damaged vessel, often by means of an interposed graft of a vein taken from the superficial tissues of the leg. For example, surgeons in Northern Ireland have become experts at reconstruction of the popliteal vessels behind the knee destroyed in terrorist ‘knee capping’ punishments with salvage of the leg in almost every case.

Severe arterial disease of the leg arteries is common and once inevitably led to amputation. Fortunately, this again may be overcome by a bypass of the obstructed segment of the artery, using the patient's own vein or a synthetic graft. In other cases, the diseased artery can be opened and cored out, in the operation of endarterectomy. Alternatively, the narrowed, stenosed segment can be dilated by a catheter which carries an inflatable balloon, inserted above the segment and guided to it under X-ray.

Limbs that once had to be removed due to a tumour can now sometimes be preserved by removing the bone growth itself and replac-ing the missing segment by means of a metal prosthesis.

When amputation is necessary, rehabilitation of the amputee is an important adjunct to management. The crude artificial limbs of the past — the amputee kneeling on a peg leg, or a purely cosmetic and non-functional upper limb prosthesis — have now been replaced by very sophisticated devices. For lower limb amputees lightweight limbs with ingenious ‘joints’ allow a below-knee amputee to walk normally, and even engage in various exercises, such as running in Olympic-style events. Above-knee prostheses are more of a problem, but a ‘knee joint’ with a locking device enables efficient walking to be carried out. An upper limb prosthesis may be fitted with pulleys activated by the shoulder girdle muscles, which enable activation of an artificial gripping ‘hand’ and a functioning ‘elbow’. These devices, ingenious though they are, can only be made to be effective if used by an enthusiastic and motivated patient trained by a dedicated team of orthopaedic surgeons, physiotherapists, and limb makers; these are combined in the modern speciality of orthotics.

Harold Ellis

Amputation

Amputation is the surgical removal of all or part of an appendage (such as a leg or arm). Amputation has been practiced since earliest times, but usually out of desperation, as in the case of a crushed limb. Early attempts at amputation were often unsuccessful because the patient was likely to die from bleeding or infection during or soon after the procedure was performed.

From the time of ancient Greek physician Hippocrates (460-370 b.c.) until the 1500s, amputations usually involved cutting through dead rather than living tissue because dead tissue did not hemorrhage (bleed uncontrollably). Stumps, or the remaining limb tissues, were then sealed with red-hot irons or boiling oil or tar. This burning procedure stopped most bleeding and was also thought to help prevent gangrene (tissue rotting). In the mid-1500s, German surgeon Fabricius Hildanus (1560-1634) began using a red-hot knife for amputations, which both removed the limb and controlled bleeding at the same time.

Paré's Discovery

The postamputation sealing process was called cauterization. Cauterization was terribly painful for patients, who usually did not have any anesthesia during the procedure. French surgeon Ambroise Paré (1510-1590) helped change this painful fact in the 1500s. By Pare's time, gun-powder had made battlefield injuries so horrible that amputation became commonplace. Even amputation at the thigh, which previously had been very rare because of the extremely heavy (usually fatal) bleeding, was now often necessary. Pare's great improvement was ligature (tying off of the blood vessels rather than cauterizing them). Earlier surgeons had proposed ligature, but it was Pare who developed a successful technique to carry it out. He also devised a curved instrument he called a crow's beak to draw out the severed blood vessels.

Petit Designs the Tourniquet

Although Paré's method was more effective than cauterization, it did not always work because of the large number of blood vessels involved in major amputations. A way was needed to control bleeding until the surgeon could tie off all the vessels. This control was finally provided by the effective tourniquet (pronounced "turn-i-ket") designed by J. L. Petit (1647-1750) in 1718. Petit's screw tourniquet was fixed to the lower abdomen and put direct pressure on the main artery.

With bleeding controlled by Petit's tourniquet, Paré's ligatures were now practical. Amputations on the battlefield were carried out swiftly and in great number. One French surgeon performed 200 amputations in a single day during the Battle of Borodino (Russia) in 1812. Unfortunately, while patients no longer died routinely of bleeding during an amputation, many died of infections afterward. It remained for Joseph Lister (1811-1886) to introduce antiseptics for amputation to become a successful procedure. As modern physicians learned new, effective ways to treat illnesses and infections, amputation steadily became less necessary.

Today, the majority of patients who undergo amputations do so for medical reasons (such as diabetic complications). With the problems of bleeding, anesthesia, and infections solved, the emphasis is on construction of effective prosthetics (artificial limbs ) and physical therapy that allow patients to return to a fairly normal life.

[See also Artificial limbs and joints ; Surgical instruments ]

amputation , removal of all or part of a limb or other body part. Although amputation has been practiced for centuries, the development of sophisticated techniques for treatment and prevention of infection has greatly decreased its necessity. Surgical amputation is currently performed in cases of bone and tissue cancers, gangrene, and uncontrollable infections of the arm or leg. An amputation is performed as far above the affected area as is necessary to remove all unhealthy tissue and to leave a portion of sound tissue with which to pad the bone stump. Whenever possible amputations are performed at points on the limb that permit the fitting of prosthetic devices (see artificial limb ). Ceremonial amputation of finger joints has been practiced in parts of Australia and Africa in conjunction with male initiation rites. In some areas of New Guinea women have finger joints amputated to signify mourning.

am·pu·tate / ˈampyəˌtāt/ • v. [tr.] cut off (a limb), typically by surgical operation: surgeons had to amputate her left hand the wounded had to have legs or arms amputated. DERIVATIVES: am·pu·ta·tion / ˌampyəˈtāshən/ n.

amputate ˈæmpyəˌtāt v. cut off (a limb), typically by surgical operation: the wounded had to have legs or arms amputated.
amputation ˌæmpyəˈtāʃən n.

amputate XVII. f. pp. stem of L. amputāre, f. am- for amb-, AMBI- + putāre prune, lop; see -ATE3.
So amputation XVII. — F. or L.

amputation (am-pew-tay-shŏn) n. the removal of a limb, part of a limb, or any other portion of the body (such as a breast).

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