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What is an amputation?
An amputation usually refers to the removal of the whole or part of an arm/hand or a leg/foot. Amputations can occur
after an injury (traumatic amputation) or deliberately at surgery. In vascular surgery amputations are only rarely
performed on the arms. Vascular surgeons frequently have to perform amputations of toes or legs. It is one of the oldest
surgical procedures with artificial limbs identified from over 2000 years ago.
When hardening of the arteries becomes so severe that gangrene develops or pain becomes constant and severe,
amputation may be the only option. If amputation is not performed in these circumstances infection can develop and
threaten the life of the patient. Sometimes bypass surgery can be performed to avoid amputation, but not all patients are
suitable for bypass surgery. Before amputation, the limb can cause serious problems with infection and pain and may
even be a threat to the life of some patients.
Less commonly serious accidents can lead to the loss of a limb, as can the development of a tumour or cancer in a limb.
These amputations tend to occur in younger patients.
About 370 new referrals are made to the NZ artificial limb board annually of which about 300 (70%) are due to vascular
causes and diabetes. Over the period 2003-2008 in the UK there were approximately 5 major amputations (above or
below knee) per 100,000 people (Moxey et al 2010).
Minor amputations are amputations where only a toe or part of the foot is removed. A ray amputation
is a particular form of minor amputation where a toe and part of the corresponding metatarsal bone is
removed as shown in the diagram below left. A forefoot amputation can sometimes be helpful in patients
with more than one toe involved by gangrene. In this operation all of the toes and the ball of the foot is
removed.
Major amputations are amputations where part of the leg is removed. These are usually below the knee or above the
knee.
Occasionally an amputation of just the foot can be performed with a cut through the ankle joint (Symes amputation).
This is not suitable for the majority of patients, but can rarely be an option in some patients with diabetes. It is
particularly important for this amputation that the posterior tibial artery is patent and has a reasonable blood flow. This
artery is found on the inside of the foot just below the ankle. Your surgeon may advise you if this operation may be
possible.
Amputations through the knee joint or just above the knee joint (Gritti-Stokes amputation) can also sometimes be
performed. They were much more popular amputations in the past but there is little or no advantage for present day
patients compared with above knee amputation. If a major amputation is to be performed then a below knee
amputation will always give the patient the best chance of remaining mobile and walking post-operatively.
If you wish to see an amputation being performed a short search of the internet will
provide many video examples - see here.
Causes of
Trauma (crushing injury where it can·t be repaired, burns, frostbite)
Congenital deformities
Chronic infection (osteomyelitis)
Malignant tumors
o Usually with younger people
Peripheral vascular disease (diabetes, cardiovascular disease)
o Have such bad circulation they develop stasis ulcers, no blood supply
to extremities, causes necrosis
Levels of Amputation
Performed at most distal point that will heal
Must have adequate circulation
Needs to be best level to promote use of prosthesis
Staged amputation
o After a big crushing trauma, quick amputation to be sure that part of
the body doesn·t cause infection, with the intention of taking you back
to surgery and do another amputation after you·ve stabilized
Will try to amputate below a joint because it makes mobility easier
Diagnostic test to determine circulation
Phantom limb pain
o Due to cutting through nerves
Joint contracture ² due to positioning, important to do ROM exercises, start
early post-op
Pre-op
Assessment of extremity
o Neurovascular and function-compared to unaffected extremity
History and Physical
Assessment of psychosocial needs
o Important to be understanding of the patient, might be angry, upset,
etc.
Teach about what to expect post-op
Referrals to support group when needed
o Home health, social work, others who have already had the surgery to
come talk to them, etc.
Post-op
Assess for hemorrhage
o Tourniquet at bedside
o Assess dressing
o Assess vital signs and labs
o Assess drains
o Assure compression dressing is intact
Nursing interventions