Why do patients need to undergo amputations?
The vast majority of amputations are performed because the arteries of the legs have become blocked due to hardening of the arteries (atherosclerosis). Blockages in the arteries result in insufficient blood supply to the limb. Because diabetes can cause hardening of the arteries, about 30-40% of amputations are performed in patients with diabetes. Patients with diabetes can develop foot/toe ulceration and about 7% of patients will have an active ulcer or a healed ulcer. Ulcers are recurrent in many patients and approximately 5-15% of diabetic patients with ulcers will ultimately require an amputation. Because hardening of the arteries occurs most commonly in older men who smoke, the majority of amputations for vascular disease occur in this group.
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.
An amputation is usually done for one of the following reasons: -
- Poor blood flow cannot be corrected, resulting in tissue loss or extreme pain
- Severe infection
- Trauma or injury
- Congenital disorder
What sort of amputations can be performed?
Amputations can be divided into minor and major.
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.
Minor amputationsAfter minor amputations the wound is not always closed completely with stitches. If infection is present or too much skin has had to be removed then the surgeon may leave the amputation wound open. When a ray amputation is performed the wound is usually left open to heal. This sounds awful and to the untrained eye the resulting wound can appear dreadful. If the wound is open do not be disheartened. If the conditions are right for healing these wounds can heal well over a period of 1-3 months and leave a fully functioning leg and foot. It is possible to walk virtually normally after losing toes. Even after a forefoot amputation where all the toes are removed, walking is usually straightforward.
This sort of operation is performed frequently for foot infections in patients with diabetes.
Major amputationsIt is usually possible before the operation (although not always) for the surgeon to decide at what level the amputation will be performed (above knee or below knee). Sometimes gangrene or infection will only involve a toe or part of a foot and a limited or minor amputation can be performed. This is only worthwhile if the surgeon thinks that the wound that is created will heal. In some patients, it is better to try a limited amputation if there is a chance of healing, but to be prepared to proceed to a major amputation if healing doesn't take place.
One of the most important factors in healing is the blood supply to the tissues. If the blood supply is damaged or impaired it may not be possible for the tissues to heal even after a minor amputation. If in the opinion of the surgeon the tissues will clearly not heal because of a poor blood supply it would be reckless to proceed with a minor amputation when really a major amputation is required. Unfortunately, there is no test that can predict in every patient whether healing will take place and it is a matter of surgical judgement and experience whether a wound is likely to heal or not.
In general the more limited the amputation the lower the risks and the better the chances of walking. It is better to have a below knee amputation when compared with an above knee amputation, because the chances of successfully walking after the operation are much better. Unfortunately, not everyone is suitable for this operation and many people need to have an above knee amputation. This may be because the blood supply to the lower leg is too poor and a below knee amputation would not heal properly. If the knee cannot straighten out properly before the surgery (fixed flexion deformity), it will be impossible to walk with an artificial leg after the operation. In these circumstances it may be better to undergo an above knee amputation.
Once an amputation stump is created it is a potentially vulnerable area that will require lifelong care and attention. A major amputation wound is almost always closed with stitches or staples.
Below knee amputationThis operation can be performed using 2 major techniques (skew flap and posterior flap). There is no proven advantage for one technique, but sometimes it is easier to perform a skew flap amputation if there has been alot of skin damage above the ankle. The bone in the lower leg (tibia) is divided about 12-15 cms below the knee joint. This produces a good size stump to which a prosthesis can be fitted.
Above knee amputationIn this operation the bone in the thigh (femur) is divided about 12-15 cms above the knee joint and the muscle and skin closed over the end of the bone.
How will having an amputation affect me?
Amputation of a limb or limbs will affect people in different ways. It is a very personal loss and in many patients can feel like a bereavement. The emotional loss can be like losing a relative and it will take time to adapt to such a loss. Physically your body will be permanently altered and can affect all areas of your life. How much your amputation affects your life will to some degree depend on the extent of your physical recovery.
There are virtually no activities that a person with an amputation cannot perform with the right help, training and equipment. However, the most important rehabilitation objective for the majority of elderly patients with a lower limb amputation is to walk again. It is important to remember that rehabilitation from an amputation in an elderly person is a much more difficult process than in a young person. Regaining the ability to walk will be a major achievement.
What are the risks of amputation surgery?
There are significant risks attached to undergoing an amputation if you are elderly and have hardening of the arteries. In this group of patients the chances of dying in hospital after a major amputation are somewhere between 10% and 20%. In other words between 1 in 10 and 1 in 5 patients, undergoing a major amputation for hardening of the arteries, will die in hospital. This is why amputation is always a last resort and your surgeon will not advise you to undergo this operation unless it is absolutely necessary. Remember these statistics also mean that 4 out of 5 patients undergoing an amputation will do well.
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