Amputation

What is an amputation?

When performing an amputation, a surgeon removes a limb, or part of a limb, that is no longer useful to you and is causing you great pain, or threatens your health because of extensive infection. Most commonly, a surgeon must perform this procedure on your toe, foot, leg, or arm. Physicians as well as patients consider amputation a last resort.

Although amputations may be required for other reasons, such as severe injury or the presence of a tumor, the most common reason you may need an amputation is if you have peripheral arterial disease (PAD) due to atherosclerosis (hardening of the arteries). In PAD, the blood vessels in your limbs become damaged because of hardening of the arteries or diabetes. Your body's cells depend on a constant supply of oxygen and nutrients delivered to them by your blood. If your blood vessels are unable to supply blood and oxygen to your fingers or toes, the cells and tissues die and are vulnerable to infection.  If the blood supply cannot be improved sufficiently or if the tissue is beyond salvage, extensive tissue death may require amputation, especially if you are experiencing severe pain or infection.

How do I prepare?

Your physician will perform a physical examination to determine whether your limb can be saved or if you need an amputation. He or she will check you for:

• Fever
• Cool skin near your wound
• Extremely painful skin
• Wound odor
• Infected or non-healing sores or wounds

Your physician will also arrange for tests to see how well blood is reaching your limbs. These tests may include blood pressure tests, duplex ultrasound, and angiography. Sometimes computed tomography or magnetic resonance imaging is used.

If you have any other conditions, such as diabetes, high blood pressure, heart problems, poor kidney function, or infections, your physician will discuss with you how to treat them to get you in the best condition. Your physician will also test your physical strength, balance, and coordination to assess your potential for rehabilitation. If you are going to use an artificial limb, sometimes your physician may arrange for you to be measured for the device before your operation. This way, your artificial limb will be ready as soon as you recover. Often, however, your physician may advise waiting until your incision is healed adequately before getting your artificial limb. You also may receive counseling before your surgery to help you adapt to the loss of your natural limb.

Your physician will discuss with you whether to reduce or stop any medications that might increase your risk of bleeding or other complications. If you have any allergies to anesthesia, pain medications, or antibiotics, you should tell your physician at this time.

When do I need amputation?

Most people who require an amputation have PAD, a traumatic injury, or cancer.

PAD is the leading cause of amputation in people age 50 and older, and accounts for up to 90 percent of amputations overall. Normally, surgeons treat advanced PAD through other methods, like controlling infection using antibiotics and draining or removing any infected tissue as well as performing surgery or other procedures to increase the blood flow to the affected area. However, if these treatments do not work, or if the tissue damage is too far advanced initially, amputation will remove a source of major infection and may be necessary to save your life.

A traumatic injury, such as a car accident or a severe burn, can also destroy blood vessels and cause tissue death. As a result, infection if not adequately treated, can spread through your body and threaten your life. Your medical team will make every effort to save your limb by surgically replacing or repairing your damaged blood vessels or using donor tissue. However, if these measures do not work, amputation can save your life. Traumatic injuries are the most common reason for amputations in people younger than age 50.

Your physician may recommend amputation if you have a cancerous tumor in your limb. You may also receive chemotherapy, radiation, or other treatments to destroy the cancer cells. Depending upon the particular circumstances, these treatments can shrink the tumor and may increase the effectiveness of your amputation.

Am I at risk for complications during amputation?

If you have other conditions, like diabetes or heart disease, you have a higher risk of complications from an amputation. Having a very serious traumatic injury also increases your risk of complications. Above-the-knee amputations can be associated with more risk than below-the-knee amputations, because people who require above-the-knee amputations are more likely to be in poorer health. Depending upon your particular situation, your physician will attempt to save as much of your limb as is possible.

What happens during amputation?

To perform an amputation, your physician must remove your diseased limb but preserve as much healthy skin, blood vessel, and nerve tissue as possible.

Choosing the incision site is important. If your surgeon removes too little tissue, your wound will not heal because unhealthy tissue remains and the circulation at that level may not be sufficient for healing. To determine how much tissue to remove, before the operation your physician will check for a pulse at a level close to the site. He or she will also compare the skin temperatures in the diseased limb with those in a healthy limb, and note places where the skin appears red, since an incision made through reddish skin may be less likely to heal. Your physician will also check that your skin around the proposed incision point still has sensitivity to touch. Finally, during the operation after he or she makes the initial cut, your physician may decide that more of your limb needs to be removed if the edges of your skin do not bleed enough to allow them to heal.

Before the procedure begins, your anesthesiologist will either put you to sleep with a general anesthetic, or numb your body in the region of the amputation using a regional anesthetic. You will be connected to machines that monitor your heart rate, blood pressure, temperature, and brain function. When the anesthetic has taken effect and you are not able to feel any pain, your surgeon then makes an incision into your skin, leaving enough healthy skin to cover your stump for better healing.

When your surgeon divides the muscles, he or she may shape them, to make sure that your stump has a comfortable contour for your artificial limb. Your surgeon also divides and protects your nerves, so that they are not exposed and painful.

During your surgery, clamps are applied to the healthy major blood vessels to minimize bleeding. Before finishing your amputation, your surgeon will stitch the vessels, and then release the clamps to ensure that all bleeding points are secure.

If you have a traumatic injury, your surgeon will remove the crushed bone and other tissue, a process called "debridement." Your surgeon then will smooth the uneven areas of your bone to prevent pain once you receive your artificial limb. If necessary, your surgical team may then install temporary drains that will drain blood and other fluids that may accumulate.

When your surgeon has removed the dead tissue, he or she may decide to leave the site open (open flap amputation) or to close the skin flaps (closed amputation). In an open flap amputation, your skin remains drawn back from the amputation site for several days so your surgical care team can clean off any questionable or infected tissue. Once the stump tissue is clean and free of infection, the skin flaps are sewn together to close the wound, a procedure called delayed closure. In a closed amputation, the wound is sewn shut immediately. A closed amputation is usually done if your surgeon is reasonably certain that the chance of infection is small and healing is likely.

Your surgical care team may place a stocking over your stump to hold drainage tubes and wound dressings, or your limb may be placed in traction, or a splint, depending upon your particular situation.

What can I expect after amputation?

After your surgery, you will stay in the hospital for approximately 5 to 14 days, depending upon your particular situation. Your physician may teach you how to change your wound dressings, or the hospital staff will change them for you. Your physician usually checks the progress of your wound in about 7 to 10 days, or as often as necessary. Your physician will also monitor any conditions you have that might slow your healing, such as hardening of the arteries or diabetes. If you need pain medications or antibiotics, your physician will prescribe them. Ideally, your wound should fully heal in about 4 to 8 weeks after your surgery.

If your condition permits, you will receive physical therapy soon after your surgery. Physical therapy includes gentle stretching for the first 2 or 3 days. Later, you will perform exercises, such as getting in and out of your bed or in and out of your wheelchair. Eventually, you will learn how to bear your weight on your remaining limb.

Depending upon your particular situation and your comfort and wound healing progress, you may also begin to practice with your artificial limb as early as 10 to 14 days after your surgery. However, it is common to require more time before you are ready for this.

You may experience phantom pain (a sense of feeling pain in your amputated limb) or other emotional concerns, such as grief over the lost limb, after surgery. If this is the case, your physician can recommend counseling or drug therapy, as appropriate.

Are there any complications?

You may have complications following any surgical procedure. Complications that occur specifically from amputation include a joint deformity called contracture, a severe bruise called a hematoma, death of the skin flaps (necrosis), wound opening from poor healing, or infection. Your surgeon or physician can treat all of these complications. Rarely, you may need to undergo further surgical treatment or another amputation procedure.

What can I do to stay healthy?

If your wound has healed well and your artificial limb fits you, your amputation should cause you minimal long-term medical concerns. However, if you have PAD, amputation does not stop plaque from building up in your remaining arteries. To prevent hardening of the arteries from affecting other parts of your body, including your heart, you should consider the following changes:

• Eat more foods low in saturated fat, cholesterol, and calories
• Exercise regularly
• Maintain your ideal body weight
• Avoid smoking

You can learn how to adapt to having an artificial limb, including getting regular exercise, with the help of physical therapy. Studies have found that amputees who engage in regular physical exercise feel better about themselves than those who are more sedentary. Also, people who recover from an amputation are more likely to have greater job satisfaction, possibly because of changes in their attitudes regarding life goals.

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Reviewed February 2011

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