AMPUTATION

INTRODUCTION:
It is derived from the Latin word “Amputare” which means “to cut away”, from ambi(about or
around) and putare (to prune). Amputation is the complete removal of an injured or deformed
body part. The English word amputation was first applied to surgery in the 17th century.

DEFINITION:

Amputation is the calculated surgical removal of all or part of an extremity when its blood
supply is irreversibly compromised by disease or severe injury.

INCIDENCE:

The National Center for Health Statistics estimated that more than 300,000 patients with
amputations live in the US. The reported annual incidence of LLA related to peripheral vascular
disease has ranged from approximately 20 to 35 per 100,000 inhabitants. It has been reported
that one in four diabetic individuals develops peripheral vascular diasease that, when severe, may
require amputation.

CAUSES:

It is either congenital or acquired.

The main acquired causes of amputation are:

 Peripheral vascular disease

 Trauma (severe tissue damage)
 Malignant tumour
 Scleroderma
 Diabetes
 Crush injury
 Infection
 Neoplasm
 Iatrogenic
 Neuropthic
 Burns
 Frostbite
PRINCIPLES:

General principles:

To save as much limb as possible while providing a residual limb that is able to tolerate the stress
of the prosthesis and return to mobility.

Surgical principles:

 The use of tourniquet is advised to obtain a bloodless fied- except in ischemic condition.
 Level of amputation: Effort should be made to preserve all possible limb length, keeping
in mind the prosthesis to be fit.
 Skin flaps- skin should be mobile, sensation intact and without adherent scars.
 Muscles are divided 3-5 cm distal to the level of bone resection.
 Nerves are gently pulled and cut cleanly so that they retain well proximal to the bone
level. This reduces complication of neuroma.

CLINICAL INDICATIONS:

 Peripheral neuropathy
 Tropic ulcers
 Subsequent gangrenes
 Thermal injuries
 Tumours
 Osteomyelitis

DIAGNOSTIC STUDIES:

 History and physical examination

 Physical appearance of soft tissues
 Skin temperature
 Sensory function
 Presence of peripheral pulses
 Anteriography
 Venography
 Plethysmography
 Transcutaneous ultrasonic Doppler recordings

COLLABORATIVE THERAPY:

Medical:

 Appropriate management of underlying disease

  Stabilization of trauma victim

Surgical:

Surgical procedures are

Myodesis:

 In this technique, muscles and fasciae are sutured directly to the distal residual bone
through drill holes.
 Muscles inserted function better, resulting in good prosthetic control.
 Procedure compromises blood supply to the muscles and hence is contraindicated in
patients with severe peripheral vascular disease.
 Sometimes myodesis fails even with best care.

Myoplasty:

 This procedure requires surgeon to suture the opposing muscles in the residual limb to
each other and to the periosteum or to the distal end of the cut bone.
 Muscles must be stretched enough so that they control the residual limb.
 Muscles sutured to each other provide distal soft tissue padding over the residual bone.
 Sometimes a painful bursa develops between the soft tissues and underlying bone and
some of this bursa can become infected and painful.

Osteomyodesis:

It is similar to myodesis but the periosteum is stripped. This enables bone growth in that area.

TYPES OF AMPUTATION:

According to the surgical technique or emergency situation:

1. Provisional: It is used when primary healing is unlikely or delayed because of infection,

ischemia, or inadequate wound debridement. It is done as an emergency procedure, to
save the life of the patient.
2. Definitive: It is used after provisional amputation as an elective surgery. In this, level is
well defined and thought out, with the ultimate prosthesis kept in mind.

According to the anatomical level:

Depending on whether the amputation is through the joint or the bone, this may be defined as:

 Disarticulation: Amputation through joint.

 Through the shaft of a long bone.
Level of amputation in the lower limb:

 Hemicorporetomy: Ampuatation of both lower limbs and pelvis below L4-L5 level.
 Hemipelvectomy: Resection of lower half of the pelvis.
 Hip disarticulation: Amputation of hip joint, keeping the pelvis intact.
 Short transfemoral: (above knee), amputation of less than 35% femoral length.
 Transfemoral: (above knee), amputation between 35% and 60% femoral length.
 Long transfemoral: (above knee), more than 60% femoral length
 Knee disarticulation: amputation through the knee joint keeping femur intact.
 Short tibial: (below knee), less than 20% tibial length.
 Transtibial: (below knee), between 20-50% of tibial length.
 Long transtibial: (below knee), more than 50% tibial length
 Syme’s amputation: Ankle disarticulation with attachment of heel pad to distal end of
tibia. Many include removal of malleoli and distal tibia/fibular flares.
 Transmetatarsal: Amputation through mid section of all metatarsals.
 Partial foot/ray resection: Resection of 3rd, 4th, 5th metatarsals and digits.
 Toe disarticulation: Disarticulation at the metatarsal phalangeal joint.
 Partial toe: Excision of any part of one or more toes.

CLOSED AMPUATATION : Closed amputation is the one in which flaps are made from the
skin and subcutaneous tissue are sutured over the end of the bone.

 Amputation in contiguity: Amputation at a joint.

 Amputation in continuity: Amputation of a limb elsewhere than at a joint.
 Double-flap amputation: Amputation where two laps are formed
 Elliptic amputation: It is the one in which the cut has an epithelial outline.
 Teale’s amputation: Amputation with short and long rectangular flaps.
 Gritti-Stokes amputation: Amputation of the leg through the knee using an oval
anterior flap.
 Guillotine amputation: It is the one performed rapidly by a circular sweep of the knife
and a cut of the saw, the entire cross-section being left open for dressing.
 Racket amputation: It is the one in which there is a single longitudinal incision
continuous below with a spiral incision on either side of the limb.
 Boyd’s amputation: It is the amputation at the ankle with removal of the talus and
fusion of tibia and calceneous.
 Spontaneous amputation: It is the loss of part without surgical intervention, as in
diabetes mellitus.
 Subperiosteal amputation: It is the one in which the cut end of the bone is covered by
periosteal flaps.
 Chopart’s amputation: Amputation of the foot by a midtarsal disarticulation.
  Lisfranc’s amputation: Amputation of the foot between the metatarsus and tarsus.

COMPLICATIONS:

The common complication are:

 Haematoma
 Dehiscence/wound breakdown
 Infection
 Tissue necrosis
 Pain
 Stump edema
 Bone erosion/osteomyelitis
 Delayed healing : Gap if wider than 1 cm needs revision
 Skin adherence to bone of the residual limb

*PHANTOM LIMB PAIN:

 The phantom is the sensation of limb that is no longer there. The phantom, which usually
occurs initially immediately after surgery, is often described as a tingling, burning,
itching or pressure sensation, sometimes a numbness.
 Phantom pain and sensations are defined as perceotions ranging from slight tingling to
sharp, throbbing pain or aching that patient perceives relating to an extremity or an organ
that is physically no longer a part of the body.
 It has been reported that in various trials that the estimated prevalence of phantom pain
varies from 49% to 83%

NURSING MANAGEMENT:

Nursing assessment: Assess any preexisting illnesses because most amputations are performed
as a result of vascular problems. Assessment of vascular and neurologic status is an important
part of the assessment process.

Nursing diagnosis:

Nursing diagnosis for the patient with an amputation may include, but are not limited to the
following:

 Disturbed body image related to loss of body part and impaired mobility
 Impaired skin integrity related to immobility and improperly fitted prosthesis
 Chronic pain related to phantom limb sensation or residual limb pain
 Impaired physical mobility related to amputation of lower limb

Planning:
The overall goals are that the patient with an amputation will

 Have adequate relief from the underlying health problem

 Have satisfactory pain control
 Reach maximum rehabilitation potential with the use of a prosthesis
 Cope with the body image changes
 Make satisfying lifestyle adjustments

Nursing implementation:

Health promotion:

 Control of causative illness such as PVD, diabetes mellitus, chronic osteomyelitis, and
pressure ulcers can eliminate or dalay the need for amputation. Teach patients with these
problems to carefully examine their lower extremities daily for signs of potential
problems.
 Instruct patients and their caregivers to report changes in the feet or toes to their health
care provider, including changes in skin color or temperature, decrease or absence of
sensation, tingling, burning pain, or lesion.
 Instruct people in proper safety precautions for recreational activities and potentially
hazardous work. This responsibility is especially critical for the occupational health
nurse.

Acute intervention:

Preoperative management:

 Before surgery, reinforce information that the caregiver and patient have received about
the reasons for amputation, proposed prosthesis, and mobility-training program.
 To meet the patient’s educational needs, know the level of amputation, type of post
surgical dressings to be apllied and type of prosthesis to be used.
 Instruct the patient in the performance of upper extremity exercises such as push-ups in
bed or the wheel chair to promote arm strength. This instruction is essential for crutch
walking and gait training.
 Discuss general postoperative nursing care, including positioning, support and residual
limb care. If a compression bandage is to be used after surgery, instruct the patient about
its purpose and how it will be applied.
 If an immediate prosthesis is planned, discuss general ambulation expectations.

Postoperative management:

 General postoperative care for the patient who has had an amputation depends largely on
the patient’s general state of health, reason for amputation, and patient’s age.
  Monitor individuals who undergo amputation as a result of a traumatic injury for post
traumatic stress disorder because they have had no time to prepare or perhaps to even
participate in the decision to have a limb amputated.
 Prevention and detection of complications are important during the post operative period.
Carefully monitor the patient’s vital signs and dressings for haemorrhage in the operative
area. Careful attention to sterile technique during dressing changes reduces the potential
for wound infection.
 If an immediate postoperative prosthesis has been applied, careful surveillance of the
surgical site is required.
 The delayed prosthetic may be the best choice for patients who have had amputations
above the knees or below the elbow, older adults, debilitated individuals, and those with
infections. The appropriate timing for use of a prosthesis depends on satisfactory healing
of the residual limb and on the patient’s general condition. A temporary prosthesis may
be used for partial weight bearing once the sutures are removed.
 Mirror therapy reduces phantom limb sensation and pain in some patients. The mirror is
thought to provide visual information to the brain, replacing the sensory feedback
expected from the missing limb.
 Flexion contractures may delay the rehabilitation process. The most common and
debilitating contracture is hip flexion. Hip adduction contracture is rare. To prevent
flexion contractures, have patients avoid sitting in a chair for more than one hour with
hips flexed or having pillows under the surgical extremity. Unless specifically
contraindicated, patients should lie on their abdomen for 30 minutes three or more times
each day and position the hip in extension while prone.
 Proper residual limb bandaging fosters shaping and molding for eventual prosthesis
fitting. The physician usually orders a compression bandage to be applied immediately
after surgery to support the soft tissues, reduce edema, hasten healing, minimize pain and
promote residual limb shrinker which is an elastic stocking that fits tightly over the
residual limb and lower trunk area.
 As the patient’s overall condition improves, an exercise regimen is normally started
under the supervision of the health care provider and the physical therapist. Active ROM
exercises of all joints should be started as soon after surgery as the patient’s pain level
and medical status permits.
 Crutch walking is started as soon as the patient is physically able. After an immediate
postsurgical fitting, orders related to weight bearing must be carefully followed to avoid
injury to the skin flap and delay of tissue healing.

Ambulatory and home:

 When healing has occurred satisfactorily and the residual limb is well molded, the patient is ready
for fitting of the prosthesis. A prosthesis initially makes a mold of the residual limb and measures
landmarks for fabrication of the prosthesis.
 The limb is covered with a residual limb stocking to ensure good fit and prevent skin breakdown.
  The patient may need to have the prosthesis adjusted to prevent rubbing and friction between the
residual limb and socket.
 Excessive movement of a loose prosthesis can cause sever skin irritation, breakdown, and gait
disturbance.
 Instruct the patient to clean the prosthesis daily with a mild soap and rinse thoroughly to remove
irritants.
 Encourage the patient to have regular maintenance of the prosthesis. Consideration of the
condition of the shoe is also necessary. A badly worn shoe alters the gait and may damage the
prosthesis.

Evaluation:

The expected outcomes are that the patient with an amputation will

 Accept changed body image and integrate changes into lifestyle

 Have no evidence of skin breakdown
 Have reduction or absence of pain
 Become mobile within limitations imposed by amputation.
BIBLIOGRAPHY:

1. Lewi’s Medical Surgical Nursing, 2nd South Asian Edition, Volume II, Page no.1590-
1594
2. Ansari’s textbook of Medical Surgical Nursing, 1st Edition, Page no. 1442-1445
3. https://en.m.wikipedia.org/wiki/Amputation