Amputation

An amputation is the separation of a portion of the limb or the entire limb from the body, along with the bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Structure of Bones. Amputations are among the oldest recorded medical procedures and date back to 2000 BC in India, with significant advances made during wartime. Amputations are generally indicated for conditions that compromise the viability of the limb or promote the spread of a local process that could manifest systemically. Individuals who have undergone amputation are indicated a multidisciplinary rehabilitation process after the procedure to equip them with a prosthesis fitted to their needs.

Last update:

Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

Table of Contents

Share this concept:

Share on facebook
Share on twitter
Share on linkedin
Share on reddit
Share on email
Share on whatsapp

Terminology and Surgical Anatomy

Definitions

  • Amputation: separation of a portion of or an entire limb of the body
  • Complete amputation: complete separation (tissues and bones)
  • Partial amputation: Some soft tissue remains, connecting the body part to the body.
  • Traumatic amputation: secondary to accident or injury on the field, usually manifests as a partial amputation
  • Surgical amputation: amputation performed in the OR
    • Elective
    • Urgent (life saving)
  • Disarticulation: amputation performed at a joint
Partial traumatic amputation

Partial traumatic amputation

Image: “Partial traumatic amputation” by Department of Orthopaedics and Spine Surgery, Ganga Hospital, Coimbatore 641043, India. License: CC BY 2.0

Anatomy

The surgeon should be familiar with the anatomical landmarks and important corresponding structures (nerves, vessels) of the amputation site to avoid injury. As an amputation can be performed at any point along the length of the limbs, a review of the anatomy depends on the site that is selected:

Upper limb amputation:

  • Forearm Forearm The forearm is the region of the upper limb between the elbow and the wrist. The term "forearm" is used in anatomy to distinguish this area from the arm, a term that is commonly used to describe the entire upper limb. The forearm consists of 2 long bones (the radius and the ulna), the interosseous membrane, and multiple arteries, nerves, and muscles. Forearm (transradial): forearm
  • Elbow disarticulation: elbow joint Elbow joint The elbow is the synovial hinge joint between the humerus in the upper arm and the radius and ulna in the forearm. The elbow consists of 3 joints, which form a functional unit enclosed within a single articular capsule. The elbow is the link between the powerful motions of the shoulder and the intricate fine-motor function of the hand. Elbow Joint
  • Above elbow (transhumeral):
    • Axilla Axilla The axilla is a pyramid-shaped space located between the upper thorax and the arm. The axilla has a base, an apex, and 4 walls (anterior, medial, lateral, posterior). The base of the pyramid is made up of the axillary skin. The apex is the axillary inlet, located between the 1st rib, superior border of the scapula, and clavicle. Axilla and Brachial Plexus and brachial plexus
    • Cubital fossa Cubital Fossa The cubital fossa is the region anterior to the elbow joint. The cubital fossa is seen as the triangular depression between the brachioradialis and pronator teres muscles. The 4 important structures of the cubital fossa (from lateral to medial) are the radial nerve, tendon of the biceps brachii muscle, brachial artery, and median nerve. Cubital Fossa
    • Arm
  • Shoulder disarticulation: shoulder complex Shoulder complex The shoulder complex comprises the glenohumeral joint, sternoclavicular joint, acromioclavicular joint, and the scapulothoracic articulation, and connects the upper limb to the trunk. This group of joints consists of the clavicle, scapula, and humerus bones, multiple muscles and supporting ligaments, cartilage, and bursae. Shoulder Complex
  • Digit (transphalangeal, finger disarticulation): hand
  • Hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand (transmetacarpal, transcarpal, and wrist disarticulation): wrist joint Wrist joint The wrist connects the forearm to the hand. It consists of 8 carpal bones, multiple joints, and various supporting ligaments, as well as the distal bones of the forearm and the proximal portion of the 5 metacarpal bones of the hand. Wrist Joint

Lower limb amputation:

  • Hip disarticulation:
    • Pelvis Pelvis The pelvis consists of the bony pelvic girdle, the muscular and ligamentous pelvic floor, and the pelvic cavity, which contains viscera, vessels, and multiple nerves and muscles. The pelvic girdle, composed of 2 "hip" bones and the sacrum, is a ring-like bony structure of the axial skeleton that links the vertebral column with the lower extremities. Pelvis
    • Gluteal region Gluteal region The gluteal region is located posterior to the pelvic girdle and extends distally into the upper leg as the posterior thigh. The gluteal region consists of the gluteal muscles and several clinically important arteries, veins, and nerves. The muscles of the gluteal region help to move the hip joint during walking, running, standing, and sitting. Gluteal Region
    • Hip joint
    • Femoral region and hernias
  • Above-knee amputation: thigh Thigh The thigh is the region of the lower limb found between the hip and the knee joint. There is a single bone in the thigh called the femur, which is surrounded by large muscles grouped into 3 fascial compartments. Thigh
  • Knee disarticulation:
    • Knee joint Knee joint The knee joint is made up of the articulations between the femur, tibia, and patella bones, and is one of the largest and most complex joints of the human body. The knee is classified as a synovial hinge joint, which primarily allows for flexion and extension with a more limited degree of translation and rotation. Knee Joint
    • Popliteal fossa Popliteal fossa The popliteal fossa or the "knee pit" is a diamond-shaped, fat-filled, shallow depression on the posterior aspect of the knee joint. The popliteal fossa is located at the dorsal aspect of the knee and contains an increased number of lymph nodes as well as structures of the neurovascular system that travel from the thigh to the lower leg. Popliteal Fossa
  • Below-knee amputation: leg Leg The lower leg, or just "leg" in anatomical terms, is the part of the lower limb between the knee and the ankle joint. The bony structure is composed of the tibia and fibula bones, and the muscles of the leg are grouped into the anterior, lateral, and posterior compartments by extensions of fascia. Leg
  • Ankle disarticulation (Syme procedure): ankle joint
  • Foot amputations: foot
    • Midfoot (transmetatarsal)
    • Hindfoot
    • Toes

Indications and Contraindications

Indications

  • Unsalvageable limbs due to:
    • Extreme injury (e.g., mangled limb, crush injury)
    • Failed primary reconstruction
  • Ischemia:
    • Frostbite Frostbite Injuries due to cold weather are common among children and athletes who are involved in sports played in cold conditions. Frostbite is a direct freezing injury to the peripheral tissues and occurs when the skin temperature drops below 0°C (32°F). Common sites of frostbite include the nose, ears, fingers, and toes. Frostbite-related gangrene
    • Critical limb ischemia:
      • Peripheral vascular disease
      • Large venous thromboembolic burden
      • Compartment syndrome Compartment Syndrome Compartment syndrome is a surgical emergency usually occurring secondary to trauma. The condition is marked by increased pressure within a compartment that compromises the circulation and function of the tissues within that space. Compartment Syndrome
  • Infection (in high-risk individuals):
    • Treatment-resistant necrotizing fasciitis Necrotizing fasciitis Necrotizing fasciitis is a life-threatening infection that causes rapid destruction and necrosis of the fascia and subcutaneous tissues. Patients may present with significant pain out of proportion to the presenting symptoms and rapidly progressive erythema of the affected area. Necrotizing Fasciitis
    • Severe osteomyelitis Osteomyelitis Osteomyelitis is an infection of the bone that results from the spread of microorganisms from the blood (hematogenous), nearby infected tissue, or open wounds (non-hematogenous). Infections are most commonly caused by Staphylococcus aureus. Osteomyelitis
    • Pressure wounds (heels of individuals who are bedridden)
    • Diabetic wounds/ulcerations
  • Malignancy:
    • Large, recurrent tumors in the proximal upper limb region
    • Unresectable malignant tumors derived from bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Structure of Bones, muscle, nerves, blood vessels, or soft tissue
  • Deformity:
    • Congenital
    • Charcot deformity

Contraindications

  • Vascular insufficiency or active cellulitis Cellulitis Cellulitis is a common infection caused by bacteria that affects the dermis and subcutaneous tissue of the skin. It is frequently caused by Staphylococcus aureus and Streptococcus pyogenes. The skin infection presents as an erythematous and edematous area with warmth and tenderness. Cellulitis at the site of a planned, elective amputation
  • The individual is unstable for anesthesia Anesthesia Anesthesiology is the field of medicine that focuses on interventions that bring a state of anesthesia upon an individual. General anesthesia is characterized by a reversible loss of consciousness along with analgesia, amnesia, and muscle relaxation. Anesthesiology: History and Basic Concepts.

Procedure

General surgical principles

Therapeutic goals:

  • Preserve life despite the relative loss of functionality (e.g., hemorrhage or infection).
  • Salvage maximum amount of tissue for the creation of a functional residual limb.

Selection of amputation type and level:

  • Age: In children, the metaphyseal cartilage Cartilage Cartilage is a type of connective tissue derived from embryonic mesenchyme that is responsible for structural support, resilience, and the smoothness of physical actions. Perichondrium (connective tissue membrane surrounding cartilage) compensates for the absence of vasculature in cartilage by providing nutrition and support. Cartilage is preserved to allow for proportional growth of the remnant limb.
  • Level of activity
  • Indication for amputation
  • Available prosthesis for rehabilitation
  • Presence of local infection

Preoperative care Preoperative Care Thorough preoperative care is important for patients scheduled to undergo surgery so that they can have the best possible outcomes after their surgical procedure. The preoperative process begins once the decision has been made to proceed with a surgical procedure. Preoperative Care

Emergency:

  • Stabilize shock Shock Shock is a life-threatening condition associated with impaired circulation that results in tissue hypoxia. The different types of shock are based on the underlying cause: distributive (↑ cardiac output (CO), ↓ systemic vascular resistance (SVR)), cardiogenic (↓ CO, ↑ SVR), hypovolemic (↓ CO, ↑ SVR), obstructive (↓ CO), and mixed. Types of Shock (i.e., hemodynamic stability) before the procedure.
  • Apply tourniquet to control hemorrhage (traumatic amputation).
  • Assess vascular supply to the limb.
  • Tetanus Tetanus Tetanus is a bacterial infection caused by Clostridium tetani, a gram-positive obligate anaerobic bacterium commonly found in soil that enters the body through a contaminated wound. C. tetani produces a neurotoxin that blocks the release of inhibitory neurotransmitters and causes prolonged tonic muscle contractions. Tetanus prophylaxis
  • Antibiotic prophylaxis
  • Blood transfusion if needed

Elective:

  • Complete preoperative evaluation (especially cardiac status).
  • Psychological analysis: screen for depression
  • Thromboprophylaxis (for lower limb amputations)
  • Perioperative antibiotics (to be administered within 1 hour of incision)
    • Vancomycin
    • 1st-generation cephalosporins Cephalosporins Cephalosporins are a group of bactericidal beta-lactam antibiotics (similar to penicillins) that exert their effects by preventing bacteria from producing their cell walls, ultimately leading to cell death. Cephalosporins are categorized by generation and all drug names begin with "cef-" or "ceph-." Cephalosporins

Operative care

General techniques to minimize tissue ischemia and complications:

  • Handle soft tissue gently.
  • To prevent ischemia to the skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin flaps, do NOT separate fascia from the skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin.
  • Identify and name arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries and veins Veins Veins are tubular collections of cells, which transport deoxygenated blood and waste from the capillary beds back to the heart. Veins are classified into 3 types: small veins/venules, medium veins, and large veins. Each type contains 3 primary layers: tunica intima, tunica media, and tunica adventitia. Veins, and ligate and suture accordingly.
  • Ligate nerves proximally before transection.
  • Stabilize muscle groups using myoplasty (suturing to bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Structure of Bones).
  • Avoid the use of cauterization and ligate instead.
  • Bevel and file the sharp bony prominence.
  • Closure:
    • Done in layers
    • Skin closed off using nonabsorbable sutures
    • Compressive stump dressing to avoid edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema

Postoperative care Postoperative care After any procedure performed in the operating room, all patients must undergo close observation at least in the recovery room. After larger procedures and for patients who require hospitalization, observation must continue on the surgical ward. The primary intent of this practice is the early detection of postoperative complications. Postoperative Care

  • Wound care:
    • Daily examination of the wound for signs of infection
    • Inspect for ulcers in weight-bearing areas (sacrum) and the bony protuberance.
    • Foley catheters may be left in place in above-knee amputations to avoid contamination of the surgical wound.
    • Individuals with diabetes should be advised strict glycemic control.
  • Postoperative pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain:
    • Acute:
      • Related to the initial trauma or trauma of surgery
      • Subsides in a few weeks
    • Optimize analgesia (combination of epidural, IV, and oral analgesics).
    • Screen for mental state and signs of depression.
  • Ambulation after lower limb amputations must be avoided for 6 weeks until complete wound healing Wound healing Wound healing is a physiological process involving tissue repair in response to injury. It involves a complex interaction of various cell types, cytokines, and inflammatory mediators. Wound healing stages include hemostasis, inflammation, granulation, and remodeling. Wound Healing has occurred.

Rehabilitation

  • Multidisciplinary
  • Psychological support is a priority.
  • Prosthesis:
    • Must be started early, during wound healing Wound healing Wound healing is a physiological process involving tissue repair in response to injury. It involves a complex interaction of various cell types, cytokines, and inflammatory mediators. Wound healing stages include hemostasis, inflammation, granulation, and remodeling. Wound Healing
    • Early fittings promote stump maturation.
    • Temporary prostheses for weight-bearing (lower) limbs may facilitate early ambulation.
    • Definite (long term) prostheses require readjustments (every 2–3 years) as the stump remodels.
    • Individuals are equipped with a prosthesis fitted for their needs.

Complications

Local complications

  • Wound infection
  • Stump pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain due to:
    • Hematoma
    • Ulcer
    • Symptomatic neuroma
  • Flexion contracture
  • Need for reamputation/stump revision: very common in lower limb amputations

Medical complications

  • MI MI MI is ischemia and death of an area of myocardial tissue due to insufficient blood flow and oxygenation, usually from thrombus formation on a ruptured atherosclerotic plaque in the epicardial arteries. Clinical presentation is most commonly with chest pain, but women and patients with diabetes may have atypical symptoms. Myocardial Infarction:
    • Many individuals requiring amputation often have debilitating systemic illnesses (e.g., uncontrolled diabetes, peripheral vascular disease) and multiple cardiac risk factors (i.e., diabetes, smoking, hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension).
    • The risk of MI MI MI is ischemia and death of an area of myocardial tissue due to insufficient blood flow and oxygenation, usually from thrombus formation on a ruptured atherosclerotic plaque in the epicardial arteries. Clinical presentation is most commonly with chest pain, but women and patients with diabetes may have atypical symptoms. Myocardial Infarction is very high in the postoperative phase.
    • Optimizing preoperative health is key to preventing morbidity and mortality.
    • Individuals who have undergone lower limb amputation are at increased risk.
  • Deep venous thrombosis ( DVT DVT Deep vein thrombosis (DVT) usually occurs in the deep veins of the lower extremities. The affected veins include the femoral, popliteal, iliofemoral, and pelvic veins. Proximal DVT is more likely to cause a pulmonary embolism (PE) and is generally considered more serious. Deep Vein Thrombosis) and pulmonary embolism Pulmonary Embolism Pulmonary embolism (PE) is a potentially fatal condition that occurs as a result of intraluminal obstruction of the main pulmonary artery or its branches. The causative factors include thrombi, air, amniotic fluid, and fat. In PE, gas exchange is impaired due to the decreased return of deoxygenated blood to the lungs. Pulmonary Embolism (PE):
    • 50% of lower limb amputations lead to DVT DVT Deep vein thrombosis (DVT) usually occurs in the deep veins of the lower extremities. The affected veins include the femoral, popliteal, iliofemoral, and pelvic veins. Proximal DVT is more likely to cause a pulmonary embolism (PE) and is generally considered more serious. Deep Vein Thrombosis.
    • Above-knee amputations pose the greatest risk.
    • Proper thromboprophylaxis and monitoring are important in these cases.

Adverse outcomes

  • Loss of functionality, especially with thumb/hand amputations
  • Phantom limb pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain:
    • Pain in the area of the lost limb
    • Centrally mediated pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain and paresthesia, generally neuropathic in nature
    • “Telescopes” with time (i.e., painful phantom area shrinks proximally toward the stump)
  • Chronic pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain of the remnant limb:
    • Stump-related pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain (compression of soft tissue elements by bony elements)
    • Neuroma-related pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain
    • Prosthesis-related pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain
  • Permanent disfigurement
  • Depression

References

  1. Norgren, L., Hiatt, W.R., TASC II Working Group, et al. (2007) Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). J Vasc Surg. 45 Suppl S, S5-67. https://doi.org/10.1016/j.jvs.2006.12.037
  2. Robertson, L., Roche, A. (2013). Primary prophylaxis for venous thromboembolism in people undergoing major amputation of the lower extremity. Cochrane Database Syst Rev. 12, CD010525. https://doi.org/10.1002/14651858.CD010525.pub2
  3. Hasanadka, R., McLafferty, R.B., Moore, C.J., et al. (2011). Predictors of wound complications following major amputation for critical limb ischemia. J Vasc Surg. 54, 1374-82. https://doi.org/10.1016/j.jvs.2011.04.048
  4. Stone, P.A., Flaherty, S.K., Hayes, J.D., AbuRahma, A.F. (2007). Lower extremity amputation: a contemporary series. W V Med J.103, 14-8. Retrieved from https://pubmed.ncbi.nlm.nih.gov/18309862/ 
  5. Fitzgibbons, P., Medvedev, G.(2015). Functional and Clinical Outcomes of Upper Extremity Amputation. J Am Acad Orthop Surg. 23, 751-60. https://doi.org/10.5435/JAAOS-D-14-00302

Study on the Go

Lecturio Medical complements your studies with evidence-based learning strategies, video lectures, quiz questions, and more – all combined in one easy-to-use resource.

Learn even more with Lecturio:

Complement your med school studies with Lecturio’s all-in-one study companion, delivered with evidence-based learning strategies.

User Reviews

0.0

()

¡Hola!

Esta página está disponible en Español.

🍪 Lecturio is using cookies to improve your user experience. By continuing use of our service you agree upon our Data Privacy Statement.

Details