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Amputation

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Amputation is the removal of a limb or other body part by trauma, medical illness, or surgery. As a surgical measure, it is used to control pain or a disease process in the affected limb, such as malignancy or gangrene. In some cases, it is carried out on individuals as a preventive surgery for such problems. A special case is that of congenital amputation, a congenital disorder, where fetal limbs have been cut off by constrictive bands. In some countries, judicial amputation is currently used to punish people who commit crimes.<ref name="iran">Template:Cite news</ref><ref name="Chuback 2005">Template:Cite conference</ref><ref>Template:Cite journal</ref><ref>Template:Cite book</ref> Amputation has also been used as a tactic in war and acts of terrorism; it may also occur as a war injury. In some cultures and religions, minor amputations or mutilations are considered a ritual accomplishment.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> When done by a person, the person executing the amputation is an amputator.<ref>Template:Cite encyclopedia</ref><ref>Template:Cite encyclopedia</ref> The oldest evidence of this practice comes from a skeleton found buried in Liang Tebo cave, East Kalimantan, Indonesian Borneo dating back to at least 31,000 years ago, where it was done when the amputee was a young child.<ref>Template:Cite journal</ref> A prosthesis or a bioelectric replantation restores sensation of the amputated limb.

TypesEdit

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LegEdit

Lower limb amputations can be divided into two broad categories: minor and major amputations. Minor amputations generally refer to the amputation of digits. Major amputations are commonly below-knee- or above-knee amputations. Common partial foot amputations include the Chopart, Lisfranc, and ray amputations.

Common forms of ankle disarticulations include Pyrogoff, Boyd, and Syme amputations.<ref>Template:Cite journal</ref> A less common major amputation is the Van Nes rotation, or rotationplasty, i.e. the turning around and reattachment of the foot to allow the ankle joint to take over the function of the knee.

Types of amputations include:

File:Diagram showing an above knee amputation CRUK 094.svg
An above-knee amputation
partial foot amputation
amputation of the lower limb distal to the ankle joint
ankle disarticulation
amputation of the lower limb at the ankle joint
Template:Anchortrans-tibial amputation
amputation of the lower limb between the knee joint and the ankle joint, commonly referred to as a below-knee amputation
Template:Anchorknee disarticulation
amputation of the lower limb at the knee joint
trans-femoral amputation
amputation of the lower limb between the hip joint and the knee joint, commonly referred to an above-knee amputation
hip disarticulation
amputation of the lower limb at the hip joint
trans-pelvic disarticulation
amputation of the whole lower limb together with all or part of the pelvis, also known as a hemipelvectomy or hindquarter amputation

ArmEdit

File:Amputations 18c.jpg
The 18th century guide to amputations

Types of upper extremity amputations include:

  • partial hand amputation
  • wrist disarticulation
  • trans-radial amputation, commonly referred to as below-elbow or forearm amputation
  • elbow disarticulation
  • trans-humeral amputation, commonly referred to as above-elbow amputation
  • shoulder disarticulation
  • forequarter amputation

A variant of the trans-radial amputation is the Krukenberg procedure in which the radius and ulna are used to create a stump capable of a pincer action.

OtherEdit

File:Index finger amputation.jpg
Partial amputation of index finger

Genital modification and mutilation may involve amputating tissue, although not necessarily as a result of injury or disease.

Laryngectomy is the amputation of the larynx.

Self-amputationEdit

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In some rare cases when a person has become trapped in a deserted place, with no means of communication or hope of rescue, the victim has amputated their own limb. The most notable case of this is Aron Ralston, a hiker who had amputated his own right forearm after it was pinned by a boulder in a hiking accident and he was unable to free himself for over five days.<ref>Template:Cite news</ref>

Body integrity identity disorder is a psychological condition in which an individual feels compelled to remove one or more of their body parts, usually a limb. In some cases, that individual may take drastic measures to remove the offending appendages, either by causing irreparable damage to the limb so that medical intervention cannot save the limb, or by causing the limb to be severed.<ref>Template:Cite journal</ref>

UrgentEdit

In surgery, a guillotine amputation is an amputation performed without closure of the skin in an urgent setting.<ref name=GuilAnk>Template:Cite journal</ref> Typical indications include catastrophic trauma or infection control in the setting of infected gangrene.<ref name=GuilAnk/> A guillotine amputation is typically followed by a more time-consuming, definitive amputation such as an above or below knee amputation.<ref name=GuilAnk/>

CausesEdit

Circulatory disordersEdit

NeoplasmEdit

File:1daypost.jpg
Transfemoral amputation due to liposarcoma

TraumaEdit

File:World War I radiography amputee.jpg
Three fingers from a soldier's right hand were traumatically amputated during World War I.
  • Severe limb injuries in which the efforts to save the limb fail or the limb cannot be saved.
  • Traumatic amputation (an unexpected amputation that occurs at the scene of an accident, where the limb is partially or entirely severed as a direct result of the accident, for example, a finger that is severed from the blade of a table saw)
  • Amputation in utero (Amniotic band)

Congenital anomaliesEdit

InfectionEdit

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FrostbiteEdit

Frostbite is a cold-related injury occurring when an area (typically a limb or other extremity)<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> is exposed to extreme low temperatures, causing the freezing of the skin or other tissues.<ref name="handford2017">Template:Cite journal</ref> Its pathophysiology involves the formation of ice crystals upon freezing and blood clots upon thawing, leading to cell damage and cell death.<ref name="handford2017" /> Treatment of severe frostbite may require surgical amputation of the affected tissue or limb;<ref>Template:Cite journal</ref> if there is deep injury autoamputation may occur.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>

Athletic performanceEdit

Sometimes professional athletes may choose to have a non-essential digit amputated to relieve chronic pain and impaired performance.

  • Australian Rules footballer Daniel Chick elected to have his left ring finger amputated as chronic pain and injury was limiting his performance.<ref>{{#invoke:citation/CS1|citation

|CitationClass=web }}</ref>

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Criminal penaltiesEdit

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  • According to Quran 5:38, the punishment for stealing is the amputation of the hand. Under Sharia law, after repeated offense, the foot may also be cut off. This is still in practice today in countries like Brunei, the United Arab Emirates,<ref>{{#invoke:citation/CS1|citation

|CitationClass=web }}</ref> Iran,<ref>Template:Cite news</ref><ref name="Telegraph 2008">Template:Cite news</ref> Saudi Arabia,<ref name="MC 2007">Template:Cite news</ref> Yemen,<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> and 11 of the 36 states within Nigeria.<ref>Template:Cite news</ref><ref>Template:Cite news</ref>

  • Cross-amputation is one of the Hudud punishments prescribed under Islamic jurisprudence (Sharia law) and involves cutting off the right hand and left foot of the alleged transgressor.<ref>{{#invoke:citation/CS1|citation

|CitationClass=web

}}</ref><ref>Template:Cite book</ref> The scriptural authority for the double amputation procedure is in the Quran (surah 5.33–34) which stipulates:<templatestyles src="Template:Blockquote/styles.css" />

The punishment of those who wage war against Allah and His Messenger, and strive with might for mischief through the land is execution or crucifixion, or cutting of hands and feet from opposite sides, or exile from the land. As for the thief, male or female, cut off their hands and feet from opposite ends in recompense for what they have committed.<ref>{{#invoke:citation/CS1|citation

|CitationClass=web }}</ref>{{#if:|{{#if:|}}

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SurgeryEdit

MethodEdit

File:Curvy amputation knife DSC09451.jpg
Curved knives such as this one were used, in the past, for some kinds of amputations.

Surgeons performing an amputation have to first ligate the supplying artery and vein, so as to prevent hemorrhage (bleeding). The muscles are transected, and finally, the bone is sawed through with an oscillating saw. Sharp and rough edges of bones are filed, skin and muscle flaps are then transposed over the stump, occasionally with the insertion of elements to attach a prosthesis.

File:Últimos momentos do heroico 1º tenente - Mariz e Barros - commandante do encouraçado - Tamandaré. -.jpg
Amputation of the leg of First Lieutenant Antônio Carlos de Mariz e Barros, commander of the Brazilian Battleship Tamandaré (Henrique Fleiuss, Semana Illustrada, 1866)

Distal stabilisation of muscles is often performed. This allows effective muscle contraction which reduces atrophy, allows functional use of the stump and maintains soft tissue coverage of the remnant bone. The preferred stabilisation technique is myodesis where the muscle is attached to the bone or its periosteum. In joint disarticulation amputations tenodesis may be used where the muscle tendon is attached to the bone. Muscles are attached under similar tension to normal physiological conditions.<ref>Template:Cite book</ref>

An experimental technique known as the "Ewing amputation" aims to improve post-amputation proprioception.<ref>Template:Cite news</ref><ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> Another technique with similar goals, which has been tested in a clinical trial,<ref>New surgery may enable better control of prosthetic limbs</ref> is Agonist-antagonist Myoneural Interface (AMI).<ref>Agonist-antagonist Myoneural Interface (AMI)</ref>

In 1920,  Dr. Janos Ertl Sr. of Hungary, developed the Ertl procedure in order to return a high number of amputees to the workforce.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> The Ertl technique, an osteomyoplastic procedure for transtibial amputation, can be used to create a highly functional residual limb. Creation of a tibiofibular bone bridge provides a stable, broad tibiofibular articulation that may be capable of some distal weight bearing. Several different modified techniques and fibular bridge fixation methods have been used; however, no current evidence exists regarding comparison of the different techniques.<ref>Template:Cite journal</ref>

Post-operative managementEdit

A 2019 Cochrane systematic review aimed to determine whether rigid dressings were more effective than soft dressings in helping wounds heal following transtibial (below the knee) amputations. Due to the limited and very low certainty of evidence available, the authors concluded that it was uncertain what the benefits and harms were for each dressing type. They recommended that clinicians consider the pros and cons of each dressing type on a case-by-case basis: rigid dressings may potentially benefit patients who have a high risk of falls; soft dressings may potentially benefit patients who have poor skin integrity.<ref>Template:Cite journal</ref>

A 2017 review found that the use of rigid removable dressings (RRD's) in trans-tibial amputations, rather than soft bandaging, improved healing time, reduced edema, prevented knee flexion contractures and reduced complications, including further amputation, from external trauma such as falls onto the stump.<ref>Template:Cite journal</ref>

Post-operative management, in addition to wound healing, considers maintenance of limb strength, joint range, edema management, preservation of the intact limb (if applicable) and stump desensitization.

TraumaEdit

Traumatic amputation is the partial or total avulsion of a part of a body during a serious accident, like traffic, labor, or combat.<ref>Template:Cite book</ref><ref name="Watson1986">Template:Cite book</ref>

Traumatic amputation of a human limb, either partial or total, creates the immediate danger of death from blood loss.<ref>Template:Cite journal</ref>

Orthopedic surgeons often assess the severity of different injuries using the Mangled Extremity Severity Score. Given different clinical and situational factors, they can predict the likelihood of amputation. This is especially useful for emergency physicians to quickly evaluate patients and decide on consultations.<ref>Template:Cite journal</ref>

CausesEdit

File:3372709503 10dc75d783 oSéquelleAmputation.jpg
Private Lewis Francis was wounded July 21, 1861, at the First Battle of Bull Run by a bayonet to the knee.

Traumatic amputation is uncommon in humans (1 per 20,804 population per year). Loss of limb usually happens immediately during the accident, but sometimes a few days later after medical complications. Statistically, the most common causes of traumatic amputations are:<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>

  • Vehicle accidents (cars, motorcycles, bicycles, trains, etc.)
  • Labor accidents (equipment, instruments, cylinders, chainsaws, press machines, meat machines, wood machines, etc.)
  • Agricultural accidents, with machines and mower equipment
  • Electric shock hazards
  • Firearms, bladed weapons, explosives
  • Violent rupture of ship rope or industry wire rope
  • Ring traction (ring amputation, de-gloving injuries)
  • Building doors and car doors
  • Animal attacks
  • Gas cylinder explosions<ref>Template:Cite magazine</ref>
  • Other rare accidents<ref>Template:Cite journal</ref>

TreatmentEdit

The development of the science of microsurgery over the last 40 years has provided several treatment options for a traumatic amputation, depending on the patient's specific trauma and clinical situation:<ref>Template:Cite journal</ref>

  • 1st choice: Surgical amputation - break - prosthesis
  • 2nd choice: Surgical amputation - transplantation of other tissue - plastic reconstruction.
  • 3rd choice: Replantation - reconnection - revascularisation of amputated limb, by microscope (after 1969)
  • 4th choice: Transplantation of cadaveric hand (after 2000)<ref name="Watson1986" />

EpidemiologyEdit

File:In Khmelnytskyi, the President Paid a Visit to the Warriors Recovering from Wounds and Presented Them with Awards. (53698029200).jpg
Up to 50,000 Ukrainians lost their limbs during the Russian invasion of Ukraine.<ref>Template:Cite news</ref>
  • In the United States in 1999, there were 14,420 non-fatal traumatic amputations according to the American Statistical Association. Of these, 4,435 occurred as a result of traffic and transportation accidents and 9,985 were due to labor accidents. Of all traumatic amputations, the distribution percentage is 30.75% for traffic accidents and 69.24% for labor accidents.<ref name="amstat.org">{{#invoke:citation/CS1|citation

|CitationClass=web }}</ref>Template:Nonspecific

  • The population of the United States in 1999 was about 300,000,000, so the conclusion is that there is one amputation per 20,804 persons per year. In the group of labor amputations, 53% occurred in laborers and technicians, 30% in production and service workers, 16% in silviculture and fishery workers.<ref name="amstat.org"/>Template:Nonspecific
  • A study found that in 2010, 22.8% of patients undergoing amputation of a lower extremity in the United States were readmitted to the hospital within 30 days.<ref>Template:Cite journal</ref>
  • In 2017, an estimated 57.7 million people globally were living with existing traumatic limb injuries. Of these 57.7 million, the leading causes of amputation "were falls (36.2%), road injuries (15.7%), other transportation injuries (11.2%), and mechanical forces (10.4%)."<ref>Template:Cite journal</ref>
  • On 2 August 2023, an investigation by The Wall Street Journal found that Ukrainian medical amputations in the war came to between 20,000 and 50,000 including both military and civilians. In comparison, during World War One 41,000 British and 67,000 Germans needed amputations.<ref>{{#invoke:citation/CS1|citation

|CitationClass=web }}</ref>

PreventionEdit

Methods in preventing amputation, limb-sparing techniques, depend on the problems that might cause amputations to be necessary. Chronic infections, often caused by diabetes or decubitus ulcers in bedridden patients, are common causes of infections that lead to gangrene, which, when widespread, necessitates amputation.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>

There are two key challenges: first, many patients have impaired circulation in their extremities, and second, they have difficulty curing infections in limbs with poor blood circulation.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref><ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>

Crush injuries where there is extensive tissue damage and poor circulation also benefit from hyperbaric oxygen therapy (HBOT). The high level of oxygenation and revascularization speed up recovery times and prevent infections.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>

A study found that the patented method called Circulator Boot achieved significant results in prevention of amputation in patients with diabetes and arteriosclerosis.<ref name=dillon1>Template:Cite journal</ref><ref name=dillon2>Template:Cite journal</ref> Another study found it also effective for healing limb ulcers caused by peripheral vascular disease.<ref name=vella>Template:Cite journal</ref> The boot checks the heart rhythm and compresses the limb between heartbeats; the compression helps cure the wounds in the walls of veins and arteries, and helps to push the blood back to the heart.<ref>Template:Cite AV media</ref>

For victims of trauma, advances in microsurgery in the 1970s have made replantation of severed body parts possible.

The establishment of laws, rules, and guidelines, and the employment of modern equipment help protect people from traumatic amputations.<ref>Template:Cite journal</ref>

PrognosisEdit

The individual may experience psychological trauma and emotional discomfort. The stump will remain an area of reduced mechanical stability. Limb loss can present significant or even drastic practical limitations.<ref name="Amputation">{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>

A large proportion of amputees (from 50 to 80% to 80-100%, according to different studies) experience the phenomenon of phantom limbs;<ref>Template:Cite journal</ref><ref name="PhantomReview2007">Template:Cite journal</ref> they feel body parts that are no longer there. These limbs can itch, ache, burn, feel tense, dry or wet, locked in or trapped or they can feel as if they are moving. Some scientists believe it has to do with a kind of neural map that the brain has of the body, which sends information to the rest of the brain about limbs regardless of their existence. Phantom sensations and phantom pain may also occur after the removal of body parts other than the limbs, e.g. after amputation of the breast, extraction of a tooth (phantom tooth pain) or removal of an eye (phantom eye syndrome).

A similar phenomenon is an unexplained sensation in a body part unrelated to the amputated limb. It has been hypothesized that the portion of the brain responsible for processing stimulation from amputated limbs, being deprived of input, expands into the surrounding brain, (Phantoms in the Brain: V.S. Ramachandran and Sandra Blakeslee) such that an individual who has had an arm amputated will experience unexplained pressure or movement on his face or head.<ref>Template:Cite journal</ref>

In many cases, the phantom limb aids in adaptation to a prosthesis, as it permits the person to experience proprioception of the prosthetic limb. To support improved resistance or usability, comfort or healing, some types of stump socks may be worn instead of or as part of wearing a prosthesis.<ref name="Amputation"/>

Another side effect can be heterotopic ossification, especially when a bone injury is combined with a head injury. The brain signals the bone to grow instead of scar tissue to form, and nodules and other growth can interfere with prosthetics and sometimes require further operations. This type of injury has been especially common among soldiers wounded by improvised explosive devices in the Iraq War.<ref>Template:Cite news</ref>

Due to technological advances in prosthetics, many amputees live active lives with little restriction. Organizations such as the Challenged Athletes Foundation have been developed to give amputees the opportunity to be involved in athletics and adaptive sports such as amputee soccer.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>

Nearly half of the individuals who have an amputation due to vascular disease will die within 5 years, usually secondary to the extensive co-morbidities rather than due to direct consequences of an amputation. This is higher than the five year mortality rates for breast cancer, colon cancer, and prostate cancer.<ref>Template:Cite journal</ref> Of persons with diabetes who have a lower extremity amputation, up to 55% will require amputation of the second leg within two to three years.<ref>Template:Cite book</ref>

EtymologyEdit

The word amputation is borrowed from Latin amputātus, past participle of amputāre "to prune back (a plant), prune away, remove by cutting (unwanted parts or features), cut off (a branch, limb, body part)," from am-, assimilated variant of amb- "about, around" + putāre "to prune, make clean or tidy, scour (wool)". The English word "Poes" was first applied to surgery in the 17th century, possibly first in Peter Lowe's A discourse of the Whole Art of Chirurgerie (published in either 1597 or 1612); his work was derived from 16th-century French texts and early English writers also used the words "extirpation" (16th-century French texts tended to use extirper), "disarticulation", and "dismemberment" (from the Old French desmembrer and a more common term before the 17th century for limb loss or removal), or simply "cutting", but by the end of the 17th century "amputation" had come to dominate as the accepted medical term.<ref>Template:Cite book</ref>

Notable casesEdit

Without prosthesisEdit

With prosthesisEdit

OtherEdit

See alsoEdit

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ReferencesEdit

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Further readingEdit

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