Amputation Procedure (Surgical Removal of an Extremity or Limb)

Procedure overview
What is amputation?
Amputation is a surgical procedure that involves removal of an extremity or limb (leg or arm) or a part of a limb (such as a toe, finger, foot, or hand), usually as a result of injury, disease, infection, or surgery (to remove tumors from bones and muscles). Amputation of the leg (above and below-knee) is the most common type of amputation procedure performed.

Why are amputations done?

The most common reason for an amputation is poor circulation. The lack of circulation is caused by narrowing of or damage to the arteries (also known as peripheral arterial disease). Peripheral arterial disease (PAD), which most frequently occurs in persons between the ages of 50 to 75 years, usually results from diabetes or atherosclerosis (a buildup of plaque inside the artery wall). When the blood vessels become damaged and the blood flow is impaired to the extremities, the tissue starts to die and may become infected. Advanced peripheral arterial disease is generally treated through other methods. However, amputation may be necessary for some individuals. Peripheral vascular disease with or without diabetes is the most common indication for amputation. PADrelated causes account for up to 90 percent of all amputations. Other indications for amputation include a traumatic injury, such as severe burn or accident, or a cancerous tumor in a limb. Trauma is the leading indication for amputations in younger persons. Amputation may also be performed for acute or chronic infections that do not respond to antibiotics or surgical debridement (removal of dead or damaged tissue). In some cases, an amputation procedure may be performed due to neuroma (a thickening of nerve tissue that may develop in various parts of the body), frostbite, or arterial blockage. There may be other reasons for your doctor to recommend an amputation.

What are the risks of the procedure?

Patients with diabetes, heart disease, or infection have a higher risk of complications from amputation than persons without these conditions. Serious traumatic injury increases the risk of complications. In addition, persons receiving above-knee amputations are more likely to be in poor health; therefore, these surgeries can be riskier than below-knee amputations. As with any surgical procedure, complications can occur. Some possible complications that can occur specifically from an amputation procedure include a joint deformity, a hematoma (a bruised area with blood that collects underneath the skin), infection, wound opening, or necrosis (death of the skin flaps). Deep vein thrombosis and pulmonary embolism pose a risk after an amputation primarily due to prolonged immobilization after surgery. There may be other risks depending on your specific medical condition. Be sure to discuss any concerns with your doctor prior to the procedure.

Before the procedure

Your doctor will explain the amputation procedure to you and offer you the opportunity to ask any questions

that you might have about the procedure. You will be asked to sign a consent form that gives permission to do the procedure. Read the form carefully and ask questions if something is not clear. In addition to taking a complete medical history, your doctor may perform a complete physical examination to ensure you are in good health before you undergo the procedure. You may undergo blood tests or other diagnostic tests. You will be asked to fast for eight hours before the procedure, generally after midnight. If you are pregnant or suspect that you may be pregnant, you should notify your doctor. Notify your doctor if you are sensitive to or are allergic to any medications, latex, tape, or anesthetic agents (local and general). Notify your doctor of all medications (prescription and over-the-counter) and herbal supplements that you are taking. Notify your doctor if you have a history of bleeding disorders or if you are taking any anticoagulant (bloodthinning) medications, aspirin, or other medications that affect blood clotting. It may be necessary for you to stop these medications prior to the procedure. You may be measured for an artificial limb prior to the procedure. You may receive a sedative prior to the procedure to help you relax. Based on your medical condition, your doctor may request other specific preparation.

During the procedure

An amputation requires a stay in a hospital. Procedures may vary depending on the type of amputation, your condition, and your doctor's practices. An amputation may be performed while you are asleep under general anesthesia, or while you are awake under spinal anesthesia. If spinal anesthesia is used, you will have no feeling from your waist down. Your doctor will discuss this with you in advance. Generally, an amputation follows this process: 1.You will be asked to remove any jewelry or other objects that may interfere with the procedure. 2.You will be asked to remove your clothing and will be given a gown to wear. 3.An intravenous (IV) line may be started in your arm or hand. 4.You will be positioned on the operating table. 5.The anesthesiologist will continuously monitor your heart rate, blood pressure, breathing, and blood oxygen level during the procedure. 6.A urinary catheter (thin, narrow tube) may be inserted into your bladder to drain urine. 7.The skin over the surgical site will be cleansed with an antiseptic solution. 8.To determine how much tissue to remove, the doctor will check for a pulse at a joint close to the site. Skin temperatures, color, and the presence of pain in the diseased limb will be compared with those in a healthy limb. 9.After the initial incision, it may be decided that more of the limb needs to be removed. The doctor will maintain as much of the functional stump length as possible. The doctor will also leave as much healthy skin as possible to cover the stump area. 10.If the amputation is due to trauma, the crushed bone will be removed and smoothed out to help with the use of an artificial limb. If necessary, temporary drains that will drain blood and other fluids may be inserted. 11.After completely removing the dead tissue, the doctor may decide to close the flaps (closed amputation) or to leave the site open (open flap amputation). In a closed amputation, the wound will be sutured shut immediately. This is usually done if there is minimal risk of infection. In an open flap amputation, the skin will remain drawn back from the amputation site for several days so any infected tissue can be cleaned off. At a later time, once the stump tissue is clean and free of infection, the skin flaps will be sutured together to close the wound.

12.A sterile bandage or dressing will be applied. The type of dressing used will vary according to the surgical technique performed. 13.The doctor may place a stocking over the amputation site to hold drainage tubes and wound dressings, or the limb may be placed in traction or a splint, depending on your particular situation.

After the procedure

In the hospital
After the procedure, you will be taken to the recovery room for observation. Your recovery process will vary depending on the type of procedure performed and the type of anesthesia that is given. The circulation and sensation of the affected extremity will be monitored. Once your blood pressure, pulse, and breathing are stable and you are alert, you will be taken to your hospital room. You may receive pain medications and antibiotics as needed. The amputation site dressing will be changed and monitored very closely. Physical therapy will usually begin soon after your surgery. Rehabilitation will be designed to meet the needs of the individual patient. This may include gentle stretching, special exercises, and assistance in getting in and out of bed or a wheelchair. If a leg amputation was performed, you will learn how to bear weight on your remaining limb. There are specialists who make and fit prosthetic devices. They will visit you soon after surgery and will instruct you how to use the prosthesis. You may begin to practice with your artificial limb as early as 10 to 14 days after your surgery, depending on your comfort and wound healing process. After an amputation, depending on your particular situation, you will remain in the hospital for several days. You will receive instructions as to how to change your dressing. You will be discharged home when the healing process is going well and you are able to take care of yourself with assistance. After surgery, you may experience emotional concerns, such as grief over the lost limb or a physical condition known as phantom pain (a sense of feeling pain or sensation in your amputated limb). If this is the case, you may receive medications or other types of nonsurgical approaches.

At home
Once you are home, it is important to follow the instructions given to you by your doctor. You will receive detailed instructions as to how to care for the surgical site, dressing changes, bathing, activity level, and physical therapy. Take a pain reliever for soreness as recommended by your doctor. Aspirin or certain other pain medications may increase the chance of bleeding. Be sure to take only recommended medications. Notify your doctor to report any of the following: Fever and/or chills Redness, swelling, or bleeding or other drainage from the incision site Increased pain around the amputation site Numbness and/or tingling in the remaining extremity You may resume your normal diet unless your doctor advises you differently. Following an amputation, your doctor may give you additional or alternate instructions after the procedure, depending on your particular situation.

Long-term care
There have been many advances over the past several years in the surgical techniques performed, postoperative rehabilitation, and prosthetic design and development. Proper healing and fitting of the artificial limb help to reduce the risk of long-term medical complications. An amputation requires a process of adaptation that can be helped with physical therapy. If the amputation was the result of PAD, continued steps will need to be taken to prevent the condition so that it does not affect other parts of your body. You may be advised to adopt the following lifestyle modifications to help halt the progression of PAD: Maintain a healthy diet that does not exceed your daily calorie requirement and that is low in saturated fat and cholesterol. Stop smoking. Work towards achieving or maintaining an ideal body weight. Maintain a regular exercise program.