Amputation - Meaning, Types, Causes, Indications, Recovery

Amputation is defined as the surgical removal of a part of the body, such as an arm or a leg. Amputation can be of several types based on the body part being amputated. These include:

1. Above-knee amputation: All body parts below the knee and a part of the thigh are surgically removed.
2. Below-knee amputation: Any body part below the knee is removed
3. Foot amputation: Surgical removal of the foot
4. Toe amputation: Surgical removal of the toe
5. Arm amputation: Surgical removal of the forearm, upper arm or the entire arm
6. Hand amputation
7. Finger amputation 

Amputation is usually performed by an orthopaedic and a plastic and reconstructive surgeon together. They work together to remove the diseased body part and reconstruct the remaining limb or tissues to restore maximum function.

Anatomy and Physiology 

No matter which limb or body part is getting amputated, the basic layers of the body part remain the same throughout the body.

From outside to inside, these layers constitute of:

1. Skin: This layer consists of the epidermis and the dermis. The epidermis is made of five types of layers of cells. The dermis consists of the blood vessels, nerves, and hair follicles.
2. Fascia: This connective tissue holds the skin, nerves, and blood vessels above the muscle and bones below.
3. Fat: Fat is present below the fascia and above the muscle layer. It is inevitably excised while perfor kind of amputation.
4. Muscles: Depending upon the part of the body amputated, the muscles vary. For example, in below-knee amputations, at the level of the tibia, the leg muscles (peroneal are amputated)
5. Bones: This, again, varies depending on the site of amputation. For example, in below-knee amputation, the bones of the legs, i.e., the tibia and fibula, are amputated. Similarly, the thigh bone (femur) is amputated in above-knee amputation.

These layers are bound to get cut and surgically removed in all types of amputations. 

Not only amputation helps in the prevention of developing complications, but also in the treatment of a variety of conditions. It is indicated in the following conditions:

1. Peripheral Arterial Disease
   1. Peripheral Arterial Disease is where fat plaques accumulate in the blood vessels, eventually leading to their complete blockage.
   2. This may further result in ischaemia or blockage of the blood supply causing the limb not to receive any nutrients. Ischaemia may cause necrosis or tissue death that needs amputation.
   3. Conditions like diabetes mellitus accelerate the development of PAD; hence, patients with coexisting diabetes mellitus are more prone to undergo amputation.
   4. The most common types of amputations due to PADs are toe amputations (33.2%), below-knee amputation (28.2%), above-knee amputation (26.1%), and foot amputations (10.6%).
2. Injury
   1. A severe crushing injury due to a road traffic accident or other traumatic causes needs amputation. 
   2. Diseases affecting a particular limb 
   3. Certain diseases result in tissue death or non-functional limb which needs to be amputated. For example, gangrene refers to the tissue's death due to blocked vascular supply; diabetes, which leads to non-healing ulcers and ultimately tissue death when not treated on time; frostbite, etc.
3. Frostbite 
   1. A very cold exposure to the fingers and toes can lead to frostbite due to tissue death. This needs a surgical amputation.
4. Local infections that may be life-threatening if spread to other body parts, for example, gas gangrene
5. Neuroma
   1. This benign nerve tumour results in the thickening of the nerve. Some severe cases of neuroma might need an amputation.
6. Cancer of a particular limb
   1. This is another less common reason for amputation. Malignant tumours such as osteosarcoma need an amputation.
7. Congenital deformities of limbs or digits, for example, extra hand digits.

The right candidate for amputation is the one with the following:

1. Normal wound healing parameters
2. Willingness to perform rehabilitation exercises postoperatively to ensure the maximum function of the residual limb
3. Appropriate psychological and emotional support from home

Who is not suitable to undergo Amputation?

1. Poor blood flow to the site to be amputated
2. Severe lung or heart disease
3. Poor immune system function
4. Scarred tissue
5. Muscle or skin loss

Amputation is a surgical procedure performed under anaesthesia. It can be general or spinal. The type of anaesthesia depends upon which part of the body is getting amputated. General anaesthesia numbs the whole body and will make one fall asleep. In contrast, spinal anaesthesia acts on the spine and numbs the lower half of the body (legs and lower abdomen).

Talk to the doctor before the procedure to get an idea of what to expect. The procedure slightly varies according to the type of amputation, the severity of the condition, the doctor's expertise and preferred ways. 

Nevertheless, the basic steps of the operation are as follows: 

1. The doctor will ask the patient to change into the hospital gown and go to the treatment room.
2. The patient is made to lie supine on the operation table. The surgical sites are well exposed and positioned depending upon the type of amputation.
3. The doctor marks the limb to be amputated.
4. An IV line is established in the arm or hand to administer medications.
5. A thin tube (urinary catheter) is inserted into the bladder via the urethra to drain the urine.
6. The anaesthesiologist monitors blood pressure, heart rate, pulse, breathing, and oxygen levels.
7. The skin at the operating site is cleansed with the help of antiseptic solutions.
8. The skin is incised, and tissues are dissected to explore the nerves and blood vessels.
9. The blood vessels and nerves supplying the amputation site are identified and isolated.
10. Muscles are then identified and cut according to the condition. The blood vessels and nerves are also cut.
11. After isolating and cutting the tissues, the bones are drilled and removed with the help of a saw.
12. All the damaged tissues and crushed bone particles are removed.
13. The uneven bone is smoothened.
14. A healthy stump is left behind to take the load off the body. This stump can be fitted with a prosthetic limb to help the patient walk normally. The skin over the healthy stump is desensitised before fitting a prosthesis. This is achieved by massaging and rubbing the part that will come in contact with the prosthesis. 
15. After the tissues are amputated, the remaining muscle is stitched back to the leftover bone. This process is called myodesis to restore muscle function as much as possible.

The entire procedure takes one to two hours to complete.

The doctor will thoroughly examine the patient before deciding if the patient needs an amputation. Based on the patient's condition and rehabilitation options, the doctor will choose the type of amputation. 

After a careful assessment of the following parameters, the doctor shall recommend surgery:

1. Patient's overall condition 
2. Status of the healthy limb
3. Nutritional status
4. Sugar control in patients with diabetes
5. Bowel and bladder habits
6. Lung function 
7. Heart function 
8. Psychological and emotional assessment 
9. Support from home and work environment 
10. After deeming the patient fit for surgery, the doctor will explain the entire procedure and its impact on the patient. 

Before Amputation 

1. The doctor will ask about all the medications the patient takes, including supplements and herbs bought without a prescription.
2. The doctor will ask you to avoid painkillers and anticoagulants before the surgery.
3. One should avoid smoking at least until the surgery is done because smoking may alter the blood flow and slow down the healing process after amputation.

1. C reactive protein
2. Haemoglobin levels
3. Albumin levels
4. WBC count (White Blood Cell)
5. CT, USG, and MRI can be ordered depending on the patient's condition. 
6. The patient will be asked to sign an informed consent form before the procedure.

On the day of Amputation

1. The patient will mostly be advised to fast at least six hours before the procedure.
2. The doctor shall prescribe a medication to take on the morning of the day of surgery.
3. The patient will be advised to remove any metallic jewellery or objects that might hinder the procedure.
4. Prophylactic antibiotics shall be administered to the patients before the surgery.
5. A tourniquet (band) can be applied to the limb to restrict the blood flow to the amputation site.

The recovery process in the Hospital

1. The doctor shifts the patient to the recovery room/ ward to provide oxygen via a mask and IV fluids through a drip for the first few days.
2. The patient is advised to complete bed rest for the first few days and not be required to go to the toilet to pee due to the urinary catheter. The patient has to poop in the amputation bed itself with the help of a commode.
3. The doctor will give painkillers to reduce the pain at the amputation site.
4. Local anaesthetic medications will be given to numb the pain in the stump.
5. The time of discharge from the hospital depends upon the patient's recovery process in the hospital, overall status of health, and the type of amputation. The patient is usually discharged after 3 to 7 days of amputation.
6. The patient is advised to make minor movements in the remaining leg to maintain circulation.

Recovery process/expectation after hospital discharge 

1. The recovery process after amputation depends upon existing comorbidities such as diabetes or poor blood supply. Patients with diabetes should keep their blood sugar levels in check. Those with poor blood flow must talk to the doctors and take the medications as prescribed. 
2. It may also take longer to recover after an amputated leg or above-knee amputation for older people.

Irrespective of the patient, the following things are essential to bear in mind about the recovery process after hospital discharge:

1. Wound care:
   1. Keep the wound clean and dry. Avoid getting in contact with water until the doctor suggests you to. 
2. Physiotherapy: 
   1. Physiotherapy is a must after amputation. One can start physiotherapy a few days after the surgery or as the doctor recommends. The physiotherapist will exercise the affected joints and muscles that need strengthening so that the patient gets back on their feet as soon as possible. For example, Buerger's exercise. 
   2. The physiotherapist will also teach how to walk with a prosthetic limb and help in the recovery process. Keep performing these exercises for as long as the doctor has suggested.
3. Occupational Therapy
   1. Occupational Therapy is also vital for amputees. Without a limb, it becomes difficult for an amputee to earn a livelihood. Hence, taking help from occupational therapists becomes crucial in determining work goals. 
   2. Besides, an occupational therapist also sees if the patient's house should be catered to according to the surgery. For example, one may need a wheelchair ramp to make moving around the house and travelling in cars easier for patients with amputated legs.
4. Compression garment: 
   1. Oedema is a common side effect of amputation. This can be prevented by using a compression garment or stocking.
   2. Remove any items that might make you trip at home, for example, slippery rugs.
   3. Avoid sitting in one position for too long to prevent stiffening of the joints. Keep moving and lie in different positions in the bed.
   4. Use heat or cold therapy to reduce the swelling around the amputated leg or whichever area has been amputated.
   5. If the limbs have been amputated, avoid putting too much pressure on the non-amputated limb.
   6. The patients are advised to undergo the following training, depending upon their levels of amputation:
5. Balance training:
   1. This is the first step in recovery. Patients must be able to balance themselves and stabilise their gait first so as to move forward in the journey of healing. 
6. Transfer training:
   1. The patient is taught to transfer from one seat to another, from their bed to a seat, etc. This is essential in the initial days of recovery.
7. Mobility training:
   1. This is done to ensure the patient can move independently from one place to another. Initially, this is done with the help of crutches or walkers. One can use the following walking aids:
      1. Axillary crutches
      2. Elbow crutches
      3. Walking frame
      4. Walking stick 
8. Strength training:
   1. The muscles surrounding the amputated area are strengthened to accommodate maximum movement.
9. Prosthetic training:
   1. During this, the patient is taught how to live and perform daily activities with the help of a prosthesis. 

It is common to feel sad or depressed after an amputation. One must talk to the treating physician or a mental health professional to avoid such feelings, make the best out of whatever they have, and be grateful because amputation is a life-saving procedure. The benefits of amputation are far more important than its adverse outcomes. 

First Follow-Up Appointment:

1. The patient is usually expected to come for the first follow-up a few weeks after the procedure. 
2. The doctor will ask about the recovery process and whether any additional changes can be made to ensure a smooth transition to everyday life.
3. The patient may be advised to join support groups where they can connect with similar people and recover faster.

The benefits of amputation are as follows:

1. Life-saving procedure as it prevents the spread of deadly infections to the whole body
2. Effective in removing the diseased body parts
3. Prevents further loss of other body parts
4. Provide pain relief from the disease affecting the limbs or toes

Amputation is an essential and life-saving procedure, but it has quite a few side effects. Even though the side effects can be painful, the benefits of amputation far outweigh the side effects.

Common amputation side effects include:

1. Pain
2. Swelling
3. Bruising at the site of the procedure 
4. Muscle weakness due to the muscles that are cut and repositioned during the procedure 
5. After procedures such as leg amputation or below knee amputation, it is common to feel as if the limb is still there. This is called phantom sensation.
6. Joint instability 

Just like any other procedure, amputation too has some complications associated with it. People with heart problems or diabetes have an increased risk of developing complications. 

These complications include: 

1. Infections
2. Haematoma (blood collects under the skin or any other tissue)
3. Joint deformities
4. Necrosis (tissue death)
5. Wound opening
6. Deep vein thrombosis (blood clot in the veins of the legs)

Patients who have undergone above-knee amputation are more prone to developing severe complications than below knee amputation.

The costs of amputation depend upon various patient and hospital factors. These factors include the type of amputation, severity of the condition, existing comorbidities, hospital charges, doctor's fee, surgeon's skills, etc.

Considering all these factors, the cost of amputation in India may lie between Rs. 5,000 to Rs. 35,000. If you're looking for a doctor or a hospital to consult regarding your condition, look no further! 

At HexaHealth, we have an excellent team of doctors who are ready to help you. We ensure that you get the best treatment at an affordable price, as our patient's health is our top priority. So what are you waiting for? Get in touch with us right now!