c



What is an amputation?
An amputation usually refers to the removal of the whole or part of an arm/hand or a leg/foot. Amputations can occur
after an injury (traumatic amputation) or deliberately at surgery. In vascular surgery amputations are only rarely
performed on the arms. Vascular surgeons frequently have to perform amputations of toes or legs. It is one of the oldest
surgical procedures with artificial limbs identified from over 2000 years ago.

Why do patients need to undergo amputations?

The vast majority of amputations are performed because the arteries of the legs have become blocked due to hardening
of the arteries (atherosclerosis). Blockages in the arteries result in insufficient blood supply to the limb. Because
diabetes can cause hardening of the arteries, about 30-40% of amputations are performed in patients with diabetes.
Patients with diabetes can develop foot/toe ulceration and about 7% of patients will have an active ulcer or a healed
ulcer. Ulcers are recurrent in many patients and approximately 5-15% of diabetic patients with ulcers will ultimately
require an amputation. Because hardening of the arteries occurs most commonly in older men who smoke, the majority
of amputations for vascular disease occur in this group. Diabetes may be an important factor in nearly 40% of patients
undergoing major amputation (Moxey et al 2010).

When hardening of the arteries becomes so severe that gangrene develops or pain becomes constant and severe,
amputation may be the only option. If amputation is not performed in these circumstances infection can develop and
threaten the life of the patient. Sometimes bypass surgery can be performed to avoid amputation, but not all patients are
suitable for bypass surgery. Before amputation, the limb can cause serious problems with infection and pain and may
even be a threat to the life of some patients.

Less commonly serious accidents can lead to the loss of a limb, as can the development of a tumour or cancer in a limb.
These amputations tend to occur in younger patients.

About 370 new referrals are made to the NZ artificial limb board annually of which about 300 (70%) are due to vascular
causes and diabetes. Over the period 2003-2008 in the UK there were approximately 5 major amputations (above or
below knee) per 100,000 people (Moxey et al 2010).

Back to the top

What sort of amputations can be performed?

Amputations can be divided into minor and major. Most vascular surgeons will have extensive experience in this type of
surgery.

Minor amputations are amputations where only a toe or part of the foot is removed. A ray amputation
is a particular form of minor amputation where a toe and part of the corresponding metatarsal bone is
removed as shown in the diagram below left. A forefoot amputation can sometimes be helpful in patients
with more than one toe involved by gangrene. In this operation all of the toes and the ball of the foot is
removed.
Major amputations are amputations where part of the leg is removed. These are usually below the knee or above the
knee.

Occasionally an amputation of just the foot can be performed with a cut through the ankle joint (Symes amputation).
This is not suitable for the majority of patients, but can rarely be an option in some patients with diabetes. It is
particularly important for this amputation that the posterior tibial artery is patent and has a reasonable blood flow. This
artery is found on the inside of the foot just below the ankle. Your surgeon may advise you if this operation may be
possible.

Amputations through the knee joint or just above the knee joint (Gritti-Stokes amputation) can also sometimes be
performed. They were much more popular amputations in the past but there is little or no advantage for present day
patients compared with above knee amputation. If a major amputation is to be performed then a below knee
amputation will always give the patient the best chance of remaining mobile and walking post-operatively.

Below knee amputation

This operation can be performed using 2 major techniques. The most common technique is the posterior myoplastic flap
(Burgess technique) where the skin and muscle from the calf are brought forward to cover the shin bones after they have
ben divided (see below left). The other main technique is the skew flap (Kingsley Robinson technique) in which the
muscles of the calf are brought forward in the same way as in the posterior technique but the skin flaps are skewed in
relation to the muscle. There is no proven advantage for one technique, but sometimes it is easier to perform a skew
flap amputation if there has been significant skin damage above the ankle. The bone
in the lower leg (tibia) is divided about 12-15 cms below the knee joint. This produces
a good size stump to which a prosthesis can be fitted.

Above knee amputation

In this operation the bone in the thigh (femur) is divided about 12-15 cms above the
knee joint and the muscle and skin closed over the end of the bone.

If you wish to see an amputation being performed a short search of the internet will
provide many video examples - see here.

Back to the top


Causes of
Trauma (crushing injury where it can·t be repaired, burns, frostbite)
Congenital deformities
Chronic infection (osteomyelitis)
Malignant tumors
o Usually with younger people
Peripheral vascular disease (diabetes, cardiovascular disease)
o Have such bad circulation they develop stasis ulcers, no blood supply
to extremities, causes necrosis
Levels of Amputation
 Performed at most distal point that will heal
Must have adequate circulation
Needs to be best level to promote use of prosthesis
Staged amputation
o After a big crushing trauma, quick amputation to be sure that part of
the body doesn·t cause infection, with the intention of taking you back
to surgery and do another amputation after you·ve stabilized
Will try to amputate below a joint because it makes mobility easier
Diagnostic test to determine circulation
Phantom limb pain
o Due to cutting through nerves
Joint contracture ² due to positioning, important to do ROM exercises, start
early post-op

Pre-op

Assessment of extremity
o Neurovascular and function-compared to unaffected extremity
History and Physical
Assessment of psychosocial needs
o Important to be understanding of the patient, might be angry, upset,
etc.
Teach about what to expect post-op
Referrals to support group when needed
o Home health, social work, others who have already had the surgery to
come talk to them, etc.
Post-op
Assess for hemorrhage
o Tourniquet at bedside
o Assess dressing
o Assess vital signs and labs
o Assess drains
o Assure compression dressing is intact

Keeps muscle and soft tissue firm and tight

Begins to form a residual limb that is packed and intact for
prosthetic device
Prevents edema
Provide for safety
Side rails, call light, bed low position, leave low light on at night
Check on client frequently and assist as needed
Common for patient to forget about amputation and get up in the middle of
the night and try to go to the bathroom
Balance is a big issue as well
Relieving Pain
Residual limb/ incision pain
o Usually sever and has minimal if any relieve by non pharmacological
measures
o Still can reposition, distract, etc.
o If they continue to have unrelieved pain, think INFECTION
Phantom Pain
o Real pain might not start for a week or two after amputation
o Usually must be treated with medications of TENS unit for actual relief
It stimulates same nerves that gives impulses of phantom pain
o Cause not well understood
Infection Control
Hand washing
Aseptic technique
Give antibiotics
Assess vital signs
Provide adequate diet
Control glucose levels
Skin breakdown prevention
Repositioning and turning
Keep dressing dry
Assure that dressing is not causing irritation
Adequate nutrition and hydration
Promote mobility/ independence
Measures to decrease edema and form the residual limb to prepare
prosthesis
Elevate residual limb for the first 24 hours post op then do not elevate
Position prone 15-30 minutes twice a day if lower extremity amputation
ROM, maintain good body alignment
When incision healed press extremity against increasingly firm surface
Assure client has mobility needs met at home prior to discharge
Provide psychosocial support
Establish trusting relationship
Encourage patient to look, touch and care for residual limb
Create an accepting and supportive atmosphere
Assist with dealing with immediate needs and realistic rehab and functional
goals

Nursing interventions

Prevent further loss of circulation to extremity

Promote comfort
Promote optimum level of mobility
Stump wound care
Discourage semi-fowlers position in client with above the knee amputation o
prevent contractures of the hip
Stump care after wound has healed
Assess for skin breakdown
Wash, rinse and dry stump daily
Client goals
Relief of pain
Absence of altered sensory perception
Wound healing image
Resolution of grieving process
Independence in ADL·s
Restoration of mobility
Absence in complications
Acceptance of body