Generality
Amputation consists of surgical removal or accidental (spontaneous or traumatic) loss of a limb or part of it.
Accidental loss means that amputation can occur after traumas or accidents where the limb can be severed, crushed or torn. The spontaneous fall of a finger (or part of it) or of an extremity can result from gangrene or from another serious morbid process.
Surgical amputation is an intervention usually carried out to manage vascular complications or control an ongoing pathological process, such as a malignant tumor . This treatment can also be indicated for preventive purposes to limit the consequences of these same problems.
What's this
What is meant by Amputation?
Amputation is understood as the accidental loss or surgical removal of a limb (lower or upper), total or one of its segments, with all its components (skin, vessels, nerves, bone and muscle).
Less correctly, the term is used in common medical practice, referring to the removal of other parts of the body (for example: "amputation of the breast" in reference to mastectomy to treat breast cancer).
The extremity of the amputated limb is called amputation stump .
Causes
Surgical Amputation
Surgical amputation is an intervention performed to control pain, irreparable trauma or a severe pathological process in the affected limb. Most of these interventions are practiced to manage peripheral vascular complications, mainly related to diabetes, arteriosclerosis and gangrene of arterial origin (eg Bürger's disease).
Amputation can also be used to prevent particular problems, such as, for example, to prevent the extension of a particularly aggressive malignant tumor or to limit damage in the presence of necrotizing processes .
Surgical amputation is an operation performed since ancient times; over time, the techniques used to remove the part of the limb affected by pathology have undergone an evolution in a conservative sense, ie we tend to limit, as far as possible, the amplitude of the amputation.
Spontaneous Amputation
Spontaneous amputation occurs mainly in the limbs affected by gangrene (in the common language also known as gangrene ). In this situation, it is possible to observe that the healthy part clearly delimits the sick part, until the latter breaks off spontaneously.
Gangrene is a type of tissue necrosis caused, generally, by a deficient blood supply in the affected part. This condition can result from severe traumatic injuries, frostbite, infections and other situations in which the necrotic process (ie tissue death) is irreversible.
To learn more: Cancrena - What it is, Causes and Symptoms »Traumatic amputation
Amputation from physical trauma is an occurrence that is observed mainly in the case of road accidents (cars, motorcycles, bicycles, etc.) and accidents at work (chainsaws, presses, equipment for processing meat or for cutting wood, etc.). ). A limb or segment of this can be severed during investments, explosions and cutting wounds.
This event can also occur due to the sudden breakage of a rope (metal or rope), the joint between the gears of a machine or the effects of firearms.
In traumatic amputation, limb loss can be the direct consequence of the event, ie it occurs immediately during the accident (for example: a finger accidentally cut by the blade of a table saw. Sometimes, the amputation occurs a few days later, due to medical complications.
In most cases, the fingers of the hand are involved. The traumatic amputation of a limb, partial or total, creates the immediate danger of death due to the copious loss of blood.
Congenital Amputation
Congenital amputation is a rather rare occurrence that occurs when the unborn child is still in the uterus.
This particular shape almost always results from the presence of a bridle of the amniotic membrane, which acts as a constricting band directly on a limb of the fetus, determining its amputation.
Other forms of Amputation
- In some countries, including Saudi Arabia, Yemen, United Arab Emirates and Iran, amputation of hands or feet was used (or even continues to be used) as a form of legal punishment for people who committed crimes.
- Amputation can occur due to war causes, such as war wounds and acts of terrorism. Less often, on the other hand, there are self-tests performed for fraudulent purposes (for example, to receive insurance money) or as a form of protest.
- Self-sampling can be the consequence of the bodily integrity identity disorder (Body Integrity Identity Disorder, BIID), a rare and severe psychiatric disorder . People who suffer from this condition experience an intense desire to amputate one or more parts of their bodies.
- Certain cultural or religious traditions provide for the practice of minor amputations such as an initiation ritual to emphasize the transition from one condition to another (for example, from childhood to adulthood). Some African tribes and the Australian aborigines, for example, practice the avulsion of the incisors as a ritual ceremony. Scarifications, facial disfigurations (rhinotomies, amputations of the ears, etc.), circumcision or mutilation (infibulation and clitoridectomy) can also take on the meaning of belonging to a community.
What is it for
Surgical amputation is practiced to treat pathological conditions, which:
- They take on a severity such as to compromise blood circulation in the affected limb;
- They cannot be managed with other approaches;
- They threaten the survival of the patient.
Surgical amputation: when is it performed?
The indications for this type of treatment are different.
More frequently, surgical amputation is practiced in the following cases:
- Serious injuries to a limb that caused unrecoverable vascular lesions;
- Bone or soft tissue tumors (osteosarcoma, osteochondroma, etc.) and any other type of cancer in an advanced or metastatic stage ;
- Vasculopathies ;
- Deforming osteoarthritis ;
- Bone infections, such as osteomyelitis;
- Diabetes complications, such as:
- Infections arising from the diabetic foot;
- Circulation problems;
- Deformation of the fingers and / or limbs :
- Focal deficiency of the proximal part of the femur;
- Fibular hemimelia;
- Supernumerary fingers (eg polydactyly);
- Gangrena, developed following:
- Atherosclerosis;
- Buerger's disease (or Bürger's disease);
- Freezing.
- Sepsis with peripheral necrosis .
Types
Which parts are subject to amputation?
Surgical amputations can be divided into two broad categories:
- Minor amputations : they generally refer to the removal of fingers;
- Major amputations : consist of the removal of large sections (eg below the knee, above the knee and so on);
As a rule, it is preferred to opt for partial amputations to preserve the articulation. In oncological surgery, however, disarticulation is preferred (ie amputations performed at the level of a joint).
In general, the technique varies according to the extent of the disease: the different levels of surgical amputation and the respective lines of skin incision try to provide the prosthesis with a valid and functional residual stump.
Some examples of surgical amputation
LOWER LIMBS
- Amputation of the toes;
- Partial amputation of the foot (note: the most common techniques are those of Chopart and Lisfranc);
- Ankle disarticulation (eg amputation of Syme, A. of Pyrogoff etc.);
- Trans-tibial amputation (commonly referred to as an amputation below the knee);
- Amputation of the patella (disarticulation of the knee);
- Transfemoral amputation (above the knee);
- Hip disarticulation (amputation of the lower limb at the hip joint).
A particular example of major amputation related to the leg is the hemipelvectomy, that is the surgical removal of half of the pelvis and of the ipsilateral lower limb. This type of intervention is practiced above all in case of malignant tumors or bone metastases extended to the hip and the sacrum.
Another example of a very invasive intervention is the amputation combined with the rotation of Van-Ness, in which the foot is rotated 180 ° and thus sutured to allow the use of the ankle joint as if it were a knee and to guarantee greater effectiveness of the prosthesis.
UPPER ARTS
- Amputation of the fingers of the hand;
- Metacarpus amputation;
- Wrist disarticulation;
- Trans-radial amputation (commonly referred to as amputation of the forearm or below the elbow);
- Disarticulation of the elbow;
- Trans-humeral amputation (above the elbow);
- Shoulder disarticulation.
A variant of the trans-radial amputation to be mentioned is the Krukenberg technique, which offers the restitution of a certain "manual", using the ulna and radius bones to create a stump similar to a pincer.
Procedure
How do you perform an amputation?
Surgical amputation involves first of all interrupting the blood supply to the area to be removed, by means of an elastic bandage (possibly in combination with the refrigeration). This step helps prevent bleeding.
Next, the muscles are dissected and the bone is severed with an oscillating saw.
The skin flaps and muscle fibers are positioned above the stump, occasionally with the insertion of elements to facilitate the application of a prosthesis.
Muscles should be attached in conditions similar to normal physiological conditions. This allows an effective muscle contraction, able to:
- Reduce the atrophy of the part;
- Allow functional use of the abutment;
- Keep the soft tissue coverage of the residual bone.
The distal stabilization technique of the muscles for which one opts most is myodesis (direct muscle suture to the bone or periosteum). In articular amputations of disarticulation, instead, tenodesis can be used, where the tendon is attached to the bone.
The artificial prosthesis is applied a few months after surgery; the patient is supported with a rehabilitation course .
How is the amputation level determined?
Compatibly with the aims of the intervention, the amplitude of the amputation is established in such a way as to allow:
- Adequate arterial blood supply to the residual part;
- The application of orthopedic prosthesis .
As far as possible:
- The surgeon who practices amputation tries to preserve the limb;
- Blood circulation should be sufficient at the level of amputation, to avoid complications and further interventions;
- The point where the amputation is to be performed must allow the patient to use the artificial limb effectively.
Characteristics of the Amputation Abutment
The "ideal" stump should:
- Have a good muscular tropism;
- Maintain an efficient blood circulation;
- Don't be sore.
The part remaining from the amputation is usually reconstructed with stabilization and microsurgery techniques to favor the continuity of the limb.
Post-operative management
After amputation, in the post-operative regime, it is important:
- Facilitate wound healing, reduce swelling and prevent the risk of infection;
- Maintain limb strength and joint extension, preventing contractures and mobility limitations;
- Desensitize the stump (as anticipated, it must not be sore).
In the past, the amputation involved a profound disability; thanks to the continuous and remarkable evolution of surgical techniques (in terms of haemostasis, asepsis, anesthesia and microsurgical practices) and the development of orthopedic prostheses, it is currently possible to recover with excellent results and resume their daily activities, even if limited by impairment.
Possible complications
The possible problems that can arise after an amputation also include:
- Failed healing of the stump;
- Infections;
- Progression of the basic pathology;
- Impediments to mobilization;
- Psychological trauma and emotional distress.
Clearly, the stump will remain an area of reduced mechanical stability and the loss of limbs is a very serious impairment that can present significant practical limitations. As regards the recovery of the mobility of the residual part and of the prosthetic limb, physiotherapy sessions are indicated to the patient, in combination with pain therapy .
Another possible complication of amputation is heterotopic ossification : in practice, instead of developing scar tissue at the level of the stump, nodules are formed and other growths can interfere with the prosthesis. This can sometimes make further surgical operations necessary.
Finally, after amputation, the patient may experience pain from the limb or segment of it removed; this condition is known as phantom limb syndrome .
