Common Cares

Amputation – The Necessary Evil - Part I

Human beings are the most prolific of survivors and have the ability to turn their loss into an advantage. They are capable of finding a way out of the odds and making a way when there is none. Come enemy come disease, they are sure to try the most tiring of ways to overpower the crisis. Amputation is one method that they have taken up, to save themselves from the vicious circle of death, when any of their body parts; such as the arms, legs, fingers get diseased. One such disease, which can lead to amputation of the limbs, is diabetes.

The reasons that can lead to amputation in diabetics are manifold. The first and foremost important reason is the diabetic foot and diabetic ulcer. The presence of the ulcer would lead to infection and which in turn becomes a non-healing ulcer, ultimately leading to diabetic foot. This, if untreated or inadequately treated, would lead to formation of gangrenous limbs-where there is not enough supply of blood to the limb, which is one of THE indication for amputation and the most common site of diabetic ulcer leading to amputation is lower limb.

Definition

Amputation is the intentional surgical dislodging of a limb or body part. It is performed to remove diseased tissue or relieve pain and mainly, to save the life of the person.

Purpose

Amputation is a technique, which is used to prevent diseased tissue from affecting other healthy tissue. It is a preventive measure rather than a cure, since it results in the permanent loss of a body part. In our body, the arms, legs, hands, feet, fingers, and toes can all be amputated. Most amputations involve small body parts such as a finger, rather than an entire limb. It is generally performed for the following reasons:

• To remove tissue that has impaired blood supply.
• To remove malignant tumors and cancerous tissue.
• Because of severe trauma to the body part.

Role of Diabetes

Most of the amputations performed throughout the world are a result of impaired circulation due to diabetes; though gangrene, frostbite, Raynaud’s disease (A disease found mainly in young women that causes decreased circulation to the hands and feet) and Buerger’s disease (An episodic disease that causes inflammation and blockage of the veins and arteries of the limbs, mostly the lower limbs) are major risk factors. In these conditions the blood circulation to an extremity can be blocked due to an injured blood vessel. As many as 60% of amputations, performed in the world, are due to circulatory complications of diabetes.

Precautions

There are many precautions that need to be kept in mind before performing an amputation. It must be remembered that, as with all surgeries, amputations cannot be performed on patients with uncontrolled diabetes mellitus, heart failure, or infection. It could lead to major complications if performed on candidates who have blood clotting disorders.

Specification

Amputations can be either planned or be opted for as emergency procedures. The operation is performed under regional or general anesthesia by a general or orthopedic surgeon. The procedure for the operation varies, depending on the part that is to be removed. Amputation serves a dual purpose; it removes the diseased tissue so that the wound will heal cleanly, and constructs a stump that will allow the attachment of a prosthesis or artificial replacement part.

The procedure involves making an incision around the part to be amputated. The part is removed, and the bone is smoothed. A flap of muscle, connective tissue, and skin is constructed to cover the raw end of the bone and is sutured. Sometimes, a rigid dressing or cast is applied that stays in place for about two weeks.

Groundwork

Extensive testing and analysis is done before an amputation is performed, so as to determine the proper level of amputation. The surgeon should see to it that the amputation is performed at such a location of the body part where healing is most likely to be complete, while allowing the maximum amount of limb to remain for effective rehabilitation.

The greater the blood flow through an area, the more likely healing is to occur. These tests are designed to measure blood flow through the limb. Several or all of them can be done to help choose the proper level of amputation.

• Measurement of blood pressure in different parts of the limb
• Xenon 133 studies, which use a radio pharmaceutical to measure blood flow
• Oxygen tension measurements: which uses an oxygen electrode to measure oxygen pressure under the skin. If the pressure is 0, the healing will not occur. If the pressure reads higher than 40mm Hg (40 milliliters of mercury), healing of the area is likely to be satisfactory.
• Laser Doppler measurements of the microcirculation of the skin
• Skin fluorescent studies that also measure skin microcirculation
• Skin perfusion measurements using a blood pressure cuff and photoelectric detector
• Infrared measurements of skin temperature.

Though these tests may not predict the level of healing individually, but taken together, the results give the surgeon an excellent idea of the best place to amputate.

Care for

Effective care should be taken after amputation. Medication is prescribed for pain, and patients are treated with antibiotics to discourage infection. The stump should be moved often so as to improve circulation. Patients are advised to take up physiotherapy and rehabilitation as soon as possible, usually within 48 hours. Studies have shown that there is a positive relationship between early rehabilitation and effective functioning of the stump and prosthesis.

Rehabilitation

Rehabilitation is a long, arduous process, especially for above the knee amputees. Patients are usually recommended to go for physiotherapy twice a day. Many people feel a sense of loss and grief when they lose a body part; therefore it is important that these patients are given psychological counseling too. Some are bothered by phantom limb syndrome, where they feel as if the amputated part is still in place. They may even feel pain in this limb that does not exist. Many amputees benefit from joining self-help groups and meeting others who are also living with amputation. Addressing the emotional aspects of amputation often speeds the physical rehabilitation process.

Risks

Amputation is major surgery. All the risks associated with the administration of anesthesia exist, combined with the possibility of heavy blood loss and the development of blood clots. Infection is of special concern to amputees. Infection rates in amputations are generally an average of 15%. There might be cases when the stump may get infected. If this happens, it is necessary to remove the prosthesis and sometimes to amputate a second time at a higher level.

Many a times the stump may not heal, which is a major complication. This generally happens due to inadequate blood supply. The rate of nonhealing varies from 5-30% depending on the facility.

Persistent pain in the stump or pain in the phantom limb is experienced by most amputees to some degree. Treatment of phantom limb pain is difficult. One final complication is that many amputees give up on the rehabilitation process and discard their prosthesis. This problem has been checked by better fitting prosthetics and earlier rehabilitation.

Normal results

The five year survival rate for all lower extremity amputees is less than 50%. Up to 50% of people who have one leg amputated because of diabetes will lose the other within five years. For diabetic amputees, the rate is less than 40%. Those with artificial limbs, face difficulty in walking and have an unstable gait. Three to five percent of these people fall and break bones because of this instability. Although the fractures can be treated, about half the amputees who suffer them then remain wheelchair bound.

(to be concluded next week)