Amputations may be the result of congenital limb deficiencies or may be acquired. Acquired amputations are traumatic, ischemic, or surgical in origin. Surgical amputation is an ancient procedure. At first glance amputation may appear a purely destructive measure, incompatible with recognized orthopedic principles of physical conservation and restoration. Usually, however, amputation is the only essential first step to a series of measures designed to achieve ultimately the maximum rehabilitation of the patient. The surgeon who plans an amputation should be prepared not only to execute the surgical operation but also to direct postoperative care, including physical therapy and preparation of the stump for use of the prosthesis; to deal with the patient’s emotional problems associated with limb loss; to guide the patient’s return to work; to look over the proper selection and fitting of the prosthesis and adequate training in its use; and to carry out a medical follow-up that may last for several years. Such considerations emphasize the close relationship that exists between amputations and reconstructive orthopaedic surgery.
Surgical amputation should be done when in the judgment of physician and patient if the patient’s welfare will be significantly improved by the removal of an irreparably damaged, deformed, dangerous, painful, or useless part of the body. The supporting opinion of a consultant is helpful and reassures the patient when a major amputation is recommended. When the blood supply of a limb has been lost and cannot be restored, amputation is always necessary. In permanent, irreparable loss of nerve supply, amputation is occasionally indicated to remove a limb or part of a limb that may be useless, unsightly, and subject to chronic ulceration and other trophic changes. The most common reasons for amputation are (1) vascular disease or accident; (2) trauma; (3) tumor; (4) infection; (5) thermal, chemical, or electrical injury; and (6) congenital anomaly.
Local blood supply, especially in the lower limbs may be destroyed suddenly by thrombosis or embolism or gradually by peripheral vascular disease such as arteriosclerosis or thromboangiitis obliterans. For a limb with impaired circulation, arterial reconstruction should always be considered by orthopedic surgeons. When an adequate blood supply cannot be maintained or restored by treatment, gangrene ensues and amputation becomes necessary.
Amputation is indicated when severe trauma has so destroyed the blood supply or so damaged the tissues of the limb that gangrene is inevitable or useful reconstruction is impossible. Although some severely injured limbs may be salvaged by microvascular surgery, trauma remains the most frequent cause of amputation of the upper limb.
Amputation is frequently indicated when a limb is involved by a primary malignant tumor, of which osteogenic sarcoma is a classic example. Amputation should not be done, however, until it has been ascertained, usually by biopsy, that the tumor is definitely malignant and that it cannot be treated satisfactorily by measures such as irradiation, resection, or both. Limb salvage surgery can be an option for certain malignant tumors; its feasibility must be considered though before considering amputation.
In acute fulminating infections that endanger life by extending proximally and that cannot be controlled by less radical means, amputation is indicated. The commonest of these infections is gas gangrene of high virulence. In chronic infection, such as a long-standing draining osteomyelitis that has not responded to medical and ordinary surgical treatment, amputation may be indicated because of either local or systemic sequelae. However, amputations for infection and its sequelae are uncommon today as improved methods for the control of acute sepsis and chronic bone infection have been developed.
Extensive, severe tissue damage from excessive heat or cold or from chemical or electrical burns may necessitate amputation. Occasionally radiation therapy, used in treating a malignant tumor of a limb, may, in destroying the neoplasm, so damage normal tissue that amputation becomes necessary.
Several types of congenital anomaly are best treated by amputation. Supernumerary fingers or toes form a clear example; amputation is indicated when they impair appearance or function. Congenital absence of distal parts of a limb may require amputation for the modeling of a stump satisfactory for prosthesis.
Because of its better blood supply, the upper limb requires amputation less frequently than the lower. This is fortunate, because the requirements of upper limb function are not nearly so well met by prosthetic devices as are those of the lower extremity. These requirements include fine, coordinated movements of the hand, tactile sensation, and proprioceptive feedback of pressure and position. Prosthetic rejection is common in upper limb amputees, and the higher the amputation, especially above the elbow, the less likely is the amputee to accept and wear prosthesis. On the other hand, amputations of the lower limb are about five times as common as those of the upper limb. The most important requirement of the lower extremity stump is that it be able to bear weight in standing and walking.
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