Amputations

The term amputation in medical language means the removal of a part or the whole of an extremity. Such may be necessary in many con­ditions.

When an amputation is the direct result of an injury, it is referred to as traumatic ampu­tation, such as might occur when a finger is struck off by an axe. Others are performed se­lectively in conditions which make amputation mandatory to save life or to restore function. Amputation which is performed at a joint is known as a disarticulation (dis-joint). A sec­ondary amputation is called re-amputation. Operative procedure to improve the end of a previously amputated extremity is referred to as stump revision.

An attitude of conservatism is always main­tained by surgeons when amputation is to be considered. Any such crippling or deforming surgery is carefully avoided whenever conserva­tive measures offer even the slightest chance of recovery. Amputation may be deferred for long periods if any hope for disease recovery is pos­sible. Especially is such true in injured and/or infected limbs. Often time spent with conserva­tive measures pays great dividends in salvaging a limb.

Indeed, the psychological factors involved in amputation of a major limb or even a digit de­mand the greatest consideration. In prolonged disease where amputation may be anticipated, and especially with pain and disability, accept­ance of an amputation may not be difficult. But when amputation suddenly occurs follow­ing an injury, the psychological shock may be great; one day an individual is perfectly nor­mal, the next day he must accept his loss. An individual can do much on the behalf of him­self and his loved ones to meet the situation and try to attain maximal rehabilitation. To be sure, many of us with all our physical capabilities could well heed a lesson in resourcefulness from those with physical handicaps.

INDICATIONS FOR AMPUTA­TION

Indications for amputation are several, most of which are necessary for death or impending death of the part.

Injury is a frequent cause of amputation of a portion of an extremity. Such may be complete loss of a part by the injury itself, in which in­stance operative procedure to close and perfect the stump is necessary. When traumatic ampu­tation is partial, surgical procedure to recon­struct the tissues may be attempted; successful healing may be expected if there is adequate blood supply to the end fragment. In some in­stances, a part may be so badly mangled and the blood supply so completely destroyed, that amputation is the only choice (for example, the hand caught in a corn picker). In other cases of injury, infection may develop and rapidly spread, so that amputation is mandatory to save life.

Disturbance of circulation may give rise to a condition which necessitates amputation. Such is most common in the lower extremity. Arterio­sclerosis (artery-hardening) in the older age groups is the greatest offender; artery blood clots and other artery blockages, may also curtail adequate blood supply to a limb. The result is gangrene, or death of the part. Amputation for circulatory disturb­ance must be selected at a level where the blood supply is adequate, often much higher than the gangrenous part.

Tumor of a limb may indicate amputation. With malignant new growths, sacrifice of an extremity may be the only means of combating the spread; only very rarely does benign tumor indicate amputation. When cancer strikes in an extremity, its loss by amputation is a small price to pay for life, when dealing with this tragic disease. The ideal level of ablation must be well above the part involved in the spreading growth. Operation must be performed before there has been spread to other parts of the body. Malignant tumor of a limb requiring op­eration may take its origin in any of the extrem­ity parts—bones, muscles, fat, fascia, etc. Biopsy to confirm the nature of a tumor is most often necessary.

Infection of a limb, which is uncontrollable by other means, may give rise to indications for amputation. Such an infection may follow a major or minor injury to the limb, or may occur spontaneously; formerly osteomyelitis was a common cause. A serious specific offender still is gas gangrene infection. This occurs after injury when a specific type of germ gains entrance by a break in the skin; the organisms live on dead tissue, produce gas as their waste product, and spread rapidly. Treatment is by antitoxins, x-ray therapy, medi­cations, and incisions to expel the gases; but amputation of the involved limb may be neces­sary to spare life. Other various infections may also proceed unhalted in their course, even with the great armament against infection that the surgeon has at his command today, so that am­putation is life-saving.

Deformities of the extremities take a great variety of forms from a great variety of causes. Each demands individual consideration as to what is the best means of rehabilitating the afflicted individual to maximal functional capa­bilities as a whole. In some instances, deformity of a limb may suggest amputation as a means of restoration to a mode of life of maximal function and comfort.

METHODS OF AMPUTATION

Methods of amputation are several, but in general the technique is similar. Basically, the outer tissue layers must be cut longer to close over the underlying layers. The bone is to be the center core of the stump and is made slightly shorter than the overlying muscles. The muscles, fascia, and fat are closed over the bone end. Blood vessels are ligated (tied) securely to prevent bleeding. Nerves are treated by ligations and injections to preclude neuroma formation. The skin flaps usually are so designed that one is longer than the other so that the incision and subsequent scar are away from the weight-bearing bone end. This allows a more practical and painless stump for the fitting of an artificial limb.

Level of amputation is selected in consid­eration of an artificial device of functional use most nearly simulating the normal. Maximum length is always sought, but in some instances a substitute artificial part may be better fitted and more useful if the level of amputation is slightly higher. The ideal levels of removing a part of a limb, in consideration of the fitting of its substitute artifact and the function thereof. It must be realized that there are many variations in the ideal level of removal of a part, by individual consideration; generalities cannot be applied to singular cases.

PROSTHESES

A prosthesis is an artificial device which re­places a missing body part. A simulated struc­ture which substitutes for an amputated limb may be just as beneficial a replacement as the dental prosthesis (plate) is for extracted teeth; however, a greater adjustment is usually re­quired. It cannot be within the realm of this book to outline all the various and different types of prostheses. Each case of limb amputa­tion requires individual consideration for fit­ting. The surgeon keeps under consideration the principles of successful prosthesis fitting when he performs an amputation. Various physical treatments are included in the post­operative care to prepare the amputated limb for fitting. In some cases a temporary device will be used to hasten the readiness of the stump for wearing the artificial part. As a rule, a pros­thesis may be applied 6 weeks or more after the amputation.

The prosthesis-maker, or prosthetist, is the person who specializes in the construction and fitting of artificial limbs. The appliance that will replace the lost member is designed to give the greatest comfort, maximal functional value, and natural appearance. Today prostheses are well perfected for use by all ages.

For the lower extremity there are two main types of prostheses. The end-bearing type is that by which the weight of the body is borne directly on the stump end. With the cone-bear­ing prosthesis the body weight is borne above the end by a cone-shaped socket fitted over the stump; with this type the stump itself acts as a lever to activate the prosthesis.

The primary functions of the upper extrem­ity are grasp and touch. A great variety of prostheses have been designed which can pro­vide the grasp but cannot replace the lost sen­sation of touch. The cineplastic amputation is one which enables the transmission of volun­tary movement of a muscle to a prosthesis. This has been mostly applicable to forearm ampu­tation, in which a tunnel of skin is made through the biceps muscle into which a peg is placed to transmit the pull of the muscle to the terminal apparatus. Many other such surgical schemes are currently under investigation.

Perseverance and patience are all-important qualities in accepting an amputation and learn­ing to utilize a prosthesis.

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