Lower Limb Amputation - Part Two

By Jonathan Blood Smyth

Diagnosis is relatively straightforward as most patients will have peripheral vascular disease and will have had considerable treatment for it already. As the small blood vessels block off gradually the toes can develop gangrene and ulcers on the pressure areas, which permits bacterial invasion leading eventually to bony infection. If treatment is incremental there may be a long period of minor amputations and other operations, all the time the patient being unable to walk due to pain in the limb. They may use wheelchair due to the pain and energy requirement of ambulation.

In accidents and injuries the amputation may be traumatic or involve a compound fracture severe enough to damage the nerves and blood vessels beyond salvaging. Here an amputation may be the best choice as against long term efforts at salvaging the damaged limb. An attempt at salvaging the limb may result in a non-functioning leg which is painful, leading to mood changes such as depression and limited activity. A careful assessment of the potential to save the limb needs to be made after the injury to avoid a lengthy and painful treatment period when amputation might deliver good function much sooner.

Keeping the length of the leg and achieving maximum functional independence is the main goal of the amputation process. Because the amputation cannot be undone the surgical decision must be a good one and the only obstacles then are the medical status of the patient in terms of coping with an operation. The abnormality of the limb has a medically negative effect on the overall health status of the patient and its removal may not only save the patient's life but allow them to restore their healthy status. Pre-operative preparation for the operation should prepare for their life after operation and include assessment by a social worker, psychologist and physiotherapist.

The management of severe trauma to the leg has dramatically improved with the ability to fix fractures internally, perform microsurgery to the blood vessels and attempting to restore the blood supply to areas where it is compromised. If these techniques do not work then amputation may be seen as a failure of treatment but should be seen as a reconstruction procedure leading to increased functional ability. Advances in amputation techniques have seen much less development and patients still present problems with feeling unstable, persistent pain, oedema and limited wear of the prosthesis.

Surgical technique is to maintain the length of the skin so that it can be folded over the stump and not be under any tension, the muscle is positioned over the cut bone end and opposing muscle groups may be stitched together and the nerves are cut when they are under tension and away from the bone ends so that they are in a non tension environment. One of the general rules for the length of an amputated limb is to allow 2.5cm of length for every 30cm of overall height. Once the operation is over the wound will have the chosen dressing applied and the patient be given post-operative painkillers.

After the immediate period post-operatively the patient will be assessed and treated by a physiotherapist who will review their respiratory condition, teach correct positioning of the remaining limb, encourage appropriate exercises, practice transfers and progress to walking with an aid if possible. Around the two week point the physiotherapist may progress to exercise for the affected extremity and start with a desensitisation programme for the operated part. This involves reducing the tenderness of the limb end so that it can cope with the pressures and stresses of wearing a prosthesis and weight bearing.

The wound and area may have settled by the six week point to allow the beginning of the development period for wearing the prosthesis, however some patients will not cope with using one due to poor understanding, muscular weakness and reduced balance capacity. There is a large number of complications which may get in the way of restoring the maximum degree of physical independence for the patient. As the local circulation is poor the wound may breakdown or the skin give problems, there may be local swelling, losses of joint movements, phantom sensations and pain problems. - 32188

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