Amputation is the removal of a limb by trauma, medical illness, or surgery. As a surgical measure, it is used to control pain or a disease process in the affected limb, such as malignancy or gangrene. In some cases, it is carried out on individuals as a preventative surgery for such problems. A special case is that of congenital amputation, a congenital disorder, where fetal limbs have been cut off by constrictive bands. In some countries, amputation of the hands, feet or other body parts is or was used as a form of punishment for people who committed crimes. Amputation has also been used as a tactic in war and acts of terrorism; it may also occur as a war injury. In some cultures and religions, minor amputations or mutilations are considered a ritual accomplishment.
In the US, the majority of new amputations occur due to complications of the vascular system (the blood vessels), especially from diabetes. Between 1988 and 1996, there were an average of 133,735 hospital discharges for amputation per year in the US. In 2005, just in the US, there were 1.6 million amputees. In 2013, the US has 2.1 million amputees. Approximately 185,000 amputations occur in the United States each year. In 2009, hospital costs associated with amputation totaled more than $8.3 billion. There will be an estimated 3.6 million people in the US living with limb loss by 2050. African‐Americans are up to four times more likely to have an amputation than white Americans.
|J. McKnight, who lost his limbs in a railway accident in 1865, was the second recorded survivor of a simultaneous triple amputation.|
Lower limb, or leg, amputations can be divided into two broad categories - minor amputations and major amputations, Minor amputations generally refers to the amputation of digits. Major amputations are commonly referred to as below-knee amputation, above-knee amputation and so forth. To avoid ambiguity the correct terminology for major amputations is described in ISO 8549-2:1989, these being:
Common partial foot amputations include Chopart, Lisfranc and ray amputations, Common forms of ankle disarticulations include Syme, Pyrogoff and Boyd. A less commonly occurring major amputation is the Van Ness rotation/rotationplasty (foot being turned around and reattached to allow the ankle joint to be used as a knee).
The correct terminology for arm, or upper-limb amputations is also described in ISO 8549-2:1989, these being:
A variant of the trans-radial amputation is the Krukenberg procedure in which the radius and ulna are used to create a stump capable of a pincer action.
Many of these facial disfigurings were and still are done in some parts of the world as punishment for some crimes, and as individual shame and population terror practices.
Genital modification and mutilation may involve amputating tissue, although not necessarily as a result of injury or disease.
In some rare cases when a person has become trapped in a deserted place, with no means of communication or hope of rescue, the victim has amputated his or her own limb. The most notable case of this is Aron Ralston, a hiker who amputated his own right forearm after it was pinned by a boulder in a hiking accident and he was unable to free himself for over five days.
Body integrity identity disorder is a psychological condition in which an individual feels compelled to remove one or more of their body parts, usually a limb. In some cases, that individual may take drastic measures to remove the offending appendages, either by causing irreparable damage to the limb so that medical intervention cannot save the limb, or by causing the limb to be severed.
Sometimes professional athletes may choose to have a non-essential digit amputated to relieve chronic pain and impaired performance.
The first step is ligating the supplying artery and vein, to prevent hemorrhage (bleeding). The muscles are transected, and finally, the bone is sawed through with an oscillating saw. Sharp and rough edges of the bone(s) are filed down, skin and muscle flaps are then transposed over the stump, occasionally with the insertion of elements to attach a prosthesis.
Distal stabilisation of muscles is recommended. This allows effective muscle contraction which reduces atrophy, allows functional use of the stump and maintains soft tissue coverage of the remnant bone. The preferred stabilisation technique is myodesis where the muscle is attached to the bone or its periostium. In joint disarticulation amputations tenodesis may be used where the muscle tendon is attached to the bone. Muscles should be attached under similar tension to normal physiological conditions.
In 1920, Professor Janos Ertl, Sr., MD, of Hungary, developed the Ertl procedure in order to return a high number of amputees to the work force. The Ertl technique, an osteomyoplastic procedure for transtibial amputation, can be used to create a highly functional residual limb. Creation of a tibiofibular bone bridge provides a stable, broad tibiofibular articulation that may be capable of some distal weight bearing. Several different modified techniques and fibular bridge fixation methods have been used; however, no current evidence exists regarding comparison of the different techniques.
The use of rigid removable dressings (RRD's) in trans-tibial (below knee) amputations, rather than soft bandaging has been shown to improve healing time, reduce edema, prevent knee flexion contractures and reduce complications, including further amputation, from external trauma such as falls onto the stump and should be considered standard practice.
Post-operative management, in addition to wound healing, should consider maintenance of limb strength, joint range, edema management, preservation of the intact limb (if applicable) and stump desensitisation.
Traumatic amputation of a human limb, either partial or total, creates the immediate danger of death from blood loss.
Orthopedic surgeons often assess the severity of different injuries using the Mangled Extremity Severity Score. Given different clinical and situational factors, they can predict the likelihood of amputation. This is especially useful for emergency physicians to quickly evaluate patients and decide on consultations.
Traumatic amputation is uncommon in humans (1 per 20,804 population per year). Loss of limb usually happens immediately during the accident, but sometimes a few days later after medical complications. Statistically the most common causes of traumatic amputations are:
The development of the science of microsurgery over last 40 years has provided several treatment options for a traumatic amputation, depending on the patient's specific trauma and clinical situation:
Amputations are usually traumatic experiences. They can reduce the quality of life for patients in addition to being expensive. In the USA, a typical prosthetic limb costs in the range of $10,000–15,000 according to the American Diabetic Association. In some populations, preventing amputations is a critical task.
Methods in preventing amputation, limb-sparing techniques, depend on the problems that might cause amputations to be necessary. Chronic infections, often caused by diabetes or decubitus ulcers in bedridden patients, are common causes of infections that lead to gangrene, which would then necessitate amputation.
There are two key challenges: first, many patients have impaired circulation in their extremities, and second, they have difficulty curing infections in limbs with poor vasculation (blood circulation).
Crush injuries where there is extensive tissue damage and poor circulation also benefit from hyperbaric oxygen therapy (HBOT). The high level of oxygenation and revascularization speed up recovery times and prevent infections.
A study found that the patented method called Circulator Boot achieved significant results in prevention of amputation in patients with diabetes and arterioscleorosis. Another study found it also effective for healing limb ulcers caused by peripheral vascular disease. The boot checks the heart rhythm and compresses the limb between heartbeats; the compression helps cure the wounds in the walls of veins and arteries, and helps to push the blood back to the heart.
For victims of trauma, advances in microsurgery in the 1970s have made replantations of severed body parts possible.
The establishment of laws, rules, and guidelines, and employment of modern equipment help protect people from traumatic amputations.
The individual may experience psychological trauma and emotional discomfort. The stump will remain an area of reduced mechanical stability. Limb loss can present significant or even drastic practical limitations.
A large proportion of amputees (50–80%) experience the phenomenon of phantom limbs; they feel body parts that are no longer there. These limbs can itch, ache, burn, feel tense, dry or wet, locked in or trapped or they can feel as if they are moving. Some scientists believe it has to do with a kind of neural map that the brain has of the body, which sends information to the rest of the brain about limbs regardless of their existence. Phantom sensations and phantom pain may also occur after the removal of body parts other than the limbs, e.g. after amputation of the breast, extraction of a tooth (phantom tooth pain) or removal of an eye (phantom eye syndrome).
A similar phenomenon is unexplained sensation in a body part unrelated to the amputated limb. It has been hypothesized that the portion of the brain responsible for processing stimulation from amputated limbs, being deprived of input, expands into the surrounding brain, (Phantoms in the Brain: V.S. Ramachandran and Sandra Blakeslee) such that an individual who has had an arm amputated will experience unexplained pressure or movement on his face or head.
In many cases, the phantom limb aids in adaptation to a prosthesis, as it permits the person to experience proprioception of the prosthetic limb. To support improved resistance or usability, comfort or healing, some type of stump socks may be worn instead of or as part of wearing a prosthesis.
Another side effect can be heterotopic ossification, especially when a bone injury is combined with a head injury. The brain signals the bone to grow instead of scar tissue to form, and nodules and other growth can interfere with prosthetics and sometimes require further operations. This type of injury has been especially common among soldiers wounded by improvised explosive devices in the Iraq War.
Due to technologic advances in prosthetics, many amputees live active lives with little restriction. Organizations such as the Challenged Athletes Foundation have been developed to give amputees the opportunity to be involved in athletics and adaptive sports such as Amputee Soccer.
Nearly half of the individuals who have an amputation due to vascular disease will die within 5 years. This is higher than the five year mortality rates for breast cancer, colon cancer, and prostate cancer. Of persons with diabetes who have a lower extremity amputation, up to 55% will require amputation of the second leg within two to three years.
The word amputation is derived from the Latin amputare, "to cut away", from ambi- ("about", "around") and putare ("to prune"). The English word “Poes” was first applied to surgery in the 17th century, possibly first in Peter Lowe's A discourse of the Whole Art of Chirurgerie (published in either 1597 or 1612); his work was derived from 16th-century French texts and early English writers also used the words "extirpation" (16th-century French texts tended to use extirper), "disarticulation", and "dismemberment" (from the Old French desmembrer and a more common term before the 17th century for limb loss or removal), or simply "cutting", but by the end of the 17th century "amputation" had come to dominate as the accepted medical term.
Amputee sports classification is a disability specific sport classification used for disability sports to facilitate fair competition among people with different types of amputations. This classification was set up by International Sports Organization for the Disabled (ISOD), and is currently managed by IWAS who ISOD merged with in 2005. Several sports have sport specific governing bodies managing classification for amputee sportspeople.
Classification for amputee athletes began in the 1950s and 1960s. By the early 1970s, it was formalized with 27 different classes. This as reduced to 12 in 1976, and then down to 9 in 1992 ahead of the Barcelona Paralympics. By the 1990s, a number of sports had developed their own classification systems that in some cases were not compatible with the ISOD system. This included swimming, table tennis and equestrian as they tried to integrate multiple types of disabilities in their sports.Amputee sportspeople have specific challenges that different from other types of disability sportspeople.
The classes for ISOD's amputee sports classification system are A1, A2, A3, A4, A5, A6, A7, A8 and A9. The first four are for people with lower limb amputations. A5 through A8 are for people with upper limb amputations. A9 is for people with combinations of upper and lower limb amputations. The classification system is largely medical, and generally has four stages. The first is a medical examination. The second is observation at practice or training. The third is observation during competition. The final is being put into a classification group. There is some variance to this based on sport specific needs.Body integrity dysphoria
Body integrity dysphoria (BID, also referred to as body integrity identity disorder, amputee identity disorder and xenomelia, formerly called apotemnophilia) is a disorder characterized by a desire to be disabled or discomfort with being able-bodied beginning in early adolescence and resulting in harmful consequences. BID appears to be related to somatoparaphrenia. People with this condition may refer to themselves as "transabled".Bone tumor
A bone tumor is a neoplastic growth of tissue in bone. Abnormal growths found in the bone can be either benign (noncancerous) or malignant (cancerous).
Average five-year survival in the United States after being diagnosed with bone and joint cancer is 67%.Clitoridectomy
Clitoridectomy or clitorectomy is the surgical removal, reduction, or partial removal of the clitoris. It is rarely used as a therapeutic medical procedure, such as when cancer has developed in or spread to the clitoris. It is often performed on intersex newborns. Commonly, non-medical removal of the clitoris is performed during female genital mutilation (FGM).Congenital amputation
Congenital amputation is birth without a limb or limbs, or without a part of a limb or limbs.
It is known to be caused by blood clots forming in the fetus while in utero (vascular insult) and from amniotic band syndrome: fibrous bands of the amnion that constrict foetal limbs to such an extent that they fail to form or actually fall off due to missing blood supply. Congenital amputation can also occur due to maternal exposure to teratogens during pregnancy.Critical limb ischemia
Critical limb ischemia (CLI), also referred to as limb threat, is an advanced stage of peripheral artery disease (PAD). It is defined as a triad of ischemic rest pain, arterial insufficiency ulcers, and gangrene. The latter two conditions are jointly referred to as tissue loss, reflecting the development of surface damage to the limb tissue due to the most severe stage of ischemia. Compared to the other manifestation of PAD, intermittent claudication, CLI has a negative prognosis within a year after the initial diagnosis, with 1-year amputation rates of approximately 12% and mortality of 50% at 5 years and 70% at 10 years.CLI was conceived to identify patients at high-risk for major amputation, but the increasing prevalence of diabetes mellitus has led to a broader conception of limb threat that includes the risk of amputation associated with severely infected and non-healing wounds.Diabetic foot
A diabetic foot is a foot that exhibits any pathology that results directly from diabetes mellitus or any long-term (or "chronic") complication of diabetes mellitus. Presence of several characteristic diabetic foot pathologies such as infection, diabetic foot ulcer and neuropathic osteoarthropathy is called diabetic foot syndrome.
Due to the peripheral nerve dysfunction associated with diabetes (diabetic neuropathy), patients have a reduced ability to feel pain. This means that minor injuries may remain undiscovered for a long while. People with diabetes are also at risk of developing a diabetic foot ulcer. Research estimates that the lifetime incidence of foot ulcers within the diabetic community is around 15% and may become as high as 25%.In diabetes, peripheral nerve dysfunction can be combined with peripheral artery disease (PAD) causing poor blood circulation to the extremities (diabetic angiopathy). Around half of patients with a diabetic foot ulcer have co-existing PAD.Where wounds take a long time to heal, infection may set in and lower limb amputation may be necessary. Foot infection is the most common cause of non-traumatic amputation in people with diabetes.Gangrene
Gangrene is a type of tissue death caused by a lack of blood supply. Symptoms may include a change in skin color to red or black, numbness, swelling, pain, skin breakdown, and coolness. The feet and hands are most commonly affected. Certain types may present with a fever or sepsis.Risk factors include diabetes, peripheral arterial disease, smoking, major trauma, alcoholism, HIV/AIDS, frostbite, and Raynaud's syndrome. It can be classified as dry gangrene, wet gangrene, gas gangrene, internal gangrene, and necrotizing fasciitis. The diagnosis of gangrene is based on symptoms and supported by tests such as medical imaging.Treatment may involve surgery to remove the dead tissue, antibiotics to treat any infection, and efforts to address the underlying cause. Surgical efforts may include debridement, amputation, or the use of maggot therapy. Efforts to treat the underlying cause may include bypass surgery or angioplasty. In certain cases, hyperbaric oxygen therapy may be useful. How commonly the condition occurs is unknown.Hemicorporectomy
Hemicorporectomy is a radical surgery in which the body below the waist is amputated, transecting the lumbar spine. This removes the legs, the genitalia (internal and external), urinary system, pelvic bones, anus, and rectum. It is a severely mutilating procedure recommended only as a last resort for people with severe and potentially fatal illnesses such as osteomyelitis, tumors, severe traumas and intractable decubiti in, or around, the pelvis. It has only been reported a few dozen times in medical literature.The nomenclature is somewhat at odds with generally accepted anatomical terms, as hemi is generally used to refer to one of two sides (e.g., hemiplegia, which affects the arm and leg on one side of the body). In that sense, paracorporectomy might more closely reflect the nature of the procedure.Hemipelvectomy
A hemipelvectomy is a high level pelvic amputation. Along with hip disarticulations, hemipelvectomies are the rarest of lower extremity amputations. In some cases, an internal hemipelvectomy can be performed, which is a limb-sparing procedure. A complete hemipelvectomy, however, is the amputation of half of the pelvis and the leg on that side. This type of procedure is also called transpelvic amputation.
Hemipelvectomies may be required for several reasons, such as a car accident or cancer. Examples of cancers that can require hemipelvectomies are sarcomas like Ewing's Sarcoma, osteosarcoma or chondrosarcoma.
People who have experienced a hemipelvectomy may or may not be able to use a prosthesis. They may use adaptive devices such as a wheelchair, underarm crutches, forearm crutches, or, in the case of internal hemipelvectomies, a cane.
Physical therapy can be useful to those with hemipelvectomies to build strength and prevent problems like back pain and scoliosis. Because a hemipelvectomy is a rare type of amputation, it is important that the physical therapist is trained in the special needs of a post-hemipelvectomy patient.
There are two types of hemipelvectomy:
External - Amputation of the whole leg plus the pelvis on that side. Another name for external hemipelvectomy is hindquarter amputation.
Internal - Removal of the pelvis on the one side, but without removal of the leg.Hudud
Hudud (Arabic: حدود Ḥudūd, also transliterated hadud, hudood; plural of hadd, حد) is an Arabic word meaning "borders, boundaries, limits". In the religion of Islam it refers to punishments that under Islamic law (shariah) are mandated and fixed by God. These punishments were rarely applied in pre-modern Islam, and their use in some modern states has been a source of controversy.
Traditional Islamic jurisprudence divides crimes into offenses against God and those against man. The former are seen to violate God's hudud or "boundaries", and they are associated with punishments specified in the Quran and in some cases inferred from hadith. The offenses incurring hudud punishments are zina (unlawful sexual intercourse such as fornication), unfounded accusations of zina, drinking alcohol, highway robbery, and some forms of theft. Jurists have differed as to whether apostasy from Islam and rebellion against a lawful Islamic ruler are hudud crimes.Hudud punishments range from public lashing to publicly stoning to death, amputation of hands and crucifixion. Hudud crimes cannot be pardoned by the victim or by the state, and the punishments must be carried out in public. These punishments were rarely implemented in practice, however, because the evidentiary standards were often impossibly high. For example, meeting hudud requirements for zina and theft was virtually impossible without a confession, which could be invalidated by a retraction. Based on a hadith, jurists stipulated that hudud punishments should be averted by the slightest doubts or ambiguities (shubuhat, sing. shubha). The harsher hudud punishments were meant to deter and to convey the gravity of offenses against God, rather than to be carried out.During the 19th century, sharia-based criminal laws were replaced by statutes inspired by European models nearly everywhere in the Islamic world, except some particularly conservative regions such as the Arabian peninsula. The Islamic revival of the late 20th century brought along calls by Islamist movements for full implementation of sharia. Reinstatement of hudud punishments has had particular symbolic importance for these groups because of their Quranic origin, and their advocates have often disregarded the stringent traditional restrictions on their application. In practice, in the countries where hudud have been incorporated into the legal code under Islamist pressure, they have often been used sparingly or not at all, and their application has varied depending on local political climate. Their use has been a subject of criticism and debate.
Hudud is not the only form of punishment under sharia. For offenses against man — the other type of crime in Sharia — that involve inflicting bodily harm Islamic law prescribes a retaliatory punishment analogous to the crime (qisas) or monetary compensation (diya); and for other crimes the form of punishment is left to the judge's discretion (ta'zir). Criminals who escaped a hudud punishment could still receive a ta'zir sentence. In practice, since early on in Islamic history, criminal cases were usually handled by ruler-administered courts or local police using procedures that were only loosely related to sharia.Liston knife
The Liston knife is a type of knife used in surgical amputation.
The knife was named after Robert Liston a Scottish surgeon noted for his skill and speed in an era prior to anaesthetics, when speed made a difference in terms of pain and survival. The knife was made out of high-quality metal and had a typical blade length of 6–8 inches. Surgical amputation knives came in many styles and changed very much between 1840 and the American Civil War. These changes reflect changes in techniques used by the surgeons and makers of surgical knives during the period.
Amputation blades from the 18th century to the 1840s are generally known for their distinctive "down" curving blades. By 1870, amputation blades had become straighter, and more closely resembled the "Liston" European style. Since the Crimean War ended in 1856, it is likely the American Civil War had a greater impact on long slender blade style than the actual Dr. Liston. The dedicated task of amputation may be more responsible for the Liston title than any specific design.
It is noted by collectors that the handles on earlier knives (pre-1850) are of a much bigger and heavier construction.
The majority of the history of amputation blade evolution is referenced from the medical textbook Handbook of Surgical Operations, U.S.A. Medical Department, 1863, written during the Civil War by Stephen Smith, M.D., with various drawings from the medical literature credited to Bourgery & Jocob.Penectomy
Penectomy is penis removal through surgery, generally for medical or personal reasons.Phantom limb
A phantom limb is the sensation that an amputated or missing limb is still attached. Approximately 60 to 80% of individuals with an amputation experience phantom sensations in their amputated limb, and the majority of the sensations are painful. Phantom sensations may also occur after the removal of body parts other than the limbs, e.g. after amputation of the breast, extraction of a tooth (phantom tooth pain) or removal of an eye (phantom eye syndrome).Phantom pain
Phantom pain sensations are described as perceptions that an individual experiences relating to a limb or an organ that is not physically part of the body. Limb loss is a result of either removal by amputation or congenital limb deficiency. However, phantom limb sensations can also occur following nerve avulsion or spinal cord injury.
Sensations are recorded most frequently following the amputation of an arm or a leg, but may also occur following the removal of a breast, teeth, or an internal organ. Phantom limb pain is the feeling of pain in an absent limb or a portion of a limb. The pain sensation varies from individual to individual.
Phantom limb sensation is any sensory phenomenon (except pain) which is felt at an absent limb or a portion of the limb. It has been known that at least 80% of amputees experience phantom sensations at some time of their lives. Some experience some level of this phantom pain and feeling in the missing limb for the rest of their lives.
The term "phantom limb" was first coined by American neurologist Silas Weir Mitchell in 1871. Mitchell described that "thousands of spirit limbs were haunting as many good soldiers, every now and then tormenting them". However, in 1551, French military surgeon Ambroise Paré recorded the first documentation of phantom limb pain when he reported that, "For the patients, long after the amputation is made, say that they still feel pain in the amputated part".Prosthesis
In medicine, a prosthesis (plural: prostheses; from Ancient Greek prosthesis, "addition, application, attachment") or prosthetic implant is an artificial device that replaces a missing body part, which may be lost through trauma, disease, or is a condition present at birth (congenital disorder). Prostheses are intended to restore the normal functions of the missing body part. Amputee rehabilitation is primarily coordinated by a physiatrist as part of a inter-disciplinary team consisting of physiatrists, prosthetists, nurses, physical therapists, and occupational therapists. Prostheses can be created by hand or with CAD (Computer-Aided Design), a software interface that helps creators visualize the creation in a 3D form.T43 (classification)
T43 is a disability sport classification for disability athletics (track and jump events only), applying to athletes with "Double below knee amputation (or combined arm/leg amputation) or similar disability." It includes ISOD classified athletes from the A4 and A9 classes.T46 (classification)
T46 and F46 are disability sport classification for disability athletics. People in this class have a single below or above the elbow amputation. The amputee sports equivalent class is ISOD the A6 and A8 classes. People in this class can have injuries as a result of over use of their remaining upper limb. The classification process to be included in this class has four parts: a medical exam, observation during training, observation during competition and then being classified into this class.Traumatic neuroma
A traumatic neuroma (also known as "amputation neuroma" or "pseudoneuroma") is a type of neuroma which results from trauma to a nerve, usually during a surgical procedure. The most common oral locations are on the tongue and near the mental foramen of the mouth. They are relatively rare on the head and neck.