Amputation: Information & Amputation Specialists

The causes can vary widely. The leading cause, accounting for about 90 percent of cases, is chronic arterial occlusive disease (atherosclerosis—commonly known as “hardening of the arteries”). It can occur in combination with diabetes mellitus (diabetes).

Arteriosclerosis

When arteries become narrowed or even completely blocked, the tissue beyond the narrowing receives less oxygen. This can lead to tissue death. If the person also has diabetes mellitus, a metabolic disorder is added to the mix.

Therefore, atherosclerosis—especially when combined with diabetes—is the most common cause of amputation.

Risk factors for atherosclerosis also include a sedentary lifestyle combined with lipid metabolism disorders and diabetes. Smoking has a particularly adverse effect (“smoker’s leg”).

Illustration of a narrowed blood vessel due to atherosclerosis © peterschreiber.media | AdobeStock

Diabetic Foot

This differs from the so-called diabetic foot, which is based on diabetic neuropathy (nerve damage) without occlusion of the large blood vessels. Due to the nerve damage, the blood vessels tend to be dilated, and blood flow is sometimes even increased. Consequently, amputation is less frequently necessary in these cases.

The causes of amputation in these cases stem from the sometimes accompanying destruction of bones and joints (osteoarthropathy). A neuropathic ulcer may also develop, usually on the sole of the foot. Infections enter from the outside in.

However, blood flow is often still sufficient in these cases. Therefore, resection of individual bones is frequently sufficient, while the foot can be preserved to the greatest extent possible.

Infections

Infections, primarily following accidents and tumors (about 10 percent overall), can also lead to amputation. Only in rare cases of limb malformation is amputation necessary to improve the fit of a prosthesis or orthosis.

Here, a distinction must be made between

• chronic arterial occlusive disease with or without diabetes mellitus and
• diabetic neuropathic foot

.

Chronic arterial occlusive disease with or without diabetes mellitus

Chronic arterial occlusion begins with exertional pain in the lower extremities. The pain results from insufficient oxygen supply (progressive ischemia). O

Often, patients can walk only 100 to 200 m or less before the pain in their legs becomes too severe (“intermittent claudication”). They must then stop until an adequate oxygen supply is restored to the lower extremities.

Over time, this symptom worsens and, in extreme cases, leads to pain even at rest. Similarly (Stage IV according to Fontaine), tissue death (necrosis) occurs.

An important sign is the disappearance of arterial pulses in the lower extremities. In addition, the feet are often cold. However, sensation and pain are present without neuropathic changes.

Neuropathic Diabetic Foot

Due to nerve damage, the blood vessels in the lower extremities—especially in the feet—often dilate. This results in swelling of the feet.

This swelling cannot be treated with lymphatic drainage. In addition, increasing numbness in the foot is noticeable. This can result in accidentally and unnoticed penetration of sharp objects into the sole of the foot. These objects become infected and then lead to an ulcer.

Bacteria can enter the interior of the foot through this ulcer and cause severe infections there. These infections usually require surgical treatment.

In summary, the neuropathic diabetic foot is characterized by

• sensation,
• pain perception, and
• temperature sensation

are reduced or, depending on the stage of the disease, completely lost.

A freshly bandaged leg stump after an amputation © Choo | AdobeStock

Chronic arterial occlusive disease with or without diabetes mellitus

It is recommended to see an angiologist at the latest when the first signs appear, such as calf pain or a reduced walking distance. Depending on the stage of the occlusive disease, the angiologist will prescribe medication or a tailored physical therapy regimen.

Once tissue in the feet begins to die off—typically at Fontaine Stage III or IV—amputation may be considered. However, this is only an option if vascular reconstruction by a vascular surgeon is no longer possible.

A Brückner-type lower-leg amputation offers the best prospects for rehabilitation, with a knee preservation rate of 93 percent. Preserving the knee ensures better mobility in the patient’s daily life. 

In rare cases, amputation at the knee joint or in the thigh area is necessary.

Neuropathic Diabetic Foot

It may be necessary to immobilize the foot or surgically remove the infection in the foot area. In some cases, individual bones may need to be removed.

The main challenge is to prevent foot ulcers as much as possible. To achieve this,

• providing the patient with appropriate guidance on future care and
• providing shoes appropriate for the stage of the condition

.

The patient or their caregivers must inspect the feet daily. At the slightest sign of change, the diabetologist or an orthopedic surgeon/trauma surgeon should be consulted.

Post-traumatic amputations and tumors

In cases of infections following accidents or primary accident-related limb amputation, as well as tumors, the level of amputation is determined by the extent to which the affected tissue can be separated from healthy tissue.

Amputations in the hip or pelvic region are also possible in these cases (hip disarticulation or hemipelvectomy).

Immediately after surgery, the stump is bandaged. Care must be taken to ensure that, in cases of circulatory disorders, the pressure—especially over bony prominences—is not too high. During the first 14 days, checks are required at least four times a day.

For amputations following an accident or tumor, the stump is bandaged from the bottom up with decreasing pressure to prevent edema.

Following the amputation, optimal prosthetic fitting and training—both with and without the prosthesis—at a competent rehabilitation clinic are urgently needed.

It is strongly recommended that the initial prosthetic fitting be performed by a team. The following are highly recommended:

• a physician with experience in prosthetics,
• physical therapists, and
• a prosthetist located as close to the patient’s home as possible.

Subsequent adjustments can then be made by the orthotist in the patient’s hometown based on the initial fitting.

The idea that an expensive prosthesis will solve gait problems on its own is a complete misconception. With any type of prosthesis, it is necessary to learn a new gait pattern under expert supervision.

Chronic arterial occlusive disease

The prognosis for healing following an amputation due to severe circulatory disorders is challenging, but not impossible. In most cases, a prosthetic fitting can be performed.

2. Neuropathic diabetic foot

The most important prerequisite for managing a neuropathic diabetic foot is optimal blood sugar control. However, if there are advanced, irreversible nerve disorders, the diabetic foot is irreversible, and treatment must be tailored accordingly.

Any ulcers or bone changes that have developed should generally be limited to a minimum of tissue loss. This can be achieved conservatively through immobilization or by resecting affected bone segments (known as an “internal amputation”).

Major amputations (of the entire foot, lower leg, or even the thigh) are rarely necessary.

Sports After an Amputation

Primarily younger amputees without chronic arterial occlusive disease can resume sports activities with a prosthesis. The Paralympics demonstrate this impressively.