Amputation: Information & amputation specialists

Possible causes of an amputation

The causes can be many and varied. Chronic arterial occlusive disease(arteriosclerosis - colloquially known as "hardening of the arteries") is the most common indication, accounting for around 90 percent of cases. It can occur in combination with diabetes mellitus (diabetes).

Arteriosclerosis

If arteries are narrowed or even blocked, the tissue is supplied with less oxygen after the narrowing. This can lead to dying tissue. If the person also suffers from diabetes mellitus, there is also a metabolic disorder.

This is why arteriosclerosis, especially in combination with diabetes, is the most common reason for amputation.

Risk factors for arteriosclerosis are also physical inactivity in conjunction with lipometabolic disorders and diabetes. Smoking has a particularly unfavorable effect ("smoker's leg").

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

Diabetic foot

This differs from the so-called diabetic foot due to diabetic neuropathy (nerve disorder) without occlusion of the large vessels. Due to the nerve disorder, the vessels tend to be dilated and blood flow is sometimes even increased. As a result, amputations are less frequent in these cases.

The causes of amputation in this case are the sometimes accompanying destruction of the bones and joints (osteoarthropathy). A neuropathic ulcer can also occur, which usually forms on the sole of the foot. The infections occur from the outside in.

However, the blood supply is often still sufficient in these cases. It is therefore often sufficient to resect individual bones, while the foot can be preserved as far as possible.

Infections

Infections, mainly after accidents and tumors (about 10 percent in total) can also lead to amputation. Only in rare cases does a limb deformity require amputation to improve fitting with a prosthesis or orthosis.

Initial symptoms that can lead to amputation

A distinction must be made here between

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

must be distinguished.

Chronic arterial occlusive disease with or without diabetes mellitus

Chronic occlusive arterial disease begins with pain on exertion in the lower extremities. The pain is caused by insufficient oxygen supply (increasing ischemia). O

Patients can often only walk 100 to 200 m or less before the pain in the legs becomes too severe ("intermittent claudication"). They then have to stand still until sufficient oxygen supply is restored to the lower extremities.

Over time, this symptom intensifies and in extreme cases leads to pain at rest. Similarly (stage IV according to Fontaine), the tissue dies (necrosis).

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

Neuropathic diabetic foot

The nerve disorder often causes the vessels in the lower extremities to dilate, especially in the foot area. This results in swelling of the foot.

This swelling cannot be treated by lymphatic drainage. In addition, the increasing numbness in the foot area is noticeable. This can lead to sharp objects accidentally entering the sole of the foot unnoticed. These become inflamed and then lead to an ulcer.

Bacteria can enter the inside of the foot via this ulcer and lead to serious infections. These can usually only be treated surgically.

In summary, neuropathic diabetic feet are characterized by

• the sensation,
• the sensation of pain and
• the sensation of temperature

are reduced or, depending on the stage of the disease, eliminated.

Freshly bandaged leg stump after an amputation © Choo | AdobeStock

What methods are used for amputations?

Chronic arterial occlusive disease with or without diabetes mellitus

An appointment with an angiologist is recommended at the latest at the first signs of e.g. calf pain or limited walking distance. He or she will prescribe medication or dosed physiotherapy according to the stage of the occlusive disease.

As soon as tissue dies off on the feet from stage III or IV according to Fontaine, amputation may be an option. However, this requires that vascular reconstruction by a vascular surgeon is no longer possible.

A lower leg amputation according to Brückner has the best rehabilitation prospects with a knee preservation rate of 93 percent. Preserving the knee ensures better mobility in the patient's everyday life.

In a few cases, amputation of the knee joint or thigh is necessary.

Neuropathic diabetic foot

It may be necessary to immobilize the foot or surgically remove the infection in the foot area. It may be necessary to remove individual bones.

The main problem is to prevent ulcers on the foot as far as possible. This requires

• appropriate education of the patient about future behavior and
• the appropriate footwear for the stage of

is necessary.

Daily assessment of the feet by the patient or their relatives is necessary. The diabetologist or specialist in orthopaedics/trauma surgery should be consulted in the event of the slightest changes.

Post-traumatic amputations and tumors

In the case of infections after accidents or primarily accident-related separation of the limb and tumors, the level of amputation depends on the possibility of separation in healthy tissue.

Amputations in the hip or pelvic area are also possible (hip disarticulation or hemipelvectomy).

Aftercare following an amputation

The residual limb is wrapped immediately after the operation. Care must be taken to ensure that the pressure is not too strong, especially over bony prominences, in the event of circulatory disorders. During the first 14 days, daily checks are necessary at least 4 times a day.

In the case of amputations following an accident or tumor, wrapping is carried out from the bottom upwards with decreasing pressure to prevent oedema.

After the amputation, an optimal prosthetic fitting and training with and without a prosthesis in a competent rehabilitation clinic is urgently required.

It is strongly recommended that the initial prosthetic fitting is carried out by a team. Highly recommended are

• A doctor with prosthetic experience,
• physiotherapists and
• an orthopaedic technician who is as close to home as possible.

The second fitting can then be carried out on the basis of the initial fitting by the prosthetist at home.

The idea that an expensive prosthesis will solve the gait problem by itself is an absolute misconception. With any type of prosthesis, it is necessary to learn a new gait pattern under professional supervision.

Healing prospects after amputations

Chronic arterial occlusive disease

The prospects of recovery after an amputation due to severe circulatory disorders are difficult, but not impossible. In most cases, a prosthetic restoration can be carried out.

2. neuropathic diabetic foot

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

Ulcers or bony changes that have occurred must usually be limited to a minimum of tissue loss. This can be done conservatively by immobilization or by resection of altered bone sections (so-called internal amputation).

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

Sport after an amputation

Predominantly younger amputees without chronic arterial occlusive disease can take up sporting activities with a prosthesis. The Paralympics are impressive proof of this.