Amputation of the Leg – Part Two

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 traumatic injuries the patient may suffer a traumatic amputation or a severe compound fracture with concomitant vascular and nerve injuries which are beyond repair. An amputation in this case may make good sense rather than trying to salvage a severely damaged limb over a long time. If the limb is salvaged it may not be functional and be a source of significant pain which may be depressing for the patient and less useful than having an artificial limb. At some stage after the injury a decision needs to be made if the long period of treatment and non-function is worth it for the end result as compared to an amputation.

The overall goal of amputation is to maintain the length of the limb and preserve the greatest degree of functional use from the leg. As amputation is irreversible the decision has to be correct but the only restrictions are the patient’s ability to withstand an operation. As the abnormal limb may be the main factor maintaining the unwell medical status of the patient then amputation can be seen as a way to restore medical balance and in many cases to save a patient’s life. Pre-operative preparation involves a multidisciplinary team to assess the physical, social and psychological aspects of the patient’s condition to prepare them for future changes.

Surgical management of severe leg trauma has shown significant advances in the ability to perform microsurgery to the vascular structures, advanced fixation of fractures and techniques to promote revascularisation of tissues. Amputation may then be viewed as a failure if these techniques cannot save the limb, but viewing it as a reconstructive process is more positive, allowing an increase in useful functional capacity. Techniques of amputation have seen much less development and patients still consult with difficulties such as persisting pain, swelling, limited use of the prosthetic limb and feelings of instability.

During surgery the surgeons are careful to keep a good skin length so it can be folded across the remaining limb and not with significant tension, position muscle over the bone end and perhaps stitch opposite muscle groups together and cut the nerves when they are tensioned to some degree and position their cuts away from the limb end so they do not suffer future tension. A general rule for planning the length of the remaining limb is to give 2.5cm of length for every thirty cm of the person’s height. After the operation the wound is dressed and post operative analgesia given.

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 planning and development for the provision of a prosthesis can be started around the six week point as the operated area will have settled to some degree, remembering that some patients will never be able to use a prosthesis well due to mental inability, overall weakness and poor standing balance. Many complications can potentially interfere with the patient working towards their maximum capacity. Vascular disease means potentially poor wound healing or breakdown and poor skin condition and there may be local swelling, joint stiffness, pain problems and phantom sensations.

Jonathan Blood Smyth, editor of the Physiotherapy Site, writes articles about Physiotherapy, back pain, orthopaedic conditions, neck pain, injury management and physiotherapist in Lincoln. Jonathan is a superintendant physiotherapist at an NHS hospital in the South-West of the UK.

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