Amputation

Amputation
Classification and external resources
J. McKnight, who lost his limbs in a railway accident in 1865, was the second recorded survivor of a simultaneous triple amputation.
ICD-10	T14.7
MeSH	D000673

Amputation is the removal of a body extremity by trauma, prolonged constriction, 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 the congenital amputation, a congenital disorder, where fetal limbs have been cut off by constrictive bands. In some countries, amputation of the hands or feet 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. Unlike some non-mammalian animals (such as lizards that shed their tails, salamanders that can regrow many missing body parts, and hydras, flatworms, and starfish that can regrow entire bodies from small fragments), once removed, human extremities do not grow back, unlike portions of some organs, such as the liver. A transplant or a prosthesis are the only options for recovering the loss.

In the US, the majority of new amputations occur due to complications of the vascular system (of or pertaining to the blood vessels), especially from diabetes. Between 1988 and 1996, there was an average of 133,735 hospital discharges for amputation per year in the US. ^[1].

Types

Types of amputation include:

• Leg
  • amputation of digits
  • partial foot amputation (Chopart, Lisfranc, Ray)
  • ankle disarticulation (Syme,^[2] Pyrogoff)
  • below-knee amputation (transtibial e.g. Burgess, Kingsley Robinson)
  • knee-bearing amputation (knee disarticulation, e.g. Gritti or Gritti-Stokes)
  • above knee amputation (transfemoral)
  • Van-ness rotation/rotationplasty (Foot being turned around and reattached to allow the ankle joint to be used as a knee.)
  • hip disarticulation
  • hemipelvectomy/hindquarter amputation
• Arm
  • amputation of digits
  • metacarpal amputation
  • wrist disarticulation
  • forearm amputation (transradial)
  • elbow disarticulation
  • above-elbow amputation (transhumeral)
  • shoulder disarticulation and forequarter amputation
  • Krukenberg procedure
• Teeth
  • The avulsion of some teeth (mainly incisives) is or was practiced by some cultures for ritual purposes (for instance in the Iberomaurusian culture of Neolithic North Africa).
• Facials
  • amputation of the ears.
  • amputation of the nose.
  • amputation of the tongue.
  • amputation of eyes blinding. Many of these facial disfigurings were and still are done in some parts of the world as punishment to some crimes, and as individual shame and population terror practices.
• Breasts
  • amputation of female mammaries. Mastectomy This was done still during the Middle Ages after enemy razzias as mass abuse and extreme individual punishment to prevent women from suckling their children and doom them, still able to bear but unabling them to nurse and thus, to see with despair their neonates die.
• Genitals
  • amputation of the scrotum.
  • amputation of the testicles (castration).
  • amputation of the penis (penectomy)
  • amputation of the foreskin (circumcision)
  • amputation of the clitoris (clitoridectomy)

Hemicorporectomy, or amputation at the waist, and decapitation, or amputation at the neck, are the most radical amputations.

Genital modification and mutilation may involve amputating tissue, although not necessarily as a result of injury or disease.

As a rule, partial amputations are preferred to preserve joint function, but in oncological surgery, disarticulation is favored.^{[citation needed]}

Self-amputation

See also: Autotomy and Body integrity identity disorder

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 their own limb:

• In 2007, 66-year-old Al Hill amputated his leg below the knee using his pocketknife after the leg got stuck beneath a fallen tree he was cutting in California.^[3]
• In 2003, 27-year-old Aron Ralston amputated his forearm using his pocketknife and breaking and tearing the two bones, after the arm got stuck under a boulder when hiking in Utah.^[4]
• In 2003, an Australian coal miner amputated his own arm with a Stanley knife after it became trapped when the front-end loader he was driving overturned three kilometers underground.^[5]
• In the 1990s, a crab fisherman got his arm caught in the winch during a storm and had to amputate it at the shoulder, as reported in The New Englander.^{[citation needed]}

Even rarer are cases where self-amputation is performed for criminal or political purposes:

• About 50 people in Vernon, Florida collected insurance claims for loss-of-limb accidents in the late 1950s and early 1960s; this was more than two-thirds of all such claims in the United States during that time.^[6][7]
• On March 7, 1998, Daniel Rudolph, the elder brother of the 1996 Olympics bomber Eric Robert Rudolph, videotaped himself cutting off one of his own hands with an electric saw in order to "send a message to the FBI and the media."^[8]

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.

Causes of amputation

Circulatory disorders

• Diabetic foot infection or gangrene (the most common reason for non-traumatic amputation)
• Sepsis with peripheral necrosis

Neoplasm

Transfemoral amputation due to liposarcoma

• Cancerous bone or soft tissue tumors (e.g. osteosarcoma, osteochondroma, fibrosarcoma, epithelioid sarcoma, ewing's sarcoma, synovial sarcoma, sacrococcygeal teratoma, liposarcoma)
• Melanoma

Trauma

• Severe limb injuries in which the limb cannot be spared or attempts to spare the limb have failed
• Traumatic amputation (an unwanted amputation that occurs at the scene of an accident, where the limb is partially or wholly severed as a direct result of the accident, for example a fingertip that is cut off by a meat grinder).
• Amputation in utero (Amniotic band)

Deformities

• Deformities of digits and/or limbs
• Extra digits and/or limbs (e.g. polydactyly)

Infection

• Bone infection (osteomyelitis)

Athletic performance

• Sometimes professional athletes may choose to have a non-essential digit amputated to relieve chronic pain and impaired performance. Australian Rules footballer Daniel Chick elected to have his left ring finger amputated as chronic pain and injury was limiting his performance.^[9] Rugby union player Jone Tawake also had a finger removed.^[10] NFL safety Ronnie Lott had the tip of his little finger removed after it was damaged in the 1985 NFL season.

Legal punishment

• Amputation is used as a legal punishment in a number of countries, among them Iran, Yemen, Saudi Arabia, Sudan, and Islamic regions of Nigeria. .^[11]

Method

Curved knives such as this one were used, in the past, for some kinds of amputations.

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.

Prevention

Amputations are traumatic experiences that reduce the quality of life for patients in addition to being expensive. A typical prosthetic limb costs in the range of $10,000-15,000 in the USA according to the American Diabetic Association while it's practically free in the European countries. Preventing amputations is a critical task.

Methods in preventing amputation 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).

Various approaches have been attempted to work around these problems, including hyperbaric oxygen therapy (HBOT) and low powered lasers. HBOT has proved to be particularly effective in revascularizing or rebuilding the smaller blood vessels in extremities and, as a result, preventing deterioration of the tissue and resulting infections. At the same time, delivering oxygen under pressure in a hyperbaric chamber increases oxygenation by up to 400 times in the blood, speeding up healing processes and killing off anaerobic bacteria (gas gangrene), the source of infections. The general research conclusion is that around 80% of resistant diabetic infections can be cured with HBOT.

Crush injuries where there is extensive tissue damage and poor circulation also benefit from 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 got significant results in prevention of amputation in patients of diabetes and arterioscleorosis.^[12][13] Another study found it also effective for healing limb ulcers caused by peripheral vascular disease.^[14] 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.^[15]

For victims of trauma, advances in microsurgery in the 1970's have made replantations of severed body parts possible.

Prognosis

The individual may experience psychological trauma as well as 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;^[16] 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^{[citation needed]}.

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.^[17]

Due to technologic advances in prosthetics, amputees can 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.

History

The word amputation is derived from the Latin amputare, "to cut away", from ambi- ("about", "around") and putare ("to prune"). The Latin word has never been recorded in a surgical context, being reserved to indicate punishment for criminals. The English word "amputation" 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.

• 

  A woodcut engraving in Feldbuch der Wundarzney (1519) by Hans von Gersdorff, showing how to perform removal of a leg.

• 

  In a 1786 James Gillray caricature, the plentiful money bags handed to King George III are contrasted with the beggar whose legs and arms were amputated, in the left corner

• 

  John McFall, who has an above-knee leg amputation, and uses a prosthetic leg, is a sprinter and winner of a gold medal at the 2007 Paralympic World Cup

References

1. ^ Amputee Coalition Factsheet
2. ^ Pinzur, M.S.; Stuck, RM; Sage, R; Hunt, N; Rabinovich, Z (September 2003). "Syme ankle disarticulation in patients with diabetes". J Bone Joint Surg Am 85-A (9): 1667–1672. PMID 12954823. 
3. ^ Man Pinned Under Tree Amputates His Leg
4. ^ Kennedy, J. Michael (May 9, 2003). "CMU grad describes cutting off his arm to save his life". Pittsburgh Post-Gazette. Archived from the original on 2010-11-18. http://www.post-gazette.com/nation/20030509climbernat2.asp. Retrieved 2008-05-07. 
5. ^ "Arm trapped, and fearing fire, tough miner knew what to do". The Sydney Morning Herald. Archived from the original on 2010-11-18. http://www.smh.com.au/articles/2003/06/29/1056825279321.html. 
6. ^ Life: Dismembered again
7. ^ Errol Morris: Profiles
8. ^ "Bombing suspect's brother cuts hand off with saw". March 9, 1998. Archived from the original on 2010-11-18. http://www-cgi.cnn.com/US/9803/09/briefs.pm/rudolph.amputation/. 
9. ^ RTE: Aussie Rules star has finger removed
10. ^ SportsAustralia.com: Tawake undergoes surgery to remove finger
11. ^ UNHCR article on amputation as a punishment in Iran.
12. ^ Richard S. Dillon (May 1997). "Fifteen Years of Experience in Treating 2177 Episodes of Foot and Leg Lessions with the Circulator Boot". Angiology 48 (5 (part 2)): S17–S34. doi:10.1177/000331979704800503. Archived from the original on 2010-11-18. http://www.circulatorboot.com/literature/angiology1.html. 
13. ^ Richard S. Dillon; Yai, H; Maruhashi, J (May 1997). "FPatient Assessment and Examples of a Method of Treatment. Use of the Circulator Boot in Peripherical Vascular Disease". Angiology 48 (5 (part 2)): S35–S58. doi:10.1177/000331979704800504. PMID 915838. Archived from the original on 2010-11-18. http://www.circulatorboot.com/literature/angiology1.html. 
14. ^ Vella A, Carlson LA, Blier B, Felty C, Kuiper JD, Rooke TW (2000). "Circulator boot therapy alters the natural history of ischemic limb ulceration.". Vasc Med. 5 (1): 21–25. PMID 10737152. 
15. ^ Circulator Boot at Mayo Clinic 1:08-1:32
16. ^ Heidi Schultz (January 2005). "Phantom Input". National Geographic Magazine. http://magma.nationalgeographic.com/ngm/0501/resources_who.html. ^{[dead link]}
17. ^ Ryan, Joan (March 25, 2006). "War without end / Damaged soldiers start their agonizing recoveries". The San Francisco Chronicle. Archived from the original on 2010-11-18. http://www.sfgate.com/cgi-bin/article.cgi?f=/c/a/2006/03/26/MNSOLDIERS26.DTL. 

External links

• Philipose Vaidyar writes how a both-legs amputee in Champa, India wins his bread
• Amputation from Cooper's 1835 "Practice of Surgery"
• Imaging of Lower Extremities Amputations