Buerger's disease

Definition

Amputation is the intentional surgical removal of a limb or body part. It is performed to remove diseased tissue or relieve pain.

Purpose

Arms, legs, hands, feet, fingers, and toes can all be amputated. Most amputations involve small body parts such as a finger, rather than an entire limb. About 65,000 amputations are performed in the United States each year.

Amputation is performed for the following reasons:

• To remove tissue that no longer has an adequate blood supply.
• To remove malignant tumors
• Because of severe trauma to the body part.

The blood supply to an extremity can be cut off because of injury to the blood vessel, hardening of the arteries, arterial embolism, impaired circulation as a complication of diabetes mellitus, repeated severe infection that leads to gangrene, severe frostbite, Raynaud's disease, or Buerger's disease.

More than 90% of amputations performed in the United States are due to circulatory complications of diabetes. Sixty to eighty percent of these operations involve the legs.

Precautions

Amputations cannot be performed on patients with uncontrolled diabetes mellitus, heart failure, or infection. Patients with blood clotting disorders are also not good candidates for amputation.

Description

Amputations can be either planned or emergency procedures. Injury and arterial embolisms are the main reasons for emergency amputations. The operation is performed under regional or general anesthesia by a general or orthopedic surgeon in a hospital operating room.

Details of the operation vary slightly depending on what part is to be removed. The goal of all amputations is twofold: to remove diseased tissue so that the wound will heal cleanly, and to construct a stump that will allow the attachment of a prosthesis or artificial replacement part.

The surgeon makes an incision around the part to be amputated. The part is removed, and the bone is smoothed. A flap is constructed of muscle, connective tissue, and skin to cover the raw end of the bone. The flap is closed over the bone with sutures (surgical stitches) that remain in place for about one month. Often, a rigid dressing or cast is applied that stays in place for about two weeks.

Preparation

Before an amputation is performed, extensive testing is done to determine the proper level of amputation. The goal of the surgeon is to find the place where healing is most likely to be complete , while allowing the maximum amount of limb to remain for effective rehabilitation.

The greater the blood flow through an area, the more likely healing is to occur. These tests are designed to measure blood flow through the limb. Several or all of them can be done to help choose the proper level of amputation.

No one test is highly predictive of healing, but taken together, the results give the surgeon an excellent idea of the best place to amputate.

• Measurement of blood pressure in different parts of the limb
• Xenon 133 studies, which use a radiopharmaceutical to measure blood flow
• Oxygen tension measurements in which an oxygen electrode is used to measure oxygen pressure under the skin. If the pressure is 0, the healing will not occur. If the pressure reads higher than 40mm Hg (40 milliliters of mercury), healing of the area is likely to be satisfactory.
• Laser Doppler measurements of the microcirculation of the skin
• Skin fluorescent studies that also measure skin microcirculation
• Skin perfusion measurements using a blood pressure cuff and photoelectric detector
• Infrared measurements of skin temperature.

Aftercare

After amputation, medication is prescribed for pain, and patients are treated with antibiotics to discourage infection. The stump is moved often to encourage good circulation. Physical therapy and rehabilitation are started as soon as possible, usually within 48 hours. Studies have shown that there is a positive relationship between early rehabilitation and effective functioning of the stump and prosthesis. Length of stay in the hospital depends on the severity of the amputation and the general health of the amputee, but ranges from several days to two weeks.

Rehabilitation is a long, arduous process, especially for above the knee amputees. Twice daily physical therapy is not uncommon. In addition, psychological counseling is an important part of rehabilitation. Many people feel a sense of loss and grief when they lose a body part. Others are bothered by phantom limb syndrome, where they feel as if the amputated part is still in place. They may even feel pain in this limb that does not exist. Many amputees benefit from joining self-help groups and meeting others who are also living with amputation. Addressing the emotional aspects of amputation often speeds the physical rehabilitation process.

Risks

Amputation is major surgery. All the risks associated with the administration of anesthesia exist, along with the possibility of heavy blood loss and the development of blood clots. Infection is of special concern to amputees. Infection rates in amputations average 15%. If the stump becomes infected, it is necessary to remove the prosthesis and sometimes to amputate a second time at a higher level.

Failure of the stump to heal is another major complication. Nonhealing is usually due to an inadequate blood supply. The rate of nonhealing varies from 5-30% depending on the facility. Centers that specialize in amputation usually have the lowest rates of complication.

Persistent pain in the stump or pain in the phantom limb is experienced by most amputees to some degree. Treatment of phantom limb pain is difficult. One final complication is that many amputees give up on the rehabilitation process and discard their prosthesis. Better fitting prosthetics and earlier rehabilitation have decreased the incidence of this problem.

Normal results

The five year survival rate for all lower extremity amputees is less than 50%. For diabetic amputees, the rate is less than 40%. Up to 50% of people who have one leg amputated because of diabetes will lose the other within five years. Amputees who walk using a prosthesis have a less stable gait. Three to five percent of these people fall and break bones because of this instability. Although the fractures can be treated, about half the amputees who suffer them then remain wheelchair bound.

Key Terms

Arterial embolism

A blood clot arising from another location that blocks an artery.

Buerger's disease

An episodic disease that causes inflammation and blockage of the veins and arteries of the limbs. It tends to be present almost exclusively on men under age 40 who smoke, and may require amputation of the hand or foot.

Diabetes mellitus

A disease in which insufficient insulin is made by the body to metabolize sugars.

Raynaud's disease

A disease found mainly in young women that causes decreased circulation to the hands and feet. Its cause is unknown.

Further Reading

For Your Information

Organizations

• American Diabetes Association. 1660 Duke Street, Alexandria, VA 22314. http://www.diabetes.org.

  Other

• Amputation: The Online Magazine for Amputees. http://www.portal.ca/~igregson/amputation.html.
• Amputation Prevention Global Resource Center. http://www.diabetesresource.com.
• The Amputation Website. http://www.harbour.com/commorgs/amputee/amputee.html.

Gale Encyclopedia of Medicine. Gale Research, 1999.