Terminology
Causes of Amputation
Levels of Amputation
Amputation Surgery
Helpful Links
ROMP Documentary
Terminology
O & P
The combined profession of rehabilitation medicine known as orthotics and prosthetics.
Orthotics
The field responsible for designing customized braces (orthoses) for elements of the human musculo-skeletal system in order to protect, stabilize, enhance biomechanical function, maintain or restore mobility and increase quality of life for individuals with disabilities.
An Orthotist directs the design, fabrication and fitting of and orthosis.
ProstheticsThe O & P profession whose practitioners are responsible for designing artificial functional devices (prostheses) that replace missing limbs in order to restore mobility, independence, function while enhancing quality of life for individuals with amputations.
A Prosthetist directs the design, fabrication and fitting of a prosthesis.
Causes of Amputation
The exact number of people who have had amputations worldwide is difficult to determine. Many countries do not keep records of the number of people with amputations or their causes. The causes of amputation vary greatly from region to region around the world. The three main causes of amputation are disease, trauma and congenital deformities. Disease and trauma are the most common causes.
Table 1. Causes of Amputation Around the World
| Country | War Related Trauma | Other Trauma | Disease |
| Cambodia | 94.5% | 4.5% | 1% |
| Zimbabwe | 65% | 25% | 10% |
| United States | 3% | 32% | 65% |
| Denmark | 2% | 30% | 68% |
Trauma
Trauma is a major cause of amputation around the world. Again, number of people whose amputation is due to trauma varies from country to country. In developed nations, trauma usually occurs as a result of industrial accidents, farming accidents, or motor vehicle accidents, which include automobiles, motorcycles and trains. Trauma accounts for approximately 30% of new amputations. In countries with a recent history of war or civil unrest, trauma can account for up to 80% or more of all amputations. In many of these countries landmines have become a major problem. There are over 100 million landmines in more than 60 nations around the world. United Nations Organization data indicates that mines kill or disable over 150 people each week. Often injuries involve multiple limbs, the chest, genitals and the face. Traumatic amputations occur in a much younger and more active population than those due to disease. Infected insect, animal and human bites and other wounds are an iimportant cause of limb amputation, particularly in areas where antibiotics are not readily available. Inappropriate use of traditional medicines for these conditions may also increase infections that can lead to amputation.
Diseases
The major diseases that contribute to amputation are vascular diseases, diabetes and tumors. In industrialized countries like the United States and Denmark, disease causes approximately 65% of all amputations performed each year. This is not true of many developing countries where trauma is the main cause of amputation. In general those individuals who have amputations due to disease are older with the amputation usually occurring after age 60. Of the diseases that cause amputation, vascular disease with poor circulation is the most common. This disease limits the flow of arterial blood to the lower extremities causing ulcers and gangrene, which can lead to amputation. Diabetes is another common cause of limb loss. There are an estimated 135 million people with diabetes in the world. Complications of diabetes decrease the circulation and sensation in the limbs. This can result in ulcers and infection that may lead to amputation. Tumors of bone, muscle and skin account for a small portion of diseaserelated amputation.
The limb where the tumor exists is removed to prevent the spread of the cancer and avoid death. Leprosy can cause a loss of sensation in the hands and feet. Injuries to the desensitized areas can become infected and, if not treated, can lead to amputation. Various researchers have studied the age of people who have amputations. The worldwide statistics on age related amputations are very difficult to obtain. In general, those individuals with limb loss due to disease are older with the amputation usually occurring after age 60. Traumatic amputations occur in a much younger and active population.
Congenital Malformation
Congenital malformation accounts for a small portion of reported amputations. In these cases a child is born with an abnormally shortened, malformed limb or no limb at all. Depending on the extent of malformation the limb is surgically removed or the shortened limb is treated like an amputation and an artificial limb may be applied. Congenital amputation accounts for up to 3 % of reported limb loss.
Levels of Amputation
The most frequesnt level of amputation is below the knee amputation (transtibial) followed in frequency by above the knee amputation (transfemoral). Figure 1.1 illustrates the percentage of limb amputation at all levels.
Amputation Surgery
General Principles of Amputation SurgeryThe decision to amputate is an emotional process that will have life long implications for the person with an amputation and her family. Limb amputation should be seen as a means to return the person to a more functional level. The selection of the surgical level of amputation is probably one of the most important decisions that must be made. For each joint and muscle lost and replaced by an artificial limb, there will be greater cost, greater loss of function, a greater degree of impairment and increased energy cost in using the prosthesis.
The ability of the soft tissues to heal themselves usually determines the best possible level for amputation. Skin bleeding is the simplest and most common way to determine this level. After surgery, the person with a lower limb amputation may use an artificial leg to walk. Ideally for the person with a leg amputation, full body weight will be borne through the part of the limb that remains after amputation (stump). For the person with an arm amputation; lifting and pushing will be possible with an artificial limb. Bony prominences, skin rubbing, and sweating will increase the friction between skin and artificial limbs. For these reasons the stump must be surgically constructed with care.
The skin and muscles are the crucial padding between the limb and the prosthesis. Promoting wound healing without joint contractures or infection is desirable. Once healing has occurred, avoiding scar tissue adhesions is an important goal of rehabilitation. The absolute indication for amputation in trauma is a limb with unreconstructable blood vessel injury and no blood flow.
Recent studies show the value of early amputation not only in saving lives, but also in preventing the emotional, marital, financial, and addictive disasters that can follow desperate attempts for limb salvage. In the multiple limb injured person, and the elderly individual, salvage of a mangled limb even though technically possible, may be life threatening. The person may be best served by an early amputation. This is a truly difficult, but extremely important decision to make.
Lower Limb Levels of AmputationToe and partial foot amputations should only be considered when primary full skin thickness coverage can be provided. Skin grafts that have no feeling are inadequate because they can have frequent breakdowns resulting in increased complications.
In the person with poor circulation, the below knee (transtibial) amputation ideally should be done at the junction of the upper and the middle third of the tibia or shinbone. (Figure 2.1 and 2.2) It is important to understand that the healing rate improves when the amputation is closer to the knee, but the functional outcome decreases the shorter the limb is. People with below knee amputations will be more likely to accept and use a prosthesis than persons with higher level amputations.
An above knee (transfemoral) amputation will heal in most instances because of increased available blood supply. Unfortunately it will eliminate the anatomical knee joint, resulting in increased energy consumption during ambulation.
Level of Amputation Energy Increase- Partial foot 10 to 20 %
- Symes 0 to 30 %
- Below knee 40 to 50 %
- Above knee 90 to 100 %
- Bilateral below knee 60 to 100%
Careful balance of the hip flexor and extensor muscles and reattachment of the distal hip adductor musculature and myodesis (muscle to muscle attachment) of other muscles should be attempted in the transfemoral or above knee amputation. (Figure 2.3 a, b) When the muscles are not reattached during surgery, this will cause the person with an above knee amputation to have an abnormal walking pattern.
Through hip (hip disarticulation) (Figure 2.4-a) and hemipelvectomy amputations are seen as the result of tumors or major trauma. In these types of amputation, using crutches without a prosthesis is often the preferred way to walk.
Through knee (knee disarticulation) and Symes (through ankle amputations) (Figure 2.4-b) may provide direct end-bearing characteristics for the limb and improved suspension of the artificial limb. They maintain the integrity of the distal musculature resulting in improved biomechanics of walking. One disadvantage of these amputation levels may be the less optimal cosmetic appearance of the prosthesis. For the bilateral lower limb amputation, when possible, the through knee amputation is more desirable than the above knee amputation.
Upper Limb Levels of Amputation
The preferred level of amputation when no hand function can be expected, and the most common, is the below elbow (transradial) amputation (Figure 2.5 a, b). This level of amputation allows the highest level of functional recovery. Preservation of the elbow joint will significantly increase the acceptance of an arm prosthesis and its integration into functional activities. A long forearm amputation is preferred, in particular for persons who are expected to perform physically demanding work.
When the elbow can not be maintained and the person must have an above elbow (transhumeral) amputation it is important to preserve as long a stump as possible. This will allow the person to use a prosthetic device more easily. (Figure 2.6)
The through shoulder (shoulder disarticulation) and forequarter amputations are the most difficult to fit with a functional prosthesis due to the number of joints to be replaced and the challenges suspension of the prosthesis presents. After unilateral upper limb amputation early prosthetic fitting (1 to 6 months after surgery) is imperative if successful prosthetic restoration is to be expected. After that period of time the likelihood of functional use of the prosthesis decreases.
Helpful Links
Orthotics and Prosthetics Humanitarian Database
http://www.oandp.com/resources/humanitarian/
Resources for amputees
http://www.oandp.com/resources/patientinfo/
Informacion en espanol
http://www.sitiosdeoyp.com/
Information for amputees in Ecuador
www.proteus-ec.com
Center for International Rehabilitation
www.cirnetwork.org
Healing Hands for Haiti
www.healinghandsforhaiti.org
Hearts in Motion
ww.heartsinmotion.org
Scheck and Siress Advanced O&P
www.scheckandsiress.com
ROMP Documentary
Range Of Motion Project (ROMP), have developed an informative DVD short documentary about the ROMP Zacapa, Guatemala clinic.
The intent of the film is twofold: to raise awareness about ROMP's clinic in Zacapa, Guatemala and to highlight the lives of a few individuals treated at the ROMP clinic.
This film was provided as a generous donation and was not funded by ROMP or any donations received by ROMP supporters.
Please contact us to receive a copy of this DVD.
