Amputation

A woodcut engraving in a 1537 surgery book, 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

J. McKnight, who lost his limbs in a railway accident in 1865, was the second recorded survivor of a simultaneous triple amputation.

John McFall, an above-knee leg amputee with a prosthetic leg, sprinter and winner of a gold medal at the 2007 Paralympic World Cup

Amputation is the removal of a body extremity by trauma 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 foetal 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. 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), once removed, human extremities do not grow back. A transplant or a prosthesis are the only options for recovering the loss.

In many developed countries, diabetes is the major cause of amputation. In the US, the risk of losing a foot or leg is 15-40X higher for diabetics. And 80,000 lower limb amputations are performed in the US according to International Diabetes Federation. Diabetes leads to poor circulation which in turn leads to infection and gangrene.

There are some treatments that try to prevent amputation. Hyperbaric oxygen therapy (HBOT) has been found to be an effective way of revascularizing poor performing circulation, killing the anaerobic bacteria in diabetic ulcers and preventing amputation. The Circulator Boot is also effective in patients of diabetes and arteriosclerosis,^[1] and in limb ulcers caused by peripheral vascular disease.^[2]

History

Origins of the word

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.

Types

Types of amputation include:

• leg
  • amputation of digits
  • partial foot amputation (Chopart, Lisfranc, Ray)
  • ankle disarticulation (Syme,^[3] 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).

Hemicorporectomy, or amputation at the waist, is the most radical amputation.

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.

Preventing amputation

Chronic infections, often caused by diabetes or decubitus ulcers in bed ridden patients, are common causes of infections that lead to gangrene. An amputation is a traumatic experience that reduces the quality of life for patients and is also expensive for the medical system and the family of the patient. A typical prosthetic limb costs in the range of $10,000-15,000 according to the American Diabetic Association. Preventing amputations is, as a result, a critical task. 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 included hyperbaric oxygen treatment (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 anearobic 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 speeds up recovery times and prevents infections.

A study found that the a patented method called Circulator Boot got significant results in prevention of amputation in patients of diabetes and arterioscleorosis.^[1][4]Another study found it also effective for healing limb ulcers caused by peripheral vascular disease.^[2] 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.^[5]

Reasons for amputation

Circulatory disorders

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

Neoplasm

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

Trauma

• Severe limb injuries in which the limb cannot be spared or attempts to spare the limb have failed
• Traumatic amputation (Amputation occurs usually at scene of accident, where the limb is partially or wholly severed). This would be the case of a trapped limb with no other way to extract without harm to other parts of the body.
• Amputation in utero (Amniotic band)
• Punishment/Torture (e.g. in some countries theft is prevented by the threat of amputation of a hand, although the practice is highly controversial and some Islamic authorities are calling for a moratorium upon it,^[6] pending developments in Islamic law.^[7])

Deformities

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

Infection

• Bone infection (osteomyelitis)

Other

• 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.^[8] Rugby union player Jone Tawake also had a finger removed.^[9] NFL safety Ronnie Lott had the tip of his little finger removed after it was damaged in the 1985 NFL season.

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. 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. Transtibial Amputation with Extended Flap and Bone Bridging

Self-amputation

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 his 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.^[10]
• 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.^[11]
• Also 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.^[12]
• 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.

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.^[13][14]
• 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."^[15]

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.

After-effects

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, such that an individual who has had an arm amputated will experience unexplained pressure or movement on his face or head.

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]

Notable amputees

• Rick Allen—drummer for the band Def Leppard; lost his left arm in a car accident.
• Walid bin 'Attash—member of Al-Qaeda; lost his right leg fighting the Northern Alliance in 1997.
• Douglas Bader—Royal Air Force fighter pilot during World War II; lost both legs performing low-flying aerobatics, but continued to fly and even engaged in escape attempts as a POW of the Germans.
• Alexey Maresyev—Russian fighter pilot during World War II; lost both legs after being shot down in a dog fight; returned to the front a year later and continued flying completing 86 combat missions; awarded Hero of the Soviet Union Gold Star.
• Lucien Bouchard—Canadian politician and Quebec nationalist; lost a leg to necrotizing fasciitis.
• Mariana Bridi da Costa—Brazilian model and beauty queen; suffered several amputations in a failed attempt to save her life. Died at age 20 on January 24, 2009 of septicemia resulting from Pseudomonas aeruginosa infection that quickly spread throughout her body.
• Jim Byrnes—American actor; lost both legs above the knee in a vehicle accident.
• Roberto Carlos—Brazilian singer; had the lower half of his left leg slashed off by a train wheel in his teenage years.
• Ronald D. Castille—Chief Justice of the Pennsylvania State Supreme Court and former Philadelphia District Attorney; lost his leg in the Vietnam War.
• Lars Grael—Brazilian windsurfing champion; his right leg was sliced off by a private boat's chopper engine in a sea accident.
• Wagner Montes—Brazilian journalist and politician; his motorbike crushed the lower half of his right leg against a lamppost.
• Max Cleland—former U.S. Senator; lost both legs and right forearm following injuries inflicted by a fellow soldier's grenade in the Vietnam War.
• Richard Collier—American Football Player; lost left leg after a shooting incident in Jacksonville, Florida.
• Denzil Connick the co-founder and secretary of the South Atlantic Medal Association formed in 1997. He served with 3 PARA during the 1982 Falklands War and lost a leg during the Battle of Mount Longdon.
• Dadullah—Taliban military commander; lost a leg fighting against Soviet occupation in the 1980s.
• James Doohan—Canadian actor best known as Montgomery Scott on Star Trek; lost right middle finger in friendly fire incident on Juno Beach during the Normandy landings.
• Dave Dravecky—Major League Baseball pitcher with the San Diego Padres and San Francisco Giants; lost left arm to cancer complications.
• Tammy Duckworth—American politician; lost both legs in the Iraq War.
• Graham Edwards—Australian politician; lost both legs in the Vietnam War.
• Rahm Emanuel—White House Chief of Staff; lost part of his finger to a meat slicer while an employee at Arby's as a teenager.
• George Eyser American gymnast, he competed in the 1904 Summer Olympics, earning six medals in one day, including three gold and two silver medals. Eyser competed with a wooden prosthesis for a left leg.
• Lindsay Ess — quadruple amputee and teacher at Virginia Commonwealth University
• Ella Fitzgerald —American jazz musician; lost leg to diabetes
• Terry Fox—Canadian athlete and cancer treatment activist; lost a leg to cancer.
• Khujo Goodie—rapper, member of the hip hop group Goodie Mob, lost bottom right leg in a car accident
• Zach Gowen—American professional wrestler; lost a leg to cancer as a child.
• Bethany Hamilton—American surfer; lost an arm to a shark attack.
• Robert David Hall—American actor, lost both legs due to a vehicle accident with a semi.
• Burkhard Heim—German theoretical physicist; lost both hands in a laboratory explosion.
• Lord Uxbridge—British; lost his leg during the Battle of Waterloo
• Daniel Ken Inouye—Medal of Honor recipient, U.S. Senator; World War II war hero; lost his right arm due to battle wounds.
• Stonewall Jackson—Confederate general during the American Civil War; had his left arm amputated by Dr. Hunter McGuire on May 2, 1863 only to die eight days later on May 10, 1863.
• Peter Lalor—Australian politician and leader of the Eureka Stockade rebellion, a battle often characterised as the "birth of democracy" in Australia. Had his left arm amputated due to injuries sustained during the uprising.
• Matthias Lanzinger—Austrian Alpine skier; lost leg after fracturing his shin and fibula during a World Cup Super-G run at Kvitfjell, Norway.
• Harold Lloyd—American film actor and producer, most famous for his silent comedies. Lost his right thumb and index finger during an accident on the set of Haunted Spooks.
• Bruce Marshall—Scottish novelist and author; lost leg as a result of wounds suffered in World War I.
• Kyle Maynard, an American motivational speaker and athlete.
• Heather Mills—ex-wife of former Beatle Paul McCartney as well as an activist and former model; lost left leg six inches below the kneecap in an accident where she was hit by a police motorcycle.
• Aimee Mullins—American model and athlete; lost both legs due to congenital disease.
• Horatio Nelson—(England) British Naval commander during Napoleonic war. Lost right arm and eye during various sea battles. Defeated Villeneuve during the Battle of Trafalgar.
• Oscar Pistorius—South African sprinter; lost both legs due to a congenital disorder.
• Hans-Ulrich_Rudel—German; WWII pilot, leg amputated below the knee.
• Daniel Scioli—former Vicepresident of Argentina; lost right arm during a boat race.
• Eric Shinseki—Incumbent Secretary of Veterans Affairs, retired U.S. Army four-star general, and Army Chief of Staff during early stages of the War on Terrorism and Iraq War; lost part of foot in a land mine explosion during Vietnam War.
• Darío Silva—Uruguayan footballer; lost his right leg after a car accident.
• Deke Slayton—Mercury Seven astronaut; lost a finger as a child in a farming accident.
• Claus von Stauffenberg — German Colonel who lost his right hand during World War II; mastermind behind a failed attempt to assassinate Hitler;
• Edward Teller — Physicist; lost his leg from the knee down after he jumped from a train station platform trying to catch a train.
• John Tester —U.S. Senator; as a child, lost the middle, index, and ring finger on his left hand in an accident while working with a meat grinder.
• Fred Titmus, former English Test cricketer and professional footballer, who lost four toes while swimming, when his foot got caught up with a boat propeller.
• Lee Van Cleef —American actor; lost the tip of his middle finger on his right hand while building a playhouse for his daughter.
• Kerry Von Erich American wrestler "The Texas Tornado", lost right foot in motorcycle accident but continued his wrestling career with a prosthetic foot.
• Pyotr Nikolayevich Vlasov—Russian photographer; lost his left thumb, index finger, and middle finger, as well as an inch of his right index finger, when dynamite exploded in his hands in the coal mine where he worked as a teenager during World War II.
• Paul Wittgenstein — Austrian-born pianist, brother of philosopher Ludwig Wittgenstein; lost right arm during World War I.
• Alex Zanardi—Italian car racing driver; lost both legs in a CART car accident at Lausitzring then returned to race in the World Touring Car Championship.
• Natalie Du Toit — South African swimmer, after George Eyser,^[18] became the second amputee ever to qualify for the Olympics, where she placed 16th in the 10 km Marathon.^[19]
• Patrick Watson— Canadian broadcaster, author, commentator and television writer, producer and director, lost his left leg above the knee in 1960 following an accident.
• Amy Palmiero-Winters — American ultramarathon runner; first amputee to compete on a senior able-bodied nationals team in any sport, took 19th place at the 2010 World 24-Hour Championship after running 129 miles in 24 hours, winner of the 2010 Sullivan Award and a 2010 ESPY, first amputee to finish the Western States Endurance Race; missing one lower leg and foot due to a motorcycle accident.

See also

• Tourniquet
• Autotomy
• Amputee Soccer Championship, Central America
• Acrotomophilia
• Congenital amputation
• Miracle of Calanda

References

External links

• Amputation from Cooper's 1835 "Practice of Surgery"
• Imaging of Lower Extremities Amputations