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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[citation needed]. 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]

Contents

[edit] History

[edit] 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.

[edit] 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
  • teeth

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.[citation needed]

[edit] 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]

[edit] Reasons for amputation

[edit] Circulatory disorders

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

[edit] Neoplasm

[edit] Trauma

Amputation
Classification and external resources
ICD-10 T14.7
MeSH D000673
  • 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])

[edit] Deformities

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

[edit] Infection

[edit] Other

[edit] 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

[edit] 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.[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.[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.

[edit] 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[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]

[edit] Notable amputees

[edit] See also

[edit] References

  1. ^ a b 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. http://www.circulatorboot.com/literature/angiology1.html. 
  2. ^ a b 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. 
  3. ^ 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. 
  4. ^ 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. http://www.circulatorboot.com/literature/angiology1.html. 
  5. ^ Circulator Boot at Mayo Clinic 1:08-1:32
  6. ^ Islam Online- News Section
  7. ^ "Tariq Ramadan : Do you trust this man?". The Independent (London). March 11, 2007. http://news.independent.co.uk/people/profiles/article2342952.ece. Retrieved April 23, 2010. 
  8. ^ RTE: Aussie Rules star has finger removed
  9. ^ SportsAustralia.com: Tawake undergoes surgery to remove finger
  10. ^ Man Pinned Under Tree Amputates His Leg
  11. ^ "CMU grad describes cutting off his arm to save his life". http://www.post-gazette.com/nation/20030509climbernat2.asp. Retrieved 2008-05-07. 
  12. ^ "Arm trapped, and fearing fire, tough miner knew what to do". The Sydney Morning Herald. http://www.smh.com.au/articles/2003/06/29/1056825279321.html. 
  13. ^ Life: Dismembered again
  14. ^ Errol Morris: Profiles
  15. ^ . http://www-cgi.cnn.com/US/9803/09/briefs.pm/rudolph.amputation/. 
  16. ^ Heidi Schultz (January 2005). "Phantom Input" ([dead link]). National Geographic Magazine. http://magma.nationalgeographic.com/ngm/0501/resources_who.html. 
  17. ^ Ryan, Joan (March 25, 2006). "War without end / Damaged soldiers start their agonizing recoveries". The San Francisco Chronicle. http://www.sfgate.com/cgi-bin/article.cgi?f=/c/a/2006/03/26/MNSOLDIERS26.DTL. 
  18. ^ Natalie du Toit ready to make Olympic history. Retrieved November 5, 2009.
  19. ^ Hart, Simon (May 4, 2008). "Dreams carry Natalie Du Toit to Beijing". The Daily Telegraph (London). http://www.telegraph.co.uk/sport/main.jhtml?xml=/sport/2008/05/04/sbswim104.xml. Retrieved April 23, 2010. 

[edit] External links



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