Vascular Surgery Major Amputation

It is usually possible before the operation (although not always) for the surgeon to decide at what level the amputation will be performed (above knee or below knee). Sometimes gangrene or infection will only involve a toe or part of a foot and a limited or minor amputation can be performed. This is only worthwhile if the surgeon thinks that the wound that is created will heal. In some patients, it is better to try a limited amputation if there is a chance of healing, but to be prepared to proceed to a major amputation if healing doesn't take place.

One of the most important factors in healing is the blood supply to the tissues. If the blood supply is damaged or impaired it may not be possible for the tissues to heal even after a minor amputation. If in the opinion of the surgeon the tissues will clearly not heal because of a poor blood supply it would be reckless to proceed with a minor amputation when really a major amputation is required. Unfortunately, there is no test that can predict in every patient whether healing will take place and it is a matter of surgical judgment and experience whether a wound is likely to heal or not.

In general the more limited the amputation the lower the risks and the better the chances of walking. It is better to have a below knee amputation when compared with an above knee amputation, because the chances of successfully walking after the operation are much better. Unfortunately, not everyone is suitable for this operation and many people need to have an above knee amputation. This may be because the blood supply to the lower leg is too poor and a below knee amputation would not heal properly. If the knee cannot straighten out properly before the surgery (fixed flexion deformity), it will be impossible to walk with an artificial leg after the operation. In these circumstances it may be better to undergo an above knee amputation.

Once an amputation stump is created it is a potentially vulnerable area that will require lifelong care and attention. A major amputation wound is almost always closed with stitches or staples.

Below knee amputation

This operation can be performed using 2 major techniques (skew flap and posterior flap). There is no proven advantage for one technique, but sometimes it is easier to perform a skew flap amputation if there has been a lot of skin damage above the ankle. The bone in the lower leg (tibia) is divided about 12-15 ems below the knee joint. This produces a good size stump to which prosthesis can be fitted.

Above knee amputation

In this operation the bone in the thigh (femur) is divided about 12-15 ems above the knee joint and the muscle and skin closed over the end of the bone.

Major Amputation FAQ's

How will having an amputation affect me?
Amputation of a limb or limbs will affect people in different ways. It is a very personal loss and in many patients can feel like bereavement. The emotional loss can be like losing a relative and it will take time to adapt to such a loss. Physically your body will be permanently altered and can affect all areas of your life. How much your amputation affects your life will to some degree depend on the extent of your physical recovery.

There are virtually no activities that a person with an amputation cannot perform with the right help, training and equipment. However, the most important rehabilitation objective for the majority of elderly patients with a lower limb amputation is to walk again. It is important to remember that rehabilitation from an amputation in an elderly person is a much more difficult process than in a young person. Regaining the ability to walk will be a major achievement.

Whether or not a patient will be able to walk following an amputation has been studied by looking at factors present before surgery. Poor pre-operative mobility, age over 70 years, dementia, severe kidney and heart disease are factors which make it unlikely a patient will walk after their amputation.

What are the risks of amputation surgery?
There are significant risks attached to undergoing an amputation if you are elderly and have hardening of the arteries. In this group of patients the chances of dying in hospital after a major amputation are somewhere between 10°10 and 20°10. In other words between 1 in 10 and 1 in 5 patients, undergoing a major amputation for hardening of the arteries, will die in hospital. This is why amputation is always a last resort and your surgeon will not advise you to undergo this operation unless it is absolutely necessary. Remember these statistics also mean that 4 out of 5 patients undergoing an amputation will do well. If you are younger and healthy and undergo amputation because of an injury or a tumor, the risks of an amputation are usually much less.

What are the complications of amputation surgery?
The most important complication is the risk of dying. However, there are other complications.

General complications
These mainly consist of problems such as chest infections, angina, heart attacks and strokes. Because your mobility is restricted after an amputation, pressure sores can also develop. The nursing staff particularly will make great efforts to avoid this occurring. Special mattresses and beds are used to reduce pressure on areas at risk of sores. Regular turning to relieve pressure is also important.

Local complications
These mainly consist of wound infections that can develop in the stump. Antibiotics are given to reduce the risk of infection developing at the time of surgery. The stump can sometimes fail to heal or breakdown either as a result of a fall, infection or a poor blood supply. When this happens it can sometimes mean a further operation to revise the amputation or to remove more of the leg. Sometimes contractures can develop in the knee or hip joint and once present and established can be impossible to correct. The knee or hip will not straighten and then fitting an artificial limb can become impossible.

Deep venous thrombosis can also occur because the veins in the leg will have been tied during the amputation operation and because of the immobility after the surgery. Blood thinners (heparin) will usually be given to reduce the risk of blood clots developing.

Phantom Limb pain
Phantom limb is the sensation of still being able to feel the amputated limb. Most amputees experience this sensation, although the intensity can vary from person to person. In many patients pain is also experienced in the amputated limb. This is phantom limb pain and can occur in many patients, but is usually fairly mild and self limiting, although it may be a nuisance. In a few patients phantom limb pain can be a serious problem and difficult to treat.

What will happen after my amputation?
Initially there will be a period of recovery from the operation. Once recovery from the surgery has taken place, physiotherapists and occupational therapists will concentrate on enabling you to manage independently. This will require learning new skills, such as moving from a wheelchair to the bed and back again, using a wheelchair and starting to use an artificial limb. There will be various exercises to strengthen the upper body and maintain flexibility and movement in the amputated leg.

A permanent made-to-measure artificial leg will be made for you when you are ready for one. This can only be done when your leg swelling is getting better and may take more than one attempt before the right fit is obtained.

After an amputation the majority of patients need the help of a wheelchair to remain mobile. Sometimes the use of a wheelchair may be the best way of remaining mobile. If you are very elderly or have had other serious illnesses such as heart disease or stroke then it can frequently be better not to be fitted with an artificial leg.