It is usually possible before the operation for the surgeon to determine if the amputation will be performed above the knee or below. Sometimes gangrene or infection will only involve a toe or part of a foot, and the surgeon can perform a limited or minor amputation. 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.
An important factor in healing is the blood supply to the tissues. If the blood supply is damaged or impaired, the tissues may not heal even after a minor amputation. If the surgeon thinks the tissues will not heal because of poor blood supply, it would be reckless to proceed with a minor amputation when a major amputation is required. Unfortunately, there is no test to predict in every patient whether healing will take place. It is a matter of surgical judgment and experience whether a wound is likely to heal.
Generally, the more limited the amputation the lower the risks and the better the chances of walking. It is better to have a below-the-knee amputation because the chances of successfully walking are much better. Not everyone is suited for this procedure, and many people need to have an above-the-knee amputation. This may be because the blood supply to the lower leg is too poor and a below-the-knee amputation would not heal properly. If the knee cannot straighten out properly before the surgery, it will be impossible to walk with an artificial leg after the operation. In these circumstances it may be better to have an above-the-knee amputation.
Once an amputation stump is created, it is a potentially vulnerable area that requires lifelong care and attention. A major amputation wound is almost always closed with stitches or staples.
Below the knee amputation
Above the knee amputation
Major amputation FAQs
How will having an amputation affect me?
Amputation of a limb or limbs affects people in different ways. It is very personal, and for many patients can feel like bereavement. The emotional loss is similar to losing a family member and it takes time to adapt. Physically, your body is permanently altered and this affects all areas of your life. How much your amputation affects your life also depends 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 older patients with a lower limb amputation is to walk again. It is important to remember that rehabilitation from an amputation in an older person is much more difficult than in a young person. Regaining the ability to walk is a major achievement.
Whether a patient will be able to walk following an amputation has been studied by looking at factors present before surgery. Poor preoperative mobility, over age 70, dementia and 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 amputation if you are older and have hardening of the arteries. In this group of patients the chance of dying in the hospital after a major amputation is high. Between 1 in 10 and 1 in 5 patients with hardening of the arteries who have a major amputation will die in hospital. This is why amputation is always a last resort and your surgeon will not advise you to have the procedure unless it is absolutely necessary. Remember these statistics also mean that 4 out of 5 patients who have an amputation will do well. If you are younger, healthy and have an amputation because of an injury or a tumor, the risks are much less.
What are the complications of amputation surgery?
The most important complication is the risk of dying. However, there are other complications.
These 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 will make every effort to avoid this from occurring. We use special mattresses and beds to reduce pressure on areas at risk of sores. Regular turning to relieve pressure is also important.
These consist of wound infections that can develop in the stump. We give antibiotics to reduce the risk of infection developing at the time of surgery. Sometimes, the stump fails to heal or breaks down as a result of a fall, infection or poor blood supply. When this happens, it can 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. Once these are present and established, they can be impossible to correct. The knee or hip will not straighten and then fitting an artificial limb becomes impossible.
Deep venous thrombosis can also occur because the veins in the leg will have been tied during the amputation procedure and because of immobility after 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 varies from person to person. In many patients, pain is also experienced in the amputated limb. This is phantom limb pain, but is usually fairly mild and self limiting, although a nuisance. In a few patients, phantom limb pain can be serious 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 takes place, physiotherapists and occupational therapists will concentrate on enabling you to manage independently. This requires 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. 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 a wheelchair to remain mobile. Sometimes using a wheelchair may be the best way to remain mobile. If you are older, or have had other serious illnesses such as heart disease or stroke, then it can be better not to be fitted with an artificial leg.