Considerations

What should someone consider before having amputation?
One of the most difficult decisions facing an individual with trauma is whether to proceed with an amputation or have another type of surgery that attempts to salvage the limb. This is referred to as limb salvage surgery. There is evidence to suggest that there is no significant outcome in terms of function between limb salvage surgery and amputation, however, reconstruction or limb salvage surgery is associated with higher risk of complications, additional surgeries and repeat hospitalizations. Therefore, if time permits, individuals who face losing a limb as a result of trauma should have a complete and informed discussion with the rehabilitation and surgical teams before making any of these difficult decisions.

Surgical options for individuals with PVD may be different and may not involve limb salvage surgery. For instance, individuals with atherosclerosis of major arteries in the lower limbs may need an arterial bypass graft attempted in order to save the limb with poor blood supply. Typically an artificial graft or tube is used to “jump” or bypass these occluded vessels, which may allow better blood flow to the limb and prevent amputation. Unfortunately, individuals with diabetes often have smaller vessels that are most involved. Bypassing a larger vessel would not help these smaller vessels. Therefore, diabetics who have smaller vessels involved are often not considered adequate candidates to have this surgery attempted.

Additionally, diabetics will often have a concomitant peripheral neuropathy present along with the PVD. A peripheral neuropathy causes the limbs of diabetics not only to be painful with pins and needles and burning sensations, but also they have reduced sensation. Together PVD and neuropathy in diabetics can lead to serious problems, putting the limb as well as the individual’s life at risk from serious infections from relatively minor trauma or ulcerations. To avoid the potential complications of PVD and neuropathy, it is strongly advised that diabetics have regular feet and leg inspections as well as have their toenails trimmed by a professional such as a podiatrist. In this way, lower limb amputations that result from undetected or untreated infections may be prevented.

If a person knows that an amputation is necessary, what should he/she consider?
If the decision to proceed with an amputation has been made by the individual and the surgical team, a rehabilitation consultation should be made before surgery. The rehabilitation specialist, either a physiatrist or physical therapist, can assist in many ways. First they may be able to assist the surgeon in deciding what level of amputation may be most appropriate for the individual. For example, amputees with a transtibial amputation on one side require more energy to walk at the same speed then an individual with two intact limbs. Additionally, an amputation across the femur (transfemoral amputee) requires more energy to walk than a transtibial amputee. Bilateral amputees require even more effort and may need an assistive device such as a walker or canes to assist them with balance. Therefore, if an individual has any type of cardiac condition or is weakened by bed rest and/or the disease process, he may have a difficult time trying to function after an amputation. If the patient is weak (deconditioned), his ability to walk with a prosthesis with these high-energy demands may not be possible. Therefore the rehabilitation can institute a rehab program for the future amputee before surgery so that he will be in the best shape possible after the surgery is complete.

Additionally, some limbs after amputation fit into a prosthesis better than others and do not have as many post-operative problems. For instance, an individual with a Syme’s or above ankle amputation may be able to bear weight on the residual limb for short distances without a prosthesis. This may be convenient in the middle of the night when the individual has to go to the bathroom but doesn’t want to put on a prosthesis to get there. Also amputations that occur through a joint (i.e., elbow or knee) known as disarticulations are better able to withstand weight on their residual limb than ones that occur through long bones. However, fitting amputees who have a disarticulation with a prosthesis may be challenging, therefore an amputation through the long bone may be a better option. There are many other considerations to face before surgery, and this is where the rehabilitation specialists can help.

The rehabilitation specialist may also be able to educate the individual and family regarding realistic expectations or goals following amputation. Making generalizations regarding normal function after an amputation may be difficult to predict prior to surgery and often these goals should be on a case-by-case basis. For example, a family member may want to know if his grandfather will be able to walk with a prosthesis after lower limb amputation. If the grandfather was not walking at all before surgery and has severe cardiac disease as an associated problem, then a more realistic goal would be that the older gentleman be able to transfer himself in and out of a chair; he may need a wheelchair for any type of locomotion.

The other advantage the rehabilitation team can provide is education regarding phantom sensation, phantom pain and residual limb pain. Each of these topics will be discussed in a separate section. All amputees experience phantom sensation, which is the feeling that the amputated part of the limb is still attached. Explanation of this sensation is very important prior to surgery for various reasons. One is that the individual experiencing this sensation may believe he is going crazy. Patients may even report that the amputated limb is itchy and needs to be scratched. These fears or concerns should be allayed as a normal occurrence and the individual reassured that such sensations will decrease with time. Another reason for educating the patient about phantom sensation is that he may mistakenly believe that the lower limb is still under him when he attempts to take a step, only to find that it is no longer present. The individual thinks he is going to walk on two limbs only to fall onto the floor, possibly injuring the surgical wound as well as other parts of the body. For this reason the rehabilitation team will educate the individual about such potential problems.