Amputation

Lower limb amputations can be divided into two broad categories: minor and major amputations. Minor amputations generally refer to the amputation of digits. Major amputations are commonly below-knee- or above-knee amputations. Common partial foot amputations include the Chopart, Lisfranc, and ray amputations.

Common forms of ankle disarticulations include Pyrogoff, Boyd, and Syme amputations.[11] A less common major amputation is the Van Nes rotation, or rotationplasty, i.e. the turning around and reattachment of the foot to allow the ankle joint to take over the function of the knee.

Types of amputations include:

An above-knee amputation

partial foot amputation

amputation of the lower limb distal to the ankle joint

ankle disarticulation

amputation of the lower limb at the ankle joint

trans-tibial amputation

amputation of the lower limb between the knee joint and the ankle joint, commonly referred to as a below-knee amputation

knee disarticulation

amputation of the lower limb at the knee joint

trans-femoral amputation

amputation of the lower limb between the hip joint and the knee joint, commonly referred to an above-knee amputation

hip disarticulation

amputation of the lower limb at the hip joint

trans-pelvic disarticulation

amputation of the whole lower limb together with all or part of the pelvis, also known as a hemipelvectomy or hindquarter amputation

The 18th century guide to amputations

Types of upper extremity amputations include:

• partial hand amputation
• wrist disarticulation
• trans-radial amputation, commonly referred to as below-elbow or forearm amputation
• elbow disarticulation
• trans-humeral amputation, commonly referred to as above-elbow amputation
• shoulder disarticulation
• forequarter amputation

A variant of the trans-radial amputation is the Krukenberg procedure in which the radius and ulna are used to create a stump capable of a pincer action.

Partial amputation of index finger.

• Facial amputations include but are not limited to:
  • amputation of the ears
  • amputation of the nose (rhinotomy)
  • amputation of the tongue (glossectomy).
  • amputation of the eyes (enucleation).
  • amputation of the teeth (Dental evulsion). Removal of teeth, mainly incisors, is or was practiced by some cultures for ritual purposes (for instance in the Iberomaurusian culture of Neolithic North Africa).
• Breasts:
  • amputation of the breasts (mastectomy).
• Genitals:
  • amputation of the testicles (castration).
  • amputation of the penis (penectomy).
  • amputation of the foreskin (circumcision).
  • amputation of the clitoris (clitoridectomy).

Hemicorporectomy, or amputation at the waist, and decapitation, or amputation at the neck, are the most radical amputations.

Genital modification and mutilation may involve amputating tissue, although not necessarily as a result of injury or disease.

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 their own limb. The most notable case of this is Aron Ralston, a hiker who amputated his own right forearm after it was pinned by a boulder in a hiking accident and he was unable to free himself for over five days.[12]

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.

In surgery, a guillotine amputation is an amputation performed without closure of the skin in an urgent setting.[13] Typical indications include catastrophic trauma or infection control in the setting of infected gangrene.[13] A guillotine amputation is typically followed with a more time-consuming, definitive amputation such as an above or below knee amputation.[13]

• Diabetic vasculopathy
• Sepsis with peripheral necrosis
• Peripheral artery disease which can lead to gangrene
• A severe deep vein thrombosis (phlegmasia cerulea dolens) can cause compartment syndrome and gangrene[14]

Transfemoral amputation due to liposarcoma

• Cancerous bone or soft tissue tumors (e.g. osteosarcoma, chondrosarcoma, fibrosarcoma, epithelioid sarcoma, Ewing's sarcoma, synovial sarcoma, sacrococcygeal teratoma, liposarcoma), melanoma

Three fingers from a soldier's right hand were traumatically amputated during World War I.

• Severe limb injuries in which the efforts to save the limb fail or the limb cannot be saved.
• Traumatic amputation (an unexpected amputation that occurs at the scene of an accident, where the limb is partially or entirely severed as a direct result of the accident, for example, a finger that is severed from the blade of a table saw)
• Amputation in utero (Amniotic band)

• Deformities of digits and/or limbs (e.g., proximal femoral focal deficiency, Fibular hemimelia)
• Extra digits and/or limbs (e.g., polydactyly)

• Bone infection (osteomyelitis) and/or diabetic foot infections
• Gangrene
• Trench foot
• Necrosis
• Meningococcal meningitis
• Streptococcus
• Vibrio vulnificus
• Necrotizing fasciitis
• Gas gangrene
• Legionella
• Influenza A Virus
• Animal bites
• Sepsis
• Bubonic plague

Frostbite is a cold-related injury occurring when an area (typically a limb or other extremity)[15] is exposed to extreme low temperatures, causing the freezing of the skin or other tissues.[16] Its pathophysiology involves the formation of ice crystals upon freezing and blood clots upon thawing, leading to cell damage and cell death.[16] Treatment of severe frostbite may require surgical amputation of the affected tissue or limb;[17] if there is deep injury autoamputation may occur.[18]

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.[19]
• Rugby union player Jone Tawake also had a finger removed.[20]
• National Football League safety Ronnie Lott had the tip of his little finger removed after it was damaged in the 1985 NFL season.[21]

• According to Quran 5:38, the punishment for stealing is the amputation of the hand. Under Sharia law, after repeated offense, the foot may also be cut off. This is still in practice today in countries like Brunei, the United Arab Emirates,[22] Iran,[23][24] Saudi Arabia,[25] Yemen,[26] and 11 of the 36 states within Nigeria.[27][28]
• In 1779, Thomas Jefferson proposed a bill to the Virginia Assembly that ostensibly would have replaced capital punishment with other penalties, including amputation, for certain crimes,[29][30] although not all were really punishable by death at the time.[31] For the crimes of rape, sodomy, and polygamy (the latter removed from a later version), the punishment was to be castration for men or rhinotomy for women.[32] For intentional maiming, the bill specified literal eye for an eye retribution.[33] The bill never passed, due to the combination of its barbarity in some parts and perceived leniency in others.[30][34]
• From the 16th century, English law provided for cutting off a hand as punishment for striking someone inside a courtroom. Thomas Jefferson's punishments revision bill also intended to repeal this.[35]
• As of 2021, this form of punishment is controversial, as most modern cultures consider it to be morally abhorrent, as it has the effect of permanently disabling a person and constitutes torture. It is thus seen as grossly disproportionate for crimes less than those such as murder.[36]

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 (bleeding). The muscles are transected, and finally, the bone is sawed through with an oscillating saw. Sharp and rough edges of bones are filed, skin and muscle flaps are then transposed over the stump, occasionally with the insertion of elements to attach a prosthesis.

Amputation of the leg of First Lieutenant Antônio Carlos de Mariz e Barros, commander of the Brazilian Battleship Tamandaré (Henrique Fleiuss, Semana Illustrada, 1866).

Distal stabilisation of muscles is recommended. This allows effective muscle contraction which reduces atrophy, allows functional use of the stump and maintains soft tissue coverage of the remnant bone. The preferred stabilisation technique is myodesis where the muscle is attached to the bone or its periosteum. In joint disarticulation amputations tenodesis may be used where the muscle tendon is attached to the bone. Muscles should be attached under similar tension to normal physiological conditions.[37]

An experimental technique known as the "Ewing amputation" aims to improve post-amputation proprioception.[38][39]

In 1920,  Dr. Janos Ertl, Sr. of Hungary, developed the Ertl procedure in order to return a high number of amputees to the work force.[40] The Ertl technique, an osteomyoplastic procedure for transtibial amputation, can be used to create a highly functional residual limb. Creation of a tibiofibular bone bridge provides a stable, broad tibiofibular articulation that may be capable of some distal weight bearing. Several different modified techniques and fibular bridge fixation methods have been used; however, no current evidence exists regarding comparison of the different techniques.[41]

A 2019 Cochrane systematic review aimed to determine whether rigid dressings were more effective than soft dressings in helping wounds heal following transtibial (below the knee) amputations. Due to the limited and very low certainty evidence available, the authors concluded that it was uncertain what the benefits and harms were for each dressing type. They recommended that clinicians consider the pros and cons of each dressing type on a case-by-case basis: rigid dressings may potentially benefit patients who have a high risk of falls; soft dressings may potentially benefit patients who have poor skin integrity.[42]

A 2017 review found that the use of rigid removable dressings (RRD's) in trans-tibial amputations, rather than soft bandaging, improved healing time, reduced edema, prevented knee flexion contractures and reduced complications, including further amputation, from external trauma such as falls onto the stump.[43]

Post-operative management, in addition to wound healing, should consider maintenance of limb strength, joint range, edema management, preservation of the intact limb (if applicable) and stump desensitization.

Private Lewis Francis was wounded July 21, 1861, at the First Battle of Bull Run by a bayonet to the knee.

Traumatic amputation is uncommon in humans (1 per 20,804 population per year). Loss of limb usually happens immediately during the accident, but sometimes a few days later after medical complications. Statistically, the most common causes of traumatic amputations are:[48]

• Vehicle accidents (cars, motorcycles, bicycles, trains, etc.)
• Labor accidents (equipment, instruments, cylinders, chainsaws, press machines, meat machines, wood machines, etc.)
• Agricultural accidents, with machines and mower equipment
• Electric shock hazards
• Firearms, bladed weapons, explosives
• Violent rupture of ship rope or industry wire rope
• Ring traction (ring amputation, de-gloving injuries)
• Building doors and car doors
• Animal attacks
• Gas cylinder explosions[49]
• Other rare accidents

The development of the science of microsurgery over the last 40 years has provided several treatment options for a traumatic amputation, depending on the patient's specific trauma and clinical situation:

• 1st choice: Surgical amputation - break - prosthesis
• 2nd choice: Surgical amputation - transplantation of other tissue - plastic reconstruction.
• 3rd choice: Replantation - reconnection - revascularisation of amputated limb, by microscope (after 1969)
• 4th choice: Transplantation of cadaveric hand (after 2000)[45]

• In the United States in 1999, there were 14,420 non-fatal traumatic amputations according to the American Statistical Association. Of these, 4,435 occurred as a result of traffic and transportation accidents and 9,985 were due to labor accidents. Of all traumatic amputations, the distribution percentage is 30.75% for traffic accidents and 69.24% for labor accidents.[50]
• The population of the United States in 1999 was about 300,000,000, so the conclusion is that there is one amputation per 20,804 persons per year. In the group of labor amputations, 53% occurred in laborers and technicians, 30% in production and service workers, 16% in silviculture and fishery workers.[50]
• A study found that in 2010, 22.8% of patients undergoing amputation of a lower extremity in the United States were readmitted to the hospital within 30 days.[51]