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Leg amputations are performed when limb salvage is no more possible. This can be due to extensive tissue loss, severe arterial disease that is not amenable to surgery and severe infection. The two most commonly performed procedures are below and above knee amputations. These amputations are designed so as to provide the best functional result. As a rule, below knee amputations are functionally superior and are always considered first.
An epidural anaesthetic may be initiated one to two days before surgery. This helps with controlling the pain around the time of surgery. A urinary catheter will be required at the same time. At the time of surgery, the epidural anaesthetic is increased and supplemented with sedation. This combination provides adequate analgesia with minimum anaesthetic risk to the patient. In most patients, the level of amputation is determined preoperatively. However, in some cases the level can only be determined at the time of surgery after assessing the degree of blood supply. After completion of surgery, a drain is sometimes left in the wound.
Patients are usually transferred back to their original ward. Oral intake is allowed very early on with a special emphasis on a high protein content. Physiotherapy will also start at the early stages of postoperative recovery. This will include breathing exercises together with simple limb exercises. The epidural catheter is usually removed after three to four days and an alternate method of analgesia will be given. Removal of venous lines and the urinary catheter will largely depend on the individual patient's speed of recovery. In the early postoperative period, patients will be counselled regarding rehabilitation and possible limb fitting. Overall, 47% of unilateral and 17% of bilateral amputees for peripheral arterial disease will be able to walk again. However, only half of this group will be able to walk outdoors. 17% of patients who lived independently in the community before surgery will require nursing home care following surgery.
The majority of limb amputations are performed for severe limb ischaemia or infection. These conditions are quite debilitating and patients are usually weak and malnourished "due to the chronic pain and infection". With this background, the complications rate is expected to be quite high. Between 10% to 17% of patients will suffer lethal cardiac or pulmonary complications. Up to 30% of patients will have wound complications ranging between infection to complete healing failure requiring amputation to a higher level. In the immediate postoperative period, pain control can be difficult. In addition to surgery-related pain, patients may experience "phantom pain". This pain is frequently seen in patients who had chronic leg pain prior to amputation. In the early postoperative period, the brain continues to interpret sensory signals from the affected leg as pain from the now amputated part, hence the term "phantom". This type of pain is not treated with analgesia but with other drugs which mainly have a sedative effect. Another common complication is depression. Most patients undergoing major limb amputation will suffer from depression. The severity and duration of this complication vary widely between individual patients. In most cases, depression will be offset by the physiological improvement that follows the removal of a painful or an infected limb. Some patients will, however, require professional counselling and drug therapy.
Admission: Variable Anaesthetic: Epidural / Spinal Stay in hospital: 4-8 weeks Time off work: 3-6 months First follow-up appointment: 6 weeks |
Transtibial (below knee) amputation.
Transfemoral (above knee) amputation.
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