The Lower Limb And Amputation

By: David Ravech

Amputation of a limb is a major event for an individual and can result in significant psychological difficulties as they undergo rehabilitation, get fitted for a prosthetic limb and learn to walk effectively again. The surgical planning has to be done with the aim that the patient can easily and comfortably wear the prosthesis, engage fully and speedily in rehabilitation and have a reduced level of energy expenditure when they are walking. Patients in this situation have a lot to learn - to get the prosthesis on and off, to check the skin for pressure areas, to walk on surfaces of varying difficulty and to manage the times when the prosthesis is off.

The team managing the amputee needs to be multidisciplinary and skilled in this field to get the best out of the patient in terms of independence and the team may consist of the physiotherapist, an occupational therapist, the surgeon, the personal medical practitioner, a prosthetist and advisors on social care and employment. As the industrialised countries' populations continue to age the number of amputations will also rise as the main cause of amputation is vascular disease in the periphery. The number of above knee versus below knee amputations has changed as surgeons have learned to preserve the knee joint in more cases, with seventy percent now being below knee.

Peripheral vascular disease (PVD) is the most common reason for amputation with a significant number of patients suffering an amputation on the other side within three years. Most patients are elderly and have ischaemic problems which are secondary to diabetes, with peripheral neuropathy a common difficulty which can lead to ulcers and gangrenous changes. Trauma to the lower limb which involves the arteries and nerves can be treated but may result in a leg which is painful and does not function well, meaning that an amputation would be preferable for speedy rehabilitation and return to normality.

Amputation is also employed for less common conditions such as infections, congenital lower leg abnormalities and tumours. The planning for an amputation should be viewed as an operation targeted at reconstruction and not just removing a body part, aiming for the planned independence and function of the patient. As the level of the amputation progresses up the leg this increases the work of walking, requiring increased levels of oxygen concentration, increased expenditure of energy levels and reducing the speed the person is able to walk. Below knee amputation shows little increase in energy needed for walking but mid thigh can increase this by fifty percent.

The energy requirements for gait are extremely important as amputated patients frequently suffer from ischaemic tissue problems or other medical conditions which lead to walking consuming much of their energy abilities. Independence in functional activities may be hard to achieve as much of their limited energy supplies is taken up with simply walking. After the amputation, due to the skin viability and ischaemic diagnosis, healing may be delayed and this can have an important bearing on the eventual outcome for the patient's independence. The soft tissues at the site of amputation must act as the connecting point between the leg and the prosthesis.

Allowing a bony area higher up to take some of the weight transfer indirectly can be successfully integrated with weight transfer sideways through the soft tissues of the lower leg. There may still be pain issues for patients despite the many advances made in modern prosthetics. Significant pain can lead to a reduction in function, reduced use of the prosthesis and even to further surgery.

PVD or peripheral vascular disease is the most prevalent reason for amputation, with elderly patients being the largest group and often having a second amputation inside three years. Ischaemia of the tissues occurs, often the result of diabetes which can then progress to neuropathy of the peripheral nerves, ulcers and eventually gangrenous changes in the limb. An accident to the leg involving open fractures and arterial and nerve damage can now be medically managed to save the leg but this may not always be positive as an amputation could permit early progress via rehabilitation towards independence.

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Jonathan Blood Smyth, editor of the Physiotherapy Site, writes articles about Physiotherapy, back pain, orthopaedic conditions, neck pain, injury management and physiotherapists in London. Jonathan is a superintendant physiotherapist at an NHS hospital in the South-West of the UK.

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