Amputation is the removal of a limb or other body part by trauma, medical illness, or surgery. As a surgical measure, it is used to control pain or a disease process in the affected limb, such as malignancy or gangrene. In some cases, it is carried out on individuals as a preventive surgery for such problems. A special case is that of congenital amputation, a congenital disorder, where fetal limbs have been cut off by constrictive bands. In some countries, judicial amputation is currently used to punish people who commit crimes. Amputation has also been used as a tactic in war and acts of terrorism; it may also occur as a war injury. In some cultures and religions, minor amputations or mutilations are considered a ritual accomplishment. When done by a person, the person executing the amputation is an amputator. The oldest evidence of this practice comes from a skeleton found buried in Liang Tebo cave, East Kalimantan, Indonesian Borneo dating back to at least 31,000 years ago, where it was done when the amputee was a young child. A prosthesis or a bioelectric replantation may restore sensation of the amputated limb.
Types
Leg 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. 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:
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
Arm 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.
Other
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 (orchiectomy) amputation of the penis (penectomy) amputation of the foreskin (circumcision) amputation of the clitoris (clitoridectomy) amputation of the vulva (vulvectomy) Radicals: Amputation of the waist (hemicorporectomy) Amputation of the head (decapitation)
Genital modification and mutilation may involve amputating tissue, although not necessarily as a result of injury or disease.
Laryngectomy is the amputation of the larynx.
Self-amputation 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.
Body integrity dysphoria is a rare 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.
Urgent In surgery, a guillotine amputation is an amputation performed without closure of the skin in an urgent setting. Typical indications include catastrophic trauma or infection control in the setting of infected gangrene. A guillotine amputation is typically followed by a more time-consuming, definitive amputation such as an above or below knee amputation.
Causes
Circulatory disorders 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
Neoplasm
Cancerous bone or soft tissue tumors (e.g. osteosarcoma, chondrosarcoma, fibrosarcoma, epithelioid sarcoma, Ewing's sarcoma, synovial sarcoma, sacrococcygeal teratoma, liposarcoma), melanoma
Trauma
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)
Congenital anomalies Deformities of digits and/or limbs (e.g., proximal femoral focal deficiency, Fibular hemimelia) Extra digits and/or limbs (e.g., polydactyly)
Infection
Frostbite
Frostbite is a cold-related injury occurring when an area (typically a limb or other extremity) is exposed to extreme low temperatures, causing the freezing of the skin or other tissues. Its pathophysiology involves the formation of ice crystals upon freezing and blood clots upon thawing, leading to cell damage and cell death. Treatment of severe frostbite may require surgical amputation of the affected tissue or limb; if there is deep injury autoamputation may occur.
Athletic performance 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. Rugby union player Jone Tawake also had a finger removed. National Football League safety Ronnie Lott had the tip of his little finger removed after it was damaged in the 1985 NFL season.
Criminal penalties
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, Iran, Saudi Arabia, Yemen, and 11 of the 36 states within Nigeria. Cross-amputation is one of the Hudud punishments prescribed under Islamic jurisprudence (Sharia law) and involves cutting off the right hand and left foot of the alleged transgressor. The scriptural authority for the double amputation procedure is in the Quran (surah 5.33–34) which stipulates: The severe punishment, for "highway robbery (hirabah, qat' al-tariq) and civil disturbance against Islam", is usually carried out in a single session in public, without anaesthetic and using a sword. The ancient punishment is practised in Islamic countries such as Saudi Arabia, Sudan, Somalia, Mauritania, the Maldives, Iran, Afghanistan (under Taliban rule), and Yemen. 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, although not all were really punishable by death at the time. For the crimes of rape, sodomy, and polygamy (the last removed from a later version), the punishment was to be castration for men or rhinotomy for women. For intentional maiming, the bill specified literal eye for an eye retribution. The bill never passed, due to the combination of its perceived barbarity in some parts and perceived leniency in others. In England, the Offences within the Court Act 1541 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.. Jefferson cited a work of Stamford and the Offences within the Court Act 1541 (33 Hen 8 c. 12). The punishment was abolished in England and Wales by the Offences Against the Person Act 1828. 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.
Surgery
Method
Surgeons performing an amputation have to first ligate the supplying artery and vein, so as 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, and skin and muscle flaps are then transposed over the stump, occasionally with the insertion of elements to attach a prosthesis.
Distal stabilisation of muscles is often performed. 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 are attached under similar tension to normal physiological conditions.
An experimental technique known as the "Ewing amputation" aims to improve post-amputation proprioception. Another technique with similar goals, which has been tested in a clinical trial,New surgery may enable better control of prosthetic limbs is Agonist-antagonist Myoneural Interface (AMI).Agonist-antagonist Myoneural Interface (AMI)
In 1920, Dr. Janos Ertl Sr. of Hungary, developed the Ertl procedure in order to return a high number of amputees to the workforce. 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.
Post-operative management 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 of 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.