Arms and legs, hands and feet: These unique and wonderful extensions of our bodies allow us to touch, to feel and to manipulate our environment. They provide us with the invaluable capability of propulsion and allow us to move freely throughout the world. The word ‘limb’ hardly captures the sum and substance of these magnificent structures. Loss of part or all of a limb will forever change how we move, touch, work and play. The individual who loses a limb faces enormous emotional, psychological and physical challenges. When an individual loses part of his physical self he may perceive himself as no longer whole. To survive he has no alternative but to supplement his newly altered physical body with modern mechanical prosthetics in order to regain lost function. This is how he will once again find peace and wholeness. One fantastic young lady, who only recently underwent a transfemoral amputation, recently advanced a revolutionary new vision. She would like to see medicine and science move from artificial limbs to replacement limbs. The replacement limbs would be so comfortable, natural and functional that limb loss would become much less of a event, on par with the loss of an appendix or a gall bladder (ref. Laura Willingham, PRS).

Amputation surgery severs all the varied tissues of the limb. Each tissue must heal in its own particular manner, and the knowledgeable surgeon considers each tissue’s unique role as he plots a reconstructive course. This careful calculation is essential to create the most functional residual limb possible. Limb loss is not only a major physical and functional loss; it also presents the patient with a matchless psychological and emotional situation. Our limbs are a major part not only of our physical being but also of our body image and our self-image. Losing a limb will forever alter all these aspects of the amputee’s life. Even if only a portion of the limb is removed, the brain will still perceive sensations, movement and even pain in the tissues no longer physically present. As Dr. Burgess has pointed out, no amount of psychological testing and evaluation can completely measure the effects of limb loss on a given individual. Only the amputee knows what it is like to lose a limb and how that loss impacts their life (ref to edition 1, 1981).

Amputation surgeons have a unique role and responsibility. When facing any surgical case, the surgeon must strive towards two primary goals, both of which are critical to the success of the procedure. The first goal is the removal of the diseased, damaged or dysfunctional portion of the limb. The second goal is the reconstruction of the remaining limb. Reconstruction must promote primary or secondary wound healing as well as create the most optimal sensory and motor end organ possible. The reconstructive nature of amputation surgery and the potentially positive impact that proper technique can have on an individual’s post-amputation function cannot be over emphasized. The success of every amputation surgery depends on the balance between these two main goals. To be effective, the amputation surgeon must understand not only surgical principles, but also all the aspects of healing, rehabilitation, residual limb physiology and the nature of prosthetic substitutes. Only through a comprehensive grasp of all of these elements of the amputation process can a surgeon truly become an expert and provide the best care for each patient.

The team approach to amputee rehabilitation leads to a more enlightened and successful healing, and it is important to remember that the surgeon is but one member of the amputation rehabilitation team. Communication between team members is essential. The surgeon can benefit from the wisdom and perspectives of the other team members throughout all phases of the amputation process. Other members will have insights on the pre-operative evaluation, during the operation itself, in the healing phase of the early post-operative period and all the way to the management of late complications long after the definitive surgery is complete. The surgeon would be wise to encourage the opinions of his teammates, and wiser still to take these opinions into his calculated and comprehensive consideration.

Levels of Amputation
Amputation is an extraordinarily broad term, covering the entire range of body-part loss. It covers the loss of part of a finger to an entire arm to chest-wall level, and from the loss of a toe all the way to the entire leg or pelvic area. Even above-pelvis, waist-level amputation is occasionally required.

The term ‘amputation’ is typically used to describe the removal of all or part of a limb, but technically it is more precise to reserve this term for the process of limb removal by dividing through one or more of the bones. The term ‘disarticulation’ is more precise for the process of removing a limb between joint surfaces. Each particular site throughout the upper or lower limbs has individualized characteristics of bone shape, nerves, musculature and blood vessels, as well as particular muscles, skin and soft tissue envelope structures available for padding, protecting, and reconstruction. An intimate understanding of the anatomy of all these sites and the various attributes and characteristics that impact healing and prosthetic rehabilitation are important when deciding where and how to amputate.

Upper and lower extremity issues are very different, and deciding between limb salvage versus amputation requires different considerations for upper versus lower extremity injuries. For example, the upper extremity is not weightbearing and can function with minimal sensation. Cases show that even if the salvage of an upper limb results in only minimally assistive function, this salvage is often better than the prosthetic substitutes available on the market today. In contrast, for the lower extremity, weightbearing is mandatory and salvage often functions poorly if it does not provide enough protective sensation. In contrast to an upper limb, a salvaged lower limb must hold up to the demanding forces of walking and weightbearing in order to achieve functional results superior to prosthetic substitution.

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