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Diagnosis is relatively straightforward as most patients will have peripheral vascular disease and will have had considerable treatment for it already. As the small blood vessels block off gradually the toes can develop gangrene and ulcers on the pressure areas, which permits bacterial invasion leading eventually to bony infection. If treatment is incremental there may be a long period of minor amputations and other operations, all the time the patient being unable to walk due to pain in the limb. They may use wheelchair due to the pain and energy requirement of ambulation.

In traumatic injuries the patient may suffer a traumatic amputation or a severe compound fracture with concomitant vascular and nerve injuries which are beyond repair. An amputation in this case may make good sense rather than trying to salvage a severely damaged limb over a long time. If the limb is salvaged it may not be functional and be a source of significant pain which may be depressing for the patient and less useful than having an artificial limb. At some stage after the injury a decision needs to be made if the long period of treatment and non-function is worth it for the end result as compared to an amputation.

With amputation the major goal is to preserve the length of the leg and to get the maximum functional use from the limb. As the operation cannot be reversed the surgeon must be sure the decision is correct and the only limits are the medical fitness of the patient to manage operation. Because the patient’s poor medical status will likely be closely linked to their abnormal limb the operation should remove the negative influence on their health and may save their life. Preparation for the operation, rehabilitation and life after amputation is a multidisciplinary matter also involving physiotherapists, social workers and psychologists.

Surgical management of severe leg trauma has shown significant advances in the ability to perform microsurgery to the vascular structures, advanced fixation of fractures and techniques to promote revascularisation of tissues. Amputation may then be viewed as a failure if these techniques cannot save the limb, but viewing it as a reconstructive process is more positive, allowing an increase in useful functional capacity. Techniques of amputation have seen much less development and patients still consult with difficulties such as persisting pain, swelling, limited use of the prosthetic limb and feelings of instability.

The plan for the surgery is to cut any nerves under a tensioned state and to place the cut away from the bone ends, stitching opposing muscle groups together and underneath the bone ends and to maintain the length of the skin to allow it to fold under the cut end. This way the end of the new extremity can have good skin cover and a suitable cushion of muscle to absorb forces. A typical surgical rule is for every 30 centimetres of a person’s height to give 2.5cm of length in the new limb. A wound dressing is then applied and the person given their post-operative painkillers.

After the immediate period post-operatively the patient will be assessed and treated by a physiotherapist who will review their respiratory condition, teach correct positioning of the remaining limb, encourage appropriate exercises, practice transfers and progress to walking with an aid if possible. Around the two week point the physiotherapist may progress to exercise for the affected extremity and start with a desensitisation programme for the operated part. This involves reducing the tenderness of the limb end so that it can cope with the pressures and stresses of wearing a prosthesis and weight bearing.

Around six weeks after the operation the state of the wound may permit the start of the planning period for wearing the prosthesis although some patients will never manage one because of impaired balance, muscle weakness or lack of understanding. There are many other potential complications to having an amputation which may interfere with restoring the patient to their maximum independence. There may be breakdown of the wound as healing is poor in patients with peripheral vascular disease, skin problems, swelling of the area, contractures of the nearby joints, pain and phantom limb pain and sensations.

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

categories: Back pain,injury management,sciatica,Piriformis Syndrome,pain management,sciatica,back injury,back pain relief,Frozen Shoulder,Alternative medicine,physiotherapists,physiotherapy,Health,physical fitness

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