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Approximately 150,000 patients per year undergo a lower extremity amputation in the United States. The most common causes leading to amputation are diabetes mellitus, peripheral vascular disease, neuropathy, and trauma. The level of amputation will depend on the viability of the soft tissues used to obtain bone coverage. This activity reviews the evaluation and treatment of patients requiring a lower-extremity amputation and highlights the role of an interprofessional approach toward caring for this patient population. Objectives: Identify the anatomical structures of the lower extremity. Identify the indications and decision-making process regarding the level of a lower extremity amputation. Determine the equipment, personnel, preparation, and technique in regard to lower extremity amputations. Assess the appropriate evaluation of the potential complications and clinical significance of lower-extremity amputations. Communicate interprofessional team strategies for improving care coordination and communication to advance lower extremity amputations and improve outcomes. Access free multiple choice questions on this topic.

Over 150,000 people undergo amputations of the lower extremity in the United States each year.[1] This incidence is directly proportional to rates of peripheral arterial occlusive disease, neuropathy, and soft tissue sepsis.[2] This correlation is due to the increased incidence of diabetes mellitus, which is present in 82% of all vascular-related lower extremity amputations in the United States. Patients with diabetes mellitus have an astounding 30 times greater lifetime risk of undergoing an amputation when compared to patients without diabetes mellitus, which translates to an economic strain in healthcare systems of over $4.3 billion in annual costs in the USA alone.[3] Trauma to the lower extremity can lead to amputation in over 20% of patients when associated with severe wound contamination and significant soft tissue loss.[4] Battle-related explosive events can lead to amputation in 93% of cases and approximately 2% of combat casualties least to limb amputation.[5] This activity focuses on amputations at the level of the femur and distally. It covers above-knee, through-knee, and below-knee amputations (see Image. Digital Amputation). In addition, it describes the technique for certain foot amputations (Syme, Chopart, Boyd), but the reader is encouraged to seek further in-depth text to review these techniques. Amputations are procedures performed surgically, although on rare occasions and in limited settings, they can be performed employing cryoamputation.[6]

Lower extremity amputations involve significant perioperative morbidity and mortality. Thirty-day postoperative mortality rates can range from 4% to 22%.[18] Long-term mortality rates at 1, 3, and 5 years can reach 15, 38, and 68%, respectively.[19] Mortality rates in diabetic lower extremity amputation patients can be as high as 77% at 5 years.[20] Risk factors for death in the perioperative setting include AKA, postoperative cardiac complications, age over 74 years, and acute renal failure.[21] A review of 2879 amputees demonstrated the most common post-surgical complications included pneumonia (22%), acute kidney injury (15%), deep venous thrombosis (15%), acute lung injury/acute respiratory distress syndrome (13%), osteomyelitis (3%) and flap failure (6%).[22] Wound complications, which include dehiscence, seroma, and hematoma, can occur in 12% to 34% of BKA patients and 6% to 16% of AKA patients.[23] Risk factors for wound complications include sepsis, compartment syndrome, end-stage renal disease, ongoing tobacco use, body mass index over 30 kg/m2, and BKA.[24] A retrospective study showed that the use of incisional negative pressure wound therapy (NPWT) in major limb amputation and revision amputation had demonstrable benefits in decreasing the risk of wound complications.[25] Phantom limb pain (PLP) is the pain that persists after complete tissue healing and is characterized by dysesthesia at the level of the absent limb. Patients describe this pain as burning, throbbing, stabbing, and sharp, as well as the sensation that the amputated limb is in an abnormal position.[26] This pain can be present in 67% of patients at 6 months and 50% of patients at 5 to 7 years.[27][28] There are several risk factors for developing PLP, which include: the presence of pre-amputation pain, female gender, upper extremity amputations, and bilateral amputations of the upper and/or lower extremities.[26] A multidisciplinary approach, which includes surgical technique, regional analgesia, pharmacological agents, physical therapy, and psychotherapy, are all key components in the peri-operative care of an amputee that can have a strong impact on decreasing the risk of PLP.

Phantom limb pain (PLP) is the pain that persists after complete tissue healing and is characterized by dysesthesia at the level of the absent limb. Patients describe this pain as burning, throbbing, stabbing, and sharp, as well as the sensation that the amputated limb is in an abnormal position.[26] This pain can be present in 67% of patients at 6 months and 50% of patients at 5 to 7 years.[27][28] There are several risk factors for developing PLP, which include: the presence of pre-amputation pain, female gender, upper extremity amputations, and bilateral amputations of the upper and/or lower extremities.[26] A multidisciplinary approach, which includes surgical technique, regional analgesia, pharmacological agents, physical therapy, and psychotherapy, are all key components in the peri-operative care of an amputee that can have a strong impact on decreasing the risk of PLP. Revision amputation procedures can occur in as many as 42% of patients who underwent a below-knee amputation secondary to trauma. Additionally, up to 13% of patients undergo revision to a higher level of amputation. Age, presence of a crush injury, compartment syndrome, and experiencing a major post-surgical complication were significant risk factors of revision amputation.[22] It is also important to include psychological trauma as a complication of limb loss. A recent review performed by Mckechnie et al. reveals that depression can occur in 20.6 to 63% of patients (3 times higher than the general population) and anxiety in 25% to 57% (approximately the same as the general population) with 83% of patients attending a psychiatric clinic at 1 point after their surgery.[29] Darnall et al. demonstrated an increased risk of depressive symptoms in patients undergoing an amputation secondary to trauma versus vascular disease or cancer.[30] Current research, such as "Amputees Unanimous: A 12-step Program", focuses on a multimodal approach toward the care of an amputee, which aims to provide encouragement, support, and optimism for the future.[31] Further research is needed to determine their impact on this patient population.

An interprofessional approach is necessary for the care of an amputee. Performing an amputation is a stressful period for most patients. If the procedure is elective, a mental health clinician should consult with the patient. Also, a prosthetic professional should consult with the patient to explain the different prosthetics and when the patient gets fitted with the appliance. After surgery, a wound care clinician must follow the patient to ensure complete healing before fitting any prosthetic device. Pharmacists support glycemic control in patients with diabetes, pain control, and overall medication reconciliation, reporting any issues to the rest of the interprofessional team. Providers caring for this patient population should include an interprofessional team working closely to provide the best outcome. Every clinician is responsible for ensuring that the patient still can function in society. The social worker must ensure that the home is suitable and that the patient has adequate resources and support services. The care of an amputee should be individualized based on the patient's overall health status. Clear communication with the patient and their families regarding their treatment course and expectations must be established in the pre-operative setting to facilitate post-operative care and improve the patient-physician relationship. Only through a thorough interprofessional team effort, extending across many months, can patients receiving a lower extremity amputation achieve optimal results and maintain an adequate quality of life.

The care of an amputee begins and ends with the healthcare team's actions and interventions. Diabetic or peripheral vascular disease patients with foot or leg wounds can often undergo wound care with the assistance of a home healthcare team. Should there be a lack of progression in wound healing or early signs of infection, they are the first to refer the patient to a medical provider and, in some instances, the emergency department. After that, an ER or hospital clinician is generally the first to greet a patient and obtain vital signs, which can indicate the severity of the disease and, therefore, dictate the hospital setting where this patient receives their care. With the assistance of a clinician, the wound is exposed, and the patient is assessed from head-to-toe looking for pressure ulcers, ecchymosis, or hematomas in patients who are wheelchair or bed-bound. Other actions include obtaining adequate intravenous access, medication dispensing and administration, serial symptom assessment including pain, monitoring vital signs, providing wound care and patient hygiene, and liaising between patients, their families, and medical providers.

The care of an amputee involves an interprofessional approach. Monitoring in the post-operative setting includes obtaining and recording vital signs, pain scores, and laboratory values. Serial wound assessments allow for early detection of postoperative bleeding and allow the clinician to perform temporizing maneuvers (digital pressure, dressing reinforcement). Pain scores are diligently obtained to titrate the patients' pain medication accordingly and provide the best condition for early mobilization. Close communication between the interprofessional team is necessary to provide patients individualized care based on their needs.