Amputation

Amputation is the removal of a body extremity by trauma 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 preventative surgery for such problems. A special case is the congenital amputation, a congenital disorder, where foetal limbs have been cut off by constrictive bands. In some countries, amputation of the hands or feet is or was used as a form of punishment for people who committed crimes. Amputation has also been used as a tactic in war and acts of terrorism. In some cultures and religions, minor amputations or mutilations are considered a ritual accomplishment. Unlike many non-mammalian animals (such as lizards that shed their tails), once removed, human extremities do not grow back. A transplant or a prosthesis is the only option for recovering the loss.

History

Origins of the word

Amputation is derived from the Latin amputare, to cut away, from amb (about) and putare (to prune). The Latin word has never been recorded in a surgical context, being reserved to indicate punishment for criminals. The English word amputation was first applied to surgery in the 17th century, possibly first in Peter Lowe's A discourse of the Whole Art of Chirurgerie (published in either 1597 or 1612), his work was derived from 16th century French texts and early English writers also used the words "extirpation" (16th century French texts tended to use extirper), "disarticulation," and "dismemberment" (from the Old French desmembrer and a more common term before the 17th century for limb loss or removal), or simply "cutting." but by the end of the 17th century amputation had come to dominate as the accepted medical term.

Overview

The history of human amputation can be divided into a number of periods. Initially, limb loss was usually the result of trauma or 'nonsurgical' removal. This was followed by the hesitant beginnings of surgical intervention, mainly on gangrenous limbs or those already terribly damaged, which developed through to surgical amputations around the 15th century, the distinction is marked by the choice of the patient and the aim of saving a life and achieving a healed stump, despite the difficulties with infection and the lack of effective control for pain or blood loss. Improvements in surgical techniques were married with better haemorrhage control in the 19th century and in the 1840s with anaesthesia and around twenty years later efficient infection control. The 20th century noted marked improvements in surgical techniques and also a move to increasingly sophisticated prosthetic limbs.

Types

Types of amputation include:

• leg
  • amputation of digits
  • partial foot amputation (Chopart, Lisfranc)
  • ankle disarticulation (Syme, Pyrogoff)
  • below-knee amputation (transtibial)
  • knee-bearing amputation (knee disarticulation)
  • above knee amputation (transfemoral)
  • Van-ness rotation/rotationplasty (Foot being turned around and reattached to allow the ankle joint to be used as a knee.)
  • hip disarticulation
  • hemipelvectomy
• arm
  • amputation of digits
  • metacarpal amputation
  • wrist disarticulation
  • forearm amputation (transradial)
  • elbow disarticulation
  • above-elbow amputation (transhumeral)
  • shoulder disarticulation and forequarter amputation
  • Krukenberg procedure
• teeth
  • The avulsion of some teeth (mainly incisives) is or was practiced by some cultures for ritual purposes (for instance in the Iberomaurusian culture of Neolithic North Africa).

Hemicorporectomy, or amputation at the waist, is the most radical amputation.

Genital modification and mutilation may involve amputating tissue (as the case is with circumcision), although not necessarily as a result of injury or disease.

As a rule, partial amputations are preferred to preserve joint function, but in oncological surgery, disarticulation is favored.

Reasons for amputation

• Diabetic foot infection or gangrene (the most common reason for non-traumatic amputation)
• Cancerous bone or soft tissue tumours (e.g. osteosarcoma, osteochondroma, fibrosarcoma, epithelioid sarcoma, synovial sarcoma, sacrococcygeal teratoma)
• Severe limb injuries in which the limb cannot be spared or attempts to spare the limb have failed
• Circulation problems
• Deformities of digits and/or limbs
• Extra digits and/or limbs (e.g. polydactyly)
• Any advanced cancers
• Bone infection (osteomyelitis)
• Traumatic amputation (Amputation occurs actually at scene of accident, the limb can be partially or wholly severed)
• Amputation in utero (Amniotic band)
• Punishment/Torture (e.g in some countries, for example the Muslim world, theft is prevented by the threat of amputation of a hand, although the practice is highly controversial and some Islamic authorities are calling for a moratorium upon it, pending developments in Islamic law.)
• Sometimes professional athletes may choose to have a non-essential digit amputated to relieve chronic pain and impaired performance. 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.

Method

Curved knives such as this one were used, in the past, for some kinds of amputations.

The first step is ligating the supplying artery and vein, to prevent hemorrhage. The muscles are transected, and finally the bone is sawed through with an oscillating saw. Skin and muscle flaps are then transposed over the stump, occasionally with the insertion of elements to attach a prosthesis.

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 his own limb:

• In 2007, 66-year old Al Hill amputated his leg below the knee using his pocketknife after the leg got stuck beneath a fallen tree he was cutting in California.
• In 2003, 27-year old Aron Ralston amputated his forearm using his pocketknife and breaking and tearing the two bones, after the arm got stuck under a boulder when hiking in Utah.
• Also in 2003, an Australian coal miner amputated his own arm with a Stanley knife after it became trapped when the front-end loader he was driving overturned three kilometers underground.
• In the 1990s, a crab fisherman got his arm caught in the winch during a storm and had to amputate it at the shoulder, as reported in The New Englander.

Even rarer are cases where self-amputation is performed for criminal or political purposes:

• About 50 people in Vernon, Florida, collected insurance claims for loss-of-limb accidents in the late 1950s and early 1960s; this was more than two-thirds of all such claims in the United States during that time.
• On March 7 1998, Daniel Rudolph, the elder brother of the 1996 Olympics bomber Eric Robert Rudolph, videotaped himself cutting off one of his own hands with an electric saw in order to "send a message to the FBI and the media."

Body Integrity Identity Disorder is a psychological 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 can not save the limb, or by causing the limb to be severed.

After-effects

A large proportion of amputees (50-80%) experience the phenomenon of phantom limbs; they feel body parts that are no longer there. These limbs can itch, ache, and feel as if they are moving. Some scientists believe it has to do with a kind of neural map that the brain has of the body, which sends information to the rest of the brain about limbs regardless of their existence. Phantom sensations and phantom pain may also occur after the removal of body parts other than the limbs, e.g. after amputation of the breast, extraction of a tooth (phantom tooth pain) or removal of an eye (phantom eye syndrome). A similar phenomenon is unexplained sensation in a body part unrelated to the amputated limb. It has been hypothesized that the portion of the brain responsible for processing stimulation from amputated limbs, being deprived of input, actually expands into the surrounding brain, such that an individual who has had an arm amputated will experience unexplained pressure or movement on their face or head. The individual may also experience some trauma as well as emotional discomfort.

In many cases, the phantom limb aids in adaptation to a prosthesis, as it permits the person to experience proprioception of the prosthetic limb.

Another side-effect can be heterotopic ossification, especially when a bone injury is combined with a head injury. The brain signals the bone to grow instead of scar tissue to form, and nodules and other growth can interfere with prosthetics and sometimes require further operations. This type of injury has been especially common among soldiers wounded by improvised explosive devices in the Iraq war. [1]

Notable amputees

• Rick Allen—Drummer for the band Def Leppard; lost his left arm in a car accident.
• Douglas Bader—Royal Air Force fighter pilot during WWII; lost both legs performing low-flying aerobatics.
• Lucien Bouchard—Canadian politician and Quebec nationalist; lost a leg to necrotizing fasciitis.
• Roberto Carlos—Brazilian singer; lost his leg in a train accident.
• Tammy Duckworth—American politician; lost both legs in the Iraq War.
• Graham Edwards—Australian politician; lost both legs in the Vietnam War.
• Rahm Emanuel—U. S. Congressman; lost part of his right middle finger to a meat slicer while an employee at Arby's as a teenager.
• Terry Fox—Canadian athlete and cancer treatment activist; lost a leg to cancer.
• Zach Gowen—American professional wrestler; lost a leg to cancer as a child.
• Lou Fananek Hagen—Singer of Czech Rock Band, Tři sestry. Lost his leg in train accident.
• Bethany Hamilton—American surfer; lost an arm to a shark attack
• Burkhard Heim—German theoretical physicist; lost both hands in a laboratory explosion
• Daniel Ken Inouye— Medal of Honor recipient, U.S. Senator; WWII war hero; lost his right arm due to battle wounds.
• Matthias Lanzinger—Austrian Alpine skier; lost leg after fracturing his shin and fibula during a World Cup Super-G run at Kvitfjell, Norway.
• Heather Mills—estranged wife of former Beatle Paul McCartney as well as an activist and former model.
• Aimee Mullins—American model and athlete; lost both legs due to congenital disease.
• Oscar Pistorius—South African sprinter; lost both lower legs due to a congenital disorder.
• Daniel Scioli—Argentine politician, Buenos Aires governor, former vice-president of Argentina, large appliances company owner and motorboat offshore driver; lost right arm at Offshore racing race.
• Darío Silva—Uruguayan footballer; lost his right leg after a car accident.
• Bionica von Takedown—American roller derby girl; lost her leg in an automobile accident.
• Alex Zanardi—Italian car racing driver; lost both legs in a CART car accident at Lausitzring

Amputation in Fiction

• In the 1989 book Geek Love by Katherine Dunn, Arty Binewski starts a cult centered around elective amputation.
• In the 2008 book "Duma Key" by Stephen King. Edgar Freemantle is a wealthy contractor who suffers a traumatic brain injury and loses his right arm in an accident at a job site; he feels almost compelled to draw and paint, a compulsion he relates to a phantom limb sensation he has in his right arm.

See also

• Tourniquet
• Autotomy
• Amputee Soccer Championship, Central America
• Amputee fetishism

External links

• Amputation Prevention Center
• Artificial Limb & Appliance Sevice of Wales
• Amputation from Cooper's 1835 "Practice of Surgery"
• The amputee website from the UMC St Radboud Amputee Team
• OandPCare.org provide information for amputees, their families, the media and the general public on prosthetic care for amputees.