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Understanding amputation: upper and lower limbs

Amputation is the surgical removal of a limb or part of a limb. It is performed in extreme cases where restoration of limb function is impossible or where the health risks associated with continuing treatment outweigh the expected benefits.

What is amputation?

Amputation is the surgical removal of a limb or part of a limb. It is performed in extreme cases where restoration of limb function is impossible or where the health risks associated with continuing treatment outweigh the expected benefits. Complications of diabetes, peripheral vascular disease, severe trauma and certain cancers are the main medical conditions requiring amputation1,2,3.

Amputation has significant physical, psychological and social consequences, and often requires a long period of rehabilitation. It is also common for patients to experience phantom pain after amputation, where they feel pain in the missing limb. Phantom pain is the result of a combination of factors, including tissue damage, nerve damage and changes to the central nervous system1.

 

Different types of amputation

The different types of amputation can be classified according to the body part amputated and the level of amputation. Here are the main categories identified:

Upper limb amputation

Upper limb amputations are much less common than lower limb amputations and account for around 3% of all amputation cases26.

The main cause of upper limb amputations in adults is trauma, with around 75% of these amputations being of traumatic origin27. Amputations can be performed at various levels, from the tip of a finger to the shoulder. The general principles of upper limb amputation are common to all amputations, whatever the level. The main objective is to remove the affected part of the limb, while preserving as much length as possible7.

Lower limb amputation


Les amputations des membres inférieurs sont beaucoup plus courantes et représentent environ 97% de tous les cas d'amputation26.

Minor amputation
Lower limb amputations can be classified as minor when they are limited to the toes or to partial amputations of the foot4,5.

Major amputation
In contrast, a major amputation involves the loss of a larger part of the limb, such as a transtibial (below the knee) or transfemoral (above the knee) amputation4,5.

  • Transtibial (below knee) amputation: Among major lower limb amputations, transtibial amputation is the most common, accounting for 50% of cases. Advances in surgery and rehabilitation have enabled a significant number of transtibial amputees to achieve a level of rehabilitation equal to or close to that which they had before the operation5.
  • Transfemoral (above-knee) amputation: Transfemoral amputation, the removal of the above-knee limb, is a major surgical procedure resulting in severely compromised mobility, significant lifestyle impairment and damage to the patient's self-confidence. The only solution to mitigate these consequences and support the patient's movement is to provide a prosthesis6.

These different forms of amputation can have a major impact on mobility and quality of life, requiring physical and psychological adjustments.

The main causes of amputation

  • Diabetes and diabetic foot complications

    Diabetic foot ulcers are the main cause of non-traumatic lower limb amputations. Epidemiological studies suggest that around 75% of foot amputations are carried out in patients with diabetes. The development of a diabetic foot ulcer is traditionally considered to result from a combination of peripheral vascular disease, peripheral neuropathy and infection (11).

  • Peripheral vascular disease

    Peripheral vascular disease mainly affects the arteries in the legs and is often caused by the build-up of fatty deposits (atherosclerosis) in the blood vessels. This reduces blood circulation, which can cause pain in the muscles when you walk or even at rest, especially in the feet. If circulation remains inadequate, wounds may appear, and if left untreated, they may worsen until gangrene sets in, leading to amputation. To assess the seriousness of this situation, doctors use a tool called the ‘Fontaine score’. Patients in the most serious stages (III or IV) have a particularly high risk of serious complications (12).

  • Trauma

    Amputations related to severe trauma, such as those caused by road accidents, injuries in the workplace or in areas of armed conflict (such as war) are the most common cause of upper limb amputation. Amputations may be necessary when soft tissue and bone are severely damaged (13).

  • Cancer

    The number of cancer-related lower limb amputations is relatively small, but affects all age groups. Surgery is the main treatment for most bone tumours, with the primary aim of complete removal of the tumour. In some cases, limb amputation is the only option, leading to severe impairment of body function and activity limitations (14).

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Improving quality of life after amputation

Amputation can profoundly change your self-perception and affect your self-confidence. It often brings ongoing challenges and upheaval to daily life, especially for lower-limb amputees. Here are the main keys to living better after an amputation:

Physical rehabilitation

Physical rehabilitation is essential to regaining better mobility and independence. Thanks to regular physiotherapy sessions, amputees learn to use their prosthesis and regain important functions, such as walking faster and more easily. This plays a crucial role in their day-to-day independence17.

Accept and adapt

Accepting one's new situation is an important process. Coping strategies, such as active coping, help to reduce stress and improve quality of life. As each person is different, interventions must be tailored to meet individual needs and circumstances throughout the rehabilitation process18.

Social and psychological support

Good emotional and psychological support is essential for adapting to this new reality. Family and friends, medical supervision and good communication with the healthcare team all play a key role. Receiving clear information, regular guidance and ongoing support makes all the difference19.

In short, a combination of physical rehabilitation, emotional adjustment and caring social support can help amputees return to a more fulfilling and independent life.

Post-amputation rehabilitation

Post-amputation rehabilitation is a crucial process in helping patients regain their mobility and independence. Here are the key points based on recent research:

Evidence-based rehabilitation programmes
A programme such as Evidence-Based Amputee Rehabilitation (EBAR) follows a structured approach: patient assessment, personalised treatment, follow-up and reassessment. This model, which is close to traditional physiotherapy practices, has been shown to be effective for unilateral transtibial amputees. It improves their functional capacity and their ability to walk, with or without a prosthesis20.

Pre-operative rehabilitation
Preoperative rehabilitation is a strategy commonly used to enhance the physical and mental fitness of patients prior to surgery, aiming to improve postoperative outcomes. Findings from the literature suggest that pre-rehabilitation interventions in the setting of major lower limb amputation can improve post-operative outcomes, such as mobility and quality of life. However, it appears that the integration of pre-rehabilitation into the care of patients with major lower limb amputations is currently limited to a select group of patients with vascular disease21.

Optimal fit of the prosthesis
A key factor in post-operative rehabilitation is the proper fit of the prosthesis. A well-fitting prosthesis can improve comfort, function, the appearance of the missing limb and overall quality of life. Conversely, poor fit can lead to discomfort and even skin lesions. These problems can slow down the patient's rehabilitation progress22.

In conclusion, the success of post-amputation rehabilitation depends on structured programmes such as EBAR, appropriate preparation prior to surgery, and optimal management of the prosthesis. These elements maximise the chances of regaining satisfactory autonomy and quality of life.

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  11. Namgoong, S., Jung, S., Han, S., Jeong, S., Dhong, E., & Kim, W. (2016). Risk factors for major amputation in hospitalised diabetic foot patients. International Wound Journal, 13. https://doi.org/10.1111/iwj.12526.
  12. Beard, J. (2000). ABC of arterial and venous disease: Chronic lower limb ischaemia.. BMJ, 320 7238, 854-7 . https://doi.org/10.1136/BMJ.320.7238.854.
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  14. Metka et al. "Rehabilitation of Oncological Amputee Patients." , 3 (2015): 81-84. https://doi.org/10.17265/2328-7136/2015.02.004.
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  16. Imaoka, S., Sato, K., Furukawa, M., Okita, M., & Higashi, T. (2021). Re‐amputation in patients with diabetes‐related minor amputations who underwent physical therapy during their hospitalization. Journal of Foot and Ankle Research, 14(1). https://doi.org/10.1186/s13047-021-00454-y
  17. Pereira, Â. M., Ramos, A., Rafaela, A., João, M., & Arrifes, V. (2019). Mobility in patients with lower limb amputation after prosthesis. Annals of Medicine, 51(sup1), 212. https://doi.org/10.1080/07853890.2018.1560175
  18. Pereira, M., Ramos, C., Lobarinhas, A., Machado, J., & Pedras, S. (2018). Satisfaction with life in individuals with a lower limb amputation: The importance of active coping and acceptance.. Scandinavian journal of psychology, 59 4, 414-421 . https://doi.org/10.1111/sjop.12444.
  19. Ligthelm, E., & Wright, S. (2014). Lived experience of persons with an amputation of the upper limb. International Journal of Orthopaedic and Trauma Nursing, 18, 99-106. https://doi.org/10.1016/J.IJOTN.2013.08.018.
  20. Robert Gailey, Ignacio Gaunaurd, Michele Raya, Neva Kirk-Sanchez, Luz M Prieto-Sanchez, Kathryn Roach, Effectiveness of an Evidence-Based Amputee Rehabilitation Program: A Pilot Randomized Controlled Trial, Physical Therapy, Volume 100, Issue 5, May 2020, Pages 773–787, https://doi.org/10.1093/ptj/pzaa008
  21. Juha M. Hijmans, Rienk Dekker, Jan H.B. Geertzen, Pre-operative rehabilitation in lower-limb amputation patients and its effect on post-operative outcomes, Medical Hypotheses, Volume 143, 2020,110134, ISSN 0306-9877, https://doi.org/10.1016/j.mehy.2020.110134.
  22. Butler, K., Bowen, C., Hughes, A., Torah, R., Ayala, I., Tudor, J., & Metcalf, C. (2014). A systematic review of the key factors affecting tissue viability and rehabilitation outcomes of the residual limb in lower extremity traumatic amputees.. Journal of tissue viability, 23 3, 81-93 . https://doi.org/10.1016/j.jtv.2014.08.002.
  23. Thibaut, A., Beaudart, C., Noordhout, B., Geers, S., Kaux, J., & Pelzer, D. (2022). Impact of microprocessor prosthetic knee on mobility and quality of life in patients with lower limb amputation: a systematic review of the literature.. European journal of physical and rehabilitation medicine. https://doi.org/10.23736/S1973-9087.22.07238-0.
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  25. Psychosocial impact on anophthalmic patients wearing ocular prosthesis Goiato, M.C. et al. International Journal of Oral and Maxillofacial Surgery, Volume 42, Issue 1, 113 – 119
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  27. Annemarie E. Orr, 31 - Rehabilitation for Persons With Upper Extremity Amputation, Editor(s): Kevin K. Chui, Milagros "Millee" Jorge, Sheng-Che Yen, Michelle M. Lusardi, Orthotics and Prosthetics in Rehabilitation (Fourth Edition), Elsevier, 2020, Pages 784-797, ISBN 9780323609135, https://doi.org/10.1016/B978-0-323-60913-5.00031-3.