- surgically when the life of the patient is threatened or healing the affected body part is not expected
- as a consequence of an accident ( traumatic )
- as punishment, which used to be common in many regions and is still taking place today in some Islamic countries such as Iran , Saudi Arabia or Sudan with reference to Sharia law
- seldom already in the womb ( congenital ) by means of tying rings ( amniotic band syndrome ).
Amputation as a surgical procedure
In addition to injuries and infections, acute or chronic arterial circulatory disorders are the most common causes of amputation. The predominant cause of chronic arterial circulatory disorders is generalized arteriosclerosis . According to the distribution pattern of the vascular occlusions, the lower extremity is most often at risk of amputation. The following definitions therefore relate to the lower extremity, but also apply mutatis mutandis to the upper extremity.
Major amputation means an amputation above the ankle region. In the DRG accounting system of the health insurance companies, the major amputation begins with the transmetatarsal forefoot amputation due to the higher material consumption.
Minor amputation means a “small amputation” below the ankle region (i.e. up to and including the Chopart amputation). In the DRG system, it only includes toe amputations or beam resections.
Depending on the indication , a distinction is made between scheduled amputation and emergency amputation.
Indications for amputation
Most scheduled limb amputations must be performed as a result of arterial occlusive disease (PAD) . The indication is usually made in stage IV if there is extensive tissue necrosis or infected gangrene with impending sepsis and vascular surgical measures have been exhausted or cannot be considered. As an exception, the indication is also made in stage III , if the persistent pain present here is not manageable and restricts the patient's quality of life so severely that the amputation is the “lesser evil”. The amputation level depends on the quality of the blood circulation, which is determined by angiography , and on the most sensible option for prosthetic treatment. On the leg, the thigh amputation is usually about a hand's width above the knee (in the case of PAD of the pelvic type) or the lower leg amputation about a hand's width below the knee (in the case of AOD of the thigh type). The amputation of arms due to arterial disease is a rarity.
The second most common indication is diabetic gangrene . In contrast to the AVK, the so-called "border zone amputation" is usually aimed for, that is, the amputation as distal as possible , in the area that is barely healthy. Therefore, these are often amputations of toes, the forefoot (amputation or disarticulation in Chopart - or Lisfranc -hinge) or the hindfoot ( Pirogov butt ). This approach, previously frowned upon as “salami tactics”, has become widely accepted since the 1990s due to improvements in wound management , systemic antibiotic therapy and the cessation of diabetes. Nevertheless, many lower or upper leg amputations still have to be carried out as a “last resort”.
Amputations as a result of accidental injuries are rare compared to the first two indications. The aim is always to preserve the limbs, with good conditions even larger traumatically severed limbs can be replanted more and more frequently . If the severed section is destroyed, however, often only the stump restoration can be performed. Unmanageable wound infections after injuries, an extensive compartment syndrome and open grade IV fractures , in which the nerves or blood vessels are irretrievably destroyed, force amputation. The amputation level is chosen here - without following a scheme - as far distal as possible. Modern prosthetics allow almost any residual limb to be restored.
Very rarely do malignant tumors force amputation of a limb. These are usually bone or soft tissue tumors ( sarcomas ). The primary aim here is local resection of the tumor and restoration of bone continuity using special endoprostheses .
In addition, serious complications can ultimately lead to an amputation, such as infected endoprostheses of the knee, infected pseudarthroses , large traumatic bone defects for which surgical attempts at treatment are unsuccessful. Occasionally, patients with severe malformations of an extremity and difficult orthotic fitting opt for an amputation.
No statistics are available for Germany on the number of amputations . According to estimates by the AOK Scientific Institute , more than 55,000 surgical amputations of the lower extremities were performed in more than 41,000 hospital cases in 2002 . According to other information, there are currently around 60,000 amputations per year in Germany. In a European comparison that is a high number. 70 percent of amputations in Germany affect diabetics . You would have a 10 to 15 times higher risk of amputation.
Performing an amputation
The result of the rehabilitation after amputation depends largely on the possibility of prosthesis fitting. Therefore, a scheduled amputation must be carried out in such a way that a residual limb that is as good as possible is created. The soft tissue coverage of the bony stump is decisive here. The skin incision is therefore made in such a way that it is sufficiently but not too far below the intended bony amputation height ("frog's mouth cut") to ensure that the end of the bone is safely covered as a muscular skin flap including the underlying muscles. After cutting through the bone (s ) ( osteotomy ), the bone edges must be smoothed and possibly beveled. This is particularly necessary with the lower leg amputation at the front of the shin, where a bone wedge is usually removed ( triangle de Farabœuf ).
The musculature is then cut in such a way that it surrounds the bony stump as a “cushion”. For secure fixation, the muscles are connected to each other ( myoplasty ) or connected directly to the bone stump via drill holes ( myodesis ). The skin scar should be placed away from the stress zone of the stump.
The main nerves are exposed far in the proximal direction and cut there so that the nerve end lies deep in the soft tissue outside the stress zone. This is to prevent adhesion with the skin scar, neuroma formation and phantom pain .
In the first phase of follow-up treatment, it is important to achieve good wound healing. Wound healing disorders or infections are not uncommon, especially with the two most common reasons for amputations, arterial occlusive disease and diabetes. In order to shape the stump, which should be as cylindrical as possible for a good prosthesis fitting, a special bandage is regularly applied from the day of the operation. After the wound has healed and the initial swelling has subsided, the residual limb is usually provided with a liner , an elastic cover that further shapes the residual limb and over which the prosthetic socket is later placed.
After an amputation, there are other options for reconstruction or techniques that increase the functionality of the residual limb, especially with arm amputations:
- Kineplasty after Sauerbruch: A muscle belly above the stump forms a skin channel through which a pin can be passed, which is connected to the prosthesis and thus active movements e.g. B. allows the prosthetic hand. This was often used after the First World War , mostly on the biceps brachii muscle in forearm amputees.
- Krukenberg grasping forceps : In amputations of the forearm, the radius and ulna can be separated so that a grasping function between the two bones is possible. This is similarly possible with metacarpal amputations.
- Angular osteotomy on the humerus according to Ernst Marquardt : Occasionally, if the upper arm is amputated above the condyles, the prosthesis cannot be rotationally stable . An osteotomy of the humerus shaft with angling of the distal segment forward can then enable a rotation-safe restoration.
- Lengthening of extremely short stumps by means of callus distraction with a sufficient skin flap, also especially on the arms.
In some cases, specific surgical techniques have developed:
- Pirogoff amputation as amputation of the foot with partial preservation of the heel bone and the sole of the foot underneath and arthrodesis between the heel bone and shin bone after removal of the talus.
- Gritti-Stokes amputation refers to a thigh amputation that is carried out very close to the knee joint, just above the knee condyles ( supracondylar ), whereby the kneecap is preserved, brought under the stump that has a tip of about 15 ° and is fixed with transosseous sutures. The kneecap tendon is sutured to the knee flexor tendons; no muscle transection is necessary. A slightly longer front flap means that the seam is usually located at the back. The advantage is a very long residual limb that can quickly endure the load, with a good lever arm and largely unrestricted strength of the adductors and hip extensors. In addition to trauma patients, the technology can also be used for circulatory disorders. Thanks to the preserved upper knee arteries for supplying the anterior lobe, wound healing disorders are rarely observed. Compared to a standard thigh amputation with a prosthesis, patients walk faster with better balance and fewer additional walking aids.
- Ertl modification for lower leg amputations with the creation of a solid bone bridge between the tibia and fibula at the end of the residual limb, especially for traumatic amputations. First described by Janos Ertl in 1949, it should create a more stable and better resilient lower leg stump. However, studies have not shown any benefit to this technique.
For special indications, especially in the case of malignant bone or soft tissue tumors , partial amputations are occasionally carried out in which only a section of the extremity is removed and e.g. B. the foot is then reconnected to the remaining stump, sometimes by rotating the foot by 180 °, as is done for example in the reverse sculpture according to Borggreve.
In addition, residual limb revisions are often necessary, for example for scar correction, joint mobilization, removal of protruding bone portions or axis corrections.
First aid and medical care in the case of accidental amputations
In the event of an emergency of a traumatic complete (total) or partial (subtotal) amputation, vessels are injured, which can result in life-threatening bleeding . Stopping this bleeding is the primary goal of caring for the injured person. If the injured person is trapped, acutely threatened and cannot be cleared within a reasonable time, an emergency amputation is carried out in the most extreme case (see below). Depending on the situation of the injured are measures to stabilize the vital signs taken at unconsciousness the recovery position prepared in respiratory arrest the ventilation machine or in a cardiovascular arrest resuscitation performed. In addition, any shock that may occur is treated accordingly and appropriate pain therapy is carried out.
To secure the severed body part, the amputate, the first aider temporarily stores it in sterile materials such as bandages . In order to facilitate a possible accident-surgical reconstruction of the injury, in addition to sterile and dry storage, transport as cool as possible is necessary. The wrapped amputate is put into a clean plastic bag which, after being closed, is fixed in a second bag filled with cold water or ice. It is important to ensure that the amputate does not come into contact with ice in order to avoid frostbite and the associated tissue damage. The amputate should not be cleaned by the first aider, as improper handling may make reconstruction impossible. After the amputate is handed over, it is cleaned in the hospital.
If an extremity is not completely severed, existing tissue connections should not be severed, as they can ensure a minimal blood supply.
In desperate accident situations, it may be necessary for the emergency doctor to perform an amputation at the scene of the accident. This primarily concerns burial accidents (quarries, mining, earthquakes, gas explosions) when an extremity is trapped and the injured person, who is in mortal danger, cannot otherwise be saved. In the case of traffic accidents, this procedure is only required in extremely rare exceptional cases due to the extensive possibilities of technical rescue , for example in accidents with large or rail vehicles in which the hydraulic rescue devices designed for car accidents reach their limits.
If help is not available in desperate, life-threatening accident situations, a self-amputation can save your life. The American mountaineer Aron Ralston achieved international fame, who freed himself from a canyon by self-amputating his trapped hand in 2003.
Amputation as a punishment
In many cultures and epochs, amputations were carried out as a more severe form of corporal punishment . The oldest known source for this is the Codex Hammurapi from Babylonia from the 18th century BC, in which amputation was described as a punishment for violence by slaves against free citizens. Punitive amputations are also documented in Peru in the fourth century BC. Amputations were also used as punitive measures during the Roman Empire and the subsequent Byzantine Empire . This continued in Europe until the 17th century, when more humane punishment became common during the Enlightenment and corporal punishment was pushed back overall. In numerous Arab and African countries, punitive amputations continue to the present day.
In Islamic law
In Islamic jurisprudence, there are individual criminal offenses that are punished with amputation within the framework of the Hadd penalties . For example, according to the Koran ( Sura 5 : 38), male and female thieves should have their hands cut off “as compensation for what they have committed and as a warning to God”. The cross-cutting of hand and foot is mentioned in the Qur'an (Sura 5:33) as a possible punishment for fighting God and his Messenger as well as for robbery. In Islamic jurisprudence , however, the execution of such sentences was linked to strict requirements. For example, a theft ( sariqa ), which is supposed to result in such a punishment, must have happened secretly, the stolen property must have a certain minimum value ( niṣāb ), the thief must not have any property in it and he must have it from custody ( ḥirz ) have taken away. In addition, the amputation may only be carried out by state authorities.
In reality, punitive amputations of this kind were very rare in most Islamic countries even in the early modern period. Occasionally, however, cross amputations were used as a punishment for spies, for example in the late 19th century in the Sudanese Mahdi Empire (see illustration). Between the late 19th century and the early 20th century, hadd sentences were abolished in almost all Islamic countries. Saudi Arabia is the only Islamic country where the amputation penalty has never been interrupted to this day. However, judicial amputations are relatively rare here. Between 1981 and 1992 there was a total of 45 cases.
In the course of the re-Islamization after 1972, the Islamic criminal law was codified in various states and in this context amputation was reintroduced as a punishment for theft. Examples are Libya , Pakistan , Iran , Sudan and northern Nigeria . In Sudan, there was a worrying expansion of the amputation offense . For example, Article 320 of the Sudanese Penal Code of 1983 dropped secrecy and removal from custody as conditions for theft. Here, too, the enforcement of the amputation penalty was pursued with great energy. Between September 1983 and the fall of the Numeiri regime in April 1985 alone, 96 to 120 amputations were performed. Although the government suspended the amputations afterwards, amputation sentences were again carried out after the coup in 1989 and executioners were sent to Saudi Arabia for training. In January 2001 five men were cross amputated for street robbery.
With the Japanese mafia
History of amputation surgery
Surgical interventions were carried out as early as the Paleolithic , which patients survived. This art was not limited to Homo sapiens : A skeletal find of a male Neanderthal man in a cave in northern Iraq about 45,000 years ago shows a clean severing of a forearm. Later successful amputations e.g. B. from the French Buthiers-Boulancourt of the Neolithic Age (around 4900 BC) prove the successful severing of the left forearm of an older man. There is further evidence of Neolithic amputations from Germany and the Czech Republic. Amputations were also carried out in Egypt 3000 years ago . However, researchers have already discovered representations of amputations of fingers on cave paintings . These images date from the Mesolithic (8000–6000 BC). It is not known whether the amputations took place for medical or ritual reasons.
Early written descriptions of amputations in antiquity are e.g. B. by Hippocrates of Kos , Aulus Cornelius Celsus , Archigenes of Apamei (48-117) and Galen . Also Oribasius , Aëtius of Amida and Paul of Aegina mentioned surgical amputations. The high and late Middle Ages saw amputations through the works of Roger von Parma , Hugo and Theoderich von Borgognoni , Wilhelm von Saliceto and Guy de Chauliac .
The surgeon Hans von Gersdorff first described the tourniquet ligation system and cauterization to control bleeding in his field book der Wundarzney published in 1517, while the French surgeon Ambroise Paré reintroduced arterial ligatures in amputation surgery in the middle of the 16th century , as had been done by Hippocrates of Kos had been described. Paré was also the first to describe phantom pain .
With his proposals, which were noticed throughout Europe, to manage without amputation even with severe limb injuries, the military surgeon Johann Ulrich Bilger (1720–1796) became a pioneer in conservative surgery in the 18th century .
The first successful metatarsal amputation at the level of the tarsometatarsal joints was carried out in 1815 by the French surgeon Jacques Lisfranc , after whom this amputation level and the joint line continue to be designated. The first disarticulation of the ankle was carried out by the Scottish surgeon James Syme in 1842, while the Russian surgeon Nikolai Iwanowitsch Pirogow received the heel bone during the Pirogoff amputation and fused it with the shin by resecting the ankle . However, both received the heel skin capable of endurance. The later development goes back to the attempt of the Italian surgeon Giuliano Vanghetti to attach muscles directly to the prosthesis, particularly by Ferdinand Sauerbruch , who formed muscle channels to control kineplastic prostheses.
It was only after the Second World War that myoplasty was introduced by R. Dederich and popularized by E. Burgess. The muscle flaps are sewn together over the bone stump in order to create a stump tip that can withstand stress. Later, M. Weiss also recommended myodesis , in which the muscles are anchored directly in the bone.
Thanks to myoplasty and the long posterior muscle flap, transtibial amputation developed into a safe and successful procedure in the 1960s, especially in the technique developed by E. Burgess, so that it replaced the transfemoral amputation, which was standard until the 1970s, as the new standard for vascular diseases corresponding benefit for the patient by maintaining an active knee joint.
One speaks of congenital amputation when protein ligaments are formed during pregnancy by tearing the amnion , which constrict the fetal limbs so that whole limbs are missing at birth that were originally created. It is the extreme form of amniotic ligament syndrome .
Congenital lack of an extremity or part of it is also known as dysmelia .
- Ablation (medicine) , partly synonymous with amputation
- Amelotatism is a sexual preference for people with missing limbs . It is also called deformation fetishism
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