Amputation of the Leg

The amputation of a leg is a major happening for a person and represents an upheaval in their life, with psychological problems added to the difficulties of learning the rehabilitation, the management of the new prosthesis, and the relearning of ambulation. The surgeon’s plan will be to manage the process to allow the patient early access to rehabilitation, reduce their energy requirements in walking to the minimum and allow them to manage the prosthesis successfully. Many new skills have to be learnt such as mobilising without the new limb, checking the skin pressure areas and managing to get the limb on and off.

The team managing the amputee needs to be multidisciplinary and skilled in this field to get the best out of the patient in terms of independence and the team may consist of the physiotherapist, an occupational therapist, the surgeon, the personal medical practitioner, a prosthetist and advisors on social care and employment. As the industrialised countries’ populations continue to age the number of amputations will also rise as the main cause of amputation is vascular disease in the periphery. The number of above knee versus below knee amputations has changed as surgeons have learned to preserve the knee joint in more cases, with seventy percent now being below knee.

Weight transfer can be achieved indirectly by allowing pressure through a bony point higher up the leg and also by effecting force transfer through the sides of the leg tissues. There may often be a pain issue after this procedure despite modern prosthetic accomplishments and if the pain is significant it can lead to limited use of the prosthesis, functional reduction and eventually to further attempts at surgery.

Other reasons for amputation are less common and include tumours, infections and congenital abnormalities of the lower limbs. Overall amputation is considered an operation which involves reconstruction rather than just removal of a limb, as the patient’s future life and independence is the crucial matter. The higher that the surgeon has to amputate the limb the higher levels of energy are needed for walking, with the speed of walking decreasing and the required oxygen consumption increasing. Low below knee amputation may make little difference to the energy required for gait, however once the level moves up to mid thigh the load may be over 50% more.

The energy requirements for gait are extremely important as amputated patients frequently suffer from ischaemic tissue problems or other medical conditions which lead to walking consuming much of their energy abilities. Independence in functional activities may be hard to achieve as much of their limited energy supplies is taken up with simply walking. After the amputation, due to the skin viability and ischaemic diagnosis, healing may be delayed and this can have an important bearing on the eventual outcome for the patient’s independence. The soft tissues at the site of amputation must act as the connecting point between the leg and the prosthesis.

Allowing a bony area higher up to take some of the weight transfer indirectly can be successfully integrated with weight transfer sideways through the soft tissues of the lower leg. There may still be pain issues for patients despite the many advances made in modern prosthetics. Significant pain can lead to a reduction in function, reduced use of the prosthesis and even to further surgery.

Effective walking requires the soft tissues of the stump of the limb to be big enough and of high enough quality to manage the shearing and lengthways forces applied to it by its close apposition to the prosthesis socket. The end of the leg can bear the stresses directly in a lengthways direction in those amputations through the joints such as the ankle and the knee, though this type of amputation can present problems. The prosthetic knee joint has to be formed below the level of the original and this forces the knee to project further than a normal knee and so makes the calf significantly shorter.

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

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