The majority of patients undergoing amputation of the lower limb have peripheral vascular disease, often resulting in significant morbidity and mortality. The incidence of amputations is higher in smokers, rises with age and is higher in men than women. Furthermore, people with diabetes form just less than half of all amputees. Consequently, it is not surprising to find that such patient risk factors can result in an array of wound-healing difficulties, thus prolonging debilitation and reducing quality of life. The UK's increasingly ageing population means that more elderly patients will be operated on in the future, thus giving rise to a growing trend in postoperative tissue viability problems where skin fragility and multiple pathologies such as diabetes and peripheral vascular disease co-exist. Hence wound healing complications associated with amputation are becoming more commonplace, requiring sophisticated management strategies to meet the needs of these vulnerable patients. The most important factor in ensuring a successful amputation is the correct choice of amputation site based on assessment of limb perfusion and functional requirements. The following factors will affect the outcome of amputation: the patient's nutritional status, age, tissue perfusion, smoking habits, infection and the presence of co-existing diseases such as anaemia and renal failure. This paper describes a number of problems associated with amputation wound healing, including infection, tissue necrosis, pain, difficulties associated with the surrounding skin, bone erosion, haematoma, oedema and dehiscence/wound breakdown. It draws on the available literature to guide best practice in this complex area of surgical wound care and highlights the importance of multidisciplinary team working.
Amputation is the term given to the severance of a limb, or part of a limb, from the rest of the body . Amputations above or below the knee are termed major. Minor amputations involve partial removal of a foot, including toe or forefoot resections . Amputation is performed on patients with advanced critical limb ischaemia who cannot be treated with reconstructive vascular surgery (to restore blood flow to the leg) or in whom vascular surgery has failed, for patients with diabetic foot infections, extensive venous ulceration or following major trauma .
The lower limb amputee population in England is thought to be around 52,000 . Patients who have undergone lower limb amputation account for 92% of all amputees referred to prosthetics centres in the UK . Significant geographical variation in lower extremity amputation rates has been reported in the UK, with variability in clinical decision-making a likely factor (though further research is required to explore the reasons for this) . The incidence of amputation is higher in smokers (6), rises steeply with age, with most amputations occurring in patients aged more than 60 years, and is higher in men than women . Diabetes is a significant factor in lower-limb amputation . People with diabetes constitute 50% of all major lower limb amputees . Diabetes-related lower extremity amputation rates have been found to be 12.5 to 31.6 times those of patients without diabetes.
Amputation is performed at a number of different levels (see Figure 1). The most common continues to be the trans-tibial level, accounting for almost half of all referrals to the prosthetic services in the UK . Determining the ideal level of amputation for a patient depends on a number of factors. An holistic assessment considers factors such as healing potential, rehabilitation potential, prosthetic considerations, the patient's own wishes, discharge arrangements , and the extent of non-viable tissue on the affected limb . Consideration must be given to knee and hip function and the presence of joint prostheses. The final choice of the level of amputation is considered to be a compromise between ensuring primary wound healing and maximising the patient's function postoperatively.
Surgical wounds that heal by primary intention are expected to heal successfully without complications . However, there is little evidence to demonstrate that this actually happens in practice. Although wound infection is acknowledged to be a significant problem in surgical wounds, there are anecdotal reports that other complications such as dehiscence, the splitting open of a closed wound, and skin blistering occur, yet these problems do not feature widely in the literature.
Wounds associated with amputation of the lower extremity continue to be a challenge. Patients who endure such wounds are often in poor health, with co-existing medical pathologies. Wound healing outcomes for amputees can be improved through multidisciplinary teams working together. Such healthcare professionals need to be equipped with the appropriate knowledge and skills in wound management to meet the needs of this vulnerable patient population. Surgical wound management in the lower extremity amputee has moved into a new era where complications such as infection, tissue necrosis and dehiscence are demanding more sophisticated therapies.