About Amputation:

Amputation means a condition of disability resulting from the loss of one or more limbs or a surgical removal of all or part of a limb. For instance, a foot, part of a foot, a leg, a hand or part of a hand etc. There are many reasons for amputation, but the main reasons are:

•  Diabetes & Vascular disease
•  Accidents

Diabetes:

Too much glucose (sugar) in the blood for a long time can cause diabetes problems. This high blood glucose (sugar) can damage many parts of the body, such as heart, blood vessels, eyes and kidneys. Heart and blood vessel disease can lead to heart attacks and strokes. You can do a lot to prevent or slow down diabetes problems.

People with diabetes are far more likely to have a foot or leg amputated than other people. The problem? Many people with diabetes have artery disease, which reduces blood flow to the feet. Also, many people with diabetes have nerve disease, which reduces sensation. Together, these problems make it easy to get ulcers and infections that may lead to amputation. Most amputations are preventable with regular care and proper footwear.

For these reasons, take good care of your feet and see your doctor right away about foot problems. Always follow your doctor's advice when caring for ulcers or other foot problems.

One of the biggest threats to your feet is smoking. Smoking affects small blood vessels. It can cause decreased blood flow to the feet and make wounds heal slowly. A lot of people with diabetes who need amputations are smokers.

People having diabetes can develop many different foot problems. Even ordinary problems can get worse and lead to serious complications.

Nerve damage (Neuropathy):

One problem is damage to nerves in your legs and feet. With damaged nerves, you might not feel pain, heat, or cold in your legs and feet. A sore or cut on your foot may get worse because you do not know it is there. This lack of feeling is also called diabetic neuropathy. It can lead to a large sore or infection. The infection might cause gangrene.

Poor blood flow (Peripheral Vascular Disease):

When not enough blood flows to your legs and feet it makes it hard for a sore or infection to heal. This problem is called vascular disease. Poor blood flow to your legs can slow down healing. Once in a while a bad infection never heals. The infection might cause gangrene. If a person has gangrene, the skin and tissue around the sore die. The area becomes black and smelly. To keep gangrene from spreading, a surgeon may have to do amputation of a toe, foot, or part of leg.

Foot Ulcers:

Ulcers occur most often on the ball of the foot or on the bottom of the big toe. Ulcers on the sides of the foot are usually due to poor fitting shoes. Even though some ulcers do not hurt, every ulcer should be seen by your doctor right away.

What your doctor will do varies with your ulcer. The doctor may clean out any dead and infected tissue. Keeping off your feet is very important. Walking on an ulcer can make it get larger and force the infection deeper into your foot. Your doctor may advice for special shoes, brace, or cast on your foot to protect it. The doctor may refer you to a vascular surgeon if your ulcer is not healing and the blood circulation is poor. Remember, neglecting ulcers can result in infection, which in turn can lead to loss of a limb.

Calluses:

Calluses occur more often and grow faster on the feet of people with diabetes. This is because there are high pressure areas under the foot. Too much callus may mean that you will need therapeutic shoes and inserts.

Calluses, if not trimmed, get very thick, break down, and turn into ulcers. Never try to cut calluses or corn yourself – this can lead to ulcers and infection. Let your Pedicurist (contact M/s Foot Comfort, Fleet Club, Karachi ) cut your calluses. Please do not try to remove calluses and corns with chemical agents. These products can burn your skin.

Skin changes:

Diabetes can cause changes in the skin of your foot. At times your foot may become very dry. The skin may peel and crack. The problem is that the nerves that control the oil and moisture in your foot no longer work. Dry skin can become cracked and allow germs to enter. If your blood glucose is high, it feeds the germs and makes the infection worse.

Prevention:

Ensure, your doctor should perform a complete foot exam once in a year – more often if you have foot problems.

Remember to take off your socks and shoes while you wait for your physical examination.

Because people with diabetes are more prone to foot problems, a foot care specialist (contact M/s Foot Comfort, Karachi ) may be on your health care team.

•  TAKE CARE OF YOUR DIABETES. Work with your health care team to keep your blood glucose in your target range.

•  CHECK YOUR FEET EVERY DAY. Look at your bare feet for red spots, cuts, swelling, and blisters. If you cannot see the bottoms of your feet, use a mirror or ask someone for help.

•  BEMORE ACTIVE. Plan your physical activity program with your doctor.

•  WASH YOUR FEET EVERYDAY. Dry them carefully, especially between the toes.

•  KEEP YOUR SKIN SOFT AND SMOOTH. Rub a thin coat of skin lotion over the tops and bottoms of your feet, but not between toes.

•  CUT YOUR TOE NAILS REGULARLY. If you can see and reach your toenails, trim them once a week. Cut toenails when they are soft from washing. Trim your toenails straight across and file the edges. If the nails are hard to trim contact your pedicurist.

•  WEAR SHOES AND SOCKS. Never walk barefoot. Always wear comfortable shoes that fit well and protect your feet. Shop for shoes at the end of the day when your feet are bigger. Before putting your shoes on, feel the insides to make sure they have no sharp edges or objects that might injure your feet. Do not wear socks or knee-high stockings that are too tight below your knee.

•  PROTECT YOUR FEET FROM HOT AND COLD. Wear shoes at the beach or on hot pavement. Don't put your feet into hot water. Test water before putting your feet in it just as you would before bathing a baby. Never use hot water bottles, heating pads. You can burn your feet without realizing it.

•  KEEP THE BLOOD FLOWING TO YOUR FEET. Put your feet up when sitting. Wiggle your toes and move your ankles up and down for 5 minutes 2 or 3 times a day. Don't cross your legs for long periods of time. Don't smoke.

•  GET STARTED NOW. Start taking good care of your feet right now. Set a time every day to check your feet.

AFTER THE AMPUTATION:

For many people, the time leading up to the amputation is a very sedentary period. Time is spent slowly watching an ulcer heal, and in the physician-prescribed bed rest with limited activity. During this time strength and cardio-vascular endurance diminish. Postoperatively, a good rehabilitation program should include upper and lower limb strengthening in addition to a well-planned cardiovascular program. Just walking with a walker or crutches around the house is frequently not enough to prepare for the demands of prosthetic rehabilitation and ambulation. The metabolic energy requirements of walking with a prosthesis are far more greater than during normal walking and thus, require preparation and training.

For optimal rehabilitation, it is important to consult with a physical therapist and begin an exercise program immediately after surgery. Then continue exercising at home with a family member. This applies to people of all ages and those who lost a limb for any reason.

Amputees can do several things to create favorable conditions for an early prosthetic fit. They should learn how to improve their health from the rehabilitation team, how to become more physically fit, and how to take proper care of the healing limb. By learning about their care and participating in every step of the healing process, including taking prescribed medications, eating correctly, exercising, changing dressings and using the prescribed pressure garment, amputees will increase readiness for a prosthetic fitting.

One of the primary concerns is stump swelling. It describes the abnormal condition in which an excessive amount of fluid has collected in the soft tissues in some part of the body. Usually, the supply and removal of fluid in the body are well balanced; however, amputation of a lower extremity (foot or leg) greatly disturbs the normal pattern of blood and lymph channels and the relationship of pressures, both inside the vessels and in the surrounding tissues of the stump. Postoperative swelling occurs in most cases and gradually disappears over many months following amputation.

Treatment of swelling is relatively simple: compression, wrapping, shrinkers or some other form of pressure garment. The pressure created by compression garments helps move the fluids out of the recovering limb, reduce the pressure on other tissues, and, as a result, reduce pain. One of the key ingredients in successfully reducing swelling as quickly as possible is around-the-clock maintenance of pressure until the volume of fluids within the limb stabilizes.

Elevating the limb can have a positive effect only if the limb is raised above the heart. Dangling the limb from a chair or long periods of standing can have a negative effect. Conversely, activity can have a very positive effect. Contractions of the muscles help to move the fluids out of the muscle and other surrounding tissues. The time it takes for the swelling to subside varies depending on age, body type and cause of amputation. Younger people will generally heal more quickly.

ARE YOU READY FOR THE PROSTHESIS?

The Prosthetist will determine readiness for a prosthesis based on the amputee's health status. The decision is usually made when the stump is well healed at the suture line, when there are no other open lesions on the stump or intact foot, when the swelling has been significantly reduced, and when the rehabilitation program is completed.

The goal of any prosthetic rehabilitation program is to assist the amputee from the time of surgery to successful prosthetic ambulation as quickly as possible and without complication. This is a team effort and requires participation by all the members, the surgeon, the physiotherapist, the prosthetist including the person who lost the limb. When the rehabilitation team works together, the time to prosthetic fitting can be relatively quick, barring any complications. Rehabilitation begins the day after surgery and for most becomes a part of everyday life. As frustrating as that can be for some, the truth is that the sooner the reality of limb loss is embraced, the sooner an amputee can get back to life.