CMScript recently released an informational paper, giving some valuable insights into amputations. Here is what they have to say:
Amputations
Amputation is the loss or removal of a body part such as a finger, toe, hand, foot, arm or leg. It can be a life-changing experience affecting an individual’s ability to move, work, interact with others and maintain independence. The number of people who end up with amputations vary across the world. In America, almost 54% of amputations are attributed to complications of diseases of the blood vessels (vascular) and other conditions that affect blood flow such as diabetes mellitus, peripheral arterial disease (PAD), and blood clots. Traumatic injuries account for nearly 45% of all amputations. Certain types of cancer account for less than 2% of amputations. 65% of amputations are of the lower limbs compared to 35% of the upper limb. In South Africa, diabetes mellitus is a major cause of non-traumatic amputations.
What causes Amputations?
Traumatic injuries may cause a body part to be cut off or torn away in a serious motor vehicle accident leading to a traumatic amputation. Severe damage to a body part from a crush injury or severe burns may also necessitate an amputation.
Diseases such as diabetes mellitus and peripheral arterial disease (PAD) or narrowing of the blood vessels causing tissue death in legs, feet, and toes may necessitate an amputation.
Cancers such as sarcomas can aggressively affect the bones and muscle in the limbs leading to an amputation.
Severe infections that do not respond to treatment can affect blood flow and cause tissues to die, especially in the hands, fingers, feet and toes necessitating an amputation.
Congenital amputation where a portion of the body could be missing before birth. An incompletely formed hand, arm, leg or foot at birth may warrant an amputation.
Amputation as a surgical procedure
During the procedure, the following are usually performed by the surgeon:
Removal of crushed bone and diseased bodily tissues
Smoothing of uneven areas of the bone
Sealing off the blood vessels and nerves
Cutting and shaping the muscles at the end of the limb (stump) to enable a prosthesis attachment at a later stage.
Recovery and rehabilitation from amputation
After surgery, the wound is monitored in hospital for any conditions that might interfere with the healing process. Medicines to control pain and prevention of infection are usually prescribed. It may take four to eight weeks for the wound to heal, however, emotional, and physical adjustment to losing a limb takes time.
Many people who have been amputated experience some level of stump pain or ‘phantom limb’ pain. Causes of stump pain include nerve damage during surgery, development of neuromas (non-cancerous nerve tumours), and rubbing or sores where the stump touches a prosthetic limb. Physical rehabilitation program is crucial and is usually started a few days after surgery based on individual needs. The physiotherapists and occupational therapists work with the patient to achieve the set goals.
Long-term recovery and rehabilitation include:
Exercises to improve muscle strength and control
Activities to restore the ability to perform daily activities and promote independence
Use of prosthetics/artificial limbs and assistive devices
Emotional support, including psychological counseling, to deal with grief over the loss of the limb and adjustment to the new body image.
Prosthetic limbs
People who are frail and those with a serious health condition such as heart failure may not be suitable for a prosthetic limb because adjusting to life with a prosthesis requires energy to compensate for the loss of muscle and bone in the amputated limb. If a prosthesis is recommended, the type of prosthesis will depend on the following:
amputation that was done
amount of muscle strength in the remaining section of the limb
patient’s general health
tasks expected to be performed using a prosthesis
Children who are born with congenital amputations may undergo surgery later in life or be fitted with artificial limbs if such an intervention will improve the child’s function and well-being.
Complications
Continuing pain, phantom limb phenomena and emotional trauma can complicate recovery. The risk of serious complications is lower in planned amputations than in emergency amputations. Complications associated with having an amputation include:
Heart problems such as heart attacks
Deep vein thrombosis (DVT) or clots in the calf muscles
Slow wound healing and wound infection
Pneumonia
Stump and “phantom limb” pain
It is unfortunate that almost half of the patients undergoing amputation with chronic or pre-existing conditions die within five years of the procedure.
Prevention
Prevention depends on addressing the problems that may warrant an amputation. In cases of conditions affecting the blood vessels and blood flow, modifying lifestyle is necessary and the following should be considered:
Following a well-balanced diet plan with the help of a dietician. Eating more fruits and vegetables, low-fat dairy products, and lean meat.
Maintaining a stable blood sugar, blood pressure and cholesterol
Exercising regularly and losing weight if overweight
Quitting smoking and avoiding second-hand smoke and all tobacco products
Taking medication as prescribed
Limiting alcohol consumption or quitting altogether.
Period examination of the legs and feet for sores or changes in skin colour or temperature
Daily washing of feet and drying the feet well, nail hygiene, wearing comfortable and well-fitting shoes and socks that keep the feet dry and enhance circulation.
Looking out for leg or foot wounds that are slow to heal, unexplained leg pain or cramping, skin problems or discolouration on the legs and feet, poor nail growth
Early treatment of wounds
What is covered as PMB level of care?
Amputations due to traumatic and crush injuries, severe burns, diabetes mellitus, peripheral artery diseases, severe infections, and cancers must be funded in line with the PMB Regulations. According to the PMB Regulations, the medical scheme should fund the diagnosis, treatment, and care of PMBs irrespective of the member’s option. In making funding decisions, medical schemes are required to fund the diagnosis, treatment and care which are evidence-based, cost-effective and affordable. Prosthetics/ artificial limbs and assistive devices when recommended must be funded in line with the PMB Regulations.
The use of Designated Service Providers (DSPs) is also important to have PMBs paid in full. Physiotherapy for rehabilitation after amputation should be funded until a plateau has been reached or skills have been transferred to the patient or care giver. Where mental health benefits are required, they should be funded in relation to the PMB Regulations.
References
Azura Vascular Care. 2018. Help prevent amputation due to pad with these lifestyle changes. [online]. Available from: https://www.azuravascularcare.com/ infopad/prevent-amputation-due-to-pad-with-lifestylechanges [Accessed 20 July 2022].
Barnes, J.A. Eid, M.A. Creager, M.A. & Goodney, P.P. 2020. Epidemiology and risk of amputation in patients with diabetes mellitus and peripheral artery disease. Arteriosclerosis, Thrombosis, and Vascular Biology, 40:1808–1817.
Dunkin, M.A. 2022. Amputation overview. [online]. Available from: https://www.webmd.com/a-to-z-guides/ definition-amputation. [Accessed 15 July 2022].
Gill. H. No Date. Open access textbook of general surgery: The diabetic foot. [online]. https://vula.uct.ac.za/ access/content/group/9c29ba04-b1ee-49b9-8c85- 9a468b556ce2/Open%20access%20textbook%20 of%20general%20surgery/files/5/5.3_DIABETIC_ FOOT.pdf. [Accessed 20 July 2022].
John Hopkins Medicine. 2022. Amputation. [online]. Available from: https://www.hopkinsmedicine.org/ health/treatment-tests-and-therapies/amputation#:~:- text=Amputation%2C%20Diabetes%20and%20Vascular%20Disease,in%20toes%2C%20feet%20and%20 legs. [Accessed 15 July 2022].
LAM Vascular Associates. 2022. Four tips to prevent amputation. [online]. Available from: https://lamvascular.com/four-tips-prevent-amputation/ [Accessed 18 July 2022].
Pillay, S., Pillay, D., Singh, D. & Pillay, R. 2019. Diabetes-related amputations in the public healthcare sector in KwaZulu-Natal: a five-year perspective. Are we winning? Journal of Endocrinology, Metabolism and Diabetes of South Africa, 24(1):32–36
McDonald, C.L., Westcott-McCoy, S. & Weaver, M.R. 2021. Global prevalence of traumatic non-fatal limb amputation. Prosthetics and Orthotics International, 45(2):105-114.
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2023-02-08 13:04:04
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