Multiple Limb Amputations

Original Editor - Tarina van der Stockt

Top Contributors - Tarina van der Stockt, Claire Knott, Amrita Patro and Lauren Lopez  

The challenges for a person with multiple limb amputations are greater than a person with a single limb amputation. These challenges are: pain, adjustment to lifestyle, return to quality of life. Multiple amputation could be the result of trauma but in recent years the multiple amputations due to dysvascular disease escalated.

Causes

Vascular Disease

Amputations due to dysvascular reasons occur after the development of peripheral vascular disease (PVD) and, or diabetes. The risk of amputation is increased with the a combination of comorbidities like diabetes, PVD, and renal disease. Patients with diabetes and vascular disease have a 55% increase in risk of having an amputation in the contralateral leg within 2-5 years following the initial amputation. Another scary statistic is that 50% of patients who underwent an amputation due to vascular disease will die within 5 years of the amputation.

Trauma

In the USA trauma is the second most common cause for amputations. Blunt force is the most prominent trauma leading to amputation while penetrating injury can lead to amputation and overall severe injury. According to the National Trauma Database (USA) from 2000 to 2004 that most multiple limb amputation are as a result of motor vehicle accidents, and second on the list is railway accidents. Bilateral lower amputations were more common, followed by unilateral upper and lower limb amputations, then by bilateral upper limb loss, and the least amount with three limb amputations. The conflict in Iraq and Afghanistan also led to multiple limb amputations amongst soldiers due to blast injuries. The amputations are “usually accompanied by a host of comorbidities ranging from additional fractures, soft tissue damage, and peripheral nerve injury to traumatic brain injury (TBI), post-traumatic stress disorder and other behavioral health problems”.

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Cancer

Multiple amputations due to cancer is extremely rare and due to improvement in early detection the rate of amputations due to cancer has decreased.

Congenital

Multiple limb loss is possible but extremely rare.

Medical and Surgical Management

Factors to remember when treating a patient with multiple limb loss in the acute phase:

• Initial treatment is to preserve life and limb
• While optimizing the residual limb also treat the underlying disease or trauma that led to the amputation
• With dirty wounds avoid immediate and primary amputation as well as wound closure, as this could lead to infection
• Preserve as much limb length as possible while keeping the patient’s function and mobility goals in mind
• Preserve adequate soft tissue covering on the distal end of the residuum with optimal balancing of the muscles
• In this crucial initial phase when the patient may undergo multiple surgeries make sure that the patient’s nutritional needs are met and that the patient’s pain is properly managed. Avoid secondary complications like “venous thrombosis, pulmonary embolism, joint contractures, pressure ulcers, disuse atrophy, osteopenia, and deconditioning.”
• A transdisciplinary team approach is of utmost importance

The surgeon is faced with a choice between amputation and limb salvage. There are different schools of thought regarding this. Early amputation and prosthetic fitting might be a better option for some people as they may have a quicker hospital discharge, independence, and improved quality of life. Limb salvage might lead to multiple surgeries, long hospital stay, extended rehabilitation, and the risk for infection. But when one limb has already been amputated all efforts should go to avoid amputation of the other limbs, especially the upper limbs.

The transdisciplinary team should be involved in the decision making regarding reconstructive surgery like transferring muscles from one part of the body to another, as this might influence the patient’s functional ability. The patient should also be included in all discussions and should contribute regarding their functional expectations and goals. Available prosthetic and orthotic options should be considered during the decision making process.

Be realistic when counseling a patient regarding potential prosthetic use. Keep in mind that the rate of successful gait for a person with vascular disease and bilateral above knee amputations is extremely low. Also, energy expenditure in a patient with bilateral above knee amputations increases almost threefold, and double that of a bilateral below knee amputee, resulting in increased demand on the cardiac system during walking. Rehabilitation should include a thorough cardiac evaluation and management and the base line levels for oxygenation, target heart rate and blood pressure should be established and activities adjusted accordingly.

Patient education is extremely important and should include adjustments to nutrition as needed, smoking cessation, and weight management.

Pain management

Optimal pain management should be achieved by “integrating a variety of interventional procedures, oral and intravenous medications, physical modalities, and complementary and alternative medicine approaches.”

Pharmacotherapy might include:

• opioids (should be monitored closely for side effect, opioid use could be minimized by combining other pharmacological agents)

• NSAIDs (should be used cautiously as it may negatively influence bone growth and is contraindicated in patients with renal failure and a risk of GI bleeding)

• COX-2 inhibitors

• Ketamine (a common anesthetic agent for the management of pain)

• Gabapentin (a neuroleptic medication considered a first line treatment in patients with multiple limb loss for the treatment of neuropathic pain at the surgery site and for phantom limb pain)

Non-pharmacological treatments:

• Heat

• Cryotherapy

• TENS

• Acupuncture

• Mirror Therapy

• Early mobilisation through the use of immediate post-operative prosthetic (IPOP)

• Psychosocial support

Behavioral Health Complications

This is a very common phenomenon in persons with limb loss and even more so in persons with multiple limb loss.  During the rehabilitation process the team should focus on decreasing the negative behavioral health effects. These might include the following:

• Depression

• Body image anxiety

• Behavioral Health Issues Associated with Upper Limb Amputation - “increased difficulties in social adjustment, adjustment to functional limitations, as well as anxiety, depression, and body image disturbance, which was worsened when the dominant hand was involved”

• Combat Amputees may have a combination of behavioral health issues due to physical and psychological effects like multiple trauma, TBI, depression, PTSD, and a long period of rehabilitation.

Resources
Rehabilitation and multiple limb amputations: A clinical report of patients injured in combat. Melcer T, et al. Journal of rehabilitation research and development. 2016;53(6):1045.