Amputation is a very old surgical act, which first originated with the recent discovery, in 2020, of a human body with part of the leg amputated, dating from more than 30,000 years ago on an island in Southeast Asia. It is until recently used in the quasi case of life support of an injured patient if his vital prognosis originating from a limb or another is engaged. It has also been a sanction used in many countries throughout the ages to punish crimes and is still applied as part of the hadd, a Koranic punishment that consists of cutting off the hand of a thief, in some countries such as Afghanistan or Egypt. Today, medical progress has allowed us to drastically reduce the number of amputations, by limiting the number of life-threatening emergencies, by offering new and more efficient medical solutions, and also thanks to prevention. Only outside of these emergency cases where it remains mandatory, it is sometimes necessary to choose amputation because it remains the best solution. The cases leading to amputation are diverse, defined through three categories: congenital amputations, traumatic causes or pathological causes.
Amputation is certainly an indelible physical mark, but it is also the subject of a real need for support, because it also leaves a psychological mark on the patient who may undergo it more or less violently. It is therefore important to define what amputation is, what it represents and the different aspects that concern it; the reasons, the different types, but also the post-amputation.
The definition of amputation is given as such: "Removal of a limb or limb segment." Ablation, which is the act of separating the limb or segment from its attached part consists of the precise cutting of the body at the chosen junction by a specialized surgeon. Worldwide in 2017, it was recorded that 57.7 million people were living with limb amputation, which is approximately 0.8% of the population. Each year, approximately 1.5 million people worldwide are amputated. Despite the increasing number of discoveries in the medical field that have largely contributed to reducing the number of amputations over the last decades, amputation remains a topical subject that is sometimes neglected or misunderstood. Amputation is therefore a preferred choice in several cases that fall into three categories mentioned earlier: pathological, traumatic or congenital causes
Pathological causes are the most important ones with regard to amputation. They are the cause of nearly 80% of amputations. It is interesting to know that among this pathological population, people over 65 years old represent 65%. The aging population is therefore more concerned by pathologies that can lead to amputation.
Firstly and most often we can identify vascular diseases, which depending on the type will lead to poor blood circulation. This is the case of arteritis such as gangrene or sensory-motor ischemia. Their origin, whether degenerative or inflammatory, will cause arterial lesions resulting in a partial or total obliteration of the vessels as well as their dilation. These diseases have their roots in smoking or other pathologies such as Buerger's disease, but remain mostly senile or presenile.
Secondly, arteriosclerosis is a pathology that can lead to amputation. Its degenerative nature takes hold when fatty material accumulates on the internal surface of arteries. It then leads to the obstruction of of the arteries and thus complicates the circulation. The affected part of the body may then lack sufficient oxygen supply, which in acute cases leads to amputation. Most frequently, the areas concerned are those of the lower limbs at the level of the distal branches, interrupting the blood supply and resulting in ischemic gangrene. Diabetes, which favors the deposition of atheromatous plaques, which are therefore equivalent to these deposits of fat in the form of cholesterol, presents a drastically higher risk of complications that lead to amputation for diabetics. Indeed, a diabetic is subject to a risk of amputation 15 times higher than the average in these cases.
Finally, it is also possible to opt for an amputation in the case of certain cancers. Indeed, cancer will cause the anarchic proliferation of its cells in the rest of the body. If a malignant tumor has been identified in a limb and is difficult to treat directly, it is therefore possible to opt for an amputation in order to avoid proliferation through the nerves or blood vessels.
The notion of trauma as used in the case of an amputation designates the accident that leads to medical follow-up. With regard to the 80% of amputations of pathological origin, traumatic causes represent 20% of the causes of amputation. These are the causes that intervene in the emergency context of an amputation. Indeed, since trauma is not predictable, its potential severity leads to the need for rapid surgery, which is the case for limbs or segments that have suffered too much irreversible damage. If the limb is wrongly judged to be preservable, amputation may be postponed until a second stage after it is found to be worsening or difficult to keep the limb in good health over the long term.
Logically, traumas have a wide variety of origins, but follow similar patterns: accidents in the home, at work, following burns or electrocution, or frostbite. Frostbite is a trauma that is very prone to amputation and was one of the main causes in earlier times when medicine was more rudimentary. One of the main traumas is very systemic, it is the road accidents: in most cases, they involve motorcyclists, of young age and 70% of them are not at fault when the accident occurs.
As opposed to acquired amputations, the designation of amputation in the congenital context is debated because it does not designate a surgical act but the absence or malformation of a limb or a segment. The word congenital specifies that this absence is observed from birth. This phenomenon is a type of agenesis, a scientific term that translates an organic non-development and in the case of congenital amputations, the agenesis is called "limb". From a scientific point of view, congenital amputation is called dysmelia, the designation corresponding to all disorders of embryonic development of the limbs. There are different types of dysmelias, such as ectromelia, which identifies the one where one or more limbs have not developed, amelia, which designates the absence of all 4 limbs, or phocomelia, which groups together the dymelias where some extremities are attached to the trunk with the absence of a segment or the whole limb. It is therefore not a question of rehabilitation, but of accompaniment, given the congenital nature of the amputation, which implies learning or adaptation patterns that are very different from acquired amputations.
The three previous categories are those that represent the majority of cases of amputations or absence of segments and limbs, but there are other more rare causes that lead to acquired amputations.
Some infections cause the need for amputation in the most severe cases. This is the case of purpuma fulminans, which mainly affects infants or the young population from 15 to 20 years old, which is related to vascular risk patterns by the formation of blood clots in the veins and creates oxygen deficiencies, which can lead to necrosis. Other rarer infections such as actinomycosis or leprosy can lead to this result, as well as certain neurological conditions such as spinal agenesis or spina bifida. These causes have become much less frequent and representative thanks to the many advances in medicine, which have brought antibiotic treatment or prevention phases sufficient to avoid aggravations.
Some cultures around the world make use of amputation in a framework quite different from that of medicine, this is the case of what has been presented as a punishment implemented in the Koranic states to punish thieves, but also in some tribal cultures to express grief. Indeed, according to a study published in 2011, some tribes of New Guinea have for ritual at the time of the death of a close one to amputate a phalanx. This ritual is put in place in order to link, according to them, the psychological pain of the loss to the physical pain and the daily sight of the absence (of the phalanx), in order to remember the loss of a loved one and the gap it creates in life. Again, this kind of case tends to become more and more rare, both because this tribal practice is not very widespread, and because few remain the countries of Koranic influence to apply this sanction.
Finally, there is also the problem of war wounded. In order to illustrate this quantitatively, it is possible to consult the figures of the French engagement in Afghanistan. Of the 399 survivors of injuries causing vascular lesions, 9 of them had to go through a surgical amputation phase (80% of the amputations concerned the upper limbs due to screening). In spite of the international agreement banning anti-personnel mines in 1997, 7 soldiers suffered a mine explosion and 3 of them had to be amputated. Moreover, 35% of French amputees engaged in Afghanistan suffer from phantom pain as a result of acquired amputations. In order to illustrate the current situation regarding the problem of amputations due to war traumas, Le Monde published an article entitled "Amputees of the war in Ukraine". It is possible to read that the state in question does not wish to reveal the figures concerning amputations, but in August 2022, only half a year after the beginning of the conflict, the number of injured amputees was already counted at more than 50 in the only rehabilitation center of Bez Ozmezhen in the suburbs of Kiev, the Ukrainian capital.
There is also the very small risk of medical error. This can be of two different natures; the administration of a treatment that has led to serious complications or a misjudged diagnosis of an amputation that may not have been necessary. Recently, for example, in a country where medicine is at the cutting edge of technology, a Swiss surgeon amputated the wrong leg of her patient in 2021. These are rare events and therefore not of sufficient magnitude to be highlighted as potential causes.
As explained before, amputation throughout history was until recently a solution considered only when it was the last resort for the patient to keep his life, regardless of the living conditions that might follow. Today's medicine allows for an accurate diagnosis, which can first of all avoid going to pain in the long term. This may be due to the nerve endings being too damaged, repeated rubbing of the scars or a complex adaptation to the prosthesis. It is estimated that 60% of all amputees are affected.
Finally, there is a pain, both physical and psychological, which is exclusively linked to people affected by acquired amputations, the pain of the phantom limb. It is a hallucinosis that is still being studied and is equivalent to a perception and feeling of the missing limb, despite the knowledge of its absence. The phantom, which designates the missing but felt limb, undergoes certain evolutions according to the patient and the time, and can be reduced, become static or only be felt by certain parts that composed it. It is a very specific sensation that is still being studied and that seems once again to be very dependent on the patient, on which medicine is trying to find answers.
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Picture credit ©Satisform