An amputation is the surgical removal of part of the body, such as an arm or leg.
In the UK, some of the main reasons why amputations are carried out include:
- the limb has been affected by gangrene (when a loss of blood supply causes the body’s tissue to die) – often as a result of peripheral arterial disease (PAD)
- a disease in the limb – such as cancer or a serious infection – poses a significant danger to health
- serious trauma to the limb – such as a crush or blast wound
- deformity of the limb or persistent pain that means the limb is of limited functional use
People with diabetes are also at increased risk of amputation. This is because diabetes can lead to nerve damage in the limbs, making the person less aware of any minor injury or wound, particularly those affecting the feet.
People with diabetes are also more prone to develop arterial disease, which means any wound is less likely to heal. However, in most cases, early recognition of the problem and early treatment of the wound can avoid the need for amputation.
Approximately 5-6,000 major limb amputations are carried out in England every year.
Read more about why amputations are carried out.
How amputations are carried out
There are many different types of amputation, depending on the specific limb that needs to be removed and how much of the limb can be saved.
Lower limb amputations – such as the removal of part of a leg, foot or toe – are the most common type of amputation, particularly in older people with PAD or diabetes.
Upper limb amputations – such as the removal or an arm, hand or finger – are less common and tend to be carried out more often in young people, as a result of a serious injury.
Both lower and upper limb amputations are carried out under either general anaesthetic (where you are asleep) or an epidural anaesthetic (where a specific part of your body is numbed using a spinal injection), so you will feel no pain during surgery.
Read more about how amputations are performed.
After the amputation, it may be possible to fit a prosthetic limb onto the remaining stump.
Prosthetic limbs have become increasingly sophisticated and can reproduce many functions of the hands, arms and legs.
For example, many people who have had the foot and lower section of the leg from beneath the knee removed can walk or ride a bike using a prosthetic limb.
Your surgeon will try to spare as much of the affected limb as possible during surgery. This will ensure that you get as much as you can from a prosthetic limb when it’s fitted later.
However, adjusting to life with a prosthetic limb requires an extensive course of physiotherapy and rehabilitation. It also takes a lot more energy to use a prosthetic limb, as your body has to compensate for the missing muscle and bone.
This is why frail people or those with a serious health condition, such as heart disease, may not be suitable for a prosthetic limb.
Read more about recovering after an amputation.
The outlook for people with an amputation largely depends on:
- their age – younger people tend to cope better with the physical demands of adjusting to life with an amputation
- how much of the limb was removed
- how well they cope with the emotional and psychological impact of amputation
- other underlying conditions that may make coping with an amputation more difficult
Many people who have had an amputation reported feeling emotions such as grief and bereavement, similar to experiencing the death of a loved one.
Some people also feel pain in the remaining part of their limb, or “phantom pain” that feels like it’s coming from the amputated part of the limb.
However, with long-term support and rehabilitation, many people – particularly young people – are eventually able to return to work, sports and other activities.
Read more about the complications of amputation.
Why amputations are carried out
Most amputations in the UK are carried out on people who have severely reduced blood circulation in one of their legs or feet as a result of peripheral arterial disease (PAD) or the complications of diabetes.
Other reasons why amputation may be considered include:
- serious injury (trauma) to a limb – for example, in a traffic accident
- serious infections
- cancer affecting the skin or bone of a limb
Unless immediate treatment is needed in an emergency, a decision to amputate will only be made after a full discussion between you and the health professionals treating you.
Peripheral arterial disease (PAD)
PAD is a common condition in which a build-up of fatty deposits in the arteries (atherosclerosis) restricts blood supply to leg muscles.
In some cases, a complication called critical limb ischemia (CLI) can occur in one or both legs. This is where blood flow to the legs becomes severely restricted.
Symptoms of CLI can include:
- severe burning pain in your legs and feet, even when resting
- your skin becoming cold, pale, shiny, smooth and dry
- wounds and ulcers (open sores) on your legs and feet that don’t heal
- the muscles in your legs beginning to waste away
- your skin changing colour, from red to brown to purple or black (gangrene)
CLI can sometimes be treated using an angioplasty or bypass graft (see treating PAD for more information on these operations) to restore blood flow to the affected leg. These are more likely to be successful if carried out early.
However, even if these techniques are an option, they aren’t always successful and you may still need to have an amputation.
Diabetes is a lifelong condition that causes a person’s blood sugar level to become too high.
If you have diabetes, high blood sugar levels can damage your nerves (peripheral neuropathy) and blood vessels – particularly those in your feet.
Nerve damage can reduce the sensation in your feet, meaning you can injure your feet and develop a foot ulcer without realising it. Blood vessel damage can also reduce the blood supply to your feet, meaning ulcers take longer to heal and are more likely to become infected.
These infections can spread rapidly through the foot and up into the leg, and an amputation may be necessary to prevent it spreading further. Therefore, it’s very important to seek help early to prevent amputation.
Amputation may also be necessary if a limb has been severely injured. Examples of injury include:
- crush injuries – such as your arm or leg being severely crushed in a car crash
- blast injuries – such as those experienced by soldiers wounded by explosive devices
- avulsion injuries – where a body part is torn away from the body, such as a dog biting your finger off
- guillotine injuries – where a limb or part of a limb is cut entirely or almost entirely away from the body, such as accidentally cutting off your thumb with a power saw
- severe burns (including chemical burns)
Amputation may be considered in these cases if there is little chance of saving the injured body part, or if it is thought that amputation may lead to a quicker recovery and have a better long-term outcome in terms of the activities you will eventually be able to do.
Less common reasons why amputation may be considered include:
- cancers that develop inside the skin or bone of a limb – such as osteosarcoma (a type of bone cancer) or malignant melanoma (a type of skin cancer)
- serious infections – such as an infection of the bone (osteomyelitis) or necrotising fasciitis (a type of bacterial skin infection sometimes referred to as flesh-eating bacteria)
- Buerger’s disease – a rare condition where blood vessels supplying the hands, arms, feet and legs become swollen and blocked, which can sometimes lead to gangrene and infection
How amputations are carried out
There are numerous ways that amputations can be carried out, depending on the specific limb that needs to be removed and how much of the limb can be saved.
An amputation can be “minor” (where only a toe, finger or part of the foot or hand is removed), or “major” (where a large part of the limb is removed).
Lower limb amputations
In the UK, most amputations are carried out on the feet and legs, and the various types include:
Amputations above the ankle
- transtibial (below-knee) amputation – where the bottom section of a leg is amputated beneath the knee
- knee disarticulation or through knee amputation – where the amputation is performed through the middle of the knee joint
- transfemoral amputation – where both the bottom half of the leg and part of the thigh above the knee are amputated; also known as an above-knee amputation
- double lower amputation – where both legs are amputated, usually below the knee
- hip disarticulation – where the amputation takes place through the hip joint, removing the entire leg
- lower digit amputation – where one or more of the toes are amputated
Amputations below the ankle
- transmetatarsal or forefoot amputation – where the toes and forefoot are amputated
- digit amputation – where one or more toes are amputated
Upper limb amputations
Most upper limb amputations are needed because the hand and arm have been severely injured. The main types of upper limb amputation performed in the UK are:
- finger or digit amputation – where the thumb or one or more of the fingers are amputated
- transhumeral amputation – where the hand and a section of the arm are amputated above the elbow
- transradial amputation – where the hand and a section of the arm are amputated below the elbow
- wrist disarticulation – where the amputation occurs through the wrist joint, removing the hand
- elbow disarticulation – where the amputation occurs through the elbow joint, removing the hand, wrist and forearm
Unless your amputation is performed as an emergency, you’ll be fully assessed before surgery, to find the most suitable type of amputation and identify anything that may affect your rehabilitation.
This assessment may include:
- a thorough medical examination – including assessing your physical condition, nutritional status, bowel and bladder function, and the various systems of your body, such as your cardiovascular system (heart, blood and blood vessels) and your respiratory system (lungs and airways)
- an assessment of the condition and function of the healthy limb – removing one limb can place extra strain on the remaining limb, so it’s important to reduce any potential risk of amputation of the remaining limb at a later date
- a psychological assessment – to determine how well you will cope with the psychological and emotional impact of amputation, and whether you will require additional support
- an assessment of your home, work and social environments – to determine whether any additional provisions will need to be made to help you cope
After the assessment, your surgeon can advise you on the type of amputation you need.
You will also be introduced to a physiotherapist, who will be involved in your post-operative care and, if necessary, a prosthetist (a specialist in prosthetic limbs) who will tell you more about the type and function of prosthetic limbs (or other devices) available.
Factors that will influence the type of prosthetic limb recommended for you include:
- the type of amputation
- the amount of muscle strength in the remaining section of the limb
- your general state of health
- tasks the prosthetic limb will be expected to perform, such as whether you have a desk or manual job, and what type of hobbies you have
- whether you want the limb to look as real as possible or whether you’re more concerned with having a prosthesis which allows the widest range of activities
Although it’s possible to have a prosthetic limb that is both physically realistic and functional, there may have to be an element of compromise between the two.
Many people planning to have an amputation find it both reassuring and useful to talk to somebody who has gone through a similar type of amputation. A member of your care team may be able to put you in touch with someone.
An amputation is carried out under a general anaesthetic (where you are asleep) or an epidural anaesthetic (where a spinal injection is used to numb a certain area of your body), so you will feel no pain during surgery.
The length of the remaining limb will be determined by the ability of the tissues to heal and to retain optimum function.
Once the treated limb has been removed, a number of additional techniques can be used to help improve the remaining limb function and reduce the risk of complications.
These include shortening and smoothing the bone in your remaining limb so it is covered by an adequate amount of soft tissue and muscle, and stitching the remaining muscle to the bones to help strengthen your remaining limb.
After the amputation, the remaining stump wound is sealed with stitches or surgical staples.
Read more about recovering after an amputation.
Recovering after an amputation
After surgery, you’ll normally be given oxygen through a mask and fluids through a drip for the first few days, while you recover on the ward.
Depending on your general health, you should be able to eat and drink when you have recovered from the anaesthetic.
Your wound will be covered with a bandage or plaster dressing, and a tube may be placed under the skin next to the wound to drain away any excess fluid from the site of the surgery. This will help prevent excessive bruising and swelling at the wound. It’s usually recommended that the bandage remains in place for a few days, to reduce the risk of infection.
A small flexible tube, known as a urinary catheter, may be placed in your bladder during your surgery to drain away urine. This means you won’t need to worry about going to the toilet for the first few days after surgery.
It’s likely that you will experience considerable pain at the site of the operation, so painkillers will be given as required. Let the hospital staff know if the painkillers are not working, as you may need a larger dose or a stronger painkiller.
Preparing for discharge
As you gradually recover from the effects of surgery, you will meet a number of different health professionals, such as a social worker, occupational therapist and physiotherapist, to help plan for your discharge and long-term recovery.
For example, it’s likely that an occupational therapist will arrange a visit to see if any aids are needed to make your home environment more accessible, such as a wheelchair ramp or a stairlift. If these kinds of modifications are required, the issue can be referred to your local social services department.
You may also have meetings with a social worker to see if you need any additional support at home, such as meals on wheels.
Your physiotherapist will also teach you a number of exercises at this stage, to help prevent blood clots and improve blood supply while you are recovering in hospital.
You will notice swelling (oedema) of your stump after surgery, which is normal. This swelling can also continue once you have been discharged.
Using a compression garment will help with swelling and the shape of the stump. It may also reduce phantom pain and give a feeling of support to the limb.
Your physiotherapist will measure you for your garment once your wound has healed, and it can be placed over your stitches.
The garment should be worn every day, but taken off before you go to bed. You should be supplied with at least two garments, and these should be washed regularly.
How long it will take before you are ready to go home will depend on the type of amputation you have and your general state of health.
In many parts of the country, it’s common to be transferred to another hospital or ward for a period of rehabilitation (see below) following a major amputation. This is usually done when you no longer require the facilities of the surgical ward.
It can take several months before you are fitted with a prosthetic limb if you are a suitable candidate for a prosthetic, so you may be given a wheelchair to get around if you had a lower limb amputation.
When you do go home, you will probably be asked to attend a follow-up appointment a few weeks later to discuss how well you are coping at home and whether you require additional help, support or equipment.
You may also be given details of your nearest amputee support group, made up of both health professionals and people living with an amputation.
Fitting a prosthesis
Prosthetic limbs are not suitable for everyone who has an amputation.
This is because using a prosthetic limb takes a considerable amount of energy, as you have to compensate for loss of muscle and bone in the amputated limb.
If it’s thought that your body would not withstand the strain of using a prosthetic limb – for example, if you have a heart condition – a purely cosmetic limb may be recommended instead (a limb that looks like a real limb, but cannot be used).
If you’re a suitable candidate for a prosthetic limb, you will begin a programme of activities while still in hospital to prepare for the prosthetic.
Before a prosthetic is fitted, the skin covering your stump may be made less sensitive (known as desensitisation). This will make the prosthetic more comfortable to wear.
Skin desensitisation consists of the following steps:
- gently tapping the skin with a face cloth
- using compression bandages to help reduce swelling and prevent a build-up of fluid inside and around your stump
- rubbing and pulling the skin around your bone to prevent excessive scarring
Your physiotherapist will also teach you a range of exercises designed to strengthen muscles in the remainder of your limb, while also improving your general energy levels, so you can cope better with the demands of an artificial limb.
Depending on what is available in your local area, it can be several months before you get your first appointment with a prosthetist (specialist in prosthetic limbs).
Lower limb prosthetics
There is a large range of lower limb prosthetics. Most lower limb prosthetics consist of:
- a socket is the area where your prosthetic limb touches the remainder of your real limb – the most common type of socket used in lower limb prosthetics is known as a patellar tendon-bearing socket, which is a plaster mould designed to fit around the knee joint
- a suspension system keeps the prosthetic limb in place – examples of suspension systems include strapping systems and suction cups
- an artificial joint is a type of metal hinge designed to replicate the function and range of movement of real joints, such as the knee or ankle joints
- a pylon is a metal rod designed to replicate the function of the main bones of the leg
- a prosthetic foot is made from metal, plastic, or a combination of both, and is designed to replicate the main functions of a real foot, such as bearing the weight of the limb and aiding balance and stability
Upper limb prosthetics
Again, there is a wide range of upper limb prosthetics, which generally consist of:
- a socket is usually made from a lightweight mineral and is designed to fit around the remaining limb, which in most cases is a section of the arm just below the elbow joint
- a suspension system – either a strapping or suction system, which keeps the limb in place
- a control mechanism is designed to replicate the movements of the arm and hand – one commonly used type of control system is to attach cables to muscles in other parts of your body, such as your shoulder or upper arm, allowing you to learn a range of movements that control the prosthetic limb
- a terminal device serves as the “hand” of the prosthetic limb – terminal devices have tended to either be physically realistic and cosmetically pleasing but with little practical function, or look very artificial (such as a hook or a claw) but with a wide range of potential functions, although more sophisticated terminal devices are now being developed that are both cosmetically pleasing and functional
An important part of the recovery process is physical rehabilitation. This is a highly individualised programme that aims to allow you to carry out as many of your normal activities as possible after surgery.
You will work closely with physiotherapists and occupational therapists to discuss what you would like to achieve from rehabilitation, and come up with some realistic goals.
Your rehabilitation programme will usually start within a few days of surgery, beginning with some simple exercises you can do while lying down or seated. If you have had a leg amputation, you will be encouraged to move around as early as possible using a wheelchair.
You will also be taught “transfer” techniques to help you move around more easily, such as how to get into a wheelchair from your bed.
Once your wound has started to heal, you may begin an exercise programme with a physiotherapist in the hospital gym to help maintain your mobility and muscle strength. This may involve activities such as walking using an early walking aid (a “practice leg”) while supporting yourself with metal bars running either side of you (parallel bars).
After having a prosthetic limb fitted, your physiotherapist will also teach you how to use your prosthetic limb – for example, how to walk on a prosthetic leg or grip with a prosthetic hand.
Physical rehabilitation can be a long, difficult and frustrating process, but many people will ultimately be able to return to work and other activities as a result.
It’s important to keep the skin on the surface of your stump clean to reduce the risk of the skin becoming irritated or infected.
Wash your stump gently at least once a day (more frequently in hot weather) with a mild unscented soap and warm water, and dry it carefully.
If you regularly take baths, do not leave your stump submerged in water for long periods of time because the water will soften the skin on the stump, making it more vulnerable to injury.
If your skin becomes dry, use a moisturising cream before bedtime or when you are not wearing your prosthesis.
Some people find wearing one or more socks around their stump can also help absorb perspiration and reduce skin irritation. The size of the stump may change as swelling goes down, meaning the number of socks you need to use may vary. Make sure you change the socks every day to maintain a hygienic environment.
If you have a prosthetic limb, clean the socket regularly with soap and warm water.
Check your stump carefully every day for any sign of infection, such as:
- warm, red and tender skin
- discharge of fluid or pus
- increasing swelling
If you think you may be developing a skin infection, contact your care team for advice.
Taking care of your remaining limb
After having a leg or foot amputated, it’s very important to avoid injury and damage to your remaining “good” leg, particularly if your amputation was needed because of diabetes, as your remaining leg may also be at risk.
Therefore, make sure you avoid poorly fitting footwear, and that an appropriately trained individual (such as a podiatrist) is involved in the care of your remaining foot.
Read more about diabetes and foot care.
Complications of amputation
Like any type of surgery, having an amputation carries a risk of complications. The treatment also carries a risk of additional problems directly related to the loss of a limb.
There are a number of factors that influence the risk of complications from amputation, such as your age, the type of amputation you had, and your general health.
The risk of serious complications is lower in planned amputations than in emergency amputations.
Complications associated with having an amputation include:
- heart complications – such as heart attack
- blood clots (venous thrombosis)
- slow wound healing and wound infection
- pneumonia (infection of the lungs)
- stump and “phantom limb” pain
- psychological problems
In some cases, further surgery may be required to correct problems that develop.
An amputation is often seen a last resort when other treatments have failed. However, for many people, the loss of pain and a properly healed limb results in a significant improvement in their quality of life. If the person is supported appropriately, they can return to a near normal life.
Stump and ‘phantom limb’ pain
Many people who have an amputation will experience some degree of stump pain or “phantom limb” pain.
Phantom limb sensations are when a person experiences sensations that seem to be coming from the limb that has been amputated. Sometimes this is just awareness of the limb, but it can occasionally be painful. This is known as phantom limb pain.
The term “phantom” does not mean that the symptoms of pain are imaginary and all in your head. Phantom limb pain is a very real phenomenon, which has been confirmed using brain imaging scans to study how nerve signals are transmitted to the brain.
The symptoms of phantom limb pain can range from mild to severe. Some people have described brief “flashes” of mild pain, similar to an electric shock, that last for a few seconds. Other people have described constant severe pain.
The causes of phantom limb pain are unclear. There are three main theories:
- The peripheral theory argues that phantom limb pain may be the result of nerve endings around the stump forming into little clusters known as neuromas. These may generate abnormal electrical impulses that the brain interprets as pain.
- The spinal theory suggests that the lack of sensory input from the amputated limb causes chemical changes in the central nervous system. This leads to “confusion” in certain regions of the brain, triggering symptoms of pain.
- The central theory proposes that the brain has a “memory” of the amputated limb and its associated nerve signals. Therefore, the symptoms of pain are due to the brain trying to recreate this memory, but failing because it is not receiving the feedback it was expecting.
Stump pain can have many different causes, including rubbing or sores where the stump touches a prosthetic limb, nerve damage during surgery and the development of neuromas.
Treating stump and phantom limb pain
Both stump and phantom limb pain will usually improve over time, although there are many treatments available to help relieve your symptoms.
However, it can be difficult to treat the pain, as the effectiveness of each treatment varies between different people. Several types of treatment may need to be tried.
Medications that may be tried by your doctor to help relieve pain include:
- non-steroidal anti-inflammatory drugs (NSAIDs) – such as ibuprofen
- anticonvulsants – such as carbamazepine or gabapentin
- antidepressants – such as amitriptyline or nortriptyline
- opioids – such as codeine or morphine
- corticosteroid or local anaesthetic injections
There are several non-invasive techniques that may help relieve pain in some people. They include:
- checking the fit of your prosthesis and making any adjustments to make it feel more comfortable
- applying heat or cold to your limb, such as using heat or ice packs, rubs and creams
- massage – to increase circulation and stimulate muscles
- acupuncture – where needles are inserted into the skin at specific points on the body thought to stimulate the nervous system and relieve pain
- transcutaneous electrical nerve stimulation (TENS) – a small, battery-operated device that has leads connected to electrodes is used to either deliver electrical impulses to the affected area of your body, or block or reduce the pain signals going to the spinal cord and brain
- mental imagery (see below)
Research carried out in Liverpool in 2008 found that if people spent 40 minutes imagining using their phantom limb, such as stretching out their “fingers” or bunching up their “toes”, they experienced a reduction in pain symptoms.
This may be related to the central theory of phantom limb pain (that the brain is looking to receive feedback from the amputated limb), and these mental exercises may provide an effective substitution for this missing feedback.
One technique that can also be used is known as mirror visual feedback. This is where a mirror is used to create a reflection of the other limb. Some people find that by doing exercises and moving their other limb, it can help to relieve pain from a phantom limb.
In some cases, further surgery may be considered to relieve your pain. For example, if neuromas are thought to be causing pain, the cluster of nerves may need to be removed.
Psychological impact of amputation
The loss of a limb can have a considerable psychological impact. Many people who have had an amputation report feeling emotions such as grief and bereavement, similar to experiencing the death of a loved one.
Coming to terms with the psychological impact of an amputation is therefore often as important as coping with the physical demands.
Having an amputation can have a considerable psychological impact for three main reasons:
- you have to cope with the loss of sensation from your amputated limb
- you have to cope with the loss of function from your amputated limb
- your sense of body image, and other people’s perception of your body image, has changed
It’s common to experience negative thoughts and emotions after an amputation. This is especially true in people who had an emergency amputation, as they did not have time to mentally prepare themselves for the effects of surgery.
Common negative emotions and thoughts experienced by people after an amputation include:
- denial (refusing to accept that they need to make changes, such as having physiotherapy, to adapt to life with an amputation)
- feeling suicidal
People who have had an amputation due to trauma (especially members of the armed forces injured while serving in Iraq or Afghanistan) also have an increased risk of developing post-traumatic stress disorder (PTSD). This is when a person experiences a number of unpleasant symptoms after a traumatic event, such as “reliving” the event and feeling constantly anxious.
Talk to your care team about your thoughts and feelings, especially if you are feeling depressed or suicidal. You may require additional treatment, such as antidepressants or counselling, to improve your ability to cope with living with an amputation.