Introductory Chapter: General Remarks Regarding Limb Amputations

3.1 Peripheral arterial disease

Limb loss is most often due to peripheral arterial disease (54–82%); the estimated increase in the rate of dysvascular amputations was 27%. On the other hand, rates of trauma- and cancer-related amputations both declined by approximately half [10]. Peripheral arterial disease affects the distal vessels and results in occlusion, which is one of the major causes of ulcer development and a risk factor for amputation (Figure 5).

These patients often require challenging distal revascularization surgery or angioplasty to avoid limb amputation. Revascularization is the only way to prevent major amputation of an ischemic foot, and the ulcer healing rate after revascularization ranges from 46 to 91% [11].

3.2 Diabetes mellitus

Patients with diabetes are likely to develop infections, because of the alteration of immune defense mechanisms due to the hyperglycemic environment [12]. Furthermore, more than 50% of patients by diabetes mellitus are complicated with peripheral arterial disease [2].

Once a diabetic foot develops infection, it progresses rapidly and requires the removal of all necrotic tissue (Figure 6).

These patients are common in developing countries, and extremity amputations associated with diabetes mellitus accounted for most indications (57.0%) in northeast Nigeria [13]. Thus, diabetes prevention, detection, and management should be prioritized in any attempt to reduce the current incidence of amputation [3]

3.3 Infection

Necrotizing fasciitis and myositis are life-threatening infections with associated mortality rates of 10–20% [14]. Especially, Vibrio vulnificus and group A streptococci often cause aggressive and fatal gangrene and necrotizing myofasciitis, and a reported 23% of patients die of vibrio, and 20–34% die of group A streptococci infection [15]. Regarding surgical intervention, early and appropriate debridement to reduce infection is recommended to achieve infection control. Thus, surgical debridement including limb amputation should be considered in the early stage.

Patients with group A streptococci infection can develop streptococcal toxic shock syndrome (STSS). When STSS is complicated by myositis, multiple limb amputations should be considered, and the reported mortality rate is 80–100% [16] (Figures 7 and 8).

3.4 Trauma

Treatment of patients with severe injury with vasculopathy of the extremities, such as trauma-related amputation and Gustilo-Anderson type IIIC fracture, is challenging, because it often requires the resurfacing of tissue defects as well as preservation of functional blood flow to distal areas [1]. Previously, patients with these severe limb injuries underwent amputation. Now, most severed limbs can be replanted, and vascular and soft tissue defects can be reconstructed, owing to the development of microsurgical techniques [17]. Therefore, indications for limb amputation due to injuries are now limited.

3.5 Neoplasm

Malignant bone and soft tissue tumors are rare conditions, but a delay in diagnosis or the misinterpretation of data can have limb- and life-threatening consequences. Although a tissue defect following oncologic resection can be reconstructed using a flap transfer technique, hand and leg salvage cannot always be achieved, because radical surgery sometimes requires the removal of important organs such as the bone, arteries, and nerves [17] (Figure 9).