Assessment before surgery

Unless you need to have an emergency amputation, you'll be fully assessed before surgery to identify the most suitable type of amputation and any factors that may affect your rehabilitation.

The assessment is likely to include a thorough medical examination to check your physical condition, such as your cardiovascular system (heart, blood and blood vessels) and your respiratory system (lungs and airways).

The doctor will also check the condition and function of your healthy limb. Removing one limb can place extra strain on the remaining limb, so it's important to look after the healthy limb.

It may also include a psychological assessment to determine how well you'll cope with the psychological and emotional impact of amputation, and whether you'll need additional support.

There may be an assessment of your home, work and social environments to check if any changes will need to be made to help you cope.

Yo may also be introduced to a physiotherapist, who will be involved in your post-operative care. A prosthetist (a specialist in prosthetic limbs) will advise you about the type and function of prosthetic limbs or other devices available.

If you're having a planned amputation, you might find it reassuring to talk to someone who's had a similar type of amputation. A member of your care team may be able to put you in touch with someone.

How amputations are carried out

Amputations can be carried out under general anaesthetic (where you're unconscious) or using either an epidural anaesthetic or spinal anaesthetic (both of which numbs the lower half of the body). The choise of anaesthetic can depend on what part of your body is being amputated.

Most amputations involve removing a section of a limb rather than the entire limb.

Once the section of the limb has been amputated, additional techniques can be used to help improve the function of the remaining limb and reduce the risk of complications.

These include shortening and smoothing the bone in your remaining limb so it's covered by an adequate amount of soft tissue and muscle. The surgeon then stitches the muscle to the bones to help strengthen the remaining section (a technique known as myodesis).

After the amputation, your wound will be sealed with stitches. It will be covered with a bandage and a tube may be placed under your skin to drain away any excess fluid. The bandage will usually need to be kept in place for a few days to reduce the risk of infection.

Recovering after an amputation

After surgery, you'll usually be given oxygen through a mask and fluids through a drip for the first few days while you recover on the ward.

A small flexible tube (a urinary catheter) may be placed in your bladder during surgery to drain away urine. This means you will not need to get out of bed to go to the toilet for the first few days after operation. You may be given a commode or bedpan so you can also poo without having to get up to use the toilet.

The site of the operation may be painful, so you'll be given painkillers if you need them. Tell a member of your care team if the painkillers aren't working, as you may need a larger dose or a stronger painkiller. 

Your physiotherapist will teach you some exercises to help prevent blood clots and improve your blood supply while you're recovering in hospital.

Compression garments

You'll notice swelling (oedema) of your stump after surgery. This is normal and it may continue after you've been discharged.

Using a compression garment will help with swelling and the shape of the stump. It may also reduce phantom pain (pain that seems to be coming from your missing limb) and help support the limb.

You'll be fitted with a compression garment once your wound has healed. It should be worn every day, but taken off at bedtime. You should be given at least two garments, which should be washed regularly.

Rehabilitation

Physical rehabilitation is an important part of the recovery process. It can be a long, difficult and frustrating process, but it's important to persevere. After rehabilitation, you should be able to return to work and other activities.

Your rehabilitation programme will be tailored to your individual needs and will aim to allow you to carry out as many of your normal activities as possible.

You'll work closely with physiotherapists and occupational therapists who will discuss with you what you'd like to achieve from rehabilitation so that some realistic goals can be set.

Your rehabilitation programme will usually start within a few days of surgery, beginning with some simple exercises you can do while lying down or sitting. If you've had a leg amputation, you'll be encouraged to move around as soon as possible using a wheelchair.

You'll 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 start working on an exercise programme with a physiotherapist in the hospital gym to help you maintain your mobility and muscle strength.

If you have a prosthetic limb fitted your physiotherapist will teach you how to use it – for example, how to walk on a prosthetic leg or grip with a prosthetic hand.

Going home and follow-up

The length of time it will take before you're ready to go home will depend on the type of amputation you've had and your general state of health.

Before you're discharged from hospital, an occupational therapist may arrange to visit you at home to see whether your home environment needs to be adapted to make it more accessible.

For example, you may need a wheelchair ramp or a stairlift. If these types of modifications are required, the issue can be referred to your local social services department.

You may be given a wheelchair to help you get around if you've had a lower limb amputation.

You'll probably need to attend a follow-up appointment a few weeks after being discharged to discuss how well you're coping at home and whether you require additional help, support or equipment.

At your appointment, you may also be given details of your nearest amputee support group, made up of both healthcare professionals and people living with an amputation.

Prosthetics limbs

After an amputation, you may be able to have a prosthetic limb fitted.

Prosthetic limbs aren't suitable for everyone who's had an amputation because an extensive course of physiotherapy and rehabilitation is required.

Adjusting to life with a prosthetic limb takes a considerable amount of energy because you have to compensate for the loss of muscle and bone in the amputated limb.

This is why frail people or those with a serious health condition, such as heart disease, may not be suitable for a prosthetic limb.

If you're able to have a prosthetic limb, the type of limb that's recommended for you will depend on:

• the type of amputation you had
• the amount of muscle strength in the remaining section of the limb
• your general health
• tasks the prosthetic limb will be expected to perform 
• whether you want the limb to look as real as possible or whether you're more concerned with function

If it's thought that you would find it difficult to withstand the strain of using a prosthetic limb, a purely cosmetic limb may be recommended. This is a limb that looks like a real limb, but cannot be used like a prosthetic limb.

It's possible to have a prosthetic limb that's both physically realistic and functional, but there may have to be an element of compromise between the different types.

Preparing to have a prosthetic limb fitted

If a prosthetic limb is suitable for you, you'll begin a programme of activities while still in hospital to prepare for the prosthetic.

Before a prosthetic limb 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 involves 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 teach you a range of exercises to strengthen the muscles in your remaining limb and improve your general energy levels, so you're able to cope better with the demands of an artificial limb.

Depending on what's available in your local area, it can be several weeks before you get your first appointment with a prosthetist.

Stump care

It's very important to keep the skin on the surface of your stump clean to reduce the risk of it becoming irritated or infected.

Gently wash your stump at least once a day (more frequently in hot weather) with mild unscented soap and warm water, and dry it carefully.

If you have a prosthetic limb, you should also regularly clean the socket using soap and warm water.

When taking a bath, avoid leaving your stump submerged in water for long periods because the water will soften the skin on your stump, making it more vulnerable to injury.

If your skin becomes dry, use a moisturising cream before bedtime or when you're not wearing your prosthesis.

Some people find wearing one or more socks around their stump helps absorb sweat and reduces skin irritation. The size of your stump may change as the swelling goes down, so the number of socks you need to use may vary. You should change the socks every day.

Check your stump carefully every day for signs of infection, such as:

• warm, red and tender skin
• discharge of fluid or pus
• increasing swelling

Contact your care team for advice if you think you may be developing a skin infection.

Caring for your remaining limb

After having a leg or foot amputated, it's very important to avoid injuring your remaining "good" leg and foot, particularly if your amputation was needed because of diabetes. Your remaining leg and foot may also be at risk.

Avoid wearing poorly fitting footwear and ensure that an appropriately trained healthcare professional, such as a podiatrist, is involved in the care of your remaining foot. You should also be offered a regular review of your foot by the foot care team.

Complications

Like any type of operation, an amputation carries a risk of complications. It 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've 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
• deep vein thrombosis (DVT)
• slow wound healing and wound infection
• pneumonia
• stump and "phantom limb" pain

In some cases, further surgery may be needed to correct problems that develop or to help relieve pain. For example, if neuromas (thickened nerve tissue) are thought to be causing pain, the affected cluster of nerves may need to be removed.

Stump and "phantom limb" pain

Many people who have an amputation experience some degree of stump pain or "phantom limb" pain.

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.

Phantom limb sensations are sensations that seem to be coming from the amputated limb. Occasionally, these can be painful (phantom limb pain).

The term "phantom" doesn't mean the sensations are imaginary. Phantom limb pain is a 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. Others have described constant severe pain.

Treating stump and phantom limb pain

Stump and phantom limb pain will usually improve over time, but treatments are available to help relieve the symptoms.

Medications

Medications that may be used to help relieve pain include:

• non-steroidal anti-inflammatory drugs (NSAIDs) – such as ibuprofen
• anticonvulsants – such as  pregabalin or gabapentiin
• antidepressants – such as amitriptyline or nortriptyline, which are useful in treating nerve pain 
• opioids – such as codeine or morphine
• corticosteroid or local anaesthetic injections

Self-help measures and complementary therapy

There are several non-invasive techniques that may help relieve pain in some people. They include: 

• adjusting the way your prosthesis fits to make it more comfortable
• massage – to increase circulation and stimulate muscles
• acupuncture – thought to stimulate the nervous system and relieve pain
• transcutaneous electrical nerve stimulation (TENS) – where a small, battery-operated device is used to deliver electrical impulses to the affected area of your body, to block or reduce pain signals

Research has shown that people who spend 40 minutes a day imagining using their phantom limb, such as stretching out their "fingers" or bunching up their "toes", experience 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.

Another technique, known as mirror visual feedback, involves using a mirror to create a reflection of the other limb. Some people find that exercising and moving their other limb can help relieve the pain from a phantom limb.

Psychological impact of amputation

The loss of a limb can have a considerable psychological impact. Many people who've 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

Mental imagery

Research has shown that people who imagine using the part of their limb that was amputated experience a reduction in pain symptoms.

This may be related to the central theory of phantom limb pain. Researchers think the brain looks to receive feedback from an amputated limb, and these mental exercises may provide an effective substitute for this missing feedback.

Another technique, known as mirror visual feedback, involves using a mirror to create a reflection of the other limb. Some people find that exercising and moving their other limb can help relieve phantom pain.

Psychological impact of amputation

The loss of a limb can have a considerable psychological impact. Many people who've had an amputation report 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 3 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

Negative thoughts and emotions are common after an amputation. This is particularly true in people who've had an emergency amputation because they do not have time to mentally prepare for the effects of surgery.

Common emotions and thoughts experienced by people after an amputation include:

• depression
• anxiety
• denial (refusing to accept that they need to make changes, such as having physiotherapy, to adapt to life with an amputation)
• grief

People who've had an amputation as a result of trauma (particularly members of the armed forces) also have an increased risk of developing post-traumatic stress disorder (PTSD).

Talk to your care team about your thoughts and feelings, particularly if you're feeling depressed or suicidal. You may need additional treatment, such as antidepressants or counselling, to improve your ability to cope after having an amputation.

Help and support

Being told you need to have a limb amputated can be a devastating and frightening experience. Adjusting to life after an amputation can be challenging, but many people enjoy a good quality of life once they have managed to adapt and with appropriate treatment and support.

You may find it useful to contact a support group for people living with amputations. The Limbless Association can provide you with information and advice, as well as the details of various local support groups. Its phone number is 0800 644 0185 (Monday to Friday, 9am to 5pm).

You may also find the Douglas Bader Foundation (DBF) a useful source of information and advice.