GCC Context: UAE and Saudi Arabia have among the highest per-capita amputation rates in the world — driven by poorly controlled DM epidemic with diabetic foot complications as the leading cause.
| Level | Description | Rehabilitation |
|---|---|---|
| Digital | Toe / finger | Excellent |
| Transmetatarsal | Forefoot | Very good |
| Transtibial (BK) | Below knee | Good — less energy cost |
| Knee disarticulation | Through knee joint | Moderate |
| Transfemoral (AK) | Above knee | Higher energy demand |
| Hip disarticulation | Through hip | Most challenging |
Principle: maximise viable tissue while achieving primary closure — level determined by blood supply.
Imaging Protocol: CT angiography run-off defines the most distal level of adequate perfusion. Skin perfusion pressure >40 mmHg is associated with primary wound healing. Angioplasty/bypass may be attempted first to avoid or reduce amputation level.
Psychological First: Amputation represents a profound loss. Allow the patient time to express grief, fear, and anger. Avoid minimising responses such as "you'll be fine" — this invalidates the patient's experience.
Pre-emptive Analgesia: Pre-operative epidural analgesia may reduce incidence and severity of phantom limb pain post-operatively — evidence remains limited but it is common practice in many GCC centres. Discuss with anaesthetics team.
Haematoma is the most common early post-operative complication. Raises infection risk and may require surgical evacuation. Report promptly.
Shapes the stump, reduces post-operative oedema, and prepares the residual limb for prosthetic fitting.
Figure-of-8 technique — NOT circumferential. Circumferential bandaging creates a tourniquet effect and can compromise blood supply.
| Complication | Presentation | Nursing Action |
|---|---|---|
| Haematoma | Swelling, bruising, wound bulge | Escalate; possible surgical evacuation; monitor obs |
| Wound Dehiscence | Wound edges separate — high risk in DM/PVD | Wound care, NPO wound support, consider VAC dressing, secondary closure referral |
| Infection | Erythema, pyrexia, purulence | Wound swab, IV antibiotics, escalate; DM control crucial |
| Flexion Contracture | Fixed deformity — prevents prosthesis | Prone positioning, physiotherapy, splinting |
| Phantom Pain | Pain in absent limb — see Tab 4 | Analgesia, mirror therapy, refer pain team |
Early Mobilisation: Begin transfer practice and wheelchair independence from Day 2–3 with physiotherapy. Early mobilisation reduces DVT risk, improves mood, and sets the tone for rehabilitation. Bed rest should be minimised.
Prevalence: 50–80% of amputees experience phantom limb pain. It is not psychological — it has a defined neuropathic pathophysiology and requires active treatment.
| Entity | Definition | Nature |
|---|---|---|
| Phantom Limb Pain | Painful sensation perceived as coming from the amputated (absent) limb | Pathological — requires treatment |
| Phantom Sensation | Non-painful awareness of the absent limb (e.g. position, temperature, itching) | Normal — benign, reassure patient |
| Residual Limb Pain | Pain at the actual stump wound site | Local — wound/nerve/scar |
Phantom pain arises from cortical reorganisation — the somatosensory cortex area previously mapped to the amputated limb is invaded by neighbouring cortical areas, generating abnormal signals perceived as originating from the absent limb.
Sensitised central pain pathways amplify nociceptive input. Pre-operative chronic pain in the limb may prime these pathways — explaining the benefit of pre-emptive epidural analgesia.
Mirror therapy works by reversing cortical reorganisation — the brain receives visual feedback of a "complete" limb moving, which normalises cortical maps and reduces phantom pain signals.
Best evidence. Patient views mirror reflection of intact limb while moving it — creates visual illusion of absent limb. Performed 15–30 min daily.
Three-stage: limb laterality recognition, motor imagery, then mirror therapy. Systematic cortical retraining programme.
| Drug | Class | Notes |
|---|---|---|
| Gabapentin / Pregabalin | Alpha-2-delta calcium channel ligand | First-line neuropathic pain. Titrate dose. Monitor sedation. GCC: widely available. |
| Amitriptyline | TCA | Low-dose neuropathic pain. Useful in co-morbid insomnia/depression. Monitor cardiac rhythm. |
| Duloxetine | SNRI | Neuropathic pain. Also addresses comorbid depression/anxiety common post-amputation. |
| Opioids | MOR agonist | Limited evidence for phantom pain specifically. Short-term use only. Dependency risk. |
| Ketamine infusion | NMDA antagonist | Specialist pain team. IV infusion in refractory cases. Dissociative effects — monitored setting. |
Cardiac fitness assessment is mandatory prior to prosthetic training, especially for patients with vascular disease.
| K-Level | Description |
|---|---|
| K0 | No prosthetic potential — wheelchair primary mobility |
| K1 | Limited — indoor walking on level surfaces only |
| K2 | Limited community ambulation — traverses low-level barriers |
| K3 | Unlimited community walking, variable cadence |
| K4 | High activity / sport / paediatric — exceeds basic ambulation |
| Level | Energy Cost | Rehab Potential | Key Nursing Point |
|---|---|---|---|
| Digital / Transmetatarsal | Minimal | Excellent | Prevent plantar flexion contracture |
| Transtibial (BK) | +25% | Good | Prevent knee flexion contracture — prone lying |
| Knee Disarticulation | +40% | Moderate | End-bearing stump — good proprioception |
| Transfemoral (AK) | +65% | Reduced | Prevent hip flexion/abduction contracture |
| Hip Disarticulation | >100% | Most challenging | Wheelchair primary — prosthesis cosmetic/functional |
| Feature | Phantom Pain | Residual Limb Pain |
|---|---|---|
| Location | Absent limb | Stump wound site |
| Character | Burning, shooting, cramping | Aching, wound tenderness |
| Cause | Cortical reorganisation | Wound, neuroma, infection |
| Treatment | Mirror therapy, gabapentin | Analgesia, wound care |
| Onset | Often immediate post-op | Correlates with wound status |
Enter patient parameters to predict K-level functional classification and prosthetic potential.