FOREIGN LITERATURE

Toe amputation is a common procedure performed by a wide variety of health care

providers. The vast majority of toe amputations are performed on patients with
diabetic foot. Although regional variation is noted, most of these procedures are done
by general, vascular, and orthopaedic surgeons particularly those subs specializing in
foot and ankle surgery in some countries, podiatrists are involved.
When amputation of any body part is being considered, the decision to proceed is
usually made if the area falls into 1 of 3 broad categories: "dead," "deadly and dead
loss. Before any amputation, the clinician should ensure that the patients medical
circumstances have been optimized (that is, should "reverse the reversible"). With
impending toe amputation, this step encompasses such measures as glycemic control
and consideration of revascularization when severe macrovascular disease is
contributing to ischemia.
With any amputation, the degree of postoperative functional loss is generally
proportional to the amount of tissue taken. The great toe is considered the most
important of the toes in functional terms. Nevertheless, great toe amputation can be
performed with little resulting functional deficit. The method of toe amputation
(disarticulation versus osteotomy) and the level of amputation (partial or whole
phalanx versus whole digit versus ray) depend on numerous circumstances but are
mainly determined by the extent of disease and the anatomy.
In Western societies, a dead toe is most commonly seen as a complication of
diabetes and is due to a combination of macrovascular and microvascular disease.
Other major risk factors for peripheral vascular disease (as for all atherosclerotic
diseases) include smoking, hypertension, and hyperlipidemia. Rarely, pathologic
processes confined to the microvasculature are to blame (eg.Buerger disease,
vasospastic diseases, severe frostbite).
The deadly category is reserved mainly for more proximal disease processes. Usually, a
large limb segment must be affected by wet gangrene (with macroscopic putrefaction
and surrounding cellulites) before it can result in systemic sequelae. However,
malignancy may necessitate amputation, though infrequently.
A toe is a dead loss when it is diseased to the point where it is irreparable (as with
chronic), it ceases to be functional (as with significant trauma), or it is impeding
function (as with neuropathic pain).

Limb loss is one of the most physically and psychologically devastating events that can
happen to a person. Not only does lower limb amputation cause major disfigurement,
it renders people less mobile and at risk for loss of independence (Gitter and Bosker
2005). Yet with appropriate rehabilitation, many people can learn to walk or function
again and live high quality lives. Despite advances in medicine and surgery,
amputation continues to be a large problem in the world, predominantly for older
adults. It has been estimated that there were 664,000 persons living with major limb
loss in the United States in 2005 and more than 900,000 with minor limb loss
(Ziegler-Graham et al. 2008). "Major" limb loss is defined as amputation above the
elbow, below the elbow, above the knee, below the knee, or the foot. "Minor" limb loss
is defined as amputation of the hand or digits (fingers or toes) (Tseng et al. 2007).
Lower limb amputations are much more frequent than upper limb and are most
commonly the result of disease followed by trauma. This article focuses on lower limb
amputation with emphasis on studies particularly within the United States because of
the comprehensive databases that are available.
Worldwide prevalence estimates of amputation is difficult to obtain, mainly because
amputation receives very little attention and resources in countries where survival is
low (Aleccia 2010). The overall rates of amputation due to trauma or malignancy are
decreasing while the incidence of dysvascular amputations is rising (Dillingham et
al. 2002). Amputsations due to dysvascular disease accounts from roughly 54% of
limb loss cases in the United States, while traumatic amputations account for 45% of
loss (Aleccia 2010). The number of lower limb amputations is expected to increase in
the United States to 58,000 per year by 2030 (Cutson and Bongiorni 1996; Fletcher et
al., 2002), with nearly 75% occurring in those aged 65 and older (Clark et al. 1983).
The United States has a higher lower limb amputation rate compared to other
developed countries (Renzi et al. 2006). The Marshall Islands have been identified to
also have a very high rate of lower limb amputation, by world standards (Harding
2005). From 1991-2000, rates of diabetes related to lower extremity amputations
decreased in The Netherlands (van Houtum et al. 2004). In a World Health
Organization multinational study of vascular disease in diabetes, the results showed
that the incidence of lower limb amputation was higher in the American Indian centres
than in the East Asian centres (Chaturvedi et al. 2001). Moreover, the earthquake that
shook Haiti in 2010 ranks among the largest ever loss of limbs in a single natural
disaster (Aleccia 2010).
Body integrity identity disorder (BIID, also referred to as amputee identity
disorder is a psychological disorder wherein sufferers feel they would be happier living
as an amputee). It is related to xenomelia, "the oppressive feeling that one or more
limbs of one's body do not belong to one's self".
[2]

BIID is typically accompanied by the desire to amputate one or more healthy limbs to
achieve that end. BIID can be associated with apotemnophilia, sexual arousal based
on the image of one's self as an amputee. The cause of BIID is unknown. One theory
states that the origin of BIID is that it is a neurological failing of the brain's inner body
mapping function (located in the right parietal lobe). According to this theory, the
brain mapping does not incorporate the affected limb in its understanding of the
body's physical form.

Wild et al (2004) undertook a prevalence study and found that
the total number of people with diabetes is expected to rise from 171 million in 2000
(2.8% prevalence)to366 million (4.4% prevalence) by 2030. Therefore, it is likely that
the incidence of diabetic foot ulcers will also increase. In the UK every year 5,000
people with diabetes mellitus undergo lower-limb amputation (National Diabetes
Support Team, 2006) making diabetic foot ulceration a major cause of morbidity and
mortality. The roles of healthcare professionals are
expanding to include the prevention, assessment, therapeutic intervention and critical
evaluation of care relating to tissue viability. Therefore, to reduce the impact of
diabetic foot ulcers, it is necessary to not only give optimal treatment to the person
with diabetes he number of people diagnosed with diabetes is increasing. Wild et al
(2004) undertook a prevalence study and found that the total number of people with
diabetes is expected to rise from 171 million in 2000 (2.8% prevalence) to 366 million
(4.4% prevalence) by 2030. Therefore, it is likely that the incidence of diabetic foot
ulcers will also increase. In the UK every year 5,000 people with diabetes mellitus
undergo lower-limb amputation (National Diabetes Support Team, 2006) making
diabetic foot ulceration a major cause of morbidity and mortality. The roles of
healthcare professionals are expanding to include the prevention, assessment,
therapeutic intervention and critical evaluation of care relating to tissue viability.
Therefore, to reduce the impact of diabetic foot ulcers, it is necessary to not only give
optimal treatment to the person with diabetes.

FOREIGN LITERATURE
Fowler and Rayman (2006) considered that the best samples to send are those of
tissue obtained from the wound by debridement or deep swabs because supercial
swabs are likely to reveal supercial skin organisms that are not necessarily
responsible for the infection and can lead to unnecessary use of broad spectrum
antibiotics. The ADA (1998) states that most diabetic foot infections are polymicrobial,
so both aerobic and anaerobic cultures specimens should be collected. Anaerobic
bacteria such as bacteroides, clostridium and streptococcus may be active at deeper
levels of the dermis, insulated from the healing inuence of oxygen and are
responsible for many devastating amputation (OMeara and Nelson, 2003). Therefore,
cultures from supercial tissue may be of little value and cultures from tissue deep in
the ulcer base are more reliable for identifying true pathogens (ADA, 1998). However, a
study by Slater et al (2004) reported reliable bacterial identication from supercial
swabs as long as the ulcer was not down to bone. Therefore, if deep swabs or tissue
cannot be taken, supercial swabs are a second best alternative.Although the wound
swab remains the most common method of sampling (Bowler et al, 2001), Donovan
(1998)showed that few nurses are taught how to swab a wound correctly. This is
supported by Gilchrist (1996) who stated that there is no consensus on swabbing
methodology. However, the literature tends to give conicting advice on the various
procedures for obtaining a specimen using a swab. For example, there is ongoing
debate about whether wounds should be cleaned before taking the specimen. Some
nurses clean the wound beforetaking a swab, whereas others take the swab before the
wound is cleaned (Miller, 2001). Cooper and Lawrence (1996) said that wounds must
be cleaned rst to remove surface contamination, however, Wilson (1995) maintained
that the swabs need to be taken before cleansing so that the maximum number of
bacteria are present. Some practitioners swab only the pus and some nurses wipe the
swab all over the wound, yet others take the sample from just one place on the wound
bed (Miller, 2001). This inconsistency could possibly lead to unreliable results.
Therefore, there is a need for a standard criterion on the technique of wound swabbing
to be devised that can be used nationwide.


LOCAL
The majority of patients undergoing amputation of the lower limb have peripheral
vascular disease, often resulting in significant morbidity and mortality. The incidence
of amputations is higher in smokers, rises with age and is higher in men than women.
Furthermore, people with diabetes form just less than half of all amputees.
Consequently, it is not surprising to find that such patient risk factors can result in
an array of wound-healing difficulties, thus prolonging debilitation and reducing
quality of life. The UK's increasingly ageing population means that more elderly
patients will be operated on in the future, thus giving rise to a growing trend in
postoperative tissue viability problems where skin fragility and multiple pathologies
such as diabetes and peripheral vascular disease co-exist. Hence wound healing
complications associated with amputation are becoming more commonplace, requiring
sophisticated management strategies to meet the needs of these vulnerable patients.
The most important factor in ensuring a successful amputation is the correct choice of
amputation site based on assessment of limb perfusion and functional requirements.
The following factors will affect the outcome of amputation: the patient's nutritional
status, age, tissue perfusion, smoking habits, infection and the presence of co-existing
diseases such as anaemia and renal failure. This paper describes a number of
problems associated with amputation wound healing, including infection, tissue
necrosis, pain, difficulties associated with the surrounding skin, bone erosion,
haematoma, oedema and dehiscence/wound breakdown. It draws on the available
literature to guide best practice in this complex area of surgical wound care and
highlights the importance of multidisciplinary team working.
In most instances, surgeons performing a lower limb amputation will use the primary
closure technique, in which the edges of the wound are closely approximated, thus
eliminating dead space and involving minimal formation of granulation tissue. There
may be a drain in situ which will be removed on the first or second postoperative day.
The drain is often not sutured in place to allow its removal without disturbing
bandages or dressings.
It is advisable to assess amputation wounds regularly for evidence of problems such
as offensive odour, haemorrhage or excessive exudate. In most cases surgical wounds
are managed with a simple island dressing, orthopaedic wool padding and a light
retention bandage. It could be argued that such low cost, traditional dressings are
adequate for most surgical wounds. However, amputees with poor tissue integrity
often require modern woundcare products that offer additional benefits, such as the
low adherence offered by the soft silicone range. Indeed, dressing adherence as a
result of dried blood products can cause trauma, pain and anxiety at dressing
changes. Wound dressings also need to be robust enough to withstand movement and
use of the stump; they should not limit or interfere with the patient's rehabilitation.
There is a lack of agreement surrounding the length of time a surgically closed wound
should be covered. Some clinicians argue that the wound can be left exposed after 24
to 48 hours. However, others propose that exposure may contribute to wound pain,
suggesting that the wound should remain covered until suture removal. In light of
hospital-acquired infection rates, it would seem prudent to challenge regimens of the
past and maximise the time a wound is covered. Moreover, the stump often requires
additional protection from trauma, which can be experienced during transfer to and
from the patient's wheelchair.
A correctly placed stump bandage can be used to mould the stump and allow early
mobilisation so may be left in place for four to five days, only being changed if there is
increasing stump pain, odour or pyrexia. Practice varies according to local protocols -
rigid plaster dressings are fitted in some centres in the immediate postoperative
period, with reports of quicker wound healing and earlier ambulation.

Surgical wounds that heal by primary intention are expected to heal successfully
without complications. However, there is little evidence to demonstrate that this
actually happens in practice. Although wound infection is acknowledged to be a
significant problem in surgical wounds, there are anecdotal reports that other
complications such as dehiscence, the splitting open of a closed wound, and skin
blistering occur, yet these problems do not feature widely in the literature.
It has been estimated that over six million operations were undertaken in the NHS in
England and Wales in 1998-99. However, advances in surgery would suggest that the
number of surgical procedures and their resulting wounds are set to increase. The
National Institute for Health and Clinical Excellence (NICE) estimates that, based on
data from a surgical department of a district general hospital, there may be 21,000
difficult-to-heal surgical wounds per annum in England and Wales. NICE
acknowledges that this number may be a significant underestimate. The UK has an
ageing population, which suggests that an increasing number of elderly patients will
be operated on in the future, thus producing a rise in postoperative tissue viability
problems where skin fragility and multiple pathologies co-exist. Indeed, both Harding
(1993) and Mulder et al (1998) have alluded to the need for awareness of demographic
changes in relation to woundcare developments - tissue friability and prolonged
wound repair associated with ageing are acknowledged to be key problems.
Within the population of patients with peripheral vascular disease, major lower
extremity amputation results in significant perioperative morbidity and mortality.
Patients are often extremely debilitated, with multiple co-existing cardiovascular risk
factors. The prognosis following amputation is poor: nearly a third of unilateral
amputees lose the other limb within three years and half of them will die within five
years. Wound healing complications associated with the stump of an amputee are
important because in some cases these determine a patient's ability to walk with a
prosthetic limb. One study concerning lower limb amputation found that the
commonest stump-related complications were wound infection and poor healing
(70%), poorly fashioned stumps (20%) and phantom pain (10%). The healing rates for
below- and above-knee amputations vary considerably. It is thought that a total of
90% of above-knee major amputations heal, 70% primarily, whereas for below-knee
amputations, primary healing rates range between 30% and 92%, with a re-
amputation rate of up to 30%.
Important factors in healing and outcome of amputation include the patient's
nutritional status, age, whether or not the patient smokes, the presence of old
potentially infected graft material and the presence of co-existing diseases such as
renal failure, diabetes and anaemia. Site selection is considered a crucial factor as
healing depends on the adequacy of perfusion. Healing also depends on the technical
precision of the surgeon. The type of surgical technique used for below-knee
amputation has not been found to have an effect on stump healing, wound infection,
re-amputation rate or mobility with a prosthetic limb and is considered to be a matter
of surgeon preference. Chalmers and Tambyraja conclude that no system is foolproof
in predicting amputation healing.