Understanding Limb Loss: Insights from Dr. Charles Stonerock on Causes, Prevention, and Life After Amputation

An estimated 2.3 million people in the United States are living with limb loss, And the number is expected to rise to 3.5 million by 2050, according to the National Amputee Coalition. We spoke with Dr. Charles Stonerock, a vascular surgeon at MUSC Health Florence Medical Center and an associate professor of surgery, to learn more about the reasons for limb loss, whether it can be prevented, and life after limb loss.

Q. What are the most commonly amputated limbs?

A. The most commonly amputated limbs are the lower leg, toe, and foot.

Q. What are the biggest reasons for amputation?

A. The majority of amputations are a result of peripheral artery disease (PAD), also called peripheral vascular disease, and diabetes. Both can diminish blood flow to the toes and feet. The primary cause of PAD is atherosclerosis, a buildup of fat in the arteries. Fat causes the arteries to narrow and harden, decreasing blood flow to the lower legs, toes, and feet, and it causes muscle cramps when someone walks. Diabetes can also harm the blood supply to the feet. Other reasons for amputation include cancer, bone disease and trauma.

Q. What are the visible symptoms of diabetes and PAD that require someone to have an amputation?

A. The most common symptom is a non-healing sore or wound on the foot or toe. Usually, the foot or toe is discolored (black or purple) and caused by poor circulation. The condition causes severe (irreversible?) infection and unbearable pain even when someone is resting.

Q. Is amputation the only treatment?

A.  In some cases, yes. People have put off having a nonhealing wound or ulcer checked out because they are in denial. When I ask my patients what took them so long to come in, they tell me that they were afraid of getting bad news and were concerned about an amputation. As a result, they’re out of that window of opportunity for any treatment except an amputation. Eighty-five percent of diabetics who undergo amputation have a non-healing ulcer on their foot. I emphasize that the sooner someone comes in for evaluation, the better.

Q. Are alternatives to amputation available?

A. For patients with PAD who have a nonhealing wound or sore, minimally invasive options are available to increase circulation. Endovascular therapies such as vein arterialization, angioplasty and stent insertion are examples of alternative procedures that are better tolerated and can salvage a limb with the right circumstances.

Q. How concerned should patients diagnosed with PAD or diabetes be about losing a limb?

A. The two biggest risk factors for developing PAD are a combination of smoking and diabetes. Around half of patients with PAD have no symptoms, and only about one to five percent of people with PAD have concerning symptoms, with only a small minority that are in danger of losing a limb with severe symptoms.

About one-third of PAD patients have diabetes. The converse is also true: About one-third of diabetics can develop PAD. Other risk factors for PAD include high blood pressure, high cholesterol, kidney disease, and heart disease. Again, I can’t emphasize enough the importance of getting a nonhealing wound or ulcer checked out as soon as possible if you have PAD or diabetes.

Q. Are you able to preserve a limb?

A. We try to preserve as much of the leg as possible because it affects mobility and the ability to use a prosthesis. A lot of energy is needed to use an artificial leg, and that’s where circulation comes into play. If we can open some blockages, we can try to maximize the healing of lower-level amputations, including the foot. In general, the more we can save, the better off people are. The level of amputation also depends on the functional status of the patient before surgery.

Q. What is phantom pain?

A. Phantom pain is the perception of pain where the limb has been lost. It can range from mild to severe and begins soon after amputation or up to a year later. Phantom pain affects between 50 and 80 percent of patients and can be severe.

My grandfather had both his legs amputated, and for years he said he could feel pain in his toes. I tell my patients who have had a foot amputated to be very careful if they try to walk, particularly if they get up during the night because they no longer have that foot.

Q. How is phantom pain treated?

A. Phantom pain can be treated with medications, various therapies and, in severe cases, stump revision surgery.

Q. What is the survival rate after an amputation?

Most people do not die from the amputation itself but from the health issues leading up to the amputation. The mortality rate in the first year after an amputation can range from 25-50%.

Q. What do you tell someone who faces an amputation?

A. First of all, we are never judgmental when a patient presents with a non-salvageable limb. Learning that amputation is necessary is a shock for many individuals. An amputation may be necessary to save their life or to control their pain. I reassure patients that life does go on, granted, it won’t be the same – they must modify what they do – but they can still have a decent quality of life.

Q. What happens after surgery in terms of recovery, rehab and obtaining a prosthesis?

A. Therapy begins in the hospital. Our goal is to get the patient back home, but depending on the patient’s overall health and age, acute inpatient rehab or a nursing facility may be required if care is not available at home.

Q. When does someone get a prosthesis?

A. Typically, stitches and staples are removed within a month, and once the site has healed, the patient meets with a prosthetist, who takes measurements and creates a mold or digital images of the residual limb. A lot of education is involved, and the process takes several months. During this time, the patient also undergoes occupational and physical therapy to increase strength and flexibility.

Q. What advice do you have for patients with PAD and/or diabetes?

A. If a sore is not healing, or if you have pain and discoloration that is bluish or purple, get it checked out to make sure there’s no problem with circulation. An ordinary wound should heal in one to two weeks. I encourage my patients who have had an amputation to let me know if a problem develops on their other foot. Don’t put off medical care.

Dr. Stonerock is board-certified in surgery and vascular surgery. He sees patients at MUSC Health Florence Medical Center, 805 Pamplico Hwy, Medical Pavilion B, Suite 300, in Florence, SC. To make an appointment, call 843-676-2760.