Introduction

A limb salvage program aims to prevent major amputations and thus improve patients' quality of life and overall longevity. Despite the efforts of a multidisciplinary team approach, amputation prevention remains a challenging endeavor.¹ Providing both physical and socioemotional guidance for patients undergoing a major amputation is crucial for recovery. A multifaceted approach to post-amputation care may seem like a relatively modern concept, but it has deep roots in earlier civilizations.

Early History of Amputation Practices

Limb amputation is one of the oldest documented surgical procedures, dating back to early man, known as the Neanderthal period.² There is evidence of medical care and social support given to those recovering from lower extremity amputations centuries ago during the Inca Empire. A paleopathology review of 2 burials from roughly 1100-1535 AD in Pre-Hispanic Peru highlights the care continuum used by the ancient Incans in the aftermath of total foot amputation. The 2 individuals exhumed from the Túcume site were both female and between 30-40 years old at time of death.³

Skeletal Analysis

Current bioarcheological investigations into the health index of a population use the skeletal analysis of exhumed individuals of the corresponding era. Skeletal analysis has revealed the social contexts amputation has occurred in pre-Hispanic Andean civilization that existed on the north coast of Peru, such as for therapeutic intervention, punishment, and ritualistic dismemberment.³ From an anthropologic perspective, the health index of a population is determined by various skeletal indicators, including the following:

• Density of long bones
• Signs of trauma
• Infectious disease
• Degenerative joint disease
• Dental abnormalities

The skeletal analysis of these 2 young women who underwent total left foot amputations showed evidence of proficient surgical technique regarding the disarticulation of the foot bones, with evidence of osseous remodeling as an indication of survival for a significant amount of time post-procedure (available for viewing by here).³ Radiographic evaluation revealed atrophy of the left tibia in both women as a sign of disuse from reduced biomechanical forces due to the amputation (available for viewing at the source here).³ Subsequently, the left humerus demonstrated diminished density as compared to the right, likely from the use of an ambulatory aid (crutch or cane) for mobility post-amputation.³

Cranial examination revealed no signs of porotic hyperostosis or cribia orbitalia, which are demineralized areas in the skull associated with nutritional deficits, including anemia.³ It is important to note that cause of death cannot be determined for either of these women.

Cultural Context

Amputation in some ancient cultures was carried out as punishment, with other unamputated anatomic areas showing signs of trauma. The burial method for punished or ostracized individuals varied greatly from the burials of well-regarded members of society. In the case of the 2 female foot amputees, their burial chambers were adorned with elaborate textiles and copper jewelry, reflecting the status of respected members of their community.³

Researchers also noted that seeds of the sacred shrub, also known as Capparis crotonoides, were placed with the bodies. Used to treat bone and joint pain, the presence of this ancient treatment further indicates the access these 2 individuals had to medical treatment during their lifetime.³ From the skeletal assessment, it can be presumed that they had sufficient nutrition, access to ongoing medical care, and support from their community postoperatively.

Conclusion

Looking toward the future, however, some factors have helped the procedure evolve, such as more modern developments, like the tourniquet, proper vessel litigation, repair, and antisepsis. These developments have aided in decreasing the mortality rate from an amputation, perhaps alleviating some of the fears of a negative outcome from patients.²

The contemporary model of patient support for those experiencing a major lower extremity amputation includes acquiring a properly fitting prosthetic device, physical therapy, nutritional optimization, pain management, and socio-emotional assistance. These tenets were also noted in past cultures who provided comprehensive support to those undergoing the loss of a limb. Indeed, some challenges to humanity stay the same despite the passage of time.

References

1. Liu R, Petersen B, Rothenberg G, Armstrong D. Lower Extremity Reamputation in People with Diabetes: A Systematic Review and Meta-Analysis. BMJ Open Diabetes Research & Care. 2021; 9(1). https://doi.org/10.1136/bmjdrc-2021-002325
2. Markatos K, Karamanou M, Saranteas T, et al. Hallmarks of amputation surgery. Int Orthop. 2018;43(2) 493–499. https://doi.org/10.1007/s00264-018-4024-6
3. Phillips M, Cruz V, Martin E, et al. Two (missing) left feet. Bioarchaeol Int. 2021;1–20. https://doi.org/10.5744/bi.2021.1010

About the Author

Christine Miller, DPM, PhD, FACCWS is a certified wound specialist by the American Board of Wound Management and a Fellow of the American College of Clinical Wound Specialists. She currently serves as the Co-Director of the Limb Salvage Program at the University of Florida, College of Medicine-Jacksonville.