Lower limb amputations- surgical techniques
Content:
In the previous chapter, we discussed key aspects of amputations and decision-making about the level of amputation. We recommend reading that chapter first, as even experts will find something useful there.
In the following chapter, we discuss some important aspects of the different types of lower limb amputations, explore techniques, and discuss how to avoid pitfalls. We have included several videos from YouTube here and selected the most explanatory ones. Note that you need a YouTube account to view these since the videos show graphic material. More images and videos will be uploaded soon ( we are currently sorting through our own archive).
WoundsAfrica is dedicated to wound care, and our patient population is often diabetic patients with impaired vascular status. Most of the key aspects we discuss here apply to these patients, but most of the topics mentioned here also apply to acute trauma wounds where an amputation may be necessary.
As mentioned before, lower limb amputations are complex surgeries and should not be delegated to less experienced junior doctors. While we must train the future generation of surgeons, competent supervision should always be available during these procedures. Amputations should not be carried out at dispensaries. Remember that even a "simple" toe amputation can go terribly wrong and lead to a below-knee amputation. By the way, there is nothing like a "simple" toe amputation. All amputations, even of the little toe, can have serious complications.
In situations with infection, you will often need to plan the amputation as a two-stage procedure. For example, suppose you have a severely infected ray of a forefoot. In that case, you can amputate the toe, perform debridement of the necrotic tissue of the ray, provide antibiotic coverage, and, after maybe ten days, do a transmetatarsal amputation. Using two-stage procedures will often help preserve limb length!
Antibiotic prophylaxis and amputations
Let's get one thing straight first: WoundsAfrica is all about antibiotic stewardship. The unnecessary widespread abuse of antibiotics in wound care in general is alarming. However, when it comes to antibiotic prophylaxis during and after amputation surgery, we think we should have a liberal attitude. A major amputation in itself is a life-changing and traumatic experience, and we have to ensure that we can do everything to ensure that the stump heals without complications. Since the rate of complications with wound dehiscence, skin edge necrosis, and infection is significant in this patient group, most authors recommend at least a 5-day course of antibiotics following surgery.
For major amputations, several relatively recent publications show a significant decrease in postoperative complications and hospital stays when administering antibiotics for five days postop. (Sadat 2019, Souroullas 2022). We think this should be the recommendation for the majority of patients undergoing major limb amputations. However, if the patient had an ongoing gangrenous foot infection or extensive cellulitis, you must provide extended antibiotic coverage after the surgery. In addition, several individual factors affect the length of antibiotic therapy. Some of our patients have, for example, low albumin due to protein deficiency, resulting in prolonged exudate coming from the incision wound. This increases the risk of infection, and we would use prolonged antibiotic coverage. We think that if you are in doubt, extend the duration of the antibiotic therapy. We are not encouraging you to use antibiotics without following guidelines, but we must improvise to a certain degree because an infected stump has such serious consequences. It would be fantastic if we had evidence-based recommendations for the prolonged use of antibiotics over the past five days, but we do not have this yet.
What types of antibiotics are recommended for prophylactic purposes for major amputation? In most of the literature, broad-spectrum antibiotics are administered intravenously or orally. Cefazolin 2g iv <120kg bodyweight) with 4-hour intervals is commonly used for adults. Alternatively, Cl clindamycin 900mg iv with 6-hour intervals is also recommended. Another alternative is vancomycin, but as with all aminoglycosides, you must be able to measure serum concentrations if you are taking a prolonged course. As with all prophylactic antibiotics, it is recommended that the first infusion be started about 60 minutes before the start of the surgery. While it is stan rd to administer prophylactic antibiotics as IV infusions on the first day, there is no consensus about when to switch to oral treatment. Many healthcare providers still believe that intravenous antibiotics are far superior to oral antibiotics. However, as long as the patient has regular bowel activity (i.e., absorption) and is not septic or seriously ill, oral antibiotics will be almost as effective. Many antibiotics have an absorption rate of about 90% when taken orally! In many cases, the switch from IV to oral can already be done within 24 hours.
If the patient is amputated due to an infection, the choice of antibiotics should follow the bacterial culture results. In these cases, the patient will almost always need extended antibiotic coverage past the recommended five days.
In cases with severe acute tissue damage due to traffic accidents or conflicts, the risk of infection in amputations is very high, as the extent of tissue contamination is often underestimated. These patients routinely require prolonged periods of antibiotic coverage.
Concerning the below-ankle amputations, we lack good guidelines. Should we provide antibiotic coverage for a transmetatarsal amputation, MTP disarticulation, or even a toe amputation? We are on the pro side of this debate. The risks of severe infections following these " minor" amputations are"as high" as with significant amputations, and their consequences can lead to limb loss at a higher level. The difficulty here is that it is very hard to generalize. If we do a ray amputation in a person with diabetes and significant atherosclerosis, the chances of infection seem to be alarmingly high. It really comes down to the quality of the tissue perfusion and contamination in the area you are operating in.
However, the little scientific evidence we have disagrees with us here. Rossel et al., 2019, did a cluster control Cox regression analysis of 482 minor amputations in diabetic patients. The median follow-up was 2.1 years. The DFIs predominantly affected the forefoot (n = 433; 90%). Russel et al. registered osteomyelitis in 239 cases (239/482; 50%). In total, 47 cases (10%) were complicated by bacteremia, 86 (18%) by abscesses, and 139 (29%) presented with cellulitis. Surgical amputation involved the toes (n = 155), midfoot (280), and hindfoot (47). Overall, 178 cases (37%) required revascularization. After amputation, the median duration of antibiotic administration was seven days (interquartile range, 1‐16 days). In 109 cases (25%), antibiotics were discontinued immediately after surgery. Clinical failure occurred in 90 DFIs (17%) due to the same pathogens in only 38 cases. In multivariate analysis, neither the duration of total postsurgical antibiotic administration (HR 1.0, 95% CI 0.99‐1.01) nor immediate postoperative discontinuation altered the failure rate (HR 0.9, 0.5‐1.5).
While we generally try to keep the text easily readable, we found it essential to present you with the in-depth facts of this analysis since this topic is highly debated amongst doctors. The study seems to have been carried out well. The authors conclude that they find no benefit in continuing postsurgical antibiotic administration in routine amputation for DFI below the ankle. In the absence of residual infection (i.e., resection at clear margins), antibiotics should be discontinued. Please get in touch with us if you know of good guidelines on prophylactic antibiotic treatment for this patient group.
Toe Amputations
Toe amputations have little impact on walking abilities compared to amputations at a higher level. Though the big toe, in particular, is significant for balance, this is often negligible in the chronic wound population. Most of our patients are elderly, often with peripheral neuropathy, and their sense of balance in the foot is impaired anyway.
However, in most patients with chronic wounds, the arterial circulation below the ankle, especially from the forefoot to the toes, is significantly impaired. P prepare for a high failure rate when amputating a toe in this patient group! Here, it is never a "just a toe amputation"! It "is of utmost importance that we inform the patient well beforehand and explain that a toe amputation is not a simple procedure and that the risk of complications like gangrene and infection is high! A failed toe amputation can lead to a leg amputation!
At our wound clinic, we strive to do whatever we can to prevent higher amputations, and we often attempt toe amputations in situations where the outcome is very unpredictable. In almost half of the cases, we see necrosis of the wound egdes wound edges, but we can often manage this and get the toe stump to heal over time. In other instances, the toe stump turns to wet gangrene, and the patient ends up with a higher amputation. Again, we cannot stress this point enough. Before attempting a toe amputation, you have to thoroughly explain to the patient and the relatives that the chances of failure are excessively high and that there is a high risk of a higher amputation; otherwise, they may blame you if the outcome worsens. You have to explain that you attempt a toe amputation because it may give the patient a 50% chance to avoid a higher amputation.
In cases with dry gangrene, a toe amputation is most often contraindicated! Some patients can live well with a toe with dry gangrene; if they are lucky, the toe may even heal with auto-amputation. If you attempt a partial or whole-toe amputation in such a patient, the chances of failure are almost 100%. You may even cause a situation that will lead to a below-knee amputation! We routinely cover the dry gangrenous areas with gauze soaked with iodine and change the gauze about twice weekly. The iodine penetrates the gangrenous layers and seems to prevent infections. You can also drip iodine onto the dry gangrene 2-3 times weekly to get the same effect. The treatment is continued as long as the dry gangrene persists. Some caregivers use gentian violet for the same purpose, and we used to use this for many years ourselves. Some years ago, we switched to povidone-iodine and found it performs even better. The rule is to "keep dry gangrene dry," so you might think that moistening it with iodine may turn a dry gangrene into a wet gangrene. However, although applied wet, the iodine helps to keep the dry gangrene dry!
If a patient with severe ischemia has a toe with dry gangrene that suddenly turns to wet gangrene with infection signs, you will often need to consider a toe amputation. In these situations, a one-step surgery with amputation of the toe and primary closure often has a failure rate of 90% or higher, and you may even harm the patient by causing the gangrene to spread to the forefoot. In these cases, it is far safer to do a "guillotine" type amputation in a joint of the toe, leave the wound open, and follow the patient closely afterward. If the skin flaps/skin edges survive, you may attempt a secondary closure later.
Figure 1 The image shows the feet of a diabetic patient with poor vascular perfusion. He has undergone several amputations at an elsewhere hospital previously. An MTP disarticulation of the fifth toe was done successfully on the left foot. On the right foot, a partial amputation of both the first and second toes was done over half a year ago. There is significant inflammation and edema at the end of the first toe. This is highly suspicious of a chronic infection, likely an osteomyelitis. A plain X-ray film can help us with the diagnostics here. Note that the nail rest protrudes from the first toe ( right foot). When doing a partial toe amputation in the distal joint, excise the nail root to avoid problematic nail growth. Furthermore, there are multiple signs of localized mechanical irritation on several toes- most likely a sign of inappropriate footwear. Credit istock-1672111299
Whenever we amputate a toe, we aim to perform the amputation at the joint level (for example, PIP joint level) so that the end of the bone stump is covered in cartilage. This leads to less postoperative pain, and cartilage is a better barrier to bacterial infection. The skin quality and soft tissue determine the type of skin flaps we use. Not rarely do we have to use an unconventional flap, utilizing whatever skin is available. Almost any incision that results in tension-free coverage of the transected bone can be chosen.
The standard flaps are either a dorso-plantar flap or racquet incisions with sagittal closure. For amputation of the first and fifth toes, we prefer to orient the racket handle on the medial or lateral surface of the respective metatarsal head. For the second, third, and fourth toes, the racket handle is oriented longitudinally along the dorsal surface of the digit. A transverse or vertical fish-mouth skin incision is often used for partial amputation of the toe.
It's crucial to be extremely gentle with the tissues surrounding the bone. When dissecting the bone free, we use the "stick to the bone" technique to avoid damaging blood vessels. As always, we never suture the flaps under tension! It is advantageous to have the flaps very loose—they will shrink anyway in the course of healing.
We avoid subcutaneous sutures as these will only strangle the subcutaneous blood circulation. We use absorbable sutures (often Vicryl rapid 3.0 or Monocryl 3.0) and suture with these as if they were regular nylon. Usually, we use vertical mattress sutures to achieve an exact adaptation. We do not overtighten the sutu es. After the wound has healed, the remaining suture material usually falls off itself, or we can cut it away at the skin level. Do not attempt to pull out any remaining sutures – they will absorb by themselves. We have had excellent results when using absorbable sutures with this method. Not only does it save the patient from removing the sutures (which sometimes can be pretty painful in toes), but we have achieved a better healing rate with this method, at least in our hands.
If the skin conditions are suitable for a flap at the PIP joint level, then we often prefer to do an amputation at this joint. If we encounter skin necrosis at this level, we can still debride the stump and try to salvage it. However, if we attempt an amputation at the MTP joint level as the first choice and it fails, we have a significant problem. We are not saying you should not amputate at the MTP joint level in general. If possible, try to do it at the PIP joint because it gives you a safety margin to salvage in case of failure.
A toe amputation is not a simple procedure. While not technically demanding in terms of anatomy, it requires a skilled surgeon's hands to treat the tissues with the utmost respect to prevent necrosis of the skin flaps. The dissection must be done carefully, preserving as much of the small arteries as possible. It's important not to undermine the skin flaps; instead, prepare the flaps to include the subcutaneous tissue and blood circulation. Use the "stick-to-the-bone" technique when dissecting the soft tissues to avoid damaging arteries in the soft tissues.
When performing an amputation at the MTP joint level, you must be extra cautious and gentle with the soft tissues surrounding the joint because you can harm the circulation to neighboring toes, causing them to become gangrenous, too! Even if you are very gentle with the tissues, you can risk running into this complication. The edema and inflammatory processes following the amputation at this level can quickly cause thrombosis of arteries and blood vessels in the vicinity. This is also a reason why we try to avoid MTP amputations as the first choice in this patient population. Again, do not get us wrong. An MTP amputation is an excellent choice for a patient with good arterial circulation. However, this chapter mainly discusses elderly patients with impaired blood circulation. If you amputate at the PIP joint level, you can still salvage the complications.
In patients with severe intractable ischemic pain of the lower leg, it does not make sense to amputate a toe. Most likely, this will fail anyway, and the patient should instead be offered a higher amputation.
Video 1 is an example of how to perform a toe amputation using the skin you have available to make improvised flaps. Note: This video has no sound, so there is nothing wrong with your computer if you cannot hear anything. :) Click on the image to get to the video on YouTube. Due to the film's graphic content, you must sign in with your YouTube account. Credit: Dr. James Kent/Tyler Foot Clinic/Youtube.
Figure 2 A patient with bilateral amputation of the big toe operated at an elsewhere hospital. Note that a remnant of the proximal phalanx remains at the MTP joint. We do not recommend doing this routinely, as it may increase the risk of osteomyelitis and is usually more painful in the initial phase postoperatively. Most surgeons prefer having a cartilage-covered end of the bone stump. However, there are situations where we sometimes do this. In situations with borderline tissue perfusion, the complete dissection of the MTP joint may cause unnecessary damage to surrounding arteries. Disarticulation demands more dissecting of the tissues, and you may harm the last few good remaining arteries and cause gangrene of the neighboring ray! And yes, occasionally, leaving a remnant of the proximal phalanx in place may be wise. Credit:ChooChin/istock.
Pain management: toe amputations
Especially with partial and whole-toe amputations in patients with impaired arterial supply, we always try to avoid local anesthesia at the amputation site! There is a danger of damaging the only good artery in the vicinity by poking it with a needle! Also, the pressure from the injected volume of LA can harm the tissues in these patients (impaired circulation). Fifteen years ago, we routinely used just local anesthetic around the base of the toe as the standard method for toe amputations, and we saw a higher rate of necrosis at the wound sites postoperatively. After that, we introduced regional blocks as the gold standard for toe procedures, reducing the number of wound complications significantly.
If available, a regional block is the best choice. Not only does this minimize the danger of harming the blood vessels close to the amputation stump, but it is thought that the temporary vasodilation effect of a regional block can have a positive side effect. Remember that the majority of our patients have at least some impaired arterial function! If you perform a toe amputation in an otherwise healthy youngish patient, a simple toe block will, of course, not cause any harm. These are two completely different patient groups.
When we do not have access to a regional block, we will have to resort to amputating under local anesthesia at the base of the toe. However, when we do this, we do it with utmost care. We use the thinnest needle (27G) and try to inject the smallest amount of lidocaine. We now routinely use 2% lidocaine, and this allows us to use smaller volumes—often, it is enough to place just 2ml of lidocaine on each side of the toe. We never use lidocaine with adrenaline. When using a thin 27G needle, you must use a small syringe ( for example, a 2ml syringe). Otherwise, it will be hard to press the liquid through the needle.
Postoperative pain varies a lot after toe amputations. If you have a diabetic patient with peripheral neuropathy, then the patient will most likely not have any discomfort at all postoperatively. On the other extreme side, we have vascular patients without diabetes, where toe amputations can sometimes lead to several days of agony following the procedure. It appears that the nerves in these patients are already highly sensitized, resulting in increased pain when operating on these toes. So, never tell your patient that this is just a tiny toe operation—instead, prepare them for the possibility of experiencing more pain than what is expected and make sure to provide adequate pain relief afterward.
After most toe amputations, mild opioids like Codeine + paracetamol are usually sufficient. Sometimes, we have to step up to more potent opioids like Oxycontin/Oxynorm. NSAIDs are often contraindicated in the elderly patient population due to cardiac and renal comorbidity.
Postoperative care: toe amputations:
Weight-bearing is prohibited until the wound is thoroughly healed. We usually use a simple, bulky, soft dressing to protect the wound. If a patient cannot offload the foot, we use a plaster cast with a sole that tolerates weight bearing.
Video 2 is a lecture on key aspects of digit amputations presented at the DFCon in Los Angeles. The video offers some useful tricks for avoiding pitfalls, and we recommend watching it before you read further. Due to the film's graphic content, you will have to sign in with your YouTube account. Credit: DFCon/YouTube.
Metatarsophalangeal Disarticulation (MTP Joint Amputation)
As mentioned earlier, a partial toe amputation may be preferable as the first choice because it provides a better margin for salvage if the stump becomes necrotic. If you go straight for an MTP joint disarticulation and encounter complications, it is more difficult to salvage.
When it is evident that a partial toe amputation is not feasible, the next level is the MTP joint. We leave the metatarsal head intact whenever possible to maintain a cartilage covering at the end of the bone stump. We are on the pro side in the debate for maintaining cartilage coverage. However, many surgeons argue that articular cartilage is poorly vascularized and prefer to excise the cartilage with a rongeur. There are no data to support this maneuver. If you remove the cartilage, gently shape the exposed bone to eliminate any bony projections that might lead to wounds or skin problems.
The tendons are cut at the level of the skin incision and allowed to retract.
The wound is irrigated well, and careful hemostasis is obtained. Excessive use of electrocautery is avoided.
As with all amputations, never close the flaps under tension! If your skin flaps are too tight, you may need to consider removing the metatarsal head entirely. The skin is closed without tension in one layer using interrupted, nonabsorbable monofilament suture. Weight-bearing is completely prohibited until adequate healing is observed.
Pain Management: MTP Joint Amputation
If possible, try to avoid performing this procedure under local anesthesia at the amputation site. There is a risk of damaging the only good artery in the vicinity by poking it with a needle. Also, the pressure from the injected volume of local anesthetic can harm the tissues in these patients (due to impaired circulation).
If available, a regional block is the best choice. Not only does this minimize the risk of harming the blood vessels close to the amputation stump, but the temporary vasodilation effect of a regional block is thought to have a positive side effect.
Postoperative pain is often less than partial toe amputations, primarily if the skin flaps have not been sutured tightly. The postoperative pain that usually arises is often due to swelling/edema/inflammation postoperatively. Usually, weak opioids like codeine and paracetamol are enough to manage the pain. NSAIDs are frequently contraindicated in the elderly patient population due to cardiac and renal comorbidity.
Video 3 A video by Dr. Tavyab Riaz Ch showing an exarticulation of the first MTP joint. We have added this video to this collection because we would like to comment on a few aspects of the procedure. Firstly, from the toe's appearance, we agree that there was a good indication for an amputation of the entire toe. However, at our clinic, we would have planned this surgery differently. The tissue quality on the plantar side of the toe appears fine, and we would have utilized this to make a sizeable ventral flap to achieve primary closure. From the appearance of the other tissues, it looks like the patient has satisfactory arterial perfusion. In the video above, the wound is left to secondary closure, which may have been unnecessary. We also try to avoid cutting off the cartilage-clad end of the first metatarsal, as having a stump covered in cartilage is beneficial. We are not criticizing the video above; we are simply saying that this topic has different approaches.
Postoperative care: MTP disarticulation:
Weight-bearing is prohibited until the wound is thoroughly healed. We usually use a simple, bulky, soft dressing to protect the wound. If a patient cannot offload the foot, we use a plaster cast with a sole that tolerates weight bearing.
Ray Amputation
A ray amputation involves the removal of both the toe and the corresponding metatarsal bone. Indications for this procedure include, for example, a severe infection around the MTP joint where salvage is impossible. The transection of the metatarsal bone may be done distally, mid-metatarsal, or the entire metatarsal may be removed. Ray amputations are very useful in salvaging a problematic foot situation and preventing amputation at a higher level.
Note: Because a hallux valgus deformity commonly develops following an isolated second-toe amputation, a complete second-ray amputation may be preferable because it reduces the angle between the first and third metatarsals.
The 1st and 5th rays (little toe/big toe + corresponding 1st or 5th metatarsal) are technically the easiest to approach as they are on the edge of the foot. It is much more challenging to perform a ray amputation of the 2nd-4th ray because you can do great harm to neighboring blood vessels, which can lead to catastrophic results. The danger of damaging vital arteries is more significant the more of the metatarsal you remove. The proximal end of the metatarsal is not easy to dissect, and you will find it wrapped in super-strong fibrous ligaments to provide stability. Mobilizing the entire metatarsal is challenging. Therefore, when possible, we often transect the metatarsal in the distal diaphysis or the midsection.
While a single isolated ray amputation often proves durable, multiple ray amputations, however, tend to narrow the foot excessively and create biomechanical instability. This increases the amount of weight that must be borne by the remaining metatarsal heads and can lead to new areas of increased pressure, callus formation, and ulceration.
Keep special considerations concerning the first ray in mind! Near-normal foot mechanics can be achieved after amputating one of the lateral four rays. However, amputation of the great toe and first metatarsal head markedly alters normal ambulation and may result in challenging forces in the remaining foot. Recurrent ulceration following first ray amputation has been reported in up to 50- 60% of patients. Some orthopedic surgeons, therefore, recommend transmetatarsal amputation of all five rays rather than isolated first-ray amputation. The contrarian viewpoint holds that transmetatarsal amputation of all rays may require revision or reamputation in 20% to 40% of patients and that above-ankle amputation is necessary for one of five patients. There is a lack of consensus in the literature, and the final decision between first-ray amputation and complete transmetatarsal amputation should be individualized. If the patient is followed up by an experienced podiatrist, the above complications following a first-ray amputation can often be prevented with custom-made orthotics.
Treat all tissues with extreme care and protect underlying structures with suitable retractors when cutting through the bone. When dissecting the tissue to loosen the metatarsal, use a strict "stick-to-the-bone" technique. This dramatically reduces the chances of harming important neighboring blood vessels.
In the elderly population, we often observe some wound complications after ray amputations. Typically, this includes necrosis of the wound edges, sometimes wound dehiscence, and occasionally infection. However, we have managed to salvage most of these complications as long as the arterial blood supply was sufficient.
Pain management: ray-amputations
It is challenging to achieve sufficient analgesia with local anesthesia when doing a ray amputation. Regional anesthesia or general anesthesia should be used for this procedure. Postoperative pain is usually higher than a toe- amputation or MTP-joint amputation, and we often use a short course of low-dose opioids ( for example, Oxycontin 5mg x 2 + Oxynorm 5mg x 3 o.d.)
Postoperative care: ray amputations:
Weight-bearing is prohibited until the wound is thoroughly healed. We usually use a simple, bulky, soft dressing to protect the wound. If a patient cannot offload the foot, we use a plaster cast with a sole that tolerates weight bearing.
Video 4 A Foot and Ankle Surgery Academy video shows a useful variation of a ray-amputation of the 4th ray, using a digital fillet flap to close the wound. The 5th dig t is sacrificed to provide a flap to close a defect, which is tricky to heal by other methods. Click on the image to get to the video on YouTube. Due t the film's graphic content, you must sign in with your Youtube account. Credit: Foot and Ankle Surgery Academy/Youtube
Figure 3 This is a relatively common complication of a partial ray amputation - the stump becomes necrotic, and we must debride it. We are left with a gaping hole in what is obviously marginally perfused tissue. How we should deal with this depends on a number of factors. Firstly, suppose the patient is suffering from severe chronic, ischemic pain. In that case, we should (a) never have attempted the ray amputation in the first place and (b) advise the patient to do a BKA. If the patient does not have much pain (i.e., typical diabetic neuropathic patient), we may attempt to salvage it. There are hints of pinkish tissue covering the fat pad on the plantar side of the wound - this may indicate that we can initiate granulation once we have debrided the wound better. Credit: Milorad Dimic MD; Creative Commons Attribution 3.0
Transmetatarsal (TMA) Amputations:
Transmetatarsal amputations usually provide the amputee with a satisfactory gait and are not technically too demanding. This procedure may involve one or all rays of the foot.
A complete TMA of all five metatarsal bones involves horizontal flaps, ideally with a slightly longer posterior flap that swings upwards. This way, the end of the foot is covered by more resistant plantar skin.
There is some debate about how much of the metatarsals should be resected. Some argue that the blood supply is better to the proximal ends of the metatarsals and that resection should be done at the proximal 1/3. We have performed successful transmetatarsal amputations at all levels. In our opinion, the most crucial factor is the quality of the soft tissues. Even resections at the distal end can perform well if you have well-circulated tissues with good subcutaneous fat padding. However, with a distal resection, be aware of problems arising from mechanical irritation from the resection edge upon weight-bearing. This can be a problem for patients with atrophic plantar fat pads; in these patients, a more proximal transection should be done.
We prefer to divide the metatarsals in a gentle curve from medial to lateral, with each successive shaft being 3 to 5 mm shorter than the previous one. In this manner, the bone resection follows the curve of the skin flaps.
When you perform a complete transmetatarsal amputation of all rays, you will encounter many blood vessels. Treat these and the soft tissues with utmost care to preserve the blood supply to the soft tissues. When using a power saw to transect the bone, take good care to protect the underlying structures with hooks.
In TMT skin flaps, good dorsal and plantar fascias are usually found below the subcutaneous tissue, and we routinely close the wound in two layers with interrupted absorbable 2.0 sutures in the fascia.
Always use a subfascial drain when performing amputation of all rays.
Do not undermine the skin—this will disrupt the blood supply and can cause skin necrosis at the edges. If your flaps are tight, you will have to resect more bone. The most common complications are skin necrosis due to too-tight flaps and complications arising from hematoma. We usually close the skin with vertical mattress sutures for optimal skin adaptation interrupted by skin staples between each suture. In our hands, this method leads to fewer problems with skin necrosis.
Some surgeons recommend dividing or lengthening the Achilles tendon during trans metatarsal amputation to minimize the risk of equinus deformity. Randomized data supporting this practice are not available, but some reports suggest that this technique reduces the risk of future forefoot ulceration.
Figure 4 X-rays of a patient's feet showing bilateral transmetatarsal amputations of all rays of the forefeet.Credit: Subthaburrawonk/istock
Video 5 This is another excellent video by Husky Orthopedics: Key concepts of transmetatarsal amputations (and again - even though the resolution of the images is not so good, the quality of the content certainly weighs up for this. Even more experienced surgeons will find some pearls here. Click on the image to get to the video on YouTube. Due to the film's graphic content, you must sign in with your Youtube account Credit: Husky Orthopaedics/Youtube
Video 6 We also liked this video by Dr. Kolodenker: Transmetatarsal Foot Amputation Surgery Guide. Click on the image to access the video on YouTube. Due to the film's graphic content, you must sign in with your YouTube account. Credit: Dr. Gennady Kolodenker, DPM/Youtube
Postoperative care: TMA
A posterior plaster splint that maintains the foot at 90 degrees is applied. Weight-bearing is prohibited until adequate healing is observed, usually after 3 to 4 weeks. TMA is a relatively reliable procedure following initial healing. Primary healing can be expected in 50% to 75% of patients following TMA. Revision to a higher level is necessary in approximately 25% to 40% of TMAs. An NPWT ( vacuum) dressing may effectively avoid more proximal amputation. With appropriate orthoses, patients can be expected to ambulate with usually excellent gait following complete healing.
Video 7 This video does not show surgical techniques but explains the important aftercare concept. This applies not only to forefoot amputations but also to all foot amputations. Removing parts of the foot invariably leads to pressure relocation, causing new calluses and risks of new ulcerations over time. A close follow- up by a podiatrist is essential to prevent new complications. Also, as the video clearly shows, we must take extra good care of the other foot to avoid future amputations. Click on the image to get to the video on YouTube. Due to the film's graphic content, you must sign in with your YouTube account. Credit: DC Foot Doctor/Youtube
Hindfoot amputations
At our clinic, we do not routinely handle severely injured limbs, and consequently, we lack significant experience with hindfoot amputations. The majority of our patients present with chronic wounds, and most of them are not considered ideal candidates for hindfoot amputations, except partial calcanectomys. Therefore, we will not delve into describing these techniques in detail here. However, in future revisions to this chapter, we plan to include discussions on hindfoot amputations. The most common techniques here are Lisfranc`s, Chopart`s, and Syme`s amputation techniques.
Partial calcanectomy
At our clinic, an indication for a partial calcanectomy may be a neuropathic patient who is in relatively good shape but is bed- bed-bound and has a pressure ulcer with calcaneal bone infection. You may ask why not do a BKA procedure instead, which would be a very relevant question. This procedure preserves most of the foot; one may attempt it when the patient wishes to avoid a major leg amputation.
Surgeons may address these ulcers with a partial calcanectomy and subsequent negative pressure wound therapy (NPWT) and skin grafting, which are performed in two stages. After the wound has healed sufficiently, a custom filler for the heel defect and a high-top shoe for mechanical support with or without a custom ankle brace or CROW boot will be necessary for patients with ambulation.
Video 8 This is another excellent video by Husky Orthopedics on the topic of partial calcanectomy ( and again - even though the resolution of the images is not so good, the quality of the content certainly weighs up for this. Even more experienced surgeons will find some pearls here. Click on the image to get to the video on YouTube. Due to the film's graphic content, you must sign in with your YouTube account. Credit: Husky Orthopaedics/Youtube
Video 9 A video of a partial calcanectomy lecture held at the Diabetic Foot Global Conference in Los Angeles in 2015. Click on the image to get to the video on YouTube. Due to the film's graphic content, you must sign in with your YouTube account. Credit: DFCon/Youtube
Below Knee Amputation (BKA) - Transtibial Amputation
This is the most commonly performed major amputation type worldwide. Despite its prevalence, it is not an easy surgical procedure, and paradoxically, it is often entrusted to young, inexperienced surgeons. A vascular surgeon once remarked, "An expert always performs an endovascular procedure, yet strangely, we leave the amputation to less experienced colleagues."
Many complications arising after a BKA are due to poor technique. Inadequate skin flaps, excessively tight sutures, and improper nerve identification and transection contribute to these issues.
At our clinic, we do not routinely use a tourniquet during this procedure, as most of our patients are elderly with impaired arterial circulation, and bleeding is usually not a significant problem. While using a tourniquet may theoretically lead to tissue hypoxia and postoperative complications, many clinics use it in all amputations without observing a significantly higher rate of complications. However, removing the tourniquet no later than 1.5 hours after application, preferably earlier, is essential. Deflate the tourniquet as early as possible. Never deflate it first when you've begun suturing; instead, do so while you still have access to all open surfaces to control bleeders with electrocautery or ligation. Remember, hematoma is one of the biggest enemies of a successful amputation. A postoperative drain may not prevent all hematoma complications, so ensure complete hemostasis before closure.
Generally, it is wise to have a tourniquet in place at the start of surgery, but not necessarily inflated. This allows better control over critical structures if unexpected bleeding occurs. In young patients and traumatic injuries with severe tissue damage, it's advisable to always use a tourniquet for better visualization and control over tissues.
Several methods for performing a BKA have been devised. The "gold standard" globally is still the long posterior flap method. In some Western countries, the asymmetric skew flap method has gained popularity. Advocates for the asymmetric flap method argue that it ensures better-circulated tissue and may result in better prosthesis-fitting stumps. However, in our experience, this method is slightly more challenging to master and may result in difficulties for inexperienced hands. Stick to the amputation method you are most familiar with to ensure the best results. Nevertheless, the skew flap method may be helpful in cases where a long posterior flap is not feasible due to skin conditions on the dorsum of the leg. Therefore, knowing alternative flap methods to address such situations is valuable.
Figure 5 There are several methods for determining the correct landmarks for designing the posterior flap using the traditional " long posterior flap method" ( Burgess amputation). The anterior incision (2) should be at least 12-15 cm from the tuberosity (1) of the tibia and include 2/3 of the leg circumference. The posterior incision starts at the 1/3 circumference mark (3). The length of the posterior flap (4) should be at least equal to 1/3 of the leg circumference + 1cm. We routinely add a few centimeters to be sure we have enough skin for tension-free closure. Another method to determine the optimal length of the posterior flap is the diameter of the leg + 1 cm. To determine the diameter, divide the circumference by 3 ( actually 3.14 = pi, to be exact).
The long posterior flap method
Below, you will find an older YouTube video that explains in an excellent pedagogic manner how a long posterior flap BKA is performed. Note the authors' details on finding all the relevant nerves to prevent postoperative neuroma. The film is not of high quality with regard to resolution, but it is otherwise, in our opinion, excellent at conveying the key concepts.
-
Skin/Fascia Incision- The“Two-Thirds/One-Third” Approach
-
Anterior Incision:
-
Two-Thirds of Leg Circumference
-
The usual recommendation is to start about 1 cm distal past the planned tibia Incision. However, having slightly more anterior skin may be advantageous, so making the incision 2-3 cm below the planned tibia transection gives you some lee-way in case you end up with tighter flaps than expected. This is especially useful if the gastrocnemius muscle is quite big.
-
Straight Transverse Incision
-
Posterior Incision:
-
Starts at the One-Third mark of Leg Circumference
-
-
Flap Length: This is crucial – if the flap is too short, you will encounter real problems. The standard recommendation is that the flap length should also be 1/3 of the leg circumference, but we prefer to have the flap longer at the start- 2/3 of the leg circumference. We can always trim away the surplus of the flap if necessary! Another method to establish the correct length of the posterior flap is the leg's diameter ( not circumference) + at least 1 cm. So here you have to measure the circumference and then do some maths 😊 Diameter = circumference divided by pi (3.14). Never mind the 0.14; divide by 3. So, if you measure the circumference to be 30 cm, then the flap should be at least 10 + 1 cm = 11 cm.
-
Slightly Curved Incision distally
-
It is of utmost importance to preserve the unseparated myo-fasciocutaneous flaps – i.e., avoid
-
-
Bone Transection:
-
-
Tibia: ≥ 12-15 cm Below Tibial Tubercle. A longer tibia stump is not beneficial. B vel the sharp anterior edge of the Tibia with a bone saw or file. Most orthopedic engineers will agree that a 15 cm stump is slightly easier to work with than a 12 cm stump. e distal 1 /3 of the Tibia is not helpful in weight-bearing and should not be transected there! Proximally, amputation less than 6 cm below the tibial tubercle will often require conversion to a knee disarticulation or higher!
-
-
Fibula: 1-2 cm Proximal to the Tibia. Do not resect more than 2 cm of the fibula! Excessive resection of the fibula results in a conical stump that is difficult to fit with a prosthesis.
-
When using a power saw, use plenty of irrigation fluid continuously to cool down the bone. If you see smoke coming from the bone, you have already irreversibly damaged the edge, increasing the chance of osteomyelitis and bone necrosis.
-
Many surgeons use bone wax to cover the end of the cut, Tibia. We have never used bone wax at our clinic and think its advantages are debatable.
-
Consider the Myodesis of Gastrocnemius to Tibia. Usually, we use two drill holes in the Tibia to ensure that the gastrocnemius is securely attached to its anterior aspect.
-
Neurovascular Management:
-
Major Blood Vessels: Suture ligate + regular ligation proximal to prevent fistula formation (i.e., double ligate). Do not ligate nerves together with the blood vessels! In elderly patients, the arteries and veins running together are often challenging to dissect apart, and we routinely ligate them together.
-
Consider Tourniquet to Decrease Blood Loss
-
Nerves: Whenever possible, try to find all major nerves. The following nerves should be identified to minimize the danger of neuroma formation and phantom pain: N. saphenous, n tibialis anterior, n suralis, and the peroneal nerves. Be aware of the small sural nerve in the middle of the posterior flap. T is com only gets entrapped in the sutures and not rarely causes painful neuroma there—: With gentle tension on the nerves, divide them sharply & Allow Retraction. Do not ligate the nerves! We are aware that some surgeons routinely ligate major nerves and they believe this may reduce phantom pain. In our experience, phantom pain is significantly higher when ligating nerves! Please do not ligate nerves!
-
Closure:
-
Irrigate Before Closure to rinse out bone dust
-
Close Deep Fascia with Interrupted Absorbable Suture. f ecs Vicryl 2
-
Many surgeons use only staples when closing a BKA amputation. In our experience, we have had the best results using a 50:50 ratio of staples and sutures. We start placing vertical mattress sutures with 2.0 nylon about 1,5 cm apart to adapt the skin loosely and supplement with staples between two nylon sutures.
Video 10 This video by Husky Orthopedics is one of our favorite videos about the BKA surgical technique (even though the resolution of the images is not so good, the content is excellent). Even more experienced surgeons will find some pearls here. Note especially where to see all the relevant nerves to avoid postoperative pain/phantom pain). Click on the image to get to the video on YouTube. Due to the film's graphic content, you must sign in with your YouTube account. Credit: Husky Orthopaedics/Youtube
Video 11 Dr. Vinay Kumar Singh has made this video explaining how to perform a BKA using the skew flap technique instead of the traditional long posterior flap technique. He clearly explains how to do the skin markings to make a perfect stump. Click on the image to get to the video on YouTube. Due to the film's graphic content, you must sign in with your Youtube account. Credit: Dr. Vinay Kumar Singh/Youtube
Video 12: Dr. Maham Rahimi and Dr. Kaled Diab explain how to do a quick Guillotine Amputation using a Gigli-saw. The patient has a life-threatening infection, is unstable and on pressor medication. This means the procedure must be performed quickly without wasting any time. Click the age to get to the video on YouTube. Due to the film's graphic content, you must sign in with your YouTube account. Credit: Dr. Vinay Kumar Singh/Youtube
BKA Wound Dressing
-
Soft gauze with elastic wrap is often commonly used
-
Alternatively, povidone-iodine 10% gauze should be directly on the wound, covered in dry gauze and elastic wrap.
-
We routinely use incisional negative pressure ( iNPWT) on all BKA`s. 5 days if we use a gauze NPWT, up to 14 days if we use a silicone-clad interface like PICO NPWT dressings.
-
Remain non-weight bearing for 4-6 weeks until fit for prosthesis
-
Consider thigh-level rigid plaster cast to prevent knee contracture. It may have improved primary wound healing and shorter rehabilitation times, but studies are inconclusive
-
At our clinic we only use a cast in patients where there is increased risk of contracture.
Pain management BKA
Routinely, we perform most amputations under spinal anesthesia, as this is generally better tolerated by patients with significant comorbidities than general anesthesia. Immediately after surgery, patients usually remain pain-free for a few hours. Additionally, we routinely place an epidural catheter at the start of the surgery, which is used postoperatively for at least 3-5 days. The effectiveness of such an epidural catheter varies, but most patients report significant pain reduction during the first few days after surgery. Since our main population comprises elderly patients who do not tolerate opioids well and are at high risk of postoperative delirium with suboptimal pain management or high opioid doses, epidural catheter placement is crucial. Typically, a regular epidural catheter should remain in place for no more than one week due to the risk of infection. However, after one week, pain levels are usually more manageable with other interventions.
Occasionally, we perform amputations with epidural anesthesia alone, without simultaneous spinal anesthesia. While epidural anesthesia alone can often provide 100% analgesia intraoperatively, it may not be as effective as spinal anesthesia. After consulting our anesthesia team, we recommend performing surgery under spinal anesthesia (or general anesthesia) and having an epidural catheter for the postoperative phase.
If amputation needs to be performed under general anesthesia, it is crucial to attempt to place an epidural catheter at the onset of the surgery because initial pain levels after general surgery will be significantly higher, especially during the first day.
When we have a well-functioning epidural catheter, we no longer routinely use a plaster of Paris splint. The primary function of the cast was to prevent knee contraction. Postoperatively, patients with much pain following a BKA instinctively flex the knee for comfort. Prolonged knee flexion postoperatively can lead to knee contracture, which poses a significant problem when fitting a prosthesis and ambulating without a functional knee joint. With a well-functioning epidural catheter in place, patients do not flex the knee to compensate for pain, eliminating the need for a cast. While some argue that a cast may support soft tissues and promote better healing, this has not been proven. However, we respect that most surgeons still prefer a postoperative cast. We simply state that we do not use this routinely anymore and have not encountered issues with knee contracture.
However, we routinely utilize a postoperative negative pressure dressing (incisional NPWT or INPWT) over the amputation wound. We have experimented with several variations of this technique. Previously, we would envelop the entire stump in a negative pressure dressing, but in the past year, we have transitioned to applying negative pressure only to the incision itself. This approach is more straightforward to seal and allows for continuous inspection of the stump. We typically leave the NPWT dressing in place for about 5-6 days. We routinely use regular gauze soaked in 10% povidone-iodine for the dressing, folding the gauze into a four-layer strip over the incision and covering it with dry gauze. We then apply self-adhesive plastic film, extending it up to where the drain is placed, as shown in Figure X. While regular black foam can be used to cover the incision, our experience suggests that gauze is gentler on the skin.
We have used Kerlex PMD gauze for many years as the NPWT medium, but it has become increasingly difficult to obtain in Europe (it is constantly sold out). Therefore, we switched to povidone gauze, which has proved to be just as effective. If a cast is required, it can be easily applied over the NPWT dressing. However, avoiding negative pressure exceeding 80 mmHg is essential, as higher pressures can damage the skin, particularly in patients with impaired arterial circulation. For those using an iNPWT system such as PICO (Smith & Nephew), the PICO dressing can be placed directly on the incision and left in place for up to two weeks. The PICO dressing has a very gentle interface, allowing extended use without harming the surrounding skin.
Alternatively, you can place iodine gauze on the amputation wound and wrap the entire stump loosely in cotton wool rolls (3-4 layers thick) up to just beneath the knee joint. This is then covered with self-adhesive plastic film, and negative pressure is applied. This method ensures that the entire stump receives negative pressure treatment, which aids in forming the stump.
Total knee disarticulation (TKA)
The classic TKA is often considered a more straightforward amputation procedure than others, primarily due to the straightforward anatomy involved. All essential neurovascular structures are located behind the knee, making them easy to identify during the procedure. Patients typically experience less postoperative pain with this type of amputation since less tissue needs to be cut, and there is no bone transection involved. Additionally, TKA results in a robust stump with a cartilage-covered end, which provides good weight-bearing support.
However, historically, TKA was not a popular choice for orthopedic engineers due to challenges in creating suitable prostheses. Nonetheless, advancements in materials and prosthetic technology have made it easier to develop effective prostheses for TKA. As a result, TKA procedures may become more common in the future. Currently, TKA accounts for only about 5-7% of major amputations performed.
In our experience, we have encountered varied outcomes with knee disarticulations (TKAs). On occasions, we have opted for TKAs for patients with significant comorbidities who do not require ambulation, utilizing only the classical approach. However, we have also faced challenges such as long-lasting seromas, likely resulting from fluid production from the remaining synovial structures.
There appears to be a lack of consensus among surgeons, physiotherapists, prosthetists, and patients regarding the outcomes of TKAs. Often, conflicting opinions are expressed for or against TKAs, with limited objective data to support each viewpoint.
There are three main variations of TKA:
1.Classical Approach TKA
In the classical approach, the femur is preserved, and the patella is retained.The patellar tendon is attached to the cruciate ligaments, and the skin around the knee allows for various flap closure techniques. Flaps can be sagittal, lying posteriorly, vertically between the condyles, or transverse, with the scar horizontally at the distal end of the residual limb, below, anteriorly, or posteriorly. A preferred technique regarding flaps has not yet emerged. A dorsal flap uses the gastrocnemius to cover the femoral condyles, with the scar lying anteriorly and horizontally away from the weight-bearing area. Alternatively, ventral "fish mouth" flaps of equal lengths can be used, with the scar lying on the most distal aspect of the residual limb.
The classical TKA approach provides a broader weight-bearing surface by maintaining the integrity of the femoral condyles. Surgeons and prosthetists suggest that retaining the patella and attaching the patellar tendon to the cruciate ligaments may offer additional stabilization of the quadriceps muscles and improved proprioception. Still, this hypothesis has not been conclusively verified.
2. Mazet technique TKA
The Mazet technique involves shaving the femoral condyles laterally and distally to create a "box" shape while preserving the adductor magnus insertion to maintain muscle function. The patella is removed, and the quadriceps tendon is attached to the cruciate ligaments or the posterior flap tissue, resulting in a conical-shaped residual limb.
Flaps in the Mazet technique resemble those in the classical approach but with reduced bulge due to the shaving of the femoral condyles. This modification allows for more tissue and less tension at the distal end of the residual limb, potentially improving surgical outcomes.
Although we lack personal experience with this method, we have included it in this chapter to provide readers with a comprehensive overview.
3. Gritti-Stokes technique TKA
The Gritti-Stokes technique is sometimes classified as an above-knee amputation because it is supracondylar. However, it allows for distal weight bearing on the femur, thus qualifying as a through-knee amputation. In this technique, the femur is cut transversally, and the posterior surface of the patella is shaved down to the cancellous bone and attached, under tension, to the distal cut end of the femur for weight bearing. The patellar tendon is attached to the posterior flap to prevent patellar movement and potential soft tissue damage.
Transfemoral (Above-knee amputations - AKA)
Above-knee amputations are the second most common major amputation. Similar to BKAs, these stumps are not end-bearing and must be contact-fitted. The femur is usually cut transversely at or near the distal metaphyseal-diaphyseal junction.
-
A "Fish-Mouth" incision usually has equal anterior and posterior flaps.
-
Femur Transection: 12 cm Proximal to Femoral Condyles (at the metaphyseal-diaphyseal junction).
-
Amputations through the proximal 1/3 of the femur may need to be more proximal if there is a lack of adequate tissue coverage. Note: Amputations through the proximal 1/3 of the femur are at risk of developing a flexion contracture from unopposed actions of the psoas muscle. To prevent this, every effort should be made to keep or reattach the gluteus muscle to the linea aspera posteriorly.
-
When using a power saw, continuously apply plenty of irrigation fluid to cool down the bone. If you see smoke coming from the bone, you have already irreversibly damaged the edge, increasing the chance of osteomyelitis and bone necrosis.
Neurovascular Management:
-
Major blood vessels: Suture ligate distally and regular ligation proximally (double ligate) to prevent AV fistulas and pseudo-aneurysm formation.
-
Consider a tourniquet to decrease blood loss.
-
Sciatic Nerve: Gently stretch the nerve and divide sharply, then allow retraction.
Muscle balancing:
-
The key to a successful AKA requires an appropriate balancing of agonistic and antagonistic forces. For more distal femur amputations, many surgeons perform a myodesis of the adductor magnus and Quadriceps Muscles. Alternatively, the belly of the adductor magnus is cut at or near Hunter's canal and fixed on the lateral side of the femur, preferably with trans-osseous sutures. This maneuver serves to counteract the abductor forces. The quadriceps is attached posteriorly in a similar fashion.
-
Avoid suturing the quadriceps directly to the hamstring, as this can create a painful "slinging" effect over the bone end.
-
Amputations through the proximal 1/3 of the femur are at risk of developing a flexion contracture due to the unopposed actions of the psoas muscle. To prevent this, every effort should be made to keep or reattach the gluteus muscle to the linea aspera posteriorly. This is less important in a palliative setting with a bedridden, non-ambulatory patient, but even here, we should try to prevent a flexion contracture. The same rules for muscle balancing should apply to a patient who will never receive a prosthesis but may use a wheelchair.
Video 13 This is yet another illustrative video by Husky Orthopaedics: Transfemoral Amputation (even though the resolution of the images is not so good, but the content is excellent). Also more experienced surgeons will find some pearls here. Click on the image to get to the video on YouTube. Due to the film's graphic content, you must sign in with your YouTube account. Credit: Husky Orthopaedics/Youtube
Closure AKA:
-
Bevel the end of the femur to avoid sharp edges, particularly the anterior edge of the femur.
-
Muscle balancing: see above
-
Irrigate before closure to rinse out bone dust.
-
Many surgeons use bone wax to seal off the cut edge of the bone. We have never utilized this and see no apparent need to use it.
-
Place a nr.18 drain through the lateral side of the thigh. It is highly recommended to use a drain because a large, unexpected hematoma will lead to hematoma, tissue necrosis, and wound dehiscence. We often leave the drain until day 3. Whether you have the drain on active or passive is a matter of preference, and there is no consensus on this.
-
Close the deep fascia with interrupted absorbable suture, for example Vicryl 2.
-
Many surgeons use only staples when closing a TKA amputation. In our experience, we have had the best results using a 50:50 ratio of staples and sutures. We start by placing vertical mattress sutures with 2.0 nylon about 1.5 cm apart to adapt the skin loosely, and supplement with staples in between two nylon sutures.
-
We routinely use a negative pressure dressing on TKAs and BKAs. Please refer to the section on BKA dressings above for a more detailed description. You can place the iNPWT only on the incision wound or wrap the entire stump in NPWT, thus giving a slight compression and helping to form the limb. If you do not have NPWT, we recommend covering the incision wound with gauze saturated with 10% povidone-iodine; cover this with a thick layer of dry gauze. Then, wrap the stump in cotton wool rolls and apply a light compression bandage.
-
Pain management AKA
Please refer to "pain management BKA" above as the same principles apply for TKA. We find that TKA patients operated with the classical approach often have less postoperative pain than BKA patients, and usually, we only use an epidural for 3-4 days postoperatively.
Hips disarticulation and hemipelvectomy
These are demanding surgical procedures typically indicated for severe traumatic injuries or malignancies. Such surgeries should only be performed at centers with special competence; we will not discuss them in this chapter.
Pediatric Considerations
-
If the physeal plate is intact, the limb will continue to grow. Therefore, bone resection in children should be very conservative.
-
In children, disarticulations fare better than through-the-bone amputations due to the common occurrence of exostosis and overgrowth with above-knee and below-knee amputations.
-
If possible, a long periosteal sleeve should be preserved and sutured to itself over the bone end.
-
The open bone end should be "capped" by plugging the open medullary cavity with a piece of bone harvested from the amputated segment.
References ( in alphabetical order)
Abouammoh, N., Aldebeya, W., & Abuzaid, R. (2021). Experiences and needs of patients with lower limb amputation in Saudi Arabia: a qualitative study. Eastern Mediterranean Health Journal = La Revue de Sante de La Mediterranee Orientale = Al-Majallah al-Sihhiyah Li-Sharq al-Mutawassit, 27(4). https://doi.org/10.26719/emhj.20.124
Adegoke, B. A. O., Kehinde, A. O., Akosile, C. O., & Oyeyemi, A. L. (2012). Quality of life of Nigerians with unilateral lower limb amputation. Asia Pacific Disability Rehabilitation Journal, 23(4). https://doi.org/10.5463/DCID.v23i4.192
Agha, R. al, Muneer, H., Alqaseer, A., Ismaeel, T., & Badr, O. (2017). Major lower limb amputation: Causes, characteristics and complications. Bahrain Medical Bulletin, 39(3). https://doi.org/10.12816/0047632
Akosile, C. O., Okonkwo, C. A., Maruf, F. A., & Okoye, E. C. (2020). Life accomplishment, social functioning and participation of south-eastern Nigerians with lower limb amputation. Disability, CBR and Inclusive Development, 31(2). https://doi.org/10.47985/dcidj.365
AlMehman, D. A., Faden, A. S., Aldahlawi, B. M., Bafail, M. S., Alkhatieb, M. T., & Kaki, A. M. (2022). Post-amputation pain among lower limb amputees in a tertiary care hospital in Jeddah, Saudi Arabia. Saudi Medical Journal, 43(2). https://doi.org/10.15537/SMJ.2022.43.2.20210609
Al-Wahbi, A. M. (2010). Impact of a diabetic foot care education program on lower limb amputation rate. Vascular Health and Risk Management, 6(1). https://doi.org/10.2147/VHRM.S13569
Ambler, G. K., Brookes-Howell, L., Jones, J. A. R., Verma, N., Bosanquet, D. C., Thomas-Jones, E., Edwards, A. G. K., & Twine, C. P. (2019). Development of Core Outcome Sets for Patients Undergoing Major Lower Limb Amputation for Complications of Peripheral Vascular Disease. European Journal of Vascular and Endovascular Surgery, 58(6). https://doi.org/10.1016/j.ejvs.2019.09.043
Ameyaw, E., Asafo-Agyei, S. B., Boakye-Yiadom, A. P., Baffoe-Sarpong, K., & Duku, F. A. (2020). Amputation in a 17 year old Ghanaian with type 1 diabetes: A Case Report. Endocrine and Metabolic Science, 1(3–4). https://doi.org/10.1016/j.endmts.2020.100070
Arifin, N., Hasbollah, H. R., Hanafi, M. H., Ibrahim, A. H., Wan Abdul Rahman, W. A., & Che Aziz, R. (2017). Provision of prosthetic services following lower limb amputation in Malaysia. Malaysian Journal of Medical Sciences, 24(5). https://doi.org/10.21315/mjms2017.24.5.12
Arsenault, K. A., Al-Otaibi, A., Devereaux, P. J., Thorlund, K., Tittley, J. G., & Whitlock, R. P. (2012). The use of transcutaneous oximetry to predict healing complications of lower limb amputations: A systematic review and meta-analysis. In European Journal of Vascular and Endovascular Surgery (Vol. 43, Issue 3). https://doi.org/10.1016/j.ejvs.2011.12.004
Ashraff, S., Siddiqui, M. A., Santos, D., & Carline, T. (2019). Prediction of stump healing in lower limb amputation: A narrative review. In Journal of Wound Care (Vol. 28). https://doi.org/10.12968/jowc.2019.28.Sup12.S18
Ashraff, S., Siddiqui, M., Carline, T., Rush, R., Santos, D., & Raza, Z. (2021). Development of a Prognostic Model for Stump Healing in Major Lower Limb Amputation among the Diabetic Population. Diabetology, 2(3). https://doi.org/10.3390/diabetology2030012
Belovs, L., & Lannan, F. M. (2024). Dermatologic Conditions in Persons with Lower Limb Amputations: a Review. In Current Physical Medicine and Rehabilitation Reports (Vol. 12, Issue 1). https://doi.org/10.1007/s40141-023-00427-1
Berridge, D. C., Slack, R. C. B., Hopkinson, B. R., & Makin, G. S. (1989). A bacteriological survey of amputation wound sepsis. Journal of Hospital Infection, 13(2). https://doi.org/10.1016/0195-6701(89)90023-6
Canbolat Seyman, C., & Uzar Ozcetin, Y. S. (2022). “I Wish I Could Have My Leg”: A Qualitative Study on the Experiences of Individuals With Lower Limb Amputation. Clinical Nursing Research, 31(3). https://doi.org/10.1177/10547738211047711
Chalya, P. L., Mabula, J. B., Dass, R. M., Ngayomela, I. H., Chandika, A. B., Mbelenge, N., & Gilyoma, J. M. (2012). Major limb amputations: A tertiary hospital experience in northwestern Tanzania. Journal of Orthopaedic Surgery and Research, 7(1). https://doi.org/10.1186/1749-799X-7-18
Crane, H., Boam, G., Carradice, D., Vanicek, N., Twiddy, M., & Smith, G. E. (2021). Through-knee versus above-knee amputation for vascular and non-vascular major lower limb amputations. In The Cochrane database of systematic reviews (Vol. 12). https://doi.org/10.1002/14651858.CD013839.pub2
Dillon, M. P., Kohler, F., & Peeva, V. (2014). Incidence of lower limb amputation in Australian hospitals from 2000 to 2010. Prosthetics and Orthotics International, 38(2). https://doi.org/10.1177/0309364613490441
Dunkel, N., Belaieff, W., Assal, M., Corni, V., Karaca, Ş., Lacraz, A., & Uçkay, I. (2012). Wound dehiscence and stump infection after lower limb amputation: Risk factors and association with antibiotic use. Journal of Orthopaedic Science, 17(5). https://doi.org/10.1007/s00776-012-0245-5
Fiedler, G., Akins, J., Cooper, R., Munoz, S., & Cooper, R. A. (2014). Rehabilitation of People with Lower-Limb Amputations. In Current Physical Medicine and Rehabilitation Reports (Vol. 2, Issue 4). https://doi.org/10.1007/s40141-014-0068-8
Frodl, A., Geisteuer, N., Fuchs, A., Nymark, T., & Schmal, H. (2022). Incisional negative pressure wound therapy to reduce surgical-site infections in major limb amputations: a meta-analysis. EFORT Open Reviews, 7(8). https://doi.org/10.1530/EOR-22-0049
Godlwana, L., Nadasan, T., & Puckree, T. (2008). Global Trends in Incidence of Lower Limb Amputation : SA Journal of Physiotherapy, 64(8).
Gupta, A., & Kumar, V. (2019). Multidisciplinary approach to prevent limb amputation in diabetic patients. In Journal of Endocrinology and Metabolism (Vol. 9, Issue 5). https://doi.org/10.14740/jem615
Hagenström, K., Garbe, C., Debus, E. S., & Augustin, M. (2021). Vascular Diagnostic and Surgical Treatments Before Lower Limb Amputations in Patients with Arterial Vascular Diseases: A Population Based Study from 2013 to 2015 in Germany. European Journal of Vascular and Endovascular Surgery, 62(3). https://doi.org/10.1016/j.ejvs.2021.05.016
Harker, J. (2006). Wound healing complications associated with lower limb amputation. World Wide Wounds.
Hassan Al Imam, M., Alamgir, H., Jahan Akhtar, N., Hossain, Z., Islam, R., & Sohrab Hossain, M. (2020). Characterisation of persons with lower limb amputation who attended a tertiary rehabilitation centre in Bangladesh. Disability and Rehabilitation, 42(14). https://doi.org/10.1080/09638288.2018.1544671
Hofstad, C. J., Bongers, K. T. J., Didden, M., van Ee, R. F., & Keijsers, N. L. W. (2020). Maximal walking distance in persons with a lower limb amputation. In Sensors (Switzerland) (Vol. 20, Issue 23). https://doi.org/10.3390/s20236770
Huizinga, W. K. J., Robbs, J. v., & Bhamjee, A. (1986). Wound infection after major lower-limb amputation - The role of antibiotic prophylaxis. South African Journal of Surgery, 24(3).
Huseynova, K., Sutradhar, R., Booth, G. L., Huang, A., & Ray, J. G. (2018). Risk of contralateral lower limb amputation and death after initial lower limb amputation – a population-based study. Heliyon, 4(10). https://doi.org/10.1016/j.heliyon.2018.e00836
Isaacs-Itua, A., & Sedki, I. (2018). Management of lower limb amputations. In British Journal of Hospital Medicine (Vol. 79, Issue 4). https://doi.org/10.12968/hmed.2018.79.4.205
Jarl, G., Johannesson, G. A., Carlberg, M., Jansson, S. P. O., & Hiyoshi, A. (2022). Editor’s Choice – Incidence of Lower Limb Amputations in Sweden from 2008 to 2017. European Journal of Vascular and Endovascular Surgery, 64(2–3). https://doi.org/10.1016/j.ejvs.2022.05.033
Kelle, B., Kozanoğlu, E., Biçer, Ö. S., & Tan, I. (2017). Association between phantom limb complex and the level of amputation in lower limb amputee. Acta Orthopaedica et Traumatologica Turcica, 51(2). https://doi.org/10.1016/j.aott.2017.02.007
Kolossváry, E., Ferenci, T., Kováts, T., Kovács, L., Járai, Z., Menyhei, G., & Farkas, K. (2015). Trends in Major Lower Limb Amputation Related to Peripheral Arterial Disease in Hungary: A Nationwide Study (2004-2012). European Journal of Vascular and Endovascular Surgery, 50(1). https://doi.org/10.1016/j.ejvs.2015.02.019
Kolossváry, E., Ferenci, T., Kováts, T., Kovács, L., Szeberin, Z., Sótonyi, P., Dósa, E., Járai, Z., & Farkas, K. (2020). Lower Limb Amputations and Revascularisation Procedures in the Hungarian Population: A 14 Year Retrospective Cohort Study. European Journal of Vascular and Endovascular Surgery, 59(3). https://doi.org/10.1016/j.ejvs.2019.10.021
Laloo, R., Gwilym, B. L., McLain, A. D., & Bosanquet, D. (2022). Tourniquet use for people with peripheral arterial disease undergoing major lower limb amputations. Cochrane Database of Systematic Reviews, 2022(5). https://doi.org/10.1002/14651858.CD015232
Liao, X., Li, S. H., el Akkawi, M. M., Fu, X. B., Liu, H. W., & Huang, Y. S. (2022). Surgical amputation for patients with diabetic foot ulcers: A Chinese expert panel consensus treatment guide. Frontiers in Surgery, 9. https://doi.org/10.3389/fsurg.2022.1003339
Lower Limb Amputation Wound Care: Is There A Consensus On Wound Management? Are Post-Operative Instructions Clear? (2012). The Internet Journal of Surgery, 25(1). https://doi.org/10.5580/27c0
Møsller, B. N., & Krebs, B. (1985). Antibiotic prophylaxis in lower limb amputation. Acta Orthopaedica, 56(4). https://doi.org/10.3109/17453678508993026
NCT02018094. (2013). The Amputation Surgical Site Infection Trial (ASSIT). Https://Clinicaltrials.Gov/Show/Nct02018094.
Ngarambe, R., Sagahutu, J. B., Nuhu, A., & Tumusiime, D. K. (2023). Functioning among persons with lower limb amputation with or without prostheses in Rwanda. African Journal of Disability, 12. https://doi.org/10.4102/AJOD.V12I0.1193
Norlin, R., Fryden, A., Nilsson, L., & Ånséhn, S. (1990). Short-term cefotaxime prophylaxis reduces the failure rate in lower limb amputations. Acta Orthopaedica, 61(5). https://doi.org/10.3109/17453679008993563
Obalum, D. C., & Okeke, G. C. E. (2009). Lower limb amputations at a Nigerian private tertiary hospital. West African Journal of Medicine, 28(1). https://doi.org/10.4314/wajm.v28i1.48420
O’Keeffe, B., & Rout, S. (2019). Prosthetic rehabilitation in the lower limb. In Indian Journal of Plastic Surgery (Vol. 52, Issue 1). https://doi.org/10.1055/s-0039-1687919
Oosterhoff, M., Geertzen, J. H. B., & Dijkstra, P. U. (2022). More than half of persons with lower limb amputation suffer from chronic back pain or residual limb pain: a systematic review with meta-analysis. In Disability and Rehabilitation (Vol. 44, Issue 6). https://doi.org/10.1080/09638288.2020.1783377
Owolabi, E. O., & Chu, K. M. (2022). Knowledge, attitude and perception towards lower limb amputation amongst persons living with diabetes in rural South Africa: A qualitative study. African Journal of Primary Health Care and Family Medicine, 14(1). https://doi.org/10.4102/PHCFM.V14I1.3398
Rossel, A., Lebowitz, D., Gariani, K., Abbas, M., Kressmann, B., Assal, M., Tscholl, P., Stafylakis, D., & Uçkay, I. (2019). Stopping antibiotics after surgical amputation in diabetic foot and ankle infections—A daily practice cohort. Endocrinology, Diabetes & Metabolism, 2(2). https://doi.org/10.1002/edm2.59
Saaiq, M. (2023). Epidemiology and Outcome of Nontraumatic Lower Limb Amputations. Medical Journal of the Islamic Republic of Iran, 37(1). https://doi.org/10.47176/mjiri.37.18
Sadat, U., Chaudhuri, A., Hayes, P. D., Gaunt, M. E., Boyle, J. R., & Varty, K. (2008). Five Day Antibiotic Prophylaxis for Major Lower Limb Amputation Reduces Wound Infection Rates and the Length of In-hospital Stay. European Journal of Vascular and Endovascular Surgery, 35(1). https://doi.org/10.1016/j.ejvs.2007.07.016
Sarfo-Kantanka, O., Sarfo, F. S., Kyei, I., Agyemang, C., & Mbanya, J. C. (2019). Incidence and determinants of diabetes-related lower limb amputations in Ghana, 2010-2015 - A retrospective cohort study. BMC Endocrine Disorders, 19(1). https://doi.org/10.1186/s12902-019-0353-8
Schober, T. L., & Abrahamsen, C. (2022). Patient perspectives on major lower limb amputation – A qualitative systematic review. International Journal of Orthopaedic and Trauma Nursing, 46. https://doi.org/10.1016/j.ijotn.2022.100958
Singh, R. K., & Prasad, G. (2016). Long-term mortality after lower-limb amputation. Prosthetics and Orthotics International, 40(5). https://doi.org/10.1177/0309364615596067
Sonne-Holm, S., Sorensen, T. S., & Bloeckstyns, M. E. H. (1987). Antibiotic prophylaxis of infection in amputations in the lower limbs on account of ischaemia. Ugeskrift for Laeger, 149(7).
Souroullas, P., Barnes, R., Carradice, D., Smith, G., Huang, C., & Chetter, I. (2022). Extended-course antibiotic prophylaxis in lower limb amputation: randomized clinical trial. British Journal of Surgery, 109(5). https://doi.org/10.1093/bjs/znac053
Swarnakar, R., Yadav, S. L., & Surendran, D. (2023). Lower limb amputation rehabilitation status in India: A review. World Journal of Clinical Cases, 11(30). https://doi.org/10.12998/wjcc.v11.i30.7261
Tsvetkov, V. O., Gorshunova, E. M., Kolovanova, O. v., Kozlov, J. A., & Gobegishvili, V. v. (2020). Two-phase amputation among critically ill patients with ischemic gangrene of lower limbs as a way to improve treatment outcome. Cohort study. Annals of Medicine and Surgery, 60. https://doi.org/10.1016/j.amsu.2020.11.045
Ülger, Ö., Yıldırım Şahan, T., & Çelik, S. E. (2018). A systematic literature review of physiotherapy and rehabilitation approaches to lower-limb amputation. In Physiotherapy Theory and Practice (Vol. 34, Issue 11). https://doi.org/10.1080/09593985.2018.1425938
van Eijk, M. S., van der Linde, H., Buijck, B., Geurts, A., Zuidema, S., & Koopmans, R. (2012). Predicting prosthetic use in elderly patients after major lower limb amputation. Prosthetics and Orthotics International, 36(1). https://doi.org/10.1177/0309364611430885
Walter, N., Alt, V., & Rupp, M. (2022). Lower Limb Amputation Rates in Germany. Medicina (Lithuania), 58(1). https://doi.org/10.3390/medicina58010101
Yu, T. W., & Ennion, L. (2019). Participation restrictions and vocational rehabilitation needs experienced by persons with a unilateral lower limb amputation in the Western Cape, south Africa. African Journal of Disability, 8. https://doi.org/10.4102/ajod.v8i0.456
Zaczyk, M. (2023). Validation of Gait Process Evaluation in People with Lower Limb Amputation. Rehabilitacja Medyczna, 27(3). https://doi.org/10.5604/01.3001.0053.9677
Zingg, M., Nicodème, J. D., Uçkay, I., Ray, A., & Suva, D. (2014). Lower limb amputation : Indication, preoperative workup and complications. Revue Medicale Suisse, 10(455).
Lower Extremity Amputation | Thoracic Key
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7607408/
https://journals.sagepub.com/doi/10.1177/17085381211045183?icid=int.sj-full-text.similar-articles.6
https://operativereview.com/amputation/
rev=ed8e91a9a7dc4968aac57b07c47bccf4
https://operativereview.com/amputation/