Key aspects of lower limb amputations
We recommend reading this chapter before heading to the chapter on amputation techniques. We are confident that, even if you are quite experienced, you will find one or another pearl of knowledge here.
Content:
Indications for Amputation
Acute Ischemia:
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Irreversible
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Severe with No Revascularization Options
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Failed Revascularization Attempts
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Chronic Ischemia:
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Failed Revascularization Attempts
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Severe with No Revascularization Options
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Unmanageable Pain
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Severe Comorbidities
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Poor Functional Status
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Extensive Gangrene/Infection that is Not Salvageable
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Severe Infection Causing Pedal Sepsis. It is a life-saving procedure for the treatment of an infection such as gas gangrene or decompensated systemic sepsis.
Severe Traumatic Injury:
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Mangled extremity in the absence of reconstructive capabilities
Malignancy
Other:
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The patient does not wish to go through long-term treatment of the chronic wound with uncertain outcomes and prefers to be amputated
Key Aspects to Consider
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Amputation is a surgical and reconstructive procedure that is a last resort. Evaluation by experts at type 2 and 3 facilities to assess possible options for limb salvage should be obtained whenever possible.
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Have we exhausted all realistic options and see amputation as the only solution to ensure the patient's well-being?
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An amputation should generally be viewed as a definite reconstructive option, not necessarily as a treatment failure.
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Amputations for indications other than those covered above can be performed in a delayed fashion.
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Painless, dry gangrene is NOT an absolute indication of an amputation.
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If possible, obtain a second documented opinion and photograph the foot's status to clearly show the indication for amputation. Photographic evidence and a second opinion should be obtained when possible to strengthen the documentation.
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Have we thoroughly explained to the patient that there are no other realistic options? Give your best surgical advice and avoid giving unrealistic or false hope. Have we given the patient and caregivers enough time to let the decision sink in?
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Never amputate without signed consent from the patient or guardian. Amputations should never be performed without the written and witnessed consent of the patient and guardian, and when possible, additional family members should be included in the decision process.
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Is it possible to opt for palliative wound care instead of an amputation?
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Are resources available to provide rehabilitation and prosthesis fitting?
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Do we think the patient can use a prosthesis?
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Be aware that keeping a "useless foot" with intermittent infections is generally worse for the patient than an amputation.
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Unmanageable ischemic pain alone may be an indicator of an amputation.
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Remember that extensive necrotic ischemia in a limb, even without infection, produces a lot of toxic products that derive from the necrotic tissues. These toxins can lead to a sepsis-like condition with high mortality. This is the toxic limb syndrome, and a quick amputation is necessary to save the patient's life.
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If you have a patient who cannot sleep without having their leg hanging outside their bed for better circulation, do not attempt an amputation lower than a below-knee amputation because it will fail. If you can delay the amputation, get a vascular surgical consult first if this is available.
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An amputation may be life-saving in cases with a severe infection of the limb.
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Never close the stump under tension; partial closure and a repeat attempt at delayed partial closure are preferable to a high-tension wound closure.
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Do not primarily close the stump in disaster and conflict situations; plan for delayed primary closure at 2-5 days. The risks of infection are significantly higher when amputating under these conditions. Secondary closure is, therefore, a safer alternative.
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In elderly patients with diabetes and poor arterial circulation, the chances of a second amputation (of the opposite extremity) within a few years are, unfortunately, very high.
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When deciding on amputation, at which level should we attempt it?
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Can we do a one-step or a two-step procedure?
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An amputation is not something that should be left to do by junior doctors! We need to do everything possible to ensure the best possible outcome of an amputation, and competent supervision must be available to less experienced doctors.
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Never attempt a one-step amputation in an area of skin with significant inflammation or infection. In these situations, a two-step amputation is the best choice.
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Try to avoid local anesthesia around the toes when doing a toe amputation. The needle as well as the temporary pressure from the injected fluid can irreversibly harm blood vessels that are already impaired! A regional block is a safer choice.
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Young patients with diabetic foot problems usually still have quite good arterial circulation. Even though an infection can quickly cause extensive gangrene also in a young patient with diabetes, we find that we often can choose a lower amputation level in this group because they usually heal surprisingly well.
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Start physiotherapy and rehab as soon as possible.
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Be aware of the psychological repercussions for the patient and provide support as soon as possible.
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Ensure that proper arrangements are made for the disposal of the amputated segment. The "proper arrangements" will vary across cultures.
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Amputations in this patient group have a high risk of complications. You will have to prepare yourself for this. At times you will have overestimated the arterial blood supply, at other times an unexpected hematoma or infection will sabotage the amputation.
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The amputee becomes a lifelong patient. A 30-year-old male with a 50-year life expectancy may require 15- 20 different prostheses over the course of a lifetime. Maintenance, repair, replacement need to be provided for in a sustainable and durable manner. In low-resource settings, however, it is unrealistic to find such a service for the majority of our patients. There are several charities in Africa dedicated to adapting second-hand prosthesis for patients who could otherwise not afford this. At the end of the chapter, you will find a list of relevant NGO`s and charities.
Figure 1a An algorithm for dealing with lower-limb amputations in patients with chronic wounds and/or infections. Decision making for acute, traumatic wounds is similar but entails other factors like fractures and tissue contamination , which are not discussed in this chapter.
Improving Circulation Before Amputation
In settings where all resources are available, we strive to optimize arterial circulation through all available means before considering amputation. If the patient's condition doesn't necessitate immediate amputation due to life-threatening gangrene with infection, we routinely seek a vascular consult beforehand. This typically involves angiography and an evaluation to determine the feasibility of percutaneous transluminal angioplasty (PTA) with or without stent placement, bypass, or other re-vascularization procedures.
PTA is the predominant procedure in our health region for this patient group. It's minimally invasive and performed under local anesthesia. It's important to note that age alone isn't a contraindication for PTA; our patients are often over 80 years old. The threshold for performing PTA is relatively low, but the patient must be able to cooperate (without impaired cognitive function), not have knee contractures, and have a reasonable life expectancy. Despite its minimally invasive nature, complications such as perforations with bleeding or thrombosis leading to worsened arterial circulation can occur.
Additionally, treated blood vessels may become occluded again over time. The term "patency" of a PTA refers to how long the blood vessels remain open after the procedure. In some patients, patency may last only a few months, but typically, it ranges from 1 to 2 years. However, patients often develop collaterals that compensate for this re-occlusion within that timeframe.
Ideally, we prefer patients to undergo re-vascularization before amputation whenever necessary and feasible to ensure proper healing of the amputation wound. In the weeks following re-vascularization, improved blood circulation often triggers an inflammatory response, particularly in the periphery of the affected limb. This period is not ideal for attempting an amputation, as the risks of failure are higher. This is particularly true of toe amputations- toes can swell up considerably following a re-vascularization. Ideally, a waiting period of at least 2 to 3 weeks following re-vascularization should be observed before planning an amputation. Redness, swelling, and warmth of the skin serve as indicators for when an amputation can be attempted following re-vascularization. If the foot remains reddish and swollen three weeks after a PTA, it's advisable to wait longer before attempting an amputation of the forefoot or toes. When it comes to leg amputation, this inflammatory reaction to re-vascularization is usually less of a problem, as the peripheral areas of the limb ( below the ankle) are most affected by this reaction.
Currently, few vascular centers in most African countries provide re-vascularization services to the public for affordable prices. In Southern Africa, several high-tech centers offer advanced re-vascularization techniques to those who can afford them. In the article by Ismail et al., another challenge is described- in Africa, there is a significant problem with patient delay. Patients with limb ischemia first turn to help from a hospital when the disease has advanced to a severe stage. Sometimes, there are cultural reasons for this, but this delay is often due to economic disadvantages.
Figure 1b In most African countries, centers are starting to offer limb revascularization, including percutaneous transluminal angioplasties. This service is, however, far from being available to everyone on the continent. In areas with meager resources, it is likely unrealistic for your patient to be able to afford such a procedure. This article is from 2019, and it summarizes the experiences of a hospital in Northwestern Nigeria. Click on the image to get to the full-length article. credit: Nigerian Journal of Surgery
Dealing with infection before an amputation
In the presence of infection, we sometimes have to do an emergency amputation due to sepsis or because the infection is spreading uncontrolled. In other situations where the infection is not as alarming, it is usually wise to load the tissues with at least a few courses of antibiotics before planning the amputation. If you already have results from a bacterial swab, you can often use narrow-spectrum antibiotics that fit the bacteria in the cultures. If you do not have a result from the lab yet, you may have to start with a broad-spectrum antibiotic and re-assess the choice once the culture results are back.
Remember: Always take a bacterial swab when you are planning on administering antibiotics. Remember that the swab should also be obtained from a debrided and rinsed wound. Otherwise, you will end up with a culture report showing five or more different bacterial species and get into limbo regarding antibiotic choice. Once you have rinsed the wound thoroughly, the bacteria left behind are usually the relevant species we have to focus on. Sometimes, of course, we only have a fistula with some purulent discharge from which to take a swab, and at other times, we have no skin opening.
Figure 2 This patient with type II diabetes developed extensive necrosis on the lateral side of the fifth ray. There is some dry eschar, but we also see cellulitis further up. This is quite a challenging case. The necrotic tissue likely affects the MTP joint and much of the fifth ray. Doing a debridement and hoping for it to heal by secondary intent will likely fail because much bone will be exposed. At our center, we would debride all necrotic tissue thoroughly, take bacterial swabs from the well-irrigated wound deep within, and administer antibiotics. We would use iodine-soaked gauze to fill the wound cavity and change the dressings daily. Then, we would wait for 1-2 weeks, and in that time, the patient cannot be weight-bearing. After that time, the cellulitis should have cleared up, and we can get a realistic view of our options for skin flaps. Judging from the skin around the rest of the foot, we would expect the arterial perfusion of the foot to be adequate. In this case, we would most likely choose a 5th ray amputation. If we do not have enough skin for suitable flaps, we will use NPWT ( vacuum therapy) for a few weeks and later do a split-thickness skin graft. Credit: Dr Gnu CC BY-SA 3.0
Improving nutritional status before an amputation
Although we know the importance of nutrition regarding wound healing, this is often overlooked in amputations. If the patient needs to undergo an emergency amputation, our focus must be optimizing the nutritional status post-operatively. However, suppose we are in a situation where we can schedule the amputation a few weeks in advance. In that case, we should do anything to improve the nutritional status. Many of our patients with chronic wounds already have some nutritional deficiency. If there is one aspect of nutrition you should concentrate on, then this would be protein intake. As a rule of thumb, the patient should have a daily intake of 1g proteins/ kilogram bodyweight. So, a man weighing 80 kg requires at least 80 grams of protein daily. This is the equivalent of about 12 medium-sized eggs! Preoperatively, the patient should focus on eating fish, chicken, other meats, eggs, and vegetable proteins. Peanuts are an excellent way to increase protein intake as a snack between meals.
In addition to proteins, vitamins play an important role in wound healing. Not all elderly patients are keen on eating a lot of fruits and may be vitamin deficient, depending on their diet.
In patients with anemia, iron supplementation a few weeks before the amputation may improve hemoglobin levels. However, the causes of anemia in tropical countries are manifold, and simply supplementing with iron may not solve the issue.
We are working on a chapter on " Nutrition and Wound Care"—please refer to it once it is published.
Dealing with edema before an amputation
If a patient has moderate-severe edema in the lower limbs, the risk of wound complications following an amputation is high. Whenever possible, we should try to reduce the edema by compression therapy before performing the amputation. Remember that patients with severe ischemia do not tolerate compression therapy. However, in patients with advanced venous insufficiency, post-thrombotic syndrome, or even lymphedema, try to at least have a few days of compression treatment before planning the amputation. Obviously, in emergency amputations, this is not possible, and you will have to focus on good compression therapy post-operatively.
Figure 3 This patient does not have severe edema but enough swelling to cause healing problems if we were, for example, planning to amputate the second toe ( note that the first toe was already amputated previously). We have chosen this image to illustrate that we must also consider improving moderate chronic edema with compression therapy before an amputation. Ideally, we would postpone the amputation until at least two weeks after the start of compression. Remember that compression also is very important in the postoperative course. Credit: istock
Dealing with psychological aspects before an amputation
We humans react very differently to bad news. For some patients, it is best to receive the bad news and undergo the amputation as soon as possible to move on in life. Other patients need a more extended period to prepare themselves for the thought of losing a limb. It is crucial to sit down with the patient and their family and thoroughly explain why an amputation is recommended or necessary. Rash decisions can lead to lifelong bitterness because the patient may feel that the decision to amputate was made hastily.
Ask the patient and their relatives about their main concerns about life after an amputation. Is it financial insecurities, worries about pain, being viewed as a disabled person, or concerns about sexual life? During your conversation with the patient, address all these aspects.
Sometimes, the patient is very realistic about the dire prognosis for the foot and requests an amputation. However, this is the exception. Most often, we must convince the patient that an amputation is the best treatment.
We routinely inquire if our patients know anyone else who has lost a limb, and quite often, they do know someone and acknowledge that these individuals managed to live a meaningful life after an amputation. This realization usually provides some comfort.
An important psychological aspect is the patient's faith and trust in their doctor. It is a significant advantage if the patient knows they are in good hands and that you would have done everything possible to save the limb. However, it is usually very reassuring for the patient to receive a second opinion from someone else. We often ask a colleague doctor or experienced nurse to attend the consultation to confirm the indication for an amputation so that the patient receives the same information from another healthcare professional.
If possible, it is usually beneficial to have another amputee speak with the patient and explain to them that life with the loss of a limb is manageable. Occasionally, we arrange for patients to visit the rehabilitation center before an amputation to show them what they can expect after the operation. There, they would also meet other patients who have lost limbs, and in most cases, this leads to a more positive attitude in a patient who is worried about the future.
In areas with limited resources, it may not be realistic to guarantee that financial resources are available to supply the patient with a prosthetic. In this case, the psychological burden of losing a limb is even higher. However, throughout Africa, many NGOs and other programs provide prosthesis fitting services to patients with limited resources. We will provide links to some of these organizations. Africa is a vast continent, and we obviously cannot have a complete overview of it, so you will have to conduct a thorough Google search to find out what options are available in your country.
Deciding on the level of amputation
Sometimes, this decision is straightforward, while at other times, it is challenging. Generally, better functional outcomes result from preserving more of the limb. The viability of distal tissues should determine the indication for amputation, not the distal sensory or motor function or the presence of bone loss.
Amputation Levels
Forefoot amputations:
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Partial Toe Amputation – Removal of a Portion of the Toe
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Toe Amputation – Removal of the Entire Toe
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Ray Amputation – Removal of the Toe and Corresponding Metatarsal Bone
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Transmetatarsal Amputation (TMA) – Removal of the Partial Foot Across the Metatarsal Bones
Midfoot amputations
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Tarsometatarsal (Lisfranc) Amputation – Removal of the Forefoot Across the Tarsometatarsal Line
Hindfoot amputations
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Midtarsal (Chopart) Amputation – Removal of the Forefoot and Midfoot, Sparing the Proximal Talus and Calcaneus
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Ankle Disarticulation (Syme’s Amputation) – Removal Through the Ankle Joint, Preserving the Calcaneus
Major Leg Amputations:
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Transtibial – Below-Knee Amputation (BKA)
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Exarticulation of Knee
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Transfemoral – Above-Knee Amputation (AKA)
Hip Amputations:
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Hip Disarticulation – Removal of the Entire lower extremity
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Hemipelvectomy – Removal of the lower extremity and Ipsilateral Hemipelvis
Clinical evaluation to help us decide the level of amputation
The most critical factor in deciding at which level we can perform an amputation is the quality of the arterial blood circulation. To evaluate these, we employ both low-tech and more advanced tools. Usually, we have to use several of these tools together to get a more reliable picture. Transcutaneous skin oxygen measurements are probably the best predictor for determining the outcome of an amputation. Most clinics do not have this available, and finding this tool in low-resource settings is unrealistic. We must rely on clinical appearance and our experience in areas where resources are minimal.
Skin temperature: While this is not a reliable indicator of amputation level, it gives us an idea of the circulation. Be aware of pitfalls: A warm foot does not necessarily mean sufficient arterial circulation. If an infection with inflammation is present, the foot may seem warm even though the circulation is compromised. In the ischemic extremity, we sometimes see an inflammatory response, and the affected areas may appear reddish and warm without an infection being present. An inexperienced clinician may interpret this as the foot being adequately perfused! In general, decreased skin temperature is a more reliable indicator. If you have an infrared skin thermometer, you can sometimes determine with fair accuracy at which level the limb has a lower temperature.
Skin appearance
Especially in light-skinned people, it is sometimes possible to see obvious signs of impaired arterial circulation, like pale, greyish, and thin skin without hair growth. This is usually harder to spot in people with dark skin. This is not a reliable test for determining amputation level.
Capillary refill Again, this is not a very reliable method to determine the level of amputation, but together with other tools, it may help with the decision. Normal capillary refill time is < 3 seconds. If you have severely impeded capillary refill in a toe you consider amputating, then most likely, this will not go well. Testing the capillary refill also has pitfalls. If the feet are cold, the refill may be falsely lowered. If the patient has inflammation of the foot, for example, the capillary refill may appear better than the arterial circulation truly is.
Palpating arterial pulses Ideally, we should be able to feel a pulse in an artery not far from the level we consider amputating. So, if we consider amputating a big toe, we should ideally be able to palpate a pulse in the arteria dorsalis pedis and tibialis posterior to ensure a fair outcome. If you cannot find a pulse, you may still achieve a toe amputation without complications, but the chances of a complication are higher. Conversely, if you can palpate a fine pulse, this does not necessarily guarantee that the toe amputation will heal fine. This is not a reliable test either, but if we have nothing else available, then palpable pulses, along with other clinical signs, may be the only thing you have to rely on
Using a Doppler probe to check for pulses:
If you cannot find the pulse by palpating with your finger, you may still get a good signal with a Doppler probe. This does not mean the circulation is fine, but at least there is some circulation. If you find no pulse after thorough searching with the probe, then the circulation is most likely severely impaired.
Ankle-brachial index (ABI):
Remember that the results you get from an ankle-brachial index tell us something about the circulation at the level of the cuff bladder! It doesn’t tell us all that much about the circulation in the midfoot and toes. You may have a good ABI at ankle level, yet the circulation of the small arteries in the toes is catastrophic. However, it may be a fair indicator of the circulation above the cuff. For example, if we are considering a below-knee amputation, a good ABI value at the level of the ankle may be an indicator telling us that an amputation below the knee may have a good chance of healing.
Toe pressure or toe-brachial index: Toe pressures are generally considered more reliable than ABI because the small arteries of the toe are not as affected by calcification as the arteries at ankle level. Also, an ABI tells us something about the arterial circulation at the ankle level but does not say anything about the circulation in the distal foot. So, if you are planning a toe- or midfoot amputation, a toe pressure reading is helpful. Like all of these tests, a toe pressure reading is not always reliable. If we are, for example, planning on doing an amputation of a toe, we often do not get a good reading from that toe because its arterial circulation is impaired. We may get a good reading from the neighboring toe, but this does not necessarily mean that the blood supply is adequate in the affected toe. Post-amputation healing is usually satisfactory if the toe systolic blood pressure is ≥30 mmHg.
Sequential lower extremity brachial index:
This method is quite helpful for regions with limited resources to determine whether a leg or thigh amputation is indicated. To perform this, you need several cuffs with appropriate sizes, as you will have to measure at the ankle, mid-leg, and thigh levels. The procedure is similar to a standard ABI. However, in addition to measuring the arterial pressure at ankle level, you also apply the cuff at mid-leg and on the thigh. Note: The Doppler probe is kept at the site of the arteria dorsalis pedis on the foot (or tibialis posterior) - only the cuff position is changed. Occasionally, you will see a significant fall in pulse pressure from thigh to leg, which may indicate that a leg amputation is most likely to fail. You may find a substantial drop in pulse pressures from mid-leg to ankle level, suggesting that an amputation below the ankle is not feasible.
Transcutaneous skin oxygen (tcPO2): This is generally considered the best objective test. A sensor is placed on the skin, heated to decrease flow resistance, and the oxygen partial pressure is measured. This test approximates the true arterial oxygen pressure at the questioned site.
Values:
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< 16-20 mmHg: Likely to Fail
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≥ 20-30 mmHg: Likely to Heal
Transcutaneous skin oxygen measuring devices are costly, and even in Western countries, they are only available at large clinics. They are available at some African university clinics, but that is the exception.
Figure 4 Transcutaneous skin oxygen measuring is the most reliable method for evaluating skin perfusion. Unfortunately, the equipment for this test is expensive and usually only available in specialized centers. copyright:hyperbaricmedicine.com
Infrared thermography
Infrared thermography is considered a pretty reliable method for evaluating skin perfusion. Regarding sensitivity and specificity, it probably ranks as the number two tool below transcutaneous skin oxygen evaluation for determining the safest level for amputation. Like tcPO2 equipment, a proper infrared thermography camera intended for medical purposes is very costly, and you will only find these at specialized clinics. As technology advances, cheaper infrared thermography devices have been developed for "household" purposes. Some of these can even be connected to a smartphone and only cost a few hundred dollars. We have not tested these and do not know if they can be reliably used to determine skin perfusion.
Figure 5 Infrared thermography of the lower limb is considered a reasonably reliable method for predicting amputation outcomes, though not as accurately as TcPO2 tes s. You can buy an infrared thermography unit for around 300 US Dollars, connecting it to your smartphone. However, we have not tested these and do not know if such cheaper models can be used for the purpose of determining amputation levels. However, you could map out the affected limb's temperature zones with reasonably good accuracy using an infrared thermometer. These thermometers use the same principles as thermography but will not give you an image, just a numb r. It requires more time to do this using the thermometer method, but within 5 minutes, you will have mapped out the temperature zones of a lower limb. Credit: Marccophoto/istock
Angiography
Angiography, also called arteriography, is, contrary to what you would expect, unreliable for predicting an amputation's outcome. However, if resources and time are available, an angiography should be considered to see if arterial circulation can be improved with an endovascular procedure. At our clinic, most patients have impaired arterial circulation. In cases where amputation is indicated but not immediate, a re-vascularization procedure beforehand may allow us to attempt a transtibial amputation rather than an above-knee amputation. We routinely use CT angiography for this purpose, while MRI angiography is also used in some cases. Angiographies using regular X-rays are still utilized in areas with limited resources and, when done correctly, can provide an excellent overview of the arterial situation. Since these tests use contrast agents that are potentially nephrotoxic, you must be aware of the guidelines, especially for patients with impaired renal function.
Figure 6 An angiography ( or angiogram) is a method of visualizing arteries using a contrast agent. The image above shows the arterial tree of the lower limbs. POP = Popliteal artery, PTA = posterior tibial artery, ATA = anterior tibial artery, PA= peroneal artery Credit: Schreiner et al.2017; Creative Commons Attribution 4.0
Assessment of the severely injured limb
For the assessment of severely injured limbs due to high-energy trauma, we recommend the following link from the Springer Indian Journal of Orthopaedics.
Figure 7 In our chapter, we do not discuss assessing and managing severely injured limbs. For a good overview of the assessment of these types of high-energy trauma, we recommend the link above. The article is available in full text in most regions. Copyright: Rajasekaran Shanmuganathan, Indian Journal of Orthopaedics.
Expected ambulation
It is also essential to consider whether we expect the patient to become ambulatory after the amputation. In the case of a bedridden frail patient, an above-knee amputation is usually the better choice. If you have a patient who is not expected to be able to walk with a prosthesis but will be spending much time in a wheelchair, a below-knee amputation will provide better balance while sitting.
Be aware that an above-knee amputation requires a significantly higher energy expenditure to walk. While a young person may be able to compensate for this, an elderly person with chronic heart disease may not be able to use a thigh prosthesis because it is too tiring!
Table 1 shows ambulation rates and energy expenditure for different levels of amputation ( for ambulatory patients using a prosthesis). BKA = below-knee amputation; AKA = above-knee amputation. For example, following an above-knee amputation, the patient has to expect at least a 60% increase in energy expenditure while walking. Less than half of the patients amputated above the knee can ambulate. Keep these figures in mind when deciding on the level of amputation.
Complications following an amputation
Complications after amputation in this patient group are, unfortunately, relatively high. Not rarely are inadequate surgical skills a reason for these complications! We can prevent some complications by treating the soft tissues with utmost care, ensuring good hemostasis, never suturing skin flaps under tension, and providing antibiotic coverage during the first days following surgery.
At times, we will have overestimated the arterial blood supply at the amputation site. This happens because we generally want to preserve as much limb length as possible. It happens when we are over-optimistic about the tissue's perfusion. However, being slightly over-optimistic may not be a negative trait – because sometimes it has helped us save a foot where other colleagues would have done a below-knee amputation. There is a delicate balance here. If you have done a thorough skin perfusion assessment and tried to do a midfoot amputation and it fails, this is not necessarily a mistake. If we never encounter this complication, we are either a) the most gifted surgeon ever or b) we have always amputated at a higher level than necessary. We must accept that we sometimes try a lower amputation even when we are slightly doubtful about whether it will succeed. In these situations, we must inform the patient clearly that we will try this approach but that there is a risk of having to do an amputation more proximally if complications arise.
Table 2 Complication rates and mortality for different levels of amputation BKA = below-knee amputation; AKA = above-knee amputation.
Figure 8 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
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Most common cause of death following an amputation is myocardial infarction, septicemia, or other infections.
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Necrosis of the amputated stump.
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Infection in the stump
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Bleeding: Risk of reoperation for bleeding control: 4-8%
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DVT: Up to 50% risk without prophylaxis
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Contracture ( especially BKA).Risk: 3-5% (Inhibits proper prosthetic ambulation)
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Chronic pain and phantom pain ( these are not necessarily the same thing. Chronic pain may, for example, be due to a neuroma)
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Issues with poorly fitted prosthesis- mechanically induced ulcers at the end of the stump.
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Post-traumatic stress disorder (5% risk for vascular amputations,20% risk for traumatic amputations)
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
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).