AMPUTATION

Introduction
• May be used to treat
◦ trauma
◦ infection
◦ tumor
◦ vascular disease
◦ congenital anomalies
• Prognosis
◦ outcomes are improved with involvement of
psychological counseling for coping mechanisms 
◦ amputation vs. reconstruction 
▪ LEAP study
▪ impact on decision to amputation limb
▪ severe soft tissue injury
▪ highest impact on decision-making process
▪ absence of plantar sensation
▪ 2nd highest impact on surgeon's decision making
process
▪ not an absolute contraindication to reconstruction
▪ plantar sensation can recover by long-term follow-up
▪ outcome measure
▪ SIP (sickness impact profile) and return to work not
significantly different between amputation and
reconstruction at 2 years in limb-threatening injuries
▪ most important factor to determine patient-reported outcome
is the ability to return to work 
Metabolic Demand
• Metabolic cost of walking
◦ increases with more proximal amputations  
▪ perform amputations at lowest possible level to preserve function
▪ exception
▪ Syme amputation is more efficient than midfoot amputation
◦ inversely proportional to length of remaining limb
• Ranking of metabolic demand (% represents amount of increase compared to
baseline)
◦ Syme - 15%
◦ transtibial
▪ traumatic - 25% average
▪ short BKA - 40%
▪ long BKA - 10%
▪ vascular - 40%
◦ transfemoral
▪ traumatic - 68%
▪ vascular - 100%
 ◦ thru-knee amputation
▪ varies based on patient habitus but is somewhere between transtibial
and transfemoral
▪ most proximal amputation level available in children to maintain
walking speeds without increased energy expenditure compared to
normal children 
◦ bilateral amputations
▪ BKA + BKA - 40% 
▪ AKA + BKA - 118%
▪ AKA + AKA - >200%
Wound Healing
• Dependent on
◦ vascular supply
◦ nutritional status
◦ immune status
• Improved with
◦ albumin> 3.0 g/dL 
◦ ischemic index > .5
▪ measurement of doppler pressure at level being tested compared to
brachial systolic pressure
◦ transcutaneous oxygen tension > 30 mm Hg (ideally 45 mm Hg)
◦ toe pressure > 40 mm Hg (will not heal if < 20 mm Hg)
◦ ankle-brachial index (ABI) > 0.45
◦ total lymphocyte count (TLC) > 1500/mm3
• Hyperbaric oxygen therapy
◦ contraindications include
▪ chemo or radiation therapy
▪ pressure-sensitive implanted medical device (automatic implantable
cardiac defibrillator, pacemaker, dorsal column stimulator, insulin
pump) 
▪ undrained pneumothorax
Upper Extremity Amputation
• Indications
◦ irreparable loss of blood supply
◦ severe soft tissue compromise
◦ malignant tumors
◦ smoldering infection
◦ congenital anomalies
• Levels of amputation
◦ wrist disarticulation versus transradial amputation
▪ wrist disarticulation advantages
▪ improved pronation and supination
▪ recommended in children for preservation of distal radial and
ulnar physes
▪ longer lever arm
 Figure 1. Wrist disarticulation

▪ transradial advantages
▪ more aesthetically
pleasing
▪ easier to fit prosthesis
◦ transhumeral versus elbow
disarticulation
▪ elbow disarticulation
advantages
▪ indicated in children to
prevent bony

overgrowth seen in transhumeral amputations

• Techniques
◦ transcarpal
▪ transect finger flexor/extensor tendons
▪ anchor wrist flexor/extensor tendons to carpus
◦ wrist disarticulation
▪ preserve radial styloid flare to improve prosthetic suspension
◦ transradial amputation
▪ middle third of forearm
amputation maintains
length and is ideal
◦ transhumeral amputation
▪ maintain as much length
as possible
◦ shoulder disarticulation
▪ retain humeral head to
maintain shoulder
contour
Transfemoral Amputation
• Maintain as much length as possible
◦ however, ideal cut is 12 cm above knee joint to allow for prosthetic fitting
• Technique
◦ 5-10 degrees of adduction is ideal for improved prosthesis function
◦ adductormyodesis
▪ improves clinical outcomes
▪ creates dynamic muscle balance
▪ provides soft tissue envelope that enhances prosthetic fitting
Through-Knee-Amputation 
• Indications
◦ ambulatory patients who cannot have a transtibial amputation
◦ non-ambulatory patients
• Technique
◦ suture patellar tendon to cruciate ligaments in notch
◦ use gastrocnemius muscles for padding at end of amputation
• Outcomes (based on LEAP data)
◦ slower self-selected walking speeds than BKA 
◦ similar amounts of pain compared to AKA and BKA
◦ worse performance on the Sickness Impact Profile (SIP) than BKA and AKA
◦ physicians were less satisfied with the clinical, cosmetic, and functional
recovery
◦ require more dependence with patient transfers than BKA
Below-Knee-Amputation (BKA)
• Long posterior flap 
◦ 12-15 cm below knee joint is ideal
▪ ensures adequate lever arm
◦ need approximately 8-12 cm from
ground to fit most modern high-
impact prostheses
◦ osteomyoplastictranstibial
amputation (Ertl) technique
▪ create a strut from the tibia to
fibula from a piece of fibula or osteoperiosteal flap
◦ "dog ears"
▪ left in place to preserve blood supply to the flap 
 • Modified Ertl 
◦ designed to enhance prosthetic end-bearing 
◦ technique
▪ the original Ertl amputation required a corticoperiosteal flap bridge 
▪ the modified Ertl uses a fibular strut graft
▪ requires longer operative and touniquet times than standard BKA
transtibial amputation
▪ fibula is fixed in place with cortical screws, fiberwire suture with
end buttons, or heavy nonabsorbable sutures. 
◦ there is no literature supporting this method over the traditional Burgess
amputation.
Ankle/Foot Amputation
• Syme amputation (ankle disarticulation)
◦ patenttibialis posterior
artery is required 
◦ more energy efficient than
midfoot even though it is
more proximal
◦ stable heel pad is most
important factor 
◦ used successfully to treat
forefoot gangrene in
diabetics 

• Chopart amputation (hindfoot

amputation)
◦ a partial foot amputation
through the talonavicular and
calcaneocuboid joints
 ◦ primary complication is equinus
deformity : avoid by lengthening of the
Achilles tendon and transfer of the
tibialis anterior to the talar neck 
• Lisfranc amputation
◦  equinovarus deformity is common 
▪ caused by unopposed pull of
tibialis posterior and
gastroc/soleus
▪ prevent by maintaining insertion
of peroneus brevis 
• Transmetatarsal amputation
◦ more appealing to patients who refuse
transtibial amputations
◦ almost all require achilles lengthening to prevent equinus
• Great toe amputations
◦ preserve 1cm at base of proximal phalanx
▪ preserves insertion of plantar
fascia, sesamoids, and flexor
hallucisbrevis
▪ reduces amount of weight
transfer to remaining toes
▪ lessens risk of ulceration

Figure 3- Transmetacarpal
Figure 2-Lisfranc amputation Amputation
Pediatric Amputation
• Most common complication is bone overgrowth
◦ prevent by performing disarticulation or using epihphyseal cap to cover
medullary canal