2852

C OPYRIGHT Ó 2010 BY T HE J OURNAL OF B ONE AND J OINT S URGERY, I NCORPORATED

Current Concepts Review

Traumatic and Trauma-Related Amputations
Part I: General Principles and Lower-Extremity Amputations
By LT Scott M. Tintle, MD, CDR John J. Keeling, MD, LTC Scott B. Shawen, MD,
LCDR Jonathan A. Forsberg, MD, and MAJ Benjamin K. Potter, MD

Investigation performed at the Walter Reed Army Medical Center, Washington, DC,
and the National Naval Medical Center, Bethesda, Maryland

ä Deliberate attention to the management of soft tissue is imperative when performing an amputation. Identification
and proper management of the nerves accompanied by the performance of a stable myodesis and ensuring robust
soft-tissue coverage are measures that will improve patient outcomes.

ä Limb length should be preserved when practicable; however, length preservation at the expense of creating a
nonhealing or painful residual limb with poor soft-tissue coverage is contraindicated.

ä While a large proportion of individuals with a trauma-related amputation remain severely disabled, a chroni-
cally painful residual limb is not inevitable and late revision amputations to improve soft-tissue coverage,
stabilize the soft tissues (revision myodesis), or remove symptomatic neuromas can dramatically improve
patient outcomes.

ä Psychosocial issues may dramatically affect the outcomes after trauma-related amputations. A multidisciplinary
team should be consulted or created to address the multiple complex physical, mental, and psychosocial issues
facing patients with a recent amputation.

In the United States alone, approximately 185,000 amputations nately, this proposition has not been substantiated by the lit-
are performed annually1,2, with about 16% of these being related erature, and it is now recognized that the postoperative course
to trauma. Despite this relatively low proportion of amputations following a trauma-related amputation is fraught with com-
done following trauma, individuals with a traumatic amputation plications and difficulties4. In a review highlighting the diffi-
account for nearly 45% of the estimated 1.6 million living people culties facing these individuals, Pierce et al.3 indicated that
with an amputation1. This striking disparity highlights the most nearly 51% of their sixty-one patients developed an anatomic
important difference between trauma-related amputations and complication related to their amputation. This difficult post-
those performed on more elderly or infirm individuals for other operative course has also been recognized and discussed by
indications. Trauma-related amputations are usually performed the Lower Extremity Assessment Project (LEAP) study group.
on young and previously healthy patients with substantial pre- The authors of the LEAP study reported a rehospitalization
dicted longevity as well as a high potential for rehabilitation to rate of 29.8% and a 14.5% rate of revision of the residual limb
regain previous levels of activity3. in their series of 149 patients treated with trauma-related
Historically, it was believed that individuals with a trauma- amputation4. Nonetheless, 6.5% of the 124 patients followed
related amputation rapidly adapted to the loss of the limb and for twenty-four months still did not have fully healed soft
proceeded to lead functional and productive lives. Unfortu- tissues4. Most importantly, a large percentage of these patients
Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member
of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.
Disclaimer: The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the
views of the United States Army, United States Navy, or the Department of Defense.

J Bone Joint Surg Am. 2010;92:2852-68 d doi:10.2106/JBJS.J.00257


TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG
d
V O L U M E 92-A N U M B E R 17 D E C E M B E R 1, 2 010
d d
TABLE I Checklist for Successful Performance of
Trauma-Related Amputations
Perform an aggressive initial (and subsequent) debridement and
irrigation; do not attempt to definitively close the wound at the
index procedure
Preserve reconstructive options via appropriate length selection
and salvage of all viable tissue at the initial debridement
procedure
Salvage functional joint levels; manage proximal fractures via
standard techniques
Perform a traction neurectomy for all named nerves and all
grossly visible cutaneous nerves well proximal to the end of the
residual limb
Identify, isolate, and securely ligate all named vessels
Bevel and smooth all sharp bone ends of the residual limb;
respect the periosteum
Perform a stable myodesis under physiologic muscle tension
and augment with a secondary myoplasty
Ensure robust and viable distal padding
Maintain close follow-up in the early postoperative period and
then pursue a consistent subsequent follow-up plan to
identify operative complications and problems early and
prevent nonoperative issues from escalating into operative
ones
become and remain severely disabled following a trauma-
related amputation3,5.
Considering the potential for a young, previously healthy
person returning to a high level of function after an amputa-
tion, it is imperative to provide a durable, painless residual limb
capable of prolonged prosthetic wear. Despite the apparent
simplicity of the procedure, the trauma-related amputation or
revision of a traumatic amputation and the closure itself should
TABLE II Documented Technical Errors in the Operative Care of Trauma-Related Amputations and Subsequent Untoward Results
Technical Error
Improper length selection
Failure to perform traction neurectomies
Inappropriate management of bone
Failure to adequately stabilize distal musculature
Failure to achieve a robust distal soft-tissue envelope
Failure to balance remaining muscular forces on the
residual limb
Inadequate attention to balanced incision closure
Inadequate short and intermediate-term follow-up
2853
T R AU M AT I C AND T R AU M A -R E L AT E D A M P U TAT I O N S
not be considered a nuisance, treatment failure, or surgical
opportunity for an unsupervised novice; rather, it is a challenge
for even the experienced surgeon6,7.
The two essential parts of a successful amputation in-
clude the removal of the damaged or dysfunctional portion of
the limb followed by the reconstruction of the residual limb.
The first goal is easily accomplished in all but the rarest of
circumstances, whereas reconstruction of a durable residual
limb is more challenging. Adherence to proper techniques
(Table I) and the avoidance of well-documented technical er-
rors (Table II) can dramatically affect the outcome and final
function of the residual limb6.
Limb Salvage Versus Amputation
The Lower Extremity Assessment Project (LEAP) Study
The findings of the LEAP study group have been reported over
the past decade and have become important considerations
when one is evaluating and counseling patients with severe
lower-extremity trauma. The LEAP study was a prospective,
multicenter, observational study of patients with severe lower-
extremity trauma in the United States civilian population. The
functional outcomes for 601 patients who had undergone ei-
ther limb reconstruction or amputation were assessed7,8. The
authors recognized an important study selection bias in which
study subjects were not randomly selected for amputation or
limb salvage. The more severely injured patients were treated
with amputation7. Despite the fact that the LEAP study is the
largest and best scientifically planned study of its type to date, it
remains controversial and is cited by both advocates for limb
salvage and those for amputation as support for their profes-
sional preferences, practices, and opinions. Regardless of where
one’s opinions fall in the limb salvage versus amputation de-
bate, careful scrutiny of the study reveals issues such as the lack
of randomization, the limitations of the Sickness Impact Profile
scores, and the limitations with regard to the conclusions reached
Resulting Complication(s)
Length salvage may be inappropriately aggressive with little concern for soft-tissue
coverage, leading to a poorly padded residual limb; conversely, length selection
may be overly conservative, leading to an unnecessarily shortened residual limb
Symptomatic neuromas, which can negatively affect prosthetic wear or require
revision surgery
Inappropriate handling of the periosteum or failure to smooth bone ends may
lead to sharp, symptomatic spurs or edges
Decreased residual limb control, retraction of distal padding, or overt subluxation or
snapping of distal muscle groups
Delayed healing, pain, and soft-tissue breakdown
Decreased residual limb control and proximal joint contractures
Dog ears, or soft-tissue redundancy, producing ulceration or pain
Failure to adequately recognize and treat frequent complications
 2854
TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG
d
V O L U M E 92-A N U M B E R 17 D E C E M B E R 1, 2 010
d d
concerning through-the-knee amputations that should be con-
sidered when interpreting the results of this nonetheless land-
mark study.
In the LEAP series, the outcomes in both the limb salvage
and the amputation group were poor. One-half of the patients
in both cohorts had substantial disability5,8,9. Despite equivalent
early costs in the two groups, the lifetime cost for the amputation
group was estimated to be about three times higher secondary
to prosthesis-related expenses10. The LEAP study also showed
that multiple scoring systems did not reliably predict the fate of
the injured extremities or the functional outcomes of the pa-
tients. The evaluated scoring systems were the Mangled Ex-
tremity Severity Score; the Limb Salvage Index; the Predictive
Salvage Index; the Nerve Injury, Ischemia, Soft-Tissue Injury,
Skeletal Injury, Shock, and Age of Patient Score; and the Hannover
Fracture Scale-9811. The study group also found that an in-
sensate foot on presentation should not be a critical indication
for amputation, as there was a return of plantar sensation by
two years in the majority of cases12. Finally, the study demon-
strated that predictors of lower scores on the Sickness Impact
Profile included a low educational level, non-white race, poverty,
a lack of private health insurance, a poor social-support net-
work, low self-efficacy, smoking, and involvement in disability-
compensation litigation7.
Indications for Lower-Extremity Amputation
The majority of the literature addressing lower-extremity trauma
and amputation has dealt with open tibial fractures; thus, the
majority of the literature addressing the issue of limb salvage
versus amputation deals with that particular injury. Suggested
absolute indications for lower-extremity amputation are blunt
or contaminated traumatic amputation, a mangled extremity
in a critically injured patient in shock, or a crushed extremity
with arterial injury and a warm ischemia time of greater than
six hours13-16. Other, relative indications for amputation include
severe bone or soft-tissue loss; an anatomic transection of the
tibial nerve; an open tibial fracture with serious associated
polytrauma or a severe ipsilateral foot injury; and/or a pro-
longed predicted course to obtain soft-tissue coverage and tibial
reconstruction13,15. In addition to these relative indications, we
have found that having at least two experienced surgeons
provide a frank intraoperative assessment to be a relatively
consistent way to decide whether a limb has the potential to be
saved.
Operative Techniques
Early Surgical Goals
Initial goals in the treatment of a severe lower-extremity injury
include control of life-threatening hemorrhage and patient
stabilization followed by thorough debridement of all contami-
nated wounds. All devitalized muscle, skin, and bone without
articular cartilage that is devoid of soft-tissue attachments must
be excised sharply. Conversely, viable muscle and fasciocuta-
neous tissue should be saved for possible use in the definitive
soft-tissue reconstruction. While conclusions regarding the
optimal methods of irrigation of contaminated wounds have
T R AU M AT I C AND T R AU M A -R E L AT E D A M P U TAT I O N S
varied in the literature, we currently recommend irrigation
with 9 L of normal saline solution utilizing either low-pressure
gravity-flow irrigation or low-pressure pulsatile lavage (psi <
10). This recommendation is based on mounting evidence that
higher-pressure pulsatile lavage causes host-tissue damage and
edema and produces a significantly greater bacterial rebound
(p = 0.048) than irrigation with a simple bulb syringe.
While it is common that the bacterial counts within trau-
matic wounds slowly increase following irrigation and de-
bridement procedures, Owens et al. found that, with pulsatile
lavage, the bacterial count following irrigation and debride-
ment increased to 94% of the count before the irrigation and
debridement in an animal model, whereas the bacterial count
rebounded to only 48% of the pre-irrigation and debridement
count when a bulb syringe was utilized17. This presumably occurs
as a result of the damage caused by pulsatile lavage as well as the
pressure from the device driving bacteria deeper into local
tissues17-22.
In most instances, at least one additional irrigation and
debridement procedure will and should take place. Therefore,
we recommend performing a length-preserving amputation
that retains any irregular but grossly viable muscle and skin
rather than creating formal flaps for closure at the initial de-
bridement. This length-preserving technique and these so-called
flaps of opportunity allow maximal length preservation and
maintain potentially useful soft tissue for bone coverage and
padding (Figs. 1-A and 1-B). The so-called guillotine ampu-
tation is an antiquated technique that only serves to compro-
mise length and level salvage and has few modern indications,
with the possible exception of an initial guillotine amputation
followed by a planned, staged closure at an entirely different,
more proximal level (e.g., a ‘‘guillotine’’ ankle disarticulation in
the face of a degloved or nonviable heel pad prior to a planned
revision to a transtibial level) (Fig. 2).
Definitive Wound Management
Often, multiple irrigation and debridement procedures are nec-
essary, and the use of negative-pressure wound therapy may prove
to be a useful adjuvant until the time of definitive amputation
revision. Similar to the highly touted skin-traction techniques
that were popularized during previous military conflicts, negative-
pressure wound therapy with the addition of vessel loops uti-
lized in a so-called Jacob’s ladder or shoelace manner may
contribute to the salvage of post-amputation length23. Repeat
irrigation and debridement procedures should be performed
every forty-eight to seventy-two hours until the wound is thought
to be clean and without nonviable tissue. Despite the techno-
logical advances in the treatment of severe lower-extremity
trauma, the timing of wound closure remains the subjective de-
cision of the surgeon and depends mostly on the appearance of
the bone and soft tissues and, to a lesser degree, on laboratory
values and the patient’s overall condition24.
In addition to negative-pressure wound therapy, antibiotic-
impregnated polymethylmethacrylate beads have been fre-
quently used in the provisional management of trauma-related
extremity amputations. The study of the use of antibiotic beads
 2855
TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG
d
T R AU M AT I C AND T R AU M A -R E L AT E D A M P U TAT I O N S
V O L U M E 92-A N U M B E R 17 D E C E M B E R 1, 2 010
d d

Fig. 1-A

Fig. 1-B
Fig. 1-A Intraoperative photograph demonstrating atypical flaps utilized to salvage residual limb length in a proximal transfemoral amputation prior to
closure. The proximal part of the quadriceps and the anterior thigh skin have been lost as a result of trauma, leading to exposed bone and inadequate
anterior soft-tissue coverage. This defect has been covered with a more proximal myoplasty of the viable remaining hamstring muscles (a) following
adductor myodesis to permit salvage of residual limb length, and soft-tissue closure is facilitated by retention of atypical viable posteromedial (b) and lateral
(c) fasciocutaneous flaps. Fig. 1-B The same residual limb following definitive wound closure.
 2856
TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG
d
T R AU M AT I C AND T R AU M A -R E L AT E D A M P U TAT I O N S
V O L U M E 92-A N U M B E R 17 D E C E M B E R 1, 2 010
d d

Fig. 2
Intraoperative photograph of a guillotine-style transfemoral amputation that required
substantial residual limb shortening in order to facilitate robust soft-tissue coverage and
closure.

in humans has proven difficult because of host and wound
variability; however, animal data have demonstrated efficacy of
local antibiotic beads within open wounds to prevent infection25.
While bead pouches and the temporary closure of residual
limbs over antibiotic beads have been utilized, we frequently use
antibiotic beads in conjunction with negative-pressure wound
therapy. However, the appropriate antibiotic concentrations
remain unknown, and the efficacy of this regimen is unproven.
Soft-Tissue Management
Muscle
The condition of the soft-tissue envelope is perhaps the most
important variable in determining the outcome of treatment of
the limb. Surgeons usually utilize remaining viable muscle and
fasciocutaneous tissues for soft-tissue coverage in an attempt to
achieve a durable, well-padded limb. Muscle coverage over the
residual bone provides padding as well as assists in control of
the distal part of the extremity and overall limb alignment26,27.
Myodesis, myoplasty, and myofascial techniques are all
utilized in amputation surgery to stabilize the residual muscle
and maintain the distal bone end in a padded and covered
position. Myodesis is achieved when a residual muscle and
its fascia are sutured directly to bone through drill holes or
are firmly attached to the periosteum (Figs. 3-A and 3-B).
Myodesis provides the most structurally stable result. Myoplasty
is performed by suturing a residual muscle agonist to its an-
tagonist over the end of the bone to create physiologic tension. A
myofascial closure, which involves suturing a residual muscle
and its apposing fascia together, creates the least stable of the
constructs.
Myodesis is the recommended technique when a trauma-
related amputation is performed28,29. This technique restores
 2857
TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG
d
T R AU M AT I C AND T R AU M A -R E L AT E D A M P U TAT I O N S
V O L U M E 92-A N U M B E R 17 D E C E M B E R 1, 2 010
d d

Intraoperative photographs demonstrating a myodesis to the anterior-

distal aspect of the tibia before (Fig. 3-A) and after (Fig. 3-B) tying of the
deep myodesis stitch with utilization of two parallel drill holes in the
anterior aspect of the tibia and a number-5 nonabsorbable suture that
has been buried laterally in a horizontal mattress fashion. Additional
number-1 or number-0 sutures are then placed in a simple or figure-of-
eight fashion approximately 4 to 5 cm proximal to the end of the bone
Fig. 3-A where the distal myofascial flap terminates to reinforce the myodesis
by anchoring it to the anterior tibial periosteum.

Fig. 3-B
 2858
TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG
d
T R AU M AT I C AND T R AU M A -R E L AT E D A M P U TAT I O N S
V O L U M E 92-A N U M B E R 17 D E C E M B E R 1, 2 010
d d

the physiologic muscle tension, secures the deep soft-tissue
padding, prevents instability of the muscle unit, and allows for
functional muscle use during walking30. Myofascial and myo-
plasty closures (without myodesis) are frequently used both in
patients with dysvascular/diabetic disorders and those with
traumatic injury5,31,32. Despite their frequency of use, these tech-
niques should serve only as supplementary methods of muscle
stabilization after performance of a myodesis in a patient un-
dergoing a trauma-related amputation. Furthermore, there is no
good clinical evidence contraindicating myodesis even in pa-
tients with a diabetic/dysvascular disorder, and perhaps more
widespread utilization of this technique in those populations
may be worthwhile to obtain the benefits discussed above.
Nerve
Neuroma formation is the seemingly inevitable biologic con-
sequence of nerve transection when regenerating axons are in-
capable of reentering the distal nerve stump33. The complete
removal of the distal portion of a nerve in amputation surgery
virtually ensures neuroma formation. An important consid-
eration in amputation surgery is thus to try to prevent these
neuromas from becoming symptomatic with prosthetic wear.
Ebrahimzadeh et al. reported symptomatic neuromas in 13%
of ninety-six patients with a transtibial amputation and 32%
of thirty-one with a transfemoral amputation 34,35 . These
symptomatic neuromas are a common indication for revision
surgery3,4,36. Normal physiologic stimuli such as stretching,
pressure, or vascular pulsations can be very painful to a patient
with a neuroma and thus limit prosthetic wear. Frequently
encountered locations for symptomatic neuromas in the lower
extremity include the common peroneal nerve and the sural
nerve. As a result of its subcutaneous location directly overlying
the fibular head, the common peroneal nerve frequently be-
comes symptomatic following a transtibial amputation. A sub-
stantial amount of pressure from a prosthetic socket can develop
over this osseous prominence and underlying neuroma. The
sural nerve is often ignored when a transtibial amputation is
performed.
Numerous techniques have been advocated to prevent or
reduce formation of symptomatic neuromas; these include
traction neurectomy, epineural and silicone capping, preemp-
tive regional anesthetic blockade, and implantation of the cut
nerve end into muscle or bone36-40. Unfortunately, no technique
has proven superior for the prevention of symptomatic neu-
roma formation38. The most commonly performed of these
procedures is the traction neurectomy, in which the nerve is
pulled distally and then cut, placing the neuroma away from
the definitive closure and the ligated vessels. When an ampu-
tation is performed, all important nerves should be identified
and isolated (Fig. 4). Following this, a traction neurectomy
should be performed well proximal to the weight-bearing por-
tions of the terminal residual limb.
Vessels
All major arteries and veins should be individually identified
and ligated with nonabsorbable suture (e.g., silk). The arteries

Fig. 4
Intraoperative photograph demonstrating a sciatic nerve that had been included in the amputation
myoplasty. The resulting neuroma was symptomatic and precluded prosthetic wear and walking and
required excision to a more proximal level, as shown in this photograph.
 2859
TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG
d
V O L U M E 92-A N U M B E R 17 D E C E M B E R 1, 2 010
d d
and veins should be ligated separately. We commonly utilize
number-2-0 silk suture below the knee, while number-0 silk is
used to ligate the popliteal or femoral artery, which is then
double ligated with an additional number-2-0 suture ligature.
Level of Amputation and Length Preservation
The selection of the appropriate amputation level is critical to
the final outcome. The energy required for walking increases
as the amputation level moves proximally41-44. The gait of an
individual with an amputation is less efficient than normal gait,
as demonstrated by increased rates of oxygen consumption and
decreased customary walking speeds41-44. The gait of an indi-
vidual with an amputation depends on the proximal joints
and muscles remaining to compensate for the lost joint and
muscle function distal to the level of amputation. It is not
therefore surprising that the oxygen cost is increased at each
progressive amputation level from the transtibial to the trans-
pelvic level.
The increased rate of oxygen consumption by an indi-
vidual with a transtibial amputation is similar to that of a patient
who has undergone an ankle fusion6,45. This factor highlights
the fact that the loss of ankle joint mobility is the major bio-
mechanical component responsible for the increased energy
consumption following a transtibial amputation.
The gait of a patient with a transfemoral amputation is
hindered not only by the loss of the ankle and the knee, but also
by the weakened hip and thigh musculature. In addition, the lack
of a direct connection between the human thigh and a pros-
thetic knee, as well as persistent limitations in prosthetic foot
design, leads to a gait in which knee flexion serves only to allow
foot clearance and does not contribute to load absorption6.
While an individual with a transtibial amputation also has ab-
normal load absorption during gait, as a result of decreased
maximum knee flexion as compared with that during normal
gait, even when a state-of-the-art prosthesis with microproces-
sors is used after a transfemoral amputation there is increas-
ingly abnormal load acceptance during gait as a result of the
minimal knee flexion at foot contact that is needed to ensure
that the prosthetic knee does not collapse. These abnormalities
combined with a decreased range of motion and strength of the
ipsilateral hip and thigh lead to increased pelvic and trunk
motion as well as compensatory mechanisms in the sound
limb, involving all phases of gait, that lead to increased energy
requirements for walking6.
Because of these energy considerations, better outcomes
are usually associated with joint-level preservation and a longer
residual limb as long as length preservation does not negatively
impact the quality of the soft-tissue coverage.
In a posttraumatic scenario, the level of the most severe
soft-tissue injury will usually dictate the level of the final am-
putation. Regardless of the selected level of amputation, a full-
thickness myocutaneous flap to cushion the areas of highest
pressure and shear should be present46. In rare instances, free
tissue transfer has been utilized to successfully salvage a func-
tional joint level in the absence of adequate local soft-tissue
coverage (Figs. 5-A and 5-B)47. A fracture proximal to the
T R AU M AT I C AND T R AU M A -R E L AT E D A M P U TAT I O N S
lowest practicable amputation level should be appropriately
stabilized and should not, by itself, be considered an indication
for a more proximal amputation48,49.
Despite the increased number of complications that arise
from performing an amputation through the zone of injury, the
benefit of preserved post-amputation length usually outweighs
the increased risk of wound complications and heterotopic
ossification50,51. The LEAP study suggested that atypical flap
coverage does not increase the rate of wound complications5.
Skin grafts, soft-tissue expanders, and tissue transfer are all
methods that have been successfully utilized to maintain post-
amputation length. While successful results can be achieved
with these methods, it is often at the cost of delayed prosthetic
fitting and numerous revision operations to achieve the desired
result52-65. An alternative that can be used to salvage length in
very select cases is to perform an initial dermatomal harvest of
skin that is degloved at the initial debridement and apply a
primary skin graft over exposed muscle. This should be per-
formed only in rare instances as we do not advocate definitive
wound closure at the time of the index procedure. When con-
sidering the recommendations listed above, surgeons must still
carefully weigh the risks associated with preserving limb length
as they may adversely affect the ultimate functional outcome.
In short, limb length should not be preserved at the expense of
creating a nonhealing, marginal, or painful residual limb.
Specific Amputation Levels
Lisfranc, Chopart, and Syme Amputations
Amputations through the foot and ankle can be considered in
cases of severe forefoot trauma when the hindfoot plantar skin
and soft tissues have been spared. The Lisfranc disarticulation
removes the forefoot through the tarsometatarsal joints. The
bases of the second and fifth metatarsals should be left in order
to preserve the transverse arch of the foot as well as to leave the
insertion of the peroneus brevis intact. The tibialis anterior and
peroneus longus tendons must also be preserved carefully. The
Chopart amputation is performed through the talonavicular
and calcaneocuboid joints. In this procedure, all of the ankle
dorsiflexors are transected and the surgeon must make a dili-
gent effort to perform a proper tendinous reconstruction in
order to counteract the overpowering triceps surae. The Syme
disarticulation is performed through the tibiotalar joint with
removal of the malleoli, in the presence of a healthy undamaged
heel pad and normal posterior arterial flow66,67. The heel pad
must then be maintained directly below the distal part of the
tibia to avoid painful instability.
Potential benefits of these levels include their long lever
arm and the potential ability to continue to bear weight and
walk for short distances without the use of a prosthesis6,68.
Despite these benefits and the generally good results following
transmetatarsal amputations, substantial limitations associated
with difficult prosthetic fitting and the severe disruption of the
musculotendinous balance of the foot are common68. With the
Lisfranc and Chopart amputations, a refractory equinovarus
deformity frequently develops despite efforts to rebalance the
foot69. With the Syme amputation, it is important to maintain
 2860
TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG
d
T R AU M AT I C AND T R AU M A -R E L AT E D A M P U TAT I O N S
V O L U M E 92-A N U M B E R 17 D E C E M B E R 1, 2 010
d d

Postoperative lateral radiograph (Fig. 5-A) and follow-up clinical

photograph (Fig. 5-B) after a proximal transtibial amputation in
the setting of an intact extensor mechanism and no articular
injury. A free latissimus dorsi flap was required for soft-tissue
coverage, and the patient was able to walk without difficulty
with a modified socket and no assistive device and had
recently started running.

Fig. 5-A

Fig. 5-B

the heel pad directly beneath the residual tibia. One method of described by Smith et al.70. In addition to the difficulties with
accomplishing this is to perform a tenodesis of the Achilles the heel pad, multiple studies have demonstrated the inability
tendon to the posterior aspect of the distal part of the tibia as of many individuals with a Syme amputation to bear full weight
 2861
TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG
d
V O L U M E 92-A N U M B E R 17 D E C E M B E R 1, 2 010
d d
through the residual limb without a prosthesis68,71,72. A more
proximal transtibial amputation should be considered and dis-
cussed with any patient who has sustained severe foot and ankle
trauma as it generally provides a good functional outcome73-75.
Transtibial Amputation and Knee Disarticulation
The transtibial amputation is the most common amputation
performed for trauma patients and has, in general, been asso-
ciated with the best functional outcomes. Individuals with a
transtibial amputation have a high rate of prosthetic use and
frequently consider themselves only minimally or not disabled74,75.
Their gait is minimally disturbed, and less energy is necessary
for walking when the knee has been retained44,76.
When the amputation described by Burgess et al.31 is
performed, it is important to consider the residual limb length.
Two and one-half centimeters for every 30 cm of height should
be maintained if the injury pattern allows length to be deter-
mined by the surgeon77. This usually equates to 12.5 to 17.5 cm
of residual limb length, and erring on the side of creating a
longer residual limb is usually indicated when soft-tissue cov-
erage is adequate. Special attention to the fibula on the pre-
operative radiographs and in the operating room usually allows
detection of tibiofibular instability. When instability is present,
stabilization should be performed either proximally or distally.
A bone-bridging synostosis (discussed in greater detail later)
can be utilized to stabilize the fibula distally. In our experience,
the extended posterior myofasciocutaneous flap described by
Assal et al.78 provides excellent anterior-distal soft-tissue cov-
erage at the expense of relatively frequent edge necrosis and
minor wound complications. This extended flap places the
suture line of the amputation at the anterior aspect of the
residual limb. There is no anterior skin flap distal to the level
of the tibial bone cut.
When performing a transtibial amputation with utiliza-
tion of the extended posterior flap, we carry out a myodesis of
the posterior musculature to the anterior aspect of the tibia.
With use of two parallel drill-holes in the anterior aspect of the
tibia, a number-5 nonabsorbable suture is utilized in a laterally
buried horizontal mattress fashion to secure the myofascial flap
over the distal and anterior aspects of the bone end. Additional
number-1 or 0 sutures are placed in a simple or figure-of-eight
fashion approximately 4 to 5 cm proximal to the end of the
bone where the distal myofascial flap terminates to reinforce
the myodesis by anchoring it to the anterior tibial periosteum.
After this, the fasciocutaneous flap is further secured medially
and laterally to the anterior crural fascia, and finally skin clo-
sure is performed.
The knee disarticulation was originally described in the
pre-anesthetic era as an alternative to transosseous amputa-
tion79-81. This was ideal at the time because it could be performed
quickly with low blood loss due to the absence of bone cuts.
Historically, the residual limb was covered with only subcuta-
neous tissue and skin, but this quickly fell out of favor because
the thin coverage resulted in poor tolerance of a prosthesis6. Its
popularity has since increased among experts because of the
development and utilization of a posterior myofasciocutaneous
T R AU M AT I C AND T R AU M A -R E L AT E D A M P U TAT I O N S
flap that appropriately pads the residual limb82-84. Despite the
increased popularity and improved outcomes of the knee dis-
articulation, the LEAP study recently cast a negative light on
through-the-knee amputations after its findings indicated that
patients with such an amputation had the slowest walking
speeds and the least self-reported satisfaction5. This result may
be related to the poor soft-tissue coverage with these amputa-
tions. The study authors indicated that at least twelve of eigh-
teen limbs undergoing through-the-knee amputation were
lacking any gastrocnemius muscle for distal coverage, leaving
only subcutaneous tissue and skin for coverage, which osten-
sibly led to poor prosthetic tolerance5. Recent improvements in
prostheses have also made this level more appealing, with an
improved ability to compensate for the obligatory asymmetry
of the heights of the centers of knee rotation between the sound
limb and the limb with the through-the-knee amputation.
Transfemoral Amputation, Hip Disarticulation,
and Hemipelvectomy
The loss of the knee following a transfemoral amputation re-
sults in a less efficient gait and increased energy expenditure
during walking, ultimately translating into Short Form-36
(SF-36) scores that are lower than those for patients with a
more distal amputation41,73,85-87. At this proximal level, it is critical
to perform a biomechanically sound amputation in order to
minimize the inefficiency of the gait. The adductor myodesis is
the most critical step toward achieving this goal. Gottschalk
and Stills26 reported that the loss of the adductor magnus in-
sertion from the distal part of the femur leads to a 70% loss of
the adduction moment on the femur. This leads to progressive
muscle atrophy and decreased thigh strength and allows a
relatively unopposed abduction moment, gradually causing
a lateral drift of the residual femur within the soft-tissue en-
velope (Figs. 6-A and 6-B)26,27,30,88,89. When this occurs, the re-
maining hip musculature is unable to adequately support the
pelvis, which decreases gait efficiency even further. For this
reason, it is imperative that an adductor myodesis be per-
formed during a transfemoral amputation. We advocate an
additional myodesis of the medial hamstrings to enhance the
posteromedial forces counterbalancing the strong abductors
and hip flexors. Myoplasty of the quadriceps apron (the ret-
inacular and tendinous expansion of the distal quadriceps
musculature proximal to the patella) and biceps femoris is then
performed to maximize padding and create a cylindrical, rather
than a conical, distal part of the residual limb.
Hip disarticulation and hemipelvectomy are fortunately
rarely required and are amputations of last resort. Historically,
the functional outcomes and capacity for walking have been
poor after amputations at these levels, but the development of
modern suction-fit prosthetics has allowed good functional out-
comes in some patients. General rules regarding nerve man-
agement and padding apply to both levels. Preservation of as
much of the hemipelvis as the soft tissues permit (e.g., portions
of the iliac wing or ischium) may improve sitting balance and
prosthesis force transmission and suspension following nearly
total hemipelvectomy.
 2862
TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG
d
T R AU M AT I C AND T R AU M A -R E L AT E D A M P U TAT I O N S
V O L U M E 92-A N U M B E R 17 D E C E M B E R 1, 2 010
d d

Fig. 6-A Fig. 6-B

Figs. 6-A and 6-B Standing scanogram radiographs demonstrating the limb-alignment benefits of length preservation with a transfemoral amputation and a
stable adductor myodesis. Fig. 6-A A patient with a long residual limb after a right transfemoral amputation, with nearly anatomic femoral alignment and a
stable myodesis. Fig. 6-B A patient with a mid-length left transfemoral amputation, with lateral drift of the distal part of the femur secondary to an abduction
deformity and a failed myodesis.
 2863
TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG
d
V O L U M E 92-A N U M B E R 17 D E C E M B E R 1, 2 010
d d
Postoperative Care
Multiple, sometimes conflicting management techniques and
philosophies exist with regard to the postoperative dressing
after a trauma-related amputation. The most commonly used
techniques include utilization of soft or rigid dressings and the
immediate postoperative prosthesis (IPOP). Each of these has
advantages and disadvantages, but when utilized appropriately
all are currently acceptable as no method has proven superior
with regard to preventing complications or improving out-
comes. Regardless of the technique chosen, it is imperative that
gentle balanced compression be applied to the residual limb to
control swelling, decrease pain, and promote a stable limb vol-
ume. We advocate early utilization of elastic shrinkers as soon
as postoperative drains are removed. Regardless, a transition
from postoperative dressings to elastic shrinkers is warranted as
soon as the surgeon is satisfied with the initial wound-healing
in order to further stabilize the limb volume and ready the limb
for prosthetic wear. In addition, early physical therapy should
be initiated to prevent contracture formation.
Soft and Rigid Dressings
Trauma-related amputations are frequently performed within
the zone of injury, and atypical soft-tissue coverage is relatively
common5. The use of a soft dressing allows frequent non-labor-
intensive dressing changes and close surveillance of these
complication-prone wound closures. Rigid dressings have fre-
quently been utilized in the management of transtibial and more
distal amputations. The efficacy of this bandage lies in its ability to
control edema, prevent joint contractures, and improve pain
control6. Despite multiple studies that have shown a trend toward
better wound-healing with a rigid dressing, the soft dressing is still
frequently used and recommended after trauma-related ampu-
tations because of the ease of wound inspection, the improved
ability to mobilize the patients early, and the decreased risk of
pressure ulceration, particularly over the patella5,72,90-95.
Immediate Postoperative Prosthesis
The immediate postoperative prosthesis (IPOP) was originally
proposed shortly after World War I and has been used and
modified following World War II, the Korean War, and the
Vietnam War96-100. The premise of the IPOP is to immediately
fit patients with a temporary prosthesis following an operation.
Benefits of the IPOP have been demonstrated mainly in a non-
trauma population and include improved psychological out-
look, less perceived loss of function, shorter hospital stays,
fewer revision operations, and a faster time to initial prosthetic
fitting90,94,101,102. Despite these advantages, IPOP use is limited in
the trauma population because of expense and time require-
ments as well as the very real concerns of achieving adequate
wound-healing and the early detection of infection and asso-
ciated injuries that often preclude early mobilization.
Outcomes of Treatment
Functional Outcomes
In 1993, Pierce et al.3 questioned the concept that individuals
with a trauma-related amputation routinely had good functional
T R AU M AT I C AND T R AU M A -R E L AT E D A M P U TAT I O N S
outcomes when they discovered that 51% of their sixty-one
patients experienced anatomic or physical problems related to
the amputation. These data were supported by the findings of
Smith et al.103, who indicated that individuals with an isolated
transtibial amputation scored significantly lower than age-
matched individuals in the SF-36 categories of physical func-
tioning (p = 0.0001) and role limitations (p = 0.0004) because
of physical health problems. Despite these findings, an opti-
mistic attitude about the outcomes of trauma-related ampu-
tations persisted, as was made readily apparent by the LEAP
study hypothesis that patients who underwent amputation
after severe lower-extremity injury would have better outcomes
than those who underwent limb salvage7. The study, however,
did not confirm this and actually demonstrated that severe
disability was common following above-the-ankle amputations
due to trauma5.
The LEAP study continues to heighten the awareness that
amputation is not always the best treatment for severe lower-
extremity injuries. The study demonstrated in a prospective
fashion the short-term complications that accompany this
procedure4. Long-term follow-up studies have also indicated
that individuals with a trauma-related amputation have long-
term residual limb, phantom-limb, back, and joint pain104-107.
Low-back pain appears to be the most common chronic
disabling pain experienced by individuals with an amputation.
Smith et al.107 reported that 71% of their patients experienced
back pain following a unilateral amputation. The study subjects
indicated that the back pain was significantly more bothersome
than their phantom-limb pain (p £ 0.05). The frequency of
back pain was also significantly higher after above-the-knee
amputations (p £ 0.05).
In addition to the chronic pain experienced by individ-
uals who have had an amputation, the most concerning health
issue in this population was described by Robbins et al.104 after
a review of the long-term health outcomes associated with
war-related amputations. They reviewed multiple studies that
indicated that individuals with an amputation were at a sig-
nificantly higher risk of developing and dying of cardiovascular
disease than a control group of matched patients (p < 0.05).
Another area that should be evaluated is the ability of
patients to return to a productive vocational life following a
trauma-related amputation. Substantial evidence suggests that,
although the majority of individuals with a trauma-related
amputation are able to return to work, they frequently require a
change in their occupation following their injury108.
Pain Management
There is a distinct association between acute postoperative pain
and chronic amputation-related pain. Patients who report the
greatest acute phantom-limb pain are more likely to continue
to be affected by phantom-limb pain at both six and twelve
months following the operation109. Consequently, attempts
have been made to reduce the early pain experienced following
an amputation. The long-term positive impact of these tech-
niques is currently being debated, yet the short-term benefits of
current anesthesia techniques include increased patient com-
 2864
TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG
d
V O L U M E 92-A N U M B E R 17 D E C E M B E R 1, 2 010
d d
fort, a decreased narcotic requirement, and slightly earlier mo-
bilization. The goal of these anesthesia techniques is to prevent
central neuroplastic changes from occurring through the use of
preventive multimodal analgesia. These modalities are aimed at
various stages of the nociceptive pathways and include anti-
convulsants such as gabapentin and pregabalin, nonsteroidal
anti-inflammatory drugs, local nerve-sheath injections of an-
esthetics, alpha-2 agonists, ketamine, opioids, preemptive epi-
dural injections, and regional nerve blocks110. We believe that
the complexity of performing these various anesthesia tech-
niques, the multiple classes of medications, and the often chronic
nature of amputation-related pain suggest that a surgeon should
consult a pain specialist either prior to or shortly following an
amputation. A cooperative effort between the pain specialist and
the surgeon will ensure that causes of pain that can be relieved with
surgery are addressed while long-term chronic pain is also treated.
Psychosocial Impact of Amputation
The findings of the LEAP study group have heightened the
awareness of the psychosocial disability that individuals expe-
rience after a lower-extremity amputation5. In that study, 48%
of 505 patients who had sustained severe lower-extremity trauma
had a positive result on screening for a psychological disorder at
three months after the injury. In this same cohort, 42% of 452
patients remained positive for a psychological disorder at twenty-
four months after the injury111. Trauma-related amputations
represent a life stressor for even the highest functioning indi-
viduals. Trauma patients generally do not get time to consider
their situation, and often their first thought or discussion re-
garding amputation occurs when they awaken from anesthesia
with the loss of a limb.
In an attempt to address all of these necessary compo-
nents of rehabilitation after an amputation, including the
psychological needs, the United States military has established
Amputee Care Programs during the current conflicts as well as
during and after all previous conflicts starting with World War
I6,112. The establishment of these programs was an attempt to
standardize the care as well as pool the resources and expertise
in the multidimensional care of military personnel who had
had an amputation. The current program was developed with
the recognition of the complex multifaceted aspects of a pa-
tient’s recovery, and efforts were made to provide support in
each of these areas while utilizing a sports medicine-based,
activity-oriented rehabilitation program113.
While the implementation of such comprehensive pro-
grams is not realistic at all medical trauma facilities, many already
exist in one form or another, and those existing inpatient reha-
bilitation programs can be utilized for individuals with a trauma-
related amputation. Pezzin et al.114 demonstrated that patients who
were discharged to inpatient rehabilitation after a trauma-related
amputation had improved health and vocational prospects.
Complications Following Trauma-Related Amputations
Despite attention to perioperative and operative details, am-
putations due to trauma can be fraught with complications.
These can range from minor dermatologic problems to major
T R AU M AT I C AND T R AU M A -R E L AT E D A M P U TAT I O N S
complications requiring multiple return trips to the operating
room and possible loss of residual limb length. In a recent
investigation by the LEAP study group, >85% of 520 patients
who had severe lower-extremity trauma had a complication4.
Nearly half of 149 patients who were treated with amputation
had either a wound infection or wound necrosis. This supports
the early finding of Pierce et al.3 that half of their sixty-one
patients who had undergone a trauma-related amputation had
a postoperative complication. The most common complications
include symptomatic neuromas and phantom and residual-
limb pain4. Less frequently reported short and intermediate-
term complications include bone spurs, heterotopic ossification,
and failure of a myodesis procedure6. In the long term, most
amputations are complicated by some degree of chronic residual-
limb, phantom-limb, and low-back pain as well as degenerative
joint disease of both ipsilateral and contralateral joints104,107,115. As
noted, patients who have had an amputation are also at sub-
stantial risk of developing cardiovascular disease104.
Approach to Surgical Complications
and Revision Amputations
The long-term follow-up of individuals with a trauma-related
amputation throughout and after their initial rehabilitation
may identify a substantial proportion with potentially correct-
able symptomatic complications, including bone spurs, hetero-
topic ossification, symptomatic neuromas, failure of a myodesis,
wound complications, and redundant soft tissue in the form of
so-called dog ears (redundant soft tissue at the wound edge that
protrudes and is cosmetically unappealing and may result in
pain or ulceration within a prosthetic socket). Under these
circumstances, it is imperative to maintain a close working
relationship with both the patient and his or her prosthetist.
Exhaustive nonoperative treatment options should be used for
the early management of all of these complications, with the
exception of failure of a myodesis. Prosthesis and socket ad-
justments, padding, and gait training should all be maximized
prior to operative intervention.
Operative intervention may be warranted when func-
tional improvement ceases to progress, the patient is still not
satisfied with the current use of the prosthesis or with his or her
overall function, and a cause of symptoms for which an op-
eration is indicated is identified. In the majority of situations,
previous amputation incisions should be utilized and the sur-
gical planes should be carefully developed. Particular attention
should be paid to the myodesis. With certain complications
such as so-called dog ears, superficial neuromas, or superficial
infections, the myodesis may not have to be taken down in
order to address the problem. If the myodesis is taken down,
preservation of the muscle fascia must be accomplished in
order to perform an adequate revision myodesis. Careful dis-
section through the scarred tissue planes is performed until
anatomically identifiable structures are seen. At this time, re-
vision traction neurectomy, revision myodesis, or excision of
heterotopic bone can be carried out. In our experience, dra-
matic pain relief and increased prosthetic wear following op-
erative treatment of complications is common.

TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG
d
V O L U M E 92-A N U M B E R 17 D E C E M B E R 1, 2 010
d d
Fig. 7-A
Anteroposterior radiographs showing transtibial amputations with a distal bridge synostosis complicated by fracture and
implant failure (Fig. 7-A) and with stable, uncomplicated early consolidation of the osteosynthesis sites (Fig. 7-B).
Controversies and Future Directions
Bridge Synostosis (Modified Ertl) and Transtibial Amputation
During World War I, Ertl developed and popularized a tech-
nique for transtibial amputation that created a distal synostosis
between the tibia and the fibula in order to provide a more
stable, broad, end-bearing residual limb116. Although Ertl’s
theories regarding the sealing of the medullary canal and the
restoration of so-called normal bone physiology have been
largely discarded, his concept has been broadly utilized and
frequently modified since that time74,117,118. There is substantial
controversy surrounding this procedure, and the functional
benefit of the technique remains uncertain. In 2006, Pinzur
et al.119 reported the results of a study that suggested that patient-
perceived functional outcomes were improved by a bone-bridging
procedure. However, in a more recent study comparing the
patients in that series with patients in the United States, Pinzur
and colleagues120 were unable to demonstrate an advantage over
the traditional transtibial amputation described by Burgess et al.31.
To our knowledge, there has been no long-term review
of the complications unique to this procedure, which include
symptomatic nonunion, malunion, bone-bridge dislocation,
and implant-related complications (Figs. 7-A and 7-B)118,121.
2865
T R AU M AT I C AND T R AU M A -R E L AT E D A M P U TAT I O N S
Fig. 7-B
Further study of the complication rates of these procedures as
well as additional, ideally prospective, studies to determine if
there is functional benefit of this procedure over traditional
techniques must be conducted prior to advocating creation of a
bridge synostosis as a preferred method of primary amputation.
Osseointegration
Osseointegration is described as structurally and functionally
stable fixation and coexistence between bone and controlled
synthetic components (usually titanium) providing lasting clin-
ical function without rejection122. Osseointegration has been in
clinical use since the 1950s, but its application in amputation
surgery was only begun in 1990. It is an experimental technique
in which a titanium rod is screwed into a residual bone and
then, often at a second surgery, is brought transcutaneously to
allow prosthetic limb attachment. Osseointegration has not
been approved by the United States Food and Drug Adminis-
tration (FDA).
Potential benefits of osseointegration include easy and
fast donning and doffing of the artificial limb, direct force
transmission to the prosthesis, a proper fit every time that
always remains in the same position, no restriction of the
 2866
TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG
d
V O L U M E 92-A N U M B E R 17 D E C E M B E R 1, 2 010
d d
proximal joint range of motion, and no socket or liner that may
cause sweating, sores, and discomfort123,124. Despite these sug-
gested advantages, the concept of osseointegration remains
experimental and is associated with substantial complications
that have limited its use to date. The most frequent compli-
cations include superficial and deep infections, implant loos-
ening, and periprosthetic fracture125. Revision osseointegration
surgery or revision to a conventional residual limb following
failure of osseointegration frequently requires substantial short-
ening of the residual limb. The most concerning of these problems
is the risk of infection, and continued research efforts are being
devoted to developing methods of stabilizing the skin-implant-
environment interface around transcutaneous implants126.
Overview
Trauma-related amputations are relatively common but are
infrequently performed by the majority of orthopaedic sur-
geons. For this reason, an involved and attentive surgeon is a
necessity for optimal outcomes, and a well-performed ampu-
tation or revision amputation should always be considered a
challenge for even an experienced surgeon. Although these
procedures are associated with frequent complications and may
References
1. Ziegler-Graham K, MacKenzie EJ, Ephraim PL, Travison TG, Brookmeyer R. Esti-
mating the prevalence of limb loss in the United States: 2005 to 2050. Arch Phys
Med Rehabil. 2008;89:422-9.
2. Owings MF, Kozak LJ. Ambulatory and inpatient procedures in the United States,
1996. Vital Health Stat 13. 1998;139:1-119.
3. Pierce RO Jr, Kernek CB, Ambrose TA 2nd. The plight of the traumatic amputee.
Orthopedics. 1993;16:793-7.
4. Harris AM, Althausen PL, Kellam J, Bosse MJ, Castillo R; Lower Extremity As-
sessment Project (LEAP) Study Group. Complications following limb-threatening
lower extremity trauma. J Orthop Trauma. 2009;23:1-6.
5. MacKenzie EJ, Bosse MJ, Castillo RC, Smith DG, Webb LX, Kellam JF, Burgess
AR, Swiontkowski MF, Sanders RW, Jones AL, McAndrew MP, Patterson BM,
Travison TG, McCarthy ML. Functional outcomes following trauma-related lower-
extremity amputation. J Bone Joint Surg Am. 2004;86:1636-45.
6. Smith DG, Michael JW, Bowker JH. Atlas of amputations and limb deficiencies:
surgical, prosthetic and rehabilitation principles. 3rd ed. Rosemont, IL: American
Academy of Orthopaedic Surgeons; 2004.
7. Bosse MJ, MacKenzie EJ, Kellam JF, Burgess AR, Webb LX, Swiontkowski MF,
Sanders RW, Jones AL, McAndrew MP, Patterson BM, McCarthy ML, Travison TG,
Castillo RC. An analysis of outcomes of reconstruction or amputation after leg-
threatening injuries. N Engl J Med. 2002;347:1924-31.
8. MacKenzie EJ, Bosse MJ. Factors influencing outcome following limb-threatening
lower limb trauma: lessons learned from the Lower Extremity Assessment Project
(LEAP). J Am Acad Orthop Surg. 2006;14(10 Spec No.):S205-10.
9. MacKenzie EJ, Bosse MJ, Pollak AN, Webb LX, Swiontkowski MF, Kellam JF,
Smith DG, Sanders RW, Jones AL, Starr AJ, McAndrew MP, Patterson BM, Burgess
AR, Castillo RC. Long-term persistence of disability following severe lower-limb
trauma. Results of a seven-year follow-up. J Bone Joint Surg Am. 2005;87:1801-9.
10. MacKenzie EJ, Jones AS, Bosse MJ, Castillo RC, Pollak AN, Webb LX, Swiontkowski
MF, Kellam JF, Smith DG, Sanders RW, Jones AL, Starr AJ, McAndrew MP, Patterson
BM, Burgess AR. Health-care costs associated with amputation or reconstruction of
a limb-threatening injury. J Bone Joint Surg Am. 2007;89:1685-92.
11. Ly TV, Travison TG, Castillo RC, Bosse MJ, MacKenzie EJ; LEAP Study Group.
Ability of lower-extremity injury severity scores to predict functional outcome after
limb salvage. J Bone Joint Surg Am. 2008;90:1738-43.
12. Bosse MJ, McCarthy ML, Jones AL, Webb LX, Sims SH, Sanders RW, MacKenzie
EJ; Lower Extremity Assessment Project (LEAP) Study Group. The insensate foot
T R AU M AT I C AND T R AU M A -R E L AT E D A M P U TAT I O N S
lead to poor outcomes, adherence to proper operative tech-
niques and the avoidance of well-documented technical errors
can dramatically improve the ultimate functional outcome for
the patient. While the treatment of severe lower-extremity
trauma can be disheartening to both the patient and the sur-
geon, a successful result with dramatic functional recovery and
a highly functioning individual can be equally rewarding. n
LT Scott M. Tintle, MD
LCDR Jonathan A. Forsberg, MD
MAJ Benjamin K. Potter, MD
Walter Reed Army Medical Center,
6900 Georgia Avenue N.W.,
Building 2, Clinic 5A, Washington, DC 20307.
E-mail address for B.K. Potter: kyle.potter@us.army.mil
CDR John J. Keeling, MD
LTC Scott B. Shawen, MD
Department of Orthopaedic Surgery,
National Naval Medical Center,
8901 Wisconsin Avenue, Bethesda, MD 20889
following severe lower extremity trauma: an indication for amputation? J Bone Joint
Surg Am. 2005;87:2601-8.
13. Lange RH, Bach AW, Hansen ST Jr, Johansen KH. Open tibial fractures with
associated vascular injuries: prognosis for limb salvage. J Trauma. 1985;25:203-8.
14. Dougherty PJ. Open tibia fracture: amputation versus limb salvage. Opinion:
below-the-knee amputation. J Orthop Trauma. 2007;21:67-8.
15. Shawen SB, Keeling JJ, Branstetter J, Kirk KL, Ficke JR. The mangled foot and
leg: salvage versus amputation. Foot Ankle Clin. 2010;15:63-75.
16. Brown KV, Ramasamy A, McLeod J, Stapley S, Clasper JC. Predicting the need
for early amputation in ballistic mangled extremity injuries. J Trauma. 2009;66(4
Suppl):S93-8.
17. Owens BD, White DW, Wenke JC. Comparison of irrigation solutions and devices
in a contaminated musculoskeletal wound survival model. J Bone Joint Surg Am.
2009;91:92-8.
18. Hassinger SM, Harding G, Wongworawat MD. High-pressure pulsatile lavage
propagates bacteria into soft tissue. Clin Orthop Relat Res. 2005;439:27-31.
19. Adili A, Bhandari M, Schemitsch EH. The biomechanical effect of high-pressure
irrigation on diaphyseal fracture healing in vivo. J Orthop Trauma. 2002;16:413-7.
20. Bhandari M, Adili A, Lachowski RJ. High pressure pulsatile lavage of contami-
nated human tibiae: an in vitro study. J Orthop Trauma. 1998;12:479-84.
21. Bhandari M, Schemitsch EH, Adili A, Lachowski RJ, Shaughnessy SG. High and
low pressure pulsatile lavage of contaminated tibial fractures: an in vitro study of
bacterial adherence and bone damage. J Orthop Trauma. 1999;13:526-33.
22. Dirschl DR, Duff GP, Dahners LE, Edin M, Rahn BA, Miclau T. High pressure
pulsatile lavage irrigation of intraarticular fractures: effects on fracture healing.
J Orthop Trauma. 1998;12:460-3.
23. Harris I. Gradual closure of fasciotomy wounds using a vessel loop shoelace.
Injury. 1993;24:565-6.
24. Forsberg JA, Elster EA, Andersen RC, Nylen E, Brown TS, Rose MW, Stojadinovic
A, Becker KL, McGuigan FX. Correlation of procalcitonin and cytokine expression with
dehiscence of wartime extremity wounds. J Bone Joint Surg Am. 2008;90:580-8.
25. Seligson D, Mehta S, Voos K, Henry SL, Johnson JR. The use of antibiotic-
impregnated polymethylmethacrylate beads to prevent the evolution of localized
infection. J Orthop Trauma. 1992;6:401-6.
26. Gottschalk FA, Stills M. The biomechanics of trans-femoral amputation. Pros-
thet Orthot Int. 1994;18:12-7.
 2867
TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG
d
V O L U M E 92-A N U M B E R 17 D E C E M B E R 1, 2 010
d d
27. Gottschalk F. Transfemoral amputation. Biomechanics and surgery. Clin Orthop
Relat Res. 1999;361:15-22.
28. Smith DG, Fergason JR. Transtibial amputations. Clin Orthop Relat Res.
1999;361:108-15.
29. Pinzur MS, Gottschalk F, Pinto MA, Smith DG. Controversies in lower extremity
amputation. Instr Course Lect. 2008;57:663-72.
30. Jaegers SM, Arendzen JH, de Jongh HJ. An electromyographic study of the hip
muscles of transfemoral amputees in walking. Clin Orthop Relat Res.
1996;328:119-28.
31. Burgess EM, Romano RL, Zettl JH, Schrock RD Jr. Amputations of the leg for
peripheral vascular insufficiency. J Bone Joint Surg Am. 1971;53:874-90.
32. Pedersen HE. The problem of the geriatric amputee. Artif Limbs. 1968;12
Suppl:1-3.
33. Green DP, Hotchkiss RN, Pederson WC, Wolfe SW. Green’s operative hand
surgery e-dition: text with continually updated online reference, 2-volume set. 5th ed.
New York: Churchill Livingstone; 2005.
34. Ebrahimzadeh MH, Hariri S. Long-term outcomes of unilateral transtibial am-
putations. Mil Med. 2009;174:593-7.
35. Ebrahimzadeh MH, Fattahi AS. Long-term clinical outcomes of Iranian veterans
with unilateral transfemoral amputation. Disabil Rehabil. 2009;31:1873-7.
36. Ducic I, Mesbahi AN, Attinger CE, Graw K. The role of peripheral nerve surgery in
the treatment of chronic pain associated with amputation stumps. Plast Reconstr
Surg. 2008;121:908-17.
37. Rahimi F, Muehleman C. Epineurial capping via Surgitron and the reduction of
stump neuromas in the rat. J Foot Surg. 1992;31:124-8.
38. Whipple RR, Unsell RS. Treatment of painful neuromas. Orthop Clin North Am.
1988;19:175-85.
39. Swanson AB, Boeve NR, Lumsden RM. The prevention and treatment of am-
putation neuromata by silicone capping. J Hand Surg Am. 1977;2:70-8.
40. Martini A, Fromm B. A new operation for the prevention and treatment of am-
putation neuromas. J Bone Joint Surg Br. 1989;71:379-82.
41. Waters RL, Perry J, Antonelli D, Hislop H. Energy cost of walking of amputees:
the influence of level of amputation. J Bone Joint Surg Am. 1976;58:42-6.
42. Waters RL, Lunsford BR, Perry J, Byrd R. Energy-speed relationship of walking:
standard tables. J Orthop Res. 1988;6:215-22.
43. Pinzur MS, Gold J, Schwartz D, Gross N. Energy demands for walking in dys-
vascular amputees as related to the level of amputation. Orthopedics. 1992;15:
1033-7.
44. Gonzalez EG, Corcoran PJ, Reyes RL. Energy expenditure in below-knee ampu-
tees: correlation with stump length. Arch Phys Med Rehabil. 1974;55:111-9.
45. Waters RL, Barnes G, Husserl T, Silver L, Liss R. Comparable energy expendi-
ture after arthrodesis of the hip and ankle. J Bone Joint Surg Am. 1988;70:1032-7.
46. Pinzur MS, Gottschalk FA, Pinto MA, Smith DG; American Academy of Ortho-
paedic Surgeons. Controversies in lower-extremity amputation. J Bone Joint Surg
Am. 2007;89:1118-27.
47. Erdmann D, Sundin BM, Yasui K, Wong MS, Levin LS. Microsurgical free flap
transfer to amputation sites: indications and results. Ann Plast Surg. 2002;48:
167-72.
48. Pickard-Gabriel CJ, Ledford CL, Gajewski DA, Granville RR, Andersen RC. Trau-
matic transfemoral amputation with concomitant ipsilateral proximal femoral frac-
ture. A report of two cases. J Bone Joint Surg Am. 2007;89:2764-8.
49. Gordon WT, O’Brien FP, Strauss JE, Andersen RC, Potter BK. Outcomes asso-
ciated with the internal fixation of long-bone fractures proximal to traumatic ampu-
tations. J Bone Joint Surg Am. 2010;92:2312-8.
50. Gwinn DE, Keeling J, Froehner JW, McGuigan FX, Andersen R. Perioperative
differences between bone bridging and non-bone bridging transtibial amputations for
wartime lower extremity trauma. Foot Ankle Int. 2008;29:787-93.
51. Potter BK, Burns TC, Lacap AP, Granville RR, Gajewski DA. Heterotopic ossifi-
cation following traumatic and combat-related amputations. Prevalence, risk factors,
and preliminary results of excision. J Bone Joint Surg Am. 2007;89:476-86.
52. Gallico GG 3rd, Ehrlichman RJ, Jupiter J, May JW Jr. Free flaps to preserve below-
knee amputation stumps: long-term evaluation. Plast Reconstr Surg. 1987;79:
871-8.
53. Ghali S, Harris PA, Khan U, Pearse M, Nanchahal J. Leg length preservation with
pedicled fillet of foot flaps after traumatic amputations. Plast Reconstr Surg. 2005;
115:498-505.
T R AU M AT I C AND T R AU M A -R E L AT E D A M P U TAT I O N S
54. Gumley GJ, MacLeod AM, Thistlethwaite S, Ryan AR. Total cutaneous harvesting
from an amputated foot—two free flaps used for acute reconstruction. Br J Plast
Surg. 1987;40:313-6.
55. Henman PD, Jain AS. Skin grafting an amputation stump: considerations for the
choice of donor site. Br J Plast Surg. 2000;53:357.
56. Kasabian AK, Colen SR, Shaw WW, Pachter HL. The role of microvascular free
flaps in salvaging below-knee amputation stumps: a review of 22 cases. J Trauma.
1991;31:495-501.
57. Kasabian AK, Glat PM, Eidelman Y, Colen S, Longaker MT, Attinger C, Shaw W.
Salvage of traumatic below-knee amputation stumps utilizing the filet of foot free
flap: critical evaluation of six cases. Plast Reconstr Surg. 1995;96:1145-53.
58. Küntscher MV, Erdmann D, Homann HH, Steinau HU, Levin SL, Germann G. The
concept of fillet flaps: classification, indications, and analysis of their clinical value.
Plast Reconstr Surg. 2001;108:885-96.
59. Pelissier P, Pistre V, Casoli V, Martin D, Baudet J. Reconstruction of short lower
leg stumps with the osteomusculocutaneous latissimus dorsi-rib flap. Plast Re-
constr Surg. 2002;109:1013-7.
60. Shenaq SM, Krouskop T, Stal S, Spira M. Salvage of amputation stumps by
secondary reconstruction utilizing microsurgical free-tissue transfer. Plast Reconstr
Surg. 1987;79:861-70.
61. Wood MR, Hunter GA, Millstein SG. The value of stump split skin grafting fol-
lowing amputation for trauma in adult upper and lower limb amputees. Prosthet
Orthot Int. 1987;11:71-4.
62. Wieslander JB, Wendeberg B, Linge G, Buttazzoni G, Buttazzoni AM. Tissue
expansion: a method to preserve bone length and joints following traumatic ampu-
tations of the leg—a follow-up of five legs amputated at different levels. Plast Re-
constr Surg. 1996;97:1065-71.
63. Rees RS, Nanney LB, Fleming P, Cary A. Tissue expansion: its role in traumatic
below-knee amputations. Plast Reconstr Surg. 1986;77:133-7.
64. Jupiter JB, Tsai TM, Kleinert HE. Salvage replantation of lower limb amputa-
tions. Plast Reconstr Surg. 1982;69:1-8.
65. Dedmond BT, Davids JR. Function of skin grafts in children following acquired
amputation of the lower extremity. J Bone Joint Surg Am. 2005;87:1054-8.
66. Harris RI. Syme’s amputation; the technical details essential for success.
J Bone Joint Surg Br. 1956;38:614-32.
67. Syme J. Amputation at the ankle joint. London Edinburgh Month J Med Science.
1843;2:93-6.
68. Gaine WJ, McCreath SW. Syme’s amputation revisited: a review of 46 cases.
J Bone Joint Surg Br. 1996;78:461-7.
69. Greene WB, Cary JM. Partial foot amputations in children. A comparison of the
several types with the Syme amputation. J Bone Joint Surg Am. 1982;64:438-43.
70. Smith DG, Sangeorzan BJ, Hansen ST Jr, Burgess EM. Achilles tendon tenodesis
to prevent heel pad migration in the Syme’s amputation. Foot Ankle Int. 1994;15:14-7.
71. Hornby R, Harris R. Syme’s amputation. Follow-up study of weight-bearing in
sixty-eight patients. J Bone Joint Surg Am. 1975;57:346-9.
72. Barber GG, McPhail NV, Scobie TK, Brennan MC, Ellis CC. A prospective study of
lower limb amputations. Can J Surg. 1983;26:339-41.
73. Taghipour H, Moharamzad Y, Mafi AR, Amini A, Naghizadeh MM, Soroush MR,
Namavari A. Quality of life among veterans with war-related unilateral lower extremity
amputation: a long-term survey in a prosthesis center in Iran. J Orthop Trauma.
2009;23:525-30.
74. Dougherty PJ. Transtibial amputees from the Vietnam War. Twenty-eight-year
follow-up. J Bone Joint Surg Am. 2001;83:383-9.
75. Purry NA, Hannon MA. How successful is below-knee amputation for injury?
Injury. 1989;20:32-6.
76. Bard G, Ralston HJ. Measurement of energy expenditure during ambulation,
with special reference to evaluation of assistive devices. Arch Phys Med Rehabil.
1959;40:415-20.
77. Canale ST, Beaty JH, editors. Campbell’s operative orthopaedics e-dition: text
with continually updated online reference. 11th ed. Philadelphia: Mosby; 2008.
78. Assal M, Blanck R, Smith DG. Extended posterior flap for transtibial amputation.
Orthopedics. 2005;28:542-6.
79. Rogers SP. Amputation at the knee joint. J Bone Joint Surg Am. 1940;22:973-9.
80. Velpeau A. Memoire sur l’amputation de la jambe dans l’articulation du genou,
et description d’un nouveau procede pour pratiquer cette operation. Arch Gen Med.
1830;24:44-60.
 2868
TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG
d
T R AU M AT I C AND T R AU M A -R E L AT E D A M P U TAT I O N S
V O L U M E 92-A N U M B E R 17 D E C E M B E R 1, 2 010
d d

81. Smith N. Amputation at the knee-joint. Am Med Rev and J Original Selected 105. Ehde DM, Smith DG, Czerniecki JM, Campbell KM, Malchow DM, Robinson LR.
Papers Med Surg. 1825;II:370. Back pain as a secondary disability in persons with lower limb amputations. Arch
Phys Med Rehabil. 2001;82:731-4.
82. Pinzur MS, Bowker JH. Knee disarticulation. Clin Orthop Relat Res. 1999;361:
23-8. 106. Norvell DC, Czerniecki JM, Reiber GE, Maynard C, Pecoraro JA, Weiss NS.
The prevalence of knee pain and symptomatic knee osteoarthritis among veteran
83. Bowker JH, San Giovanni TP, Pinzur MS. North American experience with knee
traumatic amputees and nonamputees. Arch Phys Med Rehabil. 2005;86:
disarticulation with use of a posterior myofasciocutaneous flap. Healing rate and func-
487-93.
tional results in seventy-seven patients. J Bone Joint Surg Am. 2000;82:1571-4.
107. Smith DG, Ehde DM, Legro MW, Reiber GE, del Aguila M, Boone DA. Phantom
84. Klaes W, Eigler FW. [A new technic of transgenicular amputation]. Chirurg.
limb, residual limb, and back pain after lower extremity amputations. Clin Orthop
1985;56:735-40. German.
Relat Res. 1999;361:29-38.
85. Volpicelli LJ, Chambers RB, Wagner FW Jr. Ambulation levels of bilateral lower-
108. Millstein S, Bain D, Hunter GA. A review of employment patterns of industrial
extremity amputees. Analysis of one hundred and three cases. J Bone Joint Surg Am.
amputees—factors influencing rehabilitation. Prosthet Orthot Int. 1985;9:69-78.
1983;65:599-605.
109. Hanley MA, Jensen MP, Smith DG, Ehde DM, Edwards WT, Robinson LR.
86. Hagberg K, Brånemark R. Consequences of non-vascular trans-femoral ampu-
Preamputation pain and acute pain predict chronic pain after lower extremity am-
tation: a survey of quality of life, prosthetic use and problems. Prosthet Orthot Int.
putation. J Pain. 2007;8:102-9.
2001;25:186-94.
110. Wilder-Smith CH, Hill LT, Laurent S. Postamputation pain and sensory changes
87. Dougherty PJ. Long-term follow-up of unilateral transfemoral amputees from the
in treatment-naive patients: characteristics and responses to treatment with tram-
Vietnam war. J Trauma. 2003;54:718-23.
adol, amitriptyline, and placebo. Anesthesiology. 2005;103:619-28.
88. James U. Maximal isometric muscle strength in healthy active male unilateral
111. McCarthy ML, MacKenzie EJ, Edwin D, Bosse MJ, Castillo RC, Starr A; LEAP
above-knee amputees, with special regard to the hip joint. Scand J Rehabil Med.
study group. Psychological distress associated with severe lower-limb injury. J Bone
1973;5:55-66.
Joint Surg Am. 2003;85:1689-97.
89. Thiele B, James U, Stålberg E. Neurophysiological studies on muscle function in
112. Dougherty PJ. Long-term follow-up study of bilateral above-the-knee amputees
the stump of above-knee amputees. Scand J Rehabil Med. 1973;5:67-70.
from the Vietnam War. J Bone Joint Surg Am. 1999;81:1384-90.
90. Deutsch A, English RD, Vermeer TC, Murray PS, Condous M. Removable rigid
113. Potter BK, Scoville CR. Amputation is not isolated: an overview of the US Army
dressings versus soft dressings: a randomized, controlled study with dysvascular,
Amputee Patient Care Program and associated amputee injuries. J Am Acad Orthop
trans-tibial amputees. Prosthet Orthot Int. 2005;29:193-200.
Surg. 2006;14(10 Spec No.):S188-90.
91. Frogameni AD, Booth R, Mumaw LA, Cummings V. Comparison of soft dressing
114. Pezzin LE, Dillingham TR, MacKenzie EJ. Rehabilitation and the long-term
and rigid dressing in the healing of amputated limbs of rabbits. Am J Phys Med
outcomes of persons with trauma-related amputations. Arch Phys Med Rehabil.
Rehabil. 1989;68:234-9.
2000;81:292-300.
92. Kane TJ 3rd, Pollak EW. The rigid versus soft postoperative dressing controversy:
115. Struyf PA, van Heugten CM, Hitters MW, Smeets RJ. The prevalence of osteo-
a controlled study in vascular below-knee amputees. Am Surg. 1980;46:244-7.
arthritis of the intact hip and knee among traumatic leg amputees. Arch Phys Med
93. Nawijn SE, van der Linde H, Emmelot CH, Hofstad CJ. Stump management after Rehabil. 2009;90:440-6.
trans-tibial amputation: a systematic review. Prosthet Orthot Int. 2005;29:13-26.
116. Ertl J. About amputation stumps. Chirurgie. 1949;20:2-12.
94. Smith DG, McFarland LV, Sangeorzan BJ, Reiber GE, Czerniecki JM. Postoper-
117. Anderson CD, Stewart JD, Unger DV. Recent advances in lower-extremity
ative dressing and management strategies for transtibial amputations: a critical
amputations. Curr Opin Orthop. 2007;18:137-44.
review. J Rehabil Res Dev. 2003;40:213-24.
118. Berlet GC, Pokabla C, Serynek P. An alternative technique for the Ertl osteo-
95. Mooney V, Harvey JP Jr, McBride E, Snelson R. Comparison of postoperative
myoplasty. Foot Ankle Int. 2009;30:443-6.
stump management: plaster vs. soft dressings. J Bone Joint Surg Am. 1971;53:241-9.
119. Pinzur MS, Pinto MA, Saltzman M, Batista F, Gottschalk F, Juknelis D.
96. Wilson PD. Early weight-bearing in the treatment of amputations of the lower
Health-related quality of life in patients with transtibial amputation and recon-
limbs. J Bone Joint Surg Am. 1922;4:224-47.
struction with bone bridging of the distal tibia and fibula. Foot Ankle Int. 2006;
97. Berlemont M, Weber R. [Temporary prosthetic fitting of lower limb amputees on 27:907-12.
the operating table. Technic and long-term results in 34 cases]. Acta Orthop Belg.
120. Pinzur MS, Beck J, Himes R, Callaci J. Distal tibiofibular bone-bridging in
1966;32:662-7. French.
transtibial amputation. J Bone Joint Surg Am. 2008;90:2682-7.
98. Burgess EM, Romano RL. The management of lower extremity amputees using
121. Pinto MA, Harris WW. Fibular segment bone bridging in trans-tibial amputation.
immediate postsurgical prostheses. Clin Orthop Relat Res. 1968;57:137-46.
Prosthet Orthot Int. 2004;28:220-4.
99. Mooney V, Nickel VL, Snelson R. Fitting of temporary prosthetic limbs imme-
122. Brånemark R, Brånemark PI, Rydevik B, Myers RR. Osseointegration in skel-
diately after amputation. Calif Med. 1967;107:330-3.
etal reconstruction and rehabilitation: a review. J Rehabil Res Dev. 2001;38:
100. Pinzur MS, Littooy F, Osterman H, Wafer D. Early post-surgical prosthetic limb 175-81.
fitting in dysvascular below-knee amputees with a pre-fabricated temporary limb.
123. Hagberg K, Häggström E, Uden M, Brånemark R. Socket versus bone-anchored
Orthopedics. 1988;11:1051-3.
trans-femoral prostheses: hip range of motion and sitting comfort. Prosthet Orthot
101. Schon LC, Short KW, Soupiou O, Noll K, Rheinstein J. Benefits of early pros- Int. 2005;29:153-63.
thetic management of transtibial amputees: a prospective clinical study of a pre-
124. Sullivan J, Uden M, Robinson KP, Sooriakumaran S. Rehabilitation of the trans-
fabricated prosthesis. Foot Ankle Int. 2002;23:509-14.
femoral amputee with an osseointegrated prosthesis: the United Kingdom experi-
102. Weinstein ES, Livingston S, Rubin JR. The immediate postoperative prosthesis ence. Prosthet Orthot Int. 2003;27:114-20.
(IPOP) in ischemia and septic amputations. Am Surg. 1988;54:386-9.
125. Hagberg K, Brånemark R. One hundred patients treated with osseointegrated
103. Smith DG, Horn P, Malchow D, Boone DA, Reiber GE, Hansen ST Jr. Prosthetic transfemoral amputation prostheses—rehabilitation perspective. J Rehabil Res
history, prosthetic charges, and functional outcome of the isolated, traumatic below- Dev. 2009;46:331-44.
knee amputee. J Trauma. 1995;38:44-7.
126. Pendegrass CJ, Gordon D, Middleton CA, Sun SN, Blunn GW. Sealing the skin
104. Robbins CB, Vreeman DJ, Sothmann MS, Wilson SL, Oldridge NB. A review of barrier around transcutaneous implants: in vitro study of keratinocyte proliferation
the long-term health outcomes associated with war-related amputation. Mil Med. and adhesion in response to surface modifications of titanium alloy. J Bone Joint
2009;174:588-92. Surg Br. 2008;90:114-21.