CHAPTER 16
AMPUTATIONS OF THE LOWER EXTREMITY
Marcus C. Ford
FOOT AND ANKLE Rehabilitation in
AMPUTATIONS 720 nonischemic limbs
TRANSTIBIAL (BELOW-KNEE) Ischemic limbs
AMPUTATIONS 721 Rehabilitation in
Nonischemic limbs 721 ischemic limbs
Lower limb amputations are the most common of all ampu-
tations. Despite advances in revascularization techniques,
the most common indication for lower extremity amputation
remains a dysvascular limb, including that caused by diabe-
tes mellitus and peripheral vascular disease. Peripheral vas-
cular disease from all causes affects over 8 million Americans.
The rate of lower extremity amputation in this population is
around 4 per 1000. Amputation of the contralateral limb is
necessary within 5 years in 30% to 50% of patients who have
an amputation of a dysvascular lower limb. Twenty percent of
below-knee amputations are converted to above-knee ampu-
tations. Over 50% of nontraumatic amputations occur from
diabetes-related pathology. In the diabetic population, first-
year mortality rates after amputation are reported to be as high
as 40%, while overall mortality rates range from 60% to 70%.
The number of amputations for causes other than diabe-
tes and vascular disease, such as tumors and infection, has
decreased in the United States because of surgical and medi-
cal advances. In war-torn countries, improvised explosive
devices and land mines continue to be frequent causes of
traumatic amputations. Also, a high rate of combat-related
lower extremity amputations remains in the military popula-
tion. Current level I and II studies are underway to investigate
optimal lower extremity amputation techniques in this highly
active population.
We advocate a multidisciplinary approach to the medi-
cal management of lower extremity amputations. Diabetic
patients and those with vascular insufficiency who have had
lower extremity amputation demonstrate high rates of 30-day
mortality, stump complications, and hospital readmissions.
Associated coronary artery disease and end-stage renal dis-
ease are predictors for perioperative medical complications
and hospital readmissions.
The level of amputation is always a difficult decision and
has a major effect on a patient’s quality of life. Morbidity is
more frequent after transfemoral amputations than after trans-
tibial amputations. Energy expenditure is an important con-
sideration in choosing the level of amputation. The increased
energy consumption of bipedal locomotion for transtibial
amputees ranges from 40% to 50%, compared with 90% to
100% in transfemoral amputees. Patients with transfemoral
amputations are less likely to use a prosthesis successfully and
consistently than are patients with more distal amputations.
Higher-level amputations, even in children, are associated
with a decline in physical function and quality of life.
720
Descargado para Roberto Eljadue (eljadue@gmail.com) en University of Cartagena de ClinicalKey.es por Elsevier en mayo 09, 2021. Para uso
personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2021. Elsevier Inc. Todos los derechos reservados.
DISARTICULATION OF
723 THE KNEE 726
723 TRANSFEMORAL (ABOVE-
KNEE) AMPUTATIONS 729
725 REHABILITATION AFTER
TRANSFEMORAL
AMPUTATION 731
Younger patients with traumatic amputations or amputa-
tions required for tumor treatment are more successful with
prosthetic use than are patients with amputations of dysvascu-
lar limbs; dialysis patients are even less successful with pros-
theses. In dysvascular limbs, the level of amputation is critical
because of poor wound healing. The most distal level should
be chosen where the wound will have the best chance of heal-
ing. This decision process can be augmented using clinical
tools such as transcutaneous oxygen tension, determining the
nutritional status of patients (albumin level of >3 g/dL, lym-
phocyte count of >1500/mL) and preoperative medical frailty.
Amputation should not be viewed as a failed limb sal-
vage or reconstruction. The amputation must be viewed as
an opportunity to reestablish or enhance a patient’s func-
tional level and facilitate a return to near-normal locomotion.
Transtibial amputation after failed attempted limb preserva-
tion can still be successful in improving pain, decreasing nar-
cotic use, and improving function. This is especially true in
the young, highly active trauma population. Meticulous sur-
gical attention is necessary to provide an optimal base of sup-
port because the residual limb functions as a “sensorimotor
end organ” with tolerance requirements at the stump-pros-
thesis interface to meet the dynamic weight-bearing chal-
lenges of ambulation. Anesthesia pain specialty teams often
are helpful in the management of postoperative pain.
Developments in the prosthetic field range from early-stage
fitting techniques (computer-assisted stump contour scanning)
to the use of advanced prosthetic components (lighter materi-
als, silicone gel liners, computer-assisted knee units, suspension
device alternatives, and ankle-foot accommodative and energy
storage systems). Osseointegrated prosthetic components have
been investigated over the past several decades in transfemoral
and transtibial amputees. Potential advantages include improved
quality of life and body image, increased proximal joint range
of motion, greater prosthetic comfort, better osseoperception,
and improved walking ability. Minor complications include
frequent superficial infections and stump irritation, and rare
major complications include deep infection, osteomyelitis, peri-
implant fracture, and failure of osseointegration. Tillander et al.
reported a 20% cumulative risk of developing osteomyelitis.
FOOT AND ANKLE AMPUTATIONS
Amputations around the foot and ankle are discussed in
Chapter 15. 

Very short
transtibial
Short
transtibial
Standard
transtibial
Long
transtibial
Syme
FIGURE 16.1 Levels of transtibial amputations.
TRANSTIBIAL (BELOW-KNEE)
AMPUTATIONS
Transtibial amputation is the most common lower extrem-
ity amputation. The importance of preserving the patient’s
own knee joint in the successful rehabilitation of a patient
with a lower extremity amputation cannot be overempha-
sized. Transtibial amputations can be divided into three lev-
els (Fig. 16.1). The appropriate level must be determined for
each individual patient. Although many variations in tech-
nique exist, all procedures may be divided into those for
nonischemic limbs and those for ischemic limbs. General
techniques vary primarily in the construction of skin flaps,
muscle stabilization, and osseous stabilization techniques. In
nonischemic limbs, skin flaps of various design and muscle
stabilization techniques, such as tension myodesis and myo-
plasty, frequently are used. These techniques are employed to
prepare a stump more suited for weight bearing and to pro-
tect from wound breakdown. In tension myodesis, transected
muscle groups are sutured to bone under physiologic tension;
in myoplasty, muscle is sutured to soft tissue, such as oppos-
ing muscle groups or fascia. In most instances, myoplastic
closures are performed, but some authors have advocated
the use of the firmer stabilization provided by myodesis in
young, active individuals. In addition, some surgeons advo-
cate creating a bone bridge between the distal tibia and fibula
(Technique 16.2). Advocates of the Ertl technique claim that a
bone bridge creates a more stable end-bearing construct and
decreases the incidence of proximal tibiofibular joint instabil-
ity. In addition, closure of the intramedullary canal in osteo-
myoplastic transtibial amputation has been shown to increase
blood flow to the residual limb. In ischemic limbs, tension
myodesis is relatively contraindicated because it may com-
promise further an already marginal blood supply. Also, a
Descargado para Roberto Eljadue (eljadue@gmail.com) en University of Cartagena de ClinicalKey.es por Elsevier en mayo 09, 2021. Para uso
personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2021. Elsevier Inc. Todos los derechos reservados.
CHAPTER 16  AMPUTATIONS OF THE LOWER EXTREMITY 721
long posterior myocutaneous flap and a short or even absent
anterior flap are recommended for ischemic limbs because
anteriorly the blood supply is less abundant than elsewhere
in the leg.
In combat injuries that result from blasts or fragmenta-
tion wounds, the use of standard flaps may be impossible.
Often flaps have to be fashioned from viable remaining tissue.
Skin grafts may be used to cover soft-tissue defects, but skin
grafts are not ideal for a stump-prosthesis interface.
NONISCHEMIC LIMBS
Rehabilitation after transtibial amputations in nonisch-
emic limbs generally is quite successful, partly because of
a younger, healthier population with fewer comorbidities.
The optimal level of amputation in this population tra-
ditionally has been chosen to provide a stump length that
allows a controlling lever arm for the prosthesis with suf-
ficient “circulation” for healing and soft tissue for protective
end weight bearing. The amputation level also is governed by
the cause (e.g., clean end margins for tumor, level of trauma,
and congenital abnormalities). A longer residual limb would
have a more normal gait appearance, but stumps extending
to the distal third of the leg have been considered subop-
timal because there is less soft tissue available for weight
bearing and less room to accommodate some energy stor-
age systems. The distal third of the leg also has been con-
sidered relatively avascular and slower to heal than more
proximal levels. Contemporary liners and ankle-foot storage
systems now allow more options for accommodating a lon-
ger residual limb, but the long-term risk of skin breakdown
in older patients with these newer prosthetic components
is unknown. Our recent war experiences have shown that
early posttraumatic amputations decrease the risk of chronic
residual limb infection. If only one posttraumatic debride-
ment procedure and 5 days or fewer pass before definitive
amputation, the risk of infection is limited.
In adults, the ideal bone length for a below-knee amputa-
tion stump is 12.5 to 17.5 cm, depending on body height. A
reasonably satisfactory rule of thumb for selecting the level of
bone section is to allow 2.5 cm of bone length for each 30 cm
of body height. Usually the most satisfactory level is about 15
cm distal to the medial tibial articular surface. A stump less
than 12.5 cm long is less efficient. Stumps lacking quadriceps
function are not useful. In a short stump of 8.8 cm or less, it
has been recommended that the entire fibula together with
some of the muscle bulk be removed so that the stump may
fit more easily into the prosthetic socket. Many prosthetists
find, however, that retention of the fibular head is desirable
because the modern total-contact socket can obtain a better
purchase on the short stump. Transecting the hamstring ten-
dons to allow a short stump to fall deeper into the socket also
may be considered. Although the procedure has the disad-
vantage of weakening flexion of the knee, this has not been a
serious problem, and genu recurvatum has not been reported.
Amputations in nonischemic limbs result from tumor,
trauma, infection, or congenital anomaly. In each, the under-
lying lesion dictates the level of amputation and choice of skin
flaps. Microvascular techniques have made preservation of
transtibial stumps possible with the use of distant free flaps
and “spare part” flaps from the amputated limb. A description
of the classic transtibial amputation using equal anterior and
posterior flaps follows. 
722 PART VI AMPUTATIONS

  Because it contracts, the anterior flap cannot be used to

n 

measure the level of intended bone section. Instead, use

TRANSTIBIAL AMPUTATION the mark already made in the tibial periosteum to mea-
sure the original length of the flap and reestablish the
level of bone section. With a saw, mark the bone at this
TECHNIQUE 16.1 point.
Insert a curved hemostat in the natural cleavage plane at
n 

Place the patient supine on the operating table and use a

n  the lateral aspect of the tibia so that its tip follows along
pneumatic tourniquet for hemostasis. the interosseous membrane and passes over the anterior
Beginning proximally at the anteromedial joint line, mea-
n  aspect of the fibula to emerge just anterior to the pero-
sure distally the desired length of bone and mark that neus brevis muscle.
level over the tibial crest with a skin-marking pen. Identify and isolate the superficial peroneal nerve in the
n 

Outline equal anterior and posterior skin flaps, with the

n  interval between the extensor digitorum longus and pero-
length of each flap being equal to one half the anteropos- neus brevis, gently draw it distally, and divide it high so
terior diameter of the leg at the anticipated level of bone that it retracts well proximal to the end of the stump.
section. Divide the muscles in the anterior compartment of the
n 

Begin the anterior incision medially or laterally at the in-

n  leg at a point 0.6 cm distal to the level of bone section
tended level of bone section and swing it convexly distal- so that they retract flush with the end of the bone. As
ward to the previously determined level and proximally to these muscles are sectioned, take special care to identify
end at a similar position on the opposite side of the leg and protect the anterior tibial vessels and deep peroneal
(Fig. 16.2A). nerve.
When crossing the tibial crest, deepen the incision and
n  Isolate these structures and ligate and divide the vessels at
n 

mark the periosteum with a cut to establish a point for a level just proximal to the level of intended bone section.
future measurement. Exert gentle traction on the nerve and divide it proximally
n 

Begin the posterior incision at the same point as the an-

n  so that it retracts well proximal to the end of the stump.
terior and carry it first convexly distalward and then proxi- Before sectioning the tibia, bevel its crest with a saw: be-
n 

mally as in the anterior incision (see Fig 16.2A). gin 1.9 cm proximal to the level of the bone section and
Deepen the posterior incision down through the deep fas-
n  cut obliquely distalward to cross this level 0.5 cm anterior
cia, but do not separate the skin or deep fascia from the to the medullary cavity.
underlying muscle. Section the tibia transversely and section the fibula 1.2 cm
n 

Reflect as a single layer with the anterior flap the deep fascia
n  proximally.
and periosteum over the anteromedial surface of the tibia. Grasp their distal segments with a bone-holding forceps
n 

Continue this dissection proximally to the level of intended

n  so that they can be pulled anteriorly and distally to expose
bone section. the posterior muscle mass.

Amputation 4 cm
level
Periosteum
marked

8 cm

Skin flap
incision
A 4 cm

B C
FIGURE 16.2 Amputation through middle third of leg for nonischemic limbs. A, Fashioning
of equal anterior and posterior skin flaps, each one half anteroposterior diameter of leg at level of
bone section. B, Fashioning of posterior myofascial flap. C, Suture of myofascial flap to periosteum
anteriorly. SEE TECHNIQUE 16.1.

Descargado para Roberto Eljadue (eljadue@gmail.com) en University of Cartagena de ClinicalKey.es por Elsevier en mayo 09, 2021. Para uso
personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2021. Elsevier Inc. Todos los derechos reservados.

Divide the muscles in the deep posterior compartment
n 
0.6 cm distal to the level of bone section so that they
retract flush with the end of the bone. This exposes the
posterior tibial and peroneal vessels and the tibial nerve
lying on the gastrocnemius-soleus muscle group. Doubly
ligate and divide the vessels and section the nerve so that
its cut end retracts well proximal to the end of the bone.
With a large amputation knife, bevel the gastrocnemius-
n 
soleus muscle mass so that it forms a myofascial flap long
enough to reach across the end of the tibia to the anterior
fascia (Fig. 16.2B).
Smoothly round the ends of the tibia and fibula with a
n 
rasp and irrigate the wound to remove all bone dust.
Release the tourniquet and clamp and ligate or electroco-
n 
agulate all bleeding points.
Bring the gastrocnemius-soleus muscle flap over the ends
n 
of the bones and suture it to the deep fascia and the
periosteum anteriorly (Fig. 16.2C).
Place a plastic suction drainage tube deep to the muscle
n 
flap and fascia and bring it out laterally through the skin
10 to 12 cm proximal to the end of the stump.
Fashion the skin flaps as necessary for smooth closure
n 
without tension and suture them together with inter-
rupted nonabsorbable sutures.
  
TECHNIQUE 16.2 flexion contracture, and protects the limb from external
(MODIFIED ERTL; TAYLOR AND POKA)
Place the patient supine on a radiolucent bed; a tourni-
n 
quet is used for hemostasis.
Make an anterior incision at the level of the intended tibial
n 
resection and a posterior flap incision. The posterior flap
should measure 1 cm more than the diameter of the leg
at the level of bone division (Fig. 16.3A).
Sharply incise the anterior compartment fascia, transect
n 
the musculature of the anterior compartment, and ligate
the anterior neurovascular bundle.
Identify the saphenous nerve, transect it proximally under
n 
tension, and allow it to retract.
Identify the tibial resection site and elevate an osteoperi-
n 
osteal sleeve proximal to the intended transection level
both anteriorly and posteriorly before making the tibial
cut (Fig. 16.3B).
Measure the medial-to-lateral distance between the tibia
n 
and fibula at the area of transection and transect the
peroneal muscle and fibula at this distance distal to the
transected tibia.
Transect the peroneal musculature and ligate the lateral
n 
neurovascular bundle.
Transect the deep posterior compartment at the level of
n 
the tibial transection and sharply bevel the superficial pos-
terior compartment to fashion a future flap.
Identify the posterior compartment neurovascular bun-
n 
dle, ligate and transect it, allowing for retraction.
Identify the sural nerve and transect it in the posterior
n 
subcutaneous flap.
Remove the amputated limb from the operative field, sav-
n 
ing bone for possible grafting.
Descargado para Roberto Eljadue (eljadue@gmail.com) en University of Cartagena de ClinicalKey.es por Elsevier en mayo 09, 2021. Para uso
personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2021. Elsevier Inc. Todos los derechos reservados.
CHAPTER 16  AMPUTATIONS OF THE LOWER EXTREMITY 723
Osteotomize the remaining fibula at the level of the re-
n 
sected tibia; with a burr, create notches in the fibula and
tibia for placement of the cut fibular autograft strut (Fig.
16.3C,D).
Drill holes to accommodate heavy suture passage: two in
n 
the medial tibia, two in the medial fibular autograft, two
in the lateral fibular autograft, and two in the distal fibula
(screw fixation may alternatively be used; Fig. 16.3E).
Secure the autograft strut with heavy suture and sew the
n 
tibial periosteal sleeve around the strut distally. Autogenous
bone graft may augment the distal bone bridge if necessary.
Release the tourniquet and achieve hemostasis.
n 
Mobilize the peroneal musculature distally to cover the
n 
end of the bone bridge and suture it to the medial aspect
of the tibia.
Suture the posterior musculature to the anterior tibial
n 
periosteum and close the subcutaneous tissues. Use non-
absorbable stitches in a mattress fashion to close the skin.
REHABILITATION IN NONISCHEMIC LIMBS
Rehabilitation after transtibial amputation in a nonisch-
emic limb is fairly aggressive unless the patient is immu-
nocompromised, there are skin graft issues, or there are
concomitant injuries or medical conditions that preclude
early initiation of physical therapy. An immediate post-
operative rigid dressing helps control edema, limits knee
trauma.
A prosthetist can be helpful with such casting and can
apply a jig that allows attachment and alignment for early
pylon use. Weight bearing is limited initially, with bilateral
upper extremity support from parallel bars, a walker, or
crutches. The dressing is changed every 5 to 7 days for skin
care. Within 3 to 4 weeks, the rigid dressing can be changed to
a removable temporary prosthesis if there are no skin compli-
cations. The patient is shown the proper use of elastic wrap-
ping or a stump shrinker to control edema and help contour
the residual limb when not wearing the prosthesis. The phys-
iatrist and therapist can assist in monitoring progress through
the various transitions of temporary prosthetics to the per-
manent design, which may take several months. Endoskeletal
designs have been more frequently used because modifi-
cations are simpler. Formal inpatient rehabilitation is brief,
with most prosthetic training done on an outpatient basis.
A program geared toward returning the patient to his or her
previous occupation, hobbies, and educational pursuits can
be structured with the help of a social worker, occupational
therapist, and vocational counselor.
ISCHEMIC LIMBS
The frequent comorbidities in patients with ischemic limbs
demand precautionary measures and interaction with a vas-
cular surgical team. Because the skin’s blood supply is much
better on the posterior and medial aspects of the leg than
on the anterior or anterolateral sides, transtibial amputation
techniques for the ischemic limb are characterized by skin
flaps that favor the posterior and medial side of the leg. The
long posterior flap technique popularized by Burgess is most
commonly used, but medial and lateral flaps of equal length
724 PART VI AMPUTATIONS

C
FIGURE 16.3 Modified Ertl technique. A, Skin incision marked to create long posterior flap.
B, Elevation of osteoperiosteal flap from the tibia. C, Provisional notch created in distal tibia and
fibula for fibular strut. D, Fibular strut placed into the tibial and fibular notches. E, Fibular strut
secured via sutures through bone tunnels. (A, B, and E, From: Taylor BC, Poka A: Osteomyoplastic
transtibial amputation: the Ertl technique, J Am Acad Orthop Surg 24:259, 2016. C and D, From Taylor BC,
Poka A: Osteomyoplastic transtibial amputation: technique and tips, J Orthop Surg Res 6:13, 2011.) SEE
TECHNIQUE 16.2.

as described by Persson, skew flaps, and long medial flaps
are being used. All techniques stress the need for preserving
intact the vascular connections between skin and muscle by
avoiding dissection along tissue planes and by constructing
myocutaneous flaps. Also, amputations performed in isch-
emic limbs are customarily at a higher level (e.g., 10 to 12.5
cm distal to the joint line) than amputations in nonischemic
limbs. Tension myodesis and osteomyoplasty, which may
be of value in young, vigorous patients, historically have
been contraindicated in patients with ischemic limbs due
to concerns of blood flow restriction. However, recent data
demonstrate that the Ertl procedure may be safe in these
high-risk patients.
Traditionally, tourniquets have not been used in the
amputation of dysvascular limbs to avoid damage to more
proximal diseased arteries. However, recent studies (includ-
ing randomized controlled trials) demonstrate decreased
blood loss, decreased postoperative transfusion rates, and no
increased risk of vascular or wound complications with the
use of a tourniquet. 

Descargado para Roberto Eljadue (eljadue@gmail.com) en University of Cartagena de ClinicalKey.es por Elsevier en mayo 09, 2021. Para uso
personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2021. Elsevier Inc. Todos los derechos reservados.
 CHAPTER 16  AMPUTATIONS OF THE LOWER EXTREMITY 725

  Section the tibia, and at a level no more than 0.9 to 1.3 cm

n 

higher, section the fibula. Dissect the soft tissues from the pos-
TRANSTIBIAL AMPUTATION USING terior aspect of the tibia and fibula distally to the level of the
LONG POSTERIOR SKIN FLAP posterior transverse skin division and separate and remove the
leg, ligating and dividing the nerves and vessels (Fig. 16.4B).
TECHNIQUE 16.3 Carefully round the tibia and form a short bevel on its
n 

anterior and medial aspects. Tension myodesis is not rec-

(BURGESS)
Position the patient supine on the operating table; do not
n 
apply a tourniquet. Prepare and drape the limb so that
an above-knee amputation can be performed if bleeding
and tissue viability are insufficient to permit a successful
transtibial amputation. For ischemic limbs, Burgess rec-
ommended amputation 8.8 to 12.5 cm distal to the line
of the knee joint.
Outline a long posterior flap and a short anterior one.
n 
The posterior flap should measure 1 cm more than the
diameter of the leg at the level of bone division.
Fashion the anterior flap at about the level of anticipated
n 
section of the tibia (Fig. 16.4A).
Reflect as a single layer with the anterior flap the deep
n 
fascia and periosteum over the anteromedial surface of
the tibia.
Divide the anterolateral muscles down to the intermuscu-
n 
lar septum, ligating and dividing the anterior tibial vessels
and peroneal nerves as encountered.
ommended in this instance.
Bevel and tailor the posterior muscle mass to form a flap
n 
(see Fig. 16.4B) and carry it anteriorly, suturing it to the
deep fascia and periosteum (Fig. 16.4C).
Obtain meticulous hemostasis.
n 
Place a plastic suction drainage tube deep to the mus-
n 
cle flap and fascia and bring it out laterally through the
skin 10 to 12.5 cm proximal to the end of the stump; if
preferred, a through-and-through Penrose drain may be
used, but it is more difficult to remove.
Fashion the skin flaps as necessary to obtain smooth closure
n 
without too much tension. Trim any “dog ears” sparingly;
otherwise, the circulation in the skin may be disturbed.
Close the skin with interrupted nonabsorbable sutures.
n 
REHABILITATION IN ISCHEMIC LIMBS
Rehabilitation in patients with ischemic limbs must proceed
cautiously because of potential skin healing compromise

Tibial
amputation
8.8 to 12.5 cm level
Skin flap
incision

Fibular
amputation level
0.9 to 1.3 cm
A 12.5 to 15 cm

B C
FIGURE 16.4 Transtibial amputation in ischemic limbs. A, Fashioning of short anterior and
long posterior skin flaps. B, Separation and removal of distal leg. Muscle mass is tailored to form
flaps. C, Suture of flap to deep fascia and periosteum anteriorly. (Redrawn from Burgess EM, Zettl
JH: Amputations below the knee, Artif Limbs 13:1, 1969.) SEE TECHNIQUE 16.3.

Descargado para Roberto Eljadue (eljadue@gmail.com) en University of Cartagena de ClinicalKey.es por Elsevier en mayo 09, 2021. Para uso
personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2021. Elsevier Inc. Todos los derechos reservados.
726 PART VI AMPUTATIONS
and accompanying medical conditions. Initial postoperative
efforts are centered on skin healing. After transtibial amputa-
tion, a soft dressing can be applied but a rigid dressing is pre-
ferred and can be used regardless of whether early ambulation
is prescribed. If immediate or prompt prosthetic ambulation
is not to be pursued, the stump can be dressed in a simple,
well-padded cast that extends proximally to midthigh and is
applied in such a manner as to avoid proximal constriction of
the limb. Good suspension of the cast is essential to prevent it
from slipping distally and impairing stump circulation. This
may require compressive contouring of the cast in the supra-
condylar area and a waist band, suspension strap, or both. The
cast should be removed in 5 to 7 days; and if wound healing is
satisfactory, a new rigid dressing or prosthetic cast is applied.
If immediate or prompt prosthetic ambulation is pursued, a
properly constructed prosthetic cast is best applied by a quali-
fied prosthetist. Success of rehabilitation depends on multiple
variables, including cognitive status, premorbid functional
level, condition of the upper extremities and contralateral
lower limb, and coexisting medical and neurologic condi-
tions. Early rehabilitation efforts may be geared toward inde-
pendence in a wheelchair, stump care education, skin care
techniques to avoid decubitus ulcers, care of the contralateral
intact lower limb, and preprosthetic general conditioning.
Weight bearing on the residual limb is usually delayed until
skin healing has progressed. If a more aggressive approach is
taken toward prosthetic training, more frequent rigid dress-
ing changes are recommended and possibly the use of clear
sockets to allow monitoring of the skin. Some patients may
require further medical evaluation and clearance (e.g., chemi-
cally induced cardiac stress test or echocardiogram or vas-
cular studies of the contralateral limb) to evaluate tolerance
for prosthetic training. A pain management specialist may be
needed to help treat postoperative phantom limb pain. Many
patients receive inpatient rehabilitation training with subse-
quent therapy on an outpatient basis or in an extended-care
facility or home health setting. Proposed rehabilitation goals
also dictate which prosthetic components would be approved
by insurance carriers.
DISARTICULATION OF THE KNEE
Disarticulation of the knee results in a functional end-bearing
stump. Newer socket designs and prosthetic knee mechanisms
that provide swing phase control have improved function in
patients with knee disarticulation. Although the benefit of its
use in children and young adults has been proven, its use in
the elderly and especially in patients with ischemia has been
limited in the United States. Knee disarticulations are more
commonly used in cases of trauma. Based on published data,
it remains unclear if knee disarticulation provides additional
functional benefit and improved complication rates com-
pared to transfemoral amputation.
Potential advantages of knee disarticulation include (1)
preservation of the large end-bearing surfaces of the distal
femur covered by skin and other soft tissues that are natu-
rally suited for weight bearing, (2) creation of a long lever arm
controlled by strong muscles, and (3) stability of the prosthe-
sis. Techniques have been described for reducing the bulk of
bone at the end of the stump to allow more cosmetic pros-
thetic fitting while still retaining the weight-bearing, suspen-
sion, and rotational control features of the stump. Modified
Descargado para Roberto Eljadue (eljadue@gmail.com) en University of Cartagena de ClinicalKey.es por Elsevier en mayo 09, 2021. Para uso
personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2021. Elsevier Inc. Todos los derechos reservados.
skin incisions allow greater use of this amputation level in
patients with ischemia. In nonambulatory patients, addi-
tional extremity length provides adequate sitting support
and balance. Knee flexion contractures and associated distal
ulcers common with transtibial amputations also are avoided. 
 
KNEE DISARTICULATION
TECHNIQUE 16.4
(BATCH, SPITTLER, AND MCFADDIN)
Measuring from the inferior pole of the patella, fashion
n 
a long, broad anterior flap about equal in length to the
diameter of the knee (Fig. 16.5A).
Measuring from the level of the popliteal crease, fashion
n 
a short posterior flap equal in length to one half of the
diameter of the knee. Place the lateral ends of the flaps
at the level of the tibial condyles.
Deepen the anterior incision through the deep fascia to
n 
the bone and dissect the anterior flap from the tibia and
adjacent muscle. Include in the flap the insertion of the
patellar tendon and the pes anserinus (Fig. 16.5B).
Expose the knee joint by dissecting the capsule from the
n 
anterior and lateral margins of the tibia; divide the cruci-
ate ligaments, and dissect the posterior capsule from the
tibia (Fig. 16.5C).
Identify the tibial nerve, gently pull it distally, and divide it
n 
proximally so that it retracts well proximal to the level of
amputation (Fig. 16.5D).
Identify, doubly ligate, and divide the popliteal vessels.
n 
Free the biceps tendon from the fibula, complete the am-
n 
putation posteriorly, and remove the leg.
Do not excise the patella or attempt to fuse it to the
n 
femoral condyles. Do not disturb the articular cartilage of
the femoral condyles and patella. Perform a synovectomy
only if specifically indicated.
Suture the patellar tendon to the cruciate ligaments and
n 
the remnants of the gastrocnemius muscle to tissue in the
intercondylar notch (Fig. 16.5E).
Place a through-and-through Penrose drain in the wound.
n 
Close the deep fascia and subcutaneous tissues with
n 
absorbable sutures and the skin edges with interrupted
nonabsorbable sutures.
If sufficient skin for a loose closure is unavailable, resect the
n 
posterior part of the femoral condyles rather than risk loss
of the skin flaps. The wound usually heals quickly, how-
ever, and a permanent prosthesis usually can be fitted in 6
to 8 weeks because shrinkage of the stump is not a factor.
If the wound fails to heal primarily, there is no reason for
apprehension or reamputation because it usually granu-
lates and heals satisfactorily without additional surgery.
   
 
KNEE DISARTICULATION
Mazet and Hennessy recommended a method that fea-
tures resection of the protruding medial, lateral, and
posterior surfaces of the femoral condyles for creating
a knee disarticulation stump for which a more cosmeti-
 CHAPTER 16  AMPUTATIONS OF THE LOWER EXTREMITY 727

Skin flap
10 cm incision

Patellar
tendon
A
5 cm
Right leg
(medial view) Infrapatellar
fat pad
Anterior cruciate
ligament

Lateral head of
gastrocnemius
muscle

Patellar
tendon
Pes
anserinus

B
C

Tibial nerve

D E

FIGURE 16.5 Disarticulation of knee joint. A, Skin incision. B, Anterior flap elevated, including
insertion of patellar tendon and pes anserinus. C, Cruciate ligaments and posterior capsule divided.
D, Tibial nerve divided high. E, Patellar tendon sutured to cruciate ligaments. SEE TECHNIQUE 16.4.

Descargado para Roberto Eljadue (eljadue@gmail.com) en University of Cartagena de ClinicalKey.es por Elsevier en mayo 09, 2021. Para uso
personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2021. Elsevier Inc. Todos los derechos reservados.
728 PART VI AMPUTATIONS

Lines of Line of
condylar condylar
remodeling remodeling

Posterior

Skin Skin
incision incision
Anterior

A B
FIGURE 16.6 Mazet and Hennessy disarticulation of knee. A, Anterior view. B, Lateral view.
SEE TECHNIQUE 16.5. (Redrawn from Mazet R Jr, Hennessy CA: Knee disarticulation: a new technique and
a new knee-joint mechanism, J Bone Joint Surg 48A:126, 1966.)

cally acceptable prosthesis can be constructed. With this to the midpoint of the distal articular surface posteriorly
technique, tolerances within the socket are greater, more (the condyle is wider posteriorly). Discard the medial half
adduction of the stump is permitted in the alignment of of the condyle.
the prosthesis, and the decreased bulk of the stump per- Resect the lateral part of the lateral femoral condyle in
n 

mits greater ease in the application and removal of the a similar manner, starting at the junction of the medial
prosthesis. The debulked stump requires smaller skin two thirds and lateral one third of the distal articular
flaps, which may be beneficial for wound healing in dys- surface.
vascular limbs. These patients may use a suction type Direct attention to the posterior aspect of both condyles.
n 

prosthesis, which is less cumbersome to apply than a tra- Resect the posterior projecting bone by a vertical oste-
ditional above-knee amputation prosthesis and does not otomy in the frontal plane, starting at the point where
require removal for toileting needs. the condyles begin to curve sharply superiorly and pos-
teriorly.
TECHNIQUE 16.5 Smoothly round all bony prominences with a rasp, but
n 

do not disturb the remaining articular cartilage. At this

(MAZET AND HENNESSY) point, each condyle has a fairly broad weight-bearing
Fashion the usual fish-mouth skin incision, making the an-
n  area, whereas the projecting side and posterior aspect
terior flap longer and extending 10 cm distal to the level of each have been removed and the remaining bone has
of the knee joint and making the posterior flap shorter been smoothly rounded.
and extending only about 2.5 cm distal to the same level Suture the patellar tendon to the hamstrings in the inter-
n 

(Fig. 16.6). condylar notch under slight tension. Insert drains at each
Reflect the skin and deep fascia well proximal to the fem-
n  end of the wound, and close the deep fascia and the skin
oral condyles. in separate layers.
Divide the patellar tendon midway between the patella
n     
and the tibial tuberosity.
Flex the knee and section the collateral and cruciate liga-
n 
 
ments.
Increase flexion of the knee to 90 degrees, identify and
KNEE DISARTICULATION
n 

ligate the popliteal vessels, and isolate and divide the tibial
nerve.
Detach the hamstring muscles from their insertions and
n 
TECHNIQUE 16.6
remove the leg.
(KJØBLE)
Dissect the patella from its tendon and discard it.
n 
n  With the patient prone on the operating table, outline a lat-
Remodel the femoral condyles in the following manner.
n 
eral flap that is one half the anteroposterior diameter of the
Drive a wide osteotome vertically in a proximal direction
knee in length and a medial flap that is 2 to 3 cm longer to
through the medial femoral condyle to emerge at the
allow adequate coverage of the large medial femoral condyle
level of the adductor tubercle. Start this cut along a line
(Fig. 16.7). By constructing shorter medial and lateral flaps,
that extends from the medial articular margin anteriorly

Descargado para Roberto Eljadue (eljadue@gmail.com) en University of Cartagena de ClinicalKey.es por Elsevier en mayo 09, 2021. Para uso
personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2021. Elsevier Inc. Todos los derechos reservados.

FIGURE 16.7 Kjøble disarticulation of knee with medial and
lateral skin flaps. SEE TECHNIQUE 16.6.
this technique provides more frequent healing in ischemic
limbs than techniques using long anterior and posterior flaps.
Begin the incision just distal to the lower pole of the pa-
n 
tella and extend it distally to the tibial tuberosity, curving
medially from this point for the medial flap and laterally
from this point for the lateral flap.
Carry both incisions posteriorly to meet in the midline of
n 
the limb at a point 2.5 cm proximal to the joint line.
Deepen the incisions through the subcutaneous tissue
n 
and fascia down to bone.
Divide the patellar tendon at its insertion, and release the
n 
medial and lateral hamstring tendons at their insertions.
Divide the collateral ligaments and the cruciate ligaments.
n 
Divide the posterior joint capsule and expose, doubly li-
n 
gate, and divide the popliteal vessels. Identify and sharply
transect the peroneal and tibial nerves so that their cut
ends retract well proximal to the end of the stump.
Release the gastrocnemius origins from the distal femur
n 
and divide any remaining soft tissues.
Suture the patellar tendon and the hamstring tendons to each
n 
other and to the cruciate ligaments in the intercondylar notch.
Approximate the skin edges with interrupted nonabsorb-
n 
able sutures.
POSTOPERATIVE CARE  If desired, a soft dressing may be
applied, and conventional aftercare instituted as previously
described (see Chapter 14). Preferable treatment is to apply
a rigid dressing or prosthetic cast with or without immediate
or early weight-bearing ambulation. If non–weight bearing
is desired, the rigid dressing need consist only of a properly
padded cast extending to the groin and securely suspended
by compressive contouring of the cast in the supracondylar
area or by a waist belt, suspension strap, or both. If weight-
bearing ambulation is pursued, the prosthetic cast should
be applied by a qualified prosthetist. Postoperative care is
similar to that outlined after transfemoral amputation (see
section on transfemoral amputations).
   
Descargado para Roberto Eljadue (eljadue@gmail.com) en University of Cartagena de ClinicalKey.es por Elsevier en mayo 09, 2021. Para uso
personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2021. Elsevier Inc. Todos los derechos reservados.
CHAPTER 16  AMPUTATIONS OF THE LOWER EXTREMITY 729
Short
transfemoral
Medial
transfemoral
Long
transfemoral
Supracondylar
FIGURE 16.8 Levels of transfemoral amputations.
TRANSFEMORAL (ABOVE-KNEE)
AMPUTATIONS
Amputation levels above the knee can be classified as short
transfemoral, medial transfemoral, long transfemoral, and
supracondylar (Fig. 16.8). Amputation through the thigh is
second in frequency only to transtibial amputation. In this
procedure the patient’s knee joint is lost, so it is extremely
important for the stump to be as long as possible to provide
a strong lever arm for control of the prosthesis. The con-
ventional, constant friction knee joint used in conventional
above-knee prostheses extends 9 to 10 cm distal to the end
of the prosthetic socket, and the bone must be amputated
this far proximal to the knee to allow room for the joint.
Modern computer-assisted knee prostheses using variable
friction for knee stiffness allow for shorter distal femoral seg-
ments. These prostheses that have highly sensitive sensors
use hydraulic or magnetic units to allow for more natural
knee motion, especially deceleration during the swing phase
of gait. This also allows for longer femoral length without
uneven levels of knee joint function. Amputation stumps in
which the level of bone section is less than 5 cm distal to the
lesser trochanter function as and are prosthetically fitted as
hip disarticulations.
Muscle stabilization by myodesis or myoplasty is impor-
tant when constructing a strong and sturdy amputation
stump. Gottschalk pointed out that in the absence of myode-
sis of the adductor magnus, most transfemoral amputations
result in at least 70% loss of adduction power. 
730 PART VI AMPUTATIONS

  Divide the quadriceps muscle and its overlying fascia along

n 

the line of the anterior incision and reflect it proximally to

TRANSFEMORAL (ABOVE-KNEE) the level of intended bone section as a myofascial flap.
AMPUTATION OF NONISCHEMIC Identify, individually ligate, and transect the femoral ar-
n 

tery and vein in the femoral canal on the medial side of

LIMBS the thigh at the level of bone section. Incise the perios-
teum of the femur circumferentially and divide the bone
TECHNIQUE 16.7 with a saw immediately distal to the periosteal incision.
With a sharp rasp, smooth the edges of the bone and
n 
Position the patient supine on the operating table and
n 
flatten the anterolateral aspect of the femur to decrease
perform the surgery using tourniquet hemostasis.
the unit pressures between the bone and the overlying
Beginning proximally at the anticipated level of bone sec-
n 
soft tissues.
tion, outline equal anterior and posterior skin flaps. The
Identify the sciatic nerve just beneath the hamstring mus-
n 
length of each flap should be at least one half the antero-
cles, ligate it well proximal to the end of the bone, and
posterior diameter of the thigh at this level. Atypical flaps
divide it just distal to the ligature.
always are preferred to amputation at a higher level.
Divide the posterior muscles transversely so that their
n 
Fashion the anterior flap with an incision that starts at
n 
ends retract to the level of bone section and remove the
the midpoint on the medial aspect of the thigh at the
leg (Fig. 16.9B).
level of anticipated bone section. The incision passes
Isolate and section all cutaneous nerves so that their cut
n 
in a gentle curve distally and laterally, crosses the an-
ends retract well proximal to the end of the stump. Ir-
terior aspect of the thigh at the level determined as
rigate the wound with saline to remove all bone dust.
noted earlier, and curves proximally to end on the lat-
Through several small holes drilled just proximal to the end
n 
eral aspect of the thigh opposite the starting point
of the femur, attach the adductor and hamstring muscles
(Fig. 16.9A).
to the bone with nonabsorbable or absorbable sutures (Fig.
Fashion the posterior flap in a similar manner.
n 
16.9C). The muscles should be attached under slight ten-
Deepen the skin incisions through the subcutaneous tis-
n 
sion (alternatively, suture anchors with heavy nonabsorbable
sue and deep fascia and reflect the flaps proximally to the
suture or suture tape may be used instead of bone tunnels).
level of bone section.

Amputation
level Skin flap
incision

B C
FIGURE 16.9 Amputation through middle third of thigh. A, Incision and bone level. B, Myofas-
cial flap fashioned from quadriceps muscle and fascia. C, Adductor and hamstring muscles attached
to end of femur through holes drilled in bone. SEE TECHNIQUE 16.7.

Descargado para Roberto Eljadue (eljadue@gmail.com) en University of Cartagena de ClinicalKey.es por Elsevier en mayo 09, 2021. Para uso
personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2021. Elsevier Inc. Todos los derechos reservados.
 CHAPTER 16  AMPUTATIONS OF THE LOWER EXTREMITY 731

Divide the femur 12 cm above the knee joint.

n 

Drill holes in the lateral, anterior, and posterior aspects of

n 

the femur, 1.5 cm from its end.

Hold the femur in maximal adduction and suture the ad-
n 

ductor magnus to its lateral aspect using previously drilled

holes (Fig. 16.10). Also, place anterior and posterior su-
tures to prevent its sliding backward or forward.
Suture the quadriceps to the posterior femur by draw-
n 

ing it over the adductor magnus while holding the hip in

extension.
Suture the remaining posterior muscles to the posterior
n 

aspect of the adductor magnus. Close the investing fascia

and skin and apply a soft dressing.
  

FIGURE 16.10 Attachment of adductor magnus to lateral

REHABILITATION AFTER TRANSFEMORAL
femur. (Redrawn from Gottschalk F: Transfemoral amputations. In:
AMPUTATION
Bowker JH, Michael JW, editors: Atlas of limb prosthetics: surgical, pros-
A soft dressing is adequate initially for elderly dysvascu-
thetic, and rehabilitation principles, ed 2, St. Louis: Mosby, 1992.) SEE
lar patients, whereas immediate postoperative rigid dress-
TECHNIQUE 16.8.
ings and earlier weight bearing with a locked-knee pylon are
appropriate in younger patients. Patients seem more comfort-
able if weight bearing is delayed until sutures or staples are
At this point, release the tourniquet and attain meticulous
n  removed. Subsequently, ambulation can be progressed with
hemostasis. an unlocked knee and less upper extremity support. For the
Bring the “quadriceps apron” over the end of the bone
n  definitive prosthesis, a variety of prosthetic knee units are
and suture its fascial layer to the posterior fascia of the available that are lighter and accommodate constant or vari-
thigh, trimming any excess muscle or fascia to permit a able gait cadences and provide good stability during weight
neat, snug approximation. bearing.
Insert plastic suction drainage tubes beneath the muscle
n  Many concepts and strategies relevant to these patients
flap and deep fascia, and bring them out through the were discussed earlier under postoperative care of trans-
lateral aspect of the thigh 10 to 12.5 cm proximal to the tibial amputations. The emphasis is on the recognition that
end of the stump. patients with ischemic limbs generally are less healthy than
Approximate the skin edges with interrupted sutures of
n  patients with nonischemic limbs; the rehabilitative pro-
nonabsorbable material. gram generally progresses much more slowly and more cau-
    tiously. A major obstacle to rehabilitation after transfemoral
amputation is the loss of the knee joint, which exponentially
increases the energy expenditure for locomotion with a
prosthesis. This has consequences for cardiac patients and
  patients with ischemic contralateral limbs. The patient and
family must be aware of the risks involved with a physically
TRANSFEMORAL (ABOVE-KNEE) demanding rehabilitation program. Many transfemoral
AMPUTATION OF NONISCHEMIC amputees with vascular disease never use a prosthesis con-
sistently. Patients with bilateral transfemoral amputations
LIMBS frequently elect to use a wheelchair because it is faster, and
oxygen consumption is four to seven times more using bilat-
TECHNIQUE 16.8 eral transfemoral prostheses. Younger patients can experi-
ence progress more rapidly, as discussed under transtibial
(GOTTSCHALK) postoperative care.
Place the patient supine with a roll under the buttock of
n 

the affected side.

Develop skin flaps using a long medial flap in the sagittal
n 
REFERENCES
plane when possible. Al Muderis M, Khemka A, Lord SJ, et al.: Safety of osseointegrated implants
Detach the quadriceps just proximal to the patella, retain-
n 
for transfemoral amputees: a two-center prospective cohort study, J Bone
ing part of its tendon. Joint Surg Am 98(11):900, 2016.
Reflect the vastus medialis off the intermuscular septum.
n 
Albino FP, Seidel R, Brown BJ, et al.: Through knee amputation: technique
Detach the adductor magnus from the adductor tubercle
n  modifications and surgical outcomes, Arch Plast Surg 41:562, 2014.
and reflect it medially to expose the femur. Identify and Baril DT, Ghosh K, Rosen AB: Trends in the incidence, treatment, and out-
ligate the femoral vessels at Hunter’s canal. comes of acute lower extremity ischaemia in the United States Medicare
Divide the gracilis, sartorius, semimembranosus, and
n  population, J Vasc Surg 60:669, 2014.
semitendinosus 2.5 to 5 cm below the intended bone Bell JC, Wolf EJ, Schnall BL, et  al.: Transfemoral amputations: is there an
effect of residual limb length and orientation on energy expenditure? Clin
section.
Orthop Relat Res 472:3055, 2014.

Descargado para Roberto Eljadue (eljadue@gmail.com) en University of Cartagena de ClinicalKey.es por Elsevier en mayo 09, 2021. Para uso
personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2021. Elsevier Inc. Todos los derechos reservados.
732 PART VI AMPUTATIONS
Bosse MJ, Morshed S, Reider L, et al.: Transtibial amputation outcomes study
(TAOS): comparing transtibial amputation with and without a tibiofibu-
lar synostosis (Ertl) procedure, J Orthop Trauma 31(Suppl 1):S63, 2017.
Brown BJ, Iorio ML, Klement M, et al.: Outcomes after 294 transtibial amputations
in the posterior myocutaneous flap, Int J Low Extrem Wounds 13:33, 2014.
Czerniecki JM, Thompson ML, Littman A, et  al.: Predicting reamputa-
tion risk in patients undergoing lower extremity amputation due to the
complications of peripheral artery disease and/or diabetes, Br J Surg
106(8):1026, 2019.
Easterlin MC, Chang DC, Wilson SE: A practical index to predict 30-day
mortality after major amputation, Ann Vasc Surg 27:909, 2013.
Fang ZB, Hu FY, Arya S, et al.: Preoperative frailty is predictive of complica-
tions after major lower extremity amputation, J Vasc Surg 65(3):804, 2017.
Fergason J, Keeling JJ, Bluman EM: Recent advances in lower extremity
amputation and prosthetics for the combat injured patient, Foot Ankle
Clin 15:151, 2010.
Fleming ME, O’Daniel A, Bharmal H, Valerio I: Application of the orthoplas-
tic reconstructive ladder to preserve lower extremity amputation length,
Ann Plast Surg 73:183, 2014.
Goodney PP, Holman K, Henke PK, et al.: Regional intensity of vascular care
and lower extremity amputation rates, J Vasc Surg 57:1471, 2013.
Hasanadka R, McLafferty RB, Moore CJ, et  al.: Predictors of wound com-
plications following major amputation for critical limb ischemia, J Vasc
Surg 54:1374, 2011.
Hsu AR: Transfemoral amputation adductor myodesis using FiberTape and
knotless anchors, Foot Ankle Int 39(7):874, 2018.
Jain A, Glass GE, Ahmadi H, et al.: Delayed amputation following trauma increases
residual lower limb infection, J Plast Reconstr Aesthet Surg 66:531, 2013.
Jones WS, Patel MR, Dai D, et al.: High mortality risks after major lower
extremity amputation in Medicare patients with peripheral artery
disease, Am Heart J 165:809, 2013.
Kahle JT, Highsmith MJ, Kenney J, et al.: The effectiveness of the bone bridge
transtibial amputation technique: a systematic review of high-quality
evidence, Prosthet Orthot Int 41(3):219, 2017.
Karam J, Shepard A, Rubinfeld I: Predictors of operative mortality following
major lower extremity amputations using the National Surgical Quality
Improvement Program public use data, J Vasc Surg 58:1276, 2013.
Kwah LK, Webb MT, Goh L, Harvey LA: Rigid dressings versus soft dressings
for transtibial amputations, Cochrane Database Syst Rev 6:CD012427, 2019.
Leijendekkers RA, van Hinte G, Frölke JP, et  al.: Functional performance
and safety of bone-anchored prostheses in persons with a transfemoral
or transtibial amputation: a prospective one-year follow-up cohort study,
Clin Rehabil 33(3):450, 2019.
Lowenberg DW, Buntic RF, Buncke GM, Parrett BM: Long-term results and
costs of muscle flap coverage with Ilizarov bone transport in lower limb
salvage, J Orthop Trauma 27:576, 2013.
Mangan KI, Kingsbury TD, Mazzone BN, et al.: Limb salvage with intrepid
dynamic exoskeletal orthosis versus transtibial amputation: a compari-
son of functional gait outcomes, J Orthop Trauma 30(12):e390, 2016.
Nelson MT, Greenblatt DY, Soma G, et al.: Preoperative factors predict mor-
tality after major lower-extremity amputation, Surgery 152:685, 2012.
O’Brien PJ, Cox MW, Shortell CK, Scarborough JE: Risk factors for early fail-
ure of surgical amputations: an analysis of 8,878 isolated lower extremity
amputation procedures, J Am Coll Surg 216:836, 2013.
Penn-Barwell JG: Outcomes in lower limb amputation following trauma: a
systematic review and meta-analysis, Injury 42:1474, 2011.
Phair J, DeCarlo C, Scher L, et al.: Risk factors for unplanned readmission
and stump complications after major lower extremity amputation, J Vasc
Surg 67(3):848, 2018.
Plucknette BF, Krueger CA, Rivera JC, Wenke JC: Combat-related bridge
synostosis versus traditional transtibial amputation: comparison of mil-
itary-specific outcomes, Strategies Trauma Limb Reconstr 11(1):5, 2016.
Polfer EM, Hoyt BW, Bevevino AJ, et al.: Knee disarticulations versus transfem-
oral amputations: functional outcomes, J Orthop Trauma 33(6):308, 2019.
Prinsen E, Nederhand MJ, Olsman J, Rietman JS: Influence of a user-adaptive
prosthetic knee on quality of life, balance confidence, and measures of
mobility: a randomised cross-over trial, Clin Rehabil 29:581, 2015.
Descargado para Roberto Eljadue (eljadue@gmail.com) en University of Cartagena de ClinicalKey.es por Elsevier en mayo 09, 2021. Para uso
personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2021. Elsevier Inc. Todos los derechos reservados.
Reichmann JP, Stevens PM, Rheinstein J, Kreulen CD: Removal rigid dress-
ings for postoperative management of transtibial amputations: a review
of published evidence, PM R 10(5):516, 2018.
Rosen N, Gigi R, Haim A, et al.: Mortality and reoperations following lower
limb amputations, Isr Med Assoc J 16:83, 2014.
Ryan SP, DiLallo M, Klement MR, et al.: Transfemoral amputation following
total knee arthroplasty: mortality and functional outcomes, Bone Joint J
101-B(2):221, 2019.
Schuett DJ, Wyatt MP, Kingsbury T, et al.: Are gait parameters for through-
knee amputees different from matched transfemoral amputees? Clin
Orthop Relat Res 477(4):821, 2019.
Seker A, Kara A, Camur S, et al.: Comparison of mortality rates and func-
tional results after transtibial and transfemoral amputations due to
diabetes in elderly patients – a retrospective study, Int J Surg 33:78,
2016.
Shah SK, Bena JF, Allemang MT, et al.: Lower extremity amputations: factors
associated with mortality or contralateral amputation, Vasc Endovascular
Surg 47:608, 2013.
Singleton JA, Walker NM, Gibb IE, et al: Case suitability for definitive through
knee amputation following lower extremity blast trauma: analysis of 146
combat casualties, 2008-2010, J R Army Med Corps 160(187):2014.
Spahn K, Wyatt MP, Stewart JM, et al.: Do Gait and functional parameters
change after transtibial amputation following attempted limb preserva-
tion in a military population? Clin Orthop Relat Res 477(4):829, 2019.
Sumpio B, Shine SR, Mahler D, Sumpio BE: A comparison of immediate
postoperative rigid and soft dressings for below-knee amputations, Ann
Vasc Surg 27:774, 2013.
Swaminathan A, Vemulapalli S, Patel MR, Jones WS: Lower extremity ampu-
tation in peripheral artery disease: improving patient outcomes, Vasc
Health Risk Manag 10:417, 2014.
Taylor BC, Poka A: Osteomyoplastic transtibial amputation: technique and
tips, J Orthop Surg Res 6:13, 2011.
Taylor BC, Poka A: Osteomyoplastic transtibial amputation: the Ertl tech-
nique, J Am Acad Orthop Surg 24(4):259, 2016.
Theeven PJ, Hemmen B, Geers RP, et al.: Influence of advanced prosthetic
knee joints on perceived performance and everyday life activity level of
low-functional persons with a transfemoral amputation or knee disar-
ticulation, J Rehabil Med 44:454, 2012.
Tillander J, Hagberg K, Berlin Ö, et al.: Osteomyelitis risk in patients with
transfemoral amputations treated with osseointegration prostheses, Clin
Orthop Relat Res 475(12):3100, 2017.
Tintle SM, Keeling JJ, Shawen SB, et al.: Traumatic and trauma-related ampu-
tations: part I: general principles and lower-extremity amputations, J
Bone Joint Surg 92A:2852, 2010.
Tintle SM, Shawen SB, Forsberg JA, et al.: Reoperation after combat-related
major lower extremity amputations, J Orthop Trauma 28:232, 2014.
Tsai CY, Chu SY, Wen YW, et al.: The value of Doppler waveform anal-
ysis in predicting major lower extremity amputation among dialy-
sis patients treated for diabetic foot ulcers, Diabetes Res Clin Pract
100:181, 2013.
Tseng CL, Rajan M, Miller DR, et al.: Trends in initial lower extremity ampu-
tation rates among Veterans Health Administration health care system
users from 2000 to 2004, Diabetes Care 34:1157, 2011.
Vallier HA, Fitzgerald SJ, Beddow ME, et  al.: Osteocutaneous pedicle flap
transfer for salvage of transtibial amputation after severe lower-extremity
injury, J Bone Joint Surg 94A:447, 2012.
Wied C, Tengberg PT, Holm G, et al.: Tourniquets do not increase the total
blood loss or re-amputation rise in transtibial amputations, World J
Orthop 8(1):62, 2017.
Whitehead A, Wolf EJ, Scoville CR, Wilken JM: Does a microprocessor-con-
trolled prosthetic knee affect stair ascent strategies in persons with trans-
femoral amputation? Clin Orthop Relat Res 472:3093, 2014.
Zayad M, Bech F, Hernandez-Boussard T: National review of factors influ-
encing disparities and types of major lower extremity amputations, Ann
Vasc Surg 28:1157, 2014.
The complete list of references is available online at ExpertConsult.com.

SUPPLEMENTAL REFERENCES
Aulivola B, Hile CN, Hamdan AD, et al.: Major lower extremity amputation:
outcome of a modern series, Arch Surg 139:395, 2004.
Ayoub MM, Solis MM, Rogers JJ, et al.: Thru-knee amputation: the operation
of choice for non-ambulatory patients, Am Surg 59:619, 1993.
Batch JW, Spittler AW, McFaddin JG: Advantages of the knee disarticula-
tion over amputations through the thigh, J Bone Joint Surg 36A:921, 1954.
Berlet GC, Pokabla C, Serynek P: An alternative technique for the Ertl osteo-
myoplasty, Foot Ankle Int 30:443, 2009.
Burgess EM: Disarticulations of the knee: a modified technique, Arch Surg
112:1250, 1977.
Burgess EM, Matsen III FA: Determining amputation levels in peripheral
vascular disease, J Bone Joint Surg 64A:1493, 1981.
Burgess EM, Matsen III FA, Wyss CR, et al.: Segmental transcutaneous mea-
surements of Po2 in patients requiring below-the-knee amputation for
peripheral vascular insufficiency, J Bone Joint Surg 64A:378, 1982.
Burgess EM, Zettl JH: Amputations below the knee, Artif Limbs 13:1, 1969.
Buzato MA, Tribulatto EC, Costa SM, et al.: Major amputations of lower leg:
the patients two years later, Acta Chir Belg 102:248, 2002.
Catre MG, Liebermann IH: Laterally based skin flap for below-knee amputa-
tion: case report, J Trauma 43:869, 1997.
Centers for Disease Control: Diabetes surveillance system: nontraumatic
lower extremity amputation with diabetes by level, Diabetes Public Health
Resource 2003.
Choksy SA, Lee Chong P, Smith C, et al.: A randomised controlled trial of the
use of a tourniquet to reduce blood loss during transtibial amputation for
peripheral arterial disease, Eur J Vasc Endovasc Surg 31:646, 2006.
Cruz CP, Eidt JF, Capps C, et  al.: Major lower extremity amputations at a
Veterans Affairs hospital, Am J Surg 186:449, 2003.
Cull DL, Taylor SM, Hamontree SE, et  al.: A reappraisal of a modified
through-knee amputation in patients with peripheral vascular disease,
Am J Surg 182:44, 2001.
Decoster TA, Homedan S: Amputation osteoplasty, Iowa Orthop J 26:54,
2006.
Dillingham TR, Pezzin LE, MacKenzie EJ: Limb amputation and limb defi-
ciency: epidemiology and recent trends in the United States, South Med
J 95:875, 2002.
Ertl J: Über amputationsstümpfe, Chirurg 20:218, 1949.
Gottschalk F: Transfemoral amputation, Clin Orthop Relat Res 361:15, 1999.
Fergason J, Keeling JJ, Bluman EM: Recent advances in lower extremity
amputation and prosthetics for the combat injured patient, Foot Ankle
Clin 15:151, 2010.
Hagberg E, Berlin OK, Renström P: Function after through-knee compared
with below-knee and above-knee amputation, Prosthet Orthot Int 16:168,
1992.
Harrington IJ, Lexier R, Woods JM, et  al.: A plaster-pylon technique for
below-knee amputation, J Bone Joint Surg 73B:76, 1991.
Humzah MD, Gilbert PM: Fasciocutaneous blood supply in below-knee
amputation, J Bone Joint Surg 79B:441, 1997.
Jain AS, Stewart CPU, Turner MS: Below-knee amputation using a medially
based flap, Br J Surg 81:512, 1994.
Januszkiewicz JS, Mehrotra ON, Brown GE: Calcaneal fillet flap: a new osteo-
cutaneous free tissue transfer for emergency salvage of traumatic below-
knee amputation stumps, Plast Reconstr Surg 98:538, 1996.
Descargado para Roberto Eljadue (eljadue@gmail.com) en University of Cartagena de ClinicalKey.es por Elsevier en mayo 09, 2021. Para uso
personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2021. Elsevier Inc. Todos los derechos reservados.
Kasabian AK, Glat PM, Eidelman Y, et al.: Salvage of traumatic below-knee
amputation stumps utilizing the filet of foot free flap: critical evaluation
of six cases, Plast Reconstr Surg 96:1145, 1995.
KjØble J: The surgery of the through-knee amputation. In Murdock G, ed:
Prosthetic and orthotic practice, London, 1970, Edward Arnold.
Kock HJ, Friederichs J, Ouchmaev A, et al.: Long-term results of through-
knee amputation with dorsal musculocutaneous flap in patients with
end-stage arterial occlusive disease, World J Surg 28:801, 2004.
MacKenzie EJ, Bosse MJ, Castillo RC, et  al.: Functional outcomes following
trauma-related lower-extremity amputation, J Bone Joint Surg 86A:1636, 2004.
Malek F, Somerson JS, Mitchel S, Williams RP: Does limb-salvage surgery
offer patients better quality of life and functional capacity than amputa-
tion? Clin Orthop Relat Res 470:2000, 2012.
Mazet Jr R, Hennessy CA: Knee disarticulation: a new technique and a new
knee-joint mechanism, J Bone Joint Surg 48A:126, 1966.
Mazet Jr R, Schmitter ED, Chupurdia R: Disarticulation of the knee: a follow-
up report, J Bone Joint Surg 60A:675, 1978.
Mohler DG, Kessler JI, Earp BE: Augmented amputations of the lower
extremity, Clin Orthop Relat Res 371:183, 2000.
Morse BC, Cull DL, Kalbaugh C, et al.: Through-knee amputation in patients
with peripheral arterial disease: a review of 50 cases, J Vasc Surg 48:638, 2008.
Nehler MR, Coll JR, Hiat WR, et al.: Functional outcome in a contemporary
series of major lower extremity amputations, J Vasc Surg 38:7, 2003.
Persson BM: Sagittal incision for below-knee amputation in ischemic gan-
grene, J Bone Joint Surg 56B:110, 1974.
Pinzur MS, Beck J, Himes R, Callaci J: Distal tibiofibular bone-bridging in
transtibial amputation, J Bone Joint Surg 90A:2682, 2008.
Pinzur MS, Bowker JH: Knee disarticulation, Clin Orthop Relat Res 361:23, 1999.
Pinzur MS, Gottschalk F, Pinto MA, Smith DG: Controversies in lower
extremity amputation, Instr Course Lect 57:663, 2008.
Pinzur MS, Gottschalk F, Smith D, et al.: Functional outcome of below-knee
amputation in peripheral vascular insufficiency: a multicenter review,
Clin Orthop Relat Res 286:247, 1993.
Rayman G, Krishnan ST, Baker NR, et al.: Are we underestimating diabetes-
related lower-extremity amputation rates? Results and benefits of the first
prospective study, Diabetes Care 27:1892, 2004.
Saleh M, Datta D, Eastaugh-Waring SJ: Long posteromedial myocutaneous
flap below-knee amputation, Ann R Coll Surg Engl 77:141, 1995.
Sandnes DK, Sobel M, Flum DR: Survival after lower-extremity amputation,
J Am Coll Surg 199:394, 2004.
Smith DG, Fergason JR: Transtibial amputations, Clin Orthop Relat Res
361:108, 1999.
Sonja MHJ, Jaegers MD, Arendzen JH, et al.: Changes in hip muscles after
above-knee amputation, Clin Orthop Relat Res 319:276, 1995.
Stokes R, Whetzel TP, Stevenson TR: Three-dimensional reconstruction of
the below-knee amputation stump: use of the combined scapular/para-
scapular flap, Plast Reconstr Surg 94:732, 1994.
Subramaniam B, Pomposelli F, Talmor D, et al.: Perioperative and long-term
morbidity and mortality after above-knee and below-knee amputations
in diabetics and nondiabetics, Anesth Analg 100:1241, 2005.
Topper AK, Fernie GR: Computer-aided design and computer-aided manu-
facturing (CAD/CAM) in prosthetics, Clin Orthop Relat Res 256:39, 1990.
Toursarkissian B, Shireman PK, Harrison A, et  al.: Major lower-extremity
amputation: contemporary experience in a single Veterans Affairs insti-
tution, Am Surg 68:606, 2002.
732.e1