VASCULAR SURGERY e II

Amputation and Types of amputation

Amputations are often referred to as major e where the majority
rehabilitation of the limb is removed, or minor. A detailed discussion of upper
limb amputations is beyond the scope of this review, which will
concentrate on amputations of the lower limb.
Colette Marshall
Tarig Barakat
Gerry Stansby Preoperative assessment of the patient
Preoperative assessment of the patient ideally involves a multi-
disciplinary approach with input from surgical and anaesthetic
Abstract teams, prosthetic specialist, nursing staff, physiotherapists,
Most lower limb amputations in the UK are performed in order to treat occupational therapists and psychologists. For diabetics, input
peripheral arterial disease and its complications, or are due to dia- from diabetic medicine and podiatry may also be helpful.
betes. Amputations are usually classified as minor, which includes Careful consideration of the level of amputation should take
toe and partial foot amputations, or major, when most of the limb is into account the likely ability of the patient to undergo successful
removed. Principles of selecting amputation level are considered rehabilitation. Walking with a prosthesis compared to normal
and importance of optimization of the patient’s general medical status ambulation requires an additional energy expenditure of 25
is stressed. Most patients requiring amputations have significant e40% for a below-knee prosthesis and 65e100% for an above-
comorbidities and amputation carries an appreciable anaesthetic knee prosthesis. This may severely limit the mobility of patients
risk. Minor amputations include toe and ray amputations, transmeta- with co-existing ischaemic heart disease. In contrast, wheelchair
tarsal and mid-food amputations. Ankle-level amputations, such as use demands energy expenditure of only 8% greater than normal
Syme’s amputation, are rarely indicated and it is difficult to fit prosthe- walking. An above-knee or through-knee amputation is often the
ses to these stumps. Below-knee and above-knee amputations are the best option for a patient who is only ever likely to be mobile in a
most commonly performed major amputations. Below-knee amputa- wheelchair. A below-knee stump in a non-ambulant patient is
tions may be carried out using either a long posterior flap or skewed more liable to develop fixed flexion and pressure ulceration and
flaps. Skewed flaps may be preferred when the posterior skin is of is contraindicated in the bedbound patient. A flexion contracture
poor quality, and produce a cylindrical stump well suited for limb at the knee of greater than 15 also precludes below-knee
fitting. Through-knee and hip disarticulations are also described. Suc- amputation.
cessful amputation surgery, with good outcomes for the patient, re- For the surgeon, assessment of the level of amputation should
quires an attention to detail and careful coordination with take into account the severity and pattern of vascular disease,
physiotherapy and rehabilitation departments. The aim is to produce degree of tissue loss and the viability of tissues in the vicinity of
a well-healed, pain-free stump suitable for limb fitting. the proposed flaps. Use of adjunctive tests such as laser Doppler
Keywords Amputation; critical ischaemia; peripheral arterial disease; studies, transcutaneous pO2 measurement, thermography or
prosthesis; rehabilitation isotope blood flow measurements of skin blood flow are used by
some but are essentially unproven and most surgeons mainly
rely on clinical judgement.
Epidemiology and aetiology Major amputation is high-risk surgery and therefore optimi-
zation of comorbid disease such as diabetes or cardiopulmonary
Most amputations (80%) are carried out to treat complications of disease, is crucial to limit perioperative complications
peripheral vascular disease and the vast majority involves the Preoperative preparation should include DVT prophylaxis and
lower limb. Forty per cent of these are performed in diabetics. prescription of broad spectrum antibiotic prophylaxis including
Other indications include trauma, malignant tumours, congenital activity against anaerobes. For major amputations, a urinary
deformity, chronic pain or a ‘useless’ limb (usually due to catheter is useful for postoperative monitoring of urine output,
neurological injury). and for ease of micturition, whilst the patient is bedbound. A
careful history and examination is required to detect the presence
of previous orthopaedic prostheses or vascular bypass grafts that
may be encountered during surgery. Major amputation in the UK
carries with it greater than 10% hospital-related mortality and
patients may require critical care support postoperatively.
Colette Marshall BM MSc FRCS is a Consultant Vascular Surgeon and
Medical Director at Bedford Hospital NHS Trust, UK. Conflicts of
interest: none declared. Lower limb amputation

Tarig Barakat MB BS is a Senior Vascular Fellow at the Freeman Toe amputation

Hospital, Newcastle upon Tyne, UK. Conflicts of interest: none Toe amputation is the most common amputation performed in
declared. the lower limb. It is essential to evaluate the arterial circulation
Gerry Stansby MB BChir FRCS is a Professor of Vascular Surgery and prior to considering toe amputation. The presence of palpable
Consultant Vascular Surgeon at the Freeman Hospital, Newcastle foot pulses is associated with a healing rate of 98%, reducing to
upon Tyne, UK. Conflicts of interest: none declared. 75%, with absent foot pulses.

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Please cite this article in press as: Marshall C, et al., Amputation and rehabilitation, Surgery (2016), http://dx.doi.org/10.1016/
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 VASCULAR SURGERY e II

Toe amputation may be carried out using fish-mouth or cir- The initial incision is made through skin and subcutaneous fat
cular incisions. Amputation must never be performed through a with a scalpel and continued through the muscles of the anterior
joint as this exposes avascular cartilage, which will not heal. and peroneal compartments with a diathermy blade. The vessels
Therefore toe amputation is usually performed through the are identified prior to division and ligated with absorbable suture
proximal phalanx. material. The tibial nerve should be divided under gentle traction
with a scalpel blade taking care to identify and diathermy the
Ray amputation vasa nervorum, which will otherwise cause troublesome
A ray amputation refers to excision of the toe through the bleeding in the depths of the wound. Nerves should not be
metatarsal bone. A tennis racquet-shaped incision is used to ligated as this can cause neuroma development.
expose the metatarsal head, which is excised at the neck. The fibula is stripped of periosteum up to 2 cm above the skin
Dissection should remain close to bone to avoid devitalization of incision, divided and filed smooth. The tibia is also stripped of
flaps or adjacent toes. Tendon remnants are excised as far periosteum to the level of planned division and divided with a
proximally as possible. In the presence of infection the wound hand or oscillating saw. In order to prevent a prominent bony
should be left open. Ray amputation usually allows normal protuberance the tibia is bevelled anteriorly and filed smooth.
ambulation although ray excision of the hallux may cause ul- Soleus should be excluded from the posterior flap and cut
ceration of the plantar skin due to abnormal weight-bearing. This level with the bone section. The gastrocnemius muscle is suitably
can be prevented by appropriate footwear in most cases. thinned to provide coverage for the tibial bone end. Excessive
bulk in the posterior flap may hinder subsequent limb-fitting:
Transmetatarsal amputation aim for a cylindrical stump.
This is also called a forefoot amputation. Transmetatarsal Before closure meticulous attention should be paid to hae-
amputation is indicated for gangrene or infection affecting mostasis and a suction drain inserted. The fascia is brought
several toes. It is essential that the plantar skin is healthy as the together with interrupted sutures and the skin closed.
incision uses a total plantar flap. The metatarsals are divided at
the mid-shaft level. A well-healed transmetatarsal amputation Skew flap technique: the skew flap technique is useful when use
provides excellent function. of a long posterior flap is compromised by ulceration or gangrene
extending proximally onto the site of the proposed posterior flap.
Mid-foot amputations The skew flap amputation naturally gives a more cylindrical
A mid-foot amputation may be carried out when more proximal stump shape than the posterior flap technique. This potentially
forefoot disease precludes amputation at transmetatarsal level. avoids the need for lengthy postoperative stump moulding prior
This amputation should only be considered in the patient with to prosthetic fitting.
correctable ischaemia. The Lisfranc amputation is a disarticula- The skin flaps are marked on the limb using as a basis the
tion between the metatarsal and tarsal bones and the Chopart circumference of the leg at the proposed site of tibial division
amputation is a disarticulation of the talonavicular and calca- which is located 10e12 cm from the joint line at the tibial plateau
neocuboid joints. The main disadvantages of these procedures (Figure 2). The anterior junction between the flaps must lie more
are the unpredictable healing rates and development of equinus than 2 cm from the tibial crest. Medial and lateral myoplastic
deformity, which may limit ambulation. flaps are fashioned with division of the bones carried out as
described above.
Ankle-level amputation
The Syme and Pirogoff amputations at the ankle level are rarely Through-knee amputation
indicated in vascular surgical practice. It is difficult to fit pros- A through-knee amputation may occasionally be indicated when
theses to these stumps and in most cases below-knee amputation infection or gangrene precludes creation of the flaps normally
is preferable, to allow successful healing and ambulation. used for successful healing of a BKA. It is useful when above-
knee amputation would be hampered by the presence of ortho-
Below-knee amputation (BKA) paedic metalware in the femur. A through-knee amputation re-
There are two basic techniques commonly used for BKA. The long sults in an end-bearing stump for prosthetic attachment. In the
posterior flap technique was introduced by Burgess and Romano non-ambulatory patient the stump provides a long lever arm
in 1967 and is the most commonly used method. The Skew flap for better mobility and balance in bed.
technique was described by Robinson in 1982. A randomized trial A through-knee amputation is fashioned by creation of ante-
comparing the two techniques demonstrated equivalence in terms rior and posterior flaps or sagittal flaps. Transection of the
of healing, need for revision and successful walking. femoral condyles allows easier skin flap closure and better
prosthesis fitting. In the Gritti-Stokes amputation the patella is
Burgess long posterior flap: the usual elective site for below- fixed to the underside of the transected femoral condyles. The
knee amputation is 14 cm below the knee joint or 10e12 cm main disadvantage of through-knee amputation is the difficulty
below the tibial tuberosity. The absolute minimum level of fitting a knee joint mechanism in the prosthesis and poor
permitted for successful limb-fitting is 7 cm below the joint line. cosmetic result due protrusion of the limb and prosthesis when
The skin incision is placed 1 cm distally to the proposed level of sitting.
tibial transection. Skin flaps may be accurately marked using a
length of suture material and a skin marker using a rule of thirds
(Figure 1).

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 VASCULAR SURGERY e II

Removal of less than 10 cm of femur will result in difficulty

Marking the flaps for a Burgess long posterior flap attaching a jointed prosthesis. The shortest stump recommended
below-knee amputation is measured as 15 cm from the greater trochanter to the level of
femoral section. If this is not achievable hip disarticulation is
often preferable.
10–12 cm
(from tibial The flaps for AKA are based on equal myoplastic flaps fash-
tuberosity) ioned as a fishmouth marked out using a quarter of the leg
circumference as a guide (Figure 3). The general principles
a
follow that outlined for BKA.

Hip disarticulation and hindquarter amputation

The main indications for these operations are malignant disease,
extensive trauma, infection or gangrene, or a non-healing high
above-knee amputation. There is a low incidence of successful
ambulation in vascular patients following this type of surgery.
b
1/ 3
Postoperative complications
1/ 3
Complications specific to amputation surgery include local
1/ 3
complications such as stump haematoma, flap necrosis or
infection. Stump trauma from falls is common, often due to
failure to remember the limb is missing. The pain management
team is useful in helping with postoperative wound pain and
phantom pain. The latter can often be successfully treated with a
c combination of amitriptyline and gabapentin or pregabalin as
first-line pharmacotherapy. There is equivocal evidence that
good preoperative analgesia can reduce phantom pain in the
long-term (pre-emptive analgesia); however, most of the studies
Figure 1
in this area are plagued by poor numbers of patients recruited
into the study groups. Psychological problems and depression
are common following amputation, as part of the emotional
adaptation to limb loss. Late complications include neuroma
Marking the flaps for a skew flap amputation formation, osteomyelitis, bony erosion, ulceration and ongoing
ischaemia.
10–12 cm
(from Outcome of surgery
joint line)
Successful surgery will result in a well-adjusted, rehabilitated
a patient. Fifty percent of patients undergoing major lower limb
amputation for ischaemia will require amputation of the
1/ 4 contralateral limb within two years. Survival following amputa-
2 cm tion in the patient with vascular disease is 31% at 5 years
following surgery, underlining the severe co-morbid diseases that
coexist in these patients. Figures from the National Vascular
Database and Hospital Episode Statistics in the UK suggest that
perioperative mortality following major amputation may be as
b high as 9e14%. In response to these figures the Vascular Society
of Great Britain and Ireland have published a Quality Improve-
ment Framework in order to improve outcomes following
surgery.
Figure 2
Rehabilitation
Postoperatively, physiotherapy begins with an aim to prevent
Above-knee amputation (AKA) contractures, limit oedema and to aid general mobility in bed and
For ambulation following AKA the ideal level of transfemoral on transfer. Once the wound has healed an elasticated stump-
amputation aims to achieve a stump long enough to act as a lever shrinker sock (e.g. JuzoÔ) is applied to provide stump
arm for locomotion whilst allowing adequate clearance of the moulding. Early ambulation is commenced with a variety of early
knee for jointed prostheses. A bone section 15 cm above the tibial walking aids such as the Pneumatic Post Amputation Mobility
plateau or 25 cm below the greater trochanter is optimal. Aid (PPAM Aid) for BKA or the Femurette for AKA. Once the

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 VASCULAR SURGERY e II

standing. Prostheses designed for different activities are also now

Marking the flaps for an above-knee amputation available (e.g. golf, athletics, swimming).
Summary of the principles of amputation surgery
 Avoid undermining or devitalizing skin flaps.
 Use a tourniquet to control haemorrhage.
 Ligate vessels as they are encountered to minimize
bleeding.
 Divide nerves cleanly and away from bone ends to avoid
neuroma formation.
Minimum
 Presence of muscle that does not bleed or contract in
15 cm from
greater trochanter response to diathermy stimulation indicates devitalization
e select a higher level for amputation.
1/ 4
 Guillotine amputation of highly infected tissue with later
stage completion of amputation is indicated for severe
1/ 4
sepsis and may reduce revision rates.
 Avoid unnecessary bulk in the stump when closing.
Minimum  Use a suction drain/s for major amputation.
10 cm from
 Avoid stump bandaging which can cause skin
knee joint
breakdown. A

Figure 3 FURTHER READING

Bianchi C, Abou-Zamzam Jr . AM Lower extremity amputations:
general considerations. In: Cronenwett JL, Wayne Johnston K, eds.
stump has moulded satisfactorily a cast can be made for pros-
Rutherford’s vascular surgery. 8th edn. WB Saunders Company,
thesis fabrication. During this phase the amputee undergoes gait
2015; 1836e47. Chapter 117.
retraining and exercises designed to strengthen proximal mus-
Choksey PA, Chong PL, Smith C, Ireland M, Beard J. A randomized
cles. Walking is gradually reintroduced initially with the assis-
controlled trial of the use of a tourniquet to reduce blood loss
tance of gait aids.
during transtibial amputation for peripheral arterial disease. Eur J
Vasc Endovasc Surg 2006; 31: 646e50.
Prosthetics
Do we have the tools to prevent phantom limb pain? Anesthesiology
For BKA a patellar-tendon-bearing prosthesis is used. An inner- 2011; 114: 1021e4.
lining, elasticated stocking or silicone gel sleeve is used as an Halbert J, Crotty M, Cameron ID. Evidence for the optimal manage-
attachment for the plastic laminate prosthesis to the residual ment of acute and chronic phantom pain: a systematic review. Clin
limb. A variety of foot and ankle design options are available. J Pain 2002; 18: 84e92.
Dynamically responsive or energy-storing designs permit a Robinson KP, Hoile R, Coddington T. Skew flap myoplastic below-
greater range of physical activity. Multiaxial units provide knee amputation: a preliminary report. Br J Surg 1982; 69: 554e7.
movement in both the medial-lateral and dorsiflexion- Symposium on amputation. Ann Royal Coll Surg Engl 1991; 73:
plantarflexion directions allowing easier walking on uneven 133e77.
terrain. For AKA, the prosthesis is attached to the limb with an Tang PCY, Ravji K, Key JJ, Mahler DB, Blume PA, Sumpio B. Let them
ischial containment socket held in place with suction or a total walk! Current prosthesis options for leg and foot amputees. J Am
elastic suspension system. Sophisticated knee mechanisms now Coll Surg 2008; 206: 548e60.
exist to provide a more natural gait. These include hydraulic, Vascular Society of Great Britain and Ireland, Quality Improvement
pneumatic or computerized systems. For elderly patients’ safety, Framework for amputation: http://www.vascularsociety.org.uk/

knees with an autolock are often provided to aid stability when vascular/wp-content/uploads/2012/11/qif_for_amputation._full_
version_for_the_website.doc.

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Please cite this article in press as: Marshall C, et al., Amputation and rehabilitation, Surgery (2016), http://dx.doi.org/10.1016/
j.mpsur.2016.02.006