Techniques for lower extremity amputation
- Venkat Kalapatapu, MD
Venkat Kalapatapu, MD
- Assistant Professor
- Division of Vascular Surgery
- Penn Presbyterian Medical Center
- University of Pennsylvania Health System
- Section Editors
- Joseph L Mills, Sr, MD
Joseph L Mills, Sr, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor and Chief
- Division of Vascular Surgery and Endovascular Therapy
- Baylor College of Medicine
- John F Eidt, MD
John F Eidt, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor of Surgery
- University of South Carolina School of Medicine Greenville
Lower extremity amputation is performed to remove ischemic, infected or necrotic tissue, or locally unresectable tumor, and at times, may be life-saving. The majority of lower extremity amputations are performed for lower extremity ischemia (peripheral artery disease, embolism) and diabetes mellitus. Extremity trauma is the second leading cause for amputation, and malignancy accounts for the remainder [1,2].
The techniques for major amputation and foot amputations are reviewed here. The indications for lower extremity amputation, preoperative and postoperative care, complications and outcomes are reviewed separately. (See "Lower extremity amputation".)
Hip and thigh — The hip joint is a multiaxial ball-and-socket joint. The ligamentous structures of the joint are the fibrous capsule, the acetabular labrum, the ligament of the head of the femur, iliofemoral, ischiofemoral, pubofemoral and the transverse acetabular ligament.
The muscles that surround the hip joint are divided into three groups: anterior, posterior, and inferior. The anterior group, lateral to medial, includes the rectus femoris, iliopsoas, and pectineus. Anterior to this group are the sartorius and tensor fascia lata. The posterior group consists of the piriformis, obturator internus, quadratus femoris, and obturator externus.
The muscles of the thigh are divided into three groups (figure 1): The anterior group consists of the sartorius, tensor fascia lata, and quadriceps femoris (vastus medialis, intermedius, and lateralis, rectus femoris); the medial group includes the gracilis, pectineus, and adductor longus, brevis and magnus; the posterior group consists of the biceps femoris, semitendinosus and semimembranosus. The adductor muscles insert into the posterolateral femur along a narrow ridge called the linea aspera.
- Dillingham TR, Pezzin LE, MacKenzie EJ. Limb amputation and limb deficiency: epidemiology and recent trends in the United States. South Med J 2002; 95:875.
- Heikkinen M, Saarinen J, Suominen VP, et al. Lower limb amputations: differences between the genders and long-term survival. Prosthet Orthot Int 2007; 31:277.
- Humzah MD, Gilbert PM. Fasciocutaneous blood supply in below-knee amputation. J Bone Joint Surg Br 1997; 79:441.
- Eidt JF, Kalapatapu VR. Lower extremity amputation: Techniques and Results. In: Rutherford's Vascular Surgery, 7th ed, 2010. Vol 2.
- McIntyre KE Jr, Bailey SA, Malone JM, Goldstone J. Guillotine amputation in the treatment of nonsalvageable lower-extremity infections. Arch Surg 1984; 119:450.
- Fisher DF Jr, Clagett GP, Fry RE, et al. One-stage versus two-stage amputation for wet gangrene of the lower extremity: a randomized study. J Vasc Surg 1988; 8:428.
- Desai Y, Robbs JV, Keenan JP. Staged below-knee amputations for septic peripheral lesions due to ischaemia. Br J Surg 1986; 73:392.
- Payne JE, Breust M, Bradbury R. Reduction in amputation stump infection by antiseptic pre-operative preparation. Aust N Z J Surg 1989; 59:637.
- Scher KS, Steele FJ. The septic foot in patients with diabetes. Surgery 1988; 104:661.
- Hunsaker RH, Schwartz JA, Keagy BA, et al. Dry ice cryoamputation: a twelve-year experience. J Vasc Surg 1985; 2:812.
- Winburn GB, Wood MC, Hawkins ML, et al. Current role of cryoamputation. Am J Surg 1991; 162:647.
- Brinker MR, Timberlake GA, Goff JM, et al. Below-knee physiologic cryoanesthesia in the critically ill patient. J Vasc Surg 1988; 7:433.
- Bunt TJ. Physiologic amputation. Preliminary cryoamputation of the gangrenous extremity. AORN J 1991; 54:1220.
- 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 2006; 31:646.
- Jaegers SM, Arendzen JH, de Jongh HJ. Changes in hip muscles after above-knee amputation. Clin Orthop Relat Res 1995; :276.
- Coulston JE, Tuff V, Twine CP, et al. Surgical factors in the prevention of infection following major lower limb amputation. Eur J Vasc Endovasc Surg 2012; 43:556.
- Sugarbaker PH, Chretien PB. A surgical technique for hip disarticulation. Surgery 1981; 90:546.
- 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 2001; 182:44.
- Blanc CH, Borens O. Amputations of the lower limb--an overview on technical aspects. Acta Chir Belg 2004; 104:388.
- Faber DC, Fielding LP. Gritti-Stokes (through-knee) amputation: should it be reintroduced? South Med J 2001; 94:997.
- Mazet, R.J. and C.A. Hennessy, Knee Disarticulation: a new technique and a new knee-joint mechanism. J Bone Joint Surg Am 1966; 48:126.
- 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.
- Allcock PA, Jain AS. Revisiting transtibial amputation with the long posterior flap. Br J Surg 2001; 88:683.
- Smith DG, Fergason JR. Transtibial amputations. Clin Orthop Relat Res 1999; :108.
- Tisi PV, Than MM. Type of incision for below knee amputation. Cochrane Database Syst Rev 2014; :CD003749.
- Assal M, Blanck R, Smith DG. Extended posterior flap for transtibial amputation. Orthopedics 2005; 28:542.
- Robinson KP. Amputations in vascular patients. In: Surgical Management of Vascular Disease, Bell PRF (Ed), W.B. Saunders, London 1992. p.609.
- Persson BM. Sagittal incision for below-knee amputation in ischaemic gangrene. J Bone Joint Surg Br 1974; 56:110.
- Termansen NB. Below-knee amputation for ischaemic gangrene. Prospective, randomized comparison of a transverse and a sagittal operative technique. Acta Orthop Scand 1977; 48:311.
- Jain AS, Stewart CP, Turner MS. Transtibial amputation using a medially based flap. J R Coll Surg Edinb 1995; 40:263.
- Ng VY, Berlet GC. Improving function in transtibial amputation: the distal tibiofibular bone-bridge with Arthrex Tightrope fixation. Am J Orthop (Belle Mead NJ) 2011; 40:E57.
- Malloy JP, Dalling JG, El Dafrawy MH, et al. Tibiofibular bone-bridging osteoplasty in transtibial amputation: case report and description of technique. J Surg Orthop Adv 2012; 21:270.
- Keeling JJ, Shawen SB, Forsberg JA, et al. Comparison of functional outcomes following bridge synostosis with non-bone-bridging transtibial combat-related amputations. J Bone Joint Surg Am 2013; 95:888.
- Pinzur MS, Pinto MA, Schon LC, Smith DG. Controversies in amputation surgery. Instr Course Lect 2003; 52:445.
- Pinzur M, Kaminsky M, Sage R, et al. Amputations at the middle level of the foot. A retrospective and prospective review. J Bone Joint Surg Am 1986; 68:1061.
- Barnes R, Cox B. Amputations: An illustrated manual, 1st ed, Hanley & Belfus, Philadelphia 2000.
- Early JS. Transmetatarsal and midfoot amputations. Clin Orthop Relat Res 1999; :85.
- Sanders LJ. Transmetatarsal and midfoot amputations. Clin Podiatr Med Surg 1997; 14:741.
- Stone PA, Back MR, Armstrong PA, et al. Midfoot amputations expand limb salvage rates for diabetic foot infections. Ann Vasc Surg 2005; 19:805.
- Chang BB, Bock DE, Jacobs RL, et al. Increased limb salvage by the use of unconventional foot amputations. J Vasc Surg 1994; 19:341.
- HULNICK A, HIGHSMITH C, BOUTIN FJ. Amputations for failure in reconstructive surgery. J Bone Joint Surg Am 1949; 31A:639.
- Richardson D. Amputations of the foot. In: Campbell's Operative Orthopedics, Canale S, Beaty J (Eds), Elsevier, Philadelphia p.595.
- Armstrong DG, Stacpoole-Shea S, Nguyen H, Harkless LB. Lengthening of the Achilles tendon in diabetic patients who are at high risk for ulceration of the foot. J Bone Joint Surg Am 1999; 81:535.
- HATT RN, LAMPHIER TA. Triple hemisection: a simplified procedure for lengthening the Achilles tendon. N Engl J Med 1947; 236:166.
- Murdoch DP, Armstrong DG, Dacus JB, et al. The natural history of great toe amputations. J Foot Ankle Surg 1997; 36:204.
- Bowker J. Amputations and disarticulations. In: Foot and Ankle Disorders, M. MS (Ed), WB Saunders, Philadelphia 2000. p.466.
- Dalla Paola L, Faglia E, Caminiti M, et al. Ulcer recurrence following first ray amputation in diabetic patients: a cohort prospective study. Diabetes Care 2003; 26:1874.
- Funk C, Young G. Subtotal pedal amputations. Biomechanical and intraoperative considerations. J Am Podiatr Med Assoc 2001; 91:6.
- Sumpio B, Shine SR, Mahler D, Sumpio BE. A comparison of immediate postoperative rigid and soft dressings for below-knee amputations. Ann Vasc Surg 2013; 27:774.
- Tang PC, Ravji K, Key JJ, et al. Let them walk! Current prosthesis options for leg and foot amputees. J Am Coll Surg 2008; 206:548.
- Nawijn SE, van der Linde H, Emmelot CH, Hofstad CJ. Stump management after trans-tibial amputation: a systematic review. Prosthet Orthot Int 2005; 29:13.
- Kane TJ 3rd, Pollak EW. The rigid versus soft postoperative dressing controversy: a controlled study in vascular below-knee amputees. Am Surg 1980; 46:244.
- SURGICAL ANATOMY
- Hip and thigh
- Ankle and foot
- GENERAL PRINCIPLES OF AMPUTATION
- Staged amputation
- - Cryoamputation
- General techniques
- MAJOR AMPUTATIONS
- Hip disarticulation
- Above-knee amputation
- Through-the-knee (knee disarticulation)
- Below-knee amputation
- - Posterior flap technique
- - Other flap techniques
- - Adjunctive techniques
- FOOT AMPUTATIONS
- Ankle disarticulation
- Midfoot and hindfoot amputations
- Transmetatarsal amputation
- Toe amputation
- - Simple
- - Ray
- DRESSINGS AND DRAINS
- SUMMARY AND RECOMMENDATIONS