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Lower extremity amputation

Venkat Kalapatapu, MD
Section Editors
Joseph L Mills, Sr, MD
John F Eidt, MD
Deputy Editor
Kathryn A Collins, MD, PhD, FACS


Lower extremity amputation is performed to remove ischemic, infected, necrotic tissue or locally unresectable tumor, and, at times, is a life-saving procedure. Peripheral artery disease, alone or in combination with diabetes mellitus, contributes more than half of all amputations; trauma is the second leading cause. The second Trans-Atlantic Inter-Society Consensus Working group (TASC II) documented an incidence of major amputations due to peripheral artery disease ranging from 12 to 50 per 100,000 individuals per year [1]. The aging population is expected to increase this number by 50 percent in the next 15 years [2].

Factors that predict the need for lower extremity amputation in patients with extremity ischemia include tissue loss, end-stage renal disease, poor functional status, and diabetes mellitus. Patients with diabetes have a 10-fold increased risk for lower extremity amputation compared with those who do not have diabetes. Amputees with diabetes are more likely to be severely disabled, to experience their initial amputation at a younger age, progress to higher-level amputations, and die at a younger age compared with patients without diabetes [3].

The indications and techniques for lower extremity amputation, postoperative care, complications, and outcomes are reviewed here. Techniques for performing lower extremity amputation are discussed elsewhere. (See "Techniques for lower extremity amputation".)


Major amputation refers to any amputation performed above the level of the ankle. Foot amputations are those at or below the ankle. (See 'Amputation techniques' below.)

Amputation performed without an attempt at limb salvage (eg, revascularization, bony repair, soft tissue coverage) is termed primary amputation, whereas amputation following a failed attempt at revascularization is termed secondary amputation. Traumatic amputation refers to limb loss that occurs in the field at the time of injury.

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Literature review current through: Sep 2017. | This topic last updated: Jul 17, 2017.
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  1. Norgren L, Hiatt WR, Dormandy JA, et al. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). J Vasc Surg 2007; 45 Suppl S:S5.
  2. Ziegler-Graham K, MacKenzie EJ, Ephraim PL, et al. Estimating the prevalence of limb loss in the United States: 2005 to 2050. Arch Phys Med Rehabil 2008; 89:422.
  3. Dillingham TR, Pezzin LE, Shore AD. Reamputation, mortality, and health care costs among persons with dysvascular lower-limb amputations. Arch Phys Med Rehabil 2005; 86:480.
  4. 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.
  5. 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.
  6. Parsons CM, Pimiento JM, Cheong D, et al. The role of radical amputations for extremity tumors: a single institution experience and review of the literature. J Surg Oncol 2012; 105:149.
  7. Fang ZB, Hu FY, Arya S, et al. Preoperative frailty is predictive of complications after major lower extremity amputation. J Vasc Surg 2017; 65:804.
  8. Aulivola B, Hile CN, Hamdan AD, et al. Major lower extremity amputation: outcome of a modern series. Arch Surg 2004; 139:395.
  9. Nehler MR, Coll JR, Hiatt WR, et al. Functional outcome in a contemporary series of major lower extremity amputations. J Vasc Surg 2003; 38:7.
  10. Bhuvaneswar CG, Epstein LA, Stern TA. Reactions to amputation: recognition and treatment. Prim Care Companion J Clin Psychiatry 2007; 9:303.
  11. Kashani JH, Frank RG, Kashani SR, et al. Depression among amputees. J Clin Psychiatry 1983; 44:256.
  12. Vemulapalli S, Greiner MA, Jones WS, et al. Peripheral arterial testing before lower extremity amputation among Medicare beneficiaries, 2000 to 2010. Circ Cardiovasc Qual Outcomes 2014; 7:142.
  13. Dwars BJ, van den Broek TA, Rauwerda JA, Bakker FC. Criteria for reliable selection of the lowest level of amputation in peripheral vascular disease. J Vasc Surg 1992; 15:536.
  14. Yamada T, Ohta T, Ishibashi H, et al. Clinical reliability and utility of skin perfusion pressure measurement in ischemic limbs--comparison with other noninvasive diagnostic methods. J Vasc Surg 2008; 47:318.
  15. Wagner WH, Keagy BA, Kotb MM, et al. Noninvasive determination of healing of major lower extremity amputation: the continued role of clinical judgment. J Vasc Surg 1988; 8:703.
  16. Bratzler DW, Houck PM, Surgical Infection Prevention Guidelines Writers Workgroup, et al. Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project. Clin Infect Dis 2004; 38:1706.
  17. Antimicrobial prophylaxis for surgery. Treat Guidel Med Lett 2009; 7:47.
  18. McIntosh J, Earnshaw JJ. Antibiotic prophylaxis for the prevention of infection after major limb amputation. Eur J Vasc Endovasc Surg 2009; 37:696.
  19. Sonne-Holm S, Boeckstyns M, Menck H, et al. Prophylactic antibiotics in amputation of the lower extremity for ischemia. A placebo-controlled, randomized trial of cefoxitin. J Bone Joint Surg Am 1985; 67:800.
  20. Norlin R, Frydén A, Nilsson L, Anséhn S. Short-term cefotaxime prophylaxis reduces the failure rate in lower limb amputations. Acta Orthop Scand 1990; 61:460.
  21. Huizinga WK, Robbs JV, Bhamjee A, Kritzinger NA. Wound infection after major lower-limb amputation--the role of antibiotic prophylaxis. S Afr J Surg 1986; 24:98.
  22. Møller BN, Krebs B. Antibiotic prophylaxis in lower limb amputation. Acta Orthop Scand 1985; 56:327.
  23. Thomsen S, Jakobsen BW, Wethelund JO, et al. Antibiotic prophylaxis in lower-extremity amputations due to ischemia. A prospective, randomized trial of cephalothin versus methicillin. Arch Orthop Trauma Surg 1990; 109:72.
  24. Friis H. Penicillin G versus cefuroxime for prophylaxis in lower limb amputation. Acta Orthop Scand 1987; 58:666.
  25. Huizinga WK, Robbs JV, Kritzinger NA. Prevention of wound sepsis in amputations by peri-operative antibiotic cover with an amoxycillin-clavulanic acid combination. S Afr Med J 1983; 63:71.
  26. Berridge DC, Slack RC, Hopkinson BR, Makin GS. A bacteriological survey of amputation wound sepsis. J Hosp Infect 1989; 13:167.
  27. Sadat U, Chaudhuri A, Hayes PD, et al. Five day antibiotic prophylaxis for major lower limb amputation reduces wound infection rates and the length of in-hospital stay. Eur J Vasc Endovasc Surg 2008; 35:75.
  28. Lastória S, Rollo HA, Yoshida WB, et al. Prophylaxis of deep-vein thrombosis after lower extremity amputation: comparison of low molecular weight heparin with unfractionated heparin. Acta Cir Bras 2006; 21:184.
  29. Huang ME, Johns JS, White J, Sanford K. Venous thromboembolism in a rehabilitation setting after major lower-extremity amputation. Arch Phys Med Rehabil 2005; 86:73.
  30. Burke B, Kumar R, Vickers V, et al. Deep vein thrombosis after lower limb amputation. Am J Phys Med Rehabil 2000; 79:145.
  31. Yeager RA, Moneta GL, Edwards JM, et al. Deep vein thrombosis associated with lower extremity amputation. J Vasc Surg 1995; 22:612.
  32. Harper DR, Dhall DP, Woodruff PW. Prophylaxis in iliofemoral venous thrombosis. The major amputee as a clinical research model. Br J Surg 1973; 60:831.
  33. Falck-Ytter Y, Francis CW, Johanson NA, et al. Prevention of VTE in orthopedic surgery patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e278S.
  34. Hill J, Treasure T, Guideline Development Group. Reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in patients admitted to hospital: summary of the NICE guideline. Heart 2010; 96:879.
  35. Robertson L, Roche A. Primary prophylaxis for venous thromboembolism in people undergoing major amputation of the lower extremity. Cochrane Database Syst Rev 2013; :CD010525.
  36. Struijk-Mulder MC, van Wijhe W, Sze YK, et al. Death and venous thromboembolism after lower extremity amputation. J Thromb Haemost 2010; 8:2680.
  37. Easterlin MC, Chang DC, Wilson SE. A practical index to predict 30-day mortality after major amputation. Ann Vasc Surg 2013; 27:909.
  38. Armstrong DG, Lavery LA, Diabetic Foot Study Consortium. Negative pressure wound therapy after partial diabetic foot amputation: a multicentre, randomised controlled trial. Lancet 2005; 366:1704.
  39. Karanikolas M, Aretha D, Tsolakis I, et al. Optimized perioperative analgesia reduces chronic phantom limb pain intensity, prevalence, and frequency: a prospective, randomized, clinical trial. Anesthesiology 2011; 114:1144.
  40. Ephraim PL, Wegener ST, MacKenzie EJ, et al. Phantom pain, residual limb pain, and back pain in amputees: results of a national survey. Arch Phys Med Rehabil 2005; 86:1910.
  41. Berlemont M, Weber R, Willot JP. Ten years of experience with the immediate application of prosthetic devices to amputees of the lower extremities on the operating table. Prosthet Int 1969; 3:8.
  42. Burgess EM, Romano RL, Zettl CP. Amputation management utilising immediate postsurgical prosthetic fitting. Prosthet Int 1969; 3:28.
  43. 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.
  44. 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.
  45. Belmont PJ Jr, Davey S, Orr JD, et al. Risk factors for 30-day postoperative complications and mortality after below-knee amputation: a study of 2,911 patients from the national surgical quality improvement program. J Am Coll Surg 2011; 213:370.
  46. Hasanadka R, McLafferty RB, Moore CJ, et al. Predictors of wound complications following major amputation for critical limb ischemia. J Vasc Surg 2011; 54:1374.
  47. Matielo MF, Presti C, Casella IB, et al. Incidence of ipsilateral postoperative deep venous thrombosis in the amputated lower extremity of patients with peripheral obstructive arterial disease. J Vasc Surg 2008; 48:1514.
  48. Nowygrod R, Egorova N, Greco G, et al. Trends, complications, and mortality in peripheral vascular surgery. J Vasc Surg 2006; 43:205.
  49. 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.
  50. Rubin JR, Marmen C, Rhodes RS. Management of failed prosthetic grafts at the time of major lower extremity amputation. J Vasc Surg 1988; 7:673.
  51. Izumi Y, Satterfield K, Lee S, Harkless LB. Risk of reamputation in diabetic patients stratified by limb and level of amputation: a 10-year observation. Diabetes Care 2006; 29:566.
  52. Cruz CP, Eidt JF, Capps C, et al. Major lower extremity amputations at a Veterans Affairs hospital. Am J Surg 2003; 186:449.
  53. Abou-Zamzam AM Jr, Teruya TH, Killeen JD, Ballard JL. Major lower extremity amputation in an academic vascular center. Ann Vasc Surg 2003; 17:86.
  54. Ploeg AJ, Lardenoye JW, Vrancken Peeters MP, Breslau PJ. Contemporary series of morbidity and mortality after lower limb amputation. Eur J Vasc Endovasc Surg 2005; 29:633.
  55. Schofield CJ, Libby G, Brennan GM, et al. Mortality and hospitalization in patients after amputation: a comparison between patients with and without diabetes. Diabetes Care 2006; 29:2252.
  56. Stone PA, Flaherty SK, Hayes JD, AbuRahma AF. Lower extremity amputation: a contemporary series. W V Med J 2007; 103:14.
  57. Henry AJ, Hevelone ND, Hawkins AT, et al. Factors predicting resource utilization and survival after major amputation. J Vasc Surg 2013; 57:784.
  58. O'Brien PJ, Cox MW, Shortell CK, Scarborough JE. Risk factors for early failure of surgical amputations: an analysis of 8,878 isolated lower extremity amputation procedures. J Am Coll Surg 2013; 216:836.
  59. Iannuzzi JC, Chandra A, Rickles AS, et al. Resident involvement is associated with worse outcomes after major lower extremity amputation. J Vasc Surg 2013; 58:827.
  60. Glaser JD, Bensley RP, Hurks R, et al. Fate of the contralateral limb after lower extremity amputation. J Vasc Surg 2013; 58:1571.
  61. Blume P, Salonga C, Garbalosa J, et al. Predictors for the healing of transmetatarsal amputations: retrospective study of 91 amputations. Vascular 2007; 15:126.
  62. Pollard J, Hamilton GA, Rush SM, Ford LA. Mortality and morbidity after transmetatarsal amputation: retrospective review of 101 cases. J Foot Ankle Surg 2006; 45:91.
  63. Mwipatayi BP, Naidoo NG, Jeffery PC, et al. Transmetatarsal amputation: three-year experience at Groote Schuur Hospital. World J Surg 2005; 29:245.
  64. Thomas SR, Perkins JM, Magee TR, Galland RB. Transmetatarsal amputation: an 8-year experience. Ann R Coll Surg Engl 2001; 83:164.
  65. Kono Y, Muder RR. Identifying the incidence of and risk factors for reamputation among patients who underwent foot amputation. Ann Vasc Surg 2012; 26:1120.
  66. Katz J. Phantom limb pain. Lancet 1997; 350:1338.
  67. Sherman RA, Sherman CJ, Parker L. Chronic phantom and stump pain among American veterans: results of a survey. Pain 1984; 18:83.
  68. Hanley MA, Jensen MP, Smith DG, et al. Preamputation pain and acute pain predict chronic pain after lower extremity amputation. J Pain 2007; 8:102.
  69. Gehling M, Tryba M. [Prophylaxis of phantom pain: is regional analgesia ineffective?]. Schmerz 2003; 17:11.
  71. Wasiak K, Paczkowski PM, Garlicki JM. Surgical results of leg amputation according to Ghormley's technique in the treatment of chronic lower limb ischaemia. Acta Chir Belg 2006; 106:52.
  72. Murdoch DP, Armstrong DG, Dacus JB, et al. The natural history of great toe amputations. J Foot Ankle Surg 1997; 36:204.
  73. 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.
  74. Early JS. Transmetatarsal and midfoot amputations. Clin Orthop Relat Res 1999; :85.
  75. Toursarkissian B, Shireman PK, Harrison A, et al. Major lower-extremity amputation: contemporary experience in a single Veterans Affairs institution. Am Surg 2002; 68:606.
  76. Schoppen T, Boonstra A, Groothoff JW, et al. Physical, mental, and social predictors of functional outcome in unilateral lower-limb amputees. Arch Phys Med Rehabil 2003; 84:803.
  77. Taylor SM, Kalbaugh CA, Blackhurst DW, et al. Preoperative clinical factors predict postoperative functional outcomes after major lower limb amputation: an analysis of 553 consecutive patients. J Vasc Surg 2005; 42:227.
  78. Huston CC, Bivins BA, Ernst CB, Griffen WO Jr. Morbid implications of above-knee amputations. Report of a series and review of the literature. Arch Surg 1980; 115:165.
  79. Davies B, Datta D. Mobility outcome following unilateral lower limb amputation. Prosthet Orthot Int 2003; 27:186.
  80. Sauter CN, Pezzin LE, Dillingham TR. Functional outcomes of persons who underwent dysvascular lower extremity amputations: effect of postacute rehabilitation setting. Am J Phys Med Rehabil 2013; 92:287.
  81. Eidemiller LR, Awe WC, Peterson CG. Amputation of the ischemic extremity. Am Surg 1968; 34:491.
  82. Rosenberg N, Adiarte E, Bujdoso LJ, Backwinkel KD. Mortality factors in major limb amputations for vascular disease: a study of 176 procedures. Surgery 1970; 67:437.
  83. Sandnes DK, Sobel M, Flum DR. Survival after lower-extremity amputation. J Am Coll Surg 2004; 199:394.
  84. Feinglass J, Pearce WH, Martin GJ, et al. Postoperative and late survival outcomes after major amputation: findings from the Department of Veterans Affairs National Surgical Quality Improvement Program. Surgery 2001; 130:21.
  85. Mayfield JA, Reiber GE, Maynard C, et al. Survival following lower-limb amputation in a veteran population. J Rehabil Res Dev 2001; 38:341.
  86. Kazmers A, Perkins AJ, Jacobs LA. Major lower extremity amputation in Veterans Affairs medical centers. Ann Vasc Surg 2000; 14:216.
  87. Subramaniam B, Pomposelli F, Talmor D, Park KW. Perioperative and long-term morbidity and mortality after above-knee and below-knee amputations in diabetics and nondiabetics. Anesth Analg 2005; 100:1241.
  88. Panton AC. VI. A Case of Perforating Typhoid Ulcer, with Recovery, after Operation. Ann Surg 1897; 26:219.
  89. Nelson MT, Greenblatt DY, Soma G, et al. Preoperative factors predict mortality after major lower-extremity amputation. Surgery 2012; 152:685.
  90. 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 2013; 165:809.
  91. Stone PA, Back MR, Armstrong PA, et al. Midfoot amputations expand limb salvage rates for diabetic foot infections. Ann Vasc Surg 2005; 19:805.
  92. Shah SK, Bena JF, Allemang MT, et al. Lower extremity amputations: factors associated with mortality or contralateral amputation. Vasc Endovascular Surg 2013; 47:608.
  93. Wise ES, McMaster WG Jr, Williamson K, et al. Preoperative Predictors of 30-Day Mortality and Prolonged Length of Stay after Above-Knee Amputation. Ann Vasc Surg 2016; 31:124.
  94. Ebskov B. Relative mortality and long term survival for the non-diabetic lower limb amputee with vascular insufficiency. Prosthet Orthot Int 1999; 23:209.
  95. Bo Ebskov L. Dysvascular amputations and long-term survival in a 20-year follow-up study. Int J Rehabil Res 2006; 29:325.
  96. Pohjolainen T, Alaranta H. Ten-year survival of Finnish lower limb amputees. Prosthet Orthot Int 1998; 22:10.
  97. Feinglass J, Rucker-Whitaker C, Lindquist L, et al. Racial differences in primary and repeat lower extremity amputation: results from a multihospital study. J Vasc Surg 2005; 41:823.
  98. Fortington LV, Geertzen JH, van Netten JJ, et al. Short and long term mortality rates after a lower limb amputation. Eur J Vasc Endovasc Surg 2013; 46:124.
  99. Lavery LA, van Houtum WH, Armstrong DG, et al. Mortality following lower extremity amputation in minorities with diabetes mellitus. Diabetes Res Clin Pract 1997; 37:41.
  100. Collins TC, Johnson M, Daley J, et al. Preoperative risk factors for 30-day mortality after elective surgery for vascular disease in Department of Veterans Affairs hospitals: is race important? J Vasc Surg 2001; 34:634.