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Abstract
Vincent Y. Ng, MD Multiple clinical pathways lead to lower extremity amputation,
Gregory C. Berlet, MD including trauma, dysvascular disease, congenital defects, and
malignancy. However, the principles of successful
amputation—careful preoperative planning, coordination of a
multidisciplinary team, and good surgical technique—remain the
same. Organized rehabilitation and properly selected prostheses
are integral components of amputee care. In the civilian setting,
amputation is usually performed as a planned therapy for an
unsalvageable extremity, not as an emergency procedure. The
partial loss of a lower limb often represents a major change in a
From the Department of
person’s life, but patients should be encouraged to approach
Orthopaedics, The Ohio State amputation as the beginning of a new phase of life and not as the
University Medical Center, culmination of previous treatment failures.
Columbus, OH (Dr. Ng), and the
Orthopaedic Foot and Ankle Center,
Department of Orthopaedics, The
A
Ohio State University Medical mputation is among the oldest that injury severity scoring systems, in-
Center (Dr. Berlet).
recorded surgical procedures. It cluding the Mangled Extremity Sever-
Dr. Berlet or an immediate family has been documented in the Rig-Veda ity Score, the Limb Salvage Index, and
member is a board member, owner,
officer, or committee member of the
(c. 1200 BC) and the Temple of Ram- the Predictive Salvage Index, were in-
American Orthopaedic Foot and ses II (13th century BC).1 The major sensitive in identifying persons ulti-
Ankle Society; has received royalties indications for therapeutic ampu- mately needing amputation.4 The Man-
from Nexa Orthopaedics, Wright tation have remained constant gled Extremity Severity Score, however,
Medical Technology, and Bledsoe
Brace; is a member of a speakers’ throughout history and include is- was highly specific in ruling out those
bureau or has made paid chemia, trauma, infection, and ma- who did not require amputation. Open
presentations on behalf of Arthrex, lignancy. Of the 623,000 Americans tibial fractures, especially Gustilo type
Pfizer, and Wright Medical
living with the loss of a lower ex- IIIB, have a wide spectrum in actual se-
Technology; serves as a paid
consultant to or is an employee of tremity in 2005, 80% had dysvascu- verity, and initial management decisions
Wright Medical Technology; has lar disease.2 The prevalence of diabe- should be individualized5 (Figure 1).
received research or institutional tes is expected to double by 2030, The difficult decision to amputate
support from Biomet, BioMimetic
Therapeutics, DJ Orthopaedics, and
and the number of amputations is should be made expediently because
Link Orthopaedics; and has stock or likely to increase despite efforts by amputations performed after initial
stock options held in Wright Medical prevention programs such as discharge have the highest complica-
Technology and Bledsoe. Neither Healthy People 2010.2,3 tion rate.6 Absolute contraindica-
Dr. Ng nor any immediate family
member has received anything of tions for limb salvage have been pro-
value from or owns stock in a posed and include poor preinjury
commercial company or institution Indications for Amputation patient health, complete lower limb sev-
related directly or indirectly to the
erance in adults, irreparable vascular in-
subject of this article. Trauma jury, segmental tibial loss >8 cm, and
J Am Acad Orthop Surg 2010;18: The Lower Extremity Assessment ischemia time >6 hours. Transection of
223-235
Project, a prospective, multicenter, the posterior tibial nerve5 or plantar
Copyright 2010 by the American observational study for high-energy insensitivity7 as indications for am-
Academy of Orthopaedic Surgeons.
trauma to the lower extremity, found putation have been challenged by
Dysvascular
Dysvascular amputations represent
several interrelated clinical path-
ways, including ischemia, infection,
and, in 71% of cases, diabetes.2,14 Six
percent of all patients aged >60 years
experience symptomatic peripheral
arterial disease.15 Unremitting claudi-
cation refractory to revascularization
can require amputation, and critical
Photographs of a diabetic ulcer (A) and ischemic dry gangrene (B) of the limb ischemia may lead to dry gan-
foot, necessitating transmetatarsal amputation. (Reproduced with permission
grene and autoamputation. Nonheal-
from Pollard J, Hamilton GA, Rush SM, Ford LA: Mortality and morbidity after
transmetatarsal amputation: Retrospective review of 101 cases. J Foot Ankle ing decubitus ulcers and diabetic foot
Surg 2006;45:91-97.) ulcers may lead to wet gangrene, os-
teomyelitis, and sepsis (Figure 2).
Progress in vascular surgery and en-
several authors. Plantar sensation ble.5 In the Lower Extremity Assess- dovascular therapy has allowed limb
frequently recovers,7 and in the event ment Project, there was no significant salvage in more than 80% of cases.16
of severe injury to the posterior tibial difference at 2 years in functional out- Despite high graft patency rates
nerve, limb function is often possi- come between all included lower ex- (73% at 3 years), underlying end-
stage renal disease and poor ambula- Western world.19 In less developed trant cases, amputation.22 Amputa-
tory status at presentation in this countries, traumatic amputations tion is reserved for complications of
population undermine successful res- from ongoing hazards, such as land the deformity, such as nonhealing ul-
toration of ambulation, wound heal- mines, are more frequent, ranging cers with underlying osteomyelitis.
ing, and survival in 66% of pa- from 40% to 74% of cases.19,20 Man- Intractable pain from prior surgical
tients.16 Thirty percent of patients agement of conditions during in- procedures of the foot and ankle
with critical limb ischemia, defined fancy, such as fibular hemimelia, am- may necessitate amputation. Com-
as ischemic rest pain and ankle pres- niotic band syndrome, and purpura plex regional pain syndrome (CRPS),
sures <50 to 70 mm Hg or toe pres- fulminans, may necessitate amputa- characterized by episodes of sponta-
sures <30 to 50 mm Hg, undergo tion. Pediatric amputations are fun- neous hyperalgesia, vasomotor insta-
bility and local autonomic symp-
major amputation.15 Contrary to the damentally different from those in
toms, must be recognized as a
belief that peripheral arterial disease adults in several aspects and demand
separate clinical entity from pain
gradually progresses in a stepwise separate consideration. Major princi-
itself. Formerly known as reflex sym-
fashion from claudication to ampu- ples include the preservation of im-
pathetic dystrophy, CRPS can be pre-
tation, one half of patients undergo- portant growth plates, the preference
cipitated or exacerbated in psycho-
ing major amputation did not have for disarticulation over transosseous
logically predisposed patients by any
ischemic symptoms 6 months before amputation, and the recognition and painful stimulus, including surgery.
surgery.15 Because of poor healing ca- use of better soft-tissue healing. Amputation for CRPS should be ap-
pacity and comorbid conditions in Stump overgrowth is a unique com- proached with great caution. Dielis-
this population, only 60% heal by plication in pediatrics and can lead sen et al23 reported subsequent relief
primary intention, and 15% require to skin erosion, bursa formation, and of pain and use of a prosthesis in
secondary procedures. Thirty-four residual limb pain.19 only 7% of patients. Pain manage-
percent of foot and ankle amputa-
ment has emerged as a separate med-
tions and 9% to 15% of below-knee Other ical specialty, and various nonsurgi-
amputations (BKAs) progress to a
Localized cold-induced lesions, or cal interventions are now available
higher level of limb loss.14,15
frostbite, are associated with low to treat CRPS.
ambient temperatures and persons
Tumor
with psychosocial issues such as drug
In 2005, approximately 13,000 Amer- use and homelessness. Cauchy et al21 Amputations of the Foot
icans were living with lower extremity classified injuries according to ra- and Ankle
amputations necessitated by malig- diotracer uptake on bone scan and
nancy.2 With the advent of neoadju- extent of skin blistering. Technetium- Preoperative
vant chemotherapy, amputation can 99m scintigraphy on day 3 and day 7 Considerations
be avoided in nearly 95% of all pa- predicted the level of eventual ampu- A successful amputation requires
tients with nonmetastatic osteosar- tation in more than 84% of cases. careful planning. Multidisciplinary
coma and Ewing sarcoma.17 In the Charcot arthropathy, characterized preoperative assessments by an or-
industrialized world, only cases with by progressive bony and joint de- thopaedic and vascular surgeon,
significant tumor involvement of struction because of decreased sensa- physical therapist, prosthetist, psy-
neurovascular structures, poor distal tion and proprioception with or chologist, social worker, and patient
extremity function, persistent local without preceding minor trauma, is representative can maximize ultimate
recurrence, or multiple failed at- often associated with diabetes and functional status. Because of the high
tempts at limb salvage require ampu- other peripheral neuropathies. Al- prevalence of comorbid conditions in
tation. Five-year survival rates for though the exact pathogenesis of the amputee population, optimiza-
nonmetastatic high-grade osteosar- Charcot foot is controversial, early tion of the patient’s health by inter-
coma have improved from about detection and a better understanding nal medicine specialists is manda-
20% before the mid 1970s to >65% of the disease have lowered rates of tory. Thirty-day and 1-year mortality
in 2005.18 amputation. Treatment includes off- rates in dysvascular patients range
loading the foot, protection with from 1.6% and 23%, respectively,
Congenital total-contact casts, surgical stabiliza- for midfoot amputations to 17.6%
Congenital limb deficiencies account tion, excision of bony prominences, and 50%, respectively, for transfem-
for most pediatric amputations in the tendon lengthenings, and, in recalci- oral amputations.14,24
Table 1 Figure 3
Threshold Predictors of Wound
Healing in Lower Extremity
Amputations
Ultrasound Doppler ABI >0.5
tcPO2 (on room air) 20 to 30 mm Hg
Serum albumin level >2.5 g/dL
Absolute lymphocyte count >1,500/µL
Figure 4
fashion. Great toe amputations should should be reattached to maintain dy- TMA is at least attempted.35,36 This
leave at least 1 cm at the base of the namic balance of the foot if the ray decision should be made carefully to
proximal phalanx to preserve the inser- resection necessitates the removal of avoid morbidity from multiple pro-
tion of the plantar fascia, sesamoids, their original insertions. cedures; in a series of 52 TMAs done
and flexor hallucis brevis. This reduces for vascular insufficiency or infec-
the amount of weight transfer to the re- Transmetatarsal Amputation tion, Anthony et al37 reported achiev-
maining toes and lessens the risk of ul- TMA was first described in 1855 by ing primary wound closure in only
ceration. Bernard and Heute for the treatment 33%, with 56% requiring revision to
Although ray resections are more of trench foot.33 It gained favor in a more proximal level.
durable and functional than trans- the 1940s for diabetic ulcers. Success Although only tendon insertions af-
metatarsal amputations (TMAs), no rates for TMAs range from 44% to fecting toe function are lost with TMA,
more than two rays should be re- 65%.28,33,34 TMAs performed prima- the resultant loss of the forefoot lever
moved so as to retain forefoot stabil- rily for ischemia require higher-level arm can cause equinus and distal tip ul-
ity. Fifth ray resections necessitated amputations much more frequently ceration. Dynamic balance after TMA
by infected metatarsal-head pressure than do those for infection (90% ver- can be challenging, with almost all pa-
ulcers are most common. Partial foot sus 4%, respectively).35 tients requiring an Achilles tendon
amputations are better tolerated lat- For ambulatory patients, TMA lengthening as an additional procedure.
erally than medially, and central ray preserves more limb length and func- The tendon lengthening should be per-
resections have worse outcomes than tional potential than does transtibial formed before the amputation to avoid
do outer ray resections (Figure 3). amputation. Although TMAs typi- contamination.36,38
The bases of the metatarsal joints cally heal less reliably than do more As demonstrated in Figure 4, a
should be preserved to avoid destabi- proximal amputations, patients who fish-mouth incision with a long plan-
lizing the Lisfranc joint. The tibialis refuse a transtibial or transfemoral tar flap is used to ensure that the
anterior and peroneus brevis muscles amputation may be more accepting if more resilient plantar soft tissue cov-
with standard soft dressings. The midstance and externally rotated for junction with a knee immobilizer.
RRD is composed of a thin layer of mediolateral support. The foot is The optimal shape for the residual
nonadherent dressing and a soft sock also aligned posteriorly and dorsi- limb is a gentle taper from proximal
to cover the skin, a compressive tu- flexed to reduce knee extension to distal. Immediate postoperative
bular layer, and a rigid outer layer forces during the transition from prostheses are designed to provide
made of plaster or fiberglass. Addi- midstance to toe-off. Although not patients the psychological benefit of
tional “filler” socks are used to fur- all Syme amputees can tolerate full seeing a limb on waking. These pros-
ther shrink and shape the stump as end bearing initially, the socket de- theses are not typically used, how-
the initial edema decreases. Sutures sign allows the stump to “fall ever, because they do not protect the
are removed at 3 weeks, and a cast through” as it matures and wound adequately, and they tempt
for prosthetic fitting is molded at 4 progresses to direct load transfer. patients to advance prematurely to
weeks.43 Based on the difference in circumfer- weight bearing.
Prosthetic design for a Syme ampu- ences between the distal stump and For the traditional BKA without a
tation must compensate for the loss the ankle, there are different catego- tibiofibular bridging synostosis, the
of foot and ankle motion, allow ade- ries of Syme prostheses (Figures 10 prosthesis must have a total contact–
quate clearance of the ground during to 12). specific weight-bearing socket to reduce
the swing phase of gait, and provide For transtibial amputees, the post- direct loading of the end of the stump.
an intimate socket to aid push-off operative protocol is similar. To pre- Although all surface areas are in
during ambulation. For optimal bio- vent flexion contractures, the knee is contact with the prosthesis, load trans-
mechanics, the foot is everted slightly held in extension with the surgeon’s fer occurs via the popliteal region,
to allow flat ground contact during cast, and the RRD is used in con- the pretibial group (ie, anterior com-
Figure 12 Figure 13
partment muscles), and the patellar uations in space demonstrate that lower
tendon. In addition, the design mini- Rehabilitation extremity weight-bearing muscles are
mizes medial forces on the fibula to the first to atrophy.61 Resistance
To emphasize the importance of mul-
prevent compression of the syndesmotic training can attenuate these losses.
tifaceted care of the new amputee,
space. With Ertl amputation, the re- The US military uses “prehabilita-
several studies have examined the
sidual limb can support both end- tion” to maintain core strength, joint
quality of the patients’ perceived re-
bearing load transfer and medially motion, and wheelchair mobilization
directed forces on the fibula. Once sult of surgery and found it to be un-
before definitive amputation.12
the bone bridge is healed at about related to amputation level. Strong
12 weeks, the patient can transition correlations were made between pa-
to a prosthesis with a total surface- tient satisfaction and the comfort of Pain Management
bearing socket. For both types of am- the residual limb, the condition of
putations, the first prosthesis is always the contralateral limb, the presence Several categories of pain are associ-
a clear plastic test socket to allow the of psychosocial issues, and the ability ated with amputation. Residual limb
prosthetist to monitor for proper align- to exercise and work.58,59 pain (ie, stump pain) typically sub-
ment and for areas of high pressure. At Dedication to physical rehabilitation sides with surgical healing but per-
6 weeks postoperatively, the patient can is one of the most important determi- sists in about 20% of patients for up
progress gradually to full-time wear57 nants of patient outcome60 (Table 2). to 2 years postoperatively.63 Caretak-
(Figure 13). Users of more sophisti- Immobility leads to medical complica- ers should maintain a high index of
cated and expensive prosthetic de- tions such as cardiovascular decline, suspicion for incision-site complica-
vices tend to report greater satisfac- atelectasis, pneumonia, and throm- tions when patients report localized
tion scores, although functional bosis.61 Kottke62 reported a 3% loss in pain.32 Back pain is an often over-
outcomes are similar to those of sim- muscle strength per day of inactivity. looked source of discomfort. Smith
pler devices. Studies on bed rest and zero-gravity sit- et al63 found that 71% of amputees
Table 2 The prevalence of phantom limb pain studies. References 20, 21, 23, 24, 26,
is approximately 80% to 85%.63,65 28, 34, 35, 37, 40-42, 44, 46, 48-50,
Phases of Rehabilitation After
Major Lower Limb Amputation Although epidural and spinal anes- and 53 are level IV studies. References
thesia provide improved analgesia in 1, 12, 13, 15, 16, 19, 22, 25, 31, 32,
Phase 1 (week 1)
the first week postoperatively, anes- 36, 38, 43, 45, 54-57, 60-62, and 65
Bed-to-wheelchair mobility
thetic technique has no effect at 12 are level V expert opinion.
Range-of-motion exercises
to 14 months postoperatively.66 Pe- Citation numbers printed in bold type
Edema control
ripheral anesthesia may be effective indicate references published within
RRD applied at 48 h
in preventing new pain memories, the past 5 years.
Transfer to acute rehabilitation facility at
48 h but because phantom limb pain is
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