JFAS 32(1): 60-68, 1993

Lower Extremity Amputations: Basis and Outcome,

A Review of the Literature

The authors present a designed approach to lower extremity amputations. The content
includes conditions, types, and complications of amputations and emphasizes types of
prosthetic devices. This review is intended to summarize the lower extremity amputation.

Alan J. Snyder, DPM1

Jeffrey M. Robbins, DPM2

"Amputation" is the removal of a limb, other appendage, or outgrowth of the body and is
derived from the Latin word "puto," which means "to prune" or to "lop off" (1). An
amputation is a surgical procedure that is invariably followed by different degrees of
permanent disability. Within the content of this manuscript, the conditions under which
an amputation is performed, the types of amputations, complications that could occur
after the amputation, and the types of prosthetic devices that are used today will be
discussed.

Conditions Resulting in Amputation

Amputation should only be performed as a last resort when all other measures of
limb salvage have failed. In some patients, amputation is performed as a primary
procedure because the patient's limb condition is irreversible and must be removed for the
safety of that patient. Nearly 75% of all lower limb amputations are performed for
peripheral or occlusive arterial disease (2). Occlusive disease can affect the arteries in the
thigh, leg, or foot which can include but are not limited to the superficial femoral,
popliteal, posterior tibial, peroneal, and dorsalis pedis arteries. These arteries are affected
due to a narrowing, loss of elasticity, or a partial or total blockage, resulting in a decrease
or loss of blood supply to the surrounding tissues such as skin, subcutaneous fat, muscles,
tendons, and bone. Atherosclerosis of the lower extremity vessels is the main contributing
factor to occlusive disease. Occlusive arterial disease can cause ischemia in the lower
extremity and must be repaired by vascular bypass surgery, if possible. If the disease state
is not diagnosed early, or the bypass fails, tissue death at the occlusive level radiating
distally could occur, resulting in amputation.
Fifty per cent of lower extremity amputations are secondary to patients suffering
from diabetes mellitus and its ramifications. Diabetes is a main contributing factor to
occlusive arterial disease due to its plaque deposition in large and small vessels, as well
as its peripheral effects. Its peripheral effects include a decrease of blood supply to the
feet; thus, healing properties are diminished, and infection, ulcers, and wounds might
progress to amputation. Diabetes association with neuropathy causes an impairment of
pain and temperature sensation, and as a result of repeated minor trauma or puncture
wound, there can be tissue devitalization (diabetic ulcer) brought on by ischemia. In
many of these cases, the patient does not realize this problem until it is too late, due to
decreased sensation to the feet. Infection may readily occur. This combination of
neuropathy, ischemia, and sepsis can lead to osteomyelitis and gangrene, which often
results in amputation (2).
Other conditions that can lead to amputation often include acute or chronic
osteomyelitis, which can result from an infectious process. The infectious process can be
caused by a foreign object, fracture, or untreated wound that leads to sepsis. A traumatic
event, severe toe nail infection with resultant cellulitis, or tumor involvement that
incorporates many structures in the lower limb can also lead to amputation. A
neurological deficit that places the limb in a painful contracture, or congenital defect that
leaves the patient with a partially developed limb, must be refashioned to be functional.
Another cause of amputation is a traumatic emergency situation. An important
point to remember is that an emergency amputation is usually a provisional or life saving
step. Therefore, it should be done at the lowest level consistent with viable tissues. When
healed, an elective amputation can then be performed at the best site. Two circumstances
that require an

_____________________________________________________________
From the Primary Care Residency Program, Ohio College of Podiatric Medicine,
Cleveland, Ohio.

1067-2516/93/3201-0060$3.00/0
Copyright © 1993 by the American College of Foot and Ankle Surgeons

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emergency amputation include: 1) freeing someone who is physically trapped in a

crashed vehicle, collapsed building, or mine, where the patient cannot otherwise be
extracted in time to save his or her life; and 2) for a crushing or mangling injury that
results from an accident in which the blood supply of the distal portion of the limb is
completely lost, there is severe sepsis (especially due to anaerobic organisms), or loss of
blood supply and gross infection are both present (3).

Types of Amputations

The surgeon must select an amputation site that allows removal of all necrotic and
irreversibly infected tissue, since progressive infection may be fatal. Attempts to
determine the most distal amputation site that can be safely selected have incorporated
such diagnostic techniques as physical examination, angiography, transcutaneous oxygen
monitoring, thermography, and blood pressure measurement of the lower extremity or
digits such as ankle/arm index and photoplethysmography. The goal of making these
assessments is to determine, preoperatively, the most distal amputation level that will
allow removal of all necrotic tissues, then heal, and hopefully, still be functional (4).
 Amputation above the knee should provide the patient as long a lever as possible
to be functional, while allowing for satisfactory fitting of a prosthesis (5). The exact level
is determined by the vascularity of the skin, while attempts are made at providing as long
a stump as possible to enable the patient to be more independently mobile (2). Ten
centimeters are required to interpose an artificial knee joint between the level of the distal
end of the stump and the normal joint axis (5). Most of these amputations are performed
for atherosclerosis, failed distal amputations, as well as the other reasons mentioned.
A transverse knee amputation is a compromise as it reduces the incidence of a
nonhealing below-the-knee amputation, while maintaining a stump long enough to fit a
satisfactory prosthesis. Since the prosthesis requires external knee hinges, the knee
disarticulation patient sacrifices the advantages of inherent prosthetic knee mechanisms.
In return for stability the patient has increased strength which the end-bearing stump
provides (6).
Below-the-knee amputations preserve the most vital structure for mobility, the
knee joint. The presence of a functioning knee joint is extremely valuable, whether or not
a prosthesis is being used. A stump of 5 to 7 inches distal to the joint line is ideal (7). The
largest problem with this type of amputation is the failure in which it heals and must be
refashioned and/or reamputation to a higher level.
The Syme's amputation is an ankle disarticulation with reconstruction of the
malleoli. James Syme first described this amputation at the ankle in 1843 (8). This
procedure allows the patient to be mobile without a prosthesis. The foot is disarticulated
at the ankle and the tibia and fibula are separated immediately above the joint line. This
appears to be an ideal amputation for a diabetic with distal gangrene (9).
When considering an amputation of the foot, reduction of the plantar surface will
correspondingly reduce the effective size of the physiologic stance platform (6). Bick
(25), Lisfranc (26), Pirogoff (27), and Boyd (28) amputations, in general, have not been
very successful. Equinus deformity is the major complication. Recurrent pressure
problems, with ulceration and infection, are common (10). The remaining portion of the
foot is difficult to fit in the conventional shoe and has problems with stability (Fig. 1).

Figure 1. Postoperative example of a Lisfranc's amputation.

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The indication for a transmetatarsal amputation is gangrene, infection, structural

deformity, and trauma limited to a toe or toes that do not extend into the web space or
onto the foot itself. When considering doing this level of amputation, one must consider
the patient's underlying conditions, and stability of infection. Is this the level that will be
most beneficial to the patient? This type of amputation can also be assisted by skin
grafting and rotational skin flaps for healing of the amputation. The contributory
infection must also be controlled (11).
Single digital amputation or disarticulation is usually performed when gangrene
and infection are localized, or chronic osteomyelitis without gangrene appears.
Amputation also must be considered after trauma to a single digit when neurovascular
damage is irreversible. When considering a single digit amputation, one must amputate to
the level where there will be noninfected tissue and bone and enough skin for primary or
secondary closure. What effects this amputation will cause during gait must also be
determined. Ingrown toenails (onychocryptosis) and similar problems have been
implicated in causing infections severe enough to require a Symes terminal amputation
(8, 12) (Figs. 2, 3).

Complications Resulting after Amputation

Postoperative management is dependent on adequate preoperative preparation of

the patient, both psychologically and physically. Operative technique and postoperative
wound dressing care influence the subsequent course (5). The patient must also take an
active role following surgery to help decrease postoperative complications such as
infection, delayed healing, and disuse problems. If the complications are not avoided, or
not properly treated, they could result in revision of the existing amputation, and more
proximally, even morbidity of the patient.
Complications in lower extremity amputations occur because each such amputee
presents a complex situation. These stem from variable etiologies and differing
physiologic and psychologic reactions to the surgical procedure, thus producing differing
attitudes toward

Figure 2. Postoperative example of a single digit amputation.

Figure 3. Amputation levels of the foot and ankle. (Reprinted with permission
from Parziale, J. R., Hahn, K. K. Functional considerations in partial foot amputations.
Orthop. Rev. 17:262-266, 1988.

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the resultant physical disfigurement (14). Complications that could occur before use of a
prosthetic device can include delayed healing of the surgical incision, joint contractures,
bone spur formation, stump edema, biomechanical problems, and infection.

A major complication is the phantom limb phenomena. The phantom limb

sensation is an awareness of some of the missing portion. This phantom sensation is
usually not painful, but occasionally may be quite unpleasant. No treatment is needed,
except reassurance that this is a normal reaction (15). Unfortunately, a small percentage
of patients may state that the phantom limb sensation has become painful or develop what
is called phantom pain. There are a number of treatment alternatives for phantom pain
such as prosthetic devices, local therapy, surgical resection of neuromas, surgical revision
of the amputation stump, and psychologic evaluation (16).
 Other possible complications that could occur after the prosthetic device is fitted
include skin breakdown, blister formation, or painful callouses. The complications can
also include ulceration of the stump, enlarged sebaceous cysts, edema, weakness of the
stump, degenerative arthritis, redundant soft tissues that atrophy, and problems with the
nerve endings such as neuromas. Biomechanical problems such as equinus, asymptomatic
chondromalacia, and osseous edges that cause enormous pain when the prosthesis is in
place are also complications that are a concern not only to the patient but also to the
doctor (14).

Types of Prosthetic Devices

The goal of any prosthetic fitting is to restore lost function to the amputee in as
nearly normal a manner as possible. In the lower extremity amputee, this requires a
prosthesis that allows comfortable and cosmetic ambulation, with a minimal amount of
energy expenditure (17). Biomechanical studies relate to the design of the prosthesis for
the foot, Syme, below, and above-the-knee amputations have been well documented and
show the characteristics of a normal gait pattern. Normal gait is achieved through
interaction of various parts of the lower extremity and the muscular activity controlling
them (18).
Components of the above-the-knee prosthesis consist of a socket, a thigh section,
an articulated knee joint, a shank, and a foot. This device is called the "quadrilateral total
contact socket." Total contact of the distal end of the stump relieves some of the
weightbearing pressure from the ischial tuberosity, prevents the formation of edema, and
provides the amputee with an enhanced sense of proprioception (19) (Fig. 4).
A below-the-knee prosthesis provides the amputee with the means for voluntary
knee control and an anatomical structure capable of weightbearing (17). The type of
prosthesis used today is the patella tendon-bearing prosthesis or PTB prosthesis, and
consists of a solid ankle cushion heel type of foot or SACH foot. This prosthesis is then
bolted to a wooden block into which a plastic total contact socket containing a rubber and
horsehide liner is inserted. Suspension is maintained by a supracondylar strap attached to
the socket and the total contact fit of the patella tendon-bearing prosthesis not only
reduces the distal stump edema, but also minimizes the complication of thigh atrophy
produced by the constricting leather strap (21) (Figs. 5, 6).
Prosthetic principles for the Syme prosthesis dictate that the total contact socket
permits distal weightbearing of the amputee.

Figure 4. An above-the-knee prosthesis with a quadrilateral, total contact socket.

(Reprinted with permission from Wilson, A. B. Recent advances in the above knee
prosthetics. Artif. Limbs 12:1-22, 1968.

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 Figure 5. A below-the-knee, patella tendon-bearing (PTB) prosthetic.

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Figure 6. PTB prosthetic with the cosmetic cover.

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Figure 7. Solid ankle cushion heel (SACH) assembly designed for a shoe with no
heel.

Figure 8. SACH assembly designed for a shoe with a 1-inch heel.

Figure 9. A mold that was fabricated from the patient's foot (on left) to make
prosthetic device/spacer.

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The socket must contain the SACH foot in the proper anatomical position required for
distal weightbearing (17). New designs and materials in prosthetic foot and ankle
assemblies now offer the individual with lower limb amputation a much wider choice. All
prosthetic feet display the same basic features to help restore normal function and
appearance. Some models are molded to suggest toes and toenails and a few are
manufactured in styles to be worn in shoes of various heel heights. Several functions are
common to all prosthetic foot and ankle assemblies. These include a proper base of
support when the patient is in the stance phase of gait, shock absorption during heel
strike, and simulation of metatarsophalangeal joint hyperextension during the late phase
of stance (22) (Figs. 7, 8).
Absence of the first toe, multiple toes, an entire ray or rays, adversely affects the
stability and push off of the patient during stance and gait (23). The types of inserts used
today can include the foot orthotic, prosthetic filler or spacer, or a long steel spring that
will extend the foot lever to restore length, add spring to push off, and increase stability
(24). With these new types of prosthetics, the patient is able to maintain balance to help
in the gait cycle and hopefully have a good, cosmetic-appearing foot (Figs. 9, 10).

Summary
 There are a number of conditions that potentiate amputation such as peripheral or
occlusive arterial disease, diabetes mellitus, atherosclerosis, osteomyelitis, sepsis, trauma,
and emergency situations. The types of amputations include above-the-knee, through the
knee, below-the-knee, Syme's, and a multitude of foot amputations such as Bick (25),
Lisfranc (26), Pirogoff(27), Boyd (28), transmetatarsal, and single toe amputation or
disarticulation in which all of these can be fitted with prosthetic devices. The
complications could include delayed healing, joint contractures, bone spur formation,
infection, phantom limb pain, ulceration, soft tissue atrophy, neuromas, biomechanical
problems, and stump weakness.
It is imperative for the patient to seek medical attention as soon as possible, to
receive the appropriate care. It is also the responsibility of the physician to do every
conservative and/or surgical treatment to prevent amputation. If amputation is needed, the
physician and patient should discuss the indications and alternatives, so that a procedure
that is not only therapeutic, but beneficial to that particular patient is selected. The goal of
the amputation is to restore a patient to the best level of function possible.

Figure 10. The finished prosthetic device that fits into molded/fitted shoe.

References

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8. Syme, J. Amputation at the ankle joint. J. Med. Sci. 2:93, 1843.

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13. Deleted in proof.
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20. Deleted in proof.
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Bone Joint Surg. 21:997, 1939.

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