Amputation

• Trauma
most common reason for an upper extremity amputation
• vascular disease
most common reason for a lower extremity amputation
• ***Soft tissue injury severity
has the greatest impact on decision making regarding limb salvage versus
amputation
• ***absence of plantar sensation
2nd highest impact on surgeon's decision making process
**not an absolute contraindication to reconstruction
**plantar sensation can recover by long-term follow-up
*Bone overgrowth most common complication with pediatric amputations*
• SIP (sickness impact profile) and return to work not significantly different
between amputation and reconstruction at 2 years in limb-threatening
injuries
• most important factor to determine patient-reported outcome is the
ability to return to work
• SIP (sickness impact profile) and return to work not significantly different
between amputation and reconstruction at 2 years in limb-threatening
injuries
• most important factor to determine patient-reported outcome is the
ability to return to work
 Metabolic Demand

• Metabolic cost of walking increases with more proximal amputations , Except

Syme amputation is more efficient than midfoot amputation
• Syme - 15%
• Transtibial A- traumatic - 25% average (1- short BKA -
40%),( 2-long BKA - 10%) B- vascular - 40%
• Transfemoral A- traumatic - 68% B- vascular - 100%
• Bilateral amputations
• BKA + BKA - 40%
• AKA + BKA - 118%
• AKA + AKA - >200% (280%)
• Wound Healing Improved with
1. albumin > 3.0 g/Dl
2. ischemic index > .5
3. transcutaneous oxygen tension > 30 mm Hg
4. toe pressure > 40 mm Hg
5. ankle-brachial index (ABI) > 0.45
6. total lymphocyte count (TLC) > 1500/mm3
• Hyperbaric oxygen therapy contraindications include
1. chemo or radiation therapy (Bleomycin)
2. pressure-sensitive implanted medical device (automatic implantable cardiac defibrillator,
pacemaker, dorsal column stimulator, insulin pump)
3. undrained pneumothorax
 Dog ears
• Very short transtibial amputation occurs when less if present, left in place
than 20 %of tibial length is preserved. to preserve blood
• Standard Transtibial Amputation occurs when between supply to the
20% and 50% of tibial length ispreserved.o posterior flap
At least 8cm of tibia is required below the knee joint for
optimal fitting of aprosthesis.
• Long Transtibial Amputation occurs when more than
50% of tibial length is preserved.
• Fibula is usually transected 1-2cm shorter than the tibia
to avoid distal fibula pain.

original Ertl amputation

required a corticoperiosteal flap
bridge

Skew flap bridging transtibial

amputation
Modified burgess long posterior flap incision
modified Ertl uses a fibular , is the traditional
strut graft Non-bone bridging transtibial amputation
 Great toe amputations
preserve 1cm at base of proximal phalanx to
preserves insertion of plantar fascia,
sesamoids, and flexor hallucis brevis

*patent tibialis posterior artery is required

*more energy efficient than midfoot *almost all require achilles lengthening to
*stable heel pad is most important factor , prevent equinus
The tibialis anterior is usually tenodesed to
the anterior heel pad along with the EDL
tendon to avoid posterior migration of the
heel pad.

*through the talonavicular and

calcaneocuboid joints
*primary complication is equinus deformity
avoid by lengthening of the Achilles tendon
and transfer of the tibialis anterior to the
talar neck

*equinovarus deformity is common Pirogoff amputation

caused by unopposed pull of tibialis posterior and
gastroc/soleus
prevent by maintaining insertion of peroneus
brevis and performing achilles lengthening
*Energy cost of walking similar to that of BKA
*removal of the forefoot and talus followed
by calcaneotibial arthrodesis
*calcaneus is osteotomized and rotated 50-
90 degrees to keep posterior aspect of
calcaneus distal
*allows patient to mobilize independently
without use of prosthetic