10

Extremity Amputations: Principles,

Techniques, and Recent Advances
Carol D. Morris, MD, MS
Benjamin K. Potter, MD
Edward A. Athanasian, MD
Valerae O. Lewis, MD

Abstract require considerable preoperative plan-

It is estimated that approximately 1.7 million Americans are living with the loss of a ning, knowledge of prosthetic design,
limb, and this number is expected to nearly double by 2050. The most common reasons and consideration of postoperative ex-
for amputation include vascular compromise, trauma, cancer, and congenital deformities. pectations. This chapter reviews the
Orthopaedic surgeons are often called on to manage patients requiring an amputation or principles and techniques for perform-
those with amputation-related conditions. It is helpful to review the principles and techniques ing lower and upper limb amputations,
for performing lower and upper limb amputations, with a focus on common complications with a focus on common complications
and how to avoid them and to be familiar with recent advances in prosthetic design and and how to avoid them, and discusses
management of a residual limb. recent advances in prosthetic design
Instr Course Lect 2015;64:105–117. and management of the residual limb.

It is estimated that approximately have decreased over time, but compli- Upper Limb Amputations
1.7 million Americans are living with cations from vascular disease leading to Amputation Levels
the loss of a limb, and this number is amputation have increased. The num- Fingertip amputations are commonly
expected to nearly double by 2050. Vas- ber of amputations performed for con- seen in the emergency department.
cular compromise, trauma, cancer, and genital deformities has remained steady. Treatment methods vary and are large-
congenital deformities are among the Although amputation is typically ly based on the level of amputation, the
most common reasons for amputation. considered a nonchallenging surgical angle of injury, and soft-tissue status.
Traumatic and neoplastic etiologies procedure, good functional results Transverse injuries may be allowed to
heal by secondary intention in most cas-
es because skin match and sensation
Dr. Morris or an immediate family member serves as a board member, owner, officer, or committee member of the American
Academy of Orthopaedic Surgeons. Dr. Potter or an immediate family member serves as a board member, owner, officer, or are often superior to grafting. At times,
committee member of the Society of Military Orthopaedic Surgeons and the American Academy of Orthopaedic Surgeons. bone shortening may be required. V-Y
Dr. Lewis or an immediate family member has received research or institutional support from Stryker and serves as a board Atasoy and Cutler flaps may be used on
member, owner, officer, or committee member of the American Academy of Orthopaedic Surgeons and the Western Ortho-
paedic Association. Neither Dr. Athanasian nor any immediate family member has received anything of value from or has occasion.1 Severe oblique injuries may
stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this chapter. require full-thickness skin grafting,

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Orthopaedic Medicine and Practice

volar advancement flaps, or cover-

age from adjacent digits (for example,
cross-finger flaps, reverse cross-finger
flaps, and dorsal metacarpal artery
flaps).
More proximal-level traumatic
digit amputations are most commonly
closed directly with some shortening
or conversion to a ray amputation. In-
dications for ray amputation must take
into account individual patient con-
siderations. Preoperative consultation
should include discussion of cosmetic
change, neuroma formation, and grip
strength reduction.2 Replantation may
be considered for amputations in sin-
gle digits distal to the flexor digitorum
Figure 1 Clinical photograph of a Figure 2 Clinical photograph of a
superficialis insertion on the middle double ray (index and middle finger) ring and small finger amputation for
phalanx, multiple digits, and thumbs amputation for sarcoma. sarcoma.
and in children.
rarely will metacarpophalangeal dis-
Elective Digit and articulation be favored by patients. highest rate of painful neuromas.4,5
Ray Amputation Ray amputation without transpo- Phantom sensation is common, but
Elective digit amputation may be in- sition is an excellent treatment op- phantom pain is infrequent. Rarely,
dicated in patients with vascular defi- tion for severe ring avulsion injuries painful neuromas may require reexci-
ciency, infection, or tumors. In the or malignant tumors of the digits.2 sion or cryoablation.
elective setting, the level of amputa- Transposition may be considered for Multiple ray amputation may be
tion and flap design can be carefully the treatment of middle finger lesions; required in the presence of tumor or
planned. Fish-mouth incisions often however, it is often not needed. During severe trauma. The defect produced
have the optimal appearance. Vo- this procedure, the base of the index by multiple ray amputation is much
lar flaps are particularly useful in the metacarpal is osteotomized, and the en- more apparent (Figures 1 and 2).
setting of distal interphalangeal joint tire digit is transposed to the position of Grip strength is often dramatically de-
disarticulation or interphalangeal dis- the middle ray. The index metacarpal is creased. In the tumor setting, it may be
articulation in the thumb. The volar then fixed to the base of the transected reduced by 75%.5 Function is markedly
skin provides excellent sensation and middle finger metacarpal. Attention to diminished.
durable skin and may maximize tactile digit rotation is critical. This procedure Thumb ray amputation is not fre-
sensation. The level of amputation re- can improve the appearance of the hand quently indicated. Whenever possible,
quired may influence the decision for but at the risk of malrotation, nonunion, thumb salvage procedures should be
ray amputation. When amputation at and (in the presence of tumors) contam- considered.6 Tumors distal to the in-
the proximal phalanx level is indicated ination of the index ray. terphalangeal joint often can be treated
in the digits, ray amputation should be Metacarpal ligament reconstruction safely with interphalangeal disarticu-
considered. The cosmetic appearance allows narrowing of the defect and lation. Tumors at the proximal pha-
and function are often superior in the improves cosmetic appearance. Grip lanx level often can be widely excised
setting of ray amputation. If breadth of strength is often reduced by approx- with reconstruction of the defect using
the palm is important for function, ray imately 30%.3 Neuroma formation is bone, tendon, and vascular and nerve
amputation may not be elected. Only common, and the index ray has the grafts with microsurgical soft-tissue

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Extremity Amputations: Principles, Techniques, and Recent Advances Chapter 10

reconstruction. Ray amputation of the assistive devices and greater use of the
thumb produces a substantial function- contralateral limb. Transhumeral-level
al deficit. Toe-to-thumb transfer or in- amputation may be required for severe
dex pollicization may be reconstruction forearm trauma, traumatic amputation,
options in this setting. or tumors of the proximal forearm or
Wrist disarticulation is rarely re- elbow with involvement of multiple ma-
quired in the tumor setting. Large jor nerves. Wide excision of the entire
tumors in the region of the wrist usu- elbow with reconstruction may be an al-
ally require forearm-level amputation. ternative if major nerves can be spared.
Smaller tumors may be amenable to In the presence of a malignant tu-
wide excision and reconstruction us- mor, the humerus-level amputation site
ing vascularized and nonvascularized is determined in large part by the level Figure 3 Intraoperative pho-
bone grafts with wrist arthrodesis. At of injury or the level of amputation re- tograph of a myoplasty for a
forearm-level amputation.
times, bone transport can be used to quired for achieving a wide excision.
bridge defects at the wrist. However, In general, amputations that maximize
wrist disarticulation may be considered length are preferred, as are anterior and posteriorly or anteriorly. Vessels are su-
in the trauma setting when replanta- posterior fish-mouth–type flaps. The ture ligated, nerves are transected prox-
tion is not possible. Equal flaps dorsally triceps and brachialis are used for myo- imally, and the clavicle is disarticulated
and palmarly are ideal, but the extent of plasty closure. Nerves are transected at the sternum or transected medially.
soft-tissue injury may determine which proximally to minimize pain from neu- Skin flaps may be determined by the
flaps are appropriate. romas. Suture ligation of vessels is pre- extent of tumor contamination and
Forearm-level amputation may be ferred to control proximal level vessels. previous surgical procedures. Preoper-
required for large wrist-level or carpal Shoulder disarticulation may be re- ative plastic surgery consultation may
tunnel–based tumors. This level of quired for very proximal-level humeral be helpful in planning closure. At times,
amputation is functionally devastat- amputations or when the presence of a fillet forearm flap from the amputated
ing. Because patients may have diffi- malignancy dictates the need for am- limb may facilitate closure.8
culty coping with the loss, preoperative putation at the level of the joint. Most
psychological counseling should be commonly, a lateral flap is used for cov- Lower Limb Amputations
routinely considered. Most commonly, erage. If the deltoid can be spared, it is General Principles
when major nerves can be spared, incorporated into the flap. More prox- Between 30,000 and 40,000 lower
wide excision and reconstruction are imal level amputations are commonly limb amputations are performed in
preferred. Fish-mouth incisions with associated with phantom sensation and the United States annually, and this
volar and dorsal flaps are ideal. Myo- phantom pain. rate has remained fairly steady during
plasty will ensure durable soft-tissue Forequarter amputation is most the past 15 years.9 The main causes of
coverage for the amputated bone ends commonly indicated for very large these amputations are vascular disease
(Figure 3). Myodesis may improve re- shoulder girdle tumors or multiple (54%, including diabetes and peripheral
sidual forearm rotation and may facil- recurrent shoulder-level tumors.7 Am- arterial disease) and trauma (45%); can-
itate prosthetic function. Nerve ends putation at this level produces a major cer is responsible for less than 2%.10 In
should be resected proximally to allow cosmetic defect and functional deficit. elderly patients or those with ischemic
adequate soft-tissue coverage for the Preoperative counseling should be disease, amputation of one lower limb is
neuromas, which routinely form after strongly considered. Prosthetic use is often followed by the amputation of the
amputation. Prosthetic fitting should usually limited to a shoulder pad that contralateral limb; 15% to 28% of such
be encouraged, but many patients com- supports clothing. Anterior, posterior, amputations occur within 3 years.11,12
monly use prostheses only for specific or combined approaches may be used. Despite the advances in medicine, these
activities or tasks. Most patients will Periscapular muscles are transected statistics have not greatly improved for
adapt with the use of nonprosthetic posteriorly. Vessels can be approached the dysvascular amputee. Only 50% of

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Orthopaedic Medicine and Practice

elderly dysvascular amputees survive tissue at the end of the residual limb be- control, protection of the suture site,
the first 3 years after an amputation.13 cause the extra tissue makes prosthesis contracture prevention, and possibly
However, an amputation should not wear and control quite difficult. To help earlier ambulation; however, consen-
be considered a failure of treatment. avoid extra tissue, the muscle should be sus on the most effective dressing is
Frequently, an amputation is the treat- transected to the level where the skin lacking.14
ment of choice for a devastating injury has naturally retracted after the skin
to the lower extremity, especially when incision, which should be distal to the Amputation Levels
reconstruction may be a long and costly level of the bone osteotomy. The term classic hemipelvectomy is used
process that results in a functionally un- The handling of the nerves during to describe an amputation of the pelvic
satisfactory limb. an amputation remains controversial. ring via disarticulation of the pubic sym-
Although amputation may be per- There is a consensus that the nerves physis and the sacroiliac joint, division
ceived as a technically nonchallenging should be isolated and gently pulled into of the common iliac vessels, and closure
procedure, it must be well planned to be the wound before transection. Addi- with a posterior fasciocutaneous flap.
well performed. Although each ampu- tional treatment of the severed nerve Another current term for this proce-
tation and amputation level has specific ending with ligation and/or injection dure is hindquarter amputation. Older
considerations, there are several funda- with anesthetic is controversial because terms include interpelviabdominal or
mental principles common to amputa- there is no definitive evidence-based interinnomino-abdominal amputation.
tion. Skin and muscle flaps should be consensus. Major blood vessels should Hemipelvectomy may be indicated for
fashioned to achieve the longest resid- be tied with a double ligature. If a tour- patients with massive pelvic trauma,
ual limb that will give the patient the niquet is used, it should be released, and uncontrollable sepsis of the lower ex-
best functional outcome. This length meticulous hemostasis should be ob- tremity, pervasive metastatic lesions of
depends not only on the amount of vi- tained before wound closure. The use the extremity, or primary pelvic bone
able tissue but on the anatomic location of drains is encouraged to help prevent and soft-tissue tumors. The three es-
and the desired prosthesis that will be the development of hematomas. sential components for a functional leg
fashioned (for example, high-function- The treatment of an amputee does are the lumbosacral plexus, the femoral
ing knee joint or ankle joint). Skin flaps not start and end in the operating room. neurovascular bundle, and the hip joint.
can be uniform (such as fish-mouth or Preoperative and postoperative plan- If two of these three structures are not
posterior-anterior–based flaps) but in ning is important. Preoperative consul- functional, then amputation is usually
the dysvascular, traumatic, or oncologic tation with a prosthetist can facilitate indicated. Pelvic resections have been
setting, the flaps are often nonconven- the choice of appropriate limb length classified by Enneking and Dunham15
tional. It is important to carefully eval- and help set a patient’s expectations. to facilitate consistent discussions about
uate the blood supply to the area before There are two schools of thought resection and reconstruction technique.
initiating the flap design. There are sev- regarding the postoperative dressing: The basic pelvic resection types are as
eral methods that can predict at which soft versus rigid. When a soft dressing is follows: type I, resection of the iliac
level of the lower limb the circulation used, the wound is closed, a small sterile wing; type II, resection of the peria-
in the skin is adequate for primary dressing is applied to the incision, and cetabular regions of the pelvic bone;
wound healing; these methods include an elastic bandage is snugly wrapped and type III, resection of the obturator.
xenon-133 clearance and transcutane- over the dressing and around the resid- Preoperative planning for hind-
ous measurement of oxygen tension. ual limb. Throughout the postoperative quarter amputations is essential. To
These measures are particularly helpful period, the residual limb is kept snugly decrease the possibility of intraoper-
in patients with dysvascular disorders. wrapped in an elastic bandage until the ative contamination and improve in-
As mentioned previously, the length prosthesis is fit. When a rigid dressing traoperative surgical view and bowel
of the residual limb can be critically is used, a plaster of Paris or fiberglass handling, some surgeons advocate the
important, both in terms of prosthesis cast is applied to the residual limb af- use of preoperative bowel preparation.
wear and the type of prosthesis that can ter surgery. The rigid dressing offers In theory, a bowel preparation will de-
be worn. It is important to avoid extra the benefit of pain reduction, edema crease the bacterial count and volume

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Extremity Amputations: Principles, Techniques, and Recent Advances Chapter 10

of bowel contents if there is spillage into

the wound. However, recent gyneco-
logic literature suggests that mechanical
bowel preparation may not provide a
substantial advantage in this regard.16
The placement of stents in the ure-
ters can be beneficial and will help iden-
tify the ureters within the surgical field.
Arterial and venous access should be
established to facilitate intraoperative
monitoring of the hemodynamic status
and fluid resuscitation.
Discussion of the surgical procedure
is not within the scope of this chapter,
Figure 4 Intraoperative photograph of an anterior-based hemipelvectomy
but it should be noted that care must be flap.
taken when performing a hindquarter
amputation on the right side because
the inferior vena cava lies on this side,
inferior to the aorta. The surgeon must
take care not to damage nor sacrifice
the inferior vena cava when attempt-
ing to ligate the common iliac artery.
The most common flap used in hemi-
pelvectomies is a posterior-based flap.
When the inferior gluteal vessels and
cuneal vessels are preserved and the
gluteus maximus muscle can be incor-
porated into the flap, the closure will
be myocutaneous. The anterior-based
flap, which is used less commonly, is a
long anterior myocutaneous flap that
generally includes the quadriceps mus-
cle (Figure 4). Its blood supply is based
on the femoral vessels. If local anterior
or posterior flap-based coverage is not
an option, a free fillet lower leg flap can
be used. Fillet flaps are axial-pattern
Figure 5 Clinical photographs of the anterior (A) and lateral (B) views of a
flaps that function as composite tissue hemipelvectomy prosthesis.
transfers. They can be used as pedicled
or free flaps and are a good option for independence. Patients who are young, many patients fi nd that ambulating
reconstructing large defects. motivated, and in good physical condi- with crutches is much faster than with
Patients with hindquarter ampu- tion with a good sense of balance may a prosthesis and requires no additional
tations can regain the ability to walk ambulate without external aids. How- expenditure of energy.
(Figure 5). Modern advances in tech- ever, many patients may need some type Patients with this level of amputa-
nology afford the patient the opportuni- of assistive device, such as a cane or tion who ambulate with a prosthesis
ty to regain functional and ambulatory a walker, for ambulation. In addition, have increased energy expenditures

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Orthopaedic Medicine and Practice

up to 200%.17 The prosthesis uses the disarticulation rather than an above-

lower section of the rib cage for weight knee amputation. Although it is impor-
bearing and stabilization. Skin grafts tant to preserve as much femoral length
and sutures in this area should be avoid- as possible during the amputation, it is
ed, and any transected bone should equally important to provide a residual
be beveled and rounded to lessen the limb that has the proper amount of
chance of skin breakdown from a sharp clearance for the prosthetic knee and to
bony end contained within the socket. match the prosthetic knee to the center
The lower back absorbs forces during of the sound knee. The femur should be
ambulation. Stabilization of the hip transected approximately 12 to 14 cm
and knee joints at heel strike places ab- above the joint line.
normally high forces along the spine. There are two schools of thought
Forward propulsion of the prosthesis and possibilities for muscle closure.
through the swing phase of gait requires Myoplasty is the closure of the quad-
aggressive lateral trunk shifts, increased riceps to the hamstrings. This method
lumbar lordosis, and transverse rotation does not stabilize the femur, but it al-
of the lumbar spine in conjunction with lows the femur to move freely within Figure 6 Illustration showing
contralateral vaulting. the soft-tissue envelope. There is less attachment of the adductor mag-
An amputation through the hip limb control with this method, and nus to the lateral part of the femur.
(Courtesy of John Bowker, MD,
joint is called a hip disarticulation. It is movement may result in pain. Myod-
and reproduced from Gottschalk F:
commonly used for failed vascular pro- esis consists of attaching the adductor Transfemoral amputation: Surgical
cedures after multiple lower-level ampu- magnus muscle to the lateral aspect of management, in Smith DG, Michael
JW, Bowker JH, eds: Atlas of Am-
tations or for massive trauma with crush the femur, thus stabilizing the femur
putations and Limb Deficiencies,
injuries to the lower extremity. In this and re-creating the adductor moment ed 3. Rosemont, IL, American
procedure, the acetabulum and poste- arm (Figure 6). This is accomplished Academy of Orthopaedic Surgeons,
2004, pp 533-540.)
rior soft tissues are spared. The incision, by placing drill holes in the residual fe-
which transverses around the posterior mur and securing the adductor to the
thigh, distal to the gluteal crease, gener- bone with heavy suture, such as polyes- the first postoperative day and begin
ally provides sufficient posterior cover- ter suture. Attaching the adductors to hip range-of-motion exercises when
age. The posterior myocutaneous flap is the lateral aspect of the distal femur not comfort permits.
the most common method of coverage. only pulls the femur into an adducted Transfemoral prostheses stabilize
An anterior myocutaneous flap also has position but also provides good distal the pelvis through ischial containment,
been described, although it is not often padding over the cut end of the femur. ischial weight bearing, and hydrostatic
used.18 The prosthesis incorporates the The attachment of the quadriceps and pressures within the socket. With the
ischium into the prosthesis, which not hamstring muscles to the opposite sides fulcrum (ischial tuberosity) placed at
only allows the patient to bear weight of the femur from which they originate the pelvic region, controlling the distal
through the ischium but also secures further secures the femur. The overly- femur requires a strong muscle contrac-
the prosthetic limb. It acts as a fulcrum ing fascia and skin flaps are then closed. tion from the adductor group with ev-
through which the pelvis is kept level After surgery, to minimize the de- ery step. The resulting outcome is high
during ambulation. velopment of hip flexion contractures, energy consumption and fatigue com-
Transfemoral (above-knee) ampu- the iliac crest should be incorporated pared with normal gait. The amount of
tations are performed, as the name into the dressing. If it is not, it is rec- energy expenditure increase compared
suggests, through the femur, and the ommended that the patient lie prone for with baseline energy expenditure also
knee joint is sacrificed. Residual limbs 20 to 30 minutes, three times per day, relates to the reason the amputation
shorter than 5 cm (measured from the to reduce the risk of contracture devel- occurred. Patients with traumatic
lesser trochanter) function like a hip opment. Patients should be mobilized transfemoral amputations have a 68%

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Extremity Amputations: Principles, Techniques, and Recent Advances Chapter 10

increase in energy expenditure, whereas benefit. With the condyles intact, the control. However, it may be beneficial
those with vascular amputation have prosthetic socket can be suspended by to sacrifice some length to allow more
a 100% increase. Strengthening and compression immediately proximal to room for modern prosthetic foot com-
training are necessary to obtain a con- the femoral condyles. Shaving the fem- ponents. Carbon fiber foot and strut
sistent, unnoticeable gait pattern. The oral condyles will improve the cosmetic systems reduce oxygen consumption at
most common gait deviation is that of appearance by reducing coronal bulk at velocities exceeding self-selected walk-
lateral trunk lean. the distal end of the prosthetic socket. ing speeds. These feet are relatively tall
If the femur is kept in an adducted Without the condyles, the prosthesis and can require up to 7 inches of clear-
position, patients expend less energy can be suspended with suction. ance between the residual limb and the
during ambulation because lateral trunk The addition of a prosthesis on the floor. Therefore, preoperative consulta-
lean is reduced. If femoral adduction amputated side results in knee-center tion with a prosthetist is important.21
is not maintained, patients are forced discrepancies, which are especially ob- The surgical issues discussed for
to dramatically shift their weight over vious when the patient is seated. For transfemoral amputation hold true for
the prosthetic side during single-limb this reason, a patient may opt for a a transtibial operation. Closure of the
stance to allow for swing phase clear- transfemoral amputation instead of a muscle layer can be performed through
ance of the sound leg and to maintain knee disarticulation. In patients who a myodesis in which the muscles are
coronal stability. This procedure results have not reached skeletal maturity, the sutured to the bone under physiologic
in additional energy expenditure and an option of arresting the distal growth tension or myoplasty in which the mus-
exaggerated Trendelenburg gait. Several plate on the involved limb can pro- cles are attached to their opposing mus-
variations in socket design to main- vide a shorter femoral length at bone cle group. Myodesis provides greater
tain femoral adduction and improve maturity and thus enhance cosmetic control and motion of the residual limb.
gait have met with varying success, outcome by providing symmetric knee Typically, the fascia of the superficial
especially in the absence of adductor centers. The advantages of a knee dis- posterior compartment is advanced
myodesis. articulation over a transfemoral ampu- forward and attached to the anterior
A knee disarticulation is an amputa- tation include a weight-bearing stump, periosteum of the tibia and the fascia of
tion through the knee joint. By preserv- normal alignment of the residual limb, the anterior compartment. Additional
ing the distal insertion of the adductor a more efficient gait, and less energy anchorage of the muscles may be ac-
muscle group, the femur maintains its expenditure.19,20 complished through drill holes medial
normal adduction angle, which allows Transtibial amputations are typi- and lateral to the tibial crest, although
for a more energy-efficient gait than cally performed for patients with foot this technique also may limit excursion
that typically obtained in a transfemoral or tibial tumors or major trauma. Al- of the muscle advancement. Again, ex-
amputation. The fulcrum in the knee though experienced prosthetists can cessive flaps should be avoided because
disarticulation socket is moved distally often accommodate residual limbs as extra distal soft tissue will become a
to the femoral condyles, thereby mim- short as 5 cm of tibia, to create a max- large loose mass of tissue at the end of
icking normal biomechanical loading imally functional limb, 2.5 cm of tibia the residual limb, making stabilization
and alignment, which also allows for a are required for each 30 cm of adult of the limb in the socket difficult.22
more normal and energy-efficient gait height. This formula generally results in Transtibial amputations are ex-
pattern. an amputation at the level of the mus- tremely functional. Resumption of a
Although the prosthesis does not culotendinous junction of the gastroc- preamputation lifestyle and activity
require ischial weight bearing and thus nemius muscle. Residual limbs that are level, including participation in sports
does not extend as far proximally, the shorter than 5 cm are not functional, and recreational activities, is possible.23
aesthetics of the prosthesis itself often and it is recommended that if such a Rotationplasty, fi rst described by
can be disappointing. The retention residual limb is expected, then a knee Borggreve24 in 1930, was popularized
of the condyles will make for a bulky disarticulation should be performed. by Van Nes25 for proximal femoral fo-
prosthesis. However, this adverse cos- As with other amputations, a longer re- cal deficiency. Essentially, the rotation-
metic result is offset by the functional sidual limb results in better prosthetic plasty creates a transtibial amputation

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Orthopaedic Medicine and Practice

and/or a carbon plate to provide sta-

bility and push-off during ambulation.
Amputations through the midfoot
include Chopart and Lisfranc ampu-
tations. The Lisfranc amputation is per-
formed at the tarsometatarsal joint, and
the Chopart amputation is performed
through the midtarsal joints. Prevention
Figure 7 Illustrations of Syme (A) and Pirogoff (B) amputation of the foot.
of equinus and equinovarus deformities
The shaded area represents the level of amputation. In a Pirogoff amputation, after these procedures is critical to avoid
an osteotomy is performed through the calcaneus perpendicular to the long a foot with limited functional benefit.28
axis (arrow).
Overall, complete ray resections
produce minimal deformity, which is
from a transfemoral resection. It is an a weight-bearing distal end, which af- especially true in the lateral column of
excellent alternative to a transfemoral fords the patient the ability to ambulate the foot where partial metacarpal resec-
amputation and can be a salvage pro- for short distances without the pros- tion can cause a substantial functional
cedure for patients with an infected thesis. However, early weight bearing deficit, but ray resection will not. In ad-
prosthesis, failed endoprosthesis, or without a prosthesis should be avoided. dition, the gap caused by ray resection
local tumor recurrence. Rotationplasty The main difference between these can be closed with minimal deformity
requires an intact sciatic nerve, a func- procedures is that with the Pirogoff and, unlike in the hand, ray transpo-
tional ankle joint, and an intact foot. procedure, an osteotomy is performed sition is rarely needed or performed.
Initially thought to be best in children through the calcaneus perpendicular After healing, normal shoe wear is pos-
aged 8 to 10 years, rotationplasties are to the long axis, resulting in a posterior sible, and gait is unaffected. However,
being performed in older patients. The flap that contains the calcaneal rem- amputation of the first ray can cause
main issue in older patients is the de- nant and the fat pad. The benefit of this functional gait disturbances by com-
creased flexibility of the ankle.26 procedure is that the fat pad, which is promising late stance and push-off. A
Functionally, rotationplasty offers prone to migration during the healing total contact shoe insert with filler and
the advantage of a longer lever arm, a process after a Syme amputation, is at- carbon plate may be needed to establish
functional knee joint, and an end (foot) tached to the calcaneus and, therefore, the third rocker of stance.
that tolerates socket load better than a fat pad migration is rare. However, the
transfemoral amputation stump. As a disadvantage is that calcaneal-tibial fu- Residual Limb
result, there is lower energy consump- sion is required for the residual limb to Considerations and
tion with ambulation, patients are able be successful and functional. Although Prosthetic Advancements
to walk for longer periods of time, and these amputations offer the benefit of a Initial Residual Limb
they can participate in vigorous sport- weight-bearing stump, cosmesis can be Considerations
ing activities that require knee flexion. a problem. The bulbous appearance of After initial wound healing has been
With advancements in limb salvage, the stump can be unappealing to some. achieved after amputation from any
this procedure has become less pop- In addition, not only is the choice of cause—trauma, tumor, infection, or
ular. However, psychologically, these prosthetic foot limited, but the pros- ischemia—attention turns toward
patients do quite well. They tend to thesis, which fits over the end of the prosthetic fitting and rehabilitation.
adjust quickly to the limb appearance stump, often necessitates the use of a A viable and durable terminal residual
and often do not view themselves as shoe lift on the side of the healthy limb limb remains an essential prerequisite
amputees.27 to level the pelvis. to successful prosthesis fitting and
The Syme and Pirogoff amputations Transmetatarsal, midfoot, and ray use. Therefore, robust, mobile soft-
(Figure 7) are both hindfoot amputa- resections may require shoe modifi- tissue coverage is at least as important
tions that generate a residual limb with cation, a total contact insert toe filler, to ultimate amputee function as the

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Extremity Amputations: Principles, Techniques, and Recent Advances Chapter 10

underlying osseous platform. 29 Al- revision surgery is necessary. In the ex-

though length preservation is generally perience of this chapter’s authors, many
desirable, a shorter residual limb with a split-thickness skin grafts after severe
healthy soft-tissue envelope will com- trauma serve as a length-preserving
monly pose fewer long-term problems bridge to delayed soft-tissue revision,
and fitting difficulties than a longer and a high reoperation rate should be
limb with marginal coverage. Atypi- anticipated.34
cal, “tweener” amputation levels (for
example, very long transtibial or trans- Complications
femoral amputations) should generally Complications and/or persistently
be avoided because, as a result of a com- symptomatic residual limbs frequently
bination of suboptimal soft-tissue cov- develop after amputation.35-37 Deep in-
Figure 8 Clinical photograph
erage and novel socket requirements, fection or overt wound failure represent showing poor terminal coverage
such residual limbs typically offer the absolute indications for surgical inter- of the remaining femur with a
split-thickness skin graft.
limitations of the proximal and distal vention. Certain other symptoms (for
adjacent amputations levels without example, phantom pain) cannot gener-
achieving the full benefits of either. ally be effectively managed with surgical (particularly nondominant) upper limb
Stable deep muscle anchorage via myo- intervention, but aggressive treatment amputees continue to favor simple, du-
desis should be performed to maximize of focal, “fixable” problems can dra- rable, body-powered terminal devices
residual limb control and anchor deep matically improve amputee comfort, or abandon their prostheses altogether,
padding,29-32 and the overlying myo- satisfaction, and function.38 Surgically myoelectric devices incorporating mul-
plasty should be anchored to the fascia correctable symptom generators include tiple degrees of freedom have become
of the underlying myodesis whenever neuromata, failed myodesis, unstable increasingly advanced and common-
practicable. Mobile fasciocutaneous myoplasty, redundant soft tissue, ul- place.40-43 Conventional myoelectric
tissue over a terminal residual limb is ceration or poor soft-tissue coverage, devices have been widely available for
desirable; mobile muscle groups are not, and symptomatic heterotopic ossifica- nearly two decades and typically receive
and they can produce painful symp- tion.39 Although revision surgery can input signals from underlying muscle
toms associated with deep bursa that be avoided by refusal to reoperate on groups with surface electrodes with-
form beneath hypermobile, unstable the patient, this approach—beyond a in the prosthetic socket. Myoelectric
myoplasties. Split-thickness skin grafts reasonable period of nonsurgical man- hands (Figure 9) commonly outper-
represent an occasionally necessary and agement with medical management, form sequential, body-powered devices
viable alternative to more proximal re- injections, and/or socket modifica- for precise tasks. Problems associated
vision33 but should be placed only over tions—may result in a severely disabled with weight, battery life, and limited
viable, supple muscle and subcutaneous and dissatisfied patient with a marginal functions have been increasingly solved
tissues (Figure 8). Grafts that adhere to residual limb who rejects the prosthesis by improved technologies borrowed
the periosteum or the immobile tendon unnecessarily.29,35,36 from other industries.
or fascia frequently develop ulceration Since the approval and release of
or overt wound failure when subjected Prosthetic Advancements the initial C-leg (Ottobock; Figure 10),
to prolonged direct pressure and shear Building on the prosthetic ingenuity microprocessor knee joints have dra-
forces with regular prosthesis wear. of past researchers (for example, suc- matically improved function for many
Dermal substitutes may be helpful in tion socket suspension was patented patients with an amputation at or prox-
terms of augmenting the durability of in the United States in 1863) and the imal to the knee joint with onboard
eventual split-thickness skin grafts; accelerating pace of available modern sensors that detect limb position and
they also may reconstitute an effective technology, modern prosthetic de- accommodate activities through func-
neodermis that facilitates improved vices continue to evolve at an impres- tions such as stance flexion and stumble
closure and coverage in the event that sive rate.40 Although many unilateral recovery.44,45 Newer-generation devices,

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Orthopaedic Medicine and Practice

futile because of the hastening specter

of obsolescence.

Future Directions
One persistent, problematic theme,
particularly for proximal transfemoral
and transhumeral amputees, relates to
difficulties with prosthesis suspension
because of weight and comfort in con-
ventional sockets. Within the past two
decades, European investigators have
developed osseointegrated, “endo-exo”
devices for the direct skeletal anchorage
and attachment of prostheses.47-50 Func-
Figure 9 Photograph illustrating
a myoelectric hand. When tying tion has been dramatically improved
shoelaces, a myoelectric hand Figure 10 Photograph of the for many patients, but complications
can be used to stabilize and hold C-leg by Ottobock. related to infection persist because the
the laces, while the opposite hand
maneuvers the laces. (Reproduced skin-implant interface is an imperfect
from Atkin DJ: Prosthetic training, in such as stair climbing.46 Clearly, pow- and unsolved problem. Loosening
Smith DG, Michael JW, Bowker JH, ered prosthetics represent the wave of and fracture also have been variably
eds: Atlas of Amputations and Limb
Deficiencies, ed 3. Rosemont, IL, the future. reported. Of particular concern, revi-
American Academy of Orthopaedic Nevertheless, although improved sion surgery to revise and replace or for-
Surgeons, 2004, pp 275-284.) gait patterns and energy expenditure mally remove an osseointegrated stem
have been objectively documented in typically requires substantial residual
including the Genium/X2 (Ottobock) these new devices,44-46 patient com- limb and/or bone shortening. No os-
have shown quick patient adaption, bet- mitment to rehabilitation and recov- seointegrated implants for major limb
ter use of stance flexion for a more nor- ery remains essential. Importantly, the amputations are currently available in
mal and symmetric gait, and increased microprocessor knee or other devices the United States, although FDA trials
versatility for ambulating in different do not “make” the amputee walk; the are in development.
environments or over variable terrain.40 amputee has to learn to walk again. Fur- Targeted muscle reinnervation
The first powered prosthetic knee thermore, the acceleration of prosthetic (TMR), as described by Kuiken et al51,52
joint is now commercially available technology within the past decade has and Dumanian et al,53 via reinnerva-
(Power Knee; Ossur). Although in the outstripped investigators’ ability to ad- tion of “unemployed” muscles and/or
experience of this chapter’s authors equately, objectively, and critically study reassignment of residual nerves may
many patients still prefer micropro- and assess the putative end-user benefits increase signal intensity and clarity
cessor knees because of weight, noise, of each new breakthrough. Each new while increasing the number of poten-
and versatility concerns, the advent of device will help some patients and be tial myoelectric target sites for proximal
adequate robotic power to assist am- ignored or rejected by others; prosthetic upper limb amputees. For transhumeral
bulatory function represents a marked fitting has never been and may never be amputees, TMR typically involves cre-
“step” forward for many patients and a “one size fits all” methodology, re- ating four independently controlled
prosthetic technology. More recent gardless of future innovations. There- nerve-muscle units by transferring the
commercial breakthroughs have led fore, although the objective assessment distal radial/posterior interosseous
to microprocessor and powered an- of new general technologies remains nerve to the lateral head of the triceps
kles (BiOM Foot; iWalk), which may important, comparing and contrasting and the median nerve motor branch
improve function over energy-storing, specific, often competing, prosthetic to the medial (short) head of the bi-
passive devices for everyday activities components has become increasingly ceps (Figure 11). When present, the

114 © 2015 AAOS Instructional Course Lectures, Volume 64

Extremity Amputations: Principles, Techniques, and Recent Advances Chapter 10

brachioradialis also may be targeted for and obviating problems related to sig-
reinnervation with the ulnar nerve. For nal noise, involuntary cocontraction of
patients with shoulder disarticulation, antagonist muscles, and difficult socket
the musculocutaneous nerve is typically fit or sweating (because they decrease
transferred to the clavicular head of the conventional myoelectric prosthesis
pectoralis major; the median nerve to function).54,55 Intracranial signal recep-
the sterna head of the pectoralis major; tors placed over the homunculus offer
the radial nerve to the thoracodorsal similar potential for proximal upper
nerve; and the ulnar nerve to the pec- limb amputees and patients with high
toralis minor, the long thoracic nerve, spinal cord or brachial plexus injuries.
or a redundant motor branch of the In addition, numerous haptic feedback
split pectoralis major. Other transfer technologies are in development to Figure 11 Intraoperative
or target sites are possible depend- offer proxy sensory input from myo- photograph of a posterior targeted
ing on the residual limb anatomy and electric prostheses to the amputee and muscle reinnervation procedure
on a transhumeral amputee.
available musculature. In addition to facilitate improved fine motor tasks and The terminal radial-posterior
increasing the number and signal clarity touch feedback. interosseous nerve has been
of nerve-muscle myoelectric target sites, An additional treatment strategy on attached to the deliberately
denervated and reinnervated lateral
a critical advantage of TMR is that the the horizon for upper limb amputees, head of the triceps (arrow).
resultant end prosthesis actions may be particularly of the dominant limb or bi-
intuitively programmed (for example, lateral limbs, is that of composite tissue upper limb or hand transplants have
the median nerve closes the hand). allotransplantation (for example, hand been performed worldwide to date) are
A related, but different, techno- transplantation). Substantial headway promising, offering midterm function
logic advancement to TMR is that of has been made in the past decade with that is comparable with or, in some
advanced pattern recognition. In am- regard to microsurgical techniques and cases, better than reimplantation and
putees who have undergone previous improved immunosuppression, immu- generally better function than is achiev-
TMR procedures or in those who have nomodulation, and immunotolerance able with currently available prosthe-
not but experience difficulty with myo- protocols.56-58 Modern protocols include ses. With such advancements currently
electric control, computer-assisted in- steroid sparing/avoiding techniques, being evaluated, hand transplantation
terpretation of surface electrode signals cell-based immunomodulation strate- may become more widely accepted and
is used to decode electrical signals in a gies, immunosuppression reduction as feasible in the near future.
more consistent and intuitive fashion. tolerance increases, and topical thera-
These signals are then appropriately pies that limit overall systemic immuno- Summary
reassigned in a customized fashion to suppression. Critics remain concerned Advancement in prosthetic design is
the patient’s prosthesis so that volitional about the lack of convincing long-term paralleling the increasing number of
intent more closely mirrors prosthesis functional data; an unclear and evolv- amputations. It is important for or-
response, and prosthesis responsiveness ing risk-benefit ratio; and potential thopaedic surgeons to know how to
and signal reliability are improved. life-shortening or fatal complications perform “good” amputations to allow
In the near future, implanted myo- related to immunosuppression, includ- patients to achieve the maximum ben-
electric signal amplifiers in the resid- ing hyperglycemia, hyperlipidemia, efits from modern prostheses. Metic-
ual limb may further improve signal impaired renal function, arterial hypo- ulous attention to surgical technical
quality and interpretation of upper tension, and/or lymphoproliferative dis- details and familiarity with residual
limb amputees, thus improving pros- orders. However, early results in a small limb options are crucial to achieving
thesis responsiveness and function number of patients (approximately 100 the desired outcome.

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Orthopaedic Medicine and Practice

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