CHAPTER 16

AMPUTATIONS OF THE LOWER EXTREMITY

Marcus C. Ford

FOOT AND ANKLE Rehabilitation in DISARTICULATION OF

AMPUTATIONS 720 nonischemic limbs 723 THE KNEE 726
TRANSTIBIAL (BELOW-KNEE) Ischemic limbs 723 TRANSFEMORAL (ABOVE-
AMPUTATIONS 721 Rehabilitation in KNEE) AMPUTATIONS 729
Nonischemic limbs 721 ischemic limbs 725 REHABILITATION AFTER
TRANSFEMORAL
AMPUTATION 731

Lower limb amputations are the most common of all ampu- Younger patients with traumatic amputations or amputa-
tations. Despite advances in revascularization techniques, tions required for tumor treatment are more successful with
the most common indication for lower extremity amputation prosthetic use than are patients with amputations of dysvascu-
remains a dysvascular limb, including that caused by diabe- lar limbs; dialysis patients are even less successful with pros-
tes mellitus and peripheral vascular disease. Peripheral vas- theses. In dysvascular limbs, the level of amputation is critical
cular disease from all causes affects over 8 million Americans. because of poor wound healing. The most distal level should
The rate of lower extremity amputation in this population is be chosen where the wound will have the best chance of heal-
around 4 per 1000. Amputation of the contralateral limb is ing. This decision process can be augmented using clinical
necessary within 5 years in 30% to 50% of patients who have tools such as transcutaneous oxygen tension, determining the
an amputation of a dysvascular lower limb. Twenty percent of nutritional status of patients (albumin level of >3 g/dL, lym-
below-knee amputations are converted to above-knee ampu- phocyte count of >1500/mL) and preoperative medical frailty.
tations. Over 50% of nontraumatic amputations occur from Amputation should not be viewed as a failed limb sal-
diabetes-related pathology. In the diabetic population, first- vage or reconstruction. The amputation must be viewed as
year mortality rates after amputation are reported to be as high an opportunity to reestablish or enhance a patient’s func-
as 40%, while overall mortality rates range from 60% to 70%. tional level and facilitate a return to near-normal locomotion.
The number of amputations for causes other than diabe- Transtibial amputation after failed attempted limb preserva-
tes and vascular disease, such as tumors and infection, has tion can still be successful in improving pain, decreasing nar-
decreased in the United States because of surgical and medi- cotic use, and improving function. This is especially true in
cal advances. In war-torn countries, improvised explosive the young, highly active trauma population. Meticulous sur-
devices and land mines continue to be frequent causes of gical attention is necessary to provide an optimal base of sup-
traumatic amputations. Also, a high rate of combat-related port because the residual limb functions as a “sensorimotor
lower extremity amputations remains in the military popula- end organ” with tolerance requirements at the stump-pros-
tion. Current level I and II studies are underway to investigate thesis interface to meet the dynamic weight-bearing chal-
optimal lower extremity amputation techniques in this highly lenges of ambulation. Anesthesia pain specialty teams often
active population. are helpful in the management of postoperative pain.
We advocate a multidisciplinary approach to the medi- Developments in the prosthetic field range from early-stage
cal management of lower extremity amputations. Diabetic fitting techniques (computer-assisted stump contour scanning)
patients and those with vascular insufficiency who have had to the use of advanced prosthetic components (lighter materi-
lower extremity amputation demonstrate high rates of 30-day als, silicone gel liners, computer-assisted knee units, suspension
mortality, stump complications, and hospital readmissions. device alternatives, and ankle-foot accommodative and energy
Associated coronary artery disease and end-stage renal dis- storage systems). Osseointegrated prosthetic components have
ease are predictors for perioperative medical complications been investigated over the past several decades in transfemoral
and hospital readmissions. and transtibial amputees. Potential advantages include improved
The level of amputation is always a difficult decision and quality of life and body image, increased proximal joint range
has a major effect on a patient’s quality of life. Morbidity is of motion, greater prosthetic comfort, better osseoperception,
more frequent after transfemoral amputations than after trans- and improved walking ability. Minor complications include
tibial amputations. Energy expenditure is an important con- frequent superficial infections and stump irritation, and rare
sideration in choosing the level of amputation. The increased major complications include deep infection, osteomyelitis, peri-
energy consumption of bipedal locomotion for transtibial implant fracture, and failure of osseointegration. Tillander et al.
amputees ranges from 40% to 50%, compared with 90% to reported a 20% cumulative risk of developing osteomyelitis.
100% in transfemoral amputees. Patients with transfemoral
amputations are less likely to use a prosthesis successfully and
consistently than are patients with more distal amputations. FOOT AND ANKLE AMPUTATIONS
Higher-level amputations, even in children, are associated Amputations around the foot and ankle are discussed in
with a decline in physical function and quality of life. Chapter 15. 

720
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 CHAPTER 16  AMPUTATIONS OF THE LOWER EXTREMITY 721

long posterior myocutaneous flap and a short or even absent

anterior flap are recommended for ischemic limbs because
anteriorly the blood supply is less abundant than elsewhere
in the leg.
In combat injuries that result from blasts or fragmenta-
Very short
transtibial
tion wounds, the use of standard flaps may be impossible.
Often flaps have to be fashioned from viable remaining tissue.
Skin grafts may be used to cover soft-tissue defects, but skin
Short grafts are not ideal for a stump-prosthesis interface.
transtibial
Standard NONISCHEMIC LIMBS
transtibial Rehabilitation after transtibial amputations in nonisch-
emic limbs generally is quite successful, partly because of
a younger, healthier population with fewer comorbidities.
The optimal level of amputation in this population tra-
ditionally has been chosen to provide a stump length that
Long allows a controlling lever arm for the prosthesis with suf-
transtibial ficient “circulation” for healing and soft tissue for protective
end weight bearing. The amputation level also is governed by
the cause (e.g., clean end margins for tumor, level of trauma,
and congenital abnormalities). A longer residual limb would
have a more normal gait appearance, but stumps extending
Syme to the distal third of the leg have been considered subop-
timal because there is less soft tissue available for weight
bearing and less room to accommodate some energy stor-
FIGURE 16.1 Levels of transtibial amputations. age systems. The distal third of the leg also has been con-
sidered relatively avascular and slower to heal than more
proximal levels. Contemporary liners and ankle-foot storage
systems now allow more options for accommodating a lon-
TRANSTIBIAL (BELOW-KNEE) ger residual limb, but the long-term risk of skin breakdown
AMPUTATIONS in older patients with these newer prosthetic components
Transtibial amputation is the most common lower extrem- is unknown. Our recent war experiences have shown that
ity amputation. The importance of preserving the patient’s early posttraumatic amputations decrease the risk of chronic
own knee joint in the successful rehabilitation of a patient residual limb infection. If only one posttraumatic debride-
with a lower extremity amputation cannot be overempha- ment procedure and 5 days or fewer pass before definitive
sized. Transtibial amputations can be divided into three lev- amputation, the risk of infection is limited.
els (Fig. 16.1). The appropriate level must be determined for In adults, the ideal bone length for a below-knee amputa-
each individual patient. Although many variations in tech- tion stump is 12.5 to 17.5 cm, depending on body height. A
nique exist, all procedures may be divided into those for reasonably satisfactory rule of thumb for selecting the level of
nonischemic limbs and those for ischemic limbs. General bone section is to allow 2.5 cm of bone length for each 30 cm
techniques vary primarily in the construction of skin flaps, of body height. Usually the most satisfactory level is about 15
muscle stabilization, and osseous stabilization techniques. In cm distal to the medial tibial articular surface. A stump less
nonischemic limbs, skin flaps of various design and muscle than 12.5 cm long is less efficient. Stumps lacking quadriceps
stabilization techniques, such as tension myodesis and myo- function are not useful. In a short stump of 8.8 cm or less, it
plasty, frequently are used. These techniques are employed to has been recommended that the entire fibula together with
prepare a stump more suited for weight bearing and to pro- some of the muscle bulk be removed so that the stump may
tect from wound breakdown. In tension myodesis, transected fit more easily into the prosthetic socket. Many prosthetists
muscle groups are sutured to bone under physiologic tension; find, however, that retention of the fibular head is desirable
in myoplasty, muscle is sutured to soft tissue, such as oppos- because the modern total-contact socket can obtain a better
ing muscle groups or fascia. In most instances, myoplastic purchase on the short stump. Transecting the hamstring ten-
closures are performed, but some authors have advocated dons to allow a short stump to fall deeper into the socket also
the use of the firmer stabilization provided by myodesis in may be considered. Although the procedure has the disad-
young, active individuals. In addition, some surgeons advo- vantage of weakening flexion of the knee, this has not been a
cate creating a bone bridge between the distal tibia and fibula serious problem, and genu recurvatum has not been reported.
(Technique 16.2). Advocates of the Ertl technique claim that a Amputations in nonischemic limbs result from tumor,
bone bridge creates a more stable end-bearing construct and trauma, infection, or congenital anomaly. In each, the under-
decreases the incidence of proximal tibiofibular joint instabil- lying lesion dictates the level of amputation and choice of skin
ity. In addition, closure of the intramedullary canal in osteo- flaps. Microvascular techniques have made preservation of
myoplastic transtibial amputation has been shown to increase transtibial stumps possible with the use of distant free flaps
blood flow to the residual limb. In ischemic limbs, tension and “spare part” flaps from the amputated limb. A description
myodesis is relatively contraindicated because it may com- of the classic transtibial amputation using equal anterior and
promise further an already marginal blood supply. Also, a posterior flaps follows. 

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722 PART VI AMPUTATIONS

  Because it contracts, the anterior flap cannot be used to

n 

measure the level of intended bone section. Instead, use

TRANSTIBIAL AMPUTATION the mark already made in the tibial periosteum to mea-
sure the original length of the flap and reestablish the
level of bone section. With a saw, mark the bone at this
TECHNIQUE 16.1 point.
Insert a curved hemostat in the natural cleavage plane at
n 

Place the patient supine on the operating table and use a

n  the lateral aspect of the tibia so that its tip follows along
pneumatic tourniquet for hemostasis. the interosseous membrane and passes over the anterior
Beginning proximally at the anteromedial joint line, mea-
n  aspect of the fibula to emerge just anterior to the pero-
sure distally the desired length of bone and mark that neus brevis muscle.
level over the tibial crest with a skin-marking pen. Identify and isolate the superficial peroneal nerve in the
n 

Outline equal anterior and posterior skin flaps, with the

n  interval between the extensor digitorum longus and pero-
length of each flap being equal to one half the anteropos- neus brevis, gently draw it distally, and divide it high so
terior diameter of the leg at the anticipated level of bone that it retracts well proximal to the end of the stump.
section. Divide the muscles in the anterior compartment of the
n 

Begin the anterior incision medially or laterally at the in-

n  leg at a point 0.6 cm distal to the level of bone section
tended level of bone section and swing it convexly distal- so that they retract flush with the end of the bone. As
ward to the previously determined level and proximally to these muscles are sectioned, take special care to identify
end at a similar position on the opposite side of the leg and protect the anterior tibial vessels and deep peroneal
(Fig. 16.2A). nerve.
When crossing the tibial crest, deepen the incision and
n  Isolate these structures and ligate and divide the vessels at
n 

mark the periosteum with a cut to establish a point for a level just proximal to the level of intended bone section.
future measurement. Exert gentle traction on the nerve and divide it proximally
n 

Begin the posterior incision at the same point as the an-

n  so that it retracts well proximal to the end of the stump.
terior and carry it first convexly distalward and then proxi- Before sectioning the tibia, bevel its crest with a saw: be-
n 

mally as in the anterior incision (see Fig 16.2A). gin 1.9 cm proximal to the level of the bone section and
Deepen the posterior incision down through the deep fas-
n  cut obliquely distalward to cross this level 0.5 cm anterior
cia, but do not separate the skin or deep fascia from the to the medullary cavity.
underlying muscle. Section the tibia transversely and section the fibula 1.2 cm
n 

Reflect as a single layer with the anterior flap the deep fascia
n  proximally.
and periosteum over the anteromedial surface of the tibia. Grasp their distal segments with a bone-holding forceps
n 

Continue this dissection proximally to the level of intended

n  so that they can be pulled anteriorly and distally to expose
bone section. the posterior muscle mass.

Amputation 4 cm
level
Periosteum
marked

8 cm

Skin flap
incision
A 4 cm

B C
FIGURE 16.2 Amputation through middle third of leg for nonischemic limbs. A, Fashioning
of equal anterior and posterior skin flaps, each one half anteroposterior diameter of leg at level of
bone section. B, Fashioning of posterior myofascial flap. C, Suture of myofascial flap to periosteum
anteriorly. SEE TECHNIQUE 16.1.

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 CHAPTER 16  AMPUTATIONS OF THE LOWER EXTREMITY 723

Divide the muscles in the deep posterior compartment

n  Osteotomize the remaining fibula at the level of the re-
n 

0.6 cm distal to the level of bone section so that they sected tibia; with a burr, create notches in the fibula and
retract flush with the end of the bone. This exposes the tibia for placement of the cut fibular autograft strut (Fig.
posterior tibial and peroneal vessels and the tibial nerve 16.3C,D).
lying on the gastrocnemius-soleus muscle group. Doubly Drill holes to accommodate heavy suture passage: two in
n 

ligate and divide the vessels and section the nerve so that the medial tibia, two in the medial fibular autograft, two
its cut end retracts well proximal to the end of the bone. in the lateral fibular autograft, and two in the distal fibula
With a large amputation knife, bevel the gastrocnemius-
n  (screw fixation may alternatively be used; Fig. 16.3E).
soleus muscle mass so that it forms a myofascial flap long Secure the autograft strut with heavy suture and sew the
n 

enough to reach across the end of the tibia to the anterior tibial periosteal sleeve around the strut distally. Autogenous
fascia (Fig. 16.2B). bone graft may augment the distal bone bridge if necessary.
Smoothly round the ends of the tibia and fibula with a
n  Release the tourniquet and achieve hemostasis.
n 

rasp and irrigate the wound to remove all bone dust. Mobilize the peroneal musculature distally to cover the
n 

Release the tourniquet and clamp and ligate or electroco-

n  end of the bone bridge and suture it to the medial aspect
agulate all bleeding points. of the tibia.
Bring the gastrocnemius-soleus muscle flap over the ends
n  Suture the posterior musculature to the anterior tibial
n 

of the bones and suture it to the deep fascia and the periosteum and close the subcutaneous tissues. Use non-
periosteum anteriorly (Fig. 16.2C). absorbable stitches in a mattress fashion to close the skin.
Place a plastic suction drainage tube deep to the muscle
n 
  
flap and fascia and bring it out laterally through the skin
10 to 12 cm proximal to the end of the stump.
Fashion the skin flaps as necessary for smooth closure
n 

without tension and suture them together with inter- REHABILITATION IN NONISCHEMIC LIMBS
rupted nonabsorbable sutures. Rehabilitation after transtibial amputation in a nonisch-
emic limb is fairly aggressive unless the patient is immu-
   nocompromised, there are skin graft issues, or there are
concomitant injuries or medical conditions that preclude
early initiation of physical therapy. An immediate post-
operative rigid dressing helps control edema, limits knee
TECHNIQUE 16.2 flexion contracture, and protects the limb from external
trauma.
(MODIFIED ERTL; TAYLOR AND POKA) A prosthetist can be helpful with such casting and can
Place the patient supine on a radiolucent bed; a tourni-
n  apply a jig that allows attachment and alignment for early
quet is used for hemostasis. pylon use. Weight bearing is limited initially, with bilateral
Make an anterior incision at the level of the intended tibial
n  upper extremity support from parallel bars, a walker, or
resection and a posterior flap incision. The posterior flap crutches. The dressing is changed every 5 to 7 days for skin
should measure 1 cm more than the diameter of the leg care. Within 3 to 4 weeks, the rigid dressing can be changed to
at the level of bone division (Fig. 16.3A). a removable temporary prosthesis if there are no skin compli-
Sharply incise the anterior compartment fascia, transect
n  cations. The patient is shown the proper use of elastic wrap-
the musculature of the anterior compartment, and ligate ping or a stump shrinker to control edema and help contour
the anterior neurovascular bundle. the residual limb when not wearing the prosthesis. The phys-
Identify the saphenous nerve, transect it proximally under
n  iatrist and therapist can assist in monitoring progress through
tension, and allow it to retract. the various transitions of temporary prosthetics to the per-
Identify the tibial resection site and elevate an osteoperi-
n  manent design, which may take several months. Endoskeletal
osteal sleeve proximal to the intended transection level designs have been more frequently used because modifi-
both anteriorly and posteriorly before making the tibial cations are simpler. Formal inpatient rehabilitation is brief,
cut (Fig. 16.3B). with most prosthetic training done on an outpatient basis.
Measure the medial-to-lateral distance between the tibia
n  A program geared toward returning the patient to his or her
and fibula at the area of transection and transect the previous occupation, hobbies, and educational pursuits can
peroneal muscle and fibula at this distance distal to the be structured with the help of a social worker, occupational
transected tibia. therapist, and vocational counselor.
Transect the peroneal musculature and ligate the lateral
n 

neurovascular bundle. ISCHEMIC LIMBS

Transect the deep posterior compartment at the level of
n 
The frequent comorbidities in patients with ischemic limbs
the tibial transection and sharply bevel the superficial pos- demand precautionary measures and interaction with a vas-
terior compartment to fashion a future flap. cular surgical team. Because the skin’s blood supply is much
Identify the posterior compartment neurovascular bun-
n 
better on the posterior and medial aspects of the leg than
dle, ligate and transect it, allowing for retraction. on the anterior or anterolateral sides, transtibial amputation
Identify the sural nerve and transect it in the posterior
n 
techniques for the ischemic limb are characterized by skin
subcutaneous flap. flaps that favor the posterior and medial side of the leg. The
Remove the amputated limb from the operative field, sav-
n 
long posterior flap technique popularized by Burgess is most
ing bone for possible grafting. commonly used, but medial and lateral flaps of equal length

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724 PART VI AMPUTATIONS

C
FIGURE 16.3 Modified Ertl technique. A, Skin incision marked to create long posterior flap.
B, Elevation of osteoperiosteal flap from the tibia. C, Provisional notch created in distal tibia and
fibula for fibular strut. D, Fibular strut placed into the tibial and fibular notches. E, Fibular strut
secured via sutures through bone tunnels. (A, B, and E, From: Taylor BC, Poka A: Osteomyoplastic
transtibial amputation: the Ertl technique, J Am Acad Orthop Surg 24:259, 2016. C and D, From Taylor BC,
Poka A: Osteomyoplastic transtibial amputation: technique and tips, J Orthop Surg Res 6:13, 2011.) SEE
TECHNIQUE 16.2.

as described by Persson, skew flaps, and long medial flaps to concerns of blood flow restriction. However, recent data
are being used. All techniques stress the need for preserving demonstrate that the Ertl procedure may be safe in these
intact the vascular connections between skin and muscle by high-risk patients.
avoiding dissection along tissue planes and by constructing Traditionally, tourniquets have not been used in the
myocutaneous flaps. Also, amputations performed in isch- amputation of dysvascular limbs to avoid damage to more
emic limbs are customarily at a higher level (e.g., 10 to 12.5 proximal diseased arteries. However, recent studies (includ-
cm distal to the joint line) than amputations in nonischemic ing randomized controlled trials) demonstrate decreased
limbs. Tension myodesis and osteomyoplasty, which may blood loss, decreased postoperative transfusion rates, and no
be of value in young, vigorous patients, historically have increased risk of vascular or wound complications with the
been contraindicated in patients with ischemic limbs due use of a tourniquet. 

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 CHAPTER 16  AMPUTATIONS OF THE LOWER EXTREMITY 725

  Section the tibia, and at a level no more than 0.9 to 1.3 cm

n 

higher, section the fibula. Dissect the soft tissues from the pos-
TRANSTIBIAL AMPUTATION USING terior aspect of the tibia and fibula distally to the level of the
LONG POSTERIOR SKIN FLAP posterior transverse skin division and separate and remove the
leg, ligating and dividing the nerves and vessels (Fig. 16.4B).
TECHNIQUE 16.3 Carefully round the tibia and form a short bevel on its
n 

anterior and medial aspects. Tension myodesis is not rec-

(BURGESS) ommended in this instance.
Bevel and tailor the posterior muscle mass to form a flap
n 
Position the patient supine on the operating table; do not
n 
(see Fig. 16.4B) and carry it anteriorly, suturing it to the
apply a tourniquet. Prepare and drape the limb so that deep fascia and periosteum (Fig. 16.4C).
an above-knee amputation can be performed if bleeding Obtain meticulous hemostasis.
n 
and tissue viability are insufficient to permit a successful Place a plastic suction drainage tube deep to the mus-
n 
transtibial amputation. For ischemic limbs, Burgess rec- cle flap and fascia and bring it out laterally through the
ommended amputation 8.8 to 12.5 cm distal to the line skin 10 to 12.5 cm proximal to the end of the stump; if
of the knee joint. preferred, a through-and-through Penrose drain may be
Outline a long posterior flap and a short anterior one.
n 
used, but it is more difficult to remove.
The posterior flap should measure 1 cm more than the Fashion the skin flaps as necessary to obtain smooth closure
n 
diameter of the leg at the level of bone division. without too much tension. Trim any “dog ears” sparingly;
Fashion the anterior flap at about the level of anticipated
n 
otherwise, the circulation in the skin may be disturbed.
section of the tibia (Fig. 16.4A). Close the skin with interrupted nonabsorbable sutures.
n 
Reflect as a single layer with the anterior flap the deep
n 
   
fascia and periosteum over the anteromedial surface of
the tibia.
Divide the anterolateral muscles down to the intermuscu-
n 
REHABILITATION IN ISCHEMIC LIMBS
lar septum, ligating and dividing the anterior tibial vessels Rehabilitation in patients with ischemic limbs must proceed
and peroneal nerves as encountered. cautiously because of potential skin healing compromise

Tibial
amputation
8.8 to 12.5 cm level
Skin flap
incision

Fibular
amputation level
0.9 to 1.3 cm
A 12.5 to 15 cm

B C
FIGURE 16.4 Transtibial amputation in ischemic limbs. A, Fashioning of short anterior and
long posterior skin flaps. B, Separation and removal of distal leg. Muscle mass is tailored to form
flaps. C, Suture of flap to deep fascia and periosteum anteriorly. (Redrawn from Burgess EM, Zettl
JH: Amputations below the knee, Artif Limbs 13:1, 1969.) SEE TECHNIQUE 16.3.

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726 PART VI AMPUTATIONS

and accompanying medical conditions. Initial postoperative skin incisions allow greater use of this amputation level in
efforts are centered on skin healing. After transtibial amputa- patients with ischemia. In nonambulatory patients, addi-
tion, a soft dressing can be applied but a rigid dressing is pre- tional extremity length provides adequate sitting support
ferred and can be used regardless of whether early ambulation and balance. Knee flexion contractures and associated distal
is prescribed. If immediate or prompt prosthetic ambulation ulcers common with transtibial amputations also are avoided. 
is not to be pursued, the stump can be dressed in a simple,
well-padded cast that extends proximally to midthigh and is
applied in such a manner as to avoid proximal constriction of  
the limb. Good suspension of the cast is essential to prevent it
from slipping distally and impairing stump circulation. This KNEE DISARTICULATION
may require compressive contouring of the cast in the supra-
condylar area and a waist band, suspension strap, or both. The TECHNIQUE 16.4
cast should be removed in 5 to 7 days; and if wound healing is
satisfactory, a new rigid dressing or prosthetic cast is applied. (BATCH, SPITTLER, AND MCFADDIN)
If immediate or prompt prosthetic ambulation is pursued, a Measuring from the inferior pole of the patella, fashion
n 

properly constructed prosthetic cast is best applied by a quali- a long, broad anterior flap about equal in length to the
fied prosthetist. Success of rehabilitation depends on multiple diameter of the knee (Fig. 16.5A).
variables, including cognitive status, premorbid functional Measuring from the level of the popliteal crease, fashion
n 

level, condition of the upper extremities and contralateral a short posterior flap equal in length to one half of the
lower limb, and coexisting medical and neurologic condi- diameter of the knee. Place the lateral ends of the flaps
tions. Early rehabilitation efforts may be geared toward inde- at the level of the tibial condyles.
pendence in a wheelchair, stump care education, skin care Deepen the anterior incision through the deep fascia to
n 

techniques to avoid decubitus ulcers, care of the contralateral the bone and dissect the anterior flap from the tibia and
intact lower limb, and preprosthetic general conditioning. adjacent muscle. Include in the flap the insertion of the
Weight bearing on the residual limb is usually delayed until patellar tendon and the pes anserinus (Fig. 16.5B).
skin healing has progressed. If a more aggressive approach is Expose the knee joint by dissecting the capsule from the
n 

taken toward prosthetic training, more frequent rigid dress- anterior and lateral margins of the tibia; divide the cruci-
ing changes are recommended and possibly the use of clear ate ligaments, and dissect the posterior capsule from the
sockets to allow monitoring of the skin. Some patients may tibia (Fig. 16.5C).
require further medical evaluation and clearance (e.g., chemi- Identify the tibial nerve, gently pull it distally, and divide it
n 

cally induced cardiac stress test or echocardiogram or vas- proximally so that it retracts well proximal to the level of
cular studies of the contralateral limb) to evaluate tolerance amputation (Fig. 16.5D).
for prosthetic training. A pain management specialist may be Identify, doubly ligate, and divide the popliteal vessels.
n 

needed to help treat postoperative phantom limb pain. Many Free the biceps tendon from the fibula, complete the am-
n 

patients receive inpatient rehabilitation training with subse- putation posteriorly, and remove the leg.
quent therapy on an outpatient basis or in an extended-care Do not excise the patella or attempt to fuse it to the
n 

facility or home health setting. Proposed rehabilitation goals femoral condyles. Do not disturb the articular cartilage of
also dictate which prosthetic components would be approved the femoral condyles and patella. Perform a synovectomy
by insurance carriers. only if specifically indicated.
Suture the patellar tendon to the cruciate ligaments and
n 

the remnants of the gastrocnemius muscle to tissue in the

DISARTICULATION OF THE KNEE intercondylar notch (Fig. 16.5E).
Disarticulation of the knee results in a functional end-bearing Place a through-and-through Penrose drain in the wound.
n 

stump. Newer socket designs and prosthetic knee mechanisms Close the deep fascia and subcutaneous tissues with
n 

that provide swing phase control have improved function in absorbable sutures and the skin edges with interrupted
patients with knee disarticulation. Although the benefit of its nonabsorbable sutures.
use in children and young adults has been proven, its use in If sufficient skin for a loose closure is unavailable, resect the
n 

the elderly and especially in patients with ischemia has been posterior part of the femoral condyles rather than risk loss
limited in the United States. Knee disarticulations are more of the skin flaps. The wound usually heals quickly, how-
commonly used in cases of trauma. Based on published data, ever, and a permanent prosthesis usually can be fitted in 6
it remains unclear if knee disarticulation provides additional to 8 weeks because shrinkage of the stump is not a factor.
functional benefit and improved complication rates com- If the wound fails to heal primarily, there is no reason for
pared to transfemoral amputation. apprehension or reamputation because it usually granu-
Potential advantages of knee disarticulation include (1) lates and heals satisfactorily without additional surgery.
preservation of the large end-bearing surfaces of the distal    
femur covered by skin and other soft tissues that are natu-  
rally suited for weight bearing, (2) creation of a long lever arm
controlled by strong muscles, and (3) stability of the prosthe- KNEE DISARTICULATION
sis. Techniques have been described for reducing the bulk of Mazet and Hennessy recommended a method that fea-
bone at the end of the stump to allow more cosmetic pros- tures resection of the protruding medial, lateral, and
thetic fitting while still retaining the weight-bearing, suspen- posterior surfaces of the femoral condyles for creating
sion, and rotational control features of the stump. Modified a knee disarticulation stump for which a more cosmeti-

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 CHAPTER 16  AMPUTATIONS OF THE LOWER EXTREMITY 727

Skin flap
10 cm incision

Patellar
tendon
A
5 cm
Right leg
(medial view) Infrapatellar
fat pad
Anterior cruciate
ligament

Lateral head of
gastrocnemius
muscle

Patellar
tendon
Pes
anserinus

B
C

Tibial nerve

D E

FIGURE 16.5 Disarticulation of knee joint. A, Skin incision. B, Anterior flap elevated, including
insertion of patellar tendon and pes anserinus. C, Cruciate ligaments and posterior capsule divided.
D, Tibial nerve divided high. E, Patellar tendon sutured to cruciate ligaments. SEE TECHNIQUE 16.4.

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728 PART VI AMPUTATIONS

Lines of Line of
condylar condylar
remodeling remodeling

Posterior

Skin Skin
incision incision
Anterior

A B
FIGURE 16.6 Mazet and Hennessy disarticulation of knee. A, Anterior view. B, Lateral view.
SEE TECHNIQUE 16.5. (Redrawn from Mazet R Jr, Hennessy CA: Knee disarticulation: a new technique and
a new knee-joint mechanism, J Bone Joint Surg 48A:126, 1966.)

cally acceptable prosthesis can be constructed. With this to the midpoint of the distal articular surface posteriorly
technique, tolerances within the socket are greater, more (the condyle is wider posteriorly). Discard the medial half
adduction of the stump is permitted in the alignment of of the condyle.
the prosthesis, and the decreased bulk of the stump per- Resect the lateral part of the lateral femoral condyle in
n 

mits greater ease in the application and removal of the a similar manner, starting at the junction of the medial
prosthesis. The debulked stump requires smaller skin two thirds and lateral one third of the distal articular
flaps, which may be beneficial for wound healing in dys- surface.
vascular limbs. These patients may use a suction type Direct attention to the posterior aspect of both condyles.
n 

prosthesis, which is less cumbersome to apply than a tra- Resect the posterior projecting bone by a vertical oste-
ditional above-knee amputation prosthesis and does not otomy in the frontal plane, starting at the point where
require removal for toileting needs. the condyles begin to curve sharply superiorly and pos-
teriorly.
TECHNIQUE 16.5 Smoothly round all bony prominences with a rasp, but
n 

do not disturb the remaining articular cartilage. At this

(MAZET AND HENNESSY) point, each condyle has a fairly broad weight-bearing
Fashion the usual fish-mouth skin incision, making the an-
n  area, whereas the projecting side and posterior aspect
terior flap longer and extending 10 cm distal to the level of each have been removed and the remaining bone has
of the knee joint and making the posterior flap shorter been smoothly rounded.
and extending only about 2.5 cm distal to the same level Suture the patellar tendon to the hamstrings in the inter-
n 

(Fig. 16.6). condylar notch under slight tension. Insert drains at each
Reflect the skin and deep fascia well proximal to the fem-
n  end of the wound, and close the deep fascia and the skin
oral condyles. in separate layers.
Divide the patellar tendon midway between the patella
n     
and the tibial tuberosity.
Flex the knee and section the collateral and cruciate liga-
n 
 
ments.
Increase flexion of the knee to 90 degrees, identify and
KNEE DISARTICULATION
n 

ligate the popliteal vessels, and isolate and divide the tibial
nerve.
Detach the hamstring muscles from their insertions and
n 
TECHNIQUE 16.6
remove the leg.
(KJØBLE)
Dissect the patella from its tendon and discard it.
n 
n  With the patient prone on the operating table, outline a lat-
Remodel the femoral condyles in the following manner.
n 
eral flap that is one half the anteroposterior diameter of the
Drive a wide osteotome vertically in a proximal direction
knee in length and a medial flap that is 2 to 3 cm longer to
through the medial femoral condyle to emerge at the
allow adequate coverage of the large medial femoral condyle
level of the adductor tubercle. Start this cut along a line
(Fig. 16.7). By constructing shorter medial and lateral flaps,
that extends from the medial articular margin anteriorly

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 CHAPTER 16  AMPUTATIONS OF THE LOWER EXTREMITY 729

Short
transfemoral

Medial
transfemoral

Long
transfemoral

FIGURE 16.7 Kjøble disarticulation of knee with medial and

Supracondylar
lateral skin flaps. SEE TECHNIQUE 16.6.

this technique provides more frequent healing in ischemic

limbs than techniques using long anterior and posterior flaps.
Begin the incision just distal to the lower pole of the pa-
n 

tella and extend it distally to the tibial tuberosity, curving

medially from this point for the medial flap and laterally FIGURE 16.8 Levels of transfemoral amputations.
from this point for the lateral flap.
Carry both incisions posteriorly to meet in the midline of
n 

the limb at a point 2.5 cm proximal to the joint line.

Deepen the incisions through the subcutaneous tissue
n 

and fascia down to bone.

Divide the patellar tendon at its insertion, and release the
n 
TRANSFEMORAL (ABOVE-KNEE)
medial and lateral hamstring tendons at their insertions. AMPUTATIONS
Divide the collateral ligaments and the cruciate ligaments.
n  Amputation levels above the knee can be classified as short
Divide the posterior joint capsule and expose, doubly li-
n  transfemoral, medial transfemoral, long transfemoral, and
gate, and divide the popliteal vessels. Identify and sharply supracondylar (Fig. 16.8). Amputation through the thigh is
transect the peroneal and tibial nerves so that their cut second in frequency only to transtibial amputation. In this
ends retract well proximal to the end of the stump. procedure the patient’s knee joint is lost, so it is extremely
Release the gastrocnemius origins from the distal femur
n  important for the stump to be as long as possible to provide
and divide any remaining soft tissues. a strong lever arm for control of the prosthesis. The con-
Suture the patellar tendon and the hamstring tendons to each
n  ventional, constant friction knee joint used in conventional
other and to the cruciate ligaments in the intercondylar notch. above-knee prostheses extends 9 to 10 cm distal to the end
Approximate the skin edges with interrupted nonabsorb-
n  of the prosthetic socket, and the bone must be amputated
able sutures. this far proximal to the knee to allow room for the joint.
Modern computer-assisted knee prostheses using variable
POSTOPERATIVE CARE  If desired, a soft dressing may be friction for knee stiffness allow for shorter distal femoral seg-
applied, and conventional aftercare instituted as previously ments. These prostheses that have highly sensitive sensors
described (see Chapter 14). Preferable treatment is to apply use hydraulic or magnetic units to allow for more natural
a rigid dressing or prosthetic cast with or without immediate knee motion, especially deceleration during the swing phase
or early weight-bearing ambulation. If non–weight bearing of gait. This also allows for longer femoral length without
is desired, the rigid dressing need consist only of a properly uneven levels of knee joint function. Amputation stumps in
padded cast extending to the groin and securely suspended which the level of bone section is less than 5 cm distal to the
by compressive contouring of the cast in the supracondylar lesser trochanter function as and are prosthetically fitted as
area or by a waist belt, suspension strap, or both. If weight- hip disarticulations.
bearing ambulation is pursued, the prosthetic cast should Muscle stabilization by myodesis or myoplasty is impor-
be applied by a qualified prosthetist. Postoperative care is tant when constructing a strong and sturdy amputation
similar to that outlined after transfemoral amputation (see stump. Gottschalk pointed out that in the absence of myode-
section on transfemoral amputations). sis of the adductor magnus, most transfemoral amputations
    result in at least 70% loss of adduction power. 

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730 PART VI AMPUTATIONS

  Divide the quadriceps muscle and its overlying fascia along

n 

the line of the anterior incision and reflect it proximally to

TRANSFEMORAL (ABOVE-KNEE) the level of intended bone section as a myofascial flap.
AMPUTATION OF NONISCHEMIC Identify, individually ligate, and transect the femoral ar-
n 

tery and vein in the femoral canal on the medial side of

LIMBS the thigh at the level of bone section. Incise the perios-
teum of the femur circumferentially and divide the bone
TECHNIQUE 16.7 with a saw immediately distal to the periosteal incision.
With a sharp rasp, smooth the edges of the bone and
n 
Position the patient supine on the operating table and
n 
flatten the anterolateral aspect of the femur to decrease
perform the surgery using tourniquet hemostasis.
the unit pressures between the bone and the overlying
Beginning proximally at the anticipated level of bone sec-
n 
soft tissues.
tion, outline equal anterior and posterior skin flaps. The
Identify the sciatic nerve just beneath the hamstring mus-
n 
length of each flap should be at least one half the antero-
cles, ligate it well proximal to the end of the bone, and
posterior diameter of the thigh at this level. Atypical flaps
divide it just distal to the ligature.
always are preferred to amputation at a higher level.
Divide the posterior muscles transversely so that their
n 
Fashion the anterior flap with an incision that starts at
n 
ends retract to the level of bone section and remove the
the midpoint on the medial aspect of the thigh at the
leg (Fig. 16.9B).
level of anticipated bone section. The incision passes
Isolate and section all cutaneous nerves so that their cut
n 
in a gentle curve distally and laterally, crosses the an-
ends retract well proximal to the end of the stump. Ir-
terior aspect of the thigh at the level determined as
rigate the wound with saline to remove all bone dust.
noted earlier, and curves proximally to end on the lat-
Through several small holes drilled just proximal to the end
n 
eral aspect of the thigh opposite the starting point
of the femur, attach the adductor and hamstring muscles
(Fig. 16.9A).
to the bone with nonabsorbable or absorbable sutures (Fig.
Fashion the posterior flap in a similar manner.
n 
16.9C). The muscles should be attached under slight ten-
Deepen the skin incisions through the subcutaneous tis-
n 
sion (alternatively, suture anchors with heavy nonabsorbable
sue and deep fascia and reflect the flaps proximally to the
suture or suture tape may be used instead of bone tunnels).
level of bone section.

Amputation
level Skin flap
incision

B C
FIGURE 16.9 Amputation through middle third of thigh. A, Incision and bone level. B, Myofas-
cial flap fashioned from quadriceps muscle and fascia. C, Adductor and hamstring muscles attached
to end of femur through holes drilled in bone. SEE TECHNIQUE 16.7.

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 CHAPTER 16  AMPUTATIONS OF THE LOWER EXTREMITY 731

Divide the femur 12 cm above the knee joint.

n 

Drill holes in the lateral, anterior, and posterior aspects of

n 

the femur, 1.5 cm from its end.

Hold the femur in maximal adduction and suture the ad-
n 

ductor magnus to its lateral aspect using previously drilled

holes (Fig. 16.10). Also, place anterior and posterior su-
tures to prevent its sliding backward or forward.
Suture the quadriceps to the posterior femur by draw-
n 

ing it over the adductor magnus while holding the hip in

extension.
Suture the remaining posterior muscles to the posterior
n 

aspect of the adductor magnus. Close the investing fascia

and skin and apply a soft dressing.
  

FIGURE 16.10 Attachment of adductor magnus to lateral

REHABILITATION AFTER TRANSFEMORAL
femur. (Redrawn from Gottschalk F: Transfemoral amputations. In:
AMPUTATION
Bowker JH, Michael JW, editors: Atlas of limb prosthetics: surgical, pros-
A soft dressing is adequate initially for elderly dysvascu-
thetic, and rehabilitation principles, ed 2, St. Louis: Mosby, 1992.) SEE
lar patients, whereas immediate postoperative rigid dress-
TECHNIQUE 16.8.
ings and earlier weight bearing with a locked-knee pylon are
appropriate in younger patients. Patients seem more comfort-
able if weight bearing is delayed until sutures or staples are
At this point, release the tourniquet and attain meticulous
n  removed. Subsequently, ambulation can be progressed with
hemostasis. an unlocked knee and less upper extremity support. For the
Bring the “quadriceps apron” over the end of the bone
n  definitive prosthesis, a variety of prosthetic knee units are
and suture its fascial layer to the posterior fascia of the available that are lighter and accommodate constant or vari-
thigh, trimming any excess muscle or fascia to permit a able gait cadences and provide good stability during weight
neat, snug approximation. bearing.
Insert plastic suction drainage tubes beneath the muscle
n  Many concepts and strategies relevant to these patients
flap and deep fascia, and bring them out through the were discussed earlier under postoperative care of trans-
lateral aspect of the thigh 10 to 12.5 cm proximal to the tibial amputations. The emphasis is on the recognition that
end of the stump. patients with ischemic limbs generally are less healthy than
Approximate the skin edges with interrupted sutures of
n  patients with nonischemic limbs; the rehabilitative pro-
nonabsorbable material. gram generally progresses much more slowly and more cau-
    tiously. A major obstacle to rehabilitation after transfemoral
amputation is the loss of the knee joint, which exponentially
increases the energy expenditure for locomotion with a
prosthesis. This has consequences for cardiac patients and
  patients with ischemic contralateral limbs. The patient and
family must be aware of the risks involved with a physically
TRANSFEMORAL (ABOVE-KNEE) demanding rehabilitation program. Many transfemoral
AMPUTATION OF NONISCHEMIC amputees with vascular disease never use a prosthesis con-
sistently. Patients with bilateral transfemoral amputations
LIMBS frequently elect to use a wheelchair because it is faster, and
oxygen consumption is four to seven times more using bilat-
TECHNIQUE 16.8 eral transfemoral prostheses. Younger patients can experi-
ence progress more rapidly, as discussed under transtibial
(GOTTSCHALK) postoperative care.
Place the patient supine with a roll under the buttock of
n 

the affected side.

Develop skin flaps using a long medial flap in the sagittal
n 
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