Chapter 14: Amputations

William J. J. Ertl

Chapter Outline

Introduction

This chapter is written to provide the orthopedic fracture and trauma surgeon a foundation for amputation surgery. Amputation surgery is one of the oldest known surgical procedures but has, in the past generation of surgeons, been given decreased importance particularly with regard to the proper surgical handling of residual limbs. This may be due to the stigma that is attached to amputations as a procedure of failure, namely failure of vascular reconstruction, joint reconstruction, or limb salvage. Amputation should be regarded as a reconstructive procedure restoring limb function with the prosthesis serving as an extension of the limb, not the limb solely being an attachment site for the prosthesis. It is my hope with this chapter to instill renewed interest in amputation surgery in the traumatized patient. 

Historical Background

Amputation as a surgical technique has its roots dating back to prehistoric times. The earliest known documentation of an amputation as a ritualistic act was noted on cave wall drawings dating back to approximately 5000 bc. Archeologists noted that a Neanderthal skeleton found in present-day Iraq provides evidence that the individual had survived an above-elbow amputation.56 Indications for amputation were extended by Hippocrates and Celsus to include the treatment of infection, a reduction in invalidism, removal of useless limbs, and as a life-saving procedure in selected circumstances. It was not until later when the ancient surgeons Archigenes and Heliodorus expanded the indications to include traumatic injuries and the utilization of proximal tight bandages for hemorrhage control, akin to the modern tourniquet.56 During the 1500s, Paré reintroduced the importance of ligatures for hemorrhage control and Clowes is credited with performing the first successful transfemoral amputation. With the introduction of projectile weaponry in the mid-1300s, battlefield injuries became more severe and maiming, requiring a renewed interest in treating limb injuries with amputation. During the late 1700s and into the early 1800s, the British surgeon George Guthrie and the French surgeon Dominique Jean Larrey challenged the practice of delaying amputations for battlefield injuries for 3 weeks by advocating rapid primary amputation for these injuries. This change in practice resulted in fewer deaths from severe limb injury. Larrey also promoted the rapid transport of wounded soldiers from the field with his “flying ambulance.” 
The development of amputation techniques has centered on armed conflicts. As a consequence of improvements in armaments, soldiers who survived other injuries often sustained significant limb injuries requiring amputation. Having emphasized expeditious transport and rapid amputation, attention was placed on reconstructive efforts of the residual limb. This was due in part to effective developments in anesthetics, aseptic surgery, antibiotics, the understanding of the basic physiology of the lower extremity, and prosthetic devices. A primary goal of amputation reconstruction was to preserve length and maintain the end-bearing capabilities of the residual limb as emphasized by Chopart and Lisfranc at the midfoot level and Pirogoff, Boyd, and Syme at the ankle level. During the late 1800s, Bier attempted osteoplastic reconstruction by placing a bony block between the tibia and the fibula secured with screw fixation. The only transtibial amputation capable of end bearing was developed by Ertl.1820 End bearing was accomplished by combining the concepts of bony reconstruction (osteoplasty) with soft tissue reconstruction (myoplasty) to create an osteomyoplastic amputation for the transtibial level. The same concepts of reconstructive surgery have also been applied to the transmetatarsal level and the transfemoral level. Ertl20 was able to apply his reconstructive techniques to approximately 13,000 patients over the years from World War I to World War II. Dederich continued to promote soft tissue stabilization, showing the advantages of restoring normal vascularity to the limb after myoplastic amputation at the transfemoral level.13 Gottschalk et al.23,24 further elucidated the importance of myoplastic reconstruction by characterizing improved alignment and gait at the transfemoral level when using this technique. 
With new unique materials and engineering principles, the prosthetic field has rapidly advanced the art and science of prosthetic manufacturing and is now able to fit many patients with poorly performed amputations with a functional prosthesis. As a result, the emphasis on proper surgical technique and focusing on amputation as a reconstructive procedure has slowly faded over time. The remainder of the chapter will serve to re-emphasize the need for sound surgical handling of the residual limb and review various surgical approaches and outcomes. 

Goals of Amputation

The ultimate goal of amputation is to restore and provide function to the patient. Surgery is not and should not be the only focus. The surgeon should be cognizant of the effect that limb loss will have on the patient and be able to provide the patient all resources necessary to regain maximum function. This will require a team approach with the patient at the center of attention.39 The team will include the patient, surgeon, prosthetist, rehabilitation expert, peer support, family, and even psychological support. Burgess9 believed that the residual limb should function as an end organ. To this end, the surgeon responsible for the patient should strive for total comprehensive care. 

Injured Limb Scoring Systems

As orthopedic and vascular surgical techniques improved over the last couple of decades, there has been renewed interest in salvaging traumatized limbs. However, our ability to predict which limb can be salvaged and which patients would benefit from early amputation remains very subjective and is quite limited. Gregory et al. first attempted to create a scoring system, the mangled extremity syndrome (MES), in a retrospective review of 60 patients. Utilizing this scoring system, they felt patients could be identified preoperatively for salvage or amputation.25 A second scoring system, the mangled extremity severity score (MESS) was employed by Johansen et al.30 and was felt to be simple and predictive. Helfet et al.27 then applied this scoring system prospectively and found it to be simple and accurate in determining limbs that could be salvaged and those that should undergo primary amputation. The American College of Surgeons1 simplified the definition of a mangled limb as one with “high energy transfer or crush causing a combination of injuries to the artery, bone, tendon, nerve, and/or soft tissue.” Other scoring systems also have been developed, including the predictive salvage index (PSI),28 The limb salvage index (LSI),54 the nerve injury, ischemia, soft tissue injury, skeletal injury, shock, and age of patient (NISSA) score,40 and the Hannover Fracture Scale (HFS).61 Each scoring system placed emphasis on different components of the limb and developed various criteria for amputation or salvage. At this point, the most widely system utilized in the United States is the MESS. 
Although ease and applicability have been touted for each scoring system, questions regarding sensitivity and specificity have arisen. Robertson’s52 review of 152 patients suggested poor sensitivity of the MESS as some patients with scores below the amputation threshold eventually went on to an amputation. Bonanni et al. retrospectively reviewed a 10-year experience of attempted limb salvage on 58 limbs utilizing the mangled extremity severity index (MESI), MESS, PSI, and LSI. Their review suggested poor predictive utility for limb salvage for all four scoring systems in their patient population.3 Poole et al. attempted to predict limb salvage of extremities with combined osseous, soft tissue, and vascular injuries independent of a named scoring system. The severity of soft tissue and nerve injury was highly interrelated but soft tissue injury did not correlate with the severity of the osseous injury. Further, limb salvage or amputation could not be accurately predicted by any variable or group of variables studied. Due to the dynamic changes that can occur in these patients these authors suggested initial limb salvage to observe the limb and then perform delayed amputation when indicated.50 Dirschl and Dahners comprehensively reviewed the MESI, MESS, NISSA, LSI, and PSI. No scoring system was predictive of salvage or amputation. They proposed that scoring systems be used for documentation and as guides in clinical decision making, not as absolute indicators for salvage or amputation.14 Durham et al. assessed the MESI, MESS, PSI, and LSI retrospectively over a 10-year period. Although there was significant variability in predicting amputation versus salvage, no scoring system was able to predict functional outcome.16 Thuan et al.58 showed that no injury severity score could predict functional outcome in patients who underwent limb salvage. Bosse et al. (the LEAP group) prospectively evaluated the utility of multiple scoring systems: MESS, LSI, PSI, NISSA, and HFS-97. The overall analysis showed that lower scores had specificity for limb salvage potential but the low sensitivity of these scoring systems did not validate them as predictors of amputation. The authors recommended caution in using these scoring systems at or above the amputation threshold.4 In comparison, Krettek et al. re-evaluated the HFS naming it the HFS-98 and applied the new scoring system prospectively to 87 open long bone fractures. They concluded that the HFS-98 was a reliable extremity salvage scoring system.31 
Lower extremity trauma is unique to each individual patient. The spectrum of injury to each organ system, namely the skin and subcutaneous tissue, the muscle, the neurovascular structures, and the bone, is varied. No scoring system has been shown to be predictive of amputation, outcome, or function. Scores that are predictive of salvage may be helpful but caution is stressed with regard to identifying a specific amputation threshold. Scoring systems may be used as a documentation tool and as a tool to facilitate communication between surgeons. In most cases, initial limb salvage attempts should be instituted first allowing a complete assessment of the patient, informing the patient of potential surgical options, and allowing the patient to become involved in decision making regarding salvage versus amputation. Although patients undergoing salvage of a severely injured limb may require frequent rehospitalizations, 2- and 7-year results of amputation compared to limb salvage demonstrate similar outcomes as measured by the Sickness Impact Profile.5,37 However, projected lifetime costs for patients having undergone an amputation are estimated to be three times greater than those for limb salvage patients due to costs of prosthetic devices.35 

Clinical Assessment of the Patient Requiring Amputation

Urgent Evaluation

In the emergent setting, assessment of the traumatized limb and patient begins with as detailed a history and as complete a physical examination as possible using the American College of Surgeons Advanced Trauma Life Support ABC algorithm. Once the primary survey is completed and the injury inventory is complete, a secondary survey should be performed and repeated every 4 to 6 hours, especially in the obtunded and/or intubated patient. Additional information can be gained by questioning first responders regarding the initial presentation of the patient, the time required for extrication, exposure to the elements, the amount of blood loss at the scene, the potential degree of wound contamination, resuscitation efforts, and the total time lapsed from the scene to the hospital. This information may provide a much more comprehensive clinical assessment of the patient, guiding the surgeon in his/her decision making. Once the patient has been assessed, life-threatening injuries addressed and resuscitation instituted, a focused examination of the limb can be undertaken. Overall inspection of the limb should take into account its appearance and the presence of any and all open wounds. Closed soft tissue wounds can be quite severe and should be graded using the Tscherne classification60 and open wounds in association with a fracture should be classified using the Gustilo/Anderson open fracture wound classification system.26,44 Peripheral pulses should be monitored closely and documented after any reduction maneuver. Dislocations and fractures should be reduced and held reduced with an appropriate splint. Motor and sensory function should also be documented as thoroughly as possible both before and after manipulating the limb. If there are no palpable pulses, a simple Doppler examination of the entire extremity should be performed. A complete Doppler examination may identify occult injuries remote from the main zone of injury that are impacting perfusion and threatening viability of the limb. With diminished or absent distal pulses, an ankle-brachial index (ABI) should be determined in the following manner: A blood pressure cuff is placed around the calf of the extremity in question. The cuff is inflated until no audible Doppler pulse is appreciated. The cuff pressure is then slowly released and once a pulse is heard, the blood pressure value is noted. The same is then done for the upper extremity and a ratio of the lower extremity pressure to the upper extremity pressure is created. The ratio obtained should be 0.9 or greater if no vascular injury is present. A value below 0.9 is suggestive of a vascular injury that may require further workup (e.g., angiography) or intervention. This simple test has shown value in patients with knee dislocation and high-energy tibial plateau fractures.43 Further, simple duplex Doppler examination of the arterial system can be performed prior to angiography. Angiography should be reserved to determine the exact location of an arterial injury and guide potential intervention such as intraluminal stenting. If a specific vascular injury is diagnosed, revascularization should be performed to preserve limb viability. If the limb is unstable due to a fracture or ligamentous injury, a simple uniplanar external fixator can be applied quickly to maintain the length and alignment of the limb and provide provisional stability during revascularization.21 Definitive skeletal stabilization can then be staged when deemed appropriate. 

Elective Evaluation

In patients who present with delayed or nonemergent indications for amputation, a detailed physical examination is imperative. Often these patients are functionally impaired, have significant pain and have a desire to re-enter societal participation.51 These patients may present with progressive soft tissue necrosis and infection (Fig. 14-1). Overall inspection of the wounds to determine the extent of potential superficial and/or deep infection is needed as this may determine the ultimate level of amputation. Further, noninvasive vascular assessment should be performed. An ABI of less than 0.45 suggests that distal healing is unlikely.15 However, in patients with calcific arteriosclerosis, these values may be falsely high and caution should be used when evaluating this test in these patients. Other useful tests include the duplex Doppler examination of the arterial system and transcutaneous oxygen tension (TcPO2) measurements. Duplex Doppler tests will characterize the arterial anatomy and TcPO2 measurements will aid in determining the healing potential of surgical wounds. TcPO2 values below 20 mm Hg are indicative of nonhealing and values of 40 mm Hg or greater are indicative of healing. Between these values, the surgeon should take into account the patient’s pre-existing comorbidities, arterial anatomy, and nutritional status. In my experience, in a patient who has undergone a distal vascular bypass below the knee, a below-knee amputation usually will fail due to the single vessel dominance of the lower limb. The goal of this workup is to provide both the patient and the surgeon information that can be used to determine the optimal level of amputation to facilitate prosthetic planning and to estimate rehabilitation demands. A combination of tests should be used to determine amputation level as no one test has been shown to be specific or sensitive enough to predict amputation level. 
Figure 14-1
Depicted is the end-point of wound deterioration following a crush injury to the foot.
 
This patient sustained multiple metatarsal fractures that were treated with percutaneous pin fixation. The foot remained with a pulse and the wounds were closed; however, the soft tissue envelope did not survive and a transtibial amputation was eventually performed.
This patient sustained multiple metatarsal fractures that were treated with percutaneous pin fixation. The foot remained with a pulse and the wounds were closed; however, the soft tissue envelope did not survive and a transtibial amputation was eventually performed.
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Figure 14-1
Depicted is the end-point of wound deterioration following a crush injury to the foot.
This patient sustained multiple metatarsal fractures that were treated with percutaneous pin fixation. The foot remained with a pulse and the wounds were closed; however, the soft tissue envelope did not survive and a transtibial amputation was eventually performed.
This patient sustained multiple metatarsal fractures that were treated with percutaneous pin fixation. The foot remained with a pulse and the wounds were closed; however, the soft tissue envelope did not survive and a transtibial amputation was eventually performed.
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Surgical Techniques

Upper Extremity

Temporizing Versus Immediate Amputation

Patients who present with a complete amputation of the limb rarely are able to undergo successful replantation, usually because the underlying soft tissue injury is so severe compared to the bony injury (Fig. 14-2). Traumatized limbs with segmental injuries, significant vascular injury, significant soft tissue loss, and/or near amputation may be best treated with an immediate open amputation (Fig. 14-3). Traumatized limbs with a nonreconstructible vascular injury will require amputation. The most important factor regarding limb salvage versus amputation will be the severity of the soft tissue injury.36 These patients often have an obvious constellation of nonreconstructible injuries. When immediate amputation is preferred, all viable soft tissue should be maintained as it can be used later for definitive wound closure. Obviously, ischemic, devitalized tissue should be aggressively and thoroughly debrided. Osseous structures should be resected initially to the level of soft tissue resection. Wound care should then be instituted with serial debridements until a stable wound bed is achieved. Negative pressure wound therapy may play an adjunctive role in creating granulation tissue that may aid in wound healing (Fig. 14-4). During this time period, patient education and prosthetic consultation should be employed to maintain patient involvement in their treatment course. Further, the clinical workup should be continued to determine the optimum level of amputation, similar to the patient undergoing a nonemergent amputation. 
Figure 14-2
An oil well driller sustained a traumatic amputation during a drilling operation.
 
Significant soft tissue contamination and extensive degloving precluded replantation. The radius and ulna both remained attached to the arm while the hand and forearm soft tissue envelope was completely degloved.
Significant soft tissue contamination and extensive degloving precluded replantation. The radius and ulna both remained attached to the arm while the hand and forearm soft tissue envelope was completely degloved.
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Figure 14-2
An oil well driller sustained a traumatic amputation during a drilling operation.
Significant soft tissue contamination and extensive degloving precluded replantation. The radius and ulna both remained attached to the arm while the hand and forearm soft tissue envelope was completely degloved.
Significant soft tissue contamination and extensive degloving precluded replantation. The radius and ulna both remained attached to the arm while the hand and forearm soft tissue envelope was completely degloved.
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Figure 14-3
A motorcyclist sustained severe injuries to the lower leg.
 
There was segmental bone loss and extensive soft tissue loss, and the foot was pulseless. Vascular reconstruction was not feasible. Injuries such as this one should be treated with staged amputation. An open amputation preserving as much length as possible should be performed first. Following intensive wound care, a definitive amputation is performed when the wound bed seems stable.
There was segmental bone loss and extensive soft tissue loss, and the foot was pulseless. Vascular reconstruction was not feasible. Injuries such as this one should be treated with staged amputation. An open amputation preserving as much length as possible should be performed first. Following intensive wound care, a definitive amputation is performed when the wound bed seems stable.
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Figure 14-3
A motorcyclist sustained severe injuries to the lower leg.
There was segmental bone loss and extensive soft tissue loss, and the foot was pulseless. Vascular reconstruction was not feasible. Injuries such as this one should be treated with staged amputation. An open amputation preserving as much length as possible should be performed first. Following intensive wound care, a definitive amputation is performed when the wound bed seems stable.
There was segmental bone loss and extensive soft tissue loss, and the foot was pulseless. Vascular reconstruction was not feasible. Injuries such as this one should be treated with staged amputation. An open amputation preserving as much length as possible should be performed first. Following intensive wound care, a definitive amputation is performed when the wound bed seems stable.
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Figure 14-4
Negative pressure wound therapy is a powerful adjunctive tool to create healthy granulation tissue and a stable wound bed.
 
In this transhumeral amputation, length was preserved by maintaining muscle coverage over the humerus and applying negative pressure wound therapy until a healthy granulation tissue bed was created. Then a split-thickness skin graft was successfully applied and the patient was ultimately fitted with a myoelectric prosthesis.
In this transhumeral amputation, length was preserved by maintaining muscle coverage over the humerus and applying negative pressure wound therapy until a healthy granulation tissue bed was created. Then a split-thickness skin graft was successfully applied and the patient was ultimately fitted with a myoelectric prosthesis.
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Figure 14-4
Negative pressure wound therapy is a powerful adjunctive tool to create healthy granulation tissue and a stable wound bed.
In this transhumeral amputation, length was preserved by maintaining muscle coverage over the humerus and applying negative pressure wound therapy until a healthy granulation tissue bed was created. Then a split-thickness skin graft was successfully applied and the patient was ultimately fitted with a myoelectric prosthesis.
In this transhumeral amputation, length was preserved by maintaining muscle coverage over the humerus and applying negative pressure wound therapy until a healthy granulation tissue bed was created. Then a split-thickness skin graft was successfully applied and the patient was ultimately fitted with a myoelectric prosthesis.
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Patients who present with no clear-cut evidence for immediate amputation should undergo early temporizing treatment. This may include the utilization of temporary external fixation and serial wound debridements. The primary focus of initial temporizing treatment is to obtain and maintain perfusion of the limb prior to extensive and exhausting reconstructive procedures. If limb viability cannot be maintained or reconstruction/salvage is deemed unfeasible, then an elective amputation should be undertaken. 

Below-elbow Amputation

Preserving a functional elbow joint is vital as this joint serves to position the hand in space. Maintaining limb length and a functional elbow joint will substantially increase functional outcome at this level of amputation. If possible, preserving the pronator quadratus allows the patient to maintain two-thirds of active forearm rotation, and thus a body-powered prosthesis can be applied to this level. If a myoelectric prosthesis in utilized, the optimum length will be at the junction of mid- and distal thirds of the forearm. The soft tissue reconstruction must be stable and can be accomplished with myodesis (muscle sutured to bone) or a combination of a myodesis of the deeper layer and myoplasty (antagonistic muscles sutured together) of the superficial layer (using a pants-over-vest technique). This will provide adequate soft tissue coverage distally with volar and dorsal flaps and allow the residual musculature to be active and dynamic, providing a strong myoelectric signal. Although not routinely performed, a Krukenberg procedure splits the radius and ulna to create a pincers mechanism. It has been recommended for blind patients with bilateral below-elbow amputations or in third world countries where prosthetic resources are limited.56 

Transhumeral Amputation

If the elbow joint cannot be preserved, then a transhumeral amputation is performed. An amputation through the elbow is a difficult level both for prosthetic fitting and appearance as the prosthetic elbow will be more distal than the contralateral native elbow, therefore this amputation level is rarely selected. The ideal length of the humerus for a body-powered prosthesis is just proximal to the distal metaphyseal–diaphyseal junction. However, for a myoelectric prosthesis the humerus will need to be transected at the midshaft to allow for adequate fitting of this prosthesis. Achieving soft tissue stabilization again is important to provide distal bony coverage and to provide the residual limb with dynamic muscle function. This can be accomplished by securing the deeper layer via myodesis and the superficial layer with a myoplasty using a pants-over-vest technique. 
The rate of overall prosthetic use and satisfaction with a transhumeral amputation is much lower than it is for a below-elbow amputation.15 Recently, targeted nerve reinnervation has shown promise in improving myoelectric prosthetic function.32,33,41 This technique employs selective nerve implantation into various muscles to improve myoelectric signaling to the prosthesis. It has been applied to a limited number of patients and continues to evolve, providing hope for improved prosthetic function in the proximal upper extremity amputee. 

Lower Extremity

Ankle Disarticulation

Ankle disarticulation was developed as a method to preserve the end-bearing capabilities of the limb. The best known is the Syme amputation (Fig. 14-5) but variations include the Pirogoff amputation involving a calcaneotibial arthrodesis,49 the Boyd amputation (similar to the Pirogoff),7 the Lefort-Neff modification of the Pirogoff method,56 and the Camilleri modification of the Pirogoff method.10 A requirement for this level of amputation is an intact plantar soft tissue flap that will be able to provide stable coverage and wound closure. This may not be feasible in a patient with compromised soft tissue as the result of an old injury. Further, prosthetic fitting may be challenging in this patient, and prosthetic options are limited when compared to those available for a below-knee amputation. A potential limitation of the Syme amputation is migration of the heel pad after surgery which may occur in 7.5% to 45% of patients.57 Tenodesing the Achilles tendon to the distal tibia with sutures placed through drill holes was shown to be successful in eliminating this problem in a series of 10 out of 11 patients.57 
Figure 14-5
 
A: A frontal picture of a patient with a mature Syme amputation demonstrates the regional soft tissue atrophy that can occur over time and the instability of the heel pad that has occurred. The distal tibia became very prominent and painful in the prosthesis. B: The distal end of this Syme amputation demonstrates a hypertrophic callous with fissuring that developed as a result of the unstable heel pad.
A: A frontal picture of a patient with a mature Syme amputation demonstrates the regional soft tissue atrophy that can occur over time and the instability of the heel pad that has occurred. The distal tibia became very prominent and painful in the prosthesis. B: The distal end of this Syme amputation demonstrates a hypertrophic callous with fissuring that developed as a result of the unstable heel pad.
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Figure 14-5
A: A frontal picture of a patient with a mature Syme amputation demonstrates the regional soft tissue atrophy that can occur over time and the instability of the heel pad that has occurred. The distal tibia became very prominent and painful in the prosthesis. B: The distal end of this Syme amputation demonstrates a hypertrophic callous with fissuring that developed as a result of the unstable heel pad.
A: A frontal picture of a patient with a mature Syme amputation demonstrates the regional soft tissue atrophy that can occur over time and the instability of the heel pad that has occurred. The distal tibia became very prominent and painful in the prosthesis. B: The distal end of this Syme amputation demonstrates a hypertrophic callous with fissuring that developed as a result of the unstable heel pad.
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The surgical approach for a Syme amputation is based on the comprehensive description provided by Smith et al.56 An incision is marked out transversely across the anterior ankle joint 1 cm distal to the malleoli and stopping 1 cm anterior to them. Then a vertical incision is carried distally from each malleolus to the plantar aspect of the foot, anterior to the heel pad. The long extensor tendons are transected and the peroneal nerves are isolated, transected and cut, allowing them to retract into the wound bed. The anterior vascular structures should be isolated and controlled with a suture ligature. The foot is then plantarflexed, the collateral ligaments are transected, and the flexor hallucis longus tendon is isolated. The calcaneus is then stripped of soft tissue attachments and the Achilles tendon is found and carefully detached from the calcaneal tuberosity. Care should be taken to avoid penetration of the posterior soft tissues at the Achilles insertion. The plantar fascia origin is then transected and the foot is disarticulated. The malleoli should be thinned to reduce the potential for a bulbous-shaped distal limb. Closure should be meticulous and the heel pad must be secured to the distal tibia to ensure soft tissue stability. Achilles tendon tenodesis has also been recommended to achieve heel pad stability.57 

Transtibial Amputation

The most common method of transtibial amputation is with a posterior myocutaneous flap. Historically, this approach was first proposed by Verduyn in 1696 to provide better distal coverage over the residual distal tibia. Bickel is credited with utilizing this amputation in the United States in 1943 and through the educational efforts of Burgess, this technique gained wide acceptance throughout the United States.8,56 Transtibial amputation has seen multiple variations proposed: Posterior flap,8 extended posterior flap,2 symmetric anterior/posterior flaps,17 symmetric medial/lateral (sagittal) flaps,46 skewed sagittal flaps,53 medial flap,29 and distal end bearing via a tibia-fibular synostosis.19,20 With a well-constructed amputation, patients have predictable outcomes with favorable prosthetic use.55 The selection of amputation level follows guidelines similar to those described earlier for the urgent or elective workup, utilizing TcPO2 measurements and characterizing the vascular anatomy with duplex Doppler arterial ultrasonography. Staged treatment of the traumatized limb may be needed to allow a determination of the optimum level of amputation. This may not be possible until the soft tissue envelope has stabilized which may take several weeks.2 Preserving the knee joint should always be the goal and many patients can function well with a short residual below-knee stump. A variety of surgical techniques (as listed above) may need to be employed to salvage a below-knee amputation level. Finally, the overall goal is to provide the patient with a cylindrical, (not conical), residual limb that has a stable soft tissue envelope and adequate sensation and perfusion, which can then accept and support a prosthesis to maximize function. 
After observing the regenerative potential of periosteum in craniofacial reconstruction,18 Ertl19,20 applied the concept of osteoperiosteal flaps to the amputation surgery, combining bony reconstruction (osteoplasty—creating a synostosis between the tibia and the fibula distally) with soft tissue reconstruction (myoplasty). This effectively created the osteomyoplastic amputation, combining two procedures into one. To create the synostosis, osteoperiosteal flaps are raised from all surfaces of the tibia and the fibula distal to the planned level of resection of each bone. This may only require up to 3 cm of bone to be resected as the distance from the medial tibial cortex to the lateral fibular cortex is approximately 5 to 6 cm. In primary amputations, the tibial periosteum is quite thick and the surgeon can utilize only tibial osteoperiosteal flaps to create the synostosis. This will only require up to 6 cm of tissue and not unduly shorten the limb.1 The tibia and the fibula are then transected at the same level, and the anterior cortex of the tibia is beveled to reduce its prominence. The osteoperiosteal flaps are then sewn together to create a synostosis between the tibia and the fibula. Over time, this flap regenerates bone, and the bony bridge matures with progressive weight bearing. Alternative approaches have utilized a segment of fibula incorporated into the osteoperiosteal sleeve hinged on its periosteal tissue, a full section of fibula placed between the tibia and the fibula, and screw fixation of the fibular graft.11,45,47,48 Stress shielding is a concern with screw fixation, and removal of the screw has been advocated once the synostosis has formed. A modified technique was applied to a group of military amputees using a segment of fibula and various internal fixation methods. There was noted to be a 32% bone bridge complication rate,59 raising the question of the need to alter the original technique described by Ertl. 
Soft tissue stabilization is then performed to provide distal coverage over the residual osseous structures. Nerve handling should be meticulous with care being taken to resect the sural, saphanous, deep, and superficial peroneal and tibial nerves proximally and allowing them to retract away from any potential external compressive force. Burying the nerves places them on tension and may produce a neuroma (Fig. 14-6). A meticulous-layered closure should be performed, removing any and all redundant tissue and dog-ears. The resultant residual limb then assumes a cylindrical shape (Figs. 14-7 to 14-10).34 
Figure 14-6
A revision transtibial amputation demonstrating the tibial nerve which originally was buried directly into the end of the residual tibia.
 
The patient experienced exquisite neurogenic pain with ambulation. Transected nerves should not be buried, placed on tension, or compressed as doing so will promote the development of a postoperative neuroma. They should simply be transected sharply and allowed to retract into the soft tissues proximally.
The patient experienced exquisite neurogenic pain with ambulation. Transected nerves should not be buried, placed on tension, or compressed as doing so will promote the development of a postoperative neuroma. They should simply be transected sharply and allowed to retract into the soft tissues proximally.
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Figure 14-6
A revision transtibial amputation demonstrating the tibial nerve which originally was buried directly into the end of the residual tibia.
The patient experienced exquisite neurogenic pain with ambulation. Transected nerves should not be buried, placed on tension, or compressed as doing so will promote the development of a postoperative neuroma. They should simply be transected sharply and allowed to retract into the soft tissues proximally.
The patient experienced exquisite neurogenic pain with ambulation. Transected nerves should not be buried, placed on tension, or compressed as doing so will promote the development of a postoperative neuroma. They should simply be transected sharply and allowed to retract into the soft tissues proximally.
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Figure 14-7
A primary osteomyoplastic amputation.
 
The forceps demonstrate the level of planned tibial and fibular transection. Note the osteoperiosteal flaps that have been elevated from all surfaces of the tibia. If a portion of the fibula is used, it should be transected about 2 to 2.5 cm below the level of the tibial cut. The fibula can then be osteotomized at the level of the tibial transection, hinged on its medial periosteal sleeve, and incorporated into the osteoperiosteal flaps that create the synostosis.
The forceps demonstrate the level of planned tibial and fibular transection. Note the osteoperiosteal flaps that have been elevated from all surfaces of the tibia. If a portion of the fibula is used, it should be transected about 2 to 2.5 cm below the level of the tibial cut. The fibula can then be osteotomized at the level of the tibial transection, hinged on its medial periosteal sleeve, and incorporated into the osteoperiosteal flaps that create the synostosis.
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Figure 14-7
A primary osteomyoplastic amputation.
The forceps demonstrate the level of planned tibial and fibular transection. Note the osteoperiosteal flaps that have been elevated from all surfaces of the tibia. If a portion of the fibula is used, it should be transected about 2 to 2.5 cm below the level of the tibial cut. The fibula can then be osteotomized at the level of the tibial transection, hinged on its medial periosteal sleeve, and incorporated into the osteoperiosteal flaps that create the synostosis.
The forceps demonstrate the level of planned tibial and fibular transection. Note the osteoperiosteal flaps that have been elevated from all surfaces of the tibia. If a portion of the fibula is used, it should be transected about 2 to 2.5 cm below the level of the tibial cut. The fibula can then be osteotomized at the level of the tibial transection, hinged on its medial periosteal sleeve, and incorporated into the osteoperiosteal flaps that create the synostosis.
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Figure 14-8
Bridge formation is created by suturing the tibial osteoperiosteal flaps to the fibula.
 
The fibular portion can be incorporated into the flap. Cancellous bone can be placed into the created synostosis as an autogenous graft. The cut ends of the osteoperiosteal flaps should be imbricated to prevent exostosis formation from the cambium layer.
The fibular portion can be incorporated into the flap. Cancellous bone can be placed into the created synostosis as an autogenous graft. The cut ends of the osteoperiosteal flaps should be imbricated to prevent exostosis formation from the cambium layer.
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Figure 14-8
Bridge formation is created by suturing the tibial osteoperiosteal flaps to the fibula.
The fibular portion can be incorporated into the flap. Cancellous bone can be placed into the created synostosis as an autogenous graft. The cut ends of the osteoperiosteal flaps should be imbricated to prevent exostosis formation from the cambium layer.
The fibular portion can be incorporated into the flap. Cancellous bone can be placed into the created synostosis as an autogenous graft. The cut ends of the osteoperiosteal flaps should be imbricated to prevent exostosis formation from the cambium layer.
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Figure 14-9
Completed bridge formation between the tibia and the fibula.
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Figure 14-10
 
A: Soft tissue stabilization for the osteomyoplastic amputation is begun by suturing the anterior and lateral compartments into the deep fascia, providing anterior and distal soft tissue coverage. B: After debulking the deep posterior compartment, the superficial posterior compartment is brought over the end of the residual limb and secured with sutures. Final closure is performed by closing the fascia over the myoplasty, excising redundant skin and performing a meticulous skin closure.
A: Soft tissue stabilization for the osteomyoplastic amputation is begun by suturing the anterior and lateral compartments into the deep fascia, providing anterior and distal soft tissue coverage. B: After debulking the deep posterior compartment, the superficial posterior compartment is brought over the end of the residual limb and secured with sutures. Final closure is performed by closing the fascia over the myoplasty, excising redundant skin and performing a meticulous skin closure.
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Figure 14-10
A: Soft tissue stabilization for the osteomyoplastic amputation is begun by suturing the anterior and lateral compartments into the deep fascia, providing anterior and distal soft tissue coverage. B: After debulking the deep posterior compartment, the superficial posterior compartment is brought over the end of the residual limb and secured with sutures. Final closure is performed by closing the fascia over the myoplasty, excising redundant skin and performing a meticulous skin closure.
A: Soft tissue stabilization for the osteomyoplastic amputation is begun by suturing the anterior and lateral compartments into the deep fascia, providing anterior and distal soft tissue coverage. B: After debulking the deep posterior compartment, the superficial posterior compartment is brought over the end of the residual limb and secured with sutures. Final closure is performed by closing the fascia over the myoplasty, excising redundant skin and performing a meticulous skin closure.
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The posterior flap technique of transtibial amputation relies on the superficial posterior compartment for distal soft tissue coverage (Figs. 14-11 to 14-14). An incision is marked on the limb with an anterior reference point 10 to 15 cm distal to the knee joint. The width of the limb from anterior to posterior is then measured. At the junction of the anterior one-third and posterior two-thirds of the limb, the posterior flap is drawn extending distally down the leg for this measured distance with 1 cm being added for a traditional posterior flap or 5 cm for the extended posterior flap technique. At the anterior reference point, a partial transverse incision is made to the line extending distally and then the incision is carried distally to the planned end of the flap. The anterior and lateral compartments are exposed and the muscles are transected. Large vessels should be ligated. Nerves should be resected sharply and allowed to retract proximally. The tibia is transected and the fibula should be transected no higher than 1.5 to 2 cm proximal to the cut edge of the tibia. This will assure maintenance of a cylindrical residual limb. A fibula which is too short in relation to the tibia will result in a conical limb, and one which is too long will result in distal irritation of the soft tissue envelope and discomfort with the prosthesis. This will also lead to challenges in prosthetic fitting. The interval between the deep and superficial compartments is then defined and the deep posterior compartment muscles are transected. The posterior compartment vessels are also tied off with suture ligatures. The plane between the two posterior compartments is developed and the superficial posterior compartment is then transected. Multiple vascular perforators cross from the deep compartment to the superficial compartment, and they may also require suture ligature for hemostasis. The anterior cortex of the tibia should be beveled to avoid any bony prominence. Drill holes are placed in the tibia, and deep soft tissue stabilization of the posterior flap is performed by anchoring its deep fascia with sutures placed through these drill holes. A meticulous-layered closure is then performed taking care to remove any and all redundant tissue to provide a cylindrical shape to the limb. With the extended posterior flap technique, the anterior aspect of the limb will appear substantially bulky but will atrophy over time. 
Figure 14-11
An extended long posterior flap transtibial amputation.
 
The anterior–posterior distance of the limb is measured at the level of tibial transection and lines are drawn distally to equal the anterior–posterior distance of 11 cm plus 5 cm.
The anterior–posterior distance of the limb is measured at the level of tibial transection and lines are drawn distally to equal the anterior–posterior distance of 11 cm plus 5 cm.
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Figure 14-11
An extended long posterior flap transtibial amputation.
The anterior–posterior distance of the limb is measured at the level of tibial transection and lines are drawn distally to equal the anterior–posterior distance of 11 cm plus 5 cm.
The anterior–posterior distance of the limb is measured at the level of tibial transection and lines are drawn distally to equal the anterior–posterior distance of 11 cm plus 5 cm.
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The anterior cortex of the tibia should always be beveled.
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Figure 14-12
The extended posterior flap provides an adequate myofasciocutaneous flap for closure and anterior coverage.
The anterior cortex of the tibia should always be beveled.
The anterior cortex of the tibia should always be beveled.
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Figure 14-13
Drill holes are placed into the anterior tibial cortex such that sutures can be passed through them to anchor the deep fascia of the posterior flap.
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Figure 14-14
The remainder of the extended posterior flap is then closed in a layered fashion.
 
This will initially provide a bulky appearance to the distal end of the residual limb but this tissue will atrophy over time, providing adequate soft tissue protection to the anterior tibia.
This will initially provide a bulky appearance to the distal end of the residual limb but this tissue will atrophy over time, providing adequate soft tissue protection to the anterior tibia.
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Figure 14-14
The remainder of the extended posterior flap is then closed in a layered fashion.
This will initially provide a bulky appearance to the distal end of the residual limb but this tissue will atrophy over time, providing adequate soft tissue protection to the anterior tibia.
This will initially provide a bulky appearance to the distal end of the residual limb but this tissue will atrophy over time, providing adequate soft tissue protection to the anterior tibia.
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Through-knee Amputation

A through-knee amputation or knee disarticulation maintains the end-bearing capabilities of the femur and will maintain mechanical and anatomic alignment of the femur. Knee disarticulation has been indicated for the dysvascular patient, children, bedbound/nonambulatory patients and in traumatic amputations. In the nonambulatory patient, the long lever arm of the residual limb can be of assistance in transfers. Caution should be used in the traumatic amputee as the functional result with a through the knee amputation is less than that of either the transtibial amputation or transfemoral amputation.35 
The surgical approach utilizes either sagittal flaps as described by Wagner63 or a long posterior myofasciocutaneous flap.6 Employing the posterior flap technique (Figs. 14-15 to 14-17), at the level of the knee joint, a transverse anterior incision is made to the midcoronal line medially and laterally. The skin incision is then carried distally to the junction of the conjoined portion of the gastrocnemius and soleus muscles. Anteriorly, dissection is carried down to the tibial plateau and a full thickness anterior flap is made. The knee joint is entered and the collateral and cruciate ligaments are transected. Posterior dissection then transects the capsule and the medial and lateral hamstrings, exposing the neurovascular structures. The vessels are isolated and tied off with suture ligatures. The tibial and peroneal nerves should be isolated, transected and allowed to retract proximally into the soft tissue bed. The interval between the gastrocnemius and deep posterior compartment muscles should be developed and carried distally. Deep vascular perforators may need to be controlled with suture ligatures. A posterior transverse incision distally then allows the lower leg to be removed en bloc. The patella may be retained or removed. Removing the patella creates additional length for the quadriceps which should be sutured to the remnants of the cruciate ligaments and the posterior capsule. Both the medial and lateral hamstrings can be sutured to the capsular remnants to maintain their function as hip extensors. The posterior flap is then brought over the distal end of the residual femur in a pants-over-vest fashion. The anterior flap skin can be removed to accommodate the length of the posterior flap. The sural nerve should be identified and transected as high as possible to reduce the risk of postsurgical neuroma formation. 
Figure 14-15
The basic landmarks for a knee disarticulation with a long posterior flap are the tibial tubercle anteriorly and the medial and lateral epicondyles on either side of the distal femur.
 
The incision should not extend much more proximal than the epicondyles. Doing so will create large dog-ears that will be difficult to control surgically.
The incision should not extend much more proximal than the epicondyles. Doing so will create large dog-ears that will be difficult to control surgically.
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Figure 14-15
The basic landmarks for a knee disarticulation with a long posterior flap are the tibial tubercle anteriorly and the medial and lateral epicondyles on either side of the distal femur.
The incision should not extend much more proximal than the epicondyles. Doing so will create large dog-ears that will be difficult to control surgically.
The incision should not extend much more proximal than the epicondyles. Doing so will create large dog-ears that will be difficult to control surgically.
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Figure 14-16
 
A: An anterior flap which includes the extensor mechanism has been elevated and the dissection is carried into the knee joint. The cruciate and collateral ligaments are transected, the vessels are ligated and the nerves sharply transected. A plane between the gastrocnemius and soleus muscles should be developed as depicted here. This plane should be extended as far distally as possible. B: With removal of the distal limb, a long posterior myofasciocutaneous flap is created.
A: An anterior flap which includes the extensor mechanism has been elevated and the dissection is carried into the knee joint. The cruciate and collateral ligaments are transected, the vessels are ligated and the nerves sharply transected. A plane between the gastrocnemius and soleus muscles should be developed as depicted here. This plane should be extended as far distally as possible. B: With removal of the distal limb, a long posterior myofasciocutaneous flap is created.
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Figure 14-16
A: An anterior flap which includes the extensor mechanism has been elevated and the dissection is carried into the knee joint. The cruciate and collateral ligaments are transected, the vessels are ligated and the nerves sharply transected. A plane between the gastrocnemius and soleus muscles should be developed as depicted here. This plane should be extended as far distally as possible. B: With removal of the distal limb, a long posterior myofasciocutaneous flap is created.
A: An anterior flap which includes the extensor mechanism has been elevated and the dissection is carried into the knee joint. The cruciate and collateral ligaments are transected, the vessels are ligated and the nerves sharply transected. A plane between the gastrocnemius and soleus muscles should be developed as depicted here. This plane should be extended as far distally as possible. B: With removal of the distal limb, a long posterior myofasciocutaneous flap is created.
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Figure 14-17
 
A: The quadriceps should be anchored with sutures to the remnants of the cruciate ligaments. B: Final closure results in an abundant distal soft tissue envelope.
A: The quadriceps should be anchored with sutures to the remnants of the cruciate ligaments. B: Final closure results in an abundant distal soft tissue envelope.
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Figure 14-17
A: The quadriceps should be anchored with sutures to the remnants of the cruciate ligaments. B: Final closure results in an abundant distal soft tissue envelope.
A: The quadriceps should be anchored with sutures to the remnants of the cruciate ligaments. B: Final closure results in an abundant distal soft tissue envelope.
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Transfemoral Amputation

The key to transfemoral amputation is restoring mechanical and anatomic alignment of the residual femur.23,24 A long medial flap22 or equal anterior/posterior flaps can be utilized or occasionally in the trauma setting, the surgeon may have to utilize any viable residual soft tissue uniquely for wound closure (Fig. 14-18). In general, soft tissue flaps should be kept as long as possible to reduce the potential for undue tension at closure and to prevent the need to shorten the femur because of inadequate flap length. A proper soft tissue reconstruction creates a dynamic residual extremity, improves the vascularity of the residual limb, and will help to maintain alignment of the residual femur which in turn improves gait.12,13,19,20,23,24 
Figure 14-18
 
A: A medial-based flap for a transfemoral amputation as described by Gottschalk. B: Equal anterior and posterior flaps for a transfemoral amputation.
A: A medial-based flap for a transfemoral amputation as described by Gottschalk. B: Equal anterior and posterior flaps for a transfemoral amputation.
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Figure 14-18
A: A medial-based flap for a transfemoral amputation as described by Gottschalk. B: Equal anterior and posterior flaps for a transfemoral amputation.
A: A medial-based flap for a transfemoral amputation as described by Gottschalk. B: Equal anterior and posterior flaps for a transfemoral amputation.
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During a primary transfemoral amputation, a knee disarticulation can be performed first. This will preserve the soft tissues needed for closure. In the traumatic setting, all viable tissue should be preserved for wound closure. The three muscle groups (adductors, quadriceps, and hamstrings) are each isolated and reflected proximally to expose the distal femur. Vascular structures are isolated and tied off with suture ligatures, preferably double suture ligatures. The distal femur is then transected to a level that will allow for proper prosthetic fitting. In general, the minimum space required to achieve symmetric knees is 5 cm (2 in) from the end of the residual limb. Therefore, depending on the technique chosen, the surgeon will need to take into account the amount of space the soft tissue reconstruction will require and add it to the amount of femur removed. The sciatic and obturator nerves should be isolated, transected proximally, and allowed to retract into the soft tissue bed. Nerves should never be buried into bone or tethered for this may create chronic tension and neuroma formation (Fig. 14-19). Soft tissue reconstruction begins with securing the adductor musculature to the distal end of the femur, typically with suture passed through drill holes, thus restoring proper anatomic and mechanical alignment of the residual limb. The quadriceps can also be secured distally to the end of the femur with the hip in extension with sutures passed through additional drill holes. Finally, the hamstrings are secured posteriorly. A meticulous-layered closure should then be performed to create a cylindrical shape to the residual limb. 
Figure 14-19
MRI demonstrating a nerve buried into the posterior femoral cortex and an enlarged neuroma.
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Ertl19,20 described an alternative method of treatment for the femur. Osteoperiosteal flaps are elevated off of the femur. After shortening the femur to an appropriate level, the osteoperiosteal flaps are sewn over the end of the femur closing the medullary canal (Figs. 14-20 and 14-21). Soft tissue reconstruction is then performed as described above. 
Figure 14-20
Osteoperiosteal flaps elevated for the osteomyoplastic transfemoral amputation.
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Figure 14-21
Medullary canal closure in the osteomyoplastic amputation is accomplished by suturing the osteoperiosteal flaps over the end of the residual femur.
 
The femoral canal can also be packed with cancellous bone graft to augment closure with the osteoperiosteal flaps.
The femoral canal can also be packed with cancellous bone graft to augment closure with the osteoperiosteal flaps.
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Figure 14-21
Medullary canal closure in the osteomyoplastic amputation is accomplished by suturing the osteoperiosteal flaps over the end of the residual femur.
The femoral canal can also be packed with cancellous bone graft to augment closure with the osteoperiosteal flaps.
The femoral canal can also be packed with cancellous bone graft to augment closure with the osteoperiosteal flaps.
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Patient-Oriented Therapy

Following amputation, full recovery must include a comprehensive rehabilitation program to restore function maximally. The primary goal of the rehabilitation program is to return the patient back to a functional status in everyday society. The combination of a sound surgical procedure, proper prosthetic application, and comprehensive rehabilitation is essential. In the acute phase, pain control is paramount and can be accomplished via oral or intravenous narcotics, peripheral nerve blocks, patient-controlled analgesia (PCA) or epidural catheter delivery of analgesic medication. Acute phase physical therapy includes wound care, basic mobilization, swelling control, joint mobilization and prevention of contractures, desensitization, upper extremity strengthening, and isometric muscle training of the residual limb. 
The patient may want to visit with their prosthetist, if they have not done so prior to surgery, regarding their prosthesis and develop a timeline for its fabrication and application, usually about 6 weeks after surgery. Once the swelling has decreased and the wounds have healed, the patient is evaluated for socket application. Typically, the patient will have a preparatory prosthesis constructed to begin physical therapy and gait training. 
It is not simply enough to tell the patient to start walking; rather, a qualified physical therapist is required to teach the patient proper body mechanics and posture during gait and how to employ a program of core strengthening. Balance training and confidence with balance may be challenging in amputees and varies with the level of amputation and the indication for amputation.42 After the acute phase, advanced therapy should be instituted to educate the patient beyond basic functions, in preparation to return to work or sport. All patients with a limb amputation will also require in-depth occupational therapy for instructions on activities of daily living and the use of assistive technology. Finally, cognitive therapy and psychological support should be considered for all amputees, especially the posttraumatic amputee. 

Summary

Amputation resulting from trauma should not be thought of as a failure of intervention. Following severe limb trauma the surgeon should plan a dynamic, functional amputation that can accept a prosthesis and improve the functionality and mobility of the patient. Amputation should be reconstructive with a strong emphasis placed on the rehabilitative potential of the patient. 

Acknowledgments

The author would like to acknowledge and thank Janos P. Ertl, MD, FAAOS, and Christian W. Ertl, MD, FACS, for their suggestions on surgical techniques and Carol Dionne, PT, PhD, OCS, Cert MDT, and Jonathan Day, CPO, for their insightful suggestions regarding amputee rehabilitation and prosthetic application. 

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