Review Article

Evolving Techniques in Foot and

Ankle Amputation

Vincent Y. Ng, MD
Gregory C. Berlet, MD
From the Department of
Orthopaedics, The Ohio State
University Medical Center,
Columbus, OH (Dr. Ng), and the
Orthopaedic Foot and Ankle Center,
Department of Orthopaedics, The
Abstract
Multiple clinical pathways lead to lower extremity amputation,
including trauma, dysvascular disease, congenital defects, and
malignancy. However, the principles of successful
amputation—careful preoperative planning, coordination of a
multidisciplinary team, and good surgical technique—remain the
same. Organized rehabilitation and properly selected prostheses
are integral components of amputee care. In the civilian setting,
amputation is usually performed as a planned therapy for an
unsalvageable extremity, not as an emergency procedure. The
partial loss of a lower limb often represents a major change in a
person’s life, but patients should be encouraged to approach
amputation as the beginning of a new phase of life and not as the
culmination of previous treatment failures.

Ohio State University Medical
Center (Dr. Berlet).
Dr. Berlet or an immediate family
member is a board member, owner,
officer, or committee member of the
American Orthopaedic Foot and
Ankle Society; has received royalties
from Nexa Orthopaedics, Wright
Medical Technology, and Bledsoe
Brace; is a member of a speakers’
bureau or has made paid
presentations on behalf of Arthrex,
Pfizer, and Wright Medical
Technology; serves as a paid
consultant to or is an employee of
Wright Medical Technology; has
received research or institutional
support from Biomet, BioMimetic
Therapeutics, DJ Orthopaedics, and
Link Orthopaedics; and has stock or
stock options held in Wright Medical
Technology and Bledsoe. Neither
Dr. Ng nor any immediate family
member has received anything of
value from or owns stock in a
commercial company or institution
related directly or indirectly to the
subject of this article.
J Am Acad Orthop Surg 2010;18:
223-235
Copyright 2010 by the American
Academy of Orthopaedic Surgeons.
A
mputation is among the oldest
recorded surgical procedures. It
has been documented in the Rig-Veda
(c. 1200 BC) and the Temple of Ram-
ses II (13th century BC).1 The major
indications for therapeutic ampu-
tation have remained constant
throughout history and include is-
chemia, trauma, infection, and ma-
lignancy. Of the 623,000 Americans
living with the loss of a lower ex-
tremity in 2005, 80% had dysvascu-
lar disease.2 The prevalence of diabe-
tes is expected to double by 2030,
and the number of amputations is
likely to increase despite efforts by
prevention programs such as
Healthy People 2010.2,3
Indications for Amputation
Trauma
The Lower Extremity Assessment
Project, a prospective, multicenter,
observational study for high-energy
trauma to the lower extremity, found
that injury severity scoring systems, in-
cluding the Mangled Extremity Sever-
ity Score, the Limb Salvage Index, and
the Predictive Salvage Index, were in-
sensitive in identifying persons ulti-
mately needing amputation.4 The Man-
gled Extremity Severity Score, however,
was highly specific in ruling out those
who did not require amputation. Open
tibial fractures, especially Gustilo type
IIIB, have a wide spectrum in actual se-
verity, and initial management decisions
should be individualized5 (Figure 1).
The difficult decision to amputate
should be made expediently because
amputations performed after initial
discharge have the highest complica-
tion rate.6 Absolute contraindica-
tions for limb salvage have been pro-
posed and include poor preinjury
patient health, complete lower limb sev-
erance in adults, irreparable vascular in-
jury, segmental tibial loss >8 cm, and
ischemia time >6 hours. Transection of
the posterior tibial nerve5 or plantar
insensitivity7 as indications for am-
putation have been challenged by

April 2010, Vol 18, No 4 223

Evolving Techniques in Foot and Ankle Amputation

Figure 1 tremity amputations and limb recon-

structions despite substantial disability
for any above-the-ankle lower extrem-
ity amputation following trauma.8,9
Health care costs were similar after 2
years, but projected lifetime costs
were greater for amputation than for
reconstruction.10
More than 1,200 soldiers have sus-
tained major limb amputations as of
January 2009 as a result of the ongo-
ing Operation Enduring Freedom, Op-
eration Iraqi Freedom, and global ef-
forts against terrorism.11 The United
States armed forces have been closely
involved in treating combat-related
amputees since World War I and are
on the forefront of providing com-
Photographs of Gustilo type IIIB open tibial fractures. Type IIIB fractures are
prehensive, coordinated care.12 Current
represented by periosteal stripping (A), inadequate coverage of the fracture
with significant contamination (B), and extensive soft-tissue loss (C). conflict amputation rates of 2.3% are
(Reproduced with permission from Rajasekaran S, Naresh Babu J, lower than in previous wars because of
Dheenadhayalan J, et al: A score for predicting salvage and outcome in rapid evacuation from combat, early ir-
Gustilo type-IIIA and type-IIIB open tibial fractures. J Bone Joint Surg Br
2006;88:1351-1360.) rigation and débridement, optimal an-
tibiotic prophylaxis, and advances in
limb reconstruction.13 As in the mili-
Figure 2 tary, the civilian surgeon’s experience
and judgment should take prece-
dence over contemporary classifica-
tion systems in the final decision to
amputate.

Dysvascular
Dysvascular amputations represent
several interrelated clinical path-
ways, including ischemia, infection,
and, in 71% of cases, diabetes.2,14 Six
percent of all patients aged >60 years
experience symptomatic peripheral
arterial disease.15 Unremitting claudi-
cation refractory to revascularization
can require amputation, and critical
Photographs of a diabetic ulcer (A) and ischemic dry gangrene (B) of the limb ischemia may lead to dry gan-
foot, necessitating transmetatarsal amputation. (Reproduced with permission
grene and autoamputation. Nonheal-
from Pollard J, Hamilton GA, Rush SM, Ford LA: Mortality and morbidity after
transmetatarsal amputation: Retrospective review of 101 cases. J Foot Ankle ing decubitus ulcers and diabetic foot
Surg 2006;45:91-97.) ulcers may lead to wet gangrene, os-
teomyelitis, and sepsis (Figure 2).
Progress in vascular surgery and en-
several authors. Plantar sensation ble.5 In the Lower Extremity Assess- dovascular therapy has allowed limb
frequently recovers,7 and in the event ment Project, there was no significant salvage in more than 80% of cases.16
of severe injury to the posterior tibial difference at 2 years in functional out- Despite high graft patency rates
nerve, limb function is often possi- come between all included lower ex- (73% at 3 years), underlying end-

224 Journal of the American Academy of Orthopaedic Surgeons


stage renal disease and poor ambula-
tory status at presentation in this
population undermine successful res-
toration of ambulation, wound heal-
ing, and survival in 66% of pa-
tients.16 Thirty percent of patients
with critical limb ischemia, defined
as ischemic rest pain and ankle pres-
sures <50 to 70 mm Hg or toe pres-
sures <30 to 50 mm Hg, undergo
major amputation.15 Contrary to the
belief that peripheral arterial disease
gradually progresses in a stepwise
fashion from claudication to ampu-
tation, one half of patients undergo-
ing major amputation did not have
ischemic symptoms 6 months before
surgery.15 Because of poor healing ca-
pacity and comorbid conditions in
this population, only 60% heal by
primary intention, and 15% require
secondary procedures. Thirty-four
percent of foot and ankle amputa-
tions and 9% to 15% of below-knee
amputations (BKAs) progress to a
higher level of limb loss.14,15
Tumor
In 2005, approximately 13,000 Amer-
icans were living with lower extremity
amputations necessitated by malig-
nancy.2 With the advent of neoadju-
vant chemotherapy, amputation can
be avoided in nearly 95% of all pa-
tients with nonmetastatic osteosar-
coma and Ewing sarcoma.17 In the
industrialized world, only cases with
significant tumor involvement of
neurovascular structures, poor distal
extremity function, persistent local
recurrence, or multiple failed at-
tempts at limb salvage require ampu-
tation. Five-year survival rates for
nonmetastatic high-grade osteosar-
coma have improved from about
20% before the mid 1970s to >65%
in 2005.18
Congenital
Congenital limb deficiencies account
for most pediatric amputations in the
April 2010, Vol 18, No 4
Vincent Y. Ng, MD, and Gregory C. Berlet, MD
Western world.19 In less developed
countries, traumatic amputations
from ongoing hazards, such as land
mines, are more frequent, ranging
from 40% to 74% of cases.19,20 Man-
agement of conditions during in-
fancy, such as fibular hemimelia, am-
niotic band syndrome, and purpura
fulminans, may necessitate amputa-
tion. Pediatric amputations are fun-
damentally different from those in
adults in several aspects and demand
separate consideration. Major princi-
ples include the preservation of im-
portant growth plates, the preference
for disarticulation over transosseous
amputation, and the recognition and
use of better soft-tissue healing.
Stump overgrowth is a unique com-
plication in pediatrics and can lead
to skin erosion, bursa formation, and
residual limb pain.19
Other
Localized cold-induced lesions, or
frostbite, are associated with low
ambient temperatures and persons
with psychosocial issues such as drug
use and homelessness. Cauchy et al21
classified injuries according to ra-
diotracer uptake on bone scan and
extent of skin blistering. Technetium-
99m scintigraphy on day 3 and day 7
predicted the level of eventual ampu-
tation in more than 84% of cases.
Charcot arthropathy, characterized
by progressive bony and joint de-
struction because of decreased sensa-
tion and proprioception with or
without preceding minor trauma, is
often associated with diabetes and
other peripheral neuropathies. Al-
though the exact pathogenesis of
Charcot foot is controversial, early
detection and a better understanding
of the disease have lowered rates of
amputation. Treatment includes off-
loading the foot, protection with
total-contact casts, surgical stabiliza-
tion, excision of bony prominences,
tendon lengthenings, and, in recalci-
trant cases, amputation.22 Amputa-
tion is reserved for complications of
the deformity, such as nonhealing ul-
cers with underlying osteomyelitis.
Intractable pain from prior surgical
procedures of the foot and ankle
may necessitate amputation. Com-
plex regional pain syndrome (CRPS),
characterized by episodes of sponta-
neous hyperalgesia, vasomotor insta-
bility and local autonomic symp-
toms, must be recognized as a
separate clinical entity from pain
itself. Formerly known as reflex sym-
pathetic dystrophy, CRPS can be pre-
cipitated or exacerbated in psycho-
logically predisposed patients by any
painful stimulus, including surgery.
Amputation for CRPS should be ap-
proached with great caution. Dielis-
sen et al23 reported subsequent relief
of pain and use of a prosthesis in
only 7% of patients. Pain manage-
ment has emerged as a separate med-
ical specialty, and various nonsurgi-
cal interventions are now available
to treat CRPS.
Amputations of the Foot
and Ankle
Preoperative
Considerations
A successful amputation requires
careful planning. Multidisciplinary
preoperative assessments by an or-
thopaedic and vascular surgeon,
physical therapist, prosthetist, psy-
chologist, social worker, and patient
representative can maximize ultimate
functional status. Because of the high
prevalence of comorbid conditions in
the amputee population, optimiza-
tion of the patient’s health by inter-
nal medicine specialists is manda-
tory. Thirty-day and 1-year mortality
rates in dysvascular patients range
from 1.6% and 23%, respectively,
for midfoot amputations to 17.6%
and 50%, respectively, for transfem-
oral amputations.14,24
225
Evolving Techniques in Foot and Ankle Amputation
Table 1
Threshold Predictors of Wound
Healing in Lower Extremity
Amputations
Ultrasound Doppler ABI >0.5
tcPO2 (on room air) 20 to 30 mm Hg
Serum albumin level >2.5 g/dL
Absolute lymphocyte count >1,500/µL
ABI = ankle/brachial index
Standard AP, lateral, and oblique
radiographs of the affected extremity
should be obtained. For malignan-
cies, CT and MRI are usually indi-
cated to assure adequate margins of
resection. Noninfected pressure ul-
cers amenable to local débridement,
dressing changes, and off-loading
with pads and total contact casts
should be identified. Exposed bone
and a draining ulcer almost always
represent osteomyelitis. Diabetic pa-
tients who present with an edema-
tous, erythematous, warm foot must
have a proper evaluation to differen-
tiate osteomyelitis from Charcot
arthropathy. Although MRI and
scintigraphy have only moderate
specificity, and plain radiographs
may not demonstrate change early in
either disease course, the diagnosis of
deep infection can often be excluded
in the absence of skin disruption,
previous ulcers, or recent surgery,
which provide a route for infection.
Hematogenous seeding is very rare.25
Wound healing potential can be
predicted with preoperative labora-
tory and vascular perfusion studies.
Cuff occlusion tests are often unreli-
able because of calcification of pe-
ripheral vessels. With the exception
of the absolute lymphocyte count,
Pinzur et al26 reported an 88%
wound healing rate in Syme amputa-
tions when multiple predictors of
wound healing were satisfied (Table
1). Alternative thresholds for tcPO2
of 30 to 50 mm Hg or absolute Dop-
pler dorsalis pedis and/or posterior
226
Figure 3
A, Photograph demonstrating an infected diabetic pressure ulcer. B, The
patient underwent complete resection of purulent and necrotic tissue to halt
the progression of infection, which necessitated ray resection of the fourth
and fifth digits.
tibial artery pressure of 70 mm Hg
have been used to guide therapy and
prediction of wound healing in
higher level amputations.27,28 A con-
sultation regarding vascular surgery
should be obtained for patients with
poor perfusion.
Level of Amputation
The goals of amputation are to opti-
mize function of the residual limb
and maximize patient mobility and
independence. Energy demand for
walking is directly associated with
the level of amputation.29,30 Gener-
ally, the surgeon should select the
most distal level of amputation pos-
sible based on the pathology, preop-
erative work-up, and intraoperative
findings. To avoid erosion of overly-
ing soft tissue, thick myocutaneous
flaps should be used to cover osseous
prominences. In traumatic amputa-
tions, more aggressive limb-length
salvage within the initial level of in-
jury, as seen in the military, may in-
crease the occurrence of heterotopic
ossification in the residual limb.13
Nonstandard “flaps of opportunity”
Journal of the American Academy of Orthopaedic Surgeons
can be used for definitive closure,
and US Army guidelines emphasize
that soft-tissue condition, not bony
injury, determines the final amputa-
tion level.31
Amputations can be divided into two
types, disarticulation (ie, through a
joint) and transosseous (through the
bone), each with weight-bearing ram-
ifications. Disarticulations are end-
bearing, allowing direct load transfer
through the large surface area of the
joint and metaphyseal bone. Transos-
seous amputations are performed
through diaphyseal bone and have a
smaller cross-sectional area. Load trans-
fer occurs indirectly, and the patient’s
weight is dissipated through the entire
residual limb by a total-contact pros-
thesis.32
Types of Amputation
Toe Amputations and
Ray Resections
Toe amputations are the most common
partial foot amputations (Figure 3).
Skin incisions can be made in a side-to-
side, plantar-to-dorsal, or fish-mouth
 Vincent Y. Ng, MD, and Gregory C. Berlet, MD

Figure 4

Photographs demonstrating the sequence for

transmetatarsal amputation. A, A fish-mouth
incision is marked, based on the extent of
pathology. B, Forefoot detachment and
metatarsal osteotomy, preserving the natural
cascade. C, A longer plantar flap is maintained
to facilitate a dorsal suture line (D). E, Healed
plantigrade stump. (Reproduced with permission
from Pollard J, Hamilton GA, Rush SM, Ford
LA: Mortality and morbidity after transmetatarsal
amputation: Retrospective review of 101 cases.
J Foot Ankle Surg 2006;45:91-97.)

fashion. Great toe amputations should
leave at least 1 cm at the base of the
proximal phalanx to preserve the inser-
tion of the plantar fascia, sesamoids,
and flexor hallucis brevis. This reduces
the amount of weight transfer to the re-
maining toes and lessens the risk of ul-
ceration.
Although ray resections are more
durable and functional than trans-
metatarsal amputations (TMAs), no
more than two rays should be re-
moved so as to retain forefoot stabil-
ity. Fifth ray resections necessitated
by infected metatarsal-head pressure
ulcers are most common. Partial foot
amputations are better tolerated lat-
erally than medially, and central ray
resections have worse outcomes than
do outer ray resections (Figure 3).
The bases of the metatarsal joints
should be preserved to avoid destabi-
lizing the Lisfranc joint. The tibialis
anterior and peroneus brevis muscles
should be reattached to maintain dy-
namic balance of the foot if the ray
resection necessitates the removal of
their original insertions.
Transmetatarsal Amputation
TMA was first described in 1855 by
Bernard and Heute for the treatment
of trench foot.33 It gained favor in
the 1940s for diabetic ulcers. Success
rates for TMAs range from 44% to
65%.28,33,34 TMAs performed prima-
rily for ischemia require higher-level
amputations much more frequently
than do those for infection (90% ver-
sus 4%, respectively).35
For ambulatory patients, TMA
preserves more limb length and func-
tional potential than does transtibial
amputation. Although TMAs typi-
cally heal less reliably than do more
proximal amputations, patients who
refuse a transtibial or transfemoral
amputation may be more accepting if
TMA is at least attempted.35,36 This
decision should be made carefully to
avoid morbidity from multiple pro-
cedures; in a series of 52 TMAs done
for vascular insufficiency or infec-
tion, Anthony et al37 reported achiev-
ing primary wound closure in only
33%, with 56% requiring revision to
a more proximal level.
Although only tendon insertions af-
fecting toe function are lost with TMA,
the resultant loss of the forefoot lever
arm can cause equinus and distal tip ul-
ceration. Dynamic balance after TMA
can be challenging, with almost all pa-
tients requiring an Achilles tendon
lengthening as an additional procedure.
The tendon lengthening should be per-
formed before the amputation to avoid
contamination.36,38
As demonstrated in Figure 4, a
fish-mouth incision with a long plan-
tar flap is used to ensure that the
more resilient plantar soft tissue cov-

April 2010, Vol 18, No 4 227

Evolving Techniques in Foot and Ankle Amputation

Figure 5 tion at the level of the Lisfranc or Cho-

part joint is an option. In Lisfranc
amputations, the base of the fifth meta-
tarsal should be shelled out subperi-
osteally to maintain the insertion of the
peroneus brevis and to prevent equino-
varus deformity from the unopposed
pull of the tibialis posterior. The second
metatarsal base is preserved to stabilize
the medial cuneiform and plantar lig-
aments. In Chopart amputations, the
tibialis posterior must be released and
any extensor tendons secured to the ta-
lar neck to prevent equinovarus. Achil-
les tendon lengthening is performed in
both procedures.38
The Boyd amputation retains the
calcaneus and involves the difficult
task of removing the entire talus. It
has become less popular because of
difficulties with calcaneotibial fusion
and is primarily performed in pediat-
ric patients although several recent
case series have demonstrated suc-
The Syme amputation. Medial (A) and lateral (B) views of a fish-mouth cess in adults.40,41
incision. C, Dissection down to bone. D, The talus is retracted with a large
bone hook. E, The appearance of the stump after closure with a drain.
Syme Amputation
(Panels A and B reproduced and E adapted with permission from Hudson
JR, Yu GV, Marzano R, Vincent AL: Syme’s amputation: Surgical technique, Originally described in 1843 by
prosthetic considerations, and case reports. J Am Podiatr Med Assoc 2002; James Syme for chronic foot infec-
92:232-246. Panels C and D reproduced with permission from Philbin TM, tions, ankle disarticulations are now
DeLuccia DM, Nitsch RF, Maurus PB: Syme amputation and prosthetic fitting
challenges. Tech Foot Ankle Surg 2007;6:147-155.) performed for a variety of indica-
tions.42,43 Energy expenditure for am-
bulation in persons with Syme ampu-
ers the weight-bearing zone and that identified and ligated in proximal tation is nearly equivalent to that of
the eventual suture line is protected. TMAs. Any infected tendons that re- matched controls, and patients re-
The use of skin grafts to obtain soft- quire excision should be balanced by re- quire minimal rehabilitation to reach
tissue coverage of the distal or plan- lease or lengthening of their antagonist premorbid levels of functioning.26
tar aspect of a TMA should be muscle. Attempts should be made to Multiple modifications of the origi-
avoided. Skin grafts cannot with- preserve the second metatarsal base, the nal technique have been proposed,
stand shear forces and invariably attachment of the Lisfranc ligament to most notably a two-stage procedure
break down, leading to revision sur- the medial cuneiform, and the insertion first described by Spittler et al44 and
gery. of the peroneus brevis into the base of popularized by Wagner45 in 1977 as
The normal metatarsal cascade from the fifth metatarsal.33,36,38 Most au- having a 95% success rate in selected
distal-medial to proximal-lateral should thors describe closing the TMA pri- patients.46 The one-stage Syme am-
guide both the incision and the bony marily, but improved healing has putation is performed more com-
cuts as much as the underlying disease been reported with insertion of anti- monly today, except in cases of ag-
allows (Figure 4). The optimum level of biotic pellets, requiring later defini- gressive soft-tissue infection, because
metatarsal transection varies from just tive closure.39 success rates are similar and it avoids
proximal to the head to 3 cm distal to the morbidity of a second opera-
the base. All soft-tissue flaps are kept Midfoot Amputation tion.43,47 Primary wound healing has
thick, and the edges of bone are When substantial soft-tissue loss in the been reported in 50% to 88% of pa-
rounded. The dorsalis pedis artery is forefoot precludes a TMA, disarticula- tients.26,42,47 One of the most impor-

228 Journal of the American Academy of Orthopaedic Surgeons


tant requirements for a Syme ampu-
tation is a viable posterior flap and
heel pad, which constitute the
weight-bearing surface.46 The cosme-
sis of a Syme amputation may be a
concern for some patients.
The anterior and posterior inci-
sions are made down to bone in a
fish-mouth fashion between two
points 1 cm distal and anterior to the
ends of each malleoli (Figure 5). The
anterior incision is carried over the
anterior aspect of the ankle, and the
posterior incision is made at a 90°
angle, extending through the calca-
neocuboid joint. The talus and calca-
neus are removed carefully to avoid
penetration in the posterior soft tis-
sues by means of blunt dissection
and a large bone hook over the dome
of the talus to provide visualization
of the posterior ankle joint. The pos-
terior tibial artery is ligated as far
distally as possible to preserve maxi-
mum perfusion of the posterior flap.
The anterior vascular bundle is li-
gated, the tendons transected under
tension to allow retraction, and the
malleoli removed flush to the level of
the plafond. To prevent heel pad mi-
gration, the Achilles tendon or the
anterior heel-pad flap is secured with
sutures to the distal tibia via drill
holes. The skin is then closed in lay-
ers with minimal tension, using a
drain when necessary.26,42,43
Transtibial Amputation
During World War I, Ertl48 intro-
duced a technique of tibiofibular
bridging synostosis for transtibial
amputation, and it has been modi-
fied several times.49,50 Unlike simple
BKA, which prevents direct load
transfer and sometimes causes pain-
ful discordant tibiofibular movement
known as chopsticking (Figure 6),
the Ertl osteomyoplasty creates a sta-
ble platform for end weight bearing
(Figure 7) and avoids loss of distal
surface area from atrophy, known as
penciling. Not uniformly accepted
April 2010, Vol 18, No 4
Vincent Y. Ng, MD, and Gregory C. Berlet, MD
Figure 6
Lateral (A) and AP (B) radiographs of a symptomatic unstable fibula
demonstrating chopsticking, the painful discordant tibiofibular movement that
is caused by disruption of interosseous membrane in a standard transtibial
amputation between the remaining tibia and fibula. (Reproduced with
permission from Pinzur MS, Gottschalk FA, Pinto MA, Smith DG, American
Academy of Orthopaedic Surgeons: Controversies in lower-extremity
amputation. J Bone Joint Surg Am 2007;89:1118-1127.)
among surgeons, tibiofibular synos- evident on examination, late recon-
tosis may be indicated for young, ac- struction with an Ertl osteoplasty
tive patients who are likely to benefit can be performed.32
from enhanced residual limb func- Although the use of an osteoperi-
tion and less likely to suffer the con- osteal flap to seal the tibial medul-
sequences of a more complex opera- lary canal and to create a small
tion.32 In a study of veterans of the pouch with supplemental cancellous
Vietnam conflict, Dougherty51 found bone slurry has been described, the
no difference in scores on the Medi- fibular bone block technique is more
cal Outcomes Study 36-Item Short widely used today.53 A long posterior
Form for those undergoing Ertl and myocutaneous flap is developed,
those with non-Ertl transtibial am- with a goal residual limb length of
putations, although the application 12.5 to 17.5 cm below the joint line,
of these findings regarding the effi- or approximately 2.5 cm for every
cacy of the procedure has been dis- 30 cm of patient height. To create
puted. Pinzur et al52 recently re- the synostosis, the fibula is exposed,
ported no improvement in self- with as many muscular attachments
reported quality of life for 20 as possible preserved to maintain
patients who underwent a tibiofibu- periosteal blood supply, and tran-
lar bridging amputation compared sected 2 to 4 cm distal to the tibial
with control subjects who had a transection. After the surface of the
standard transtibial amputation. tibia is beveled to accept the bridge,
Postoperative pain from bone-bridge the fibula is osteotomized at the level
healing can be prolonged, lasting up of the tibia, with care taken to pre-
to 3 months. For traditional transtib- serve its medial periosteum. With
ial amputees with symptoms from an this used as a hinge, the fibular seg-
unstable fibula, which often can be ment is rotated medially and secured
229
Evolving Techniques in Foot and Ankle Amputation

Figure 7 are made, distal to the level of tibial

transection, may be sutured to the
new bone bridge to enhance vascular
supply and promote osseous healing.
Alternatively, for situations in which
the fibula is unusable, the distal tibia
can be osteotomized to provide the
tibiofibular synostosis. To close, the
posterior and anterior myofascial
layers are sutured together and then
to the bone, and the superficial lay-
ers along with skin are approximated
with minimal tension.32,53-55 Although
the Ertl osteoplasty has many advo-
cates, most BKAs are performed in
standard fashion without a bridging
Modified Ertl tibiofibular bone bridge. A, Photograph demonstrating end synostosis.
weight-bearing ability. B, AP radiograph of the distal stump demonstrating
healed bone bridge. (Reproduced with permission from Pinzur MS,
Gottschalk FA, Pinto MA, Smith DG, American Academy of Orthopaedic
Surgeons: Controversies in lower-extremity amputation. J Bone Joint Surg Postoperative Dressings
Am 2007;89:1118-1127.) and Prostheses
Following a TMA, the patient is kept
Figure 8
non–weight-bearing until the inci-
sion heals. Because the forefoot load-
bearing capacity is lost, the design
for the “prosthosis” combines princi-
ples of a lower limb prosthesis, an
ankle-foot orthosis, and a foot orthotic
device. The resultant device includes a
forefoot filler to maintain correct foot
positioning in the shoe, a plantar car-
bon plate with a toe-to-heel stiffness
gradient to reduce the forefoot ground
reaction force, and a higher supportive
design to allow adequate push-off1,36
(Figure 8).
Immediately after a Syme amputa-
tion, a plaster cast is applied over the
surgical dressings and two elastic
socks. The compressive layer beneath
the cast helps control postoperative
Photographs of prostheses for a transmetatarsal amputation. A, The Össur edema. At 48 hours, a physical ther-
AFO Dynamic (Össur, Aliso Veijo, CA). B, Partial foot prosthesis (Custom apist applies a modified rigid remov-
Composite, Providence, RI). The arrows point to the footplate. (Reproduced
with permission from Tang PC, Ravji K, Key JJ, Mahler DB, Blume PA, able dressing (RRD) (Figure 9). Orig-
Sumpio B: Let them walk! Current prosthesis options for leg and foot inally designed by Wu et al56 for
amputees. J Am Coll Surg 2008;206:548-560. Panel A courtesy of Össur. transtibial amputees, the RRD pro-
Panel B courtesy of Custom Composite.) tects the stump from trauma and al-
lows frequent monitoring of the inci-
to the tibia with sutures and drill ation system. A periosteal sleeve and sion site. Most notably, it produces
holes, screws, or the TightRope (Ar- sliver of cortical bone taken from the rapid stump shrinkage and decreases
threx, Naples, FL) suture-button fix- anterior tibia before the bone cuts time to prosthetic fitting compared

230 Journal of the American Academy of Orthopaedic Surgeons


Figure 9
Photograph of a rigid removable
dressing. A plaster or fiberglass
shell (arrow) to protect the stump is
placed over a compressive sock to
reduce swelling. A knee immobilizer
may be used on top of the rigid
shell to prevent flexion contracture.
(Reproduced with permission from
Philbin TM, DeLuccia DM, Nitsch
RF, Maurus PB: Syme amputation
and prosthetic fitting challenges.
Tech Foot Ankle Surg
2007;6:147-155.)
with standard soft dressings. The
RRD is composed of a thin layer of
nonadherent dressing and a soft sock
to cover the skin, a compressive tu-
bular layer, and a rigid outer layer
made of plaster or fiberglass. Addi-
tional “filler” socks are used to fur-
ther shrink and shape the stump as
the initial edema decreases. Sutures
are removed at 3 weeks, and a cast
for prosthetic fitting is molded at 4
weeks.43
Prosthetic design for a Syme ampu-
tation must compensate for the loss
of foot and ankle motion, allow ade-
quate clearance of the ground during
the swing phase of gait, and provide
an intimate socket to aid push-off
during ambulation. For optimal bio-
mechanics, the foot is everted slightly
to allow flat ground contact during
April 2010, Vol 18, No 4
Vincent Y. Ng, MD, and Gregory C. Berlet, MD
Figure 10
Photograph of a medial door
prosthesis, the most commonly
used type of prosthesis for Syme
amputation. The opening
accommodates the bulbous distal
end during donning of the
prosthesis. (Reproduced with
permission from Hudson JR, Yu
GV, Marzano R, Vincent AL:
Syme’s amputation: Surgical tech-
nique, prosthetic considerations,
and case reports. J Am Podiatr
Med Assoc 2002;92:232-246.)
midstance and externally rotated for
mediolateral support. The foot is
also aligned posteriorly and dorsi-
flexed to reduce knee extension
forces during the transition from
midstance to toe-off. Although not
all Syme amputees can tolerate full
end bearing initially, the socket de-
sign allows the stump to “fall
through” as it matures and
progresses to direct load transfer.
Based on the difference in circumfer-
ences between the distal stump and
the ankle, there are different catego-
ries of Syme prostheses (Figures 10
to 12).
For transtibial amputees, the post-
operative protocol is similar. To pre-
vent flexion contractures, the knee is
held in extension with the surgeon’s
cast, and the RRD is used in con-
Figure 11
Illustration of a pelite liner for a
Syme amputation. This is the
strongest and lightest type of
prosthesis for a nonbulbous distal
end. (Adapted with permission from
Philbin TM, DeLuccia DM, Nitsch
RF, Maurus PB: Syme amputation
and prosthetic fitting challenges.
Tech Foot Ankle Surg
2007;6:147-155.)
junction with a knee immobilizer.
The optimal shape for the residual
limb is a gentle taper from proximal
to distal. Immediate postoperative
prostheses are designed to provide
patients the psychological benefit of
seeing a limb on waking. These pros-
theses are not typically used, how-
ever, because they do not protect the
wound adequately, and they tempt
patients to advance prematurely to
weight bearing.
For the traditional BKA without a
tibiofibular bridging synostosis, the
prosthesis must have a total contact–
specific weight-bearing socket to reduce
direct loading of the end of the stump.
Although all surface areas are in
contact with the prosthesis, load trans-
fer occurs via the popliteal region,
the pretibial group (ie, anterior com-
231
Evolving Techniques in Foot and Ankle Amputation

Figure 12 Figure 13

Photograph of a posterior opening

design for a Syme amputation. It
allows for a bulbous distal end.
(Courtesy of American
Orthopaedics. Reproduced with
permission from Philbin TM, Photographs of prostheses for an Ertl amputation. A, A test socket to inspect
DeLuccia DM, Nitsch RF, Maurus for areas of high pressure. B, Final prosthesis with a foam cover for
PB: Syme amputation and cosmesis. (Reproduced with permission from Deluccia DM, Anderson J,
prosthetic fitting challenges. Tech Berlet GC: Postoperative management for the transtibial amputee: Part I.
Foot Ankle Surg 2007;6:147-155.) Tech Foot Ankle Surg 2007;6:162-165.)

partment muscles), and the patellar
tendon. In addition, the design mini-
mizes medial forces on the fibula to
prevent compression of the syndesmotic
space. With Ertl amputation, the re-
sidual limb can support both end-
bearing load transfer and medially
directed forces on the fibula. Once
the bone bridge is healed at about
12 weeks, the patient can transition
to a prosthesis with a total surface-
bearing socket. For both types of am-
putations, the first prosthesis is always
a clear plastic test socket to allow the
prosthetist to monitor for proper align-
ment and for areas of high pressure. At
6 weeks postoperatively, the patient can
progress gradually to full-time wear57
(Figure 13). Users of more sophisti-
cated and expensive prosthetic de-
vices tend to report greater satisfac-
tion scores, although functional
outcomes are similar to those of sim-
pler devices.
Rehabilitation
To emphasize the importance of mul-
tifaceted care of the new amputee,
several studies have examined the
quality of the patients’ perceived re-
sult of surgery and found it to be un-
related to amputation level. Strong
correlations were made between pa-
tient satisfaction and the comfort of
the residual limb, the condition of
the contralateral limb, the presence
of psychosocial issues, and the ability
to exercise and work.58,59
Dedication to physical rehabilitation
is one of the most important determi-
nants of patient outcome60 (Table 2).
Immobility leads to medical complica-
tions such as cardiovascular decline,
atelectasis, pneumonia, and throm-
bosis.61 Kottke62 reported a 3% loss in
muscle strength per day of inactivity.
Studies on bed rest and zero-gravity sit-
uations in space demonstrate that lower
extremity weight-bearing muscles are
the first to atrophy.61 Resistance
training can attenuate these losses.
The US military uses “prehabilita-
tion” to maintain core strength, joint
motion, and wheelchair mobilization
before definitive amputation.12
Pain Management
Several categories of pain are associ-
ated with amputation. Residual limb
pain (ie, stump pain) typically sub-
sides with surgical healing but per-
sists in about 20% of patients for up
to 2 years postoperatively.63 Caretak-
ers should maintain a high index of
suspicion for incision-site complica-
tions when patients report localized
pain.32 Back pain is an often over-
looked source of discomfort. Smith
et al63 found that 71% of amputees

232 Journal of the American Academy of Orthopaedic Surgeons


Table 2
Phases of Rehabilitation After
Major Lower Limb Amputation
Phase 1 (week 1)
Bed-to-wheelchair mobility
Range-of-motion exercises
Edema control
RRD applied at 48 h
Transfer to acute rehabilitation facility at
48 h
Phase 2 (week 2-5)
Wound healing
RRD education
Stump shrinkage
Independent gait training with walker/
crutches
Simulated weight bearing on stump with
elastic strap
Phase 3 (week 6-9)
New prosthesis
Progressive weight bearing with
wheeled walker
Walking on uneven surfaces, home
environment
Phase 4 (week 10 and beyond)
Return to active lifestyle
Advanced ambulation patterns
Vocational and sport-specific training
RRD = rigid removable dressing
experienced back pain, and more pa-
tients rated it severely bothersome
than they did stump or phantom
limb pain. Painful neuromas can oc-
cur after peripheral nerve injury and
often are refractory to conservative
measures. During amputation sur-
gery, all named peripheral nerves
should be carefully dissected, gently
pulled distally to allow retraction,
and transected proximally with a
new scalpel.54 Marcol et al64 recently
reported that, compared with trans-
verse transection, oblique transection
of nerves results in smaller neuroma
formation. Surgical treatment of
painful neuromas includes resection
and implantation of the nerve end
into muscle or epineural grafting of
the nerve stump.
April 2010, Vol 18, No 4
Vincent Y. Ng, MD, and Gregory C. Berlet, MD
The prevalence of phantom limb pain
is approximately 80% to 85%.63,65
Although epidural and spinal anes-
thesia provide improved analgesia in
the first week postoperatively, anes-
thetic technique has no effect at 12
to 14 months postoperatively.66 Pe-
ripheral anesthesia may be effective
in preventing new pain memories,
but because phantom limb pain is
commonly similar to preoperative
symptoms, it may be of limited
value. Typically, the sooner the pa-
tient uses the limb, the faster the
phantom limb pain resolves. Involve-
ment of the patient with dressing
changes, RRD, care and daily manip-
ulation of the residual limb facilitates
pain control. When medications are
necessary, pregabalin or gabapentin
at the lowest effective dose can help.
Summary
Foot and leg amputations are most
often performed for ischemia, infec-
tion, and traumatic indications. De-
pending on the extent of the pathol-
ogy, various levels of amputation are
available, and the advantages and
disadvantages of each must be con-
sidered. Regardless of the type of op-
eration, careful planning and the
dedication of a multidisciplinary
team, including the efforts of the pa-
tient, are required to maximize the
functional outcome. Although ampu-
tation is one of the oldest recorded
surgical procedures, advances con-
tinue in all aspects of patient care.
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