Dụng Cụ Chỉnh Hình Và Chân Tay Giả Trong Phục Hồi Chức Năng (Ấn Bản Thứ 3)

492
Section III  Prostheses in Rehabilitation
nonmolded insert in the shoe. It is important that they are
educated on what to look for in a shoe. High heels increase
forefoot pressure, shoes with narrow toes squeeze the foot,
thongs can irritate between the toes, and slip on shoes
do not stay in place very well. A supportive shoe allows
the foot to stay in proper biomechanical alignment, while
remaining relaxed. Running shoes are excellent options for
this low-risk group as they reduce pressure in comparison
to leather shoes.108–110
For higher-risk groups, specialty footwear, including cus­
tom insoles and extra-depth or molded shoes, is indicated.
Custom inserts are molded to the foot and reduce pressure
at the heel and forefoot compared to flat insoles by spread­
ing weight-bearing forces over a larger area.111 The ideal insert
strikes the perfect balance between durability and cushioning.
No single material has been identified that accomplishes both
tasks effectively, so most orthotics are fabricated with several
different materials.112,113 One concern with orthotic materials
is that they lose their resistance to compression quickly. Some
materials, such as Plastazote (Zotefoams, Inc., Hackettstown,
NY) have some ability to rebound following repeated bouts
of compression, but these softer materials need to be replaced
SKIN CARE
DO:








Wash feet daily. Dry them well, especially between the toes.
Apply a thin coat of moisturizer to feet daily, avoiding between the toes.
Trim toenails after washing and drying feet.
Cut toenails straight across; smooth any sharp edges with an emery board.
Have a podiatrist handle any thickened or ingrown toenails.
Thin thick corns or calluses by gently using a pumice stone or by professional care.
Check water temperature with a thermometer or elbow before bathing.
Wear socks at night if feet are cold.
Use sunscreen on the tops of feet during the summer.
Ask health care provider to check feet at each visit.
DO NOT:




Soak feet. This can dry them out and cause cracking.
Use moisturizer between toes. Moisture between the toes allows germs to grow.
Cut corns and calluses.
Use chemical agents, corn plasters, strong antiseptics, or adhesive tape on feet, because
they can damage skin.
Use hot water bottles or heating pads because they can burn feet.
FOOT SELF-INSPECTION
DO:





Inspect all surfaces of the feet daily (including between the toes) for signs of injury: reddened
areas, blisters, cuts, cracks, or sores.
Report any injuries to a health care provider immediately.
Feel for areas of increased temperature.
Check for tender areas on the bottom of feet.
Use a mirror if necessary to see the bottom of feet.
Have a family member, friend, or health care professional check feet if necessary.
DO NOT:
Wait to report problems to a health care provider. Early attention can often prevent small
problems from becoming big ones.
FOOTWEAR
DO:





Wear shoes that fit the size and shape of feet and leave room for any necessary insoles.
Ask a health care provider to recommend the correct type of shoe.
Break in new shoes slowly, checking feet frequently for signs of irritation. Report signs
of irritation to a health care provider.
Keep shoes and insoles in good repair.
Always wear socks or stockings with shoes, wearing a clean pair daily.
Before putting on shoes, check for rough areas, torn linings, or loose objects that can injure a foot.
DO NOT:


Walk barefoot (use slippers at night, special shoes or sandals for the beach).
Wear socks that are too baggy or have holes or prominent seams.
Wear socks or stockings that are constricting at the top.
Use sandals with thongs between the toes.
BOX 18-2  Guidelines for Preventative Foot Care

Chapter 18  Wound Care for Vulnerable Feet
493
frequently.113 In one investigation, the combinations of Poron
(Rogers Corporation, Rogers, CT), Plastazote #2 (Zotefoams,
Inc., Hackettstown, NY), Spenco (Spenco Medical Corp.,
Waco, TX), and Microcel Puff Lite (Acor Orthopaedic,
Inc., Cleveland, OH) were found to be the most effective.112
Although these multidensity insoles seem to strike a balance
between support and pressure relief, they are thicker than a
flat insole and require the use of an extra-depth shoe. Custom-
molded insoles in combination with extra-depth shoes are
effective at preventing recurrent ulceration in diabetics
(Figure 18-20).114,115
One of the most difficult times in the wound healing pro­
cess is the transition from “treatment” footwear to everyday
footwear. These patients comprise group 3 in the Texas Foot
Risk Classification. As most people with a diabetic foot ulcer
see the return to normal footwear as a goal, it is often tempt­
ing for both the patient and clinician to rush this process once
the wound has completely epithelialized. At this point in the
healing process, the wound may not be mature enough to han­
dle the pressure increase from the treatment shoe to a regu­
lar shoe. As an intermediary, some of the ­shoe-type offloading
devices mentioned earlier in this chapter can serve as a bridge
between treatment devices that immobilize the ankle and per­
manent footwear. Depending on the degree of deformity, indi­
viduals in these risk groups will need to be fit with custom
insoles and either extra-depth or custom-molded shoes. For
added pressure relief, areas surrounding the postulcerative site
can be built up with firmer materials to transfer weight away
from the maturing tissue. To reduce the risk of blisters caused
by shear forces, any adjustments should be made to the under­
side of the insole so the foot remains in contact with a smooth
surface.
More aggressive shoe modifications can be used for those
that require pressure reduction beyond what in-shoe mod­
ifications can achieve. The most effective of these modi­
fications is adding a rocker bottom to the outer sole of the
shoe (Figure 18-21). Diabetic shoes with molded inserts and
rocker bottom soles decrease pressure at the heel and fore­
foot, and simultaneously increase midfoot pressures, which
is typically a less vulnerable area.116 A review by Cavanagh
reported mixed results pertaining to the effectiveness of
rocker bottom soles, but notes several major flaws in the stud­
ies that found them to be ineffective.117 In numerous studies,
the reduced pressure associated with the rocker sole has been
shown to be clinically significant as it reduced the recurrence
rate compared to patients wearing their own shoes,115,118–120
although none of these studies were randomized, controlled
trials. For the rocker shoe to be effective, the sole must be
rigid so that the shoe can take the place of the midfoot rocker,
which would normally transfer weight anteriorly toward the
toes. Another factor to consider is the placement of the axis of
the rocker bottom. To maximize pressure relief at the toes, the
axis of the rocker bottom needs to be shifted forward to 65%
of the shoe length. For MTH pressure reduction, the most
relief occurs when the axis is placed between 55% and 60% of
the shoe length.121
Many of the strategies used for patients transitioning back
to permanent footwear following an ulceration, can be applied
to the Texas Foot Risk Classification group 4, or more simply,
those whose status is postamputation. Pressure relief remains
critical and rocker bottom shoes are effective in limiting
the transfer of weight anteriorly, but there are some unique
complications associated with transmetatarsal amputations.
FIGURE 18-19  Brannock foot measuring device (Courtesy of The
Brannock Device Co., Liverpool, NY).
FIGURE 18-21  Rigid rocker bottom shoe.
FIGURE 18-20  Extra depth shoe with removable insoles.

494
Section III  Prostheses in Rehabilitation
Depending on the amputation site, the long extensors of the
foot may be damaged or be put at a mechanical disadvantage
relative to the intact plantar flexors which attach to the poste­
rior heel. The result of this imbalance is an equinus ­deformity
which increases pressure at the distal end of the foot. In a
small study of 11 patients with great toe and partial metatar­
sal amputations, peak pressures were found to be significantly
higher under the MTHs and remaining toes compared to
the contralateral foot.17 A second problem is proper shoe fit.
A short shoe that is fit to the amputation, can reduce pressure
on the distal foot, but also increases pressure on the contra­
lateral foot; however, short shoes were not well received by
patients because of cosmesis.122 Appearance may seem trivial
in relation to preventing the recurrence of an ulcer, but it is
naïve to overlook appearance. If shoes are disliked so much
that they are not worn, they serve no purpose at all. Along the
same line of reasoning, patients need to be educated about
the importance of not only wearing their shoes while outside,
but also in the house where shoes are frequently removed.123
If this is not feasible, some other form of offloading, such as
a customized sandal may be helpful to increase compliance
with offloading. Conversely, a full-length shoe is more cos­
metically pleasing, but may increase shear forces as a result of
the foot sliding forward in the shoe. When a full-length shoe
is combined with a rigid rocker bottom and a custom-molded
insert, pressures at the forefoot of both the involved and con­
tralateral foot were reduced compared to a regular shoe with a
toe filler.122 Following a 1-month adjustment period, patients
wearing this combination also had faster walking speeds and
physical performance test scores compared to patients in reg­
ular footwear with a toe filler.124 Based on these findings, the
best option for those in risk category 4 is a full-length, rigid
rocker bottom shoe, with a custom-molded insole.
SUMMARY
The largest group of people with high-risk feet in the United
States is the population of individuals with diabetes. With an
ever-increasing number of individuals diagnosed with dia­
betes, it is important that the clinician be able to identify
risk factors so as to reduce future complications. This chap­
ter reviewed the assessment of the high-risk foot as well as
a comprehensive wound evaluation. Applicable interventions
were provided and organized according to the treatment goal
to assist with the development of a successful treatment plan.
Finally, footwear recommendations based on risk stratifica­
tion were discussed to ensure that clients are given the best
chance to return to their activities without ulcer formation
or recurrence.
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on wound healing and healing times in the therapy of neuro­
pathic diabetic foot ulcers. Diabet Med. 2003;20(8):622–625.
102. Ritz G, Kushner D, Friedman S. A successful technique for the
treatment of diabetic neuropathic ulcers. J Am Podiatr Med
Assoc. 1992;82(9):479–481.
103. Birke JA, Pavich MA, Patout CA, et al. Comparison of forefoot
ulcer healing using alternative off-loading methods in patients
with diabetes mellitus. Adv Skin Wound Care. 2002;15(5):210–215.
104. Rader AJ, Barry TP. The football: an intuitive dressing for
offloading neuropathic plantar forefoot ulcerations. Int Wound
J. 2008;5(1):69–73.

Chapter 18  Wound Care for Vulnerable Feet
497
105. McGuire J. Transitional off-loading: An evidence-based
approach to pressure redistribution in the diabetic foot. Adv
Skin Wound Care. 2010;23(4):175–188.
106. Peters EJ, Lavery LA. Effectiveness of the diabetic foot risk
classification system of the international working group on the
diabetic foot. Diabetes Care. 2001;24(8):1442–1447.
107. Lavery LA, Peters EJ, Williams JR, et al. Reevaluating the
way we classify the diabetic foot: Restructuring the dia­
betic foot risk classification system of the International
Working Group on the Diabetic Foot. Diabetes Care.
2008;31(1):154–156.
108. Perry JE, Ulbrecht JS, Derr JS, et al. The use of running shoes
to reduce plantar pressure in patients who have diabetes. J Bone
Joint Surg Am. 1995;7(12):1819–1928.
109. Lavery LA, Vela BS, Fleischli JG, et al. Reducing pressure in
the neuropathic foot: a comparison of footwear. Diabetes Care.
1997;20(11):1706–1710.
110. Kastenbauer T, Sokol G, Auinger M. Running shoes for
relief of plantar pressure in diabetic patients. Diabet Med.
1998;15(6):518–522.
111. Bus SA, Ulbrecht JS, Cavanagh PR. Pressure relief and load
redistribution by custom-made insoles in patients with neu­
ropathy and foot deformity. Clin Biomech (Bristol, Avon).
2004;19(6):629–638.
112. Foto JG, Birke JA. Evaluation of multidensity orthotic materi­
als used in footwear for patients with diabetes. Foot Ankle Int.
1998;19(12):836–841.
113. Brodsky JW, Kourosh S, Stills M, et al. Objective evaluation of
insert material for diabetic and athletic footwear. Foot Ankle.
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114. Edmonds ME, Blundell MP, Morris ME, et al. Improved sur­
vival of the diabetic foot: the role of the specialized foot clinic.
Q J Med. 1986;60(232):763–771.
115. Uccioli L, Faglia E, Monticone G, et al. Manufactured shoes
in the prevention of diabetic foot ulcers. Diabetes Care.
1995;18(10):1376–1378.
116. Hsi WL, Chai HM, Lai JS. Comparison of pressure and time
parameters in evaluating diabetic footwear. Am J Phys Med
Rehabil. 2002;81(11):822–829.
117. Cavanagh PR. Therapeutic footwear for people with diabetes.
Diabetes Metab Res Rev. 2004;20(suppl 1):S51–S55.
118. Chantelau E, Kushner T, Spraul M. Effect of therapeutic shoes
on the diabetic foot syndrome: a two year follow up [abstract].
Diabetes. 1989;38:139A.
119. Chantelau E, Kushner T, Spraul M. How effective is cushioned
therapeutic footwear in protecting diabetic feet? A clinical
study. Diabet Med. 1990;7(4):355–359.
120. Busch K, Chantelau E. Effectiveness of a new brand of stock
“diabetic” shoes to protect against diabetic foot ulcer relapse.
A prospective cohort study. Diabet Med. 2003;20(8):665–669.
121. Van Schie C, Ulbrecht JS, Becker MB, et al. Design criteria for
rigid rocker shoes. Foot Ankle Int. 2000;21(10):833–844.
122. Mueller MJ, Strube MJ, Allen BT. Therapeutic footwear can
reduce plantar pressures in patients with diabetes and trans­
metatarsal amputation. Diabetes Care. 1997;20(4):637–641.
123. Armstrong DG, Abu-Rumman PL, Nixon BP, et al. Continuous
activity monitoring in persons at high risk for diabetes-
related lower-extremity amputation. J Am Podiatr Med Assoc.
2001;91(9):451–455.
124. Mueller MJ, Strube MJ. Therapeutic footwear: enhanced func­
tion in people with diabetes and transmetatarsal amputation.
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125. Albaugh K, Loehne H. Wound bed preparation/debridement.
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126. Kirshen C, Woo K, Ayello AE, et al. Debridement: a vital com­
ponent of wound bed preparation. Adv Skin Wound Care.
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127. Schultz GS, Sibbald R, Falanga V, et al. Wound bed preparation:
A systematic approach to wound management. Wound Repair
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128. Lavery LA, Armstrong DG, Harkless LB. Classification
of diabetic foot wounds. Ostomy Wound Manage. 1997;
43(2):44–53.
129. Armstrong DG, Lavery LA, Harkless LB. Validation of a dia­
betic wound classification system: the contribution of depth,
infection, and ischemia to risk of amputation. Diabetes Care.
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130. Sittig K, Richardson K. Acute burn management. In:
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Management. 4th ed. Philadelphia: Davis; 2010:334–335.
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132. Murray HJ, Young MJ, Hollis S. The association between cal­
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ulceration. Diabet Med. 1996;13(11):979–982.
133. Young MJ, Cavanagh PR, Thomas G, et al. The effect of callus
removal on dynamic plantar foot pressures in diabetic patients.
Diabet Med. 1992;9(1):55–57.
134. Robinson A. Electrical stimulation to augment healing of
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2008:275–299.
135. McCulloch JM. Compression therapy. In: McCulloch JM,
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136. McCallon
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Philadelphia: Davis; 2010:576–593.

498
19
Amputation Surgeries for the Lower Limb
Michelle M. Lusardi and Judith L. Pepe
WHEN IS AMPUTATION NECESSARY?
The amputation of a limb is a truly life-altering event, ­affecting
the physical, functional, and psychological dimensions of a
person's world.1 The decision to amputate a limb is not made
lightly; amputation is performed as a lifesaving measure for
those affected by severe trauma,2 infection,3 peripheral arte­
rial disease,4 and certain cases of osteosarcoma.5 Amputation
can be incredibly life improving when burdensome care of a
vulnerable neuropathic or painful dysvascular foot is no lon­
ger necessary.6 Unexpected traumatic amputations, especially
in younger active individuals, can contribute to significant
depression in the postoperative and rehabilitation periods.7
Although surgical technique is one of the key determi­
nants in the success of amputation,8 other factors that are as
important include the individual's and family's understand­
ing and acceptance that amputation is the best option of
care9; effective attention to and management of comorbidi­
ties during the perioperative period, as well as avoidance of
postoperative complications such as pneumonia and wound
infection10,11; and a promptly implemented rehabilitation plan
that the individual, family, surgical team, and rehabilitation
team have developed and agreed on.12
This chapter provides an overview of the strategies used
to determine if amputation is necessary for individuals with
dysvascular/neuropathic disease, for those who have sus­
tained significant trauma to their lower limbs, for those with
diagnoses of bone or soft-tissue neoplasm, and for children
who are growing up with congenital limb deficiency. We then
describe the surgical techniques used in the most commonly
performed lower-extremity amputation and discuss the reha­
bilitation implications for each. The goal is to help rehabil­
itation professionals understand what has happened to soft
tissue and bone during surgery and to use this knowledge to
better incorporate principles of wound healing and matura­
tion into the preprosthetic and prosthetic care of those who
have undergone amputation.
Basic Principles
The decision to amputate a limb, whether related to critical
limb ischemia, infection of a neuropathic wound, trauma,
or neoplasm, is based on careful consideration of prognosis
for survival and for successful rehabilitation. Determination
of the appropriate level of amputation is guided by two
principles. The first is that there must be adequate circula­
tion to ensure successful healing of the incision and surgical
­construct.13 In addition to a physical examination (evaluation
of peripheral pulses, skin color, skin condition, and skin tem­
perature), surgeons consider the individual's ankle-brachial
index,14 results of transcutaneous oximetry,15 and vascular
studies such as magnetic resonance arteriography.16 The sec­
ond principle is to preserve as many anatomical joints as pos­
sible; having an intact anatomical knee joint typically leads to
better functional outcome.14
At times, tension occurs between these principles. For
individuals with plantar neuropathic ulcers and osteomyeli­
tis, for example, a transmetatarsal amputation has the poten­
tial to preserve the ankle joint and permit functional gait
without prosthesis and is often less difficult for individuals to
accept psychologically.17 If there is delayed or failed healing,
however, the risks of complications associated with limited
activity and bed rest (e.g., further deconditioning, pneumo­
nia, deep venous thrombosis, decubitus ulcer) and repeated
19
LEARNING OBJECTIVES
On completion of this chapter, the reader will be able to do
the following:
1. Compare and contrast the assessments typically used to
determine the need for, and optimal level of, amputation
surgery for individuals with dysvascular/neuropathic dis­
ease, trauma, neoplasm, or congenital limb deficiency.
2. Describe key perioperative concerns and issues for indi­
viduals facing lower-limb amputation (e.g., complica­
tions, hydration/nutrition, pain management, respiratory
status, concurrent medical issues for each etiology of
amputation).
3. Provide an overview of the most commonly used surgical
approaches for each level of amputation (including myo­
desis, drain position, tissue manipulation, and surgical
closures).
4. Apply understanding of biomechanics of surgical
approaches and tissue healing to the care of new and
maturing residual limbs.

Chapter 19  Amputation Surgeries for the Lower Limb
499
anesthesia if surgical revisions to more proximal levels
become necessary can be significant.18 In these instances
an initial surgery at the transtibial level might improve the
chances for optimal rehabilitation outcome.19
In individuals with traumatic crush injury to the proxi­
mal tibia but intact knee joint, an extremely short transtibial
residual limb may actually be more difficult to manage pros­
thetically than a long transfemoral residual limb: the reduced
surface area around a short residual tibia and fibula for weight
bearing within the socket increases pressure on skin and soft
tissue of the residual limb, reducing functional wearing time
of the prosthesis despite the advantage of preservation of the
anatomical knee joint.20
Dysvascular and Neuropathic Disease
The overall prevalence of peripheral arterial disease (PAD) in
the United States, across all ethnicities, is estimated to range
from approximately 2% in persons 40 to 49 years of age to 20%
or higher in persons older than age 80 years.21 Rates of PAD
vary by ethnicity and gender, however; African-American
men demonstrate two- to threefold greater rates than white
men, whereas women demonstrate lower rates than men of
their ethnicity (Table  19-1).21,22 Likelihood of amputation
increases with the number of risk factors for PAD an indi­
vidual has. Risk factors include history of smoking (especially
if currently smoking); untreated or poorly managed hyper­
cholesteremia; untreated or poorly managed hypertension,
obesity (body mass index >30); diabetes mellitus, kidney dys­
function (glomerular filtration rate <60 mL/min), and chronic
inflammatory response (elevated high-sensitivity C-reactive
protein >30 mg/L).23 Significant morbidity and mortality is
associated with PAD: It is estimated that one in four individu­
als with PAD undergoes some form of amputation, one in three
will likely die within 5 years of diagnosis, and only one in four
will survive more than 10 years after diagnosis.24,25 Comorbid
­conditions that amplify risk of death in the year following
PAD-related amputation include congestive heart failure,
renal failure, and liver disease, as well as postoperative sys­
temic sepsis.26 PAD is a significant health care issue, impact­
ing not only on the quality of an individual's life, but also on
ever-increasing health care costs.27,28
There are three reasons an individual might require revas­
cularization or amputation of the lower limb because of
underlying disease processes: (1) they have significant, often
acute, occlusive atherosclerotic vascular disease but without
neuropathy or diabetes; (2) they are without significant vas­
cular disease but have neuropathy-related wounds that may
lead to osteomyelitis; and (3) they have diabetes with a com­
bination of vascular disease and sensory, motor, and auto­
nomic neuropathy.29,30 The management and prognosis for
each of these groups are somewhat different. Vascular bypass
surgery,31 percutaneous endovascular stents,32 or the use of
thrombolytic intervention33 may preserve the limbs of those
with large-vessel vascular disease without neuropathy. Recent
reports suggest that intramuscular injection of autologous
bone marrow cells may decrease risk of amputation in per­
sons with chronic limb ischemia who are not candidates for
surgical revascularization, or when such surgeries are unsuc­
cessful.34,35 Persons with a combination of diabetes and vascu­
lar disease are the most likely to require amputation; advanced
age and multiple comorbidities (e.g., cardiovascular and cere­
brovascular disease, kidney disease, and visual impairment)
provide additional challenges for healing, early mobility after
amputation, and the prosthetic rehabilitation process.
Conservative management with total contact casting or
felted foam may be sufficient to heal a neuropathic ulcer
(when there are no indications of osteomyelitis), and accom­
modative orthoses and protective footwear may protect the
plantar surface of the foot in those with a healing neuropathic
wound.36 Hyperbaric oxygen therapy and negative-pressure
TABLE 19-1  Prevalence of Peripheral Arterial Disease by Age and Gender


Age Category, % (CI)
Gender
Ethnicity
40-49
50-59
60-69
70-79
≥ 80
Male
NHW
1.4 (0.3-2.5)
1.9 (0.9-2.9)
5.4 (3.9-6.9)
9.2 (7.9-10.5)
22.6 (18.6-26.3)

AA
1.2 (0.0-2.5)
5.0 (2.6-7.3)
13.2 (10.0-16.3)
24.4 (20.3-28.6)
59.0 (45.6-68.6)

HS
0.2 (−0.4-0.8)
3.4 (1.3-5.4)
4.3 (2.1-6.5)
9.6 (6.0-13.2)
22.5 (9.4-34.5)

AS
1.2 (−1.1-3.5)
0.9 (−0.6-2.3)
3.5 (0.7-6.4)
9.8 (8.7-11.0)
21.5 (18.8-24.0)

AI
2.6 (1.3-4.0)
4.5 (2.9-6.1)
6.1 (3.8-8.4)
11.7 (5.5-17.8)
28.7 (24.2-32.6)*
Female
NHW
1.9 (0.7-3.2)
4.3 (2.9-5.7)
5.1 (3.7-6.4)
7.9 (6.9-9.0)
18.2 (15.2-21.2)

AA
3.0 (1.2-4.7)
3.4 (1.7-5.1)
8.9 (6.6-11.1)
20.0 (16.8-23.2)
35.1 (27.0-43.2)

HS
0.3 (−0.3-1.0)
0.4 (−0.2-3.0)
3.1 (1.3-4.9)
6.9 (3.7-10.2)
18.2 (7.6-28.8)

AS
0.0 (0.0-0.0)
1.4 (−0.2-3.0)
0.7 (−0.5-2.0)
7.9 (3.4-12.4)
18.2 (3.1-33.3)*

AI
3.2 (1.9-4.5)
3.9 (2.7-5.1)
8.6 (6.4-10.8)
14.7 (9.5-19.9)
33.8 (30.1-37.4)*
AA, African-American; AI, American Indian; AS, Asian American; CI, confidence interval; HS, Hispanic, NHW, non-Hispanic white;
OTH, other.
Results are presented as prevalence estimates (95% CI).
*Imputed.
From Allison MA, Ho E, Denenberg JO, et al. Ethnic-specific prevalence of peripheral arterial disease in the United States. Am J Prev Med.
2007;32(4):328-333; Table 2, p. 330.

500
Section III  Prostheses in Rehabilitation
wound therapy also have been investigated as strategies to
close neuropathic wounds and reduce risk of limb amputa­
tion in persons with chronic limb ischemia and diabetes.37,38
When neuropathic or vascular foot wounds become infected
or osteomyelitis is evident, conservative management can be
challenging, and amputation may be necessary.39
Because both vascular disease and neuropathic disease
are typically symmetrical in distribution, individuals in all of
these groups are at risk for compromise of both lower limbs.
After amputation of one limb, careful monitoring of vascular
status and skin condition and appropriate conservative care
of the intact limb and foot are essential. This is especially true
in the postoperative–preprosthetic period when there is sin­
gle-limb ambulation with assistive devices, as well as in the
months and years following initial amputation.40,41
For all of these individuals, clinical decision making must
be informed by careful assessment of (a) vascular status to
determine whether revascularization or amputation is war­
ranted, (b) cardiovascular and cardiorespiratory function
to determine the most appropriate type of anesthesia to use
during surgery, and (c) cognitive and psychological status
to assure proper perioperative and postoperative care and
patient education.
The assessment of an individual with compromised
peripheral circulation begins with a careful and detailed
health history and review of risk factors, continues with phys­
ical examination and routine blood work, and is followed up
by additional tests or measures as needed.42,43 Cognitive and
psychological status is initially assessed by interview and as
part of the neurological examination and can be followed up
by more formal testing if warranted. Vascular status is ini­
tially examined using noninvasive methods such as the ankle-
brachial index (ABI); values less than 0.9 suggest PAD.44 Any
suspicion of vascular compromise should be further investi­
gated using duplex ultrasound,45 magnetic resonance arteri­
ography (MRA),46 or computed tomographic arteriography
(CTA). The physician's differential diagnosis process focuses
on determining which component of the circulatory system
is involved (arterial, venous, or lymphatic), if it is an acute
problem that requires immediate medical, pharmacological
or surgical intervention (e.g., vascular bypass or amputation),
or a chronic problem that necessitates conservative medical
management (Table 19-2).
Vascular Pain
One of the most common symptoms of chronic arterial vascu­
lar insufficiency is intermittent claudication.47 This vascular-
related pain has been described as a deep aching, cramping,
muscle fatigue, or tightness that develops during physical
activity and dissipates with rest. Although most common in
the posterior compartment (gastrocnemius and soleus) of the
lower leg, claudication can occur in any muscle with compro­
mised blood supply, including the muscles of the thigh and
hip. Claudication is the result of accumulation of lactic acid as
a byproduct of anaerobic metabolism during muscle contrac­
tion. Several strategies are used to classify severity of PAD and
of intermittent claudication. In 1954, Fontaine first defined
four stages of PAD on the basis of the presence and severity of
clinical symptoms (Table 19-3).48 In 2007, the Trans-Atlantic
Inter-Societal Consensus Task Force published a classifi­
cation system (TASC II) for intermittent claudication with
recommendations for appropriate intervention (endovascu­
lar angioplasty with or without stent placement, versus open
surgical endarterectomy or bypass graft) based on location,
length, and severity of occlusion or stenosis obtained from
imaging studies.49 Severity of PAD can be quantified using
treadmill testing at a constant 2 mph speed, beginning flat
and continuing with 2% increase in grade every 2 minutes,
noting time to onset of claudication and time to maximum
claudication. Change in the total distance that an individual
is able to walk (e.g., number of city blocks or actual measured
distance) before onset of symptoms is an alternative means of
tracking progression of arterial vascular impairment.50 When
an individual requires opiates to manage vascular pain while
at rest, or if there are arterial ulcers with dry gangrene in the
toes or foot, the individual is classified as having critical limb
ischemia, and is at high risk of amputation if revasculariza­
tion fails or cannot be undertaken.51
When there is an acute or sudden occlusion of an arterial
vessel (such that collateral circulation has not had sufficient
time to develop), a much different pattern of pain occurs.
Instead of relief with rest, pain is constant and somewhat
unrelenting; it may be accompanied by feelings of tingling,
numbness, or coldness as peripheral nerves of the lower limb
are affected by ischemia.34 Although a limb with chronic arte­
rial insufficiency demonstrates dependent rubor, the skin of
an acutely compromised limb may be quite pale or blanched
distal to the site of occlusion (Figure 19-1). Acute occlusion
is often an emergent situation, requiring pharmacological or
surgical intervention to restore blood flow to the limb, and
often necessitates long-term anticoagulation.
Examination: Skin and Soft Tissue
Assessment begins with visual inspection of the lower
extremity and feet, concentrating on skin condition, pres­
ence or absence of hair, and nail condition.52 Open wounds,
TABLE 19-2  Common Peripheral Vascular Disorders
System
Acute Conditions
Chronic Conditions
Arterial
Arterial thrombosis
Embolic occlusion
Vasospastic disease
(Raynaud)
Atherosclerosis
obliterans
Thromboangiitis
obliterans
Buerger disease
Diabetic angiopathy
Venous
Venous
thromboembolism
Varicose veins
Chronic venous
insufficiency
Lymphatic


Lymphangiitis


Primary lymphedema
(congenital)
Secondary lymphedema
(acquired)

Chapter 19  Amputation Surgeries for the Lower Limb
501
TABLE 19-3  Classification of Peripheral Arterial Disease Severity (Note: Ankle-Brachial Index <0.9 in All Categories)

Stage
Findings
I: Atherosclerosis
without major clinical
symptoms
IIA: Atherosclerosis with
claudication
IIB: Atherosclerosis with
claudication
III: Atherosclerosis with resting
pain; critical limb ischemia
IV: Atherosclerosis with
issue damage; critical
limb ischemia
Prognosis
No immediate threat
Marginal threat
Medical or surgical
intervention
Immediate threat
Revascularization to salvage
Irreversible damage to nerve
Revascularization to salvage
Moderate risk of amputation
Revascularization may not
salvage limb
High risk of amputation
Vascular exam
Normal to absent
pedal pulse
Bruits on auscultation
Arterial and venous
Doppler audible
(arterial not triphasic)
Diminished peak flow on
plethysmography
Absent pedal pulses
Bruits on auscultation
Inaudible arterial
Doppler, audible
venous Doppler
Diminished peak flow
on plethysmography
Absent pedal pulse
Inaudible arterial Doppler, audible
venous Doppler
Slight elevation blood viscosity,
fibrinogen, and platelet function
Toe segmental pressure
<30 mm Hg
Ankle segmental pressure
<50 mm Hg
Diminished transcutaneous
oxygen pressure
Arterial and venous Dopplers
inaudible
All findings markedly
abnormal
Pain/claudication
Distal paresthesia
Pain when walking
>200 m, relieved
with rest
Walking <200 m, relieved with rest
Resting pain, especially at night
(or with elevation of lower
limbs), relieved with dependency
of limbs
Resting pain, especially at
night, requiring opioids
for relief
Sensory loss
Minimal; adequate
protective sensation
of the entire foot
Some (toes)
Diminished protective
sensation distally
Moderate (toes and forefoot)
Diminished to absent protective
sensation
Marked sensory neuropathy,
anesthetic to sensory testing
Anesthetic to sensory testing
Motor deficit
None
Intrinsic muscle
weakness
“Claw toes” develop
Moderate weakness of toe extensors,
ankle dorsiflexion
Marked weakness of foot and
ankle
Marked weakness of foot
and ankle
Soft tissue




Intact skin
Subjectively cold
extremities


Hair loss on toes and
forefoot
“Thin” skin


Hair loss
Poor wound bed if neuropathic ulcer
present, healing unlikely


Trophic changes in nails
Fragile skin, foot, and lower leg
Nonhealing plantar neuropathic
ulcers likely

Dry gangrenous wounds in
nail beds and dorsum of
foot; desiccation likely
High-risk infection
Nonhealing plantar
neuropathic ulcers likely

502
Section III  Prostheses in Rehabilitation
­callus, ecchymosis, dry necrosis and other skin lesions, as well
as areas of erythema (redness), mottling, and altered pigmen­
tation, are documented on a body chart. Circular wounds
that lie under or are surrounded by callus on the plantar or
weight-bearing surfaces of the foot are most likely neuro­
pathic ulcers (Figure 19-2, A). Dry, blackened, or moist gan­
grenous wounds in the nail beds and between toes are likely
signs of vascular insufficiency (Figure  19-2, B). Although
“healthy” traumatic wounds often display clear serosanguine­
ous drainage, any thickened, yellowish, or foul-smelling dis­
charge from a wound suggests soft tissue or bone infection.
Open wounds around ankles or a distal leg surrounded
by areas of darkly pigmented skin are typically the result of
chronic venous stasis. Progressive circumferential measure­
ments are taken to document the presence of pitting or nonpit­
ting edema resulting from venous or lymphatic insufficiency,
localized infection, or as part of an underlying systemic dis­
ease of kidney, heart, or lung. Skin temperature is assessed
subjectively (using the web space or back of the examiner's
hand) or objectively using a surface thermometer. Cold areas
in particular may have compromised arterial flow, while areas
of increased temperature (especially if accompanied by ery­
thema and swelling) often indicate underlying infection.52
In the presence of diabetic and other polyneuropathies
there is often atrophy or wasting of the intrinsic muscles
of the foot with apparent claw or hammer toe deformity.53
Protective sensation (as measured by perception of Semmes-
Weinstein 5.07 filament), as well as touch, pressure, vibration,
and position sense, are likely to be impaired or ­inconsistent.54
Additionally, impairment of the autonomic system often
causes dry, tight, shining, easily cracked skin, as well as altered
dynamics of blood flowing to the bones of the foot, increasing
risk of Charcot arthopathy.55,56
Vascular Examination: Noninvasive Strategies
The least invasive and simplest strategy used to assess ade­
quacy of vascular supply to the distal limb is palpation of
distal lower-extremity pulses at the dorsalis pedis and pos­
terior tibial arteries, popliteal pulse at the knee, and femoral
pulse at the groin. Strength of pulses at each site is noted as
absent (0/4), weak (1/4), normal (2/4), full (3/4), or bound­
ing (4/4).40 If all pulses are palpable, it is likely that there is
adequate circulation to heal a neuropathic ulcer. Absent distal
FIGURE 19-1  A chronically ischemic limb demonstrating rubor of
dependency of the distal lower leg and rearfoot and significant pallor
suggesting acute ischemia of the forefoot. (Courtesy Carolyn Kelly,
Center for Wound Healing and Hyperbaric Medicine, Hartford
Hospital, Hartford, Conn.)
FIGURE 19-2  Comparison of neuropathic and dysvascular foot lesions: Note the typical round cal­
lus-rimmed neuropathic lesion (A) on the plantar surface of the hallux in an individual with diabetic
neuropathy and the ischemic changes (dry gangrene) (B) on the tip of the hallux in an individual
with peripheral arterial disease. (Courtesy Carolyn Kelly, Center for Wound Healing and Hyperbaric
Medicine, Hartford Hospital, Hartford, Conn.)

Chapter 19  Amputation Surgeries for the Lower Limb
503
pedal pulses do not, however, confirm vascular insufficiency;
it is estimated that pedal pulses are nonpalpable in up to 10%
of the general population.57
When pedal pulses are not palpable, further assessment
might include positional tests of capillary and venous filling
time, auscultation with Doppler ultrasound, calculation of an
ABI, taking segmental blood pressure of the limb, transcuta­
neous oximetry (pulse oximetry), pulse-volume recordings,
MRA, computed tomography (CT) angiography, or duplex
scanning.58 (Refer to Chapter 18 for a detailed description of
noninvasive assessment strategies.) Table 19-4 lists reference
ranges for noninvasive tests.
High-resolution B-mode imaging combined with color
and power Doppler and real-time spectral analysis have made
duplex scanning one of the most widely used methods of non­
invasive evaluation of arterial disease.59 Duplex scanning can
accurately assess the location and degree of arterial disease
from the level of the aorta to the level of the ankle. It provides
accurate, objective information that supplements the physi­
cal examination. A disadvantage of this modality is the pro­
longed time it takes to perform an accurate examination of
the entire extremity. Screening for arterial disease is done by
comparing the signals from the various sites along the periph­
eral arterial tree and measuring the velocities at points of nar­
rowing and comparing them with velocities in non-narrowed
areas of the arteries.60 This velocity ratio correlates to a 50%
diameter narrowing when the ratio value is greater than
2. When the velocity ratio is greater than 4, the correspond­
ing arterial narrowing is greater than 75%. Peak velocities at
sites of narrowing can also be used to estimate the degree of
­narrowing. The sensitivity and specificity of this test is on the
order of 90% or greater.61 Although some surgeons may rely
solely on duplex scanning for preoperative peripheral arterial
bypass planning, many prefer to more directly outline arterial
anatomy using other imaging options.
Two additional methods that successfully outline the spe­
cific arterial anatomy are MRA and CTA (Figure 19-3).62–65
Magnetic resonance imaging (MRI) detects radiofrequency
signals given off by protons within a powerful magnet; such
proton movement within body structures creates a detectable
echo that can be imaged. Use of a contrast agent, such as gad­
olinium injected through a peripheral vein, greatly enhances
the information gained from the images. MRA studies with
gadolinium contrast are highly specific and 100% sensitive
for identification of arterial lesions that require interven­
tion.66 The visualization of the distal runoff arterial tree when
there are multiple levels of occlusions is much better than
that seen with conventional angiography; however, the spatial
resolution of MRA images is less than that available through
invasive digital subtraction arteriography (DSA). Calcium
TABLE 19-4  Reference Values for Noninvasive Examination of Peripheral Arterial Circulation
Test/Measure
Normal Values
Abnormal Findings
Capillary refill time
Elevation of limb 20 seconds
Return to dependent position
Pressure on toe or nail
Blanch, then refill in 1 to 2 seconds
Delayed refill or persistent blanching
Rubor of dependency
Refill after occlusion
Inflation of blood pressure cuff at thigh for
5 minutes
On release, flush to normal skin color at toes
within 10 seconds
>10 seconds: impaired arterial perfusion
Venous refill time
Elevation of the limb 2 minutes
Return to dependent position
Veins on dorsum of foot refill in 10 seconds
>10 seconds: impaired arterial perfusion
<10 seconds: valvular incompetence of veins
Doppler ultrasound
Triphasic on auscultation
Biphasic: mild vascular impairment
Monophasic: significant impairment
Absent: complete occlusion
Ankle-brachial index
0.9 to 1
<0.9 impaired arterial flow
<0.5 unlikely to heal distal wound
Segmental blood pressure
<15 mm Hg drop in systolic pressure between
adjacent sites (groin, thigh, just below knee,
and at ankle)
>20 mm Hg decrease: possible occlusion
>10 mm Hg: possible vessel calcification
Pulse volume recordings
Sharp peaks at each recorded site
Similar across left and right extremities
Flattening on recording: occlusive disease
Transcutaneous oxygen
pressures
>40 mm Hg suggest healing of ulcer or surgical
incision is likely
<20 mm Hg predict nonhealing of ulcer or surgical
incision
Duplex scanning
Low velocity ratio; constant hue and intensity
of image
Velocity ratio >4 or peak velocity >400 cm/s
indicates >75% stenosis

504
Section III  Prostheses in Rehabilitation
within the artery, which impacts operative planning, cannot
be seen in MRA. Other disadvantages include the inability to
use this magnet-driven modality in patients with pacemak­
ers, defibrillators, and intracorporeal metallic fragments that
might migrate.
The advent of the helical or spiral CT scanners enabled CT
technology to be applied to the diagnosis of peripheral arterial
abnormalities due to the markedly reduced time required for
scanning.67 With this technology, large areas of the body can
be scanned in 20 or 30 seconds. An iodinated contrast agent
is given through a peripheral vein. This avoids potential com­
plications of a direct arterial injection but does not preclude
the risk of inducing renal failure. Although less-concentrated
contrast agents can be used for CTA, the volumes required are
larger than those for conventional angiography. Both noncon­
trast images and postcontrast injection images are taken. One
advantage of CTA over MRA is the excellent visualization of
vessel wall calcium deposits with CTA. But if there is much
calcium, these areas become indistinguishable from the areas
opacified after contrast injection. CTA performed for evalua­
tion of the arteries in the lower extremities is being increasingly
used in clinical practice. However, its spatial resolution is less
than that seen with DSA and small peripheral arteries are not
as well visualized.
Vascular Examination: Invasive Strategies
Conventional arteriography and DSA are classified as an
invasive examination strategies because both involve local
surgical placement of a catheter into the femoral artery in the
groin (or alternatively, the axillary, radial, or subclavian arter­
ies, or the aorta), followed by introduction of radiopaque dye
into the arterial tree and exposure to radiation.68
DSA computer-assisted x-ray method used to visualize
vascular structures without superimposed bone and soft tis­
sue usually seen on radiography.65 The computer subtracts
­initially recorded x-ray images from those taken following ion
FIGURE  19-3  Examples of imaging techniques used to evaluate the arterial vascular tree in the
lower extremity. A, Arterial and venous circulation for reference. B, Results of MRA in an indi­
vidual with intact circulation. C, Results of CTA in an individual with intact circulation. (A cour­
tesy of B reprinted with
permission from Blackwell G, Wann S, Kadekar S. Clinical applications of cardiovascular magnetic
resonance methods. J Tehran Heart Cent. 2006;1[3]:125-136; C courtesy of
ail/1190_1197_2.jpg.)
Renal vein
Renal artery
Aorta
Kidney
Kidney
A
Inferior vena cana
Common iliac artery
Common iliac artery
Internal iliac artery
Internal iliac artery
Femoral artery
Anterior tibial artery
Posterior tibial vein
Posterior tibial artery
Anterior tibial vein
Popliteal artery
Femoral vein
Popliteal vein
Peroneal artery
Great saphenous vein
B
C

Chapter 19  Amputation Surgeries for the Lower Limb
505
injection of contrast medium, to isolate arteries of the limb.
Contrast material (dye) is injected into the arterial tree, often
at the groin into the femoral artery to assess patency of distal
vessels and evaluate collateralization. This carries some risk of
cholesterol embolization from atherosclerotic plaques at the
site of puncture if the artery is diseases at the injection site; in
addition, many of the dyes used can be nephrotoxic.62 Despite
these risks, DSA is considered the gold standard against which
other less-invasive imaging methods are compared.
Because of the risks associated with invasive procedures,
conventional arteriography is most typically used just prior to
revascularization (bypass69 or thrombolysis70) or amputation
surgery to determine specific location and severity of vessel
occlusion as well as the extent of collateral circulation. It may
also be used in place of MRA imaging for individuals with
metal implants such as pacemakers and total joint prostheses.
Because contrast material used in arteriography are nephro­
toxic, this procedure is not appropriate for individuals with
renal dysfunction; it is also contraindicated for persons with
cholesterol emboli syndrome, or allergies to substances con­
taining iodine.71,72
An invasive angiography procedure can take 90 minutes
or more, depending on what is being imaged and how many
images are required.73 During the procedure the area that is
to be punctured is first numbed with a local anesthetic agent.
If the person undergoing the procedure is particularly anx­
ious, the physician can administer a sedative agent orally or
parentally before or during the procedure. After the area is
adequately anesthetized, an 18-gauge, 2.75-cm needle with a
hollow, thin-walled outer cannula and a sharp, beveled, inner
stylet is inserted into the artery. Once the artery has been
punctured, the stylet is removed and replaced with a guide­
wire that is carefully threaded farther into the vessel; this wire
then guides placement of the catheter that will deliver contrast
medium. Catheters as small as 1-mm outer diameter may be
used (3 French), but more commonly, 4 or 5 French cathe­
ters are used with outer diameters of 1.32 mm and 1.65 mm,
respectively. Once 40 to 120 mL of contrast medium has
been injected, the catheter is flushed with heparinized saline
to reduce the risk of clot formation. Successive still or con­
tinuous video radiographs record the progression of the dye
through the limb's arterial tree (Figure 19-4). After the cath­
eter is removed from the femoral artery, manual compression
is held locally at the site for several minutes and the patients
remain at bed rest for a minimum of 4 hours. To ensure heal­
ing of the puncture artery, physical activity (include rehabili­
tation interventions) is postponed until several hours to a day
after the procedure.
Decision Making: Thrombolytic Therapy, Angioplasty,
or Amputation?
Intraarterial infusion of thrombolytic agents is used to man­
age several situations: (a) acute thrombosis of the extrem­
ity, (b) following percutaneous angioplasty, (c) after surgical
bypass procedure of an extremity, or (d) after acute throm­
bosis of a diseased native artery.74–76 The most commonly
used thrombolytic agents are streptokinase, urokinase, and
tissue plasminogen activator.77 Streptokinase and urokinase
are non–fibrin-specific agents that convert circulating plas­
minogen to plasmin, which subsequently breaks down fibrin,
one of the main components of clot. Tissue plasminogen acti­
vator is a fibrin-selective agent that acts locally by activat­
ing plasminogen to form plasmin, which, in turn, breaks up
the fibrin in the clot. These agents are typically administered
directly at the site of the clot (or as close as possible to it) via
a catheter that is threaded through the arterial tree from the
initial access site. Infusion may require several days; active
rehabilitation begins after infusion is completed.
Intraarterial infusion of thrombolytic agents is typically fol­
lowed by either systemic intravenous heparin therapy or oral
warfarin therapy.78,79 For individual's status after bypass graft,
long-term warfarin therapy is used to reduce risk of graft occlu­
sion. The heparins are a class of agents that bind to antithrom­
bin III to effect anticoagulation. Warfarin blocks the action of
the vitamin K-dependent factors in the coagulation cascade.
This has implications for the patient undergoing active rehabil­
itation because these agents increase the risk of bleeding com­
plications, especially with manipulation of the wound in the
immediate postoperative period of about 7 to 10 days.
In the postoperative period, should an individual on anti­
coagulant therapy report a sudden and significant increase in
pain at the bypass site or in the residual limb following ampu­
tation, the likelihood of local bleeding must be quickly evalu­
ated.80 Outward signs of bleeding at the operative site, such
as swelling, ecchymosis, hematoma, or active bleeding, may
Medial
circumflex
femoral
artery
Deep artery
of thigh
Femoral
artery
Adductor
hiatus
Popliteal artery
Lateral circumflex
femoral artery
(transverse branch)
Perforating arteries
FIGURE 19-4  Diagram of arterial vessels of the pelvis and femur
(posterior view) that can be visualized by MRA or by invasive
arteriography.

506
Section III  Prostheses in Rehabilitation
not be readily apparent should the bleeding occur at the sub­
fascial level. Sudden onset of increased pain in the wound or
extremity, along with recurrence of signs of limb ischemia,
may also herald occlusion of the graft or progression of dis­
ease in the native vasculature following amputation at any
level. It is important to identify signs of the failing graft as
early as possible because the limb could possibly be salvaged
if intraarterial thrombolytic therapy, as described earlier, is
initiated soon enough.
Amputation is often the best option for some individu­
als with dysvascular or neuropathic disease when the arterial
anatomy precludes bypass or if severity of disease is such that
bypass cannot salvage irreversibly ischemic and gangrenous
tissue, as well as persons with complex medical conditions at
high risk for intraoperative and postoperative complications.
Arterial bypass or thrombolytic therapy may be adjuncts to
amputation so as to allow amputation at a more distal level, as
long as there is no frank infection (wet gangrene) and the per­
son's arterial anatomy is conducive to bypass. In these cases
amputation removes only nonviable portion of the limb, and
the bypass or thrombolytic therapy improves the chance of
healing at the more distal site.
Extensive gangrene of the foot, which is complicated by
infection, is an indication for an open (guillotine) distal
transtibial amputation. Time is given for the infection to be
controlled by antibiotics and local wound care of the open
surgical construct. The residual limb is then revised more
proximally and a formal transtibial or transfemoral amputa­
tion with standard closure techniques is done.
Traumatic Injuries
Within the continental United States, traumatic amputa­
tions are the result of industrial and farming accidents, motor
vehicle accidents, or injury during high-risk sport and lei­
sure activities.81 In areas of the world where there is current or
recent armed conflict, traumatic amputations are more likely
to be the result of improvised explosive devices, land mines
or grenades, shrapnel, or direct gunfire.82 Many of the injuries
sustained by U.S. military personnel during the conflicts in
Iraq and Afghanistan involve limb salvage or amputation.82 In
most traumatic injuries the wound is likely to be contaminated
by weapon fragments and organic materials (dirt, road debris,
bits of clothing, vegetation), as well as damaged bone and soft
tissue. In these situations the likelihood of infection as a con­
sequence of introduced environmental microorganism, isch­
emia caused by vascular damage, and tissue necrosis because
of direct damage is high.83 There may also be significant loss
of blood volume and hypovolemic shock, head injury, chest or
abdominal injury, and other fractures to contend with.
In emergency care the first priority is to stabilize the medi­
cal condition: maintain the airway, support respiration, and
ensure adequacy of circulation to the heart and brain.84 The
mangled limb is then carefully cleaned and debrided, a “cock­
tail” of systemic prophylactic antibiotics (e.g., cephalosporin,
gentamicin, and penicillin) is begun, and a tetanus shot is
given. Next the trauma team must decide whether the limb
can be salvaged or replanted.85 The team considers many fac­
tors in making this difficult decision including severity of
fracture and soft-tissue injury, likelihood of bony union, ade­
quacy of arterial blood supply, neuromotor and sensory func­
tion of the extremity, potential for prosthetic use, recovery
time, and anticipated long-term functional status and qual­
ity of life. Although there are a number of decision-making
models available that attempt to quantify these dimensions
when such a difficult decision is necessary (e.g., Predictive
Salvage Index, Mangled Extremity Severity Score, Limb
Salvage Index, Hanover Fracture Scale) most are more effec­
tive in determining need for amputation; few accurately pre­
dict the likelihood of a positive outcome of limb salvage.86,87
Limb Salvage
Limb salvage and replantation are associated with high health
care costs because of increased likelihood of multiple hospi­
talizations for successive surgical procedures, complications
and delayed healing, and secondary amputation if the sal­
vage attempt failed.88 With improving microsurgical tech­
niques, long-term outcome (e.g., return to work, perceived
health status) is fairly similar when primary amputation and
successful limb salvage and reconstruction are compared;
however, residual impairment, functional limitation, and dis­
ability can have a significant impact on the quality of life in
both groups.89,90 Any severe trauma to the lower extremities,
whether salvage is attempted or amputation is the interven­
tion of choice, is life altering.
In general, salvage attempts are most likely to demonstrate
delayed healing or go on to secondary amputation if there
has been high-energy injury, comminuted open fractures of
Gustillo classification IIIC or higher, periosteal stripping, arte­
rial injury with prolonged warm ischemia time, or complete
disruption of the tibial nerve.91 Individuals or their family
health proxy must be informed of the pros and cons of limb
salvage versus amputation, including risk of infection and fail­
ure, as well as intensity and time frame for rehabilitation and
likelihood of returning to premorbid functional levels.92
If the decision is made to attempt limb salvage, the indi­
vidual is taken from the emergency department to the oper­
ating room.93 Arteriography (angiography) may be used to
determine the extent of viable arterial perfusion. The next
step is precise debridement of the damaged limb; surgeons
must be sure that all compromised bone, muscle, and soft
tissue are removed to reduce the likelihood of postoperative
infection, necrosis, or later development of heterotopic ossi­
fication. It can be challenging to determine viability of corti­
cal bone; cancellous bone is more likely to be revascularized.
The biomechanical benefit of preserving as much bony length
as possible must be weighed against the risk of developing
osteomyelitis or delayed healing. Next, fractured fragments
are stabilized with appropriate internal fixation, intramedul­
lary rod, or external frame.
Defects in the bone may be filled with antibiotic-impregnated
polymethylmethacrylate beads to further reduce the risk of
infection and to preserve space for a later bone graft. The areas of
the limb that were incised during surgery are stitched or stapled
closed, while trauma-damaged areas may be temporarily closed

Chapter 19  Amputation Surgeries for the Lower Limb
507
with a biological dressing. The reconstructed limb is monitored
closely, with sharp debridement of any nonviable tissue in the
early postoperative period every 24 to 72 hours, as appropriate
for the degree of wound contamination on initial injury, until
a clean wound bed is obtained. Once the wound bed is consis­
tently clean, the individual whose limb is being salvaged returns
to the operating room (optimally within 1 week) for definitive
closure of the surgical construct. This may be accomplished by
delayed primary closure, split-thickness skin graft, local flaps,
or, in some cases, vascularized pedicle graft. Subsequent to suc­
cessful closure, the individual may return to the operating room
for bone graft or transplantation or distraction osteogenesis to
address osseous defects and limb-length discrepancy.
Amputation in Trauma Care
If limb injury is deemed too severe for salvage, a “guillotine”
amputation may be performed to remove damaged tissues
and restore hemostasis.83 If there has been significant contam­
ination of the wound, the surgical construct may be left open
(without skin closure) until the trauma team is satisfied that
no infection has occurred.94 Once the individual's medical
condition has stabilized and the wound is clean, revision to a
definitive level of amputation can be performed. Amputation
after severe injuries may require split-thickness skin graft or
pedicle graft to achieve adequate skin closure. Skin pressure
tolerance when wearing a prosthesis can be problematic later
in the rehabilitation process when any type of grafting has
been necessary.
Traumatic amputation is most likely to occur in young
and midlife adults who are otherwise healthy. Once damaged
tissue is removed and wound closure is achieved, circula­
tion is often adequate for successful healing. These individ­
uals, however, may be more likely to develop depression in
the postoperative period because the injury was so sudden,
and amputation so unexpected.95 The sense of loss and altera­
tion of body image after traumatic amputation can be more
substantial than for an older adult with a diseased limb who
“elected” to undergo amputation. Similarly, depression is a
significant risk in those who are in the midst of limb salvage
because of the likelihood of a long period of limited activity
and altered appearance of the salvaged limb.
Neoplasm
Various tumors of soft tissue and bone range from slow-
growing localized tumors to invasive and aggressive tumors
(Box  19-1).96 Presenting signs and symptoms may include
nonpainful enlargement of the limb, persistent pain, and path­
ological fracture.97 The incidence of tumors of bone and soft
tissue demonstrate two age peaks: the first occurs in adoles­
cents and young adults (especially osteosarcoma), with a sec­
ond peak in mid- and late-life adults (especially metastatic).98
The most frequently diagnosed tumor of the skeletal sys­
tem is metastatic, usually originating from a primary site in
the breast, prostate, lung, or colon.99 The most common sites of
metastatic bone disease are spine and long bones of the extremi­
ties. Metastatic cells disrupt and alter the balance of osteoblastic
and osteoclastic activity within bone, ­resulting in higher rates of
resorption and lysis of bony structure. Metastatic bone disease
is most commonly manifested as a deep pain present at rest and
during activity, and it carries an increasing risk of pathological
fracture.100 Metastatic bone disease is typically managed with a
combination of radiation and chemotherapy as well as nonste­
roidal antiinflammatory or opioid medications to relieve pain
and enhance function, and administration of bisphosphonate to
reduce likelihood of recurrent skeletal-related events and recur­
reance.100–103 Some metastatic tumors may require an orthopedic
surgical intervention such as placement of an endoprosthesis,
along with orthotic intervention to preserve or restore function,
METASTATIC TUMORS OF BONE
Primary site:
Breast
Prostate
Lung
Kidney
Melanoma
Thyroid
Most common sites:
Rib cage
Spine
Pelvis
Long bones of the extremities
Skull
Signs and symptoms:
Pain
Hypercalcemia
Anemia
Pathological fracture
PRIMARY BENIGN TUMORS OF CARTILAGE
OR BONE
Osteochondroma (exostoses, bony overgrowths)
Chondroma
Chondroblastoma
Chondromyxoid fibroma
Osteoid osteoma
Osteoblastoma
Giant cell tumor
Signs and symptoms:
Nonpainful unless pathologi­
cal fracture occurs
PRIMARY MALIGNANT TUMORS OF BONE,
CARTILAGE, OR MARROW
Chondrosarcoma
Osteosarcoma
Ewing sarcoma
Lymphoma
Myeloma
Signs and symptoms:
Pain, with no history of injury
Insidious asymmetry of limbs
Osteosarcoma:
Evidence of osteoblastic activity
on radiograph
Chondrosarcoma:
Areas of lysis and of calcification
BOX 19-1  Tumors of Bone and Soft Tissue

508
Section III  Prostheses in Rehabilitation
especially if there has been pathological fracture with neuro­
muscular impairment.104
The incidence of primary malignant neoplasm involving
bone and soft tissue is quite low when compared with tumors
of other systems.97 Because of this, the management of pri­
mary tumors of bone has evolved into a specialty practice,
which means that many newly diagnosed individuals are
referred to regional centers where national guidelines ensure
consistency of care.96 Although the number of amputations
performed as a result of neoplasm is significantly less than
those resulting from dysvascular/neuropathic disease, ampu­
tations as a consequence of neoplasm are more likely to be
performed at proximal levels, including hip disarticulation.
Along with trauma injury, neoplasm is the leading cause of
limb loss in children and adolescents.
Decision Making: Limb-Saving Surgery or Amputation?
Until the 1990s most tumors of bone were managed by
amputation with adjunctive chemotherapy or radiation.96
Currently, localized radical resection with allograph of bone,
endoprosthesis, joint replacement or rotationplasty, along
with and a combination of multiagent chemotherapy, isolated
limb perfusion with tumor-necrosis factors, and radiation
may be used.105–109 These strategies have significantly reduced
the number of tumor-related amputations performed each
year. Amputation may be necessary when there is large, mul­
tifocal, high-grade, proximally positioned sarcoma, especially
if there has been pathological fracture or significant involve­
ment of neurovascular structures and if the tumor is chemo­
resistant.110–114 Amputation is also performed when there is
local recurrence following previous limb salvage.114
Limb-sparing intervention is often staged, requiring mul­
tiple surgeries, given the comorbidities associated with con­
current chemotherapy.115 In addition, the immunosuppression
caused by chemotherapy increases risk of postoperative infec­
tion of the endoprosthesis; if such infections cannot be con­
trolled medically, amputation of the limb is likely.113,116 Survival
rates and rehabilitation outcomes are surprisingly similar for
those with primary bone or soft-tissue sarcoma managed by
amputation or by limb-sparing surgery and reconstruction,
although quality of life may be compromised as compared
with peers without sarcoma.117–119
When a tumor of bone or soft tissue is suspected, initial
assessment strategies may include a radiograph, bone scan,
CT scan, or MRI.120 In individuals with previous history of
cancer who present with bone pain, a radiograph may reveal
a “moth-eaten” area within bone, with unclear boundaries or
edges (Figure  19-5), demonstrating areas of osteolysis and
reactive osteoblastic activity. A whole-body bone scan may
be used to determine if there are multiple metastatic sites.
A CT scan may be used to assess three-dimensional structural
integrity and mineral content of the bone.
An MRI determines the extent of tissue involvement in
marrow, bone, and surrounding soft tissue that is especially
useful in planning surgical intervention for primary malig­
nant tumor of bone or soft tissue (Figure 19-6).121 Laboratory
tests may include blood assays, including sedimentation rate,
C-reactive protein levels, serum electrophoresis, alkaline and
acid phosphate levels, blood calcium levels, blood sugar levels,
and hemoglobin concentration.122 For those with primary neo­
plastic bone disease, biopsy is used to determine cell type and
contributes to pathological staging of the tumor. Depending
on the tumor location, the surgeon may use an open frozen
section, cannulated drill, or fine-needle aspiration to obtain a
biopsy sample. For those with previous cancers of the breast,
lung, bone, or colon, biopsy may not be necessary.
Once a primary tumor of bone has been typed and staged,
the appropriate intervention is initiated.123 Nonpainful local­
ized benign tumors typically do not require surgical interven­
tion and are followed serially to watch for tumor progression.
Symptomatic benign tumors (i.e., those that are painful or inter­
fere with function) are treated by excision with bone graft or
cement to fill the resulting bony defect.124 Localized ­malignant
FIGURE 19-5  Radiograph of the hip joints and pelvis of an indi­
vidual with a metastatic lesion of the right femoral neck and tro­
chanter. Note the poorly defined edges of the metastatic tumor and
the differences in appearance of bone when right and left femurs
are compared. (From Davis AM. Bone neoplasm. In Lundon K (ed),
Orthopedic Rehabilitation Science: Principles for Clinical Management
of Bone. Boston: Butterworth-Heinemann, 2000.)
FIGURE 19-6  A magnetic resonance image of osteosarcoma of the
distal femur that extends through both condyles and marrow and
into surrounding soft tissue. (From Davis AM. Bone neoplasm. In
Lundon K (ed), Orthopedic Rehabilitation Science: Principles for Clinical
Management of Bone. Boston: Butterworth-Heinemann, 2000. p. 147.)

Chapter 19  Amputation Surgeries for the Lower Limb
509
tumors are excised using limb-sparing and reconstructive strat­
egies.108 Those with osteosarcoma or Ewing sarcoma almost
always have preoperative and postoperative chemotherapy to
minimize the likelihood of recurrence, while those with chon­
drosarcoma may not require such intervention.109,125
For successful limb-saving surgery, the surgeon must first
completely remove the tumor, achieving wide, clean mar­
gins in the bone above and below the lesion. A tumor in the
middle of long bone that does not include epiphyses is often
excised en bloc and replaced with an allograft transplanta­
tion or expandable endoprosthesis.126 A tumor that crosses
the epiphysis or extends into the joint space is also excised en
bloc, and a total joint replacement performed to restore func­
tion of the limb.127 When the tumor is large, high grade, and
invasive of other soft-tissue compartments of the limb, ampu­
tation may be the most appropriate strategy.110–114
Following limb-sparing surgery or amputation, appropriate
rehabilitation interventions may include exercise to improve
strength, range of motion, and endurance; energy conserva­
tion strategies; protective weight bearing during gait training
with an appropriate assistive device; prosthetic rehabilitation
(for those with amputation); functional training for mobility
and activities of daily living; pain management (especially for
those with metastatic disease); and patient and family edu­
cation.128 The therapist's understanding of the biomechanics
and tissue manipulation undertaken in the reconstructive or
amputation surgery is essential for appropriate exercise pre­
scription and activity planning. Therapists must also be aware
of the impact of chemotherapy and radiation treatments on
healing soft tissue and bone; on peripheral sensation; and on
physiological response to exercise and activity, as well as the
individual's overall health status, immune response, progno­
sis, and level of energy.129,130 The most successful rehabilitation
programs are individualized and adapt to any adverse effects of
concurrent adjuvant oncological interventions.131 Individuals
with recent diagnosis of bone cancer often find significant
support in interacting with others who have previously reha­
bilitated from limb-sparing or amputation surgery.132
Congenital Limb Deficiency
The birth of a child with a congenital limb deficiency is ini­
tially more distressing and disruptive to the new parents than
to the infant.132 The development of the child's body schema
and personality is significantly influenced by the attitudes and
expectations of parents and caregivers within the context of
the social–cultural environment in which the child is raised.133
The rehabilitation, prosthetic, and eventual elective surgical
management of children with limb deficiency is linked to age-
appropriate developmental status, with the goal of enhanc­
ing function while minimizing deformity.134,135 The reader is
referred to Chapter 29 for in-depth information on develop­
mentally appropriate preprosthetic and prosthetic activities
for mobility and skill, as well as discussion of the therapist's
and prosthetist's role in counseling and educating the family
and child about rehabilitation and prosthetic alternatives.
Orthopedic and surgical management of children with
congenital limb deficiency focuses on enhancing ­appropriate
growth of the residual limb, maintaining relatively equal limb
length, enhancing joint function, and ensuring appropri­
ate prosthetic fit. This may include custom-fit and fabricated
orthoses or prostheses with shoe lifts; surgical and distraction
procedures to lengthen bone; rotational osteotomy; simple sur­
gical revisions to optimize shape of the residual limb; surgical
correction of terminal overgrowth; and, when the deficiency is
complex, conversion to a conventional level of amputation or
disarticulation so as to enhance functional use of a prosthe­
sis.136–140 School-age children with a partial longitudinal defi­
ciency of the femur (proximal focal femoral deficiency) may be
managed with a Van Ness procedure, a rotation osteotomy that
fuses a tibia that has been repositioned 180 degrees to the resid­
ual femur (if present) or pelvis so that the foot can function as a
knee joint (Figure 19-7), or with an osteotomy without rotation
FIGURE  19-7  Diagram of the surgical resection, rotationplasty,
and femoral arthrodesis (modified Van Ness procedure) used to cre­
ate a functional residual limb that can be fit with a prosthesis for
a child with a severe congenital proximal focal femoral deficiency.
(Modified with permission, from Brown KL. Resection, rotation­
plasty, and femoropelvic arthrodesis in severe congenital femoral
deficiency. A report of the surgical technique and three cases. J Bone
Joint Surg Am. 2001;83-A[1]:81.)

510
Section III  Prostheses in Rehabilitation
that is subsequently followed by ankle disarticulation to achieve
a weight-tolerant residual limb closely resembling traditional
transfemoral residual limb.141 Deficiencies of the fibula or tibia
may be managed, depending on the severity of the defect and
resulting deformity, by custom footwear and shoe lift, epiphys­
iodesis, ankle reconstruction or disarticulation, conversion to
traditional transtibial amputation and prosthetic fitting, derota­
tion osteotomy, and limb-lengthening procedures.142–144
AMPUTATIONS OF THE FOOT AND ANKLE
Amputations of one or more toes (digit, phalanx) or of part of
the foot are the most frequently performed surgeries in older
individuals, most often secondary to a nonhealing, often
infected, neuropathic plantar ulcer. Individuals most vulner­
able to development of plantar ulcers usually present with a
combination of sensory impairment (loss of protective sen­
sation); autonomic dysfunction (dry and brittle skin); foot
deformity resulting from weakness of the intrinsic muscles
of the foot; and impaired circulation that, although adequate
to sustain an intact limb, is insufficient to allow healing to
occur.145 In these situations it is especially important to deter­
mine (before amputation) the point at which limb circulation
is sufficient for successful healing of the residual foot.146
Physical deconditioning associated with prolonged bed
rest (especially problematic in older adults) and increasing
likelihood of systemic complications (in persons with cardiac
and pulmonary comorbidities) associated with repeated sur­
gical revisions of a poorly healing amputation can substan­
tially compromise the rehabilitation process and potential
for positive outcome.147 Amputations of the foot may also be
the result of severe crush injury, land mine explosion, shrap­
nel wounds, or similar acute trauma to the foot. The risk of
wound contamination by environmental debris and micro­
organisms increases the likelihood of infection and may
require a two-stage surgical approach.148 Not all individuals
with amputations of the toes are referred for physical therapy
and prosthetic rehabilitation, unless they require instruction
in non–weight-bearing or protected ambulation. Those with
partial foot amputation may require adaptive footwear, shoe
filler, a passive prosthesis, or accommodative foot orthoses,
and may be referred to physical therapy for gait training with
an appropriate assistive device.149
Amputations of the Toes
Phalangeal (digit) amputations are performed when there is
evidence of localized dry gangrene on the toe related to vascu­
lar insufficiency, when conservative management of a neuro­
pathic ulcer on the plantar toe surface has not been successful,
or when there is infection or osteomyelitis of the phalanges.150
Digit amputation can be performed at the distal, middle, or
proximal interphalangeal joints or with removal of the meta­
tarsal head.151 Adequate circulation for healing of the surgi­
cal wound is a prerequisite to amputation surgery at this distal
level. Depending on the age, comorbidities, and current medi­
cal condition of the individual undergoing surgery, ­phalangeal
amputations can be performed using an ankle block, an
­epidural, spinal anesthesia, or general anesthesia.152 The fore­
foot is thoroughly cleaned, especially between the toes, with an
antiseptic solution to reduce the risk of postoperative infection.
A tourniquet may be placed around the calf to be inflated to
approximately 50 mm Hg above systolic blood pressure as sur­
gery begins so as to minimize bleeding during the procedure.
For removal of digits, sagittal flaps are typically used
(Figure 19-8, A). If there will also be resection of metatarsal
head, the surgeon may opt to use a “racquet” incision. The
digits are removed, either by disarticulation through the
joint or transection through the shaft of the digit, using a
bone cutter or oscillating saw. Transection through the pha­
lanx is the preferred method because of the avascular nature
of cartilage, which compromises wound healing. Distal
nerves and tendons are cut under tension (to shorten them
5 to 10 mm) and allowed to retract into the foot. Sesamoid
bones, if present, are removed, especially when the ­metatarsal
head is resected.
FIGURE 19-8  A, Skin incision used for amputation of the fourth toe,
with disarticulation at the metatarsal-phalangeal joint. B, Postoperative
appearance of the foot after amputation of the hallux. (Photo courtesy
Michael Z. Fein, DPM, Bethel Podiatry, Bethel, Conn.)
A

Chapter 19  Amputation Surgeries for the Lower Limb
511
Once the segment being amputated is removed, the tourni­
quet is deflated to reestablish hemostasis; the surgeon may use
ligature or electrocautery to close bleeding vessels as needed.
Next, the surgical site is irrigated with sterile saline or an anti­
biotic solution to remove any tissue debris before closure.
Absorbable sutures are placed to close the internal layers of soft
tissues, and then the skin is closed with either sutures (for sim­
ple digit resection) or staples (for the larger incisions used in
resection of a metatarsal head) (Figure 19-8, B). A nonadherent
dressing (e.g., Adaptic or Xeroform) is placed over the suture
line, and several folded 4 × 4 gauze pads are positioned over
the wound and around neighboring toes to apply slight pres­
sure over the surgical wound. Kerlix or Ace bandages are then
applied in a figure-of-eight distal toward proximal wrap, leav­
ing remaining toes visible to monitor adequacy of circulation.
The initial dressing typically stays in place up to 5 days
unless there are signs of infection (localized pain, excessive
or purulent drainage, fever, loss of diabetic control).151–153 The
individual is instructed in non–weight-bearing ambulation
using an appropriate assistive device (typically a walker or
crutches), on level surfaces, inclines, and stairs. The individ­
ual is encouraged to keep the limb elevated as much as pos­
sible: education about avoiding prolonged dependency of the
limb (i.e., elevating the limb while sitting) is essential.
If the wound heals optimally, many surgeons allow progres­
sion to protected partial weight-bearing ambulation approxi­
mately 10 days after surgery. Most do not encourage return
to weight bearing as tolerated or full weight bearing until all
sutures or staples have been removed, often 2 to 3 weeks postop­
eratively. Many individuals wear a healing sandal to protect the
forefoot for several weeks or months following surgery, before
returning to normal footwear. Individuals with dysvascular and
neuropathic disease benefit from ­custom-fabricated accommo­
dative orthosis to distribute plantar pressures and minimize the
risk of developing additional neuropathic ulcers on plantar sur­
faces of the remaining digits and metatarsal heads.
Metatarsal Head Resection
Metatarsal head resections are typically performed when
there is a nonhealing plantar ulcer, especially if there is osteo­
myelitis of the metatarsal head, as long as there is evidence of
adequate circulation for postamputation wound healing. The
associated digit can be left in place to serve as a spacer in the
shoe and to minimize the risk of subsequent foot deformity.
The methods of anesthesia and preparation are similar to
those used in toe amputation. Once again, a tourniquet may
be placed to minimize bleeding during surgery.
A longitudinal incision is made along the dorsal shaft of
the targeted metatarsal (Figure 19-9, A). Soft tissue structures
are carefully detached from around the metatarsal head. The
metatarsal is transected behind its head using an oscillating
saw, and the metatarsal head is dissected from the proximal
phalanx. The tourniquet is deflated to reestablish hemostasis,
bleeding vessels are ligated or cauterized, and the wound is irri­
gated with sterile saline or antibiotic solution. Subcutaneous
layers are closed with absorbable sutures, and skin closure
is achieved with either staples or interrupted fine monofila­
ment sutures (Figure 19-9, B). As soft tissue heals, scarring will
create a pseudoarthrosis in place of the anatomical metatar­
sal head. A nonadherent dressing (e.g., Telfa pad) and several
4 × 4 gauze pads are placed over the dorsal incision site.
Next, the surgeon turns to the plantar surface of the foot to
trim any hypertrophic callus and to debride any plantar ulcer
that might be present, cleaning it and packing it with gauze
soaked in saline or antibiotic solution, and covered with fluff
gauze. To minimize forefoot pressure and reduce risk of recur­
rent or transfer ulceration once ambulation has resumed, the
surgeon may also opt to simultaneously lengthen the Achilles
FIGURE 19-9  A, Skin incision for excision of the first metatarsal head, when the plan is to leave the
hallux intact. Soft-tissue scarring will eventually create a pseudarthrosis so that forward progression
over the toe in the late stance phase of gait will not be compromised. B, Postoperative fully healed
appearance of the feet after excision of the second metatarsal head on the right foot, and resection of
the second and fourth toe and metatarsal heads on the left foot. (Courtesy Carolyn Kelly, Center for
Wound Healing and Hyperbaric Medicine, Hartford Hospital, Hartford, Conn.)
A
B

512
Section III  Prostheses in Rehabilitation
tendon.154 The foot is then wrapped, in a distal toward prox­
imal progression, with Kerlix gauze and an Ace bandage.
Because of the need to monitor and repack any plantar
wounds, dressings are typically changed daily. Instruction in
non–weight-bearing ambulation with the appropriate assis­
tive device and patient education about avoiding prolonged
dependency of the limb should occur as soon as feasible fol­
lowing surgery. Sutures or staples usually remain in place up
to 2 weeks postoperatively. Adequate followup care must be
provided. This usually includes an accommodative orthosis
to redistribute plantar pressure to avoid the future develop­
ment of a transfer neuropathic ulcer under remaining meta­
tarsal heads.155
Ray Resection
Ray resections may be performed when vascular disease, neu­
ropathic ulcer or osteomyelitis has compromised one or more
“rays” of the forefoot and circulation is compromised enough
to make healing unlikely at a more distal level. In this surgery,
50% or more of the metatarsal, as well as its associated dig­
its, are removed (see Figures 19-9, B and 19-10). The residual
metatarsal (if any) is beveled at a 30- to 45-degree angle so
that there will be no sharp edge to damage tissue during the
late stance phase, as body weight rolls over the distal plan­
tar surface of the healed residual limb. If multiple rays are
resected, skin graft may be required for wound closure.156,157
Ray resection may be the surgery of choice for problems of
the fourth and fifth rays: as long as the first through third rays are
intact, there is minimum compromise to forward progression
in gait on the healed residual limb. When the first and second
rays must be removed, however, there is significant disruption of
weight bearing forces during walking and high risk of ulceration;
a complete transmetatarsal amputation managed with custom
footwear with a rocker bottom often has better functional out­
come than leaving the third through fifth rays intact.158
Anesthesia and intraoperative care are similar to those
described for toe amputation and metatarsal head resection.
The soft dressing applied in the operating room is typically
changed daily for wound inspection, especially if there has
been skin graft or debridement of a plantar ulcer. As soon
as feasible, the individual is instructed in non–weight-bearing
mobility using a walker or crutches; non–weight-bearing
­status continues until sutures or staples have been removed.
The deformity that results when multiple rays have been
amputated may require an accommodative orthosis or a
prosthetic filler in the shoe, along with adaptive or custom
footwear to protect the residual limb from high pressures
resulting from altered biomechanics during forward progres­
sion and propulsion when walking.149
Transmetatarsal Amputation
A complete transmetatarsal amputation (TMA) is, essentially,
ray resection of all five metatarsals proximal to their meta­
tarsal heads. In this surgery, the goal is to preserve as much
length of the shaft of the metatarsals and healthy plantar skin
as possible so that the resulting residual limb will be long
enough for an effective biomechanical lever for forward pro­
gression over the foot during gait and will have enough plan­
tar surface such that higher shear forces and pressures exerted
on the shortened forefoot during the late stance phase of gait
will not compromise skin condition.159
It is difficult to predict whether primary healing is possi­
ble after TMA in persons with diabetes and critical limb isch­
emia. Rates for successful healing (primary and delayed up to
8 months) following TMA are reported as 60% to 70%; with as
many as 15% requiring revision to a shorter TMA, 15% to trans­
tibial amputation, and a 5% to 10% death rate within 6 months
of surgery.160–162 Risk factors for poor healing include concur­
rent kidney dysfunction, history of heaving smoking, and con­
current cardiovascular disease. Although the best predictor of
healing appears to be a palpable pedal pulse, ABI, unless greater
than 0.9, is not an effective indicator. Noninvasive Doppler vas­
cular assessment may help decision making about adequacy of
arterial supply for primary healing.163
If the surgeon determines that a TMA is necessary, the limb
is carefully cleaned and draped for surgery, a tourniquet is
applied to reduce distal blood flow and a guideline is marked
across the dorsal foot just proximal to the metatarsal heads, con­
tinuing in a curvilinear arc along the plantar surface almost to
the base of the toes (Figure 19-11). This type of incision cre­
ates a long posterior flap that will be sutured closed after bony
and soft-tissue elements have been excised. An oscillating saw
is used to transect each of the metatarsals, and then the toes are
plantar flexed to allow careful dissection of the soft tissue that
will be used as the posterior flap from the bony structures being
removed. The tendons and sheaths of extrinsic muscles of the
foot, as well as distal attachments of intrinsic muscles, are tran­
sected; the plantar surface of residual metatarsals are beveled
or rounded (to allow rollover in gait without high distal plantar
pressures); and any distal nerves are resected under slight ten­
sion and allowed to retract into the residual limb. The poste­
rior flap is trimmed and debulked to fit it appropriately to the
dorsal incisions for a smooth wound closure. Blood vessels that
have been transected are tied off or cauterized, the tourniquet is
released, and hemostasis is restored. Just before closure, the sur­
gical wound is thoroughly irrigated with saline and an antibiotic
solution; antibiotic beads may be used to further reduce risk of
infection.164 Meticulous attention to hemostasis should preclude
the need for placement of a drain; a closed s­uction drain placed
deep to the facial layer of closure would be the preferred choice
FIGURE 19-10  In this diagram of a metatarsal ray resection, the
fourth and fifth rays (metatarsal and phalanges) have been removed.
Surgeons can elect to transect the shaft of the metatarsal and leave
the base of the metatarsals in place or to disarticulate through the
tarsometatarsal joint.

Chapter 19  Amputation Surgeries for the Lower Limb
513
of drain if it is determined that one is required. The posterior
flap is drawn upward to approximate edges of the wound on the
dorsal surface. Deep subcutaneous fascia is sutured closed, fol­
lowed by suturing and stapling of skin.
Muscle imbalance between dorsiflexors and plantar flex­
ors increases as the length of a transmetatarsal residual limb
decreases, leaving individuals with short transmetatarsal
residual limb at risk of developing equinovarus deformity
in an already vulnerable foot. Tendon transfers or orthope­
dic stabilization using screws or pins may be used to restore
balance to the transmetatarsal residual limb.165–167 Achilles
lengthening may be used as a means to provide greater ankle
flexibility, ultimately reducing distal plantar pressures on the
TMA residual limb.168
Once the wound has been closed, a layer of nonadherent
dressing (e.g., Adaptic or Xeroform) is placed over the suture/
staple line and a bulky dressing of fluffed gauze is placed
around the forefoot. Several rolls of gauze bandage are gently
wrapped around the entire foot and ankle, and an Ace wrap is
applied to provide gentle compression (graded distally toward
proximally) and minimize postoperative swelling. Dressings
are left in place 3 to 5 days unless there are indications of
infection or significant focal pain. Limited mobility and non–
weight-bearing ambulation with a walker or crutches are
often begun after the first dressing change, although heal­
ing is enhanced if the limb is kept elevated when in bed or in
sitting in the early postoperative period. Staples and sutures
are often left in place from 2 to 3 weeks postoperatively. Once
the surgeon is satisfied that adequate wound closure has been
achieved, the individual may be placed in a healing sandal
and graded partial weight bearing during walking can begin.
Gradual progression to full weight bearing with an assis­
tive device (walker, crutches, single cane) and independent
ambulation without an assistive device is determined by skin
condition of the residual limb and the individual's previous
ambulatory status, postural control, and functional level.
Many individuals benefit from wearing a sneaker or oxford
with forefoot filler and a rocker bottom applied to the sole to
dissipate higher weight-bearing forces on the distal plantar
residual limb in the late stance phase; those with short resid­
ual transmetatarsal limbs may require a custom shoe that
encompasses the ankle or a custom thermoplastic ankle-foot
orthosis to counteract muscle imbalance leading to equin­
ovarus position during the swing phase of gait and to ensure
efficient heel strike at initial contact and appropriate forward
progression in stance. Those with polyneuropathy should be
cautioned not to go barefoot, even in their home environ­
ment: their ability to detect injury to the plantar (or dorsal)
surface of the foot may be significantly compromised. An
open wound (neuropathic or traumatic in origin) on a trans­
metatarsal residual limb that becomes infected or fails to heal
often leads to revision to the transtibial amputation level.
Amputations and Disarticulations of the Midfoot
The two most commonly performed amputations of the
midfoot are tarsometatarsal disarticulation (Lisfranc proce­
dure) and a midtarsal disarticulation (Chopart procedure)
(Figure 19-12, also see Figure 22-3). The operative approach
FIGURE 19-11  Dorsal (A) and plantar (B) incisions for a complete
metatarsal amputation. Each metatarsal will be transected just prox­
imal to its head to preserve as much foot length as possible, and the
longer plantar flap will be drawn upward and sutured to close the
wound. C, Postoperative appearance of the foot after transmetatarsal
amputation, with surgical drain in place. (Photo courtesy Michael Z.
Fein, DPM, Bethel Podiatry, Bethel, Conn.)
A
B
Calcaneus
Achilles
Tendon
Tibia
Fibula
Talus
B
A
FIGURE 19-12  Diagram of the levels of amputation or disarticula­
tion for a Lisfranc (A) procedure at the tarsal metatarsal joint and a
Chopart procedure (B) at the midtarsal (talonavicular and calcaneo­
cuboid) joints. In both surgeries, a longer plantar flap is left in place
and used to close the wound.

514
Section III  Prostheses in Rehabilitation
and postoperative care for both surgeries is similar to that
of a TMA. The surgical incision is made more proximally
across the dorsum of the foot, and a long posterior/plantar
flap is created to wrap upward toward the dorsal incision
when the surgical wound is closed. In a Lisfranc procedure,
the forefoot is excised from the midfoot through the tarso­
metatarsal joint, usually leaving the “keystone” base of the
second metatarsal in place to maintain a transverse arch of
the midfoot. The midtarsal joints may be surgically fused
as well to maintain the integrity of the architecture between
midfoot and rearfoot.
The distal attachment of the peroneus brevis, peroneus lon­
gus, and anterior tibialis may be repositioned during surgery in
an attempt to restore some level of equity (power) among mus­
cle groups controlling dorsiflexion/plantar flexion and inver­
sion/eversion positioning of the foot at rest and during walking.
In a Chopart procedure, the disarticulation takes place in the
joints between the talus and navicular bones and the calcaneus
and cuboids. Both approaches may also include lengthening
of the heel cord to ensure adequate dorsiflexion excursion for
rollover during the stance phase of gait. A bulky dressing with
an Ace wrap or a slightly dorsiflexed plaster cast is applied in
the operating room.169 Non–weight-bearing mobility with a
walker or crutches begins several days after surgery, and pro­
tected weight bearing starts once adequate wound closure has
been achieved and sutures or stables have been removed.
Lisfranc and Chopart surgeries may be used for individuals
with significant traumatic injury or bone or soft-tissue tumor in
the forefoot; they are rarely used for individuals with dysvascu­
lar or neuropathic limbs.170 Although both approaches preserve
the ability to bear weight through the calcaneus, there is even
greater likelihood of development of the equinovarus defor­
mity and prosthetic fitting can be challenging. Persons with a
­midfoot-level residual limbs typically require custom footwear
and orthoses to protect the residual limb during functional
activities and to ensure biomechanically sound, safe ambula­
tion.171 Those who develop significant equinovarus with pain
and tissue damage during ambulation may opt return to the
operating room after maturation of the residual limb, for surgi­
cal modification and subtalar arthrodesis of the residual limb, to
achieve more comfortable and functional ambulation ability.172
Syme Amputation
The most commonly performed amputation involving the
rearfoot is the Syme procedure, a surgical technique that dis­
articulates the talocrural, trims the malleoli to create a flat
weight-bearing surface, and repositions the fat pad and soft
tissue of the heel under the distal tibia and fibula. Although
the Syme procedure reduces leg length because the calcaneus
and talus have been removed, the well-healed distal residual
limb is pressure tolerant for ambulation with a prosthesis and,
if necessary, for short distances (e.g., emergencies, getting to
the bathroom at night) without a prosthesis.173 Variations of
the Syme procedure retain the weight-bearing portion of the
calcaneus, fusing it to the distal tibia and fibula.
When the limb has been scrubbed and prepared for sur­
gery and a tourniquet is in place, guidelines for incision are
drawn on the anterior ankle from medial to lateral malleoli and
then downward around the plantar (posterior calcaneus) sur­
face to outline what will be the distal pad of the residual limb
(Figure 19-13). After sharp incision through skin and subcuta­
neous tissue, toe extensor and dorsiflexor tendons are cut and
the anterior capsule of the ankle is exposed. The foot is pas­
sively plantar flexed so as to access and open the joint capsule
medially to laterally (with care to preserve the posterior tibi­
alis artery going to tissue that will be the pad of the residual
limb) and to disarticulate the talus. The posterior joint cap­
sule, posterior tibialis tendon, and flexor hallucis longus ten­
don are transected. The periosteum of the calcaneus is carefully
stripped and preserved for use in attaching the posterior flap/
fat pad to the tibia later in the procedure. The Achilles ten­
don and plantar soft tissue are then dissected from the calca­
neus, and the amputated foot completely removed. Plantar
tendons and any remaining intrinsic muscle tissue are excised
from the posterior flap/fat pad. The distal tips of the medial
and lateral malleoli are removed using an oscillating saw, level
with the articulating surface of the tibia. The flares of the mal­
leoli are trimmed parallel to the long axis of the tibia and fibula
in order to create a less bulbous residual limb.174
The tourniquet is deflated, and vessels are tied off or cauter­
ized to restore hemostasis. The surgical construct is irrigated
with a sterile saline antibiotic solution. Several obliquely ori­
ented holes are drilled in the medial, lateral, and anterior edges
of the tibia and fibula to be used as anchors for suturing the pre­
served periosteum and posterior flap/fat pad in place. A tubu­
lar drain is placed through the anterolateral skin to drain the
wound as it heals, minimizing the risk of postoperative hema­
toma between bone and posterior flap. The flap is drawn up
Medial
A
B
Lateral
Tibia
Fibula
FIGURE  19-13  Medial (A) and lateral (B) views of the incision
for a Syme ankle disarticulation. After the talus is removed from its
mortise, the distal points of malleoli are trimmed to create a flat sur­
face and the posterior heel pad is drawn upward to close the wound.

Chapter 19  Amputation Surgeries for the Lower Limb
515
into position, and the preserved periosteum is sutured to bone,
followed by suturing of the subcutaneous tissue and then sta­
pling of the skin. After wound closure, a nonadherent dressing
is placed over the suture line, followed by a fluffed-gauze, bulky
dressing, and the limb is wrapped distally toward proximally
toward the knee. Depending on surgeon preference, the limb
may then be wrapped with a slightly compressive Ace bandage
dressing; Unna paste, which will dry into a semirigid dressing;
or plaster of Paris cast.
The drain is typically pulled and removed by postopera­
tive day 2, leaving the dressing in place. The initial dress­
ing change may wait until between postoperative days 5 and
7 unless there are clinical signs of infection or necrosis, to
assist adherence of the fat pad to the distal surface of the
tibia and fibula. Non–weight-bearing ambulation with a
walker or crutches begins 2 to 3 days after surgery and con­
tinues for up to 8 weeks. This non–weight-bearing status is
essential to ensure that the fat pad is not disrupted until it
is firmly healed in place. Staples are typically removed after
3 weeks, and a program of gentle compression with Ace
wraps or shrinker garment is initiated. Depending on the
condition of the residual limb, the individual may be ready
for initial prosthetic fitting by 6 to 8 weeks following ampu­
tation. Initial prosthetic training must be with careful par­
tial weight bearing and an appropriate assistive device, with
frequent inspection of the integrity and positioning of the
distal pad. Progression to full weight bearing follows over
the next several weeks.
The successful healing of a Syme amputation is most
likely when necessitated by trauma; Persons with PAD who
undergo Syme amputation often have an extremely prolonged
period of healing and nearly half go on to amputation at the
transtibial level.174,175
TRANSTIBIAL AMPUTATION
Transtibial amputation typically has positive surgical and
rehabilitative outcomes, as long as there is sufficient circu­
lation for healing of the residual limb.176,177 In the mid-1960s
the ideal transtibial surgery preserved 15 cm (approxi­
mately 6 inches) of residual tibia to allow for effective knee
extension power to control the prosthesis and to mini­
mize discomfort and skin problems in the thermosetting
hard sockets that were commonly in use at that time.178 As
residual tibial length decreases toward the tibial tubercle,
mechanical advantage of knee flexors exceeds that of knee
extensors, making it difficult to extend the knee enough
to advance a prosthesis during swing and for controlled
(eccentric) knee extension for stability in the early stance
phase (Figure 19-14).
Because the surface area for weight bearing within the
socket decreases as the length of the residual limb decreases,
limb length, the likelihood of discomfort, skin irritation, and
limited use of a transtibial prosthesis increases. Conversely,
in long residual limbs, the larger total surface area to distrib­
ute pressures within the socket and long lever arm ­potentially
A
B
C
D
FIGURE  19-14  Anatomical diagram of the tibia and fibula (A) and of short (B), midlength,
standard (C), and long (D) residual limbs after transtibial amputation. Dotted line represents the
suture line when a posterior flap approach has been used.

516
Section III  Prostheses in Rehabilitation
enhance prosthetic control, although there is a risk of chronic
skin irritation and discomfort along the sharp edge of the
distal–anterior tibial crest. Recent advances in prosthetic
materials and design can accommodate, to some degree,
for the biomechanical and prosthetic fitting challenges of a
long residual limb (i.e., with more than 66% of original tib­
ial length) or of a short residual limb (i.e., preserving 33%
or less of original tibial length). Comfort in the prosthesis,
quality of gait, and energy cost of ambulation seem to be best
balanced when the level of amputation ­preserves 40% to 50%
of the tibia.179
The type of anesthesia chosen for transtibial amputation
surgery is determined by the individual's overall health
and comorbid conditions and consideration of potential
adverse outcomes of each method. Options include general
anesthesia, spinal anesthesia or an epidural, regional nerve
blocks, and in some cases careful local anesthesia at the site
of the incision and underlying tissues.180,181 In older individ­
uals, the likelihood of postoperative delirium and the risks
associated with concurrent cardiac disease may lead the
anesthesiologist to use spinal anesthesia or regional blocks.
In those with multiple traumatic injuries, general anesthe­
sia may allow for optimal physiological control during the
surgery.
Depending on the condition of the skin and soft tissue,
as well as the circumstances that have led to the decision
to amputate, the surgeon selects from a number of surgi­
cal approaches. Until recently, the most commonly used
approach is the long posterior (myofasciocutaneous) flap
described by Burgess in the 1960s: This technique preserves
the highly vascular gastrocnemius as well as all anterior com­
partment muscles beyond the residual tibia, brings the flap
up and forward, and positions the suture line across the dis­
tal anterior residual limb below the cut surface of the tibia
(Figure 19-15, A).182
Muscles of the anterior compartment are somewhat sus­
ceptible to necrosis which contributes to delayed healing and
may require revision to a higher level. A modification of the
posterior flap procedure described by Bruckner removes all
of the tibialis anterior as well as the bulk of the soleus to the
level of the residual tibia (see Figure 19-15, B), so as to reduce
the likelihood of muscle tissue necrosis and increase likeli­
hood of successful primary healing. The modified Bruckner
method also removes the fibula.183,184
A third options, first described by Ertl in 1949 as an osteo­
myoplastic amputation with tibia–fibula synostosis, preserves
more residual length and incorporates a bone bridge between
the distal tibia and fibula for stability (Figure  19-16).185,186
Although not frequently used in the presence of dysvascular
disease, this approach has reemerged for persons with trau­
matic and military-related lower limb injury.187 While there
is some evidence that the Bruckner and Ertl procedures are
more likely to heal successfully (i.e., without need of revision)
than the traditional Burgess posterior flap, which surgical
technique to use is based on surgeon preference.188
When a posterior flap cannot be achieved, the surgeon
may create equal anterior–posterior skin flaps in which the
incision runs in a U shape medially to laterally across the
bottom of the residual limb, or equal medial-lateral flaps, in
which the incision runs in a U anteriorly to posteriorly across
the bottom of the residual limb (Figure 19-17). The surgeon
may even use a long medial or long lateral flap that positions
the incision on the distal opposite side of the limb.189 In all
approaches the surgeon seeks to retain enough soft tissue so
that there is little or no tension across the closed incision, but
not so much that there will be redundant skin and tissue that
might challenge prosthetic fitting.
FIGURE  19-15  Comparison of the (A) traditional posterior flap
transtibial amputation (Burgess procedure) in which all mus­
cles in the residual limb are preserved and the amputation closed
with a long posterior flap, and (B) the modified Burgess procedure
described by Brückner, with removal of all of the tibialis anterior
and of the soleus beyond the distal end of the tibia, so as to reduce
likelihood of muscle tissue necrosis in the postoperative period.
(Reprinted with permission from Yurttas Y, Kurklu M, Demiralp B,
Atesalp A. A novel technique for transtibial amputation in chronic
occlusive arterial disease: modified Burgess procedure. Prosthet
Orthot Int. 2009;33[1]:25–32.)

Chapter 19  Amputation Surgeries for the Lower Limb
517
Modified Burgess Posterior Flap Surgery
The limb is cleansed, prepped, and draped for surgery, and
a tourniquet is applied at mid-thigh level.190 A guideline for
tibial length and for anterior incision sweeping into a distally
curved posterior flap is drawn on the leg. The anterior inci­
sion is made through skin and then soft tissue to the perios­
teum of the tibia, and subcutaneous blood vessels are clamped.
Next, muscles in the anterior compartment are incised so that
the anterior tibial artery, vein, and deep peroneal nerve can
be identified, clamped, transected, and ligated.194 Soft tissue
is carefully removed from around the fibula approximately
2 cm (3⁄4 inch) shorter than the residual tibia. An oscillating
saw or double-action bone cutter is used to transect the fib­
ula. The surgeon then bevels the anterior tibia at an approxi­
mate 45-degree angle with an oscillating saw and repositions
the saw to complete the transection in the transverse plane,
controlling the wedge to be removed with a clamp. The skin
and subcutaneous incision are now continued along what will
become the posterior flap.191,192
The transected lower tibia and fibula are pulled up and for­
ward to allow access to structures in the posterior compart­
ment and carefully beveled following the line of the posterior
incision to create the posterior flap. Once the amputated limb
has been removed, the posterior tibial and peroneal arteries
and veins are clamped. Major nerves are elongated with gentle
traction, resected at the most accessible proximal point, and
allowed to retract into the residual limb.193 The soleus muscle
is then dissected from the medial and lateral heads of the gas­
trocnemius and removed to debulk the posterior flap for opti­
mal wound closure. The blood vessels of the posterior and
lateral compartments are clamped, transected, and ligated.
The tibial, superficial peroneal, and deep peroneal nerves are
transected under traction so that they will retract upward,
away from the end of the residual limb, so as to minimize
the risk of subsequent neuroma formation. The tourniquet is
deflated, any bleeding small vessels are electrocauterized or
sutured, and hemostasis is restored. The beveled anterior tibia
is smoothed with a rasp. The surgical site is then irrigated
with sterile saline and antibiotic solutions in preparation for
wound closure (see Figure 19-15, A).191,192
When the residual limb is short, much of the syndesmo­
sis between tibia and fibula will have been lost. The surgeon
may opt to use an osteoplastic procedure using preserved
periosteum before closure in an effort to stabilize the ends
of the transected bones. This, theoretically, minimizes the
likelihood of dislocation of the fibular head during subse­
quent activity and prosthetic use. For mid-length and lon­
ger residual limbs, closure begins with suturing of the deep
fascia and gastrocnemius tendon in the posterior flap to the
fascia of the anterior compartment. A closed suction drain
can be positioned in the posterior flap toward the medial leg
above the incision to reduce the risk of hematoma forma­
tion within the residual limb. The limb is then irrigated again
with saline and antibiotics, and staples or sutures are used to
approximate and close the wound, with the goal of uniform
tension across the incision.
A nonadherent dressing is laid along the incision, covered
with a fluffed-gauze bulky dressing, and then a conform­
ing gauze bandage is applied evenly in a distal to proximal
­figure-of-eight. At this point the surgeon may apply a layer of
Ace wrap for slight compression of the residual limb, use an
Unna bandage to create a semirigid postoperative dressing,
use a prefabricated adjustable thermoplastic rigid dressing, or
apply a plaster or fiberglass cast (with the knee in extension).
The reader is referred to Chapter 20 for further discussion of
the indications and limitations of each type of postoperative
bandaging.
The drain is typically pulled 24 to 48 hours after sur­
gery. The operative dressing remains in place for 3 to 5 days
unless signs of infection suggest earlier dressing change
(Figure 19-18). In the first postoperative days the individual
with new transtibial amputation is encouraged to keep the
knee of the residual limb in full extension; elevation over a
pillow leads to hip and knee flexion contracture that will be
problematic later in rehabilitation. The individual is referred
for rehabilitation services on postoperative day 2 or 3 to begin
out-of-bed activity, transfers, and single-limb ambulation
with a walker or crutches. Bedside commodes and wheel­
chairs with removable armrests assist self-care and mobility
and reduce the risk of falls.
FIGURE 19-16  Radiograph of a healed bone bridge (tibia–fibula
synostosis) several months following a transtibial amputation using
the Ertl approach. (Reprinted with permission from Dionne CP, Ertl
WJ, Day JD. Rehabilitation for those with transtibial osteomyoplas­
tic amputation. J Prosthet Orthot: 2009;21[1]:64-70.)

518
Section III  Prostheses in Rehabilitation
A
B
C
D
FIGURE 19-17  Examples of transtibial amputation techniques: A, This lateral view of the resid­
ual limb illustrates the trim line of a traditional posterior flap transtibial amputation. The flap of
Bruckner approach would be slightly less full because of the excision of muscles of anterior com­
partment and more proximal trimming of the soleus. In both approaches, the suture line would run
across the anterior surface of the residual limb, distal to the cut end of the tibia. B, In this lateral view
there are equal anterior and posterior flaps, with the resulting suture line in the frontal plane, running
medial-laterally on the underside of the residual limb. C, When equal medial and lateral sagittal flaps
are used, the suture line lies in the sagittal plane, front to back across the distal inferior residual limb.
D, When a long lateral flap is used, the suture line will be on the distal medial aspect of the residual
limb. (Modified with permission from Singer JM. Hershey Board Certification Review Outline Study
Guide. Camp Hill, PA: Philadelphia College of Podiatric Medicine, 1993. p. 640.)
FIGURE 19-18  A, An anterior view of a posterior flap transtibial residual limb is healing well but
has a slightly bulbous in shape at postoperative day 5. B, An anterior view of a posterior flap trans­
tibial residual limb 3 days postoperatively in a patient with recent failed revascularization. Note the
flow of the incision from the previous bypass incision into the new posterior flap, the serosanguine­
ous drainage medially, and ecchymosis laterally over the tibial tubercle. (Courtesy Algis Maciunas,
CPO, FAAOP, Hanger Orthotics and Prosthetics, Wethersfield, Conn.)

Chapter 19  Amputation Surgeries for the Lower Limb
519
Staples or sutures typically remain in place for 3 weeks;
if there are indications of delayed healing, the surgeon may
opt to leave every second or third staple in place longer, rein­
forcing the incision with Steri-Strips when staples have been
removed. Gentle mobilization of soft tissue begins to prevent
adherence of the incision scar to underlying fascia and bone.
Casting for initial prosthesis occurs only when there has been
adequate closure of the surgical wound and the circumference
of the distal and proximal portions of the residual limb below
the knee is nearly equal. For some individuals this may occur
within 3 weeks; for others it may require several months.
Modified Bruckner Procedure
The modified Bruckner procedure is based on the premise
that, for individuals with significant PAD, risk of postopera­
tive muscle necrosis will be less likely if the muscles most sus­
ceptible to ischemia are removed during surgery.185,186 For that
reason, anterior and lateral compartment muscles, as well as
the lateral gastrocnemius, are excised. In addition, the soleus
and its large venous plexus are removed to reduce risk of post­
operative thrombosis.194 The fibula is also removed, especially
if the residuum is short, to create a limb that will be more tol­
erant of pressure within the prosthetic socket.
Preparation of the limb with tourniquet and skin inci­
sion is essentially the same as for a traditional posterior flap
surgery. The tibia is transected 10 to 12 cm distal to the knee
joint line, the edges beveled and smoothed. The fibula is dis­
articulated and completely removed. Muscles of the ante­
rior and lateral compartments are dissected away from their
attachments and removed. The soleus is completely resected,
leaving the medial and, if necessary to achieve full coverage,
lateral portions of the gastrocnemius muscle as the posterior
flap. Arteries and veins are ligated, and nerves resected as
in the traditional posterior flap surgery. A surgical drain is
placed in the space where fibula has been removed, and the
surgical construct is closed as described for traditional poste­
rior flap surgery (see Figure 19-15, B).
Modified Ertl Procedure
One problematic complication after trauma-related amputa­
tion is the development of heterotopic ossification; the modi­
fied Ertl procedure theoretically reduces the likelihood of this
complication by closing the intramedullary canal, support­
ing appropriate tension across the interosseous membrane
between tibia and fibula, and stabilizing position of the fib­
ula. This is achieved by using a bony strut harvested from the
amputated segment of the fibula supported by a periosteal flap
dissected from the tibia prior to resection of this long bone.195
In many instances, more bony length can be preserved, result­
ing in a cylindrical residual limb with some end-bearing
capacity for prosthetic use.196 This procedure is most typically
used in young, healthy individuals expected to be very active
using their prosthesis, especially for those in the military.196,197
Initial preparation of the limb is similar to that of a pos­
terior flap procedure. After initial skin incision, tibial peri­
osteum is harvested from both medial and lateral surfaces of
the bone, and prepared to be a “sling” to hold the subsequent
bone graft in place.187 Long bones are then transected with
an amputation saw. A segment of bone is harvested from the
amputated fibular shaft, sized to bridge the space between
tibia and fibula of the residual limb. The inner edges of the
tibia and fibula may be notched to allow the bone bridge to
fit securely between them. The bone bridge may be secured
in place in a number of ways; for example, use of compres­
sion screws, or running a “TightRope” (Anthrex Inc, Naples
FL) suture through a hole drilled in the fibula, then through
the shaft of the bone bridge, then through a hole drilled in
the tibia.196 The preserved tibial periosteum is then wrapped
under the bone bridge and secured to fibular periosteum.
The tourniquet is released, and hemostasis is achieved by
ligating arteries and veins. Nerves (tibial, superficial and
deep peroneal, saphenous, and sural) are injected with an
anesthetic, put under tension, resected, and allowed to
retract into the residual limb. The posterior flap is pulled
up and over the end of the residual limb, and anchored
to the anterior tibia, proximal to the bone bridge (see
Figure 19-16). Muscle of the flap is sutured to anterior fas­
cia with nonabsorbable suture, and then subcutaneous and
skin layers are closed with either silk suture or with staples.
Immediate postoperative care, focusing on management of
pain and of edema, is the same as for the modified Burgess
and modified Bruckner procedures.
Because of the extensive dissection required, this procedure
uses more operative time (and more time under anesthesia
and with tourniquet in place) than the modified Burgess and
Bruckner surgeries. Because of this, it may not be the surgery
of choice for persons with multiple comorbidities or those who
are medically frail.198 If performed prior to skeletal maturity,
there is risk of development of a progressive varus deformity
of the tibia likely to require surgical correction for functional
prosthetic use.199
KNEE AND TRANSCONDYLAR AMPUTATION
In previous centuries, before development of surgical anesthesia
and antibiotics, simple knee disarticulation surgery often had a
much more favorable outcome than transtibial amputation.200
Because this surgery does not transect major muscle mass, it
can be done in less time and with significantly less blood loss
than transtibial or transfemoral amputation. Additionally, sim­
ple disarticulation through the knee joint disrupts only the
tissue compartment of the joint itself, making postoperative
infection in fascia, muscle, or bone much less likely. The femoral
condyles, with their cartilaginous covering, are designed to tol­
erate weight bearing, and preservation of the entire femur pro­
vides mechanical advantage to the prosthetic wearer.
The residual limb heals without much atrophy, requiring
less socket replacement or revision early on, allowing fitting
with a definitive prosthesis in less time than the typical trans­
tibial or transfemoral residual limb. Additionally, this surgery
preserves the growth plate of the distal epiphysis, an impor­
tant consideration for children with neoplasm or traumatic
injury of the proximal tibia.201 For individuals with severe
bilateral vascular disease who are nonambulatory before

520
Section III  Prostheses in Rehabilitation
­surgery, the extra length of the femurs provides a larger base
of support in sitting, enhancing postural control.202
The length of an intact femur, along with the anatomy of
the condyles, creates several important challenges to prosthetic
fit and function in terms of choice and placement of the pros­
thetic knee unit, which affects energy cost, as well as efficiency
of prosthetic gait. The bony, bulbous residual limb of those who
undergo a simple knee disarticulation also creates a challenge
regarding donning and doffing the prosthesis (Figure 19-19).
Surgical techniques developed by Mazet and Hennessy in the
1960s removed the patella and trimmed the medial and lateral
condylar surfaces to address the problems associated with bul­
bous distal anatomy.203 In 1977, Burgess recommended removal
of 1.5 to 2 cm of distal condyles to permit placement of a newly
developed four-bar prosthetic knee unit closer to what had been
the anatomical axis of the knee.204,205 Some surgeons advocate
modifying the patella and then fusing it to the intercondylar
notch of the femur to create a flat, weight-bearing surface.206
Many current transcondylar surgical procedures combine
these two approaches to form a residual limb that resembles a
long transfemoral limb (Figure 19-20). Typically either equal
sagittal flaps or a long posterior flap are used to provide addi­
tional “cushion” for weight bearing through the distal residual
limb.207,208 Proponents of simple knee disarticulation, without
modification of the distal femur, suggest that the combination
of reduced rates of infection, better primary healing, larger
surface areas for weight bearing, and advances in prosthetic
design and technology lead to better functional outcome and
higher rates of prosthetic use.208,209
The preparation for knee disarticulation or transcondy­
lar amputation is similar to that of transtibial amputation. The
anesthesiologist selects spinal, epidural, or general anesthesia
as determined by the health and physiological condition of the
person undergoing disarticulation. After application of a tour­
niquet, the surgeon outlines the incision to guide creation of
equal mediolateral flaps (Figure 19-21) approximately half of
the anteroposterior diameter of knee in length; some surgeons
prefer a long posterior flap as described in the discussion of
transtibial surgery (see “Transtibial Amputation” above). After
careful incision of skin and subcutaneous tissue and reflection
of the skin flaps, the surgeon transects the patellar tendon at the
A
B
C
FIGURE 19-19  A, The residual bony architecture in a simple knee
disarticulation, in which no modification of the patella or femur is
done. B, Anterior view. C, Lateral view of transcondylar amputa­
tion, which shapes the residual femur to resemble a long transfemo­
ral residual limb.
FIGURE 19-20  Comparison of amputations through the femur. A,
Knee disarticulation transects the knee joint, while transcondylar
amputation modifies the distal femur and condyles. B, Traditional
transfemoral amputation preserves 50% to 66% of femoral length.
A long transfemoral residual limb (>66% of femoral length) and
knee disarticulation provide a mechanical advantage for prosthetic
use but problems with prosthetic cosmesis as a result of incorpora­
tion of a knee unit distal to the socket. A short transfemoral limb
(<50% of femoral length) may challenge prosthetic fit and suspension.

Chapter 19  Amputation Surgeries for the Lower Limb
521
tibial tubercle, as well as the medial and lateral collateral liga­
ments just above the menisci. Next, the knee is slightly flexed
and the infrapatellar fold is cut. This provides access to the cru­
ciate ligaments, allowing the surgeon to free them from their
attachment to the tibia. The posterior joint capsule is carefully
cut, with attention to keeping neurovascular structures in the
popliteal fossa intact, while exposing the femoral attachment
of the gastrocnemius muscle. The popliteal artery and vein and
saphenous vein are clamped and ligated, and the medial and
common peroneal and saphenous nerves are transected under
traction and allowed to retract into the residual limb. The sur­
geon then cuts through the gastrocnemius at the distal edge of
the wound, and the lower leg is removed.
For a simple disarticulation the wound is irrigated with
saline and antibiotics and prepared for closure at this point.
When transcondylar modification is desired, an oscillating
saw is used to trim the edges of the condyles before irriga­
tion. The tourniquet is removed, and hemostasis is ensured.
In preparation for closure the patellar tendon is sutured to
the anterior and posterior ligaments, and the cut edge of the
gastrocnemius muscle is sutured to the anterior joint capsule
(myoplasty). The hamstring tendons are transected high and
allowed to retract. The lateral tendons of the biceps femoris
and the iliotibial band are transected low and reconstructed at
the time of wound closure to provide muscle stability. The lat­
eral and medial flaps are positioned with approximated edges,
and subcutaneous tissues are sutured closed. Finally, the outer
layer of skin is closed using staples or external sutures.
A nonadherent gauze is placed over the wound edges, fol­
lowed by a layer of gauze fluff and a figure-of-eight gauze
wrap. The surgeon may choose to apply an Ace wrap, an Unna
dressing, a prefabricated adjustable removable rigid dressing,
or a plaster or fiberglass cast as the final layer of bandage. The
dressing is typically changed at day 5 unless there are indica­
tions of infection. Mobility training begins on postoperative
day 1, with single-limb ambulation with crutches or walker
the next day. A bedside commode and wheelchair allow the
individual with new disarticulation who is capable to manage
much of the individual's own self-care. Some or all of the sta­
ples or external sutures are removed at 2 to 3 weeks, depend­
ing on the condition of the incision. Readiness for a training
prosthesis is determined by full healing of the surgical con­
struct, typically between 3 and 8 weeks after surgery.
TRANSFEMORAL AMPUTATION
Amputation through the femur is chosen when there has
been significant trauma to the proximal tibia and knee, when
there is a tumor in the proximal tibia or distal femoral con­
dyles that cannot be replaced by allograft or a total joint,
when there is infection or failure to heal following transtib­
ial amputation, following failed revascularization of the lower
leg, and at times for intractable infection following total knee
arthroplasty.210–213 For persons with PAD, the level of choice (if
there is adequate circulation for wound healing) is transtibial
because functional prosthetic ambulation is most likely when
the knee joint has been preserved; some individuals, however,
have serious enough circulatory impairment that amputation
at transfemoral levels is necessary.214 Morbidity and mortality
following transfemoral amputation is high among older per­
sons with concurrent diabetes and PAD.215,216
Considering not only vascular status, but also muscle
attachment and biomechanics of the residual limb in gait, is
important when deciding on the precise length of the resid­
ual femur. For those needing transfemoral surgeries, function
and prosthetic control improves as length of residual femur
increases. Preservation or reattachment of the adductor bre­
vis, adductor longus, and especially adductor magnus pro­
vides sufficient power for stabilization of the residual limb in
adduction in stance so that the abductors can work to keep
the pelvis level during prosthetic gait (Figure  19-22).217–219
FIGURE 19-21  A lateral view of the guideline for incision creating
equal lateral and medial flaps during knee disarticulation.
0%
50%
100%
A
B
C
FIGURE 19-22  Diagram of point of attachment and line of pull for
the (A) adductor brevis, (B) adductor longus, and (C) adductor mag­
nus, as they relate to femoral length. As the length of the residual
femur decreases, power and efficiency of adductor muscles groups
are more and more compromised.

522
Section III  Prostheses in Rehabilitation
Preservation of femoral length and of muscle mass via myo­
plasty or myodesis, rather than trisection through muscle
belly, results in a stronger residual limb that is more easily
fit and has better prosthetic control.219,220 It also reduces the
risk of developing hip abduction and flexion contracture
during rehabilitation and over the individual's lifetime. The
surgeon must work with the viable thigh tissue to create a
residual limb that is balanced in muscular power, provides a
long enough lever to allow hip extensors to control prosthetic
knee stability in stance, and has as smooth and sensate a skin
surface as possible.214,221
Traditional Transfemoral Surgery
In preparation for surgery the patient is placed in a three-
quarters supine position, lying on the side of the body oppo­
site the limb to be amputated. The surgeon may or may not
choose to use a tourniquet depending on the etiology of
amputation. The surgeon may opt to use equal anteroposte­
rior flaps, equal mediolateral flaps, or a long flap from any one
limb surface that will be approximated to the opposite limb
surface at closure (Figure  19-23).214,222 The skin is opened,
followed by subcutaneous tissue, according to the flap pat­
tern chosen. The lower leg may be disarticulated at this point
to provide a less cumbersome operative area for subsequent
revision. The fascia and muscle of the quadriceps and adduc­
tors are transected as far distally as possible, and the femur
is scored at the desired level of amputation. The periosteum
is elevated and reflected upward and will be used during
myoplasty later in the procedure. The femur is cut with an
oscillating saw, and the distal bone is retracted (pulled) ante­
riorly so that the surgeon can access posterior structures. The
hamstrings and tensor fascia lata are incised and transected
as ­distally as possible. Major vessels are clamped and then
sutured or ligated. The sciatic nerve is sutured or ligated, cut
while under traction, and allowed to retract into hamstring
muscle tissue. The sharp edges of the residual distal femur
may be shaped and smoothed with a rasp or file. The wound
is irrigated with sterile saline and antibiotics, the tourniquet
is released, and hemostasis is restored. A drain may be placed,
at the surgeon's discretion, as residual tissues are positioned
for wound closure.
Some surgeons perform a multiple-layer myoplasty to
close the surgical wound, suturing medial and lateral soft tis­
sue and muscle groups together as a deep first layer, anterior
and posterior soft tissue and muscle groups as a second layer,
and then the skin for an outer layer (Figure 19-24). Others
prefer myodesis, first pulling the adductor magnus under the
distal femur medially to laterally and suturing it to the lateral
surface of the femur, and then pulling the quadriceps under
the distal femur in an anterior-to-posterior direction over the
repositioned adductor, attaching it to the posterior surface of
the femur, before closing the skin with staples or removable
sutures. An alternative closure places multiple single sutures
from the deep posterior subcutaneous tissue, through ham­
strings, posterior and anterior periosteum, quadriceps, and
finally anterior subcutaneous tissue, and finishing by stapling
the skin surface closed.222 The goal is to create a tapered, cylin­
drical residual limb with few “dimples” or redundant tissues.
A nonadherent dressing is placed over the suture line, fol­
lowed by fluffed gauze and a figure-of-eight and spica gauze
bandage. A layer of microporous tape may be applied at
this joint to keep the wound clean and decrease the risk of
­contamination by urine or feces. The outer dressing may be
by Ace wrap or Unna bandage for a semirigid dressing. The
first dressing change occurs 3 to 5 days postoperatively unless
there are indications of infection or excessive bleeding. If a
drain has been placed, it is usually pulled at the first dressing
change (Figure 19-25).
Adductor
longus
Adductor
brevis
Adductor
magnus
A
B
FIGURE  19-23  Illustration of incision guidelines for (A) a long
medial flap and (B) equal anterior and posterior flaps for transfem­
oral amputation surgery. Note that both preserve as much of the
adductor magnus as possible for later myoplasty or myodesis when
the wound is closed.
FIGURE 19-24  Myodesis of the muscles of the thigh is used to sta­
bilize soft tissue after transfemoral amputation. The initial layer (A)
attached medial adductor muscles to the vastus lateralis and iliotib­
ial band. The second layer (B) connected anterior quadriceps to the
posterior hamstrings, covering the first layer. Finally, the two lay­
ers are sutured together to stabilize the muscular sling that has been
­created across the bottom of the residual limb.

Chapter 19  Amputation Surgeries for the Lower Limb
523
Mobility training and early preprosthetic positioning
exercises (to encourage positioning of the residual limb in
hip extension and adduction) are optimally initiated the day
after surgery, and single-limb gait training with an appro­
priate assistive device follows as soon as the individual can
tolerate increasing activity. The environment must be set up
to minimize the risk of falls; a prefabricated, thermoplas­
tic, adjustable, removable rigid dressing might be used to
protect the healing residual limb. Strategies for consistent
gentle soft tissue compression are initiated as soon as pos­
sible using an Ace wrap, elasticized stockinette, and eventu­
ally a commercially available “shrinker.” External staples or
sutures remain in place for 3 weeks or more, perhaps being
removed in successive stages to ensure a solid wound clo­
sure. Fitting for initial prosthesis is, as in all other levels of
amputation, determined by the condition of the suture line;
for some patients this may occur as early as 3 or 4 weeks
postoperatively, and for others several months after surgery.
Osseo-Integrated Transfemoral Amputation
An alternative to traditional transfemoral amputation for oth­
erwise healthy individuals with traumatic injury or osteosar­
coma has been used since 1990 by a group of surgeons and
prosthetists at Sahlgrenska University Hospital in Sweden
(Osseointegrated Prosthesis for Rehabilitation of Amputees
[OPRA], Inegrum AB, Goeborg, Sweden).223 This approach is
an application of principles of successful endodontic implants
to persons with trauma or tumor-related need for transfemoral
amputation. In the OPRA approach, a titanium fixture is
inserted into the shaft of the femur at time of amputation, and is
permitted to heal in place for 6 months. During this time, a tra­
ditional prosthetic socket is often prescribed. A second surgery
then screws a titanium rod (abutment) through the skin and into
the fixture (Figure 19-26). This provides a mechanism to attach
the prosthesis directly to the residual limb, without need for a
socket. Six weeks after the second surgery, once adequate soft
tissue healing has occurred, rehabilitation begins with limited,
protected weight bearing in standing and then while ambulat­
ing with the prosthesis. Over the next 6 months, the individual
gradually increases both the weight bearing and the intensity of
activity.224 The overall goal of the procedure is to provide a com­
fortable and effective limb–prosthesis interface, enhancing the
overall level of function with the prosthesis.225
There are two problems reported for osseointegrated
systems: bone failure at the stem–bone interface resulting
in pain, loosening of the implant, and possible fracture,226
and infection (incidence approximately 5% to 18%).227
The source of infection is typically normal flora of the
skin; if treated effectively, few of these infections require
removal of the implant. Both qualitative and quantitative
studies suggest that the osseointegrated prosthesis option
improves quality of life and level of function for the care­
fully selected group of individuals offered this option.228,229
This approach has expanded to the United Kingdom230,231
and the United States.232
HIP DISARTICULATION AND
HEMIPELVECTOMY
Amputation at the level of the hip or pelvis is an extreme
surgery that is undertaken to preserve life in the presence of
extreme infection or damage of proximal structures: recurrent
deep decubitus ulcers in individuals with paralysis, necrotizing
wounds with wet gangrene and risk of systemic sepsis, severe
crush or shrapnel injury damaging blood vessels in the groin
when revascularization is not possible, or invasive tumor of
the proximal femur or pelvis when limb-sparing strategies are
not possible.233–236 With these surgeries, significant body mass
is removed and there is the likelihood of significant blood loss;
careful monitoring of hydration and electrolytes is necessary
during surgery and the immediate postoperative period.237,238
These are complex surgeries best performed in facilities with
an experienced interdisciplinary team available for preopera­
tive, perioperative, and postoperative care.
In the operating room the patient is placed in a three-­quarters
supine position, with the limb to be amputated uppermost. The
limb is prepped and draped for surgery, and a racquet-shaped
guideline for incision is traced on the skin, with the goal of
creating a large posterior flap of skin, subcutaneous tissue,
and gluteal muscle mass for wound closure (Figure  19-27).
The incision begins at the medial edge of the anterior ­superior
iliac spine, continues along the inguinal ligament to just
below the ischial tuberosity and gluteal crease, and then arches
upward over the greater trochanter and anterior thigh back to
the ­anterior superior iliac spine. The surgeon must carefully
free and then stabilize neurovascular structures in the inguinal
region, as well as detach each of the many surface and deeper
muscles that cross the hip joint, starting with the anterior and
medial groups, then moving laterally and posteriorly.
The gluteal muscles are detached from the greater trochan­
ter but kept in place on the pelvis to be part of the posterior
flap. The head of the humerus is forcefully dislocated from the
acetabulum. The wound is irrigated with saline and ­antibiotics,
FIGURE 19-25  Postoperative appearance of a transfemoral resid­
ual limb before bandaging. An equal anteroposterior flaps approach
has been used, placing the surgical incision in the frontal plane on
the underside of the residual limb. (Courtesy Algis Maciunas, CPO,
FAAOP, Hanger Prosthetics and Orthotics, Wethersfield, Conn.)

524
Section III  Prostheses in Rehabilitation
and hemostasis is secured. Pairs of antagonistic muscles may
be sutured together in myoplasty or to periosteum of the pel­
vis in myodesis as wound closure begins. Drains are placed; the
posterior flap is positioned against anterior, medial, and lateral
edges of the wound; subcutaneous closure is secured by a series
of sutures; and skin is closed with staples.
The wound is dressed with a layer of nonadherent gauze;
then fluff; and then a spica wrap of gauze and elastic bandage,
directing soft tissue in a posterior-to-anterior medial direction
consistent with the line of the posterior flap. Dressings are
changed every 3 or so days, more frequently if there is sig­
nificant drainage. There is considerable risk of deep venous
thrombosis of the intact limb during the immediate postop­
erative period; low-dose heparin or Coumadin (warfarin) may
be used as prophylactics. Limited periods of sitting, mobility,
and transfer training, as well as ambulation on the remaining
limb using a walker or crutches, begins as soon as the patient
is medically stable and able to tolerate increasing ­levels of
Anterior superior
iliac spine
Pubic tubercle
Ischial tuberosity
FIGURE  19-27  An example of the location of incision for a hip
disarticulation, creating a posterior flap that will be used when the
wound is closed.
FIGURE 19-26  A, A schematic of the osseointegrated fixture embedded within the femur, and the abutment protruding through the skin of
the residual limb. B, A healed transfemoral residual limb with the abutment that will be attached directly to the prosthesis. C, The platform
of the prosthesis supports the tissue of the residual limb, once the abutment screw is attached. (From Hagberg K, Branemark R. One hundred
patients treated with osseointegrated transfemoral prostheses—rehabilitation perspective. J Rehabil Res Dev. 2009;46:331-344.)
Abutment
Screw
Abutment
A
Skin
Bone
Fixture
B
C

Chapter 19  Amputation Surgeries for the Lower Limb
525
­activity, optimally within 2 to 3 days after surgery. Special atten­
tion must be paid to the sitting posture, with minimal time
spent in a posteriorly tilted “sacral sitting” position, to ensure
skin integrity. Staples or external sutures remain in place for
2 to 3 weeks postoperatively. Patient and family education must
include efforts to carefully protect the surgical site during move­
ment and activities of daily living. An early referral to the pros­
thetist for fabrication of a custom thermoplastic removable rigid
dressing may occur in the week immediately following surgery.
Fitting for initial prosthesis, as in amputation at all other levels, is
determined by rate and adequacy of healing of the surgical site.
Hemipelvectomy (transpelvic amputation) is a more
aggressive and invasive surgery that leaves the individual
without a bony case to support abdominal contents on one
side of the body. Postoperatively, there is significant risk of
developing ileus; many individuals with hemipelvectomy are
ill enough to require nasogastric tube and limited feeding in
the immediate postoperative period. Mobilization and trans­
fer training may need to be deferred until the individual is
well enough and nutritionally supported enough to tolerate
increased levels of activity. Typically, prosthetic support of the
soft tissue and abdominal contents of the residuum is neces­
sary for functional sitting.239
SUMMARY
This chapter has presented the strategies used to examine
a vascularly compromised or traumatically injured lower
extremity and discussed the surgeon's evaluative process when
making decisions about limb revascularization, thrombolytic
intervention, limb salvage, disarticulation, or amputation.
Several factors must be carefully considered: the likelihood of
successful healing of the surgical construct; the preservation
of the ankle and knee (if possible) to minimize the impact
on energy cost of gait and postural control; and the creation
of a residual limb with adequate skin surface (pressure toler­
ance), length (lever arm), and dimension for prosthetic fit­
ting and function. The most common approaches for surgery
at each level of amputation were discussed so that rehabilita­
tion professionals could appreciate the manipulation of tis­
sues and postoperative wound healing process. The authors
explored the commonalities and differences in amputations
performed because of dysvascular/neuropathic disease, bone
infection, lower-extremity trauma, neoplasm, or revision in
children with congenital limb deficiency. The authors hope
that readers developed an appreciation of the complexity and
challenges presented to the surgeon and the rehabilitation
team when an individual undergoes amputation.
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ulcers in patients with spinal cord injuries. Spinal Cord.
2008;46(2):135–139.
235. Daigeler A, Lehnhardt M, Khadra A, et al. Proximal major limb
amputations—a retrospective analysis of 45 oncological cases.
World J Surg Oncol. 2009;7:15.
236. Schnall BL, Baum BS, Andrews AM. Gait characteristics
of a soldier with a traumatic hip disarticulation. Phys Ther.
2008;88(12):1568–1577.
237. in SJ, Oliver CW, Kaufman MH. Hip disarticulation-the evolu­
tion of a surgical technique. Injury. 2004;35(3):299–308.
238. Chansky HA. Hip disarticulation and transpelvic ampu­
tation: surgical management. In: Smith DG, Michaels JW,
Bowker JH, eds. Atlas of Amputation and Limb Deficiencies.
Surgical Prosthetic and Rehabilitation Principles. 3rd ed.
Rosemont, IL: American Academy of Orthopaedic Surgeons;
2004:557–564.
239. Carroll KM. Hip disarticulation and transpelvic amputa­
tion: prosthetic management. In: Smith DG, Michaels JW,
Bowker JH, eds. Atlas of Amputation and Limb Deficiencies.
Surgical Prosthetic and Rehabilitation Principles. 3rd ed.
Rosemont, IL: American Academy of Orthopaedic Surgeons;
2004:565–573.

532
20
Postoperative and Preprosthetic Care
Michelle M. Lusardi
PATIENT-CLIENT MANAGEMENT
AFTER AMPUTATION
Individuals with New Amputation
In the early days following surgery, the person with a new
amputation is likely to experience acute surgical pain and is
likely to be grieving the loss of his or her limb. The imme­
diacy of pain combined with a sense of loss may make it dif­
ficult for those with recent amputation to recognize their
potential for a positive rehabilitation outcome.1 Older per­
sons with dysvascular or neuropathic limb loss may have had
time to physically and psychologically prepare for an elective
amputation after a prolonged period of managing a poorly
vascularized foot or nonhealing neuropathic ulcer, and there­
fore may be somewhat less distressed about the loss of their
limb than younger persons who have suddenly lost a limb in
a traumatic accident or other medical emergency. Whatever
the ­circumstances leading to amputation, however, the loss
of one's limb requires significant psychological adjust­
ment.2 Early education and discussion about the process of
rehabilitation and the person's ultimate goals are extremely
important.3
Patient-Centered Care and Multidisciplinary Teams
In response to the numbers of military personnel with trau­
matic amputation and to older veterans with dysvascular
amputation, the Departments of Defence and of Veterans
Affairs have adopted interdisciplinary, patient-centered
care as the ideal model for rehabilitation of persons with
­amputation.4,5 The physical therapist and prosthetist, as mem­
bers of the rehabilitation team, will interact with surgeons,
patients, and family members as decisions about surgical lev­
els, plans for postoperative care, potential for prosthetic use,
and prosthetic rehabilitation plans are made. For persons
facing elective amputation because of dysvascular disease,
a period of PT intervention prior to surgery can positively
impact on postoperative outcomes.6
In the days immediately after amputation, this initial stage
of acute care and early rehabilitation sets the stage for even­
tual return to functional mobility, ability to return to valued
activities, and participation in key family and social roles.4
Although the immediate goals of each member of the inter­
disciplinary team vary, all ultimately lead toward the person
with a newly amputated limb's independence and return to
his or her preferred lifestyle. To accomplish this, the team
must use an holistic and comprehensive approach to address
the person's comorbid burden of illness and psychologi­
cal and developmental needs, as well as his or her long-term
functional, vocational, and leisure goals. Surgical and medical
members of the team are most concerned about the healing
suture line and overall health status, especially for individuals
with vascular insufficiency and for those at risk of infection
after traumatic amputation.7 Nursing professionals provide
general medical and wound care as the suture line heals, and
administer medications for pain management.8 Registered
dieticians assess the patient's nutritional needs related to
wound healing and exercise demands.9 Physical and occu­
pational therapists focus on enhancing the patient's early
single limb mobility, self-care, assessment of the potential
20
LEARNING OBJECTIVES
On completion of this chapter, the reader will be able to do
the following:
1. Plan a comprehensive examination for an individual with
recent lower extremity amputation, selecting appropriate
tests and measures and documentation strategies.
2. Use information gathered in the examination, evidence
from the clinical research literature, and knowledge of
postoperative care to evaluate individuals with recent
lower extremity amputation.
3. Formulate an appropriate physical therapy (PT) movement
dysfunction diagnosis and prognosis for rehabilitation for
individuals with recent lower extremity amputation.
4. Develop appropriate short-term goals and long-term goals
and estimate duration, frequency, and intensity of care in
the postoperative, preprosthetic care of an individual with
recent lower extremity amputation.
5. Develop an appropriate PT plan of care for single limb
mobility, residual limb care and wound healing, and pre­
prosthetic rehabilitation.
6. Describe strategies to monitor progress and to adapt and
advance the plan of care during the preprosthetic period of
rehabilitation.
7. Describe strategies to evaluate outcomes of postoperative,
preprosthetic rehabilitation.

Chapter 20  Postoperative and Preprosthetic Care
533
for ­prosthetic use, control of edema and pain management,
optimal shaping of the residual limb for prosthetic wear, and
­prevention of secondary complications.10
The prosthetist may fabricate an immediate or early post­
operative prosthesis or semirigid dressing and begins to con­
sider which prosthetic components and suspension systems
will ultimately be most appropriate, given the individual's
characteristics and functional needs.11 The person with new
amputation and his or her family are often most concerned
about pain management and what life will be like without the
lost limb.12 A psychologist, social worker, vocational coun­
selor, or school counselor is involved as needed to help with
psychological adjustment and to organize long-term rehabili­
tation care or community resources in preparation for dis­
charge.13 A clergyman can also be a valuable resource for the
person with new amputation, the family, and the team.
Although the multidisciplinary team can vary in size,
depending on patient needs and practice settings, the mem­
bers at the center are the individual with new amputation and
his or her caregivers.14 Communication among all team mem­
bers, especially the opportunity for the person and family
members to ask questions and voice concerns, is more impor­
tant in this early postoperative and preprosthetic period than
it is during the process of prosthetic prescription and training
later in the rehabilitation process. This early period sets the
stage for the individual's expectations, and ultimately success,
as a person with an amputation.14
The unique training, clinical expertise, and individual
roles of each team member contribute, in a collaborative pro­
cess, to the development of a plan for rehabilitation that best
meets the needs and optimizes the potential of the individual
who has lost a limb.6 The team must come to agreement on
the timing and prioritization of specific rehabilitative inter­
ventions to meet the goals defined for each patient. Effective
communication and strong relationships among the sur­
geons, orthopedists, or trauma teams who perform the
majority of amputations and the rehabilitation team substan­
tially improve the quality of patient care and assist the reha­
bilitation process.
This chapter focuses on the roles of rehabilitation profes­
sionals who work with persons with new amputation in the
days and weeks immediately after surgery. It explores how
surgical pain and phantom sensation are managed, strategies
for controlling postoperative edema, and methods to assess
a patient's readiness for prosthetic fitting. Interventions that
help a person with new amputation gain competence with
single limb mobility tasks and exercises that provide the foun­
dation for successful prosthetic use are identified. The strate­
gies for patient management are organized around the model
outlined in the American Physical Therapy Association's
Guide to Physical Therapist Practice (Figure 20-1).15
EXAMINATION
Ideally, for those undergoing a “planned” or “elective” ampu­
tation, the rehabilitation team will meet with the individual
and caregivers before surgery to begin collecting information
that will be used to guide intervention and provide informa­
tion about the rehabilitation process. In some instances, input
from rehabilitation professionals may be sought by trauma
Outcomes
Determine impact of intervention on:
• Active pathology
• System-level impairments
• Functional limitations and capacity
• Degree of disability or handicap
• Prevention of secondary problems
• Patient/client satisfaction with care
DOCUMENT
COMMUNICATE
REFER AS
APPROPRIATE
Intervention
Provision of skilled physical therapy care:
• Implementation of plan of care
• Monitor patient progress and re-evaluate
• Adapt and advance plan of care
Prognosis
Defining anticipated outcomes:
• Develop short-term and long-term goals
• Determine specific plan of care
• Estimate duration, frequency, intensity
of care
Examination
Gathering evidence:
• Current complaint
• Medical, psychological and social history
• Systems review and screening
• Use of appropriate tests and measures
Evaluation
Integrating the evidence:
• Clinical judgment and expertise
• Research literature
• Patient’s goals and expectations
Diagnosis
Defining movement dysfunction:
• Classify primary problems
• Identify potential confounding factors
• Identify possible secondary problems
FIGURE  20-1  The components of a systematic and effective patient-client management ­process.
(Modified from American Physical Therapy Association. Who are Physical Therapists? Guide
to Physical Therapist Practice. Alexandria, VA: American Physical Therapy Association. http://
guidetoptpractice.apta.org.)

534
Section III  Prostheses in Rehabilitation
surgeons to assist patients and families in making informed
decisions when faced with amputation after severe injury of
the limb. Preoperative interaction may not always be possible,
especially when amputation occurs subsequent to failed revas­
cularization, acute and severe limb ischemia, severe infection,
or civilian or combat-related traumatic injury. If preoperative
assessment is not possible, referral to rehabilitation should
be made as soon after surgery as possible; delaying referrals
often leads to contracture formation, further cardiovascular
and musculoskeletal deconditioning, delayed prosthetic fit­
ting and training, a greater risk of dependency, and a higher
risk of reamputation, institutionalization, and mortaltity.16,17
Box  20-1 summarizes the components of a comprehensive
assessment for persons with lower extremity amputation.
HISTORY (DATA COLLECTED FROM CHART REVIEW AND INTERVIEW)
Demographics
Age, gender, primary language, race/ethnicity
Social history
Family and caregiver resources, other social support systems
Occupational history
Employment or retirement status, typical work and leisure activities
Developmental status
Physical/motor, perceptual, cognitive, and emotional dimensions
Living environment
Characteristics and accessibility of “home” environment, projected discharge destination
Current condition
Reason for referral, current concerns/needs, previous medical/surgical interventions for
­current condition
Past medical history
Prior hospitalizations and surgeries; smoking, alcohol, or drug use (past and present)
Family history
Health risk factors for vascular and cardiac disease
Medications
Prescription medication for current and other medical conditions
Over-the-counter medications typically used
Functional status
Current and prior abilities and functional limitations (ADLs/IADLs)
SYSTEMS REVIEW (CONCURRENT/COMORBID DISEASE AND IMPAIRMENT RELATED
TO PROGNOSIS FOR AND PARTICIPATION IN REHABILITATION)
Cardiopulmonary and cardiovascular systems
Endocrine and metabolic systems
Musculoskeletal system
Neuromuscular system
Gastrointestinal and genitourinary systems
TESTS AND MEASURES (AREAS FOR SPECIFIC ASSESSMENT)
Pain
Presence of phantom limb sensation or pain
Postoperative pain and pain management strategies
Muscle soreness related to altered movement patterns
Joint pain related to motion or comorbid arthritis, etc.
Anthropomorphic
characteristics

Residual limb length (bone length, soft-tissue length)
Residual limb girth, redundant tissue (“dog ears,” adductor roll)
Residual limb shape (bulbous, cylindrical, conical)
Assessment of type and severity of edema
Effectiveness of edema control strategy being used
Overall height, weight, body composition
Skin/integument
Assessment of surgical wound healing
Assessment/management of adhesions and existing scar tissue
Other skin problems (other incisions, grafts, psoriasis, cysts, etc.)
Integrity of remaining foot/limb, especially if neuropathic or dysvascular etiology
of amputation
Circulation
Palpation/auscultation of lower extremity pulses, residual and intact limbs
Skin temperature and presence of trophic changes, residual and intact limbs
Skin color and response to elevation or dependent position, residual and intact limbs
Claudication time and distance, impact on function
Range of motion/muscle
length
Range of motion, soft-tissue length, and joint contracture
BOX 20-1  Comprehensive Assessment for Patients with Lower extremity Amputation

Chapter 20  Postoperative and Preprosthetic Care
535
Joint integrity
Ligamentous integrity or joint instability
Structural alignment or joint deformity
Integrity or inflammation of synovium, bursae, cartilage
Muscle performance
Current muscle strength of upper extremity, trunk, lower extremity
Muscular power for functional activity
Muscular endurance for functional activity
Potential for improvement
Motor function
Motor control, including dexterity, coordination, agility, tone
Motor learning, including previous use of ambulatory aids, prostheses
Upper extremity function
Power and strength of upper extremity and of trunk
Ability to use upper extremity in functional activities
Aerobic capacity
Blood pressure, heart rate, respiratory rate (at rest, as well as during and following activity)
Perceived exertion, dyspnea, angina, during functional activity
Overall level of physical fitness and functional capacity
Attention/cognition/
emotion

Level of consciousness, sleep patterns
Ability to learn and preferred learning style
Cognitive dysfunction screening (delirium, depression, dementia)
Motivation, attention/distractibility, learning styles
Sensory integrity
Protective sensation of residual and remaining limb
Superficial sensation: light touch, sharp/dull, pressure, temperature
Proprioception: kinesthesia, position sense
Mobility
Changing position in bed (rolling, scooting, coming to sitting)
Postural control
Static, anticipatory, reactionary balance, in sitting, standing, during functional activities
Transfers
Ability to transfer to/from bed, toilet, wheelchair, mat, tub/shower
Assistive/adaptive
equipment
Assistive devices/adaptive equipment currently being used
Ambulation and
locomotion

Ability to use ambulatory aid safely for single limb gait
Ability to use wheelchair safely
Adaptations/equipment necessary for patient's living environment
Gait and balance
Assessment of postural control in quiet standing, reaching, ability to stop/start,
change ­direction, and alter velocity while walking
Reaction to unexpected perturbation, at rest and during activity
Observational gait assessment, identification of gait deviations
Kinematic gait assessment (e.g., speed, stride length, cadence)
Energy cost or efficiency of locomotion/gait, perceived exertion and dyspnea
Ability/safety to manage uneven terrain, stairs, ramps, etc.
Posture
Resting posture in sitting, standing, other positions
Alteration in posture due to loss of limb segment
Self-care
Ability to perform basic ADLs
Ability to perform IADLs
Availability of assistance and preparation of caregivers
Community/work
reintegration

Analysis of roles/activities/tasks
Functional capacity analysis, determination of essential functions
Analysis of environment, safety assessment
Assessment of need for adaptation
Prosthetic requirements
Potential for functional prosthetic use
Readiness for prosthetic fitting/prescription

Appropriate prosthetic design, components, suspension
BOX 20-1  Comprehensive Assessment for Patients with Lower extremity Amputation—cont'd
ADLs, Activities of daily living; IADLs, instrumental activities of daily living.
Modified from Phys Ther 2001;77(11):1354-1367.

536
Section III  Prostheses in Rehabilitation
Whenever the first contact with the individual and family
occurs, the rehabilitation team begins by gathering baseline
information that will guide planning for and implementing
of the rehabilitation process. This initial information is gath­
ered in three ways: developing a complete patient–client his­
tory, performing a review of physiological systems to identify
important comorbidities that will affect the rehabilitation
process, and using appropriate tests and measures to identify
impairments and functional limitations to be addressed in
the rehabilitation plan of care.18 The volume and complexity
of information needed to guide planning for prosthetic reha­
bilitation means that information gathering is a somewhat
continuous process and must be integrated with early mobil­
ity training in preparation for the individual's discharge from
the acute care setting. Examination in the acute care setting
likely focuses on four priorities: initial healing of the surgi­
cal site, pain management and volume control of the residual
limb, bed mobility and transfers, and readiness for single limb
ambulation. Examination later in the preprosthetic period
(in an outpatient, home care, or subacute setting) would add
more detail to determine potential for prosthetic prescription.
Patient-Client History and Interview
Rehabilitation professionals use several strategies to gather
information about an individual's medical history. In the
acute care setting, the process usually begins with a review
of the individual's current medical record or chart, as well
as previous medical records (if available). The chart review
process provides a broad overview of the individual's health,
comorbidities, current medications, previous and current
functional status, as well as details about the surgical proce­
dure. Data that other members of the health care team have
generated in their examination and evaluative processes are
quite relevant to PT care, not only to avoid redundancy in
examination but also in planning what additional informa­
tion will be necessary to collect during subsequent interviews
and discussion with the individual and family caregivers.
The interview process provides key information about the
individual's priorities and concerns so that they can be appro­
priately integrated into the plan of care. The physical therapist
may also choose to gather supplementary information from
the clinical research literature at this point to assist in the sub­
sequent development of prognosis and plan or care, especially
if the individual's situation is unusual or complex.19
Demographic and Sociocultural Information
The information gathered when reviewing history often
begins with basic demographics such as age, gender, race/­
ethnicity, primary language, and level of education. These
data help us to appropriately target communication during
our interaction with an individual with recent amputation. It
is also important to build an understanding of the individu­
al's sociocultural history including beliefs, expectations and
goals, preferred behaviors, and family and caregiver resources,
as well as access to and quality of informal and formal support
systems.20–22 Each of these is a potentially important influence
on the individual's engagement in the rehabilitation process.
Rehabilitation professionals also gather information about the
individual's employment status and task demands, roles and
responsibilities within the family system, and leisure interests
and hobbies, as well as previous and preferred involvement
in the community (access, transportation, and key activities).
Additionally, information about smoking, alcohol intake, and
other previous substance use/abuse, as well as the individu­
al's coping style and preferred coping strategies help the team
to better understand how the individual may behave in the
postoperative period. This information is important in devel­
oping a prognosis and plan of care; it helps rehabilitation pro­
fessionals to better define the long-term goals and anticipated
outcomes of rehabilitation.
Developmental Status
Another piece of information that informs an appropriate
rehabilitation plan of care is the physical, cognitive, percep­
tual, and emotional developmental status of the individual
and his or her caregivers, as well as an understanding of the
family system as an organization.23–25 Although the relevance
of developmental status is most obvious when the individual
being examined is a child, the perspective afforded by under­
standing of life span development is valuable for individuals
with recent amputation of any age. Examples of factors that
evolve over the life span that affect an individual's participa­
tion in rehabilitation include postural control, motor abili­
ties, perceptual abilities, willingness to take risks, problem
solving, coping styles and strategies, and limb dominance.
Observation and interchange during the interview process
help the therapist to determine if further clinical examination
of developmental status will be necessary.
Living Environment
Rehabilitation professionals gather information about the
characteristics of an individual's physical living environ­
ment.26 They ask about getting into and out of the house
(e.g., how far is it from the car to the house? What kind of sur­
faces will be encountered moving from the car to the house?
Are there steps and railings at the entry? What are the dis­
tances between the major living areas that the person will
have to navigate? How accessible and functional are each of
the major living areas in the home for those using ambulatory
aids or a wheelchair for mobility? Is it possible to adapt the
home if necessary? What adaptive equipment is already avail­
able? What type of assistance is likely to be routinely available?
What type of equipment is likely to be acceptable for the indi­
vidual and family?).
Asking about the individual's ability to drive, access pub­
lic transportation, or plans for alternatives for transport once
discharged from the acute care setting is important. This may
determine what services will be necessary and where they will be
provided. Will the individual be returning to his or her home
environment on discharge from acute care? If so, will he or she
require home care or is transportation available for ­follow-up
appointments with physicians and for outpatient rehabili­
tation? Alternatively, will the individual have an interim
stay in another health care facility for further ­rehabilitation?

Chapter 20  Postoperative and Preprosthetic Care
537
This information will help set rehabilitation priorities and
begin the process of discharge planning.
Health, Emotional, and Cognitive Status
During the interview the rehabilitation professional's impres­
sion of the individual's general health status that initially
developed during chart review broadens. The rehabilitation
professional asks questions to discern how the person per­
ceives his or her health and his or her ability to function in
self-care, family, or social roles. They assess the individual's
understanding of the current situation and prognosis, as well
as expectations about the rehabilitation process. They may
explore the person's coping style and response to stress, as
well as preferred coping skills and strategies.27,28 This conver­
sation also provides an indication about the individual's cur­
rent emotional status, ability to learn, cognitive ability, and
memory functions.
Because rehabilitation involves physical effort, it is impor­
tant to understand the person with recent amputation's usual
level of activity and fitness, as well as his or her readiness
to be involved in exercise. Is physical activity a regular part
of the preamputation lifestyle? Has there been a period of
prolonged inactivity prior to surgery?29 Will any additional
health habits, such as smoking and use of alcohol or other
substances, affect the individual's ability to do physical work
and ability to learn or adapt?30
Medical, Surgical, and Family History
Potentially important medical conditions that may influence
the postoperative/preprosthetic rehabilitation include diabe­
tes, cardiovascular disease, cerebrovascular disease, obesity,
neuropathy, renal disease, congestive heart failure, uncon­
trolled hypertension, and preexisting neuromuscular or
musculoskeletal pathologies or impairments, such as stroke
or osteoporosis.31–33 Each of these has a potential impact on
wound healing, functional mobility, and exercise tolerance
during rehabilitation. Healing and risk of infection are also
concerns for those with compromised immune system func­
tion, whether from diseases such as human immunodefi­
ciency virus (HIV)/acquired immunodeficiency syndrome
(AIDS), those on transplantation medications, those
involved in chemotherapy or recent stem cell transplanta­
tion, or those using medical steroids.34 Wound healing, skin
condition, and endurance may be issues for persons who are
currently undergoing chemotherapy or radiation treatments
for cancer.35,36
Review of the individual's past surgical history provides
additional information that helps rehabilitation professionals
anticipate what the individual's response to physical activity
might be like. Has the individual had a cardiac pacemaker
or defibrillator implanted? Has there been previous amputa­
tion of toes or part of the foot of either the newly amputated
or “intact” limb? Are there recent surgical scars to be aware
of (e.g., following revascularization before amputation)? Has
there been total joint replacement or lower extremity frac­
ture that might affect rehabilitation activities and prosthetic
­component selection?
The “laundry list” of comorbidities and previous surger­
ies identified in chart review does not necessarily mean that
the individual is in poor health.37 Many individuals man­
age chronic illnesses and conditions quite effectively, and
although they may have less functional reserve than those
without pathology, they have the potential for positive reha­
bilitation outcomes.38
Physical therapists must also be aware of the results of
tests and diagnostic procedures that other team members
have undertaken as part of their examination and evaluation.
These might include preoperative cardiac or peripheral vas­
cular studies, electrocardiogram (ECG), stress tests, pulmo­
nary function tests, radiographs, CT, MRI, urinalysis, and
laboratory tests for various components of blood (e.g., hemo­
globin, cell counts, cultures). Comparison of the individual's
test results to established norms provides an index of overall
health status and tolerance of levels of activity. Monitoring
laboratory test values (e.g., white blood cell [WBC], hema­
tocrit [HCT], hemoglobin [Hb], platelet, international nor­
malized ratio [INR], partial prothrombin time [PPT],
glycosylated hemoglobin [HbA1c], and blood glucose levels)
and oxygen saturation levels provide ongoing information
about general health status and exercise/activity tolerance,
allowing the therapist to adapt intervention to the individual's
potentially changing condition.39,40
Because many of the medications used to manage post­
operative pain affect thinking and learning, it is important
to understand what pain management strategies are in place
and when medication is typically administered.41,42 Given the
likelihood of cardiovascular comorbidity in older adults with
vascular disease and diabetes, it is also important to under­
stand what cardiac medications are being administered and
how these medications affect response to physical activity
and position change.43–45 It is not unusual for persons who
have been immobile or on bed rest to be at risk of postural
(orthostatic) hypotension, especially if they are taking med­
ications to manage hypertension.46 Additionally, given the
stress of the surgery and hospital environment, especially
if the amputation was performed under general anesthesia,
there is the possibility of a temporary postoperative delir­
ium or difficulty with learning and memory.47 If confusion is
observed it is important to clarify typical preoperative cogni­
tive status by speaking with family and caregivers.
Current Condition
Review of the operating room report in the medical record
provides information about surgical procedure, drain place­
ment, method of closure, and planned postoperative wound
and limb-volume strategies being used (Chapter 19 provides
an overview of the most common surgical procedures at the
transtibial and transfemoral levels). This information, when
combined with knowledge of pain management strategies
and demographic information, guides early postoperative/
preprosthetic care. Physical therapists use this information to
identify potential issues with healing, determine educational
needs for the person with new amputation, develop strategies
for early positioning of the residual limb, identify potential

538
Section III  Prostheses in Rehabilitation
issues affecting prosthetic fit, and prepare the residual limb
for wearing a prosthesis. Determining how comorbidities and
injuries are being actively managed is also important, as these
affect readiness for early mobility, learning, and memory.
Impressions of the individual's psychological state, fears, and
expectations round out the baseline with which the person
will begin early rehabilitation.
Systems Review
In the acute care setting, there has likely been a fairly com­
prehensive review of physiological systems as a component of
preoperative workup (or emergency care in the case of trau­
matic injury). Rehabilitation professionals find the results of
such review in the physician notes and intake forms in the
medical record. The therapist may choose to screen or evalu­
ate in more detail if the information in the record is insuffi­
cient in depth or detail as it relates to functional status and
response to increasing activity and exercise. Review of systems
must include anatomical and physiological status of the car­
diovascular, cardiopulmonary, integumentary, musculoskel­
etal, and neuromuscular systems, as well as communication,
affect, cognition, language, and learning style.48
Ongoing screening as rehabilitation progresses will help to
identify the onset of secondary problems and postoperative
complications that require medical intervention or referral to
other members of the team. Deterioration in cognitive status
or onset of new confusion over a relatively short period of
time is especially important to watch for, as it is often the first
indication of dehydration, adverse drug reaction, or infection
(e.g., pneumonia, urinary tract infection, infection of surgical
construct) in older adults.49
Test and Measures
In the postoperative, preprosthetic period, physical thera­
pists employ a variety of objective tests and measures to
determine the severity of impairment and functional limi­
tation and to establish a baseline that will be used to deter­
mine PT movement-related diagnosis, determine prognosis,
and assess outcomes of the rehabilitation process.50 Table 20-1
lists examples of tests and measures appropriate for the post­
operative, preprosthetic period. Although most strategies are
similar to those used in general PT practice, some may need
to be adapted to accommodate the condition or length of the
residual limb (e.g., the point of application of resistive force
TABLE 20-1  Examples of Tests and Measures Important in the Postoperative-Preprosthetic Period
Category
Examples of Test or Measurement Strategy
Pain
Description of nature or type of pain
Visual analog scale for intensity of pain
Body chart for location of painful areas
Description of factors to increase/decrease discomfort
Anthropometric characteristics
Residual limb length
Residual limb circumference
Description of edema type and location
Integumentary integrity
Condition of the incision
Nature and extent of drainage
Condition of “intact” limb
Skin color, turgor, temperature
Circulation
Palpation of peripheral pulse
Skin temperature
Arousal, attention, cognition
Mini-Mental State Examination, Mini-Cog
Delirium scales
Depression scales (e.g. Geriatric Depression Scale, Centers for Epidemiologic Studies Depression scale)
Sensory integrity
Protective sensation (Semmes-Weinstein filament)
Proprioception and kinesthesia
Visual acuity, figure-ground, light/dark accommodation
Vestibuloocular function during position change
Hearing impairment (acuity, sensitivity to background noise)
Aerobic capacity, endurance
Heart rate at rest, % maximal attainable in activity
Arm ergometry, single limb bicycle ergometry, combined upper extremity/lower extremity ergometry
Respiratory rate at rest, during activity
Ratings of perceived exertion or dyspnea
Mobility

Observation of bed mobility (e.g., rolling)
Observation of transitions (e.g., supine–sit)
Observation of description of level of assistance, cueing required transfers (various surfaces, heights)

Chapter 20  Postoperative and Preprosthetic Care
539
Category
Examples of Test or Measurement Strategy
Balance
Static postural control (various functional positions)
Anticipatory postural control in functional activity
Reaction to perturbation
Specific balance tests (e.g., Berg, Functional Reach)
Gait and locomotion
Use of assistive devices
Level of independence, cuing or assistance required
Time and distance parameters (velocity, cadence, stride)
Pattern and symmetry
Perceived exertion and dyspnea
Joint integrity and mobility
Manual examination of ligamentous integrity
Documentation of bony deformity
Neuromotor function
Observation of quality of motor control in activity
Observation of efficiency of motor planning
Determination of stage of motor learning with new or adapted tasks
Muscle tone
Reflex integrity
Muscle performance
Strength: manual muscle test, handheld dynamometer
Power: isokinetic dynamometer, manual resistance through range at various speeds of contraction
Endurance: 10 repetitions maximum, or maximum number contractions, time to fatigue
Range of motion/muscle length
Goniometry
Functional tests (e.g., Thomas test, straight-leg raise)
Self-care and home management
Observation of BADLs and IADLs
BADL and IADL rating scales
Abbreviations: BADLs, Basic activities of daily living; IADLs, instrumental activities of daily living.
TABLE 20-1  Examples of Tests and Measures Important in the Postoperative-Preprosthetic Period—cont'd
during manual muscle testing of knee extension strength after
transtibial amputation). Whenever measurement technique
is altered, however, the reliability and validity of the data col­
lected may be questionable and the data generated less pre­
cise. Therapists often begin with examination at the level of
impairment and then move into functional assessment.
Assessing Acute Postoperative Pain
The individual with new amputation is likely to be coping with
significant acute postoperative pain and may be distressed by
the sense that the limb is still in place (phantom sensation) after
amputation. Pain is a subjective sensation; each person defines
his or her own level of tolerance. Physical therapists have a num­
ber of strategies available to document the nature of pain, loca­
tion of pain, and the intensity of discomfort that the individual
is experiencing. These include descriptors generated by the indi­
vidual with recent amputation or circled on a pain checklist, body
maps, visual analog scales, provocation tests, or specific pain
indices or questionnaires developed for postsurgical patients
(Figure  20-2).51,52 It is also important to assess how severely
that pain interferes with functions, what activities or conditions
increase the pain, and what positions or strategies have been
helpful in managing the postoperative pain. Documentation of
pain management strategies is also important: narcotic and opi­
oid medications potentially impact on attention, ability to learn,
and response time during movement and balance activities.53,54
Phantom Sensation and Phantom Pain
Commonly, persons with recent amputation experience a
sense that the amputated limb remains in place in the days
and weeks after surgery.55 Research reports indicate that from
54% to 99% of persons with new amputation have noticeable
phantom limb sensation.56–59 Phantom sensations are typically
described as a sense of numbness, tingling, tickling, or pres­
sure in the missing limb, and some complain of itchy toes or
mild muscle cramps in the foot or calf.56 In contrast, phantom
pain is described as shooting pain, severe cramping, or a dis­
tressing burning sensation that may be localized in the ampu­
tated foot or present throughout the missing limb. A smaller
percentage (46% to 63%) to of those with new amputation
experience phantom pain.56–59 Fortunately, fewer than 15% of
those experiencing phantom pain rate it as severe or constant;
most experience transient mild to moderate discomfort that
does not interfere with usual activity. Phantom pain is more
likely in those with longstanding and severe preoperative dys­
vascular pain, and for those requiring amputation after severe
traumatic injury.56,59
In most cases, if the individual reports significant phan­
tom sensation or pain, careful inspection of the residual limb
helps to rule out other potential sources of pain, such as a
neuroma or an inflamed or infected surgical wound. Phantom
limb sensation and pain tend to decrease over time whether
the amputation was the result of a dysvascular/­neuropathic

540
Section III  Prostheses in Rehabilitation
No pain
at all
Worst
possible
pain
100 mm
Please mark, on the drawings below, the areas
where you feel pain.
Put “E” if the pain is external
Put “I” if the pain is internal
Put “EI” if the pain is both internal and external
Some of the words below describe your PRESENT pain. Circle ONLY
those words that best describe your pain right now. Leave out any
category that is not suitable. Use only a single word in the appropriate
category—the one that applies the best.
1
Flickering
Quivering
Pulsing
Throbbing
Beating
Pounding
2
Jumping
Flashing
Shooting
3
Pricking
Boring
Drilling
Stabbing
Lancinating
1
Continuous
Steady
Constant
2
Rhythmic
Periodic
Intermittent
3
Brief
Momentary
Transient
4
Sharp
Cutting
Lacerating
5
Pinching
Pressing
Gnawing
Cramping
Crushing
6
Tugging
Pulling
Wrenching
7
Hot
Burning
Scalding
Searing
8
Tingling
Itchy
Smarting
9
Dull
Sore
Hurting
Aching
Heavy
10
Tender
Taut
Rasping
11
Tiring
Exhausting
12
Sickening
Suffocating
13
Fearful
Frightful
Terrifying
14
Punishing
Grueling
Cruel
Vicious
Killing
15
Wretched
Blinding
16
Annoying
Troublesome
Miserable
Intense
Unbearable
17
Spreading
Radiating
Penetrating
Piercing
18
Tight
Numb
Drawing
Squeezing
Tearing
19
Cool
Cold
Freezing
20
Nagging
Nauseating
Agonizing
Dreadful
Torturing
Part 1: Where is Your Pain?
1. Which word or words would you use to describe
the pattern of your pain?
2. What kind of things relieve your pain?
3. What kind of things increase your pain?
Part 3: How Does Your Pain
Change With Time?
McGill Pain Questionnaire
Part 4: How Strong is Your Pain?
Part 2: What Does Your Pain Feel Like?
1
Mild
A
B
2
Discomforting
3
Distressing
4
Horrible
5
Excruciating
People agree that the following five words represent pain of increasing intensity.
They are:
To answer each question below, write the number of the most appropriate word in the space beside the question.
1.
2.
3.
4.
5.
6.
Which word describes your pain right now?
Which word describes your pain at its worst?
Which word describes it when it is least?
Which word describes the worst toothache you ever had?
Which word describes the worst headache you ever had?
Which word describes the worst stomach-ache you ever had?
___________________
___________________
___________________
___________________
___________________
___________________
FIGURE  20-2  Examples of tools used to document pain and discomfort. A, McGill Pain
Questionnaire. Descriptor groups: sensory (1 to 10), affective (11 to 15), evaluative (16), and mis­
cellaneous (17 to 20). (Modified from Melzack R. The McGill pain questionnaire; major properties
and scoring methods. Pain. 1975;1(3):280-281.) B, The visual analog scale. (From Bijur PE, Silver W,
Gallagher EJ. Reliability of the visual analog scale for measurement of acute pain. Acad Emerg Med.
2001;8(12):1153-1157.)