What are the general principles of lower-extremity amputations?

Updated: Apr 29, 2021
  • Author: Janos P Ertl, MD; Chief Editor: Vinod K Panchbhavi, MD, FACS, FAOA, FABOS, FAAOS  more...
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General principles for amputation surgery involve appropriate management of skin, bone, nerves, and vessels, as follows:

  • The greatest skin length possible should be maintained for muscle coverage and a tension-free closure
  • Muscle is placed over the cut end of bones via a myodesis (ie, muscle sutured through drill holes in bone), a long posterior flap sutured anteriorly, or a well-balanced myoplasty (ie, antagonistic muscle and fascia groups sutured together)
  • Nerves are transected under tension, proximal to the cut end of bones in a scar- and tension-free environment, so as to reduce the chances that neuromas will form and be a source of pain; placing the cut nerves in a more proximal scar-free environment assists in decreasing potential irritation and pain; ligation of large nerves can be performed when an associated vessel is present
  • The larger arteries and veins are dissected and separately ligated so as to prevent the development of arteriovenous fistulas and aneurysms
  • Bony prominences around disarticulations are removed with a saw and filed smooth; diaphyseal transections can be covered with a local flexible osteoperiosteal graft; although maintaining the maximal extremity length possible is desirable, below-knee amputations are best performed 12.5-17.5 cm below the joint line for nonischemic limbs
  • One application guide is to make a limb 2.5 cm long for every 30 cm of body height; for ischemic limbs, a higher level of 10-12.5 cm below the joint line is used because making limbs longer than this can interfere with prosthetic use and design [2]

Osteointegration has been performed in Sweden. This technique was initially applied in dental surgery for tooth loss, and the procedure involves a metal post, treated similarly to a total joint ingrowth prosthesis, secured to bone. Success has been achieved with replacement for thumb amputations. Case series with transfemoral amputations have been completed; however, long-term results are not available. The potential for postoperative infection and osteomyelitis is high.

Lower-limb reconstruction with a quad flap (consisting of parascapular, scapular, serratus, and latissimus dorsi free flaps combined on a single pedicle) has been described. [30]

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