Lower Extremity Combat-Related

Amputations
LT Scott M. Tintle, MD,1 LCDR Jonathan Agner Forsberg, MD,1,2 CDR John J. Keeling,
MD,1,2 LTC Scott B. Shawen, MD,1,2 and MAJ Benjamin Kyle Potter, MD1,2
Since the onset of combat activity in Iraq and Afghanistan, there have been over 1100 major limb
amputations among United States service members. With a sustained military presence in the Middle
East, continued severe lower extremity trauma is inevitable. For this reason, combat surgeons must
understand the various amputation levels as well as the anatomic and technical details that enable an
optimal functional outcome. These amputations are unique and usually result from blast mechanisms
and are complicated by broad zones of injury with severe contamination and ongoing infection. The
combat servicemen are young, previously healthy, and have the promising potential to rehabilitate to
very high levels of activity. Therefore, every practical effort should be made to perform sound initial and
definitive trauma-related amputations so that these casualties may return to their highest possible level
of function. ( Journal of Surgical Orthopaedic Advances 19(1):35 – 43, 2010)

Key words: amputation, combat trauma, residual limb, war wounds

Since the onset of combat activity in Iraq and

have the promising potential to rehabilitate to very high
levels of activity (2).
Afghanistan, there have been over 1100 major limb Therefore, every practical effort should be made to
amputations among United States servicemen (1). With a perform sound initial and definitive trauma-related ampu-
sustained military presence in the Middle East, continued tations so that these casualties may return to their highest
severe lower extremity trauma is inevitable. For this possible level of function. Adherence to established ampu-
reason, combat surgeons must understand the various tation principles at each anatomic level can dramatically
amputation levels as well as the anatomic and technical affect the outcome and ultimate function of the amputee
details that enable an optimal functional outcome.
(3). Long-term follow-up of these patients should be
Combat trauma-related amputations are unique. They
sought to ensure that the residual limb continues to be
are usually the result of a blast mechanism and are compli-
capable of tolerating prolonged prosthetic wear at a high-
cated by broad zones of injury with severe contamina-
demand level.
tion and ongoing overt or latent infection. Other limb
injuries, systemic illness, and a delay to definitive care
for intercontinental flight complicate the care of these Early Surgical Goals
amputees. These patients differ significantly from the
more common elderly, dysvascular amputee population; The initial surgical goal in the treatment of a patient
they are generally younger and previously healthy and with a severe lower extremity combat injury is the thor-
ough debridement of all contaminated wounds. All devi-
From 1 Integrated Department of Orthopaedics and Rehabilitation, talized muscle, skin, and bone must be excised during the
Walter Reed National Military Medical Center, Bethesda, MD; early surgical treatments in theater. Conversely, any and
2 Department of Surgery, Uniformed Services University of Health
all viable muscle and fasciocutaneous tissue should be
Sciences, Bethesda, MD. Address correspondence to: MAJ Benjamin
K. Potter, MD, Integrated Department of Orthopaedics and Rehabilita- saved for possible use in the definitive soft tissue recon-
tion, Walter Reed Army Medical Center, 6900 Georgia Avenue NW, struction. There is essentially no indication at this time to
Bldg 2 — Heaton Pavilion, Clinic 5A — Orthopaedics, Washington, perform a “guillotine” amputation. This is an antiquated
DC 20307; e-mail: Kyle.Potter@us.army.mil.
The views expressed in this article are those of the authors and do not technique which leaves no soft tissue coverage to maintain
necessarily reflect the official policy or position of the Department of the the amputation at that length or level (Fig. 1).
Navy, Army, Department of Defense, or the United States Government.
Received for publication September 10, 2009; accepted for publica-
tion September 28, 2009. Soft Tissue Management
For information on prices and availability of reprints call 410-494-
4994 X226.
1548-825X/10/1901-0035$22.00/0 Proper management of the soft tissue envelope is crit-
Copyright  2010 by the Southern Orthopaedic Association ical. The best predictor of the timing of definitive closure,

VOLUME 19, NUMBER 1, SPRING 2010 35

 A

FIGURE 1 Guillotine amputation with no soft tissue coverage B

available. Patient will need revision to a more proximal transfemoral
level.

final limb length, and prolonged prosthetic use is the pres-

ence of adequately robust soft tissue coverage. Myofascial
and myoplasty closures are frequently used in the dysvas-
cular and civilian trauma populations (4–7). These tech-
niques, however, should serve only as secondary measures
in most amputations and should virtually never be used
as the sole form of muscle stabilization in combat-related
amputations (Fig. 2).
Alternatively, myodesis is the preferred technique of
soft tissue stabilization following trauma-related ampu-
tation (8, 9). Myodesis is performed via suturing the
muscular fascia to the end of the bone either through FIGURE 2 (A) Transfemoral amputation relaxed with a normal-
drill holes or directly sutured to the periosteum. This appearing residual limb. (B) The same patient with active muscle
contraction revealing an unstable quadriceps-hamstring myoplasty.
restores the physiologic muscle tension, secures the deep
soft tissue padding, and prevents instability of the muscle
unit. Myoplasty and myofascial closure may then be used and scarring as well as the ligated vessels. It is recom-
to augment the primary myodesis or myodeses. Tenodesis mended for all named and other grossly visible nerves
is also an acceptable form of muscle stabilization at appro- of the lower extremity at the various amputation levels.
priate amputation levels. When performing a proximal transfemoral amputation,
the sciatic nerve may require ligation prior to transec-
tion to avoid bleeding from the substantive vaso nervosum
Management of Nerves (Fig. 3).
An association between acute postoperative pain with
Symptomatic neuromata accompany 0% –25% of major chronic amputation-related pain has been studied and
limb amputations and remain a frequent indication for identified. Patients who report the highest acute phantom
reoperation (2, 10, 11). Stimuli such as stretching, pres- limb pain are more likely to have phantom limb pain at
sure, vascular pulsation, or other irritation to the terminal 6 and 12 months following surgery (12). For this reason,
neuroma bulb can be painful and often limits prosthesis attempts have been made to reduce the acute postopera-
wear. Multiple techniques have been developed in an tive pain experienced by amputees. While the long-term
attempt to decrease the risk of a symptomatic neuroma positive impact of these techniques is debated, the short-
formation, but no method has convincingly demonstrated term benefits of anesthetic intervention include increased
any improved outcome over a carefully performed traction patient comfort and a decreased narcotic requirement and
neurectomy with burying of the cut nerve end deep in the may allow for slightly earlier mobilization. Current anes-
proximal soft tissues. A traction neurectomy places the thesia guidelines continue to focus on methods to prevent
neuroma away from the region of the definitive closure central neuroplastic changes from occurring through the

36 JOURNAL OF SURGICAL ORTHOPAEDIC ADVANCES

 Preservation of Length

Combat trauma-related amputations are usually

performed within the zone of injury. The Lower Extremity
Assessment Project (LEAP) study authors noted that 17
of 19 knee disarticulations were performed through the
zone of injury and that 38.2% of the total study patients
had atypical flap coverage of the residual limb in their
series (17). This atypical coverage within the zone of
injury is the rule rather than the exception with combat-
related amputations and, despite the LEAP study findings
to the contrary, it is associated with a substantial increase
in wound complications and heterotopic ossfication in the
combat wounded (18).
Multiple methods of preserving amputation length with
FIGURE 3 Transfemoral amputee with a symptomatic sciatic creative soft tissue coverage have been developed
neuroma at revision surgery. The nerve had been incorporated (19–
into the patient’s hamstring myodesis and was anchored to the 28). Split-thickness skin grafting is the simplest mech-
most distal aspect of his residual limb immediately adjacent to his anism to preserve length when robust muscle coverage
femoral bone cut.
is present. Soft tissue expanders may also be used in
conjunction with split-thickness skin grafting in order to
use of preventive multimodal analgesic techniques to achieve early, provisional closure and a delayed, durable
include nonsteroidal anti-inflammatory drugs, local anes- coverage at a later date (29, 30). Finally, more complex,
thetic nerve sheath injections, alpha-2 agonists, ketamine, pedicled or free tissue transfer can be used to preserve
opiods, preemptive epidurals, and regional nerve blocks limb length with good success when indicated (20, 31).
(13). These length-preserving procedures are, however, asso-
ciated with delayed prosthetic fitting and frequent revi-
Level of Amputation sion surgery (28, 32). They are most commonly indicated
around the knee to maintain a transtibial level of amputa-
There is an increasing oxygen cost of ambulation as the tion.
site of amputation moves to more proximal levels (14). In
an attempt to conserve energy, the average walking speed Lisfranc, Chopart, and Syme Disarticulations
of an amputee self-adjusts to maintain a similar overall
oxygen consumption to control patients without limb loss Amputations through the foot and ankle can be consid-
(15). For this reason, better outcomes are usually asso- ered when a patient has sustained severe forefoot trauma
ciated with longer residual limbs. However, this dictum with sparing of the hindfoot plantar skin and soft tissues.
often does not hold true in cases of severe foot and ankle The potential benefits of these levels are the long lever
trauma when a transtibial amputation is often indicated arm, an ideal cosmetic appearance of the foot amputa-
over a more distal foot or ankle amputation because of tions, and the potential ability to continue to bear weight
better prosthetic fit and component options. and walk for short distances without the use of a prosthesis
With combat trauma-related amputations, the level of (3, 33).
the most significant soft tissue injury usually determines These amputations are, however, associated with diffi-
the level of the amputation. When determining the final cult prosthetic fitting and a severe disruption of the muscu-
level of limb length and closure, the following tenets of lotendinous balance of the foot (33). The loss of the
Pinzur should be observed (16). forefoot lever length and the normal dorsiflexor insertions
allows the powerful triceps surae to overpower the foot.
1. Optimal residual limb length without osseous promi- This often leads to an equinovarus deformity that is very
nences should be chosen. difficult to both prevent and correct. Achieving a tendi-
2. Reasonable function in the joint proximal to the level nous balance so that the foot remains in its functional
of the amputation should be present in order to enhance position for comfortable prosthetic wear is challenging
prosthetic function. despite concerted efforts at tendon reattachment and peri-
3. A durable soft tissue envelope should be achieved and operative splinting or external fixation. Additionally, with
a full-thickness myocutaneous flap to cushion areas of regard to the Syme amputation, studies have repeatedly
high pressure and shear is desired. shown that 30% –50% of patients are unable to bear full

VOLUME 19, NUMBER 1, SPRING 2010 37

weight through their residual limb without a prosthesis, instability. This should be accomplished by a tenodesis of
which is one of the putative benefits of this amputation the Achilles tendon to the distal tibia through drill holes
level (33, 34). at the time of surgery. This neutralizes the strong triceps
surae pull on the heel pad and may prevent posterior heel
pad migration (48).
Lisfranc/Chopart Disarticulations
Due to the multiple problems associated with these
levels, as well as the high functional outcomes of
The Lisfranc disarticulation removes the forefoot
transtibial amputees, foot and ankle amputations have
through the tarsometatarsal joints (35). The bases of the
often been given little consideration in the young United
second and fifth metatarsals should be left in order to
States combat patient. In the authors’ experience, these
preserve the transverse arch of the foot as well as to leave amputations often perform relatively poorly and have
the insertion of the peroneus brevis intact. Careful preser- limited indications for the young active patient. Although
vation of the tibialis anterior and the peroneus longus the number of patients treated with these amputations
tendons must also be accomplished. The Chopart disartic- during the current conflict has been small, many have
ulation is an amputation through the talonavicular and the requested revision amputation to the transtibial level after
calcaneocuboid joints. In this procedure, all of the ankle being unsatisfied with their function at these levels. Crit-
dorsiflexors are transected and one must be very diligent ical considerations include the status of the soft tissues of
in performing a proper tendinous reconstruction in order the midfoot and heel pad, patient and family wishes after
to counteract the overpowering triceps surae. Multiple detailed counseling, associated ipsilateral and contralateral
methods of tendinous reconstruction and stabilization of lower extremity injuries, and the ability to perform satis-
the foot have been described, but most commonly the factory tendon stabilization appropriate to each of these
tibialis anterior is placed through drill holes in the talus levels.
and is secured with suture or a staple (36–38).
With both the Lisfranc and Chopart disarticulations, a
rebalancing of the foot must then be performed to avoid an Transtibial Amputation
equinus contracture. Percutaneous heel cord lengthening
followed by rigid casting or temporary external fixation The transtibial amputation is the most common level
in a dorsiflexed position should be performed in an effort of amputation for trauma patients and frequently has the
to prevent this. For difficult cases, even fusion of the best functional outcome. The gait of a transtibial amputee
midtarsal joints to prevent their secondary dislocation has is minimally disturbed due to the preservation of the knee
been suggested (39, 40). and less energy is required for ambulation when compared
with more proximal levels (49, 50). These patients are
often able to ambulate at a normal speed due to their
Syme Ankle Disarticulation increased exercise capability, despite a 20% higher oxygen
consumption (51–53). They also have a high rate of
When planning a Syme ankle disarticulation, there prosthetic use and are very physically active, and a large
are a number of very important technical details to percentage of them consider themselves only minimally
consider to achieve optimal outcomes. Revision surgery or nondisabled (54).
for the Syme disarticulation is common, in the range In 2001, Dougherty reported a 28-year follow-up of
of 8.5% –50%, with revision to the transtibial level United States servicemen with transtibial amputations.
being relatively frequent among dysvascular amputees SF-36 scores in the group of patients who had isolated
(33, 41–44). Two absolute contraindications exist to amputations were similar to age- and gender-matched
performing this surgery; specifically, if either the heel control individuals (55). In a recent study evaluating
pad or its blood supply, the posterior tibial artery, are Iranian veterans, Taghipour found slightly contrasting
damaged, this amputation should not be performed results. Despite finding that the transtibial amputees had
(45, 46). lower SF-36 scores than a control group, the SF-36
At the time of surgery, the distal medial and lateral scores for transfemoral amputees were significantly lower.
malloli are transected flush with the distal tibial articular The improved general health outcomes scores over trans-
surface or just proximal to this if distal tibial transection femoral amputees appears to remain constant throughout
is performed. The malleolar flare of the tibia and fibula the literature (55–57).
may also be reduced to decrease the mediolateral diam- This level of amputation should be selected, when prac-
eter of the residual limb, but some of the malleolar flare ticable, for most combat patients with severe foot or
should optimally be retained in order to assist in pros- leg trauma. The most commonly utilized technique was
thetic suspension (43, 47). The heel pad must then be originally described by Bickell and then popularized by
maintained directly below the distal tibia to avoid painful Burgess in 1943 (58, 59). Burgess reported that 2.5 cm

38 JOURNAL OF SURGICAL ORTHOPAEDIC ADVANCES

of residual tibia should be left for every 30 cm of a and fervent critics. In 2006, Pinzur et al. (65) suggested
patient’s height (60). This usually ranges from 12.5 to that patient-perceived functional outcomes may be
17.5 cm of residual limb length; we recommend erring improved by performing the distal tibiofibular synostosis.
slightly toward the higher end of this spectrum when In a more recent study, however, Pinzur was unable to
soft tissue coverage is adequate and wound characteris- demonstrate an advantage when compared with the tradi-
tics permit surgeon selection of amputation level, with the tional Burgess technique (66). Despite the controversy
caveats that robust soft tissue coverage should be achieved and uncertainty of an improved outcome with the bone
and 10.5–11 inches (27–28 cm) of ground clearance bridging procedure, patients who demonstrate tibiofibular
is required for more advanced prosthetic components. instability clinically or radiographically should have some
Despite this optimal length guideline, a high transtibial form of tibiofibular stabilization performed (Fig. 4).
amputation may be performed as long as the tibial tubercle
is preserved. There is no current role for preserving the
knee joint if one is unable to achieve at least this length. Knee Disarticulation
The tibia and fibula should then be cut at the desired level
with a sagittal saw. The fibula is sectioned and beveled The LEAP study data have recently cast a negative light
posterolaterally about 1–2 cm proximal to the tibia cut on through-knee amputations. The LEAP study patients
to ensure that the fibula does not become prominent and with through-knee amputations were found to have the
painful with prosthetic wear. Likewise, the sharp ante- lowest walking speed and self-reported outcomes. Despite
rior tibia must then be beveled and smoothed for the these findings, other studies have reported better walking
same reason. All named nerves (tibial, superficial and stability, a decreased metabolic cost of ambulation, and
deep peroneal, saphenous, and sural) should be identi- higher scores on the physical component of the SF-36 as
fied, isolated, dissected proximally, placed under tension, compared with transfemoral amputees (56, 67, 68).
transected sharply, and permitted to retract into the prox- When originally developed, the knee disarticulation was
imal soft tissues. Following this, attention is paid to the very popular because of its ability to be performed quickly
remaining soft tissue flap to be used for distal coverage. and safely in the preanesthestic era. There was a decreased
Ideally, a long posterior myocutaneous flap is present, risk of infection and severe bleeding at this level as
but sagittal and skew flaps can be utilized, when neces- compared with more proximal or distal levels. This level
sary, with reasonable outcomes expected (61). Prior to did, however, fall out of favor because many patients were
gastrocnemius myodesis, the soleus may require thin- unable to bear weight through their residual limb due to
ning or removal, depending on the patient’s anatomy, to poor soft tissue coverage consisting only of subcutaneous
ensure that the residual limb is not too bulky, closure is tissue and skin (3).
possible, and redundant soft tissue does not remain once This is very likely the explanation for why the LEAP
swelling subsides and atrophy occurs. The myodesis is study amputations did so poorly. Seventeen of the 18
then performed and the remaining gastrocnemius fascia is
secured to the anterior crural fascia of the leg. Despite
the LEAP study finding that only 22.8% of transtibial A B
amputees had a myodesis performed, we emphatically
stress the importance of this step because we have
frequently revised amputations due to an inadequate or
poorly performed myodesis that has led to painful pros-
thetic wear.

Distal Tibiofibular Synostosis

The concept of producing a synostosis between the tibia

and fibula was first proposed by Bier in 1892 and then
popularized and further developed by von Ertl (3). Von
Ertl felt that his modification of the transtibial amputation
procedure allowed for a more normal end-bearing residual
limb (62). Since the original description of the tibiofibular
synostosis procedure, multiple authors have suggested
FIGURE 4 (A) Proximal tibiofibular stabilization performed with
modifications to the original technique (63, 64). screw in a patient with distal wound contamination precluding a
The bone bridging procedure has been heavily debated bridge synostosis. (B) Distal tibiofibular stabilization performed with
in and out of the literature and has both ardent supporters a modified Ertl tibiofibular synostosis.

VOLUME 19, NUMBER 1, SPRING 2010 39

through-knee disarticulations were performed through the At the transfemoral amputation level, Gottschalk
zone of injury and 12 of them had no gastrocnemius described that the loss of the adductor magnus inser-
available for distal muscle coverage. A poor result is tion translates to an overall loss of 70% of the adductor
to be expected in this situation and most experts would moment on the femur (76). This results in an unop-
have likely recommended a well balanced transfemoral posed pull of the hip abductors, leading to an abduc-
amputation instead (3, 68). tion deformity of the femur and gradual lateral drift of
In the development of the current through-knee amputa- the femur within the soft tissue envelope (Fig. 5). This
tion technique, the soft tissue coverage shortfall was noted abducted position leads to an increased lurch and higher
and the posterior myofasciocutaneous flap was developed energy consumption during ambulation due to the inability
to adequately support the pelvis. His work, along with
to more appropriately pad the residual limb. This has
other studies, demonstrated that without adequately stabi-
produced significantly improved outcomes and increased
lizing the residual thigh musculature there would be a
popularity at this level (69–72).
decrease in thigh strength and progressive atrophy. These
The well padded distal femoral condyles can be used findings highlight the importance of performing at least
for endbearing and allow for improved proprioception an adductor myodesis during a transfemoral amputation
and walking stability. With this improved soft tissue (77–79).
coverage, other potential benefits of this level can be Following reflection of the extensor mechanism just
realized, including the long lever arm which allows for proximal to the patella, the adductor magnus tendon is
better sitting balance than more proximal levels, and the identified, tagged, and released from its femoral inser-
lower extremity muscle balance is maintained, leading to tion. The transfemoral bone cut is optimally performed
improved biomechanics and gait and obviating adductor and smoothed at 9–12 cm proximal to the medial femoral
concerns (73). Drawbacks of an optimal knee disartic- condyle. Longer cuts reduce space for prosthetic compo-
ulation include reduced room for prosthetic components nents and result in less padding of the distal residual
versus other amputation levels and a knee joint cosmetic limb. After appropriate management of the nerves (sciatic,
appearance and axis of rotation which differs from that of
the contralateral limb.
A B
To perform a through-knee amputation, the leg is
removed sharply through the knee capsule and the patellar
tendon is dissected off of the tibial tubercle. The patella
may be removed from the encasing quadriceps at the
surgeon’s discretion to decrease the potential risk of
patellofemoral pain. The medial and lateral femoral
condyles may be trimmed modestly to decrease their bulk.
A posterior condylectomy can be performed if necessary
to increase coverage of the myofasciocutaneous flap. Care
must be taken to isolate and ligate the popliteal vessels
distal to the sural arteries supplying the gastrocnemius
to avoid necrosis to the posterior muscle and skin flap.
Finally, the patellar ligament is sutured to the cruciate
ligament remnants to re-establish quadriceps tension, and
the long posterior myofasciocutaneous gastrocnemius flap
is sutured to the thick anterior joint capsule (70, 71).

Transfemoral Amputations

Transfemoral amputees have a less efficient gait, which

results in a higher energy cost of ambulation (14, 74,
75). SF-36 scores have also been shown to be signifi-
cantly lower for transfemoral amputees (56, 57). When a
transfemoral amputation is necessary, it is imperative that
FIGURE 5 (A) Transfemoral amputee with a stable adductor
the surgical and biomechanical principles that have been myodesis and normal residual femur and limb alignment. (B)
established are heeded so that the downsides of this level Transfemoral amputee with an inadequate adductor myodesis and
are minimized. lateral drift of the residual femur.

40 JOURNAL OF SURGICAL ORTHOPAEDIC ADVANCES

saphenous, and obturator, as well as the femoral and from the LEAP study group in a civilian trauma popu-
lateral and posterior femoral cutaneous nerves of the thigh lation, over 85% of patients who had a trauma-related
at more proximal levels) and double ligation of the vessls, amputation had a significant complication within the first
drill holes are placed into the lateral and anterior femoral 6 months after amputation. Nearly half of all of the
cortex and, with the limb held in maximum adduction and patients who underwent a trauma-related amputation had
slight extension, the adductor magnus tendon is myodesed either a wound infection or wound necrosis. The other
to the lateral femur. Additional stabilizing sutures should frequent complications included “stump” complications,
then be utilized to ensure that the magnus tendon is symptomatic neuromas, and phantom limb pain (10).
stable and does not subluxate posteriorly. A semimembra- These findings and our own anecdotal experience have
nosis myodesis is then recommended to prevent a flexion made it imperative to educate our patients of the very high
deformity as well as stabilize the subsequent myoplasty. likelihood of revision surgery in the first couple of weeks
Finally, the quadriceps apron is pulled distally over the to years after the closure of combat-related amputations.
residual limb and a myoplasty is performed. This provides In our experience with combat-related and traumatic
quadriceps stabilization and provides a robust muscular amputations we have witnessed virtually every complica-
padding over the residual limb. tion reported in the civilian literature and have also dealt
with a high frequency of complications outside of the first
6 months after amputation. These include heterotopic ossi-
Hip Disarticulation fication, symptomatic neuromas, late infections, myodesis
failures, and tibiofibular synostosis-related complications
The hip disarticulation is an amputation of last resort. (18). We have found that surgical treatment of many
Historically, this very proximal amputation had a dismal of these complications at this late time (>6 months
outcome, but functional potential has improved dramat- from primary amputation) can lead to better outcomes
ically by modern suction-fit prosthetics and has allowed and improved prosthetic use with high patient satisfac-
for remarkable function in some patients. Therefore, atten- tion and function. Therefore, we highly recommend the
tion to a few key points is warranted to maximize patient long-term follow-up of all trauma-related amputees by
outcomes. surgeons familiar with amputation management and revi-
The soft tissue coverage flap for the hip disarticula- sion, ideally the surgeon who performed the definitive
tion is usually composed of a posterolateral flap including amputation.
the gluteal muscles. Care must be taken during dissection
around the sciatic notch to avoid injury to the vascular References
supply of the gluteal musculature. The femoral and obtu-
rator vessels must be identified and ligated as they exit 1. U.S. OIF/OEF casualty statistics Department of Defense Statistics.
the true pelvis. The femoral, sciatic, and obturator nerves http://www.defenselink.mil/news/casualty.pdf. Accessed June 2008.
must be identified and transected or ligated as far proximal 2. Pierce, R. O., Jr., Kernek, C. B., Ambrose, T. A., II. The plight of
the traumatic amputee. Orthopedics 16(7):793 – 797, 1993.
as possible (ideally at their point of exit from the pelvis)
3. Smith, D. G., Michael, J. W., Bowker, J. H. Atlas of Amputations
to avoid symptomatic neuroma formation (3). The prox- and Limb Deficiencies: Surgical, Prosthetic, and Rehabilitation
imal femur is then removed or fused to the acetabulum Principles, pp. xvii, 965, American Academy of Orthopaedic
and the abductor musclature and pectineus are sutured to Surgeons, Rosemont, IL, 2004.
the residual joint capsule or through bone tunnels in the 4. Burgess, E. M., Romano, R. L., Zettl, J. H., et al. Amputations of
the leg for peripheral vascular insufficiency. J. Bone Joint Surg.
acetabulum to fill the dead space. The gluteus maximus 53-A(5):874 – 890, 1971.
tendon is then mobilized and sutured anteriorly to the 5. Pedersen, H. E. Treatment of ischemic gangrene and infection in
inguinal ligament, taking appropriate care not to injure the foot. Clin. Orthop. 16:199 – 202, 1960.
the structures within. This provides a robust myofascio- 6. Pedersen, H. E. The problem of the geriatric amputee. Artif. Limbs
12(2)(suppl.): 1 – 3, 1968.
cutaneous flap over the residual hemipelvis.
7. MacKenzie, E. J., et al. Functional outcomes following trauma-
related lower-extremity amputation. J. Bone Joint Surg.
86-A(8):1636 – 1645, 2004.
Complications of Amputations
8. Smith, D. G., Fergason, J. R. Transtibial amputations. Clin. Orthop.
Relat. Res. 361:108 – 115, 1999.
Despite attention to the perioperative and surgical 9. Pinzur, M. S., Gottschalk, F., Pinto, M. A., et al. Controversies in
details discussed in this review, amputations due to lower extremity amputation. Instr. Course Lect. 57:663 – 672, 2008.
combat trauma are fraught with complications. These 10. Harris, A. M., Althausen, P. L., Kellam, J., et al. Complications
following limb-threatening lower extremity trauma. J. Orthop.
can range from minor dermatologic complaints to major Trauma 23(1):1 – 6, 2009.
complications requiring multiple return trips to the oper- 11. Ducic, I., Mesbahi, A. N., Attinger, C. E., et al. The role of
ating room. In the recent review of the complications peripheral nerve surgery in the treatment of chronic pain associated

VOLUME 19, NUMBER 1, SPRING 2010 41

 with amputation stumps. Plast. Reconstr. Surg. 121(3):908 – 914; 31. Jupiter, J. B., Tsai, T. M., Kleinert, H. E. Salvage replantation of
discussion 915 – 917, 2008. lower limb amputations. Plast. Reconstr. Surg. 69(1):1 – 8, 1982.
12. Hanley, M. A., Jensen, M. P., Smith, D. G., et al. Preamputation 32. Dedmond, B. T., Davids, J. R. Function of skin grafts in children
pain and acute pain predict chronic pain after lower extremity following acquired amputation of the lower extremity. J. Bone Joint
amputation. J. Pain 8(2):102 – 109, 2007. Surg. 87-A(5):1054 – 1058, 2005.
13. Wilder-Smith, C. H., Hill, L. T., Laurent, S. Postamputation pain 33. Gaine, W. J., McCreath, S. W. Syme’s amputation revisited: a
and sensory changes in treatment-naive patients: characteristics and review of 46 cases. J. Bone Joint Surg. 78-B(3):461 – 467, 1996.
responses to treatment with tramadol, amitriptyline, and placebo. 34. Barber, G. G., McPhail, N. V., Scobie, T. K., et al. A
Anesthesiology 103(3):619 – 628, 2005. prospective study of lower limb amputations. Can. J. Surg.
14. Waters, R. L., Perry, J., Antonelli, D., et al. Energy cost of walking 26(4):339 – 341, 1983.
of amputees: the influence of level of amputation. J. Bone Joint 35. Lisfranc, J. Nouvelle methode operatoire pour l’amputation du
Surg. 58-A(1):42 – 46, 1976. pied dans son articulation tarsometatarsienne:methode precedee des
15. Waters, R. L., Lunsford, B. R., Perry, J., et al. Energy- nombreuses odifications qu’a subies celle de Chopart. Paris, France,
speed relationship of walking: standard tables. J. Orthop. Res. Gabon, 1815.
6(2):215 – 222, 1988. 36. Marquardt, E. [Chopart exarticulation using tenomyoplasty]. Z.
16. Pinzur, M. S., Gottschalk, F. A., Pinto, M. A., et al. Orthop. Ihre. Grenzgeb. 111(4):584 – 586, 1973.
Controversies in lower-extremity amputation. J. Bone Joint Surg. 37. Letts, M., Pyper, A. The modified Chopart’s amputation. Clin.
89-A(5):1118 – 1127, 2007. Orthop. Relat. Res. 256:44 – 49, 1990.
17. MacKenzie, E. J., et al. Functional outcomes following trauma- 38. Persson, B. M., Soderberg, B. Pantalar fusion for correction of
related lower-extremity amputation. J. Bone Joint Surg. 86- painful equinus after traumatic Chopart’s amputation — a report
A(8):1636 – 1645, 2004. of 2 cases. Acta Orthop. Scand. 67(3):300 – 302, 1996.
18. Potter, B. K., Burns, T. C., Lacap, A. P., et al. Heterotopic 39. Baumgartner, R. Forefoot and hindfoot amputations. Editions
ossification following traumatic and combat-related amputations. Scientifique et Medicales. Surgical Techniques in Orthopaedics and
Prevalence, risk factors, and preliminary results of excision. J. Bone Traumatology, 55-700-C-10, pp. 1 – 6, Elsevier SAS, Paris, 2001.
Joint Surg. 89-A(3):476 – 486, 2007. 40. Livingston, R., Jacobs, R. L., Karmody, A. Plantar abscess in the
19. Gallico, G. G., III, Ehrlichman, R. J., Jupiter, J., et al. Free flaps diabetic patient. Foot Ankle 5(4):205 – 213, 1985.
to preserve below-knee amputation stumps: long-term evaluation. 41. Jany, R. S., Burkus, J. K. Long-term follow-up of Syme amputations
Plast. Reconstr. Surg. 79(6):871 – 878, 1987. for peripheral vascular disease associated with diabetes mellitus.
20. Ghali, S., Harris, P. A., Khan, U., et al. Leg length preservation Foot Ankle 9(3):107 – 110, 1988.
with pedicled fillet of foot flaps after traumatic amputations. Plast. 42. Baker, G. C., Stableforth, P. G. Syme’s amputation. A review of
Reconstr. Surg. 115(2):498 – 505, 2005. sixty-seven cases. J. Bone Joint Surg. 51-B(3):482 – 487, 1969.
21. Gumley, G. J., MacLeod, A. M., Thistlethwaite, S., et al. Total 43. Mazet, R., Jr. Syme’s amputation. A follow-up study of fifty-
cutaneous harvesting from an amputated foot — two free flaps used one adults and thirty-two children. J. Bone Joint Surg. 50-
for acute reconstruction. Br. J. Plast. Surg. 40(3):313 – 316, 1987. A(8):1549 – 1563, 1968.
22. Henman, P. D., Jain, A. S. Skin grafting an amputation stump: 44. Shelswell, J. H. Syme’s amputation. Lancet 267(6852):1296 – 1299,
considerations for the choice of donor site. Br. J. Plast. Surg. 1954.
53(4):357, 2000. 45. Harris, R. I. Syme’s amputation; the technical details essential for
23. Kasabian, A. K., Colen, S. R., Shaw, W. W., et al. The role success. J. Bone Joint Surg. 38-B(3):614 – 632, 1956.
of microvascular free flaps in salvaging below-knee amputation 46. Syme, J. Amputation at the ankle joint. London and Edinburgh
stumps: a review of 22 cases. J. Trauma 31(4):495 – 500; discussion Monthly J. Med. Sci. 3(93), 1843.
500 – 501, 1991. 47. Sarmiento, A. A modified surgical-prosthetic approach to the
24. Kasabian, A. K., Glat, P. M., Eidelman, Y., et al. Salvage of Syme’s amputation. A follow-up report. Clin. Orthop. Relat. Res.
traumatic below-knee amputation stumps utilizing the filet of foot 85:11 – 15, 1972.
free flap: critical evaluation of six cases. Plast. Reconstr. Surg. 48. Smith, D. G., Sangeorzan, B. J., Hansen, S. T., Jr., et al. Achilles
96(5):1145 – 1153, 1995. tendon tenodesis to prevent heel pad migration in the Syme’s
25. Kuntscher, M. V., Erdmann, D., Homann, H. H., et al. The concept amputation. Foot Ankle Int. 15(1):14 – 17, 1994.
of fillet flaps: classification, indications, and analysis of their clinical 49. Gonzalez, E. G., Corcoran, P. J., Reyes, R. L. Energy expenditure
value. Plast. Reconstr. Surg. 108(4):885 – 896, 2001. in below-knee amputees: correlation with stump length. Arch. Phys.
26. Pelissier, P., Pistre, V., Casoli, V., et al. Reconstruction of short Med. Rehabil. 55(3):111 – 119, 1974.
lower leg stumps with the osteomusculocutaneous latissimus dorsi- 50. Bard, G., Ralston, H. J. Measurement of energy expenditure during
rib flap. Plast. Reconstr. Surg. 109(3):1013 – 1017, 2002. ambulation, with special reference to evaluation of assistive devices.
27. Shenaq, S. M., Krouskop, T., Stal, S., et al. Salvage of amputation Arch. Phys. Med. Rehabil. 40:415 – 420, 1959.
stumps by secondary reconstruction utilizing microsurgical free- 51. Molen, N. H. Energy-speed relation of below-knee amputees
tissue transfer. Plast. Reconstr. Surg. 79(6):861 – 870, 1987. walking on a motor-driven treadmill. Int. Z. Angew. Physiol.
28. Wood, M. R., Hunter, G. A., Millstein, S. G. The value of stump 31(3):173 – 185, 1973.
split skin grafting following amputation for trauma in adult upper 52. Gailey, R. S., Wenger, M. A., Raya, M., et al. Energy expenditure
and lower limb amputees. Prosthet. Orthot. Int. 11(2):71 – 74, 1987. of trans-tibial amputees during ambulation at self-selected pace.
29. Wieslander, J. B., Wendeberg, B., Linge, G., et al. Tissue expansion: Prosthet. Orthot. Int. 18(2):84 – 91, 1994.
a method to preserve bone length and joints following traumatic 53. Casillas, J. M., Dulieu, V., Cohen, M., et al. Bioenergetic
amputations of the leg — a follow-up of five legs amputated at comparison of a new energy-storing foot and SACH foot in
different levels. Plast. Reconstr. Surg. 97(5):1065 – 1071, 1996. traumatic below-knee vascular amputations. Arch. Phys. Med.
30. Rees, R. S., Nanney, L. B., Fleming, P., et al. Tissue expansion: Rehabil. 76(1):39 – 44, 1995.
its role in traumatic below-knee amputations. Plast. Reconstr. Surg. 54. Purry, N. A., Hannon, M. A. How successful is below-knee
77(1):133 – 137, 1986. amputation for injury? Injury 20(1):32 – 36, 1989.

42 JOURNAL OF SURGICAL ORTHOPAEDIC ADVANCES

55. Dougherty, P. J. Transtibial amputees from the Vietnam level of amputation. Orthopedics 15(9):1033 – 1036; discussion
War. Twenty-eight-year follow-up. J. Bone Joint Surg. 83- 1036 – 1037, 1992.
A(3):383 – 389, 2001. 69. Wagner, F. W., Jr. Management of the diabetic neurotrophic
56. Taghipour, H., Moharamzad, Y., Mafi, A. R., et al. Quality of foot. Part II. A classification and treatment program for diabetic
life among veterans with war-related unilateral lower extremity neuropathic and dysvascular foot problems. Instr. Course Lect.
amputation: a long-term survey in a prosthesis center in Iran. 28:143 – 165, 199.
J. Orthop. Trauma 23(7):525 – 530, 2009. 70. Pinzur, M. S., Bowker, J. H. Knee disarticulation. Clin. Orthop.
57. Dougherty, P. J. Long-term follow-up of unilateral transfemoral Relat. Res. 361:23 – 28, 1999.
amputees from the Vietnam War. J. Trauma 54(4):718 – 723, 2003. 71. Bowker, J. H., San Giovanni, T. P., Pinzur, M. S. North
58. Bickel, W. H. Amputations below the knee in occlusive arterial American experience with knee disarticulation with use of a
diseases. Surg. Clin. North Am. 23:982 – 994, 1943. posterior myofasciocutaneous flap. Healing rate and functional
59. Burgess, E. M. The below-knee amputation. Bull. Prosthet. Res. results in seventy-seven patients. J. Bone Joint Surg. 82-
10:19 – 25, 1968. A(11):1571 – 1574, 2000.
60. Burgess, E. M., Romano, R. L. The management of lower extremity 72. Klaes, W., Eigler, F. W. A new technic of transgenicular
amputees using immediate postsurgical prostheses. Clin. Orthop. amputation. Chirurgie 56(11):735 – 740, 1985.
Relat. Res. 57:137 – 146, 1968. 73. Baumgartner, R. F. Knee disarticulation versus above-knee
61. Assal, M., Blanck, R., Smith, D. G. Extended posterior flap for amputation. Prosthet. Orthot. Int. 3(1):15 – 19, 1979.
transtibial amputation. Orthopedics 28(6):542 – 546, 2005. 74. Volpicelli, L. J., Chambers, R. B., Wagner, F. W., Jr.
62. von Ertl, J. About amputation stumps. Chirurgie 20:212 – 218, 1949. Ambulation levels of bilateral lower-extremity amputees. Analysis
63. Anderson, C. D., Stewart, J. D., Unger, D. V. Recent of one hundred and three cases. J. Bone Joint Surg. 65-
advances in lower-extremity amputations. Curr. Opin. Orthop. A(5):599 – 605, 1983.
18(2):137 – 144, 2007. 75. Hagberg, K., Branemark, R. Consequences of non-vascular trans-
64. Berlet, G. C., Pokabla, C., Serynek, P. An alternative technique for femoral amputation: a survey of quality of life, prosthetic use and
the Ertl osteomyoplasty. Foot Ankle Int. 30(5):443 – 446, 2009. problems. Prosthet. Orthot. Int. 25(3):186 – 194, 2001.
65. Pinzur, M. S., Pinto, M. A., Saltzman, M., et al. Health- 76. Gottschalk, F. A., Stills, M. The biomechanics of trans-femoral
related quality of life in patients with transtibial amputation and amputation. Prosthet. Orthot. Int. 18(1):12 – 17, 1994.
reconstruction with bone bridging of the distal tibia and fibula. Foot 77. James, U. Maximal isometric muscle strength in healthy active male
Ankle Int. 27(11):907 – 912, 2006. unilateral above-knee amputees, with special regard to the hip joint.
66. Pinzur, M. S., Beck, J., Himes, R., et al. Distal tibiofibular Scand. J. Rehabil. Med. 5(2):55 – 66, 1973.
bone-bridging in transtibial amputation. J. Bone Joint Surg. 90- 78. Thiele, B., James, U., Stalberg, E. Neurophysiological studies on
A(12):2682 – 2687, 2008. muscle function in the stump of above-knee amputees. Scand. J.
67. Pinzur, M. S., Smith, D., Tornow, D., et al. Gait analysis of Rehabil. Med. 5(2):67 – 70, 1973.
dysvascular below-knee and contralateral through-knee bilateral 79. Jaegers, S. M., Arendzen, J. H., de Jongh, H. J. An
amputees: a preliminary report. Orthopedics 16(8):875 – 879, 1993. electromyographic study of the hip muscles of transfemoral
68. Pinzur, M. S., Gold, J., Schwartz, D., Gross, N. Energy amputees in walking. Clin. Orthop. Relat. Res. 328:119 – 128,
demands for walking in dysvascular amputees as related to the 1996.

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