Amputation: Types, Indications, and Rehabilitation

Amputation is surgical removal of a limb or limb segment. Modern indications prioritize limb salvage when possible; amputation is reserved for unsalvageable limbs or life-threatening conditions.

Indications

• Trauma: Irreparable vascular/nerve/bone/soft tissue damage (military, civilian)
• Peripheral artery disease (PAD): Critical limb ischemia (CLI) unreconstructable
• Diabetes: Infected neuropathic ulcer + osteomyelitis + ischemia
• Malignancy: Primary bone/soft tissue sarcoma; locally advanced
• Infection: Necrotizing fasciitis, gas gangrene, refractory osteomyelitis
• Congenital: Severe limb deficiency (conversion amputation)
• Severe crush/compartment syndrome

Lower Limb Amputation Levels

Upper Limb Levels

• Partial hand, wrist disarticulation, transradial, elbow disarticulation, transhumeral, shoulder disarticulation, forequarter
• Preserving elbow dramatically improves function

Preoperative Optimization

• Vascular assessment (ABI, TBI, angiography)
• Nutritional optimization (albumin >3.5, prealbumin)
• Glycemic control (HbA1c <8% if diabetic)
• Smoking cessation (4+ weeks preop)
• Psychosocial evaluation, peer support connection

Postoperative Care

• Rigid/removable rigid dressing (RRD) → early mobilization, edema control
• Pain management: multimodal (regional, NSAIDs, gabapentinoids, opioids PRN)
• Phantom limb pain: mirror therapy, desensitization, neuromodulators
• Pre-prosthetic training: strengthening, balance, shrinker sock
• Prosthetic fitting: typically 6-12 weeks postop (delayed if healing issues)

Outcomes

• 5-year mortality: 30-50% (PAD/diabetes); lower for trauma/tumor
• Functional ambulation: 60-80% BKA; 30-50% AKA with prosthesis
• Quality of life: Highly variable; peer support, adaptive sports improve outcomes

Multidisciplinary Team

Surgeon, physiatrist, prosthetist, PT/OT, psychologist, case manager, peer visitor.

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Level	Indication	Prosthetic Potential
Toe/ray	Forefoot gangrene, ulcer	Excellent; minimal gait change
Transmetatarsal (TMA)	Forefoot salvage	Good; AFO often needed
Lisfranc/Chopart	Midfoot	Fair; tendon balancing critical
Syme (ankle disarticulation)	Preserves heel pad	Good; end-bearing
Below-knee (BKA)	Most common major amputation	Excellent; knee preserved
Knee disarticulation	Preserves femoral condyles	Good; longer lever arm
Above-knee (AKA)	Proximal disease/trauma	Moderate; hip control needed
Hip disarticulation	Proximal femur/tumor	Challenging; pelvic support
Hemipelvectomy	Pelvic tumor	Very limited