1-Amputation Levels

Amputation levels above the knee are shown in Figure 1. These

levels include the following:
• Hemipelvectomy is the loss of any part of the ilium,
ischium, and pubis.
• Hip disarticulation is the loss of all of the femur. The
hemipelvectomy and hip disarticulation procedures are usually
done in cases of malignant tumors, extensive gangrene, massive
trauma, or advanced infection.
• Short transfemoral amputations occur when lessthan 35%
of femoral length is present. A larger weight bearing surface can be
created if femoral transaction can be done at the level of the lesser
trochanter. This level retains the femoral head and neck and the
greater trochanter, resulting in improved prosthetic fit. The number
of transfemoral amputations has declined since the 1980s. This
decline is due to improved surgical techniques and better
preoperative assessment of vascular status.
• Medium tansfemoral amputations occur when between 35
and 60% of femoral length is present. Ideally, tansfemoral limbs
should be at least 4 inches or 10 cm above the lower end of the
femur to allow room for the prosthetic knee. In a transfemoral
amputation, both anterior and posterior muscular surfaces are well
vascularized; therefore, equal flaps are fashioned.
• A rotationplasty is applicable to patients who have a
malignant tumor in the middle or distal femur. It is also done in
cases of PFFD. A rotationsplasty involves an osteotomy in the
proximal third of the femur, distal to the lesser trochanter, and in
the proximal part of the tibia, distal to the tibial tuberosity. The
foot is rotated 180° and the tibia reattached to the remaining femur.
The foot is fit into the prosthesis and acts as a knee joint.
Prosthetically, this amputation has the advantage of preserving the
anatomic ankle joint, which acts as a knee joint, and a long lever
arm for better prosthesis control. The rotationsplasty procedure is
illustrated in Figure 2.
• Long transfemoral amputations occur when more than 60%
of femoral length is present but not capable of end bearing. A
transfemoral amputation is depicted in Figure 1-14.
• In a supracondylar amputation, the patella may be left for
better end bearing. However, the area created between the end of
the femur and the patella may delay healing.
• A knee disarticulation amputation offers good weight
distribution and retains a long, powerful, muscle – stabilized
femoral lever arm. In addition, the thigh muscles are completely
preservfed, thereby ensuring good muscular balance. This
amputation maintains the femoral length in growing children by
preserving the growth potential of the distal femoral epiphysis.
However, the knee disarticulation amputation yields a noncosmetic
socket because of the need for an external joint mechanism and
resulting difficulty with swing-phase control. Knee disarticulation
amputation is often performed on the patient who will not become
a prosthetic walker. This amputation avoids the possibility of knee
flexion contractures and provides an excellent platform for sitting
and transfers. Transtibial amputation levels are depicted in
Figure 3. These include the flowing:
• A very short transtibial amputation occurs when less than
20% of tibial length is present. This amputation may result from
 trauma and is usually not done as an elective procedure. A very
short transtibial amputation results in a small-moment arm, making
knee extension difficult. Moment arms are further described in
Chapter 5, "Biomechanics Implications of Prosthetic and Orthosis".
• A standard transtibial amputation occurs when between 20
and 50% of tibial length is present. An elective amputation in the
middle third of the tibia, regardless of measured length, provides a
well-padded and biomechanically sufficient lever arm. At least 8
cm of tibia is required below the knee joint for optimal fitting of a
prosthesis.
• A long transtibial amputation occurs when more than 50%
of tibital length is present. This amputation is not advised because
of poor blood supply in the distal leg.
The level of tibial transaction should be as long as possible
between the tibial tubercle and the junction of the middle and distal thirds
of the tibia. A long posterior flap for transtibial amputations is
advantageous because it is well vascularized and provides an excellent
weight-bearing surface. In addition, the scar is on the anterior border, an
area that is subject to less weight bearing. The deep calf musculature is
often thinned to reduce the bulk of the posterior flap.
In a transtibial amputation, the fibula is transected 1 to 2 cm shorter
than the tibia to avoid distal fibula pain. If the fibula is transected at the
same length as the tibia, the patient senses that the fibula is too long,
which may cause pain over the distal fibula. If the fibula is cut too short,
a more conical shape, rather than the desired cylindrical – shape residual
limb results. The cylindrical shape is better suited for total contact
prosthetic fitting techniques. A bevel is placed on the anterior distal tibia
to minimize tibial pain on weight bearing. To avoid a painful neuroma, a
collection of axons and fibrous tissue, nerves should be identified, drawn
down, severed, and allowed to retract at least 3 to 5 cm away from the
areas of weight-bearing pressure.
A Syme amputation was named for James syme, a noted University of
Edinburg surgeon, in the mid-1800s. This amputation is an ankle
disarticulation in which the heel pad is kept for good weight bearing. The
Syme amputation results in a residual limb that possesses good function
due to the long lever arm to control the prosthesis and the ability to
ambulate without the prosthesis.
Associated problems with the Syme amputation include an
unstable heel flap, development of neuromas of the posterior tibial nerve,
and poor cosmesis. Performed properly, the residual limb is ideally suited
for weight bearing and lasts virtually the life of the patient.
The bulky residual limb that results from a Syme amputation may
be streamlined by trimming the remaining metaphyseal flares of the tibia
and fibula
Foot amputations levels are depicted in Figure 4. These include
the following:
• A transmetatarsal amputation (TMA) may be performed
for deformities resulting from trauma to the toes, infection or
gangrene due to frostbite, diabetes, arteriosclerosis, or autoimmune
circulatory connective tissue disorders. There are approximately
10,000 TMAs a year in the United States, with a failure rate of
about 30%. Of all the amputations done in the United Kingdom,
this amputation has the highest failure rate. This high failure rate is
due to a combination of substantial loss of weight-bearing areas on
the neuropathic foot and the decreased foot length available to
generate a plantarflexor moment. As a result, the remaining tissues
bear an increased load. This amputation should b elimited to
patients with an intact posterior tibial pulse, a warm foot, and
localization of osteomyelitis or gangrene to the phalanges. A dorsal
incision is made through the mid-to proximal metatarsal shafts. A
long, thick, myocutaneous plantar flap including the flexor tendons
is used, with closure of this flap onto the dorsum of the foot. The
transmetatarsal procedure is depicted in Figure. 1-20.
• The Lisfranc amputation is done at the tarsometatarsal joint
and involves a disarticulation of all five metatatarsal and digitis.
• The Chopart amputation, at the talonavicular and
clacaneocuboid joints, involves a disarticulation through the
midtarsal joint leaving only the clacaneus and talus. Both the
Lisfranc and Chopart amputations were introduced before blood
transfusions and antibiotics were available. They were planned as
diarticulations to be performed as rapidly as possible. These
amputations often result in an equines and varus deformity due to
the pull of the plantarflexors and loss of dorsiflexor and peroneal
muscles. In addition, a distal sensitive end often leads to skin
breakdown. There is much less indication for their use today.
• A trransphalangeal (toe disarticulation) amputation is done
at the metatarsophalangeal joint. Toe disarticulations result in
biomechnical deficiencies. Amputation of the great toe affects
push-off during fast walking and running; as a result, patients with
PVD often have a nonpropulsive gait pattern. If the base of the
proximal phalanx with the insertion of the flexor hallucis brevis
issaved, stability is enhanced. Second-digit amputation results in
severe hallux valgus.
• Phalangeal or partial toe amputation involves excision of
any part of one or more toes. The lesser toes serve little function in
patients with ischemic PVD. As a result, gait is not markedly
 affected with amputation of the lessor toes. Prosthesis is usually
not necessary for teo amputations.
In general, as much viable tissue as possible shouldbe preserved
after hand injury and partial amputation. This view must, however, be
tempered with an appreciation of what will remain functional. The
retention of a finger or part of one which is anaesthetic, cold and stiff
dose no service to the patient and will actively discourage use of the hand
and ability to work and, even after amputation, pain and a lack of desire
to return to normal function will persist.
2-Upper limb levels of amputation
Amputation of Digits
Generally the level will be determined by the degree of injury fig.5.
If the injury is solely to the index or little finger, useful function is
unlikely unless one and a half phalanges are still present. Even at this
level initial acceptance of this limited loss by the patient is often
transmuted into a desire for cosmesis and later amputation is requested.
The best cosmesis is achieved by amputation through the metacarpal
shaft with suitable beveling.This, however, reduces the span of the hand
and power of the grip and it may be better in largey manual workers to
amputate through the metacarpophalangeal joint.
The long and ring fingers are best amputated through whatever
level will leave a mobile and comfortable stump. Even a very short
stump, for example the proximal phalanx, may have some definite
functional value and in the half-closed position be at least cosmetically
acceptable. Amputations of either of these fingers in which the metatarsal
ray is excised for cosmetic reasons may seriously disturb function and are
seldom desirable.
As much of the thumb as can be must be preserved for as long as
possible. Any stump covered with sensititive skin may be of great value.
Wrist disarticulation
Indications for wrist disarticulation are rare but usually related to severe
trauma to the hand with considerable loss of tissue and loss of sensation.
Any tissue with sensation should be preserved. Even carpal bones and
remnants of metacarpals, providing they are covered by viable skin, may
be useful as the wrist extensors and flexor may be preserved as well.

The Forearm
The usual indications for amputation through the forearm are for
severe trauma affecting the wrist and hand and occasionally it is used as
treatment for chronic sepsis or tumour of the hand.
Ideally as with other amputations, the stump should be as long as
possible. A too distal amputation, however, whilst having the advantage
of a long lever and ease of fitting, often suffers from cold and cyanotic
skin with little subcutaneous and muscular tissue covering the bone ends.
Therefore the ideal distance is 17cm measured from the olecranon in the
average adult and this roughly corresponds to the junction of the proximal
two-thirds and the distal one-third of the forearm.
Occasionally the extent of the trauma or disease affecting the hand
and forearm may be too great to allow a useful below-elbow stump to be
fashioned. In the past conventional treatment would have been to
amputate at the level of the distal humerus but as a result of the recent
improvements in prosthetic design, disarticulation at the elbow is
preferable. It looks as though it will be possible, by retaining the bulbous
stump, to have a self-retaining socket and a better joint in the future.
Technique. The skin flaps will often be determined by whatever
skin is available but where possible qual anterior and posterior flaps
should be made the incisions beginning at the level of the humeral
epicondyles and extending distally 4 cm beyond the point of the
olecranon posteriorly and to point just distal to the insertion of the biceps
anteriorly.
Amputation through the Humerus
The commonest indication is severe truma of the forearm.
Occasionally this amputation may be used for sepsis or malignant
tumours. As elsewhere in the upper limb the level may be determined by
factors beyond the surgeon's control. The ideal is 10cm above the elbow
joint, which leaves room for the elbow mechanism in the prosthesis and
provides the best length of stump for fitting. Above this level as long a
stump as possible should be retained.
Amputation through the Neck of the Humerus
This operation does not leave the patient with any functional stump
and should not be performed when it is possible to leave a humeral stump
extending to three finger breadths below the anterior axillary fold. This is
the critical minimal length to which an upper limb.
Prosthesis can be fitted. It the amputation is being performed for
malignant tumour at the lower end of the humerus there is no alternative
but diarticulation at the shoulder joint. To leave the humeral head in situ
when it is permitted on pathological grounds, however, produces a better
cosmetic appearance, particularly when wearing clothes, by preserving
the rounded contour of the shoulder.
Shoulder disarticulation
The arm completely lost
Forequarter Amputation
Clavicle, scapula, and arm are excised. This amputation is rarely
performed and is indicated only for malignant tumours around the
shoulder joint, particularly where the tumour has spread into the
surrounding muscles so that the less mutilating procedures of
disarticulation of the shoulder or amputation through the neck of the
humerus are no longer practicable.

Fig .1 above knee levels of amputation

Fig. 2 Rotationplasty

Fig.3 transtibial (below knee) amputation

Fig.4 foot amputation levels

Fig.5 upper limb amputation levels