Introduction and General Principles
Robert G. Atnip, MD
T he feet and toes are surely among the most abused and
least appreciated regions of the human anatomy. There
are few structures in the body, indeed, even fewer man-made
devices or appliances, that are subjected to such intense re-
petitive, relentless punishment in such an unforgiving envi-
ronment, yet expected to perform without flaws. Though not
the only animal species capable of mobility on two feet, the
human is, nonetheless, the only species that is exclusively
bipedal and cannot fly. With human girth and mass showing
unprecedented increases of heretofore unimagined demo-
graphic proportions, it appears that the human foot will be
tested in the future more than it has ever been tested in the
past.
Only those with bad feet can truly appreciate the bliss of
having good feet. Yet bad feet and good feet alike are seldom
afforded the attention and respect that should be their due.
The good foot is expected to support a mass 200 to 300 times
its own, on a surface area no more than 1% of the body as a
whole, with such assumed performance and durability that
its owner will likely give it no conscious regard. The bad foot
is expected to heal quickly and completely, and preferably
while still in use. The inconvenience of a bad foot is one
which most persons tolerate poorly and with great impa-
tience. But rather than inspiring awe and reverence for the
miracles that the foot routinely performs, such temporary
disabilities more often provoke vexation and resentment at
the unwelcome interruption of mobility. So the host forces
his foot to function while dysfunctional, to heal while un-
healthy, and to again withstand the trauma and neglect that
caused the original problem. It is the fate of the feet and toes
to be taken for granted until catastrophe ensues, and even
beyond.
Advances in modern podiatry, plastic surgery, orthope-
dics, and vascular surgery offer hope and relief for the myriad
problems that beset the modern foot. Most such problems
can either be prevented, or alleviated with orthotic appli-
ances, or corrected with relatively minor surgery. Indeed,
many body parts, including the hips and knees, are ulti-
mately more likely than the foot to fail and require major
surgery. Unlike those structures, however, the foot cannot be
Penn State Hershey Medical Center, College of Medicine of the Pennsylvania
State University, 500 University Drive, Hershey, PA.
Address reprint requests to Dr. Robert G. Atnip, Professor of Surgery and
Radiology, Chief of Vascular Surgery, Penn State Hershey Medical Cen-
ter, College of Medicine of the Pennsylvania State University, 500 Uni-
versity Drive, Hershey PA 17033-2390. E-mail: ratnip@psu.edu
62 1524-153X/05/$-see front matter © 2005 Elsevier Inc. All rights reserved.
doi:10.1053/j.optechgensurg.2005.07.001
replaced. Irreversible disease or injury of the toes and feet
leads to amputation. Amputation surgery itself has advanced
in modern times, though perhaps not as dramatically as the
science of prosthetics. Fortunately, the end result for most
patients is a return to functional ambulation.1,2
The articles and illustrations in this journal present the
essential considerations and techniques for successful lower
extremity amputation, whether of a single toe or of the entire
limb. The methods depicted herein represent standard and
widely employed techniques for amputation surgery. As with
any surgical procedure, individual surgeons will modify their
technique as necessary to achieve optimal outcomes for each
individual patient.
Factors Leading to Amputation
Patients presenting for consideration of toe or partial foot
amputation typically have some combination of injury, ulcer-
ation, tissue necrosis, and infection. A variety of conditions
and factors exist that predispose to the occurrence of limb-
threatening tissue loss in the foot. In patients with diabetes
mellitus, the processes of infection, ischemia, and neuropa-
thy have been expressed as a combined “classic triad” of risk
factors, and many similar groupings could be proposed for
diabetics and nondiabetics alike. An alternate and helpful
way of organizing these many influences is to segregate them
into local and systemic categories.
Local Factors
Numerous inherent characteristics of the foot itself are re-
sponsible for its vulnerability to injury and infection. The
very purposes of the foot are to bear the weight of the body
and provide mobility, and the design of the foot is specific for
those purposes. The bony architecture provides surfaces that
tolerate high pressures by spreading them over as much area
as possible, while allowing the flexibility needed for all vari-
eties of locomotion. Some loss of that architecture can be
tolerated, but more so on the dorsal surface than the plantar.
Deformities that cause pressure points on the plantar surface
are the cause of much dysfunction, disability, and limb loss.
On the dorsal surface, weight bearing is less of an issue, but
an equally serious problem is the thinness of the skin and soft
tissue and relative lack of protection of the underlying ten-
dons, muscles, and joints. Full-thickness skin loss on the
dorsal surface can result in exposure and dessication of the
underlying fascia and tendons, often with few reconstructive
Introduction and general principles
options. Similar problems occur when ulcers develop over
joints on the dorsum of the toes or sides of the foot.
Although well padded on the plantar aspect, the calcaneus
is famously vulnerable on its posterior surface where soft
tissue coverage is much thinner. Decubitus ulcerations in this
area are typically full thickness, often down to the calcaneal
bone itself, and highly resistant to healing unless pressure
relief and optimal perfusion can be achieved.
In many patients, especially diabetics, limb loss is initiated
by seemingly trivial lesions on the toes. Ill-fitting footwear,
nail care accidents, and other minor trauma are the most
common causes, often in the setting of sensory loss and bony
deformity from diabetic polyneuropathy. Chronic fungal and
dermatophyte infections of the toes can act alone or with
other factors to trigger local skin injury and subsequent ne-
crotizing infections.
Patients and their physicians are equally culpable in failing
to recognize minor foot problems, and in failing to treat them
aggressively in the early reversible stages. Though persons
with normally innervated feet are exquisitely sensitive to pain
and pressure, those with neuropathic feet may be completely
unaware of even the worst noxious stimuli unless the injury is
detected visually. Even when blisters, ulcers, lacerations,
paronychiae and other warning signs are noticed and re-
ported, all too many physicians do not recognize these small
lesions for the great havoc that they can wreak, particularly in
the presence of ischemia and systemic disease.
Systemic Factors
Diabetes mellitus is unquestionably the dominant systemic
cause of major limb loss in adults. The risk of limb loss in
patients with this disease is many fold higher than in compa-
rable nondiabetic populations, owing to effects such as im-
munosuppression, neuropathy, and accelerated vascular dis-
ease. Ischemia and neuropathy have a greater incidence in
the lower extremity compared with other anatomic regions,
and clearly act in concert with local factors to promote injury,
infection, and necrosis of the foot and toes. Much remains
unknown regarding specific mechanisms of interaction be-
tween this disease and its host, perhaps in part because dia-
betes is not a single disease entity. Much attention has been
focused on the question of whether complications of diabetes
can be avoided or ameliorated by better glucose control. Yet
even with dramatic progress toward understanding diabetes,
key questions remain unanswered and key misconceptions
persist, especially as concerns the interplay of diabetes and
peripheral vascular disease.
In the classic triad of infection, neuropathy, and ischemia,
the latter entity may well be the least understood. The gaps in
knowledge begin at the level of basic science, but are perva-
sive in the clinical realm, where the difficulty lies not nearly
so much in a failure to know as in a failure to recognize and
apply that which is known. Although reconstructible athero-
sclerosis of the named axial arteries of the lower extremity is
the primary cause of ischemia in diabetics and nondiabetics
alike, a well-entrenched fallacy still circulates, even among
experienced clinicians, that nonreconstructible “small vessel
disease” of the foot is equally prevalent. Such a misperception
underlies a false belief that ischemia is untreatable, which in
turn allows it to go undiagnosed. In fact, the number of
63
effective treatment options for peripheral arterial disease has
never been greater, but there is much progress to be made in
making treatment available to those with limb-threatening
ischemia in time to prevent major tissue loss.
Other systemic factors that target the foot and toes are
becoming increasingly prevalent. Though not widely dis-
cussed in this particular context, obesity cannot be ignored as
a disease whose wide-reaching effects certainly include enor-
mous stress on feet that must support hundreds of pounds of
excess body mass. Obesity leads to increased trauma to the
feet, and promotes lipid disorders, hypertension and diabe-
tes. Obese patients are often physically unable to perform
adequate skin and nail care of the feet, and can develop
substantial edema due to venous or lymphatic insufficiency.
Obese patients pose daunting technical challenges for arterial
reconstructive surgery, but fare even worse with limb loss.
Finally, and in addition to the immunosuppression asso-
ciated with diabetes, there are numerous pharmacologic
agents that inhibit the immune system and thereby enhance
other processes that lead to skin breakdown and infection in
the feet. Corticosteroids, cyclosporin, methotrexate, plaque-
nil, and newer immune-targeted drugs not only lower resis-
tance to infection but may also impair tissue integrity, inhibit
healing, and even promote accelerated atherosclerosis.
General Principles
of Amputation
The desired end results of amputation are complete healing,
and restoration of function. An amputation is a reconstruc-
tive procedure, and as such requires precise and exacting
technique. For most patients, there will be no second chance
for healing, short of a second higher amputation, an outcome
both physically draining and emotionally devastating. Pa-
tients facing limb loss are keenly aware of this possibility, and
often fear it more than the primary procedure itself. Re-am-
putation can never be entirely prevented or avoided, and its
likelihood can only be minimized by the most rigorous sur-
gical judgment and technique.
The Decision to Amputate
Although generally viewed as the “last resort,” amputation is,
like all surgical procedures, one that will turn out best for the
patient if it is done for the right patient and the right reason at
the right time. Amputation must never be viewed as a default
procedure that is employed only after all other options have
been explored. Such a perception fails to recognize the re-
constructive nature of amputation surgery, and thus results
in grave disservice to the patient. Amputation must be among
the options considered by any clinician, medical and surgical
alike, called to treat the patient with serious infection, ulcer-
ation, ischemia, or injury of the lower extremity. In selected
cases, amputation should be the primary procedure. In all
others, the possibility of amputation should be incorporated
early into the physician’s thinking, to ensure that the chosen
treatment regimen does not needlessly compromise the
chance of successful amputation should the need arise.
Amputation is generally indicated to control refractory in-
fections, or to treat pathology of the foot that is either irre-
versible or so far advanced that healing of a functional foot is
64
not feasible. Amputation is usually an elective procedure, but
may become urgent in cases of aggressive local sepsis, espe-
cially if accompanied by systemic toxicity. In such cases, the
patient may require open or guillotine amputation to limit
the spread of infection or to avert life-threatening sepsis. The
level and extent of amputation in these circumstances will be
dictated by both local and systemic factors, but must be cho-
sen to ensure swift and effective reversal of the septic process.
Thorough drainage of deep space infections and debride-
ment of wet gangrene are essential to halt propagation of the
infection. Aggressive initial surgery in these patients will usu-
ally preserve ultimate limb length and function rather than
compromise them.
In the more typical elective amputation, the surgeon’s goal
is to select the level of amputation that will optimize both
healing and function, with the recognition that in most cases,
these dual requirements are at cross purposes. In the pres-
ence of normal perfusion to the foot, the patient will, as a
rule, obtain optimal function from an amputation that spares
as much length and tissue as is technically possible. Contrari-
wise, in the face of trauma, ischemia, or any other circum-
stance that compromises tissue perfusion, the surgeon must
face a fundamental dilemma: the chance of healing and the
chance of function vary inversely with one another. Perfusion
and healing improve with higher amputations, while func-
tion will steadily decline. In each such patient, therefore, the
surgeon will need to carefully analyze the arterial flow to the
limb, optimize it however possible, and then essentially pri-
oritize between function and healing. Factors to be consid-
ered in this process include a detailed knowledge of the pa-
tient’s psychosocial history, past and current functional
status, general medical condition, rehabilitation potential,
and an objective assessment of the healing potential of the
selected amputation level(s).
Much has been written about choice of amputation level,
but as yet, no specific tool or technology has proven any more
accurate than the combination of physical examination and
bedside Doppler. Basic surgical principles dictate that ampu-
tations are not likely to heal if performed through or near
zones of active cellulitis, suppuration, severe ischemia, or
frank necrosis. The severity of all these conditions can typi-
cally be determined by careful physical examination. In the
case of ischemia, however, additional useful information can
be obtained with a portable continuous-wave Doppler, sup-
plemented if necessary by simple noninvasive testing, such as
photoplethysmography (PPG) and transcutaneous oximetry
(TCpO2). Other more sophisticated studies such as laser
Doppler velocimetry and Xenon perfusion are much less
widely used, and do not appear to offer any greater accuracy
of prediction.3
Bedside doppler examination includes quantitative (ankle
systolic pressure, ASP) and qualitative (signal quality) infor-
mation, which both complement and objectify the basic pal-
pation of femoral, popliteal, and pedal pulses. A manual
pulse examination is essential, and can be surprisingly accu-
rate in predicting healing. At any chosen level, the presence
of a palpable pulse at the nearest proximal joint is associated
with healing rates of 90% or higher, whereas those rates drop
significantly if pulses are palpable only at two or more joints
removed from the selected site. Studies have differed as to the
exact relationship between ankle pressure (or ankle-brachial
R.G. Atnip
index, ABI) and the success of healing, but most surgeons
would attempt a toe or partial foot amputation in a nondiabetic
if the ASP were greater than 80 mm Hg, and there were no
other contraindications. As ASP is often inaccurate or not
measurable in diabetics with calcified tibial arteries, the cli-
nician will often find toe systolic pressures or PPGs more
helpful. Toe pressures greater than 40 mm Hg correlate with
improved healing, as do pulsatile PPG tracings. The useful-
ness of transcutaneous oximetry is debatable, due to a rather
wide range of indeterminate values.
The possibility of limb amputation should enter early into
the thinking of those caring for the patient with a threatened
limb, but should only be enacted after the most thoughtful
and deliberate analysis, a process which must include the
patient and family. Uncertainty of outcome is a given. In that
context, however, the surgeon’s efforts to ensure healing and
preserve function must be based on as much objective infor-
mation as possible, and on the exercise of consummate judg-
ment and technical skill.
General Technical Principles
General
Amputation surgery has never been and is not likely to be-
come a popular pursuit among surgeons of any specialty. It is
neither especially challenging nor sophisticated, and does
not require advanced technology. In the era of advanced
endoscopic surgery, complex endovascular intervention,
joint replacement, and nearly miraculous plastic reconstruc-
tive surgery, amputation surgery seems to have changed little
since the 19th century. It is no exaggeration to argue that the
persisting stereotype of major limb amputation is that of the
Civil War battlefield.4 Amputation surgery is distasteful and
disturbing to many physicians (and quite a few surgeons),
and is abhorrent for most persons to contemplate. Yet, when
done successfully and well, amputation is not just recon-
structive, but also redemptive, capable of transforming recal-
citrant suffering and incapacitation into healing and rehabil-
itation, albeit, at a great and nonrefundable cost. To this
endeavor, the surgeon must apply every skill at his or her
disposal.
In performing an amputation, the surgeon must transect,
ablate, cauterize, and sever, often with large instruments and
bold strokes. But in the same procedure, the surgeon must
debride, smooth, sculpt and re-shape, with movements both
precise and delicate. It is essential not only to possess each set
of skills, but to know when each is needed. Whether a step in
the procedure calls for strength or subtlety, every sequence of
action must be performed with control and clear intention. In
amputations, as in many types of surgery, there is a high price
for haste and carelessness. By long tradition, amputation sur-
gery is often the first procedure performed by novice surgical
trainees, but there is no better time than the beginning for
these young surgeons to learn under close supervision that
amputation requires no less skill and no less attention than
the more advanced procedures they will learn later in train-
ing.
Soft Tissue
The single most important technical aspect of amputation (at
any level) is careful handling of tissue. Even the ablative
Introduction and general principles
aspects of the procedure must be done with as little injury to
the transected edges as possible. Virtually all patients who
require amputation have impaired tissue integrity, to which
is added the unavoidable injury of the amputation itself. Yet,
with appropriate technique, the degree and extent of injury
can be controlled. Proper use of the proper tools will enable
the surgeon to divide tissues cleanly, rather than tearing,
breaking, avulsing, or crushing. Particular attention is neces-
sary to protect the skin edges from careless blunt or sharp
injury, which can lead to failure of primary healing. It is
strongly recommended to avoid use of forceps on the skin
edges at any time during an amputation.
One of the more common technical and judgmental errors
in amputation surgery is attempted wound closure under
tension, an error usually culminating in stump breakdown.
Avoiding this error requires forethought from the beginning
of the case, and careful planning throughout. Flaps must be
designed to allow closure without tension. If there is serious
doubt that this can be accomplished, the surgeon should
consider a different method, or even a more proximal ampu-
tation. Once committed, however, the surgeon should take
whatever additional time is necessary to sculpt the flaps and
successfully close them. Helpful maneuvers may include fur-
ther shortening and recessing of bone stumps, and judicious
debulking of soft tissues, as long as blood supply is not com-
promised.
Bone
The steps of dividing and shaping the bones must be handled
differently in each amputation, but some general concepts
apply. Bones should be transected through the shaft, and
amputations through joints should generally be avoided. Ar-
ticular cartilage receives its oxygen and nutrient supply from
the synovial fluid, and is at high risk for necrosis if the artic-
ular surface is left intact within an amputation wound. Al-
though this particular problem can be averted by removing
the exposed cartilage, an equally significant problem is that
bony articular prominences generally do not make good am-
putation stumps.
Bones should be methodically stripped of their perios-
teum, and then transected cleanly with minimal splintering
and fragmentation. Any bone fragements and splinters must
be removed from the wound. Bone edges should be meticu-
lously smoothed, especially in those areas that will lie closest
to the skin. In some cases, beveling of the bone stump is
advisable to avoid sharp edges and pressure points, such as
on the plantar surface of the foot. At every step, the surgeon
must be aware that orthopedic instruments (saws, drills, os-
teotomes, rongeurs, etc.) have great capacity to damage ad-
jacent soft tissues if used carelessly.
Wound Closure
The meticulous technique employed in the performance of
an amputation must be carried through to placement of the
very last suture. Whether due to trauma, ischemia, local in-
fection and inflammation, age, or other factors, the skin of an
amputation stump is seldom normal and healthy. Yet, the
success of the entire procedure often depends on that skin’s
ability to heal. Careless and indiscriminate handling of the
65
skin and soft tissues during closure can easily cause an oth-
erwise successful amputation to fail.
The skin is, in fact, often the only tissue layer that can be
readily closed. When a digit or some part of the foot has been
amputated, the surgeon is typically confronted with one or
more bone stumps surrounded by transected joint capsule,
tendons, fascia, muscle, and subcutaneous fat. Depending on
the length of bone stump available, it may be possible to
recess the stump deep enough to allow separate closure of the
fascia or muscle over the bone. The advantages of deep clo-
sure— coverage of bone and elimination of dead space—are
substantial. Not infrequently, however, the level of resection
is such that the surgeon must be satisfied with a single layer
skin closure, trusting that the deeper tissues will be coapted
by default.
Specific techniques for closure of the skin vary widely and
are largely the province of personal preference. The author
finds much to recommend in an interrupted nylon, either
simple or vertical mattress, placed without use of forceps and
reinforced by fine Steri-strips. Subcuticular closure or skin
staples are popular in some quarters, although these methods
require more handling of the skin. Whatever method is used,
the goal should be precise alignment and apposition of skin
edges to create the best opportunity for primary healing.
Failure of the skin and subcutaneous tissues to heal primarily
is an ominous development, usually resulting in wound de-
hiscence and portending greater tissue loss.
The need may occasionally arise to place a wound drain in
an amputation stump, but only if clearly indicated. Standard
measures should be employed to obtain hemostasis, includ-
ing direct pressure, judicious use of the electrocautery, topi-
cal use of local anesthetics containing dilute epinephrine, and
of course ligation of vessels. Even oozing wounds will usually
stop bleeding on re-approximation and closure of the tissues,
particularly if a bulky dressing is applied for added tampon-
ade. If a drain is necessary, it should be inserted through a
separate stab wound, not through the suture line of the
stump; it should be positioned to drain dependently, and
should be removed within 48 hours. Suction drains are pre-
ferred to passive drains. A temporary vacuum dressing with
delayed primary closure may be considered in some circum-
stances.
Dressings
The dressing of amputation stumps is often a matter of reli-
gion more than science. Practitioners adopt their favorite
dressings through training and experience, and then adhere
to them fervently. Dressings can be soft or rigid, small or
large, occlusive or open. A good dressing will pad and protect
the stump, inhibit seromas and hematomas, absorb drainage,
immobilize joints, serve as a barrier to contamination, and in
all these ways, generally promote healing. Any given type of
dressing can succeed or fail to accomplish these goals de-
pending on how it is applied. The most common and costly
error in dressing technique is to wrap the dressing too tightly,
resulting in pressure necrosis of the stump or adjacent areas,
which at best will delay healing, and at worst may require
re-amputation. Areas at risk for this complication include the
dorsum of the foot, the malleoli, the heel, and the patella.
Preventive measures include proper technique in applying
66
the dressing, and early frequent dressing changes with skin
inspection, especially if the patient complains of more pain
than expected.
Open amputation stumps are generally handled differently
from closed stumps, with great variation in individual prac-
tice. The method chosen may depend on whether the sur-
geon’s intention is for early revision, delayed primary closure,
or secondary closure. The use of vacuum-assisted closure
techniques has become increasingly popular.
Postoperative Activity
Postoperative care routines are, again, very surgeon- and am-
putation-specific. Patient positioning, allowed activity, com-
mencement of physical therapy and weight bearing, use of
antibiotics, and prophylaxis of deep vein thrombosis are all
matters of surgical judgment. A solemn reminder for all care-
givers is that patients undergoing limb amputation are
known to be at high risk for eventual loss of the contralateral
limb due to the same factors that caused ipsilateral disease. Of
these factors, one is nosocomial, insidious, and completely
preventable: the calcaneal decubitus ulcer. It is thus impera-
tive that patients who are at bedrest following amputation,
R.G. Atnip
especially those with diabetic neuropathy, must be provided all
available measures to protect their heel(s) from pressure ne-
crosis. Although a panoply of soft mattresses and foot appli-
ances are available to pad the heels, the only fully reliable way
to prevent decubitus ulceration is to avoid all contact and
pressure on the area in question. In the case of the heels, this
can be accomplished by placing pillows under the calf and
ankle such that the heel is not in contact with any surface. In
combination with a well-padded appliance such as the
Rooke® boot, and with attentive nursing care, this simple
measure will effectively prevent serious decubitus lesions of
the heel.
References
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From surgery to community reintegration. Disabil Rehabil 26:831-836,
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2. Persson B: Lower limb amputation. Part 1: Amputation methods—a 10
year literature review. Prosthet Orthot Int 25:7-13, 2001
3. Smith DG: Amputation. Preoperative assessment and lower extremity
surgical techniques. Foot and Ankle Clinics 6:271-296, 2001
4. Sachs M, Bojunga J, Encke A: Historical evolution of limb amputation.
World J Surg 23:1088-1093, 1999