This document discusses different types and procedures for lower limb amputations. It describes minor amputations like transphalangeal toe amputation and transmetatarsal amputation, which aim to preserve foot function. Major amputations include below knee (BKA), above knee, and through knee disarticulation. The Burgess technique is described for BKA, involving a myocutaneous flap from gastrocnemius and soleus muscles. Above knee amputation involves a transverse incision and ligation of the superficial femoral artery and sciatic nerve division. Postoperative management focuses on wound healing and prosthetic fitting.

1. Lower limb amputation
Dr Suhas U

2. Indications
• Trauma( younger age)
• Infection
• Diabetic foot( adults ) – M/C
• Malignancy
• Deformed or paralysed limb
• Congenital abnormalities

3. Types
• Guillotine / open amputation
Skin not closed over the amputation stump
Non healthy wounds
Followed by second surgery
 Secondary closure
 Plastic surgery
 Revision of stump and reconstruction
 Reamputation
• Closed amputation
Skin closed primarily
Elective amputations

4. • Minor amputations
Transphalangeal toe amputation
Transmetatarsal (Ray) toe amputation
Transmetatarsal foot amputatrion
• Major amputations
Below knee
Above knee
Through knee disarticulation

5. Minor amputations
Goals
• Remove anatomic pressure points and prevent
recurrent ulceration
• Control osteomyelitis and infection
• Preserve and restore the foot to optimum
ambulatory function
• Control and releive pain

6. Indications
• Simple toe amputation
Irreversible tissue loss / osteomyelitis of one toe distal to
proximal interphalangeal joint
• Ray amputation
Disease extends to web space/ MTP joint / Metatarsal
head
• Transmetatarsal amputation
Disease extending beyond single ray amputation
Need for multiple ray amputation
Failed previous ray amputation
Forefoot deformity causing severe disability and
intractable pain

7. Contraindications
• Extensive tissue loss on plantar aspect
• Untreatable foot ischemia
Anaesthesia
• Local/regional block

8. Transphalangeal toe amputation
• Incision
Mid proximal phalanx to the level of bone
Circumferencial incision
Plantar flap in 1st toe
• Stripping of periosteum
• Transection of bone with oscillating saw
1cm proximal to skin
• Tendons pulled and sharply cut to retract
• Skin is closed in anteroposterior orientation

10. Ray amputation
• Incision
Racquet shape incision on dorsum
Extending on each side of toe in semielliptical
fashion
Ratio of incision length to width of 3:1 – aids in
primary closure
• Deepened till bone
• Toe disarticulated at MTP joint

11. • Periosteum of bone elevated proximally
• Metatarsal head is excised at proximal
diaphyseal end using oscillating saw/ bone
nibbler
• Cut ends smoothened with bone file
• Wound irrigation
• Primary closure / left open for daily dressing

13. First toe ray amputation
• Two curvilinear lines on
both dorsal and plantar
aspect extending down to
the level of bone , exposing
metatarsal head.
• Flexor hallucis tendon and
sesamoids are sacrificed
• Shaft of metatarsal cut
obliquely
• Usually heal by secondary
intension

14. Transmetatarsal amputation
• Exsanguination and tourniquet application
• Incision
Transverse incision on dorsum at mid metatarsal level
Right angle turn at medial aspect of foot
Incision on plantar aspect at MTP joint level
• Sharply carried through tendons and neurovascular
structures
• Dorsalis pedis artery ligated
• Tendons examined for collection, pulled and cut

15. • Periosteum elevated on metatarsal till intended
resection
• Retract skin flaps and cut the bone with oscillating gigli
saw 2cm proximal to skin incision
• Insertion of peroneus longus, brevis and and tibialis
brevis preserved
• First and fifth metatarsal transected in oblique fashion
• 2nd to 4th metatarsal cut in parabolic fashion with long
dorsal and bevelled plantar

17. • Flexor tendons are cut
• Tourniquet released
• Irrigation and hemostasis
• Drain depending on bleeding
• Skin closed with mattress
• Dressing uptil midleg
• Limb splinted in neutral position to prevent equinus
contracture

18. Postoperative management
Simple toe / ray amputation
• Early mobilisation and evaluation by prosthetist for
shoe fitting
Transmetatarsal amputation
• Non weight bearing mobilisation until wound heals
completely
• Drain removal in 24-48hours
• Suture till 2-4weeks
• Once mobilisation – monitoring for transfer ulcers

19. Major lower limb amputations
Indications
• Acute limb ischemia
• Chronic critical limb ischemia
• Major infection in diabetics

20. Guillotine amputation
• Question regarding uncontrolled pedal sepsis
• Two staged amputation is planned
• Advantages
Remove septic focus quickly
Direct examination of calf muscle compartments
for septic extension
BKA can be planned once infection resolves

22. • Limb prepped till knee
• Circular incision above the malleolus down to
tibia and fibula
• Bones cut with gigli saw
• Vascular bundles are ligated
• Irrigation and hemostasis
• Bulky dressings apllied

23. Below knee amputation
Burgess technique
• Most frequently used technique
Principle
• Well vascularised myocutaneous flap consisting of
gastrocnemius , partial soleus and posterior skin

24. • Supine position
• Limb is prepped to groin level
Incision
• Anterior skin incision 12cm below tibial tuberosity
• Continued transversely for a distance approximately
one third of calf circumference
• Incision extended along vertical axis length
approximately one and half times length of transverse
incision
• Posterior flap then completed transversely

26. • Skin incision is deepened through fascia with ligation of GSV
Anterior compartment dissection
• Muscles divided at same level
• Tibialis anterior, extensor hallucis longus and extensor
digitorum longus,fibularis longus
• Central in anterior compartment
• Anterior tibial vessels and peroneal nerve

28. Transection of bones
• Tibia cleared of lateral and posterior attachments
• Interroseus membrane incised
• Division of tibia at skin incision level with anterior bevelling
• Lateral compatment muscles (fibularis longus and brevis )
divided
• Fibula is transected 2cm proximal to level of tibial transection

29. Posterior compartment
• Muscles divided obliquely with removal of enough soleus
• Posterior tibial and peroneal vessels ligated
• Bone edges are smoothened
• Fascial edges are closed with interruppted absorbable sutures
with or without drain
• Skin closed with mattress suture

32. Through knee disarticulation
• Equal anterior and posterior fasciocutaneous flap
• Extending approximately 2/3rd of diameter of leg in length
• Incision extended through collateral, medial, lateral and crutiate
ligaments
• Hamstring tendons transected
• Tibial nerve , peroneal nerve and popliteal vessels
• Patellar tendon separated from tibia and sutured to crutiate
ligaments
• Hamstring tendons to femoral condyles
• Fascial sutures with absorbable and skin with interrupted nylon
sutures

33. Above knee amputation
Indication
• Amputation with a fixed-knee contracture
• A nonfunctional limb, or
• Insufficient circulation to heal a BKA

35. • Transverse fish-mouth incision in the lower thigh. Deepened through
the subcutaneous tissue to allow the edges to separate
• The greater saphenous vein needs to be identified and ligated.
• The dissection is carried down to the femur, which is cleared using a
periosteal elevator to a level 2 to 3 cm proximal to the skin incision.
• The superficial femoral artery is dissected free and suture ligated.
• The bone is transected with a gigli saw, and the posterior muscle flap
is divided.

36. • The sciatic nerve is identified and pulled ,highly ligated, and
divided.
• Irrigated and hemostasis ensured.
• The fascia is then closed with absorbable suture.
• The subcutaneous tissue is closed with absorbable suture to
minimize tension on the skin edges and the skin is closed with
monofilament suture or staples.
• Alternative incisions can be made to accommodate surgical
wounds.