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Amputations of the Lower Extremity

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Interventional Treatment of Wounds

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Abstract

Non-traumatic amputations of the lower extremities are a consequence of various medical conditions. The two most common etiologies which lead to lower extremity amputations are peripheral arterial disease and infections. For patients with lower extremity pathology of an ischemic etiology, endovascular and reconstruction options are critical to favorable long-term outcomes. When these corrective measures are exhausted, amputations may become essential. Chronic soft tissue and osseous infections as well as acute infections in the unstable septic patient that require operative management increase the risk of lower extremity amputations. The patient populations most prone to develop both peripheral arterial disease and infections are those with advanced age, smokers, immune compromise, diabetes mellitus, and patients with renal disease. When peripheral polyneuropathy is encountered, patients are at the highest risk for lower extremity amputations. A thorough algorithm provides both the clinician and the patient with the opportunity to moderate disease, mitigate risk, and implement a management strategy that incorporates postoperative function and ambulation as the primary objectives.

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References

  1. Banks M. The surgeon of old in war. JAMA. 1897 Oct;29(14):665–7.

    Article  Google Scholar 

  2. Moxey PW, Gogalniceanu P, Hinchliffe RJ, Loftus IM, Jones KJ, Thompson MM, Holt PJ. Lower extremity amputations – a review of global variability in incidence. Diabet Med. 2011 Oct;28(10):1144–53.

    Article  CAS  PubMed  Google Scholar 

  3. Economides JM, DeFazio MV, Attinger CE, Barbour JR. Prevention of painful neuroma and phantom limb pain after transfemoral amputation through concomitant nerve coaptation and collagen nerve wrapping. Neurosurgery. 2016 Sept;79(3):508–13.

    Article  PubMed  Google Scholar 

  4. Attinger CE, Brown BJ. Amputation and ambulation in diabetic patients: function is the goal. Diabetes Metab Rev. 2012 Feb;28(Suppl 1):93–6.

    Article  Google Scholar 

  5. Weledji EP, Fokam P. Treatment of the diabetic foot – to amputate or not? BMC Surg. 2014;14:83.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Nather A, Wong KL. Distal amputations for the diabetic foot. Diabet Foot Ankle. 2013;4:10.

    Article  PubMed Central  Google Scholar 

  7. Altemeier WA, Fullen WD. Prevention and treatment of gas gangrene. JAMA. 1971;217(6):806–13.

    Article  CAS  PubMed  Google Scholar 

  8. Price P. The diabetic foot: quality of life. Clin Infect Dis. 2004;39(Suppl 2):S129–31.

    Article  PubMed  Google Scholar 

  9. Raspovic KM, Hobizal KB, Rosario BL, Wukich DK. Midfoot charcot neuroarthropathy in patients with diabetes: the impact of foot ulceration on self-reported quality of life. Foot Ankle Spec. 2015 Aug;8(4):255–2559.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Beaulieu RJ, Grimm JC, Lyu H, Abularrage CJ, Perler BA. Predictors for readmission and reamputation following minor lower extremity amputation. J Vasc Surg. 2015 Jul;62(1):101–5.

    Article  PubMed  PubMed Central  Google Scholar 

  11. Hobizal KB, Wukich DK. Diabetic foot infections: current concept review. Diabet Foot Ankle. 2012 Jan;1;3(1):18409.

    Google Scholar 

  12. Yazdanpanah L, Nasiri M, Adarvishi S. Literature review on the management of diabetic foot ulcer. World J Diabetes. 2015 Feb 15;6(1):37–53.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Fernandez A, Schillinger D, Warton EM, Adler N, Moffet HH, Schenker Y, Salgado MV, Ahmed A, Karter AJ. Language barriers, physician-patient language concordance, and glycemic control among insured latinos with diabetes: the diabetes study of northern California. J Gen Intern Med. 2011 Feb;26(2):170–6.

    Article  PubMed  Google Scholar 

  14. Glaser JD, Bensley RP, Hurks R, Dahlberg S, Hamdan AD, Wyers MC, Chaikof EL, Schermerhorn ML. Fate of the contralateral limb after lower extremity amputation. J Vasc Surg. 2013 Dec;58(6):1571–7.

    Article  PubMed  Google Scholar 

  15. Boulton AJM. Management of diabetic peripheral neuropathy. Clin Diabetes. 2005 Jan;23(1):9–15.

    Article  Google Scholar 

  16. Singh N, Armstrong DG, et al. Preventing foot ulcers in patients with diabetes. JAMA. 2005;293:217–28.

    Article  CAS  PubMed  Google Scholar 

  17. Muller LM, Gorter KJ, Hak E, Goudzwaard WL, Schellevis FG, Hoepelman AI, et al. Increased risk of common infections in patients with type 1 and type 2 diabetes mellitus. Clin Infect Dis. 2005;41:281–8.

    Article  CAS  PubMed  Google Scholar 

  18. Caselli A, Pham H, Giurini JM, Armstrong DG, Veves A. The forefoot-to-rearfoot plantar pressure ratio is increased in severe diabetic neuropathy and can predict foot ulceration. Diabetes care. 2002 Jun;1;25(6):1066–71.

    Google Scholar 

  19. Apelqvist J, Ragnarson-Tennvall G, Larsson J, Persson U. Long-term costs for foot ulcers in diabetic patients in a multidisciplinary setting. Foot Ankle Int. 1995 Jul;16(7):388–94.

    Article  CAS  PubMed  Google Scholar 

  20. Mold JW, Vesely SK, Keyl BA, Schenk JB, Roberts M. The prevalence, predictors, and consequences of peripheral sensory neuropathy in older patients. J Am Board Fam Med. 2004 Sep-Oct;17(5):309–18.

    Article  Google Scholar 

  21. Partanen J, Niskanen L, Lehtinen J, Mervaala E, Siitonen O, Uusitupa M. Natural history of peripheral neuropathy in patients with non-insulin-dependent diabetes mellitus. N Engl J Med. 1995 Jul 13;333(2):89–94.

    Article  CAS  PubMed  Google Scholar 

  22. Marchettini P, Lacerenza M, Mauri E, Marangoni C. Painful peripheral neuropathies. Curr Neuropharmacol. 2006 Jul;4(3):175–81.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  23. Lavery LA, Armstrong DG, Vela SA, Quebedeaux TL, Fleischli JG. Practical criteria for screening patients at high risk for diabetic foot ulceration. Arch Intern Med. 1998 Jan 26;158(2):157–62.

    Article  CAS  PubMed  Google Scholar 

  24. Duby JJ, Campbell RK, Setter SM, White JR, Rasmussen KA. Diabetic neuropathy: an intensive review. Am J Health Syst Pharm. 2004 Jan 15;61(2):160–73.

    CAS  PubMed  Google Scholar 

  25. Semel JD, Goldin H. Association of athlete’s foot with cellulitis of the lower extremities: diagnostic value of bacterial cultures of ipsilateral interdigital space samples. Clin Infect Dis. 1996 Nov;23(5):1662–164.

    Article  Google Scholar 

  26. Shammas NW. Epidemiology, classification, and modifiable risk factors of peripheral arterial disease. Vasc Health Risk Manag. 2007 Apr;3(2):229–34.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Fowler MJ. Microvascular and macrovascular complications of diabetes. Clin Diabetes. 2008 Nov;26(2):77–82.

    Article  Google Scholar 

  28. Taylor LM, Hamre D, Dalman RL. Limb salvage vs amputation for critical limb ischemia: the role of vascular surgery. Arch Surg. 1991;126(10):1251–8.

    Article  PubMed  Google Scholar 

  29. Attinger CE, Bulan E, Blume PA. Surgical debridement. The key to successful wound healing and reconstruction. Clin Podiatr Med Sug. 2000;17:599–630.

    CAS  Google Scholar 

  30. Lam K, van Asten SA, Nguyen T, La Fontaine J, Lavery LA. Diagnostic accuracy of probe to bone to detect osteomyelitis in the diabetic foot: a systematic review. Clin Infect Dis. 2016 Oct 1;63(7):944–8.

    Article  PubMed  Google Scholar 

  31. Lazaro-Martinez JL, Aragon-Sanchez J, Garcia-Morales E. Antibiotics versus conservative surgery for treating diabetic foot osteomyelitis: a randomized comparative trial. Diabetes Care. 2014;37(3):789–95.

    Article  PubMed  Google Scholar 

  32. Faglia E, Clerici G, Caminiti M, Curci V, Somalvico F. Influence of osteomyelitis location in the foot of diabetic patients with transtibial amputation. Foot Ankle Int. 2013 Feb;34(2):222–7.

    Article  PubMed  Google Scholar 

  33. Jeffcoate WJ, Lipsky BA. Controversies in diagnosing and managing osteomyelitis of the foot in diabetics. Clin Infect Dis. 2004;39(Supplement_2):S115–22.

    Article  PubMed  Google Scholar 

  34. Roukis TS, Singh N, Andersen CA. Preserving functional capacity as opposed to tissue preservation in the diabetic patient: a single institution experience. Foot Ankle Spec. 2010 Aug;3(4):177–83.

    Article  PubMed  Google Scholar 

  35. Sage RA. Biomechanics of ambulation after partial foot amputation: prevention and management of reulceration. J Prosthet Orthot. 2007 Jul;19(8):P77–9.

    Article  Google Scholar 

  36. Rinonapoli G, Ceccarini P, Altissimi M, Caraffa A. Critical appraisal of foot and ankle amputations in diabetes. Clin Res Foot Ankle. 2014;S3:005.

    Google Scholar 

  37. Oliver NG, Attinger CE, Steinberg JS, Evans KK, Vieweger D, Kim PJ. Influence of hallux rigidus on reamputation in patients with diabetes mellitus after partial hallux amputation. J Foot Ankle Surg. 2015;54(6):1076–80.

    Article  PubMed  Google Scholar 

  38. Quebedeaux T, Lavery L, Lavery D. The development of foot deformities and ulcers after great toe amputation in diabetes. Diabetes Care. 1996;19:165–7.

    Article  CAS  PubMed  Google Scholar 

  39. Elmarsafi T, Oliver NG, Steinberg JS, Evans KK, Attinger CE, Kim PJ. Long-term outcomes of permanent cement spacers in the infected foot. J Foot Ankle Surg. 2017 Mar;56(2):287–90.

    Article  PubMed  Google Scholar 

  40. Landry GJ, Silverman DA, Liem TK. Predictors of healing and functional outcomes following transmetatarsal amputations. Arch Surg. 2011;146(9):1005–9.

    Article  PubMed  Google Scholar 

  41. Thorud JC, Jupiter DC, Lorenzana J, Nguyen TT, Shibuya N. Reoperation and reamputation after transmetatarsal amputation: a systematic review and meta-analysis. J Foot Ankle Surg. 2016 Sep-Oct;55(5):1007–12.

    Article  PubMed  Google Scholar 

  42. Garwood CS, Steinberg JS. Soft tissue balancing after partial foot amputations. Clin Podiatr Med Surg. 2016 Jan;33(1):99–111.

    Article  PubMed  Google Scholar 

  43. Boffeli TJ, Thompson JC, Waverly BJ, Pfannenstein RR, Mahoney KJ. Incidence of clinical significance of heterotopic ossification after partial ray resection. J Foot Ankle Surg. 2016 Jul-Aug;55(4):714–9.

    Article  PubMed  Google Scholar 

  44. Aulivola B, Hile CN, Hamdan AD, Sheahan MG, Veraldi JR, Skillman JJ, Campbell DR, Scovell SD, LoGerfo FW, Pomposelli FB Jr. Major lower extremity Amputation Outcome of a modern series. Arch Surg. 2004;139(4):395–9.

    Article  PubMed  Google Scholar 

  45. Waters RL, Perry J, Antonelli D, Hislop H. Energy cost of walking of amputees: the influence of level of amputation. J Bone Joint Surg Am. 1976 Jan;58(1):42–6.

    Article  CAS  PubMed  Google Scholar 

  46. Bosse MJ, Morshed S, Reider L, Ertl W, Toledano J, Firoozabadi R, Seymour RB, Carroll E, Scharfstein DO, Steverson B, MacKenzie EJ. Transtibial amputation outcomes study (TAOS): comparing transtibial amputation with and without a tibiofibular synostosis (Ertl) procedure. J Orthop Trauma. 2017 Apr;31(Suppl 1):S63–9.

    Article  PubMed  Google Scholar 

  47. Morse BC, Cull DL, Kalbaugh C, Cass AL, Taylor MD. Through-knee amputation in patients with peripheral arterial disease: a review of 50 cases. J Vasc Surg. 2008 Sep;48(3):638–43.

    Article  PubMed  Google Scholar 

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Authorship Role, Participation, and Acknowledgments

  1. 1.

    Joseph Park: Provided substantial contributions to conception and design; acquisition of data, analysis, and interpretation of findings; drafting the article and revising it critically for important intellectual content; and final approval of the version to be published.

  2. 2.

    Tammer Elmarsafi: Provided substantial contributions to conception and design; acquisition of data, analysis, and interpretation of findings; drafting the article and revising it critically for important intellectual content; and final approval of the version to be published.

  3. 3.

    John S. Steinberg: Provided substantial contributions to conception and design; acquisition of data, analysis, and interpretation of findings; drafting the article and revising it critically for important intellectual content; and final approval of the version to be published.

  4. 4.

    Jocelyn Lu: MS4 Georgetown University School of Medicine – A special thank you for her contribution in clinical photography and video editing.

Financial Disclosures

Joseph Park, Tammer Elmarsafi, and John S. Steinberg have no financial disclosures, commercial associations, or any other conditions posing a conflict of interest to report.

Author information

Authors and Affiliations

  1. Division of Podiatric Surgery, MedStar Washington Hospital Center, 110 Irving Street NW, Washington, DC, 20010, USA

    Joseph Park DPM

  2. Department of Plastic Surgery, MedStar Georgetown University Hospital, 3800 Reservoir Road NW, Washington, DC, 20007, USA

    Tammer Elmarsafi DPM, MBBCh & John S. Steinberg DPM, FACFAS

  3. Department of Plastic Surgery, Center for Wound Healing and Hyperbaric Medicine, MedStar Georgetown University Hospital, 3800 Reservoir Road NW, Washington, DC, 2007, USA

    John S. Steinberg DPM, FACFAS

Authors
  1. Joseph Park DPM
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  2. Tammer Elmarsafi DPM, MBBCh
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  3. John S. Steinberg DPM, FACFAS
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Corresponding author

Correspondence to John S. Steinberg DPM, FACFAS .

Editor information

Editors and Affiliations

  1. Division of Plastic Surgery, Brigham and Women’s Hospital Harvard Medical School, Boston, Massachusetts, USA

    Dennis P. Orgill

Electronic Supplementary Material

BKA Amputee: Independent Ambulation (MP4 870 kb)

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Park, J., Elmarsafi, T., Steinberg, J.S. (2018). Amputations of the Lower Extremity. In: Orgill, D. (eds) Interventional Treatment of Wounds. Springer, Cham. https://doi.org/10.1007/978-3-319-66990-8_3

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  • DOI: https://doi.org/10.1007/978-3-319-66990-8_3

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  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-66989-2

  • Online ISBN: 978-3-319-66990-8

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