Amputations of the Lower Extremity

  • Joseph Park
  • Tammer Elmarsafi
  • John S. SteinbergEmail author


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.


Diabetes Amputation Wound Ulcer Osteomyelitis Ischemia Infection Complications Outcomes Neuropathy Biomechanics Function 


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.

Supplementary material

Video 3.1

BKA Amputee: Independent Ambulation (MP4 870 kb)


  1. 1.
    Banks M. The surgeon of old in war. JAMA. 1897 Oct;29(14):665–7.CrossRefGoogle Scholar
  2. 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.PubMedCrossRefGoogle Scholar
  3. 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.PubMedCrossRefGoogle Scholar
  4. 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.CrossRefGoogle Scholar
  5. 5.
    Weledji EP, Fokam P. Treatment of the diabetic foot – to amputate or not? BMC Surg. 2014;14:83.PubMedPubMedCentralCrossRefGoogle Scholar
  6. 6.
    Nather A, Wong KL. Distal amputations for the diabetic foot. Diabet Foot Ankle. 2013;4:10.PubMedCentralCrossRefGoogle Scholar
  7. 7.
    Altemeier WA, Fullen WD. Prevention and treatment of gas gangrene. JAMA. 1971;217(6):806–13.PubMedCrossRefGoogle Scholar
  8. 8.
    Price P. The diabetic foot: quality of life. Clin Infect Dis. 2004;39(Suppl 2):S129–31.PubMedCrossRefGoogle Scholar
  9. 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.PubMedPubMedCentralCrossRefGoogle Scholar
  10. 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.PubMedPubMedCentralCrossRefGoogle Scholar
  11. 11.
    Hobizal KB, Wukich DK. Diabetic foot infections: current concept review. Diabet Foot Ankle. 2012 Jan;1;3(1):18409.Google Scholar
  12. 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.PubMedPubMedCentralCrossRefGoogle Scholar
  13. 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.PubMedCrossRefGoogle Scholar
  14. 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.PubMedCrossRefGoogle Scholar
  15. 15.
    Boulton AJM. Management of diabetic peripheral neuropathy. Clin Diabetes. 2005 Jan;23(1):9–15.CrossRefGoogle Scholar
  16. 16.
    Singh N, Armstrong DG, et al. Preventing foot ulcers in patients with diabetes. JAMA. 2005;293:217–28.PubMedCrossRefGoogle Scholar
  17. 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.PubMedCrossRefGoogle Scholar
  18. 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. 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.PubMedCrossRefGoogle Scholar
  20. 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.CrossRefGoogle Scholar
  21. 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.PubMedCrossRefGoogle Scholar
  22. 22.
    Marchettini P, Lacerenza M, Mauri E, Marangoni C. Painful peripheral neuropathies. Curr Neuropharmacol. 2006 Jul;4(3):175–81.PubMedPubMedCentralCrossRefGoogle Scholar
  23. 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.PubMedCrossRefGoogle Scholar
  24. 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.PubMedGoogle Scholar
  25. 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.CrossRefGoogle Scholar
  26. 26.
    Shammas NW. Epidemiology, classification, and modifiable risk factors of peripheral arterial disease. Vasc Health Risk Manag. 2007 Apr;3(2):229–34.PubMedPubMedCentralCrossRefGoogle Scholar
  27. 27.
    Fowler MJ. Microvascular and macrovascular complications of diabetes. Clin Diabetes. 2008 Nov;26(2):77–82.CrossRefGoogle Scholar
  28. 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.PubMedCrossRefGoogle Scholar
  29. 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.Google Scholar
  30. 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.PubMedCrossRefGoogle Scholar
  31. 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.PubMedCrossRefGoogle Scholar
  32. 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.PubMedCrossRefGoogle Scholar
  33. 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.PubMedCrossRefGoogle Scholar
  34. 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.PubMedCrossRefGoogle Scholar
  35. 35.
    Sage RA. Biomechanics of ambulation after partial foot amputation: prevention and management of reulceration. J Prosthet Orthot. 2007 Jul;19(8):P77–9.CrossRefGoogle Scholar
  36. 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. 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.PubMedCrossRefGoogle Scholar
  38. 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.PubMedCrossRefGoogle Scholar
  39. 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.PubMedCrossRefGoogle Scholar
  40. 40.
    Landry GJ, Silverman DA, Liem TK. Predictors of healing and functional outcomes following transmetatarsal amputations. Arch Surg. 2011;146(9):1005–9.PubMedCrossRefGoogle Scholar
  41. 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.PubMedCrossRefGoogle Scholar
  42. 42.
    Garwood CS, Steinberg JS. Soft tissue balancing after partial foot amputations. Clin Podiatr Med Surg. 2016 Jan;33(1):99–111.PubMedCrossRefGoogle Scholar
  43. 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.PubMedCrossRefGoogle Scholar
  44. 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.PubMedCrossRefGoogle Scholar
  45. 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.PubMedCrossRefGoogle Scholar
  46. 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.PubMedCrossRefGoogle Scholar
  47. 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.PubMedCrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG 2018

Authors and Affiliations

  • Joseph Park
    • 1
  • Tammer Elmarsafi
    • 2
  • John S. Steinberg
    • 2
    • 3
    Email author
  1. 1.Division of Podiatric SurgeryMedStar Washington Hospital CenterWashingtonUSA
  2. 2.Department of Plastic SurgeryMedStar Georgetown University HospitalWashingtonUSA
  3. 3.Department of Plastic Surgery, Center for Wound Healing and Hyperbaric MedicineMedStar Georgetown University HospitalWashingtonUSA

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