Introduction

Amputation is the surgical removal of part or all of a limb or extremity, such as a finger, toe, hand, foot, arm, or leg. It is performed when the affected limb cannot be salvaged or when limb preservation would pose a greater risk to the patient's life or result in prolonged disability. Modern amputation surgery aims not only to remove diseased or non-viable tissue but also to maximize postoperative function, facilitate prosthetic rehabilitation, and improve overall quality of life.

Although advances in microsurgery, vascular reconstruction, orthopedic fixation, and reconstructive surgery have increased the success of limb salvage, amputation remains the definitive treatment for selected traumatic, infectious, vascular, neoplastic, congenital, and metabolic conditions.

Epidemiology

• Peripheral vascular disease and diabetes mellitus are the leading causes of non-traumatic lower limb amputations worldwide.

• Trauma remains the leading indication for amputation among younger adults.

• Malignant bone and soft tissue tumors account for a small proportion of amputations.

• Lower limb amputations are more common than upper limb amputations.

Indications for amputation

Amputation should only be considered when limb salvage is impossible or unlikely to provide a functional extremity.

Common indications include:

Trauma

• Severe crush injuries

• Mangled extremity

• Irreparable vascular injury with prolonged ischemia

• Extensive soft tissue loss

• Devastating open fractures

• Blast injuries

Infection

• Necrotizing fasciitis

• Extensive osteomyelitis not responding to treatment

• Gas gangrene

• Severe diabetic foot infection

• Uncontrolled prosthetic joint infection

• Progressive sepsis originating from the limb

Vascular disease

• Critical limb ischemia

• Irreversible gangrene

• Non-reconstructable peripheral arterial disease

• Failed vascular reconstruction

Tumours

• Primary malignant bone tumours

• Soft tissue sarcomas

• Locally advanced recurrent malignancies

• Selected metastatic bone lesions causing severe destruction

Metabolic diseases

• Diabetic foot complications

• Charcot neuroarthropathy with severe deformity or infection

Congenital anomalies

• Non-functional limb

• Severe congenital deformities preventing useful function

• Limb deficiencies unsuitable for reconstruction

Goals of amputation

The primary objectives are to:

• Preserve maximum functional limb length

• Completely remove diseased or non-viable tissue

• Preserve useful sensation where possible

• Prevent painful neuroma formation

• Preserve adjacent joint function

• Prevent joint contractures

• Create a durable, painless stump suitable for prosthetic fitting

• Allow early rehabilitation

• Facilitate return to independent activities of daily living

• Promote early return to work, education, and recreation

Clinical assessment

Evaluation should include:

History

• Mechanism of injury or underlying disease

• Duration of symptoms

• Previous surgical procedures

• Diabetes mellitus

• Peripheral vascular disease

• Smoking history

• Functional status before injury

• Occupation and rehabilitation goals

• Pain characteristics

Physical examination

• Limb viability

• Skin condition

• Presence of infection

• Tissue necrosis

• Vascular assessment

• Motor function

• Sensory function

• Joint mobility

• Soft tissue coverage

• Contralateral limb assessment

• General medical condition

Diagnostic criteria

Amputation is indicated when one or more of the following are present:

• Irreversible limb ischemia with non-viable tissue

• Extensive tissue necrosis not amenable to reconstruction

• Severe infection threatening life despite optimal treatment

• Malignant tumour requiring complete surgical excision

• Unsalvageable traumatic limb injury

• Persistent severe pain in a non-functional limb after appropriate evaluation

• Non-functional limb with no realistic potential for reconstruction

• Limb salvage expected to result in poorer functional outcome than amputation

The decision should ideally be made by a multidisciplinary team whenever feasible.

Investigations

Investigations depend on the underlying condition.

Laboratory investigations

• Complete blood count

• C-reactive protein

• Erythrocyte sedimentation rate

• Blood glucose

• HbA1c (diabetic patients)

• Renal function tests

• Liver function tests

• Coagulation profile

• Blood cultures when sepsis is suspected

• Wound or tissue culture where appropriate

Imaging

• Plain radiographs

• CT scan

• MRI

• CT angiography

• Doppler ultrasound

• Digital subtraction angiography where indicated

• Bone scan in selected cases

Classification of amputation

According to urgency

Primary amputation

Performed immediately after injury or diagnosis.

Secondary amputation

Performed after failed limb salvage or progressive disease.

According to anatomical level

Upper limb

• Finger

• Ray amputation

• Transmetacarpal

• Wrist disarticulation

• Transradial

• Elbow disarticulation

• Transhumeral

• Shoulder disarticulation

• Forequarter amputation

Lower limb

• Toe

• Ray amputation

• Transmetatarsal

• Lisfranc amputation

• Chopart amputation

• Syme amputation

• Transtibial (below-knee)

• Knee disarticulation

• Transfemoral (above-knee)

• Hip disarticulation

• Hemipelvectomy

Management

Management requires a multidisciplinary approach involving orthopedic surgeons, vascular surgeons, plastic surgeons, rehabilitation specialists, physiotherapists, occupational therapists, prosthetists, nurses, psychologists, and social workers.

Preoperative management

• Stabilize life-threatening injuries

• Treat sepsis

• Optimize nutrition

• Control blood glucose

• Correct anemia

• Manage pain

• Assess vascular status

• Counsel the patient and family

• Determine the optimal level of amputation

• Begin rehabilitation planning

Surgical principles

Successful amputation should achieve:

• Adequate removal of diseased tissue

• Preservation of viable muscle

• Well-padded stump

• Smooth bone ends

• Secure muscle stabilization (myodesis or myoplasty)

• Preservation of major nerves with proximal transection to reduce neuroma formation

• Tension-free wound closure

• Adequate haemostasis

Postoperative management

• Pain control

• Appropriate antibiotic therapy when indicated

• Wound care

• Limb elevation

• Early mobilization

• Prevention of joint contractures

• Deep vein thrombosis prophylaxis where indicated

• Nutritional support

• Psychological support

Rehabilitation

Rehabilitation should begin immediately after surgery.

It includes:

• Stump positioning

• Edema control

• Stump shaping

• Range-of-motion exercises

• Muscle strengthening

• Balance training

• Wheelchair mobility

• Transfer training

• Gait training

• Prosthetic fitting

• Prosthetic training

• Occupational therapy

• Vocational rehabilitation

• Psychological counselling

Complications

Early complications

• Hemorrhage

• Wound infection

• Skin flap necrosis

• Hematoma

• Delayed wound healing

• Deep vein thrombosis

Late complications

• Phantom limb pain

• Phantom limb sensation

• Painful neuroma

• Joint contractures

• Stump ulceration

• Heterotopic ossification

• Prosthetic fitting problems

• Chronic pain

• Depression and anxiety

Prevention

Many amputations can be prevented through:

• Early management of traumatic injuries

• Optimal diabetic foot care

• Smoking cessation

• Aggressive treatment of peripheral arterial disease

• Prompt treatment of bone and soft tissue infections

• Appropriate management of chronic wounds

• Early referral for vascular reconstruction where appropriate

Prognosis

The prognosis depends on the underlying disease, level of amputation, patient comorbidities, and access to rehabilitation. Patients undergoing amputation for isolated trauma generally achieve better functional outcomes than those with severe vascular disease or diabetes mellitus. Early physiotherapy, comprehensive rehabilitation, timely prosthetic fitting, and psychosocial support are key determinants of long-term mobility, independence, and quality of life.