If salvage is impossible and amputation is the best course of action, important differences exist in amputation level and technique between upper and lower extremities. During the preoperative, operative, and post-operative phases it is important to educate the patient as well as all others involved with their health care to the goals and differences between upper and lower limbs. Traditional amputation levels were developed over the ages through a process by which surgeons ‘passed down’ knowledge and lessons learned concerning specific techniques. The best techniques provided the fastest healing and best-padded stump, as well as a stump that could best retain its physiology. Specific amputation levels were determined by understanding what locations best adapted to prosthetic substitution.

Predictably, techniques and methodology are always subject to opinion, and modern day medical controversies still exist concerning amputation. It is to be expected that all surgeons do not necessarily agree on the best course of action in specific cases. In instances of lower limb injury for example, both the processes of amputation at the ankle and knee disarticulation have specific positive and negative attributes. This makes the selection of these two particular lower-limb amputation levels controversial, not because the techniques are questionable - most surgeons agree that the techniques are practicable - but because success rates and ease of prosthetic fitting remain disputed. Because success rates and ease of prosthetic fitting are disagreed upon, most surgeons fall into one of two camps concerning the usefulness of these procedures. However, in the past decades, great improvements in design and engineering of prosthetic devices have made these amputation levels much more successful. Today, even the more conservative surgeons are more apt to consider ankle-level amputation and knee disarticulation viable surgical procedures.

In each particular patient case, the surgeon faces many decisions and has considerable latitude exercising personal judgement. Weighing and measuring all options requires thoughtful and thorough consideration. The initial and most basic decision is the choice between amputation versus attempt to salvage. Once amputation has been decided upon as the course of action, preoperatively the surgeon must determine the most distal level of amputation still compatible with wound healing and subsequent satisfactory prosthetic fitting. Selecting this level requires detailed clinical evaluation combined with laboratory and radiographic studies. Except for those few levels that will be specifically discussed in later chapters, in most amputations the surgeon will select the most distal level consistent with successful removal of the diseased state. The surgeon must bear in mind the degree to which the remainder of the appendage can provide a well-healed, non-tender physiologic residual limb. Conservation of residual limb length is a basic principle of modern amputation surgery.

In determining amputation level, the goal is to create the best environment for the rapid return of mobility and function. The environment for wound healing should be maximized in part by evaluating the patient’s nutritional status. In the case of diabetics, controlling blood glucose levels is essential. Minimizing edema, optimizing vascular inflow, eliminating bacteremia and the appropriate use of antibiotics are other factors essential to determining amputation level. Surgical procedures and rehabilitation must be coordinated to minimize de-conditioning. Modern amputee management involves a multidisciplinary approach to address these comprehensive issues. Medical, surgical, social, rehabilitative, prosthetic and economic factors all play an important role in each individual case. Planning for optimum function in amputation surgery consists of preoperative, operative as well as short- and long-term postoperative goals.

The Skin
When amputating, the general principles of plastic and reconstructive surgery apply to incision location and placement of scars. While a painless, pliable and non-adherent scar is a primary goal in most surgeries, in amputation the prosthetic interface and socket design can make the location of the scar of increased importance. When uncomplicated primary healing results in scars that are nontender, pliable, mobile, and durable, then location does not really matter. However, when healing is less than ideal, and scars become adherant, tender, thin and non-durable,or thick and promenent; then location matters a great deal. The wise surgeon, when possible, plans scar placement appropriately to minimize future issues just in case less than perfect healing results.

The amputation site in the lower extremity functions as the patient’s foot, and as such, requires reconstructive design to provide a durable interface for walking and the transfer of body weight. The amputation site in the upper limb becomes, in essence, the patient’s hand. The skin should therefore be managed as carefully as it would be in hand surgery to maximize a successful outcome.

When closing, fasciocutaneous flaps should be made as broad-based as possible to maximize profusion and avoid compromise of blood supply. The skin closure must be without tension but it cannot be redundant. Particularly in the dysvascular limb, care must be taken to avoid separating the skin from the underlying subcutaneous tissue and fascia. Pressure sensitive areas exist in residual limbs and care should be taken not to place scars over a bony prominence or the subcutaneous bone. The more skin surface available for contact with the prosthetic socket, the less pressure will be applied to each unit area of skin surface. A cylindrical shaped residual limb with muscular padding presents fewer skin problems than the bony, atrophic tapered residual limb.

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