skin incision and separated from the plantar soft tissue flap along a plane adjacent to the bone. C: The plantar soft tissue flap is

rotated anteriorly and approximated.

The most common technique, using a long posterior flap, is illustrated in Figure 94-5. When

gangrene, wounds, or incisions preclude the use of a posterior flap, equal anteroposterior or sagittal

flaps can be used; however, the posterior flap is associated with the highest incidence of primary

healing and is thus preferred whenever possible. This higher rate of healing reflects the fact that the

posteriorly located gastrocnemius and soleus muscles are supplied by the sural arteries that originate

proximal to the knee.

The proposed skin incision is drawn on the leg with a marker. The tibia should be transected 10 cm

distal to the tibial tuberosity and the anterior aspect of the skin incision should be 1 cm distal to the site

selected for the tibial transection. The anterior incision is extended medially and laterally. The length of

the anterior incision should equal two-thirds of the circumference of the leg at the proposed level of the

tibial transection. The incision is then extended longitudinally along the medial and lateral aspects of

the leg. The length of the longitudinal incisions should equal one-third of circumference of the leg at the

level of the tibial transection. It is prudent to err on the side of making the posterior flap too long and

trim excess length at the time of closure. The medial and lateral incisions are connected posteriorly.

Curving the transitions of the incision prevents the accumulation of redundant tissue at the medial and

lateral aspects of the completed amputation. The skin incisions should be down to the fascia to allow

separation of the skin edges. This step decreases the chance of inadvertent injury to the posterior flap

later in the procedure; however, the greater and lesser saphenous veins need to be ligated and

transected.

The anterior aspect of the incision is deepened through the periosteum of the tibia. The muscles of the

anterior compartment are divided at the level of the skin incision and the anterior tibial neurovascular

bundle is identified and suture ligated. The proximal tibia is circumferentially cleared of periosteum,

and transected 1 cm proximal to the skin incision. The anterior aspect of the tibia is cut on a 45-degree

angle. The fibula is cleared and transected 1 cm proximal to the transected tibia. The bones are divided

with either a power-driven reciprocating saw, or a manual saw. Regardless, care must be taken to avoid

trauma to the anterior skin flap.

The posterior tibial and peroneal neurovascular bundles are identified and suture ligated. The tibia is

retracted anteriorly and the posterior musculature is divided along the plane of the longitudinal skin

incisions using an amputation knife. Extreme caution must be taken to avoid injury to the skin edges of

the posterior flap during this step. Often a scalpel is needed to complete the division of the

gastrocnemius tendon distally. The specimen is removed and manual compression achieves temporary

hemostasis while the remaining vascular structures are identified and ligated. The posterior tibial nerve

is retracted distally, ligated, transected sharply, and allowed to retract. The posterior flap is rotated

anteriorly to assess thickness and length. Frequently, the musculature needs to be debulked to allow a

tension-free closure. Rough edges of the bones are filed smooth and the wound is irrigated. Bone wax is

not used. A closed-system drain may be placed to prevent a hematoma. The end of the tibia is covered

and stabilized with the deep posterior musculature using absorbable sutures. The gastrocnemius fascia is

approximated to the anterior fascia using 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.

2682

Figure 94-4. A: The skin incision for the one-stage Syme amputation connects the medial and lateral malleoli in both the

horizontal and vertical planes. The skin incision for the two-stage procedure is located approximately 1.5 cm further distally. B:

The incision is extended into the tibial—talar joint space, and the foot is placed in forced plantar flexion. C: The calcaneus is

sharply dissected from the adherent plantar fascia along a plane adjacent to the bone. D: The heel pad is rotated anteriorly and

approximated after the calcaneal dissection in the two-stage procedure and after the additional transection of the medial and

lateral malleoli in the one-stage procedure. E: Elliptic incisions are made over the medial and lateral malleoli during a second

operation for the staged procedure. The medial and lateral malleoli are transected flush with the ankle joint, and the distal flares

of the tibia and fibula are removed. F: The two-stage procedure results in a less bulbous, more cosmetically acceptable residual

limb.

2683

Figure 94-5. A: The skin incision for a below-knee amputation based on a posterior flap is made 11 cm distal to the tibial

tuberosity and extended medially and laterally to the midpoint of the calf. The length of the posterior flap is about 2 cm longer

than the diameter of the calf at the point of the proximal incision. B: The tibia is transected 1 cm proximal to the skin incision.

The fibula is transected an additional 1 cm proximal to the level of the tibial transection, and the posterior calf muscles are incised

along the plane of the skin incision. C: The anterior aspect of the tibia is beveled at an angle of about 45 degrees, and the bone

edges are filed. D: The posterior flap is rotated anteriorly and approximated.

The length of the BKA may be shortened if required by the infectious or gangrenous process.

Although not ideal, a short BKA is functionally superior to an AKA. In the extreme case, the tibia can be

transected at the level of the tibial tuberosity and the stump can still be fit with a prosthesis. If a BKA is

necessary at this level, the biceps tendon and collateral ligament should be sutured to the tibia, the

common peroneal nerve should be transected above the knee, and the fibula should be removed.

A variation of the BKA is the osteomyoplastic transtibial amputation also known as the Ertl

amputation. This technique has been well described33 and involves creating a bone bridge between the

tibia and the fibula using a piece of the amputated fibula. Proposed advantages of this technique include

a more stable end-bearing of the stump and prevention of fibular instability.

In the face of extensive foot infection, an open (guillotine) amputation should be performed as the

first part of a staged procedure. A circumferential incision is made in the distal leg just proximal to the

malleoli. The fascia is divided, and the tibia and fibula are dissected free. The bones are divided at the

level of the skin incision. All major neurovascular bundles are suture ligated and the remaining soft

tissue is divided to complete the amputation. Several sutures are placed through the skin and underlying

fascia to prevent retraction. The wound is left open and dressed. A negative pressure dressing may be

used and simplifies wound care. A definitive BKA is delayed until the infectious process has resolved

which typically occurs within a week. Ankle disarticulation is an alternative to a guillotine BKA. An

incision is made at the level of the ankle joint. Vascular structures are suture ligated. The tendons are

divided sharply entering the ankle joint. The capsule is circumferentially incised removing the foot from

2684

the leg. The wound is packed open.

Above-Knee Amputation

An AKA is indicated for patients requiring an amputation with a fixed-knee contracture, a nonfunctional

limb, or insufficient circulation to heal a BKA. Typically, a transverse fish-mouth incision is made in the

lower thigh. The initial skin incision should be carried through the subcutaneous tissue to allow the

edges to separate. This step will decrease the likelihood of inadvertent injury to the posterior skin flap

during transection of the posterior muscle groups. The greater saphenous vein needs to be identified and

ligated. The dissection is carried down to the femur that 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 reciprocating or manual saw, and the posterior muscle flap is

divided with an amputation knife. Manual compression with a laparotomy pad on the newly divided

stump will easily control hemorrhage while vessels are identified and ligated or electrocoagulated. The

sciatic nerve is identified and placed on gentle traction. It is then highly ligated, sharply divided, and

allowed to retract into the wound. The flaps should be power irrigated and hemostasis assured. 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. Most AKA wounds will heal even

when the femoral pulse is nonpalpable. More proximal thigh amputations are performed when arterial

perfusion is in question.

Hip Disarticulation

Lower extremity amputation at the level of the hip is an uncommon operation. The indications include

malignancy, trauma, and infection and, rarely, because of complications of arterial insufficiency. Hip

disarticulation performed for an ischemic AKA is often associated with complications in the absence of

revascularization.34 This technique is well described.

Cryoamputation

Rarely, a patient may require an emergent amputation yet have overwhelming medical problems that

preclude any operative intervention. In this situation, a temporizing cryoamputation (aka, medical or

physiologic amputation) is indicated.14 A tourniquet is placed proximal to the infectious or gangrenous

process and the extremity is packed in dry ice. This prevents the systemic release of muscle degradation

products and allows the required procedure to be delayed while the patient’s condition can be stabilized.

This technique can be performed at any level on the extremity. Consideration of the level of tourniquet

application is extremely important to preserve as much viable tissue as possible and avoid higher levels

of limb loss. The dry ice should be placed about 3 inc below the tourniquet to reduce the chance of the

“freeze line” extending proximal to the tourniquet. Adequate pain management should always be

employed.

It should be noted that the use of cryoamputation constitutes a commitment to eventual surgical

amputation (primary or staged). Once initiated, maintenance of the physiologic amputation is vital until

definitive surgical removal is possible. As the frozen tissues thaw, a systemic inflammatory response

syndrome (SIRS) or sepsis with hemodynamic instability may occur as inflammatory mediators are

liberated back into the circulatory system. The ideal timing to proceed to the operating room would be

as soon as reasonably possible. However, the literature describes the successful maintenance of this

technique over many days if necessary.14,35,36

Other Lower Extremity Amputations

Three additional partial-foot amputations have been well described. A Lisfranc amputation is performed

at the tarsometatarsal joint level and may be an option if there is inadequate soft tissue coverage for a

TMA.37 A Chopart amputation is performed at the level of the calcaneocuboid–talonavicular bones.

Consideration of adding a percutaneous heel-cord lengthening with these amputations has been

recommended.38 A partial calcanectomy hindfoot amputation has shown good utility for chronic

posterior heel wounds and calcaneal osteomyelitis.39,40 This amputation involves removal of the

posterior body of the calcaneus behind the posterior facet of the subtalar joint. Primary closure is

typically possible and patients can ambulate following this procedure using a custom orthotic with a

heel filler. Knee disarticulation is a useful amputation for patients with immature growth plates. It is

superior to an AKA and allows end-weight-bearing, improved proprioception, and improved prosthetic

2685

control. The required prosthesis is bulky and less cosmetically appealing than that used for a BKA. The

technique is well described.41 Rotationplasty is an uncommon procedure performed primarily for

treatment of osteogenic sarcoma of the thigh.42 It involves nerve-sparing resection of the femur and

knee, 180-degree rotation of the leg, and reattachment of the leg. This results in a functional, sensate

foot that can easily be fit with a prosthesis.

Wound Dressings

An important consideration after amputation is the type of wound dressings applied to the stump. Two

important factors in the success of an amputation are time-to-rehabilitation and complete wound

healing, both of which are influenced by postoperative wound care.43 With transtibial amputations,

there are a number of options, such as soft gauze dressings with elastic wrap, rigid plaster dressings

without immediate prosthesis, rigid plaster with immediate postoperative prosthesis, and prefabricated

pneumatic postoperative prosthesis. Several studies have compared two or more of these options.

Endpoints are not standardized, however, and most studies are not randomized and prospective, making

comparisons and meta-analysis difficult.43

Benefits and drawbacks are found for each postoperative option.43 Gauze dressings with elastic wrap

are simple and low cost and provide good accessibility to evaluate wound healing. On the other hand,

they may lead to higher rates of joint contraction, increased time to ambulation, and risk pressure

ischemia from poorly placed elastic wrap. Despite these drawbacks, no convincing data show that soft

gauze dressings are inferior to other options.43,44 A removable knee immobilizer may be used in

conjunction with gauze dressings to minimize the risk of joint contracture.

Rigid plaster casts help with joint contracture and protect the wound from trauma. With addition of a

temporary prosthesis, the rigid plaster also promotes early ambulation. The plaster, however, does not

provide easy access to evaluate and care for the wound and if not fitted properly will result in sheer

stress and thereby break down the wound. Consequently, a level of skill in plaster placement is required

of the surgical team to make appropriate and often frequent plaster changes.43

Finally, a prefabricated pneumatic postoperative prosthesis allows early ambulation and weight

bearing, easy wound access for examination, prevention of joint contracture, and wound protection. The

prosthesis, however, is bulky and upfront is more expensive than the simple gauze. Prospective studies

have demonstrated statistically fewer postoperative complications with the pneumatic prosthesis and

statistically fewer limbs requiring higher revisions.45

RESULTS

Table 94-7 Amputation Mortality

Complications

Morbidity and Mortality

Operative mortality depends on the indication and the level. Mortality rates for major lower extremity

amputations in vascular and diabetic patients have been reported to be between 0% and 35%.46

Combined mortality rates from multiple series are shown in Table 94-7.47 Cardiovascular causes account

for two-thirds of these deaths, with myocardial infarction responsible for one-third.47 These review data

are further supported by recent studies by Sandnes et al.48 and Aulivola et al.49

Long-term survival following major amputation in the vascular population is shown in Table 94-8.

The 5-year survival rate is only 37% compared with 85% for age-matched controls.50

Deep Venous Thrombosis and Pulmonary Embolism

The incidence of deep venous thrombosis following lower extremity amputation ranges from 4% to

38%.51–53 Prophylactic measures including subcutaneous heparin, low–molecular-weight heparins, early

2686

mobilization, and pneumatic compression devices should be used as indicated.

Stump Complications

Stump complications include nonhealing, infection, hematoma, contractures, ulceration, phantom pain,

and trauma. Although most amputations heal primarily, a small percentage do not. Amputation at a

more proximal level usually is successful. Postoperative infections complicate 12% to 28% of all

amputations with the percentage higher in cases performed for infection.54 Local wound care with

drainage, débridement and dressing changes, and systemic antibiotics should be instituted. Wound

hematomas are best treated with prevention. Meticulous hemostasis and avoidance of subcutaneous

cavities decrease their incidence. Hematomas should be treated in the operating room with evacuation,

irrigation, and closure of the wound.

RESULTS

Table 94-8 Survival after Amputation for Ischemia

Joint contractures complicate 1% to 3% of all amputations.50,54 These contractures can occur rapidly

postoperatively and are best treated by prevention. Rehabilitation specialists and physical therapists

should evaluate patients preoperatively. Active and passive range of motion should be initiated

immediately postoperatively. Adequate pain medication, ideally with patient-controlled or epidural

anesthesia,55,56 is crucial. Pillows and bed positions that result in hip or knee flexion are to be strictly

avoided.

Ulcers tend to develop over bony prominences. Poorly fitting prostheses or shoes are the most

common causes. Diabetic patients with peripheral neuropathy are especially susceptible to the

development of ulcers following toe and limited foot amputations. They can also form on the anterior

aspect of AKAs secondary to the disproportional contraction of the hip flexors relative to the hip

extensors. Local wound care and bedrest usually lead to healing if the ulcer is superficial. Deep skin

ulcers with involvement of the soft tissue and the underlying bone are more complicated. They often

suggest borderline perfusion of the stump and require formal revision to a higher level to treat

definitively.

Another option in complicated wound closure is negative-pressure wound dressing, which has been

used for a wide range of difficult-to-heal lesions. Studies indicate that this dressing technique decreases

wound volume, whereas traditional moist gauze dressings do not.57 The dressings result in granulation

tissue and healing in otherwise difficult tissue beds, such as diabetic foot ulcers

58 and decubitus pressure

ulcers.59 In addition to helping contract the size of the wound, negative-pressure dressings also decrease

the number and frequency of dressing changes drastically when compared with wet-to-dry dressings.

Neuromas are regenerative nerve tissues that form in response to transection. They can lead to pain if

trapped in the fibrous scar or if irritated by a prosthesis. Proximal nerve division under tension during

the original operation decreases the incidence of this complication. Symptomatic neuromas should be

treated with proximal resection of the nerve because local excision of the neuroma is rarely adequate.

Some element of phantom extremity pain occurs in nearly all amputations,60 although these

complaints are not always directed to the treating surgeon. It is necessary to describe these common

symptoms to the patient and specifically inquire about their presence. The pain is disabling in 5% to

30%61 of patients surveyed. Currently, pain is felt to be a component of a central pain syndrome and

unrelated to either a neuroma or the perception of an intact extremity. Although there is no universally

effective treatment, Malone46 has reported a low incidence with an aggressive rehabilitation program,

including immediate prosthetic fitting.

Trauma to a limb following an amputation can convert a healed amputation to a nonhealing wound

requiring a more proximal amputation. Perioperatively, patients with a BKA have to be observed closely

2687

to prevent attempted ambulation. Diabetic patients with retinopathy should not walk barefoot following

toe and foot amputations secondary to the risk that minor trauma may lead to a major wound healing

problem.

Additional Amputation

The incidence of future amputation in vascular patients is not insignificant. Snyder et al. evaluated

outcomes after forefoot amputations and found that 26% underwent a subsequent forefoot amputation

and 37% had a more proximal amputation over 2 years.62 Cruz et al. demonstrated 17% contralateral

amputation in their series.63 These dismal figures reflect the systemic nature of the underlying diseases

and emphasize the importance of appropriate foot care, patient education, close follow-up, and early

intervention.64 A concerted multidisciplinary approach can dramatically decrease the incidence of initial

and subsequent lower extremity amputation.65

Special Situations

In selected cases, hyperbaric oxygen (HBO) therapy can provide benefit in treating nonhealing

amputation sites. Patients require thorough evaluation of their cardiopulmonary status before initiating

such treatment. In addition, the treating vascular surgeon has to determine that revascularization is

completed or is not indicated. Patients may benefit from treatment if there is a substantial increase in

transcutaneous oxygen pressure (TcPO2

) near the wound with administration of 100% oxygen. Daily

treatments are typically continued for 30 days. Platelet-derived growth factor (becaplermin, regranex)

is approved for use in the United States and has been effective in the management of diabetic foot ulcers

and following open foot amputations or débridements. The wound must be clear of all necrotic tissue

before initiating therapy.

REHABILITATION AND PROSTHETIC MANAGEMENT

General Considerations

Rehabilitation must be individualized. For some patients, successful rehabilitation means ambulation on

a prosthesis and resumption of an independent lifestyle. For others, success may mean being able to

pivot on the contralateral limb to be able to assist with transfer. Ambulating with a prosthesis depends

on the physiologic status of the patient. Table 94-2 illustrates the dramatic increase in energy

requirement with increasing level of the amputation. As expected, the chance of ambulating on a

prosthesis decreases with ascending amputation level. The percentages of diabetic and vascular patients

who can ambulate with amputations at various levels are shown in Table 94-9. The likelihood of

ambulating postoperatively is inversely related to the patient’s age and the length of the rehabilitation

process.66 Consideration should be given to inpatient rehab immediately after the acute care of the

amputation is complete. Not only does this allow strengthening of the upper extremities and improved

transfers, but it has been shown to reduce 1-year mortality in amputees as well.67

Specific Considerations

Digital and Ray Amputations

All patients who were ambulatory preoperatively should be able to achieve their preoperative

functional status following a digital or ray amputation. The first digit and metatarsal head are important

for weight bearing and for power. A shoe orthosis should effectively compensate for these functions

when the patient has some training.

RESULTS

Table 94-9 Ambulation after Lower Extremity Amputation for Diabetes or

Occlusive Disease

2688

The most important component of postoperative rehabilitation for patients following a digital or ray

amputation is education. The rate of repeat amputation (other toe, more proximal level, and

contralateral limb) is extremely high. Several studies have indicated that the rate of repeat amputation

is diminished with a coordinated education program.68,69

Transmetatarsal Amputation

A TMA minimally increases the energy requirement of ambulation; therefore, postoperative ambulation

is expected following successful healing. The absence of the toes and metatarsal heads results in the loss

of some forward thrust during the push-off phase of ambulation. This deficit can be overcome with

either a steel-shank or a rigid, roller-soled shoe. The void in the distal shoe is filled with an insert.

Syme Amputation

The prognosis for return to bipedal ambulation following a Syme amputation is excellent. The required

energy expenditure is only 10% more than baseline.70 A significant advantage of this amputation is the

ability to ambulate on the stump with only a cup slipper. Even though this activity is permitted on only

a limited basis in the home, it is much more convenient for the patient, especially when arising at night.

For routine activity the patient uses a prosthesis composed of a nonmotion foot attached to a leg shaft.

The shaft has a cutout on the medial aspect to allow passage of the flared distal end of the stump. The

configuration of the distal end of the stump results in a bulbous ankle, which is less aesthetically

pleasing than the typical below-knee prosthesis.

Below-Knee Amputation

The rehabilitation potential following a BKA is very good. Even when the indication for amputation is

arterial insufficiency, approximately 75% of patients are able to ambulate with a prosthesis.47 Multiple

design options are available; however, the patellar tendon and the medial and lateral tibial flares are

the weight-bearing surfaces for most prostheses. A variety of foot designs are possible to permit

extension, flexion, rotation, and energy storage.

Above-Knee Amputation

Ambulation on an above-knee prosthesis is achieved by less than 40% of patients with arterial

insufficiency.47 In this patient population, the rate of ambulation on bilateral above-knee prostheses is

less than 10%.71 Most above-knee prostheses use the ischial tuberosity as the primary weight-bearing

surface and are secured either by a belt or a suction socket. For younger patients, a suction socket

works well. Patients with groin scars from previous revascularization attempts may benefit from a belt

mechanism. The knee design depends on the patient’s general condition and thigh strength. A knee that

engages during the stance phase of gait is more stable and is frequently used in older patients.

References

1. Goodney P, Beck A, Nagle J, et al. National trends in lower extremity bypass surgery, endovascular

interventions, and major amputations. J Vasc Surg 2009;50(1):54–60.

2. Gorina Y, Owens M, Elgaggal N, et al. Comparability between the rates for all-listed inpatient

procedures using National Hospital Discharge Survey and Medicare claims, 1999 and 2007. Nat

Health Stat Report 2012;(57):1–15.

3. Falstie-Jensen N, Christensen K. A model for prediction of failure in amputation of the lower limb.

Dan Med Bull 1990;37:283–286.

4. Sanmugarajah J, Hussain S, Schwartz J, et al. Monoclonal cryoglobulinemia with extensive

2689

gangrene of all four extremities—a case report. Angiology 2000;51(5):431–434.

5. Veith FJ, Gupta SK, Samson RH, et al. Progress in limb salvage by reconstructive arterial surgery

combined with new or improved adjunctive procedures. Ann Surg 1981;194:386–401.

6. Melzack R, Wall P. Pain mechanisms: a new theory. Science 1965;150:971–979.

7. Augustinsson LE, Carlsson CA, Holm J, et al. Epidural electrical stimulation is severe limb ischemia.

pain relief, increased blood flow, and a possible limb-saving effect. Ann Surg 1985;202:104–110.

8. Tallis RC, Illis LS, Sedgwick EM, et al. Spinal cord stimulation in peripheral vascular disease. J

Neurol Neurosurg Psychiatry 1983;46:478–484.

9. Meglio M, Cioni B, Dal Lago A, et al. Pain control and improvement of peripheral blood flow

following epidural spinal cord stimulation: case report. J Neurosurg 1981;54:821–823.

10. Horsch S, Claeys L. Epidural spinal in the treatment of severe peripheral arterial occlusive disease.

Ann Vasc Surg 1994;8(5):468–474.

11. Ubbink DT, Spincemaille GH, Prins MH, et al. Microcirculatory investigations to determine the

effect of spinal cord stimulation for critical leg ischemia: the Dutch multicenter randomized

controlled trial. J Vasc Surg 1999;30:236–244.

12. Huber SJ, Vaglienti RM, Huber JS. Spinal cord stimulation in severe, inoperable peripheral vascular

disease. Neuromodulation 2000;3:131–143.

13. Gersbach PA, Argitis V, Gardza JP, et al. Late outcome of spinal cord stimulation for

unreconstructable and limb-threatening lower limb ischemia. Eur J Vasc Endovasc Surg

2007;33(6):717–724.

14. Winburn GB, Wood MC, Hawkins ML, et al. Current role of cryoamputation. Am J Surg

1991;162:647–650.

15. Lange RH. Limb reconstruction versus amputation decision making in massive lower extremity

trauma. Clin Orthop Relat Res 1989;(243):92–99.

16. Bosse MJ, MacKenzie EJ, Kellam JF, et al. An analysis of outcomes of reconstruction or amputation

of leg-threatening injuries. N Engl J Med 2002;347:1924–1931.

17. Johansen K, Daines M, Howey T, et al. Objective criteria accurately predict amputation following

lower extremity trauma. J Trauma 1990;30(5):568–572; discussion 572–573.

18. Ly TV, Travison TG, Castillo RC, et al. Ability of lower-extremity injury severity scores to predict

functional outcome after limb salvage. J Bone Joint Surg Am 2008;90(8):1738–1743.

19. Adam DJ, Beard JD, Cleveland T, et al; BASIL trial participants. Bypass versus angioplasty in severe

ischaemia of the leg (BASIL): multicentre, randomized controlled trial. Lancet

2005;366(9501):1925–1934.

20. Harwood T, Coe E, Flynn T, et al. The use of arm vein conduits during infrageniculate arterial

bypass. J Vasc Surg 1992;16:420–426.

21. Leseche G, Penna C, Bouttier S, et al. Femorodistal bypass using cryopreserved venous allografts

for limb salvage. Ann Vasc Surg 1997;11(3):230–236.

22. Raptis S, Miller J. Influence of vein cuff on polytetrafluoroethylene grafts for primary

femoropopliteal bypass. Br J Surg 1995;82:478–491.

23. Stonebridge PA, Prescott RJ, Ruckley CV. Randomized trial comparing infrainguinal

polytetrafluoroethylene bypass grafting with and without vein interposition cuff at the distal

anastomosis. The Joint Vascular Research Group. J Vasc Surg 1997;26(4):543–550.

24. Bosiers M, Deloose K, Verbist J, et al. Heparin-bonded expanded polytetrafluoroethylene vascular

graft for femoropopliteal and femorocrural bypass grafting: 1-year results. J Vasc Surg

2006;43(2):313–318.

25. Lepantalo M, Tukiainen E. Combined vascular reconstruction and microvascular muscle flap

transfer for salvage of ischaemic legs with major tissue loss and wound complications. Eur J Vasc

Endovasc Surg 1996;12:65–69.

26. Briggs SE, Banis JC Jr, Kaebnick H, et al. Distal revascularization and microvascular free tissue

transfer: an alternative to amputation in ischemic lesions of the lower extremity. J Vasc Surg

1985;2(6):806–811.

27. Biancari F, Kantonen I, Alback A, et al. Limits of infrapopliteal bypass surgery for critical leg

ischemia: when not to reconstruct. World J Surg 2000;24(6):727–733.

2690

28. Keagy BA, Schwartz JA, Kotb M, et al. Lower extremity amputation: the control series. J Vasc Surg

1986;4(4):321–326.

29. Dwars BJ, Van Den Broek TA, Ravwerda JA, et al. Criteria for reliable selection of the lowest level

of amputation in peripheral vascular disease. J Vasc Surg 1992;15:536–542.

30. Malone JM, Anderson GG, Lalka SG, et al. Prospective comparison of noninvasive techniques for

amputation level selection. Am J Surg 1987;154:179–184.

31. Misuri A, Lucertini G, Nanni A, et al. Predictive value of transcutaneous oximetry for selection of

the amputation level. J Cardiovasc Surg 2000;41(1):83–87.

32. Nishimoto GS, Attinger CE, Cooper PS. Lengthening the Achilles tendon for the treatment of

diabetic plantar forefoot ulceration. Surg Clin North Am 2003;83(3):707–726.

33. Taylor BC, Poka A. Osteomyoplastic transtibial amputation: technique and tips. J Orthop Surg Res

2011;6:13.

34. Endean ED, Schwarcz TH, Barker DE, et al. Hip disarticulation: factors affecting outcome. J Vasc

Surg 1991;14(3):398–404.

35. Still JM Jr, Wray CH, Moretz WH. Selective physiologic amputation: a valuable adjunct in

preparation for surgical operation. Ann Surg 1970; 171(1):143–151.

36. Winburn GB, Hawkins ML, Wood MC. Physiologic amputation prevents myoglobinuria from lower

extremity myonecrosis. South Med J 1993; 86(10):1101–1105.

37. Roach J, Deutsch A, McFarlane D. Resurrection of the amputations of Lisfranc and Chopart for

diabetic gangrene. Arch Surg 1987;122:931–934.

38. Leiberman JR, Jacobs RL, Goldstock L, et al. Chopart amputation with percutaneous heel cord

lengthening. Clin Orthop Relat Res 1993;296:86–91.

39. Randall DB, Phillips J, Ianiro G. Partial calcanectomy for the treatment of recalcitrant heel

ulcerations. J Am Podiatr Med Assoc 2005;95(4):335–341.

40. Lehmann S, Murphy RD, Hodor L. Partial calcanectomy in the treatment of chronic heel ulceration.

J Am Podiatr Med Assoc 2001;91(7):369–372.

41. Burgess E. Disarticulation of the knee: a modified technique. Arch Surg 1977;112:1250–1255.

42. Merkel KD, Gebhardt M, Springfield DS. Rotationplasty as a reconstructive operation after tumor

resection. Clin Orthop Relat Res 1991;270:231–236.

43. Smith DG, McFarland LV, Sangeorzan BJ, et al. Postoperative dressing and management strategies

for transtibial amputations: a critical review. J Rehabil Res Dev 2003;40(3):213–224.