SEARCH

SEARCH BY CITATION

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Adverse health outcomes leading to disability after traumatic amputation
  6. Therapeutic interventions that may improve outcome
  7. Conclusion
  8. Disclosure
  9. References

Background:

Traumatic leg amputation commonly affects young, active people and leads to poor long-term outcomes. The aim of this review was to describe common causes of disability and highlight therapeutic interventions that may optimize outcome after traumatic leg amputation.

Methods:

A comprehensive search of MEDLINE, Embase and Cumulative Index to Nursing and Allied Health Literature databases was performed, using the terms ‘leg injury’, ‘amputation’ and ‘outcome’. Articles reporting outcomes following traumatic leg amputation were included.

Results:

Studies demonstrated that pain, psychological illness, decreased physical and vocational function, and increased cardiovascular morbidity and mortality were common causes of disability after traumatic leg amputation. The evidence highlights that appropriate preoperative management and operative techniques, in conjunction with suitable rehabilitation and postoperative follow-up, can lead to improved treatment outcome and patient satisfaction.

Conclusion:

Patients who undergo leg amputation after trauma are at risk of poor long-term physical and mental health. Clinicians involved in their care have many opportunities to improve their outcome using a variety of therapeutic variables. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Adverse health outcomes leading to disability after traumatic amputation
  6. Therapeutic interventions that may improve outcome
  7. Conclusion
  8. Disclosure
  9. References

Trauma is the leading cause of leg amputation in developing countries and is second only to peripheral arterial disease in developed countries. Amongst civilians in the UK, trauma accounts for 7–9 per cent of the 5000 amputations performed annually1. The prevalence is much higher, as traumatic amputees are typically young with a long life expectancy. In the USA, for example, trauma accounts for 16 per cent of annual amputations, whereas traumatic amputees represent 45 per cent of people living with an amputation.

In the military setting, amputation rates have doubled as a result of the improved survival afforded by advances in both body armour and military medicine. Severe limb trauma is now the signature combat injury and the most common cause of disabling conditions leading to medical retirement2.

The disability following a severe leg injury is both profound and prolonged; these injuries are a major predictor of a poor outcome after trauma3–7. The most important issue for patients with these injuries is their quality of life after treatment. A decision often needs to be made as to whether attempted limb salvage will produce a better outcome than would be achieved by an amputation with prosthesis. Knowledge of the outcome of patients who undergo amputation is central to this decision-making process. When amputation is the treatment of choice, the surgical goals must be to produce a painless and useful residual limb. Moreover, to ensure the best result for each patient, a clear understanding of the therapeutic variables that affect outcome after traumatic lower limb amputation is fundamental.

The aim of this evidence-based review was to describe the common causes of disability and poor outcome in traumatic lower limb amputees, and to highlight therapeutic interventions that may improve these in the long term.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Adverse health outcomes leading to disability after traumatic amputation
  6. Therapeutic interventions that may improve outcome
  7. Conclusion
  8. Disclosure
  9. References

Relevant articles for this review were identified by a systematic search of the MEDLINE, Embase and Cumulative Index to Nursing and Allied Health Literature databases. The Medical Subject Headings ‘leg injury’, ‘amputation’ and ‘outcome’ were used. The search was limited to English-language articles on human subjects published after 1960. Additional citations were obtained from the reference lists of relevant articles. Studies that reported outcomes of adult patients with traumatic leg amputations were included.

Adverse health outcomes leading to disability after traumatic amputation

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Adverse health outcomes leading to disability after traumatic amputation
  6. Therapeutic interventions that may improve outcome
  7. Conclusion
  8. Disclosure
  9. References

Pain

Chronic pain is highly prevalent, and a significant cause of disability following trauma-related leg amputation8–10. Furthermore, pain may worsen the functional, vocational and psychiatric outcomes of amputees9. It is important to differentiate the sources of chronic pain; the common causes are described below. Interestingly, women report more problems with pain than men11.

Phantom limb pain

Phantom limb pain, a form of neuropathic pain, occurs in 50–80 per cent of amputees12. The incidence appears to be similar following both civilian and military trauma13. Classically, the onset of pain is early and, although the long-term course is unclear, there may be slight improvement with time14. Although the pathogenesis is not fully understood, the development of a cortical pain memory seems to be central, with important contributions from the peripheral and autonomic nervous systems12. As a result the development of phantom limb pain is associated with the magnitude of preamputation and residual limb pain experienced, the duration of limb pain before amputation, and psychological factors such as emotional stress and anxiety.

Residual limb pain

Residual limb pain is common immediately after amputation, but traditionally was thought to resolve with surgical healing. More recently, however, epidemiological studies have shown that it persists in 55–76 per cent of amputees8, 15, 16. Residual limb pain is nearly twice as common after traumatic lower limb amputation than following amputations for non-trauma pathologies8.

There are several causes of residual limb pain, including a poorly fitting prosthesis, symptomatic neuromas and stump infections. Both bone pathology (bone spurs and sharp bone ends, heterotrophic ossification and stress fractures) and soft tissue pathology (excess soft tissue, failure of muscle reconstruction to protect bone ends, symptomatic scar tissue, wound breakdown) have also been implicated.

Back pain

Back pain occurs in 52–81 per cent of traumatic amputees8, 15, 17–20, a considerably higher prevalence than in the general population. Back pain may be more common after above-knee than below-knee amputation15, 17, 18. The increased susceptibility is thought to be the result of the myofascial changes following amputation and the altered gait pattern developed to accommodate a prosthesis15, 20.

Contralateral joint pain

Traumatic amputees are more than twice as likely to develop knee pain in their intact limb as non-amputees21; the risk increases with amputation level17, 18, 21. The prevalence is approximately 50–63 per cent following transfemoral amputation and 36–41 per cent after transtibial amputation. In contrast, the prevalence of knee pain in matched controls is approximately 20 per cent17, 18, 21. Contralateral joint pain is thought to arise from a combination of gait abnormalities and increased physiological loads on intact joints. Residual limb knee pain is uncommon in transtibial amputees21.

Psychological responses

An intense emotional response is common following traumatic amputation and forms part of the psychological adjustment. Grief, disbelief, numbness and anger are expected, followed by a period of acceptance where sadness and despondency prevail. With this, psychological disorders are common. Mid- and long-term follow-up has shown that more than half of traumatic amputees develop a formal psychological diagnosis11, 17, 18, 22. Post-traumatic stress disorder (PTSD), anxiety, depression and substance abuse are the most common, and often coexist. Furthermore, these disorders diminish the patients' ability to cope with their physical disabilities.

PTSD is an anxiety disorder unique to trauma exposure and is characterized by symptoms of avoidance, re-experiencing and hyperarousal. It occurs in up to two-thirds of military casualties following traumatic leg amputation23 and is often the most common psychological disorder in these individuals18, 24. Depression and anxiety disorders occur in approximately one-quarter of patients22, 23, 25 and substance abuse in approximately 6 per cent18, 22.

Although much of the literature on the psychological responses to trauma focuses on military populations, a meta-analysis of psychopathology following civilian trauma showed similar results, suggesting a similar psychopathology to severe traumatic stress in both populations26. However, baseline differences in military and civilian amputee populations may affect their response to psychological treatment.

Self-reported mental and emotional health outcomes of traumatic amputees do not differ significantly from those of matched controls or the general population when examined with validated instruments such as the Short Form 36 (SF-36®; QualityMetric, Lincoln, Rhode Island, USA)27–30 (Table1). This may partly explain the small proportion of traumatic amputees who seek mental health care18, 30. A further barrier may be the perception of stigma associated with using mental health services32.

Table 1. Comparison of selected Short Form 36 health outcome scores between traumatic amputees and controls
ReferenceAmputation levelAmputee scoreControl scoreP
  • Dimensions of the Short Form 36 are scored from 0 (worst possible health outcome) to 100 (best possible health outcome).

  • *

    Results for patients with isolated transtibial amputations. n.s., Not significant; n.a., not available.

Mental health
 Smith et al.27Transtibial77780·627
 Dougherty30*Transtibial80760·375
 Pezzin et al.29Mixed7678n.s.
 Hoogendorn and van der Werken31Mixed7675n.a.
 Hagberg and Brånemark10Transfemoral7380< 0·001
 Dougherty24Transfemoral69750·001
Role limitation because of emotional problems    
 Smith et al.27Transtibial88910·247
 Dougherty30*Transtibial88850·660
 Pezzin et al.29Mixed7882n.s.
 Hoogendorn and van der Werken31Mixed8586n.a.
 Hagberg and Brånemark10Transfemoral7185< 0·001
 Dougherty24Transfemoral6385< 0·001

It is only in populations with transfemoral amputations or severe additional injuries that the mental and emotional health outcomes were significantly worse than in controls10, 24, 30 (Table1). More than half of these individuals accessed mental health services, suggesting a correlation between trauma severity and psychological distress.

Reduced physical function

Traumatic leg amputation affects physical function markedly11, 33–35. Residual limb length and the quality of soft tissue coverage are the most important variables determining physical outcome. With more proximal amputation comes greater loss of functional joints and muscle units, increasing disturbance of limb function. There are various measures of this disability. Self-reported quality-of-life measures consistently show significantly worse physical health outcomes in traumatic amputees compared with norms10, 24, 27, 29–31, 35–37. The disability increases with higher level of amputation (Table2). Objective measures such as walking speed35, gait efficiency and energy requirements for mobilization38–40 show better outcomes in transtibial amputees, and disability increases with more proximal amputations. This emphasizes the importance of joint preservation and maximizing residual limb length.

Table 2. Comparison of selected Short Form 36 health outcome scores between traumatic amputees and controls
ReferenceAmputation levelAmputee scoreControl scoreP
  1. Dimensions of the Short form 36 are scored from 0 (worst possible health outcome) to 100 (best possible health outcome). n.a., Not available.

Physical functioning    
 Smith et al.27Transtibial7091< 0·001
 Dougherty30Transtibial6787< 0·001
 Pezzin et al.29Mixed5491< 0·01
 Hoogendorn and van der Werken31Mixed4591n.a.
 Hagberg and Brånemark10Transfemoral4686< 0·001
 Dougherty24Transfemoral4687< 0·001
Role limitation because of physical health    
 Smith et al.27Transtibial4590< 0·001
 Dougherty30Transtibial5286< 0·001
 Pezzin et al.29Mixed4888< 0·01
 Hoogendorn and van der Werken31Mixed5290n.a.
 Hagberg and Brånemark10Transfemoral4981< 0·001
 Dougherty24Transfemoral4886< 0·001

The quality of the soft tissue envelope of the residual limb is important, as this provides the comfort and durability needed for prosthetic tolerance and weight-bearing. A painful, non-healing, residual leg secondary to inadequate soft tissue cover will markedly worsen physical disability.

The outcome following through-knee amputation is controversial. The retained muscle attachments and weight-bearing capacity of the femoral condyles confer a physical advantage over transfemoral amputations. This advantage is lost, however, without adequate soft tissue coverage35. Asymmetry between the prosthetic and remaining knee joint provides a further unique challenge. Improvements in surgical technique41 and prosthetic technology have overcome some of these problems42. In these situations, through-knee amputation is preferable to a more proximal amputation41, 43, 44.

Impact on employment

The ability to return to work following a traumatic leg amputation is dependent on numerous factors including age, preinjury vocational ability, level of amputation, residual limb health, associated injuries, social support and the national disability systems. Overall, more than half of traumatic amputees return to employment. In the USA, approximately 52–70 per cent of civilian traumatic amputees return to work29, 34, 45–47, whereas in the UK and parts of Europe, with different disability systems, more than 95 per cent of civilian amputees return to work48, 49. The majority of military amputees treated in specialist amputee centres return to employment24, 30. The level of amputation is an important factor in both military and civilian settings, with those with more proximal amputations having lower rates of re-employment17, 18, 24, 30, 47. The majority of amputees return to less physically demanding employment18, 29, 47, 49, 50, which frequently requires retraining49, 50. However, a large proportion of amputees who return to work remain in long-term employment24, 29, 50. Multiple studies, including a systematic review, have shown that after traumatic amputation the average rehabilitation time before returning to work is approximately 1 year46–48, 50, 51.

Cardiovascular disability

Patients with traumatic leg amputation have increased cardiovascular morbidity and mortality. Studies have shown that, over decades, unilateral above-knee amputees are at a greater risk of both ischaemic heart disease52 (relative risk 3·3 versus that in healthy controls) and abdominal aortic aneurysm53 (relative risk 5·1 versus that in veterans without amputation). Indeed, the relative risk of cardiac-related death is increased, and varies between 1·58 in unilateral and 3·5 in bilateral above-knee amputees54 (compared with that in veterans without amputation), to 2·2 when compared to healthy controls55. Evidence on the causes of this increased risk of cardiovascular disease remains inconclusive. Long-term follow-up of traumatic leg amputees has revealed higher rates of modifiable cardiovascular risk factors56, in conjunction with increased levels of factors associated with developing cardiovascular disease, such as physical inactivity, PTSD and substance abuse. Research has also demonstrated that traumatic leg amputees have higher insulin resistance and blood coagulability compared with healthy subjects57. Haemodynamic changes and abnormalities of arterial flow have also been implicated in the development of cardiovascular abnormalities, and may provide explanations as to why both more proximal levels and bilateral amputation lead to a greater risk of subsequent disease53.

Therapeutic interventions that may improve outcome

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Adverse health outcomes leading to disability after traumatic amputation
  6. Therapeutic interventions that may improve outcome
  7. Conclusion
  8. Disclosure
  9. References

Preoperative interventions

Control haemorrhage

Exsanguination from an extremity injury is a leading cause of preventable military death58–60. Although less common, civilian deaths from extremity exsanguination do occur61. Consequently, control of catastrophic haemorrhage is the first clinical priority when treating a patient with a mangled extremity, and can usually be achieved with direct pressure and limb elevation. If haemorrhage continues, a tourniquet is indicated. In extreme situations, such as those involving mass casualties or where rescuer safety is at risk, a tourniquet may be the primary means of haemorrhage control. When indicated, correct tourniquet application improves survival62 with minimal associated morbidity63. Early application improves effectiveness, particularly when applied before clinical signs of shock develop62.

Incorrect application and prolonged use of a tourniquet may result in iatrogenic morbidity and possible death. Skeletal muscle is the limb tissue most vulnerable to ischaemia. Animal studies suggest that muscle may tolerate warm ischaemia for up to 3 h; after this, progressive myonecrosis occurs64, 65. The amount of ischaemic muscle damage not only affects limb viability, it is also a critical aspect of reperfusion injury. To minimize risk, the continued need for an emergency tourniquet should be reviewed at the earliest possible opportunity, preferably within 2 h of application.

Prevent pain

Opiate or ketamine analgesia should be administered as soon after injury as possible. Not only do these agents control acute pain but they may also reduce the risk of chronic pain66, 67. Painful symptoms before amputation are associated with an increased risk of phantom limb pain12, 13 and pre-emptive analgesia may disrupt the development of pain memories, central to pathogenesis68. Several studies suggest that pre-emptive analgesia with epidural anaesthesia may also reduce the incidence of phantom limb pain69, 70, although a randomized double-blind study showed no benefit and highlighted the risks of epidural anaesthesia. Previous studies included amputation for chronic pathology, so analgesia was not truly pre-emptive as central nervous system changes may have been established12. The role of pre-emptive epidural anaesthesia in acute limb trauma has not been defined.

Minimize contamination

Infections are a common complication and an important source of morbidity following severe leg injury. The infection risk is directly related to injury severity and occurs in approximately one-quarter of civilian and military mangled extremities71, 72.

The most important step in minimizing infection risk is operative debridement. Preoperative management should aim simply to remove gross contamination, seal the wound, and administer antibiotic prophylaxis73, 74. Preoperative wound exploration, debridement and irrigation may drive infection deeper into tissues and should be avoided73. Repeated wound inspection and dressing changes also promote infection. To minimize this, wounds should be photographed, covered with a sterile, saline-soaked dressing and sealed with an adhesive film to minimize evaporation73. Dressings and wounds should not be soaked in povidone–iodine antiseptics; the antimicrobial activity after exposure to blood is disputable and the resulting tissue staining makes the assessment of tissue viability at debridement difficult. Furthermore, absorption of iodine in large open wounds can result in local and systemic toxicity73, 75.

Early administration of prophylactic antibiotics is a standard of care and of proven value in reducing the risk of infection76, 77. In military and civilian settings, antibiotics should be administered as soon as possible, preferably within 3 h of injury73, 78–80. Guidelines on the choice of antibiotic and duration of prophylaxis are summarized in Table3. Routine wound cultures are not recommended and should be obtained only to guide treatment when infection is suspected clinically74. Tetanus status should be checked and prophylaxis administered if indicated.

Table 3. Guidelines for antibiotic prophylaxis in patients with severe open fractures of the leg
ReferenceYearAssociationAntibioticDurationAdditional comments
  1. BOA, British Orthopaedic Association; BAPRAS, British Association of Plastic, Reconstructive and Aesthetic Surgeons; EAST, Eastern Association for the Surgery of Trauma; SIS, Surgical Infection Society; ICRC, International Committee of the Red Cross; i.v., intravenous; MIU, million international units.

Nanchahal732009BOA and BAPRASCo-amoxiclav 1·2 g 8-hourly i.v. or cefuroxime 1·5 g 8-hourly i.v.Until soft tissue closure or a maximum of 72 h, whichever is soonerMild penicillin allergy, use cephalosporin
     Severe penicillin allergy, use clindamycin 600 mg 6-hourly i.v.
   Single dose of gentamicin (1·5 mg/kg) on induction of anaesthesia (debridement and reconstruction)  
   Single dose of vancomycin 1 g or teicoplanin 800 mg on induction of anaesthesia (reconstruction)  
Hoff et al.772011EASTSystemic antibiotic with Gram-positive and Gram-negative cover72 h after injury or not more than 24 h after soft tissue coverage achievedAdd penicillin in suspected faecal or clostridial contamination
Hauser et al.802006SISFirst-generation cephalosporin24–48 hInsufficient evidence to support additional Gram-negative or clostridial cover; prolonged courses or repeat short courses
Dufour et al.811998ICRCPenicillin G 5 MIU 6-hourly i.v. for 48 h followed by penicillin V 500 mg 6-hourly orally5 days or until delayed primary closureAdd metronidazole in landmine injuries and delays to treatment > 72 h

Operative intervention

The best outcomes are achieved when patients with severe leg injuries are managed in a specialist trauma centre by experienced multidisciplinary teams that include combined orthopaedic and plastic surgical care73, 81, 83. Direct triage, or immediate referral, of patients with these injuries to such units is justified.

Emergency surgery is indicated when uncontrolled haemorrhage, compromised perfusion, compartment syndrome or gross contamination is present. All other limb surgery should take place only after resuscitation and normalization of physiology73.

Wound debridement

Meticulous excision of devitalized tissue followed by wound irrigation is the most important intervention in reducing infection risk. The timing is controversial; urgent surgery within 6 h of injury is a widely accepted standard, but not supported by evidence84. Delays of up to 24 h do not increase infection risk or worsen outcome72, 84–86. The best outcomes are achieved when an experienced orthoplastic team performs scheduled surgery within 24 h of injury73. All viable tissue must be preserved, flaps should not be fashioned and no part of the wound should be closed at initial operation42, 43. Removal of viable tissue at this stage may compromise residual limb reconstruction and eventual outcome. Wounds may, however, be extended along fasciotomy lines to improve exposure and facilitate complete excision of devitalized tissue. As wounds are evolving, a second procedure should be undertaken after 24–48 h; further staged procedures may be required. Accurate technique is important to avoid excessive procedures, which may worsen outcome87.

Guillotine amputations must be avoided42, 43, 88–90, the exception being a prehospital emergency procedure to relieve entrapment in an immediately life-threatening situation91.

Wound irrigation

Wound irrigation with sterile saline is performed after adequate debridement. Antibiotic and antiseptic additives should be avoided92, 93. A low-pressure (less than 15 pounds per square inch, p.s.i.) irrigation method using the traditional fluid volume of at least 9 litres is recommended73, 92. High-pressure pulsed lavage, especially above 50 p.s.i., should be avoided as it may result in tissue damage and may drive bacteria deeper into wounds92.

Temporary wound dressing

The ideal temporary wound dressing between procedures would prevent bacterial ingress, and avoid tissue damage and desiccation, whilst not needing to be changed. Negative-pressure wound therapy meets many of these criteria and has dramatically changed the way complex traumatic wounds are managed73, 94, 95. Randomized controlled trials support the improved wound healing and reduced infection risk of this therapy96, 97. The use of antibiotic bead pouches in complex wounds may also reduce infection rates compared with systemic antibiotics alone73.

Limb reconstruction

Residual limb reconstruction should be planned once the wound appears clean and free from non-viable tissue. To optimize outcome, reconstruction should aim to preserve maximal limb length while ensuring adequate soft tissue cover. Every effort should be made to preserve viable bone and functional joints. Amputation at the level of the fracture site should be avoided if viable distal bone is present. Although amputation through the zone of injury may lead to an increased risk of wound complications, this is offset by an improvement in overall outcome. Proximal fractures should be managed with standard fracture reduction and fixation techniques43, 98. Careful attention to the distal bone ends will avoid unnecessary morbidity. The tibia or femur should be bevelled anteriorly and the edges carefully smoothed. The fibula should be shortened by 3–4 cm more than the tibia73, and sculpted smooth99, 100. The role of a bone bridge between the distal tibia and fibula in traumatic amputees is controversial101. This technique may improve tibiofibular instability, enhance weight-bearing and improve functional outcome102, although more evidence is required103.

Soft tissue reconstruction must provide sufficiently durable and comfortable padding over the residual bone to allow optimal prosthesis use. This is achieved with a firmly secured myocutaneous flap. The most distal level of viable soft tissue should dictate the level of amputation43. At this level, standard amputation flaps are frequently compromised by the injury. To preserve length the available soft tissue, the so-called ‘flaps of opportunity’ should be used to reconstruct the soft tissue envelope42. This atypical flap coverage does not increase wound complication rates35. Other reconstructive surgical techniques to preserve limb length include skin grafts104, tissue expansion105, and tissue transfer with pedicled106 or free107, 108 flaps. Length preservation must not, however, be at the expense of adequate soft tissue coverage as this may result in a painful, non-healing residual limb that cannot be used.

A second function of the soft tissue reconstruction is to restore muscular control to the residual leg. Loss of normal muscle attachments results in muscular imbalance, contractures and reduced function109. This is most marked in transfemoral amputees where loss of adductor magnus attachment results in a flexion–abduction deformity that contributes to an inefficient gait. Myodesis of detached muscle groups to the residual bone will preserve normal anatomical and mechanical alignment, and optimize function109 (Fig.1). Myodesis is achieved by suturing residual muscle, under physiological tension, directly to the periosteum or bone through drill holes42. It is recommended after traumatic amputation as it improves outcome101, 109, 110.

thumbnail image

Figure 1. Diagram illustrating the advantages of length preservation and stable myodesis in a transfemoral amputation. a Residual limb length preservation and a stable adductor myodesis result in normal anatomical and mechanical femoral alignment. b Abduction deformity secondary to the loss of normal adductor attachments and no myodesis results in poor femoral alignment

Download figure to PowerPoint

Management of nerves in a lower limb amputation

Neuroma formation cannot be prevented following nerve transection. However, only 10–25 per cent of neuromas become symptomatic, usually because they are exposed to mechanical stimulation. Accurate surgical management of the nerve ending reduces the incidence of symptomatic neuromas. All named nerves should be identified. Using traction, each should be cut as proximally as possible, allowing the end to retract into the soft tissues, away from the stump. For transtibial amputations, the sural nerve requires particular attention to prevent inclusion in the scar. A novel microsurgical technique, the sciatic nerve sling, may also successfully reduce chronic postamputation pain111.

Postoperative follow-up and rehabilitation

Rehabilitation and long-term follow-up of traumatic amputees is critical to optimize outcome and minimize morbidity. For military personnel, dedicated multidisciplinary amputee rehabilitation pathways exist. In civilian practice such an approach is not standard, and the treating surgeon must often take the lead in initiating and co-ordinating care. Rehabilitation requires a large and varied team, and should include a minimum of physical and occupational therapists, psychologists, prosthetists and social workers, with measures in place to monitor both acute and chronic needs.

Acute rehabilitation and counselling

Ideally, this should begin as soon after resuscitation as possible, usually while awaiting wound closure. The aims of early counselling are to provide education and psychological support whilst addressing individual concerns. Both the expected and the likely eventual outcomes following traumatic leg amputation should be discussed. Acute rehabilitation must include mobilization to prevent contractures and thromboembolic complications.

Long-term follow-up

Traumatic amputees have high rates of both physical and psychological complications, which may pursue a chronic course. If recognized, the majority can be treated and unnecessary disability prevented. Amputees should therefore be offered regular follow-up for at least 2 years after injury, and remain under long-term surveillance for evidence of either ongoing or new physical or mental ill-health. There are several key aspects in the management and follow-up that should be addressed.

Pain

An assessment of amputation-related pain, including back pain and pain in the contralateral leg, is an important aspect of follow-up. Phantom limb pain is difficult to manage, and most analgesics, including paracetamol and non-steroidal anti-inflammatory drugs, are ineffective. As the pathogenesis is not fully understood, effective treatments targeting the underlying mechanism are not available. In established cases, pregabalin and/or tricyclic antidepressants are the recommended first-line treatment, with the addition of tramadol in resistant cases112, 113. If available, patients who develop phantom limb pain should be referred to a specialist pain service. These patients require early and regular clinical review to assess and monitor the effectiveness of treatment. Other effective treatments are available for resistant cases. Controlled studies have shown that opioids and ketamine may reduce phantom limb pain effectively66, 67. Regional nerve blocks and calcitonin achieve short-term pain relief, but no significant long-term effects. Studies of non-medical treatments, such as active prosthesis use, sensory discrimination training and transcutaneous nerve stimulation, have also shown some benefit12.

Mental health

Screening for mental health problems is another important aspect of follow-up. PTSD is often overlooked, partly because avoidance is a symptom of the disorder. It is, therefore, important to enquire specifically about the disorder, as this may be the first step in gaining access to care.

Cardiovascular disease

Traumatic leg amputees should be screened for cardiovascular risk. Primary prevention measures should be undertaken to prevent modifiable risk factors such as smoking, obesity and physical inactivity. Surveillance must be long term and seek optimal control of blood pressure and blood insulin levels, with awareness that patients are more susceptible to developing adverse cardiac events and aneurysms.

Revisional surgery

Amputation revisional surgery should be considered in selected symptomatic amputees when non-operative management fails. Revisional surgery for bone pathology may improve mobility and comfort in over 80 per cent of patients100. In patients with residual limb pain thought to be caused by a radiologically confirmed neuroma, two-thirds improve with surgical excision of the neuroma100. Amputation revisional surgery also improved residual limb pain in 70 per cent of patients with pain resulting from soft tissue pathology or poor muscle reconstruction to protect bone ends100.

Conclusion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Adverse health outcomes leading to disability after traumatic amputation
  6. Therapeutic interventions that may improve outcome
  7. Conclusion
  8. Disclosure
  9. References

Traumatic lower limb amputation is a significant cause of long-term ill-health and disability in primarily young and previously active individuals. Patients are susceptible to high rates of chronic pain, physical inactivity, psychological problems and cardiovascular abnormalities. Clinicians involved in the management of traumatic lower limb amputees should consider all interventions based on eventual outcome, and exploit any opportunities to preserve soft tissue and limb length (Table4). Amputees should be followed up carefully and rehabilitated actively.

Table 4. Priority of therapeutic interventions for patients with a traumatic leg amputation
ImmediateControl haemorrhage
 (< 10 min)Resuscitation
 Analgesia
Emergency  (< 3 h)Remove gross contamination
 Emergency surgery for continued haemorrhage, compromised perfusion, compartment syndrome and gross contamination
 Photograph and seal wound with a saline-soaked dressing
 Antibiotic prophylaxis
 Tetanus prophylaxis
Urgent (< 24 h)Thorough wound debridement and irrigation
Scheduled  (< 1 week)Repeat debridement and irrigation until wound is healthy
 Reconstruct residual limb

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Adverse health outcomes leading to disability after traumatic amputation
  6. Therapeutic interventions that may improve outcome
  7. Conclusion
  8. Disclosure
  9. References
  • 1
    Information Services Division, NHS Scotland. The Amputee Statistical Database for the United Kingdom: 2006/07. Edinburgh, 2009; http://www.limbless-statistics.org/documents/Report2006-07.pdf [accessed 10 May 2011].
  • 2
    Cross JD, Ficke JR, Hsu JR, Masini BD, Wenke JC. Battlefield orthopaedic injuries cause the majority of long-term disabilities. J Am Acad Orthop Surg 2011; 19(Suppl): S1S7.
  • 3
    Holbrook TL, Anderson JP, Sieber WJ, Browner D, Hoyt DB. Outcome after major trauma: 12-month and 18-month follow-up results from the Trauma Recovery Project. J Trauma 1999; 46: 765771.
  • 4
    Pape HC, Probst C, Lohse R, Zelle BA, Panzica M, Stalp M et al. Predictors of late clinical outcome following orthopedic injuries after multiple trauma. J Trauma 2010; 69: 12431251.
  • 5
    Seekamp A, Regel G, Tscherne H. Rehabilitation and reintegration of multiply injured patients: an outcome study with special reference to multiple lower limb fractures. Injury 1996; 27: 133138.
  • 6
    Aitken ME, Jaffe KM, DiScala C, Rivara FP. Functional outcome in children with multiple trauma without significant head injury. Arch Phys Med Rehabil 1999; 80: 889895.
  • 7
    MacKenzie EJ, Bosse MJ, Pollak AN, Webb LX, Swiontkowski MF, Kellam JF et al. Long-term persistence of disability following severe lower-limb trauma. Results of a seven-year follow-up. J Bone Joint Surg Am 2005; 87: 18011809.
  • 8
    Ephraim PL, Wegener ST, MacKenzie EJ, Dillingham TR, Pezzin LE. Phantom pain, residual limb pain, and back pain in amputees: results of a national survey. Arch Phys Med Rehabil 2005; 86: 19101919.
  • 9
    Castillo RC, MacKenzie EJ, Wegener ST, Bosse MJ; LEAP Study Group. Prevalence of chronic pain seven years following limb threatening lower extremity trauma. Pain 2006; 124: 321329.
  • 10
    Hagberg K, Brånemark R. Consequences of non-vascular trans-femoral amputation: a survey of quality of life, prosthetic use and problems. Prosthet Orthot Int 2001; 25: 186194.
  • 11
    Giannoudis PV, Harwood PJ, Kontakis G, Allami M, Macdonald D, Kay SP et al. Long-term quality of life in trauma patients following the full spectrum of tibial injury (fasciotomy, closed fracture, grade IIIB/IIIC open fracture and amputation). Injury 2009; 40: 213219.
  • 12
    Flor H. Phantom-limb pain: characteristics, causes, and treatment. Lancet Neurol 2002; 1: 182189.
  • 13
    Nikolajsen L, Jensen TS. Phantom limb pain. Br J Anaesth 2001; 87: 107116.
  • 14
    Jensen TS, Krebs B, Nielsen J, Rasmussen P. Immediate and long-term phantom limb pain in amputees: incidence, clinical characteristics and relationship to pre-amputation limb pain. Pain 1985; 21: 267278.
  • 15
    Smith DG, Ehde DM, Legro MW, Reiber GE, del Aguila M, Boone DA. Phantom limb, residual limb, and back pain after lower extremity amputations. Clin Orthop Relat Res 1999; (361): 2938.
  • 16
    Wartan SW, Hamann W, Wedley JR, McColl I. Phantom pain and sensation among British veteran amputees. Br J Anaesth 1997; 78: 652659.
  • 17
    Ebrahimzadeh MH, Fattahi AS. Long-term clinical outcomes of Iranian veterans with unilateral transfemoral amputation. Disabil Rehabil 2009; 31: 18731877.
  • 18
    Ebrahimzadeh MH, Hariri S. Long-term outcomes of unilateral transtibial amputations. Mil Med 2009; 174: 593597.
  • 19
    Ehde DM, Smith DG, Czerniecki JM, Campbell KM, Malchow DM, Robinson LR. Back pain as a secondary disability in persons with lower limb amputations. Arch Phys Med Rehabil 2001; 82: 731734.
  • 20
    Kulkarni J, Gaine WJ, Buckley JG, Rankine JJ, Adams J. Chronic low back pain in traumatic lower limb amputees. Clin Rehabil 2005; 19: 8186.
  • 21
    Norvell DC, Czerniecki JM, Reiber GE, Maynard C, Pecoraro JA, Weiss NS. The prevalence of knee pain and symptomatic knee osteoarthritis among veteran traumatic amputees and nonamputees. Arch Phys Med Rehabil 2005; 86: 487493.
  • 22
    Melcer T, Walker GJ, Galarneau M, Belnap B, Konoske P. Midterm health and personnel outcomes of recent combat amputees. Mil Med 2010; 175: 147154.
  • 23
    Reiber GE, McFarland LV, Hubbard S, Maynard C, Blough DK, Gambel JM et al. Servicemembers and veterans with major traumatic limb loss from Vietnam war and OIF/OEF conflicts: survey methods, participants, and summary findings. J Rehabil Res Dev 2010; 47: 275297.
  • 24
    Dougherty PJ. Long-term follow-up of unilateral transfemoral amputees from the Vietnam war. J Trauma 2003; 54: 718723.
  • 25
    McCarthy ML, MacKenzie EJ, Edwin D, Bosse MJ, Castillo RC, Starr A; LEAP study group. Psychological distress associated with severe lower-limb injury. J Bone Joint Surg Am 2003; 85-A: 16891697.
  • 26
    Brown ES, Fulton MK, Wilkeson A, Petty F. The psychiatric sequelae of civilian trauma. Compr Psychiatry 2000; 41: 1923.
  • 27
    Smith DG, Horn P, Malchow D, Boone DA, Reiber GE, Hansen ST Jr. Prosthetic history, prosthetic charges, and functional outcome of the isolated, traumatic below-knee amputee. J Trauma 1995; 38: 4447.
  • 28
    Dagum AB, Best AK, Schemitsch EH, Mahoney JL, Mahomed MN, Blight KR. Salvage after severe lower-extremity trauma: are the outcomes worth the means? Plast Reconstr Surg 1999; 103: 12121220.
  • 29
    Pezzin LE, Dillingham TR, MacKenzie EJ. Rehabilitation and the long-term outcomes of persons with trauma-related amputations. Arch Phys Med Rehabil 2000; 81: 292300.
  • 30
    Dougherty PJ. Transtibial amputees from the Vietnam War. Twenty-eight-year follow-up. J Bone Joint Surg Am 2001; 83-A: 383389.
  • 31
    Hoogendoorn JM, van der Werken C. Grade III open tibial fractures: functional outcome and quality of life in amputees versus patients with successful reconstruction. Injury 2001; 32: 329334.
  • 32
    Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, Koffman RL. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J Med 2004; 351: 1322.
  • 33
    Bosse MJ, MacKenzie EJ, Kellam JF, Burgess AR, Webb LX, Swiontkowski MF et al. An analysis of outcomes of reconstruction or amputation of leg-threatening injuries. N Engl J Med 2002; 347: 19241931.
  • 34
    Georgiadis GM, Behrens FF, Joyce MJ, Earle AS, Simmons AL. Open tibial fractures with severe soft-tissue loss. Limb salvage compared with below-the-knee amputation. J Bone Joint Surg Am 1993; 75: 14311441.
  • 35
    MacKenzie EJ, Bosse MJ, Castillo RC, Smith DG, Webb LX, Kellam JF et al. Functional outcomes following trauma-related lower-extremity amputation. J Bone Joint Surg Am 2004; 86-A: 16361645.
  • 36
    Dagum AB, Best AK, Schemitsch EH, Mahoney JL, Mahomed MN, Blight KR. Salvage after severe lower-extremity trauma: are the outcomes worth the means? Plast Reconstr Surg 1999; 103: 12121220.
  • 37
    Georgiadis GM, Behrens FF, Joyce MJ, Earle AS, Simmons AL. Open tibial fractures with severe soft-tissue loss. Limb salvage compared with below-the-knee amputation. J Bone Joint Surg Am 1993; 75: 14311441.
  • 38
    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; 58: 4246.
  • 39
    Pinzur MS, Gold J, Schwartz D, Gross N. Energy demands for walking in dysvascular amputees as related to the level of amputation. Orthopedics 1992; 15: 10331036.
  • 40
    Gonzalez EG, Corcoran PJ, Reyes RL. Energy expenditure in below-knee amputees: correlation with stump length. Arch Phys Med Rehabil 1974; 55: 111119.
  • 41
    Bowker JH, San Giovanni TP, Pinzur MS. North American experience with knee disarticulation with use of a posterior myofasciocutaneous flap. Healing rate and functional results in seventy-seven patients. J Bone Joint Surg Am 2000; 82-A: 15711574.
  • 42
    Tintle SM, Keeling JJ, Shawen SB, Forsberg JA, Potter BK. Traumatic and trauma-related amputations: part I: general principles and lower-extremity amputations. J Bone Joint Surg Am 2010; 92: 28522868.
  • 43
    Clasper J; Lower Limb Trauma Working Group. Amputations of the lower limb: a multidisciplinary consensus. J R Army Med Corps 2007; 153: 172174.
  • 44
    Pinzur MS, Bowker JH. Knee disarticulation. Clin Orthop Relat Res 1999; (361): 2328.
  • 45
    Puno RM, Grossfeld SL, Henry SL, Seligson D, Harkess J, Tsai TM. Functional outcome of patients with salvageable limbs with grades III-B and III-C open fractures of the tibia. Microsurgery 1996; 17: 167173.
  • 46
    Francel TJ, Vander Kolk CA, Hoopes JE, Manson PN, Yaremchuk MJ. Microvascular soft-tissue transplantation for reconstruction of acute open tibial fractures: timing of coverage and long-term functional results. Plast Reconstr Surg 1992; 89: 478487.
  • 47
    Livingston DH, Keenan D, Kim D, Elcavage J, Malangoni MA. Extent of disability following traumatic extremity amputation. J Trauma 1994; 37: 495499.
  • 48
    Purry NA, Hannon MA. How successful is below-knee amputation for injury? Injury 1989; 20: 3236.
  • 49
    Hertel R, Strebel N, Ganz R. Amputation versus reconstruction in traumatic defects of the leg: outcome and costs. J Orthop Trauma 1996; 10: 223229.
  • 50
    Schoppen T, Boonstra A, Groothoff JW, de Vries J, Goeken LN, Eisma WH. Employment status, job characteristics, and work-related health experience of people with a lower limb amputation in the Netherlands. Arch Phys Med Rehabil 2001; 82: 239245.
  • 51
    Saddawi-Konefka D, Kim HM, Chung KC. A systematic review of outcomes and complications of reconstruction and amputation for type IIIB and IIIC fractures of the tibia. Plast Reconstr Surg 2008; 122: 17961805.
  • 52
    Yekutiel M, Brooks ME, Ohry A, Yarom J, Carel R. The prevalence of hypertension, ischaemic heart disease and diabetes in traumatic spinal cord injured patients and amputees. Paraplegia 1989; 27: 5862.
  • 53
    Vollmar JF, Paes E, Pauschinger P, Henze E, Friesch A. Aortic aneurysms as late sequelae of above-knee amputation. Lancet 1989; 2: 834835.
  • 54
    Hrubec Z, Ryder RA. Traumatic limb amputations and subsequent mortality from cardiovascular disease and other causes. J Chronic Dis 1980; 33: 239250.
  • 55
    Modan M, Peles E, Halkin H, Nitzan H, Azaria M, Gitel S et al. Increased cardiovascular disease mortality rates in traumatic lower limb amputees. Am J Cardiol 1998; 82: 12421247.
  • 56
    Shahriar SH, Masumi M, Edjtehadi F, Soroush MR, Soveid M, Mousavi B. Cardiovascular risk factors among males with war-related bilateral lower limb amputation. Mil Med 2009; 174: 11081112.
  • 57
    Peles E, Akselrod S, Goldstein DS, Nitzan H, Azaria M, Almog S et al. Insulin resistance and autonomic function in traumatic lower limb amputees. Clin Auton Res 1995; 5: 279288.
  • 58
    Holcomb JB, McMullin NR, Pearse L, Caruso J, Wade CE, Oetjen-Gerdes L et al. Causes of death in U.S. Special Operations Forces in the global war on terrorism: 2001–2004. Ann Surg 2007; 245: 986991.
  • 59
    Mabry RL, Holcomb JB, Baker AM, Cloonan CC, Uhorchak JM, Perkins DE et al. United States Army Rangers in Somalia: an analysis of combat casualties on an urban battlefield. J Trauma 2000; 49: 515528.
  • 60
    Kelly JF, Ritenour AE, McLaughlin DF, Bagg KA, Apodaca AN, Mallak CT et al. Injury severity and causes of death from Operation Iraqi Freedom and Operation Enduring Freedom: 2003–2004 versus 2006. J Trauma 2008; 64(Suppl): S21S26.
  • 61
    Dorlac WC, DeBakey ME, Holcomb JB, Fagan SP, Kwong KL, Dorlac GR et al. Mortality from isolated civilian penetrating extremity injury. J Trauma 2005; 59: 217222.
  • 62
    Kragh JF Jr, Walters TJ, Baer DG, Fox CJ, Wade CE, Salinas J et al. Survival with emergency tourniquet use to stop bleeding in major limb trauma. Ann Surg 2009; 249: 17.
  • 63
    Kragh JF Jr, Walters TJ, Baer DG, Fox CJ, Wade CE, Salinas J et al. Practical use of emergency tourniquets to stop bleeding in major limb trauma. J Trauma 2008; 64(Suppl): S38S49.
  • 64
    Blaisdell FW. The pathophysiology of skeletal muscle ischemia and the reperfusion syndrome: a review. Cardiovasc Surg 2002; 10: 620630.
  • 65
    Gifford SM, Propper BW, Eliason JL. The ischemic threshold of the extremity. Perspect Vasc Surg Endovasc Ther 2011; 23: 8187.
  • 66
    Huse E, Larbig W, Flor H, Birbaumer N. The effect of opioids on phantom limb pain and cortical reorganization. Pain 2001; 90: 4755.
  • 67
    Nikolajsen L, Hansen CL, Nielsen J, Keller J, Arendt-Nielsen L, Jensen TS. The effect of ketamine on phantom pain: a central neuropathic disorder maintained by peripheral input. Pain 1996; 67: 6977.
  • 68
    Katz J, Melzack R. Pain ‘memories’ in phantom limbs: review and clinical observations. Pain 1990; 43: 319336.
  • 69
    Bach S, Noreng MF, Tjéllden NU. Phantom limb pain in amputees during the first 12 months following limb amputation, after preoperative lumbar epidural blockade. Pain 1988; 33: 297301.
  • 70
    Jahangiri M, Jayatunga AP, Bradley JW, Dark CH. Prevention of phantom pain after major lower limb amputation by epidural infusion of diamorphine, clonidine and bupivacaine. Ann R Coll Surg Engl 1994; 76: 324326.
  • 71
    Brown KV, Murray CK, Clasper JC. Infectious complications of combat-related mangled extremity injuries in the British military. J Trauma 2010; 69(Suppl 1): S109S115.
  • 72
    Pollak AN, Jones AL, Castillo RC, Bosse MJ, MacKenzie EJ; LEAP Study Group. The relationship between time to surgical debridement and incidence of infection after open high-energy lower extremity trauma. J Bone Joint Surg Am 2010; 92: 715.
  • 73
    Nanchahal J. Standards for the Management of Open Fractures of the Lower Limb. Royal Society of Medicine Press: London, 2009.
  • 74
    Murray CK, Hsu JR, Solomkin JS, Keeling JJ, Andersen RC, Ficke JR et al. Prevention and management of infections associated with combat-related extremity injuries. J Trauma 2008; 64(Suppl): S239S251.
  • 75
    Misra A, Nanchahal J. Use of gauze soaked in povidone iodine for dressing acute open wounds. Plast Reconstr Surg 2003; 111: 21052107.
  • 76
    Gosselin RA, Roberts I, Gillespie WJ. Antibiotics for preventing infection in open limb fractures. Cochrane Database Syst Rev 2004; (1)CD003764.
  • 77
    Hoff WS, Bonadies JA, Cachecho R, Dorlac WC. East Practice Management Guidelines Work Group: update to practice management guidelines for prophylactic antibiotic use in open fractures. J Trauma 2011; 70: 751754.
  • 78
    Patzakis MJ, Wilkins J. Factors influencing infection rate in open fracture wounds. Clin Orthop Relat Res 1989; (243): 3640.
  • 79
    Jackson DS. Sepsis in soft tissue limbs wounds in soldiers injured during the Falklands Campaign 1982. J R Army Med Corps 1984; 130: 9799.
  • 80
    Hauser CJ, Adams CA Jr, Eachempati SR. Surgical Infection Society guideline: prophylactic antibiotic use in open fractures: an evidence-based guideline. Surg Infect (Larchmt) 2006; 7: 379405.
  • 81
    Dufour D, Kromann Jensen S, Owen-Smith M, Salmela J, Stening F, Zetterstrom B. Surgery for Victims of War (3rd edn). International Committee of the Red Cross: Geneva, 1998.
  • 82
    Mackenzie EJ, Rivara FP, Jurkovich GJ, Nathens AB, Egleston BL, Salkever DS et al. The impact of trauma-center care on functional outcomes following major lower-limb trauma. J Bone Joint Surg Am 2008; 90: 101109.
  • 83
    Nayagam S, Graham K, Pearse M, Nanchahal J. Reconstructive surgery in limbs: the case for the orthoplastic approach. Ann Plast Surg 2011; 66: 68.
  • 84
    Crowley DJ, Kanakaris NK, Giannoudis PV. Debridement and wound closure of open fractures: the impact of the time factor on infection rates. Injury 2007; 38: 879889.
  • 85
    Webb LX, Bosse MJ, Castillo RC, MacKenzie EJ; LEAP Study Group. Analysis of surgeon-controlled variables in the treatment of limb-threatening type-III open tibial diaphyseal fractures. J Bone Joint Surg Am 2007; 89: 923928.
  • 86
    Naique SB, Pearse M, Nanchahal J. Management of severe open tibial fractures: the need for combined orthopaedic and plastic surgical treatment in specialist centres. J Bone Joint Surg Br 2006; 88: 351357.
  • 87
    Park SH, Silva M, Bahk WJ, McKellop H, Lieberman JR. Effect of repeated irrigation and debridement on fracture healing in an animal model. J Orthop Res 2002; 20: 11971204.
  • 88
    Mannion SJ, Chaloner E. Principles of war surgery. BMJ 2005; 330: 14981500.
  • 89
    Coupland RM. Technical aspects of war wound excision. Br J Surg 1989; 76: 663667.
  • 90
    Fergason J, Keeling JJ, Bluman EM. Recent advances in lower extremity amputations and prosthetics for the combat injured patient. Foot Ankle Clin 2010; 15: 151174.
  • 91
    Porter KM. Prehospital amputation. Emerg Med J 2010; 27: 940942.
  • 92
    Crowley DJ, Kanakaris NK, Giannoudis PV. Irrigation of the wounds in open fractures. J Bone Joint Surg Br 2007; 89: 580585.
  • 93
    Anglen JO. Comparison of soap and antibiotic solutions for irrigation of lower-limb open fracture wounds. A prospective, randomized study. J Bone Joint Surg Am 2005; 87: 14151422.
  • 94
    Orgill DP, Bayer LR. Update on negative-pressure wound therapy. Plast Reconstr Surg 2011; 127(Suppl 1): 105S115S.
  • 95
    Couch KS, Stojadinovic A. Negative-pressure wound therapy in the military: lessons learned. Plast Reconstr Surg 2011; 127(Suppl 1): 117S130S.
  • 96
    Mouës CM, Vos MC, van den Bemd GJ, Stijnen T, Hovius SE. Bacterial load in relation to vacuum-assisted closure wound therapy: a prospective randomized trial. Wound Repair Regen 2004; 12: 1117.
  • 97
    Stannard JP, Volgas DA, Stewart R, McGwin G Jr, Alonso JE. Negative pressure wound therapy after severe open fractures: a prospective randomized study. J Orthop Trauma 2009; 23: 552557.
  • 98
    Gordon WT, O'Brien FP, Strauss JE, Andersen RC, Potter BK. Outcomes associated with the internal fixation of long-bone fractures proximal to traumatic amputations. J Bone Joint Surg Am 2010; 92: 23122318.
  • 99
    Smith DG, Fergason JR. Transtibial amputations. Clin Orthop Relat Res 1999; (361): 108115.
  • 100
    Bourke HE, Yelden KC, Robinson KP, Sooriakumaran S, Ward DA. Is revision surgery following lower-limb amputation a worthwhile procedure? A retrospective review of 71 cases. Injury 2011; 42: 660666.
  • 101
    Pinzur MS, Gottschalk FA, Pinto MA, Smith DG. Controversies in lower-extremity amputation. J Bone Joint Surg Am 2007; 89: 11181127.
  • 102
    Pinzur MS, Pinto MA, Saltzman M, Batista F, Gottschalk F, Juknelis D. Health-related quality of life in patients with transtibial amputation and reconstruction with bone bridging of the distal tibia and fibula. Foot Ankle Int 2006; 27: 907912.
  • 103
    Pinzur MS, Beck J, Himes R, Callaci J. Distal tibiofibular bone-bridging in transtibial amputation. J Bone Joint Surg Am 2008; 90: 26822687.
  • 104
    Anderson WD, Stewart KJ, Wilson Y, Quaba AA. Skin grafts for the salvage of degloved below-knee amputation stumps. Br J Plast Surg 2002; 55: 320323.
  • 105
    Wieslander JB, Wendeberg B, Linge G, Buttazzoni G, Buttazzoni AM. Tissue expansion: a method to preserve bone length and joints following traumatic amputations of the leg—a follow-up of five legs amputated at different levels. Plast Reconstr Surg 1996; 97: 10651071.
  • 106
    Ghali S, Harris PA, Khan U, Pearse M, Nanchahal J. Leg length preservation with pedicled fillet of foot flaps after traumatic amputations. Plast Reconstr Surg 2005; 115: 498505.
  • 107
    Kasabian AK, Colen SR, Shaw WW, Pachter HL. The role of microvascular free flaps in salvaging below-knee amputation stumps: a review of 22 cases. J Trauma 1991; 31: 495500.
  • 108
    Erdmann D, Sundin BM, Yasui K, Wong MS, Levin LS. Microsurgical free flap transfer to amputation sites: indications and results. Ann Plast Surg 2002; 48: 167172.
  • 109
    Gottschalk F. Transfemoral amputation. Biomechanics and surgery. Clin Orthop Relat Res 1999; (361): 1522.
  • 110
    Persson B. Lower limb amputation. Part 1: Amputation methods—a 10 year literature review. Prosthet Orthot Int 2001; 25: 713.
  • 111
    Prantl L, Schreml S, Heine N, Eisenmann-Klein M, Angele P. Surgical treatment of chronic phantom limb sensation and limb pain after lower limb amputation. Plast Reconstr Surg 2006; 118: 15621572.
  • 112
    Dworkin RH, O'Connor AB, Backonja M, Farrar JT, Finnerup NB, Jensen TS et al. Pharmacologic management of neuropathic pain: evidence-based recommendations. Pain 2007; 132: 237251.
  • 113
    National Institute for Health and Clinical Excellence. Neuropathic Pain—Pharmacological Management. http://www.nice.org.uk/CG96 [accessed 15 October 2011].