Levels of Amputation

Amputation is performed at the most distal point that will heal successfully. The site of amputation is
determined by two factors: circulation in the part, and the requirements of the prosthesis. The classical
sites of election are only guidelines to indicate an ideal site in the segment of an extremity, which
satisfies the functional requirement and physical characteristic best adapted to the simplest available
conventional prosthesis. Modern prosthesis techniques can fit amputation at any level.
Amputation of the Lower Extremity
the surgical level may be classified on an anatomical or functional basis.
objective: create a stump optimum for weight bearing
1. Foot and Ankle
a. Lisfrancs Amputation/Distraction
a transmetatarsal disarticulation
b. Chopart Amputation
disarticulation at the midtarsal joint through the talonavicular and
calcaneocuboid joints
the remaining foot often develops a significant equinovarus deformity
adequate extensor lengthening has been advocated to prevent this deformity
c. Symes Amputation
an ankle disarticulation for destructive and infective lesions of the foot that
cannot be treated with a transmetatarsal amputation
advantage: if successful, the patient can walk on the symes residual limb
without a prosthesis, at least for short distances
disadvantages:
the heel pad can migrate posteriorly on mediolaterally if it is not
adequately anchored to the cut end of the tibia
uncosmetic because of the inability to match the shape of the
contralateral leg.
prosthesis is difficult in this type
d. Body Amputation and Pirigoff Amputation
amputation done which include tibio calcaneal fusion
rarely done
e. Partial Toe
through the metatarsophalangeal joint
f. Toe Disarticulation
through the metatarsophalangeal joint
g. Partial Foot / Ray Resection
resection of 3rd, 4th and 5th metatarsal and digits
h. Transmetatarsal
through the midsection of all metatarsals
2. Transtibial/Below knee Amputation (BKA)
o transtibial amputation performed at the function of the middle and upper thirds of the
tibia, between 8 and 10 cm below the tibial plateau
a. Short Below Knee
less than 20% of tibial length
b. Long Below Knee
more than 50% of tibial length
o Non-ischemic Limb
ideal level for amputation below the knee is at the musculotendinous junction
of the gastrocnemius muscle
distal third of the leg is not satisfactory because the tissue are relatively vascular
& soft padding is scanty
In adults, the ideal bone length for a BKA stump is 12.5 to 17.5 cm depending on
a body weight
o Ischemic Limb
performed customarily at a higher level, for example 10-12.5 cm. distal to the
joint line, than are amputations in non-ischemic limbs.
3. Amputation through or just above the knee joint

4.

5.

6.
7.

a. Gritti-Stokes
amputation done though the femoral condyles and the patella is attached
directly over the wet end of the femur
a supracondylar amputation
gives a very durable stump with full end bearing
the best kind of amputation
b. Kirks Amputation
a supracondylar tenoplastic amputation
done through the calcaneus bone of supra condylar region of the femur below
the shaft
symmetrical in contours from spurs and of maximum functional length of the
stump is 2 inches higher
c. Callander Amputation
a supracondylar amputation with minimum tissue dissection
no muscle tissue is excised
patella is removed from its bed in the quadriceps tendon leaving patellar
ligaments intact and incorporated in the long anterior skin flap
the cut of the supracondylar is lower here than in Kirks which is higher
d. Rogers Amputation
Knee joint disarticulation with arthrodesis (surgical fusion of the patella in
anatomical position of the patella to the front of femur)
no cutting of any supracondylar
no fibula if the length of the stump is 2 inches higher
e. Knee Disarticulation
through the knee joint
f. Long above knee
amputation of more than 60% femoral length
Above Knee Amputation/Transfemoral
o because patients knee joint is lost, it is extremely important that stumps be long as
possible to provide a strong lever arm for control of prosthesis. The conventional,
constant friction knee joint used in the most AK prosthesis extends for 9 10 cm. distal
to end of prosthetic socket and the bone must be amputated this for proximal to the
knee to allow room for the joint
o transfemoral amputation most commonly seen in the elderly
o ideal length is 10 -12 inches below the greater trochanter
o minimum stump length in which we can have control is 4 inches below the tip of greater
trochanter to fit and above knee amputation
o greater difficulty in learning to control his prosthesis and achieving good gait since
proprioception from the knee joint is lost and he bears weight at the ischial tuberosity
o usually performed with equal anterior and posterior length flaps
o does not tolerate total end weight bearing
o the surgeon typically transects the quadriceps just proximal to the patella, transects the
adductor magnus from the adductor tubercle, and transects the smaller muscles 1 to 3
inches longer than the bone cut
o hip flexion contractures easily occurs unless prevented
a. shorter stump
tend to become flexed and abducted due to the strong full of tensor fascia lata
b. long above knee stump
tend to become flexed and abducted due to the intact abductor group which
have a mechanical advantage over the pull of the short tensor fascia lata
Hip Disarticulation
o involves removal of the entire femur; in practice however, the proximal femur is usually
left to provide prosthetic stabilization and to avoid an uncosmetic cavity
o amputation through the hip joint, pelvis intact
o should be avoided because there is no substitute for anatomical joint
Hemipelvectomy (Hind Quarter Ablation)
o resection of lower left of the pelvis and bears weight on soft tissues and chest cage
Hemicorporectomy (Humpty-Dumpty)

o amputation of both lower limbs and pelvis below L4/L5

o translumbar amputation
o performed for pelvic malignancy, intractable decubitus ulcer, infection, or trauma
Surgical Levels of Greatest Utility:
o vascular level is relatively good
o the lower the amputation, the less energy for ambulation
transmetatarsal, the Symes and the standard below knee amputation
ultra short below the knee amputation next best level

Amputation of the Upper Extremity

Upper extremity stumps are classified by level of amputation using terminology form that used
for congenital skeletal deficiency.
First, the length of the stump must be measured.
o Above elbow stumps are measured form the tip of the acromion to the bone end; This
measurement is compared to the sound side distance from arcomion to the lateral
epicondyle and is expressed as a percentage of normal side length.
o Below elbow measurement is whichever is longer in the stump, and to the ulnar
styloid tip on the sound side.
% of N
Classification
Above elbow
0
Shoulder disarticulation
0 30
Humeral neck
30 50
Short above elbow
50 90
Long above elbow
90 100
Elbow disarticulation
Below Knee
0 35
Very short below elbow
35 55
Short below elbow
55 90
Long below elbow
90 100
Wrist disarticulation
o In bilateral amputations, where no normal segment retains for comparative
measurement, the normal upper arm length is estimated by multiplying the patients
height by 0.19 and normal forearm length is estimated by multiplying by 0.21.
Objective: preserve maximum length and function since prosthesis offer a substitute and
cosmesis is equally important
1. Forearm and Hand
o the optimal length is 7 inches below the tip of olecranon and it shouldnt exceed it.
o Minimum length of below elbow amputation is 3.5 inches
a. Finger Amputation
occur at the distal interphalangeal, proximal interphalangeal and
metacarpophalangeal levels
b. Partial Hand Amputation
creates significant functional limitation and special prosthetic and orthotic
problems.
Congenital hand deficiencies occur in many forms. Levels of loss can be
classified as follows:
Transphalangeal with involvement or sparing of thumb
Thenar Transmetacarpal Distal with involvement or sparing of thumb
Thenar Transmetacarpal Proximal with involvement or sparing of thumb
c. Amputation Through the Wrist
with adequate palmar skin, the carpal bones should be retained when possible
to be useful for a patient with or without a prosthesis.
The hand may be disarticulated at the metacarpal joints or through carpus.
Carpal bones allow some flexion and extension of the distal stump and this may
be useful when a pressure is not used.
Pronation and supination is preserved.
d. Wrist Disarticulation
although carpus disarticulation has occasionally been possible, this is not often
practical.

Disarticulation at the radio carpal joint is the much more common site for
total hand amputation.
The carpus is disarticulated at the radio carpal wrist, this has the advantage
that the prosthesis need not include the elbow joint and the pronation and
supination are retained
2. Transradial Amputation
o preferred in most cases
o as much length as possible should be preserved.
o If the wrist disarticulation cannot be done, the site of election in the forearm is the
function of the lower and middle 1/3 of the elbow.
This creates an adequate level and preserves about 2/3 of the available
pronation and supination.
o The usual prosthesis is hinged at the elbow and includes a forearm socket with a wrist
unit to which a prosthetic hand/hook may be attached interchangeably.
The hook is more useful than the hand. It can be opened by the pull of a cable
attached to the harness about the patients opposite shoulder and closed by
rubber bands about its base.
a. Medium forearm residual limb
optimal externally powered prosthetic restoration is the goal
b. Short transradial amputation
complicates suspension and limit elbow flexion strength and elbow range of
motion
c. Krukenberg Amputation
the forearm stump after a below elbow amputation is converted into a crude
pinching mechanism by separating the lower ends of radius and ulna and cover
them with soft tissues
no prosthesis is used and not popular because of its unsightliness
best expedient in blind, bilateral below amputee since it possess both tactile
sensation and pinching function
d. Long Below Elbow Amputation
preferred when optimal body-powered prosthetic restoration is the goal
e. Forearm Amputation
optimal externally powered prosthetic restoration is the goal
f. Short Below Elbow Amputation
the most proximal useful stump measures 1.5 below the insertion of the biceps
tendon.
The prosthesis for this stump must be short to allow elbow flexion yet long
enough to hold the stump securely. This may be accompanied with a special
prosthesis
3. Elbow disarticulation
o this is uncommon. When the forearm is disarticulated at the elbow or amputation
occurs at a higher level, a mechanical elbow joint is required to place the forearm and
terminal device in use. This device must allow free voluntary flexion and extension
activated by shoulder harness.
o Advantages:
surgical techniques permits reduction in surgery time and blood loss, provides
improves prosthetic self-suspension while permitting the use of the a less
encumbering socket
reduces the rotation of the socket on the residual limb, as compared with the
transhumeral level of amputation
o Disadvantages:
marginal cosmetic appearance caused by the necessary external elbow
mechanism
current limitations in technology, which impede the use of externally powered
elbow mechanisms at the level of amputation.
4. Transhumeral Amputation
o Usually performed at three levels (with long, medium and short residual limbs)
a. Long Below Elbow amputation

Supracondylar Amputation with long arm residual limb

7 to 10 cm from the distal humeral condyle is preferred for optimal prosthetic
restoration.
above elbow amputation are most satisfactory at this level, because above this
functional efficiency becomes less as shoulder ids approached and at least 2 of
bone stump should remain below anterior axillary fold.
Although amputation may be done through the condyles of the humerus, the
most frequent site is about 2 or 2.5 above the joint line
b. Short Arm Stump
amputation may be carried out within 2.5 above the anterior axillary fold.
In amputation at the shoulder, the head and neck of the humerus should be
preserved as possible to minimize disfigurement
5. Shoulder disarticulation and forequarter/interscapulothoracic amputations
o severe deforming procedure with removal of scapula and most of clavicle required for
treatment of malignant disease
o fortunately are seen less frequently than amputation at other levels
Formulae for the levels of Amputation:
A. Upper extremity
If unilateral:
Percentage from normal
Transhumeral
0
0-3
30-50
50-90

Classification
Shoulder disarticulation
Humeral neck
Short transhumeral stump
Long transhumeral stump
Elbow disarticulation

Transradio-ulnar
Classification
0-35
Very short transradio-ulnar stump
35-55
Short transradio-ulnar stump
55-90
Transradio-ulnar stump
90-100
Wrist disarticulation
100
Transcarpal
* measurement
Transhumeral stump normal measurement from tip of the acromion
process to the lateral epicondyle
Transradio-ulnar stump normal measurement: from the medial
epicondyle to ulnar styloid
%age = length of the residual limb x 100
length of the sound limb

if bilateral then:
Upper arm = patients height in cm. x 0.19
Forearm = patients height in cm. x 0.21
B. Lower Extremity
Percentage from normal
Transfemoral
Classification
0-35
Short transfemoral stump
35-60
Medium transfemoral stump
60-100
long transfemoral stump
Transtibio-fibular
0-20
20-50
50-100
* measurement :

Classification
Very short transtibio-fibular stump
Short transtibio-fibular stump
Long transtibio-fibular stump

Transfemoral stump = normal measurement: perineum to medial

femoral condyle
Transtibio-fibular stump = normal measurement: medial tibial plateau
to medial malleolus
% age = length of residual limb x 100
length of sound limb
Levels of Impairment
Upper Extremity
Thumb
Index finger
Middle finger
Ring/little finger
Wrist
Elbow
Shoulder
Forequarter
All fingers except thumb

%age of impairment
22%
14%
11%
5%
54%
57%
60%
70%
32%

Lower Extremity
Big Toe
Other toes
Choparts Amputation
Symes Amputation

%age of impairment
5%
2% (each)
21%
28%

Energy Requirements:
Type of Amputation
Unilateral transtibio-fibular
Bilateral transtibio-fibular
Unilateral transfemoral
Bilateral transfemoral
Unilateral
transfemoral/unilateral
transtibio-fibular

METS (% greater from normal)

10-40%
41%
65%
110%
75%