European Journal of Cardiovascular Medicine

Amputation involves removing part or all of a limb due to trauma, illness, or surgery, often to manage pain, infection, or disease such as gangrene. Below-Knee Amputation (BKA) refers to the surgical removal of the lower leg below the knee, typically preserving the femur while removing the tibia and fibula.[1] It’s commonly performed in cases of severe injury, infection, or conditions like diabetes and vascular disease that threaten limb function or life. The procedure aims to improve mobility, reduce complications, and enhance quality of life, often with the use of prosthetics.[2] BKA rates vary by region, influenced by health conditions like diabetes and peripheral arterial disease, with older populations being most affected. Annually, about 1.6 million lower-limb amputations occur globally, a significant portion of which are BKAs.[1,3] Other contributing causes include trauma from accidents or conflict. Additional types of amputations include Syme’s (ankle level), Lisfranc (forefoot), trans-metatarsal (midfoot), and toe amputations. Each affects mobility differently, with even minor amputations impacting balance and gait. Despite its prevalence, limited data exists comparing outcomes across different BKA levels. The level of amputation significantly affects rehabilitation, prosthetic use, mobility, and emotional well-being.[4,5] This study aimed to evaluate and compare the outcomes of varying BKA levels by examining recovery, prosthetic compatibility, psychosocial effects, and rehabilitation success.

This prospective observational study was carried out in the Department of General Surgery from 1^st October 2023 to 30^th June 2024, after obtaining approval from institutional Ethical Committee. Study included 45 patients admitted for lower limb amputations below the knee joint during the study period. All the study patients underwent a comprehensive preoperative workup, which included routine investigations, serology, and radiographic imaging, following Institutional Review Board (IRB) approval and after obtaining informed consent. During surgery, patients were positioned supine under spinal or regional anesthesia, and a tourniquet was applied to control blood loss. Sterile marking and incision were followed by muscle dissection with careful preservation of neurovascular structures. Bone transection was performed using a Gigli saw, bone cutter, or nibbler, with bone edges smoothened as needed. Myodesis or myoplasty was done for muscle attachment, and wound closure was achieved primarily where feasible; otherwise, wounds were left open to heal by secondary intention. Data were collected throughout the intraoperative and postoperative periods, noting surgical duration, bleeding, closure difficulty, and associated injuries. Postoperative outcomes included immediate complications such as pain, bleeding, flap necrosis, and surgical site infection, as well as delayed issues like wound contracture, flexion deformity, prosthetic fitting problems, dependent ulcers, and revision surgeries. Demographic analysis covered age, gender, comorbidities, and leading causes of amputation—primarily diabetes, trauma, and vascular disease. Surgical outcomes assessed included the distribution of amputation levels (e.g., below-knee, Syme’s, Chopart’s, Lisfranc’s, transmetatarsal, and toe), average blood loss, and operative time. Complication rates were categorized as immediate or delayed, and hospital metrics such as average length of stay were also recorded

The mean age of study patients was 55.65 years, with majority being male (55.56%). Diabetes mellitus (DM) was the commonest cause of amputation (51.11%). Toe amputation was done in 21 patients. (Table 1)

Table 1: Patient Characteristics

Mean duration of surgery was longest for below knee amputation cases (106 min) and shortest for Toe amputation cases (34.2 min). Blood loss >200cc was observed in 3 patients. Pain was the most common immediate post-op complication observed in 21 patients, while revision surgery was required in 10 patients. (Table 2)

Table 2: Intra- and Post-operative Findings in Study Patients

Mean duration of hospital stay was higher for patients with DM undergoing below knee amputation (28.80 days). (Table 3)

Table 3: Mean duration of Hospital Stay in days based on cause of Amputation

Association of aetiology with peri-operative and post-operative complications is presented in Table 4.

Table 4: Association of Aetiology with Perioperative and Postoperative Complexities

Lower limb amputation (LLA) is life-changing surgery. Shorter residual limbs are known to impose great physiological and psychological strain on patients. The aetiology of amputation is a major factor in deciding its level of amputation like Diabetic, Infective, Arterial insufficiency, Venous insufficiency and Trauma.[6] The study focused on assessing and comparing outcomes across different levels of below-knee amputations, with emphasis on recovery, prosthetic fit, psychosocial impact, and rehabilitation effectiveness. In our study, mean age of patients was 55.65 years, representing primarily middle-aged to older adults, with a nearly equal gender distribution (55.56% males and 44.44% females). Comparatively, Ploeg AJ et al[5] reported a mean age of 73 years among 54 participants, evenly split between men and women. In our study, DM emerged as the leading cause of amputation (51.11%), followed by vascular conditions (24.44%), infections (20%), and trauma (4.44%). In contrast, Shin JC et al[7] identified trauma (65%) as the most prevalent etiology, with vascular (31%) and infectious causes (2%) accounting for the rest.

Toe amputations were the most frequently performed (46.67%) in our sudy, followed by below-knee (33.33%) and trans-metatarsal amputations (20%). These trends mirrored the surgical time requirements, with below-knee procedures taking the longest (mean 106 minutes), followed by trans-metatarsal (57.7 minutes) and toe amputations (34.2 minutes). Significant intraoperative blood loss occurred in 6.12% of patients, exclusively among the below-knee group. Although no intraoperative injuries were observed, wound closure challenges were reported in 4.08% of cases, also within the below-knee group. Intraoperative complications were identified in 10.2% of cases in our study, whereas Ploeg AJ et al[5] reported a 30% rate. Postoperative pain was the most common complication (46.67%), followed by surgical site infections (40%), phantom limb sensation (8.89%), and flap blackening (8.89%) in our study. Among the BKA group, 9 patients reported pain (VAS mean 3.6), compared to 10 toe amputation cases (VAS mean 2.2) and 2 trans-metatarsal cases (VAS mean 3). SSIs were distributed across 7 BKA, 7 toe, and 4 trans-metatarsal cases, with DM being a key contributing factor to the high infection rates.

Wound contracture was seen in 6.67% of patients, while prosthesis-related issues were observed in 4.44% cases in our study. Revision surgeries were required in 22.22% of cases—mostly among diabetic patients—with 8 involving BKA and 2 involving trans-metatarsal amputations. Compared to this, Ploeg AJ et al[5] reported 11.7% revision rate, and Shin JC et al[7]. found that some patients couldn't use prosthetics due to deformities or general health issues. According to Saini U et al[8], revision amputation was needed in only 2.4% of cases, though 24.4% required secondary procedures. Length of hospital stay varied by amputation level and underlying cause in our study. BKA patients had the longest average stay (24.17 days), followed by trans-metatarsal (9.05 days) and toe amputations (9 days). Diabetic patients undergoing BKA had the highest average stay (28.80 days), while traumatic cases had shorter durations. These findings align with those of Dhillon MS et al[3], who reported that 43.7% of single-limb amputees were discharged within 48 hours, with average stays ranging from 4 days for finger amputations to 34 days for above-knee amputations.

We compared the intra- and post- operative complications based on etiology of amputations. Intraoperative blood loss was reported in 13.04% of diabetic patients but was absent in traumatic, infectious, and vascular groups. Difficulty in wound closure was more common in infectious (11.11%) and vascular (9%) cases. SSIs were most frequent among diabetics (56.5%), followed by infections (33.33%), trauma (50%), and vascular causes (9%). Pain affected 48% of diabetic patients, 55.5% of those with infections, 50% of traumatic cases, and 36.36% of vascular cases. Phantom limb sensation was limited to diabetic (13.04%) and infectious (11.11%) patients. Flap blackening was observed in diabetic (8.69%), vascular (9%), and traumatic (50%) cases, but not in infection-related cases. Late-stage complications such as poor prosthesis fit and wound contracture were exclusive to diabetic and vascular patients. Revision surgeries were most common among diabetics (30.4%), with lower frequencies in vascular (9%), infectious (11.11%), and traumatic (50%) groups. Smaller sample size and single centre study are few limitations of this study.

This study highlighted the multifactorial nature of lower limb amputations, with diabetes mellitus emerging as the predominant etiology, followed by vascular, infectious, and traumatic causes. Toe amputations was the most common type of amputation and below-knee amputations associated with longer surgical times and higher complication rates. Postoperative pain and surgical site infections were the most frequent complications, particularly among diabetic patients. Revision surgeries and extended hospital stays were also more common in this group. Compared to previous studies, intraoperative shortcomings were fewer, but overall outcomes highlight the need for improved management of comorbidities and careful perioperative care to reduce complications and improve recovery.

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