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Lower extremity amputation

What's new

The United States Department of Veterans Affairs (VA) and Department of Defense (DoD) have updated rehabilitation guidelines for lower limb amputation. The updated recommendations include osseointegration for transfemoral amputation, the use of microprocessor knee units, energy storing and return (ESAR) or microprocessor-controlled foot and ankle components over solid ankle cushioned heel for prosthetics, and mirror therapy, alone or combined with other therapies, for phantom pain. .

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of lower extremity amputation are prepared by our editorial team based on guidelines from the American Diabetes Association (ADA 2025), the United States Department of Defense (DoD/VA 2025), the European Society of Cardiology (ESC 2024,2023), the Vascular and Endovascular Surgery Society (VESS/SCAI/ABC/SVM/SVN/SVS/AHA/AACVPR/ACC/APMA/SIR 2024), the Wilderness Medical Society (WMS 2024), the Canadian ...
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Classification and risk stratification

Risk assessment: as per ADA 2025 guidelines, obtain a comprehensive foot evaluation in patients with diabetes at least annually to identify risk factors for ulcers and amputations. Perform foot inspection at every visit in patients with evidence of sensory loss or a history of ulceration or amputation.
A
obtain annual 10-g monofilament testing in all patients with diabetes to identify feet at risk for ulceration and amputation.
B
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Diagnostic investigations

History and physical examination
As per AAOS 2021 guidelines:
Evaluate the overall burden of injury and patient physiology when considering initial limb salvage.
B
Recognize that certain etiologies, including crush, blunt, blast, penetrating, degloving, and volumetric muscle loss/soft-tissue loss, may lead to an increased risk of adverse events or decreased functional outcomes.
B
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Medical management

Management of phantom pain: as per DoD/VA 2025 guidelines, consider offering mirror therapy, alone or in combination with other therapies, to improve pain, function, and QoL in patients with phantom limb pain.
C
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Nonpharmacologic interventions

Rehabilitation: as per DoD/VA 2025 guidelines, consider using patient-reported and performance-based measures with acceptable psychometric properties to assess function.
C
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More topics in this section

  • Orthoses and prostheses

  • Psychosocial support

  • Smoking cessation

Perioperative care

Perioperative pain management: as per DoD/VA 2025 guidelines, consider placing an intraoperative perineural catheter for the postoperative delivery of local anesthetic to reduce pain following amputation surgery.
C
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Surgical interventions

Indications for amputation, acute limb ischemia: as per AACVPR/ABC/ACC/…/VESS 2024 guidelines, consider performing concurrent and early amputation to avoid reperfusion morbidity in patients with acute limb ischemia and prolonged ischemia undergoing revascularization (endovascular or surgical, including catheter-directed thrombolysis).
C
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More topics in this section

  • Indications for amputation (chronic limb-threatening ischemia)

  • Indications for amputation (lower extremity arterial injury)

  • Indications for amputation (frostbite)

  • Indications for amputation (prosthetic joint infection)

  • Choice of surgical procedure

Preventative measures

Prevention of reamputation: as per DoD/VA 2025 guidelines, insufficient evidence to recommend for or against strategies to prevent re-amputation of the ipsilateral limb or amputation of the contralateral limb.
I
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