The importance of amputation-level determination.

The objectives in selecting a level for lower-limb amputation include the removal of the gangrenous, infected, or traumatized portion of the limb while preserving the maximum length consistent with primary healing and successful prosthetic rehabilitation. An assessment as to the adequate removal of the diseased tissue usually presents no problem in surgical judgment . In those cases in which amputation is done for trauma, the blood supply above the area of trauma is usually intact and healing of the amputation will not be compromised by vascular insufficiency . This picture is quite different in evaluating patients with occlusive vascular disease in whom the need for amputation is precipitated by rest pain, gangrene, or infection. In these instances, the likelihood of healing at the level immediately proximal to the diseased area is compromised by poor bloodflow. Since a greater blood supply is required to heal an incision than to simply maintain viability of intact skin, the presence of intact skin at a proposed level of amputation is no guarantee that the blood supply is adequate to heal an amputation at that level. Until relatively recent times two alternative surgical approaches for amputation level selection existed . One approach was to carry out the most distal amputation that would circumvent the disease process, and then to simply carry out proximal revisions as would be necessary until an ultimate level was found at which healing