October 2025

ORTHOPAEDICS

AMPUTATION LEVEL SELECTION: PROSTHETIC AND REHABILITATION CONSIDERATIONS

Featuring: ​Mark Huang, MD
Reading time: 3 – 4 minutes
Choosing the appropriate level of amputation is a critical decision that affects wound healing, prosthetic potential and long-term functional outcomes. Below is a comprehensive overview of key surgical and rehabilitation considerations for both lower and upper limb amputations, based on Mark Huang, MD’s recent Northwestern Medicine Grand Rounds presentation.

Lower Limb Amputations
Surgical and anatomical considerations:
  • Tissue viability and ability to achieve primary closure are essential for healing
  • Residual limb length and shape directly affect prosthetic fit, control and socket stability
  • Muscle anchoring (myodesis/myoplasty) improves residual limb function
  • Bone length must balance soft tissue coverage with prosthetic control
  • Neuropathic pain may require advanced interventions like targeted muscle reinnervation (TMR) or regenerative peripheral nerve interfaces

​Functional insights by level:
  • Transtibial: Most successful level for prosthetic fitting, low energy cost and excellent ambulation potential.
  • Symes (ankle disarticulation): Allows distal weight bearing and lower energy consumption. Challenges include bulky limb and limited space for prosthetic components.
  • Knee disarticulation: Good for transfers and distal weight bearing, better long-distance ambulation than transfemoral, cosmetic and prosthetic fitting limitations.
  • Transfemoral: Higher energy cost and lower prosthetic success, especially in elderly patients. Prosthesis can only be used for ambulation and standing.
  • Hip disarticulation: Limited prosthetic use, high abandonment rates and typically reserved for severe trauma or tumor cases.

Upper Limb Amputations
Upper limb amputations require careful consideration due to the complexity of hand and arm function. Preservation of joints, sensation and grasp is prioritized, with reconstructive options such as nerve transfers, tendon transfers and microvascular flaps often employed.
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Prosthetic technologies:
  • Passive devices for stabilization and cosmesis
  • Body-powered systems using cable and harness mechanisms
  • Externally powered (myoelectric) devices for advanced control
  • Hybrid solutions combining multiple technologies
Level-specific highlights:
  • Transradial: Highest prosthetic success rate (up to 90%) and excellent functional independence.
  • Transhumeral and elbow disarticulation: may benefit from TMR for control and pain management.
  • Shoulder disarticulation: Rare; high prosthetic rejection due to complexity and device weight. This level may benefit the most from TMR for prosthetic control.

​Amputation level selection should be guided by anatomical, functional and patient-specific factors. With advances in surgical techniques and prosthetic technologies, clinicians can better tailor interventions to optimize rehabilitation and quality of life.

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