What type of surgeon performs a leg amputation?

From the Guidelines

A vascular surgeon is the most appropriate specialist to perform a leg amputation, as they have the expertise to address the underlying vascular disease that often necessitates the procedure. The decision to amputate a leg is made when the limb cannot be saved due to severe trauma, infection, vascular disease, or cancer. Before amputation, patients undergo comprehensive evaluation including vascular studies, imaging, and infection assessment 1. The procedure involves removing the damaged portion of the limb, shaping the remaining bone, addressing nerves and blood vessels, and creating a stump that can potentially accommodate a prosthesis.

Some key points to consider in the management of patients with severe lower extremity peripheral artery disease include:

• The goal of surgical intervention is to eliminate clinical manifestations of severe lower extremity PAD, such as rest pain, ischemic ulcers, or distal ischemic gangrene 1
• An interdisciplinary care team, including vascular medical and surgical specialists, nurses, orthopedic surgeons, and physical medicine and rehabilitation clinicians, should be involved in the evaluation and management of patients with critical limb ischemia 1
• Patients with severe decrements in limb perfusion, such as an ankle-brachial index (ABI) less than 0.4, may require urgent surgical consultation 1
• The mortality associated with distal arterial vascular surgical reconstruction is significant, ranging from 0% to 6%, while major amputation of the lower extremity is associated with a 30-day mortality risk of 4% to 30% and a 20% to 37% risk of significant morbidity 1

In terms of rehabilitation, patients who undergo leg amputation should participate in a multidisciplinary rehabilitation program, including physical and occupational therapy, and behavioral health interventions, to improve both psychological and functional outcomes 1. The program should aim to achieve a goal of either protective or functional sensation recovery, and may involve nerve repair or grafting long after injury.

Overall, the management of patients with severe lower extremity peripheral artery disease requires a comprehensive and multidisciplinary approach, with a focus on addressing the underlying vascular disease, preventing complications, and improving functional outcomes. The most recent and highest quality study, published in 2021, recommends that patients with severe lower extremity trauma or peripheral artery disease be evaluated for psychosocial risk factors affecting patient outcomes, and that they participate in a multidisciplinary rehabilitation program to improve both psychological and functional outcomes 1.

From the Research

Types of Surgeons Performing Leg Amputations

• General surgeons (GS), orthopedic surgeons (OS), and vascular surgeons (VS) can perform below-knee amputation (BKA) operations 2
• Vascular surgeons had the highest volume of BKA with 58.9% of the cases, compared to GS at 22.9% and OS at 18.1% 2
• The choice of surgeon may depend on the specific circumstances of the amputation, such as the presence of peripheral vascular disease or other comorbid conditions 2, 3

Training and Competence in Vascular Surgery

• Vascular surgery training is not always considered a component of general surgery training, and more rotations or fellowship training may be required to become competent in management of common vascular surgery procedures 3
• A survey of general surgery program directors, vascular surgeons, and senior general surgery residents found that most respondents believed that general surgeons should be trained to perform varicose vein surgery, leg amputation, and femoral embolectomy, but not more complex vascular procedures like infrainguinal bypass grafting or carotid endarterectomy 3

Outcomes and Complications of Leg Amputations

• A study comparing outcomes of BKA patients among GS, OS, and VS found that mortality was not significantly different among the three specialties, but OS had a lower risk of complications 2
• Another study found that vascular surgery services are essential to other surgical specialties and the hospital, and can effectively facilitate the completion of nonvascular procedures even in cases with significant intraoperative blood loss 4