The present study was carried out in retrospective manner in the Department of Physical Medicine and rehabilitation and Department of Orthopaedic surgery, King George Medical University, Lucknow from January 2012 to January 2015. The objective of this study was to establish the causes for revision amputations, identify preventable causes and to asses prosthetic rehabilitation. The study population included male and female patients of all age group who required revision amputation of lower limbs. Prosthetic rehabilitation of all patients included in this study was done at Department of Physical Medicine and Rehabilitation. All revision surgeries were done by two surgeons in the same department. Revised stump was surgically reconstructed to optimize fitting of future prosthesis along with maintaining the muscle balance. In post operative period wound care, pain control, joint range of motion exercises and muscle strengthening exercises were performed. After suture removal physiotherapy was instituted for 4 to 6 weeks and after that stump was assessed for maturity of stump. Preparatory prosthesis was used in all cases for promoting stump maturation and gait training. Finally prosthesis was applied after consensus from treating surgeon. Patient’s demographic profile, level and indication of primary amputation and revision amputation, outcome and complications were analysed.

Total 32 patients of lower limb amputation who required revision amputation were included in the study. Among these patients, 62.5% were males and rest 37.5% were females. Median age of these patients was 42 years with range of 5 to 72 years. Below knee amputation was the most common site of initial amputation (56.25%) followed by above knee amputation (31.25%) and rest of the patients were undergone symes amputation and knee disarticulation [Table/Fig-1]. The indications of initial amputation are summarized in [Table/Fig-2]. Trauma was found to be most common cause of initial amputation (43.75%) followed by infection (28.12%), peripheral vascular diseases (12.25), malignancy (9.37%) and leprosy (6.25%). Indications of revision amputation were analysed [Table/Fig-3]. Poor initial stump was most common indication for revision surgery (37.5%) followed by infection (25%) and recurrent ulceration over the stump (18.75%). Mean follow up period was 15 months. The majority of revision surgeries were done within 8 week of the initial amputation. All patients were treated successfully and only two patients required higher level of amputation during revision surgery (from below knee to above knee). Only 5 patients were able to wear prosthesis prior to the revision surgery while after revision amputation 30 patients were able to use prosthesis uneventfully. Those 5 patients who were able to wear prosthesis needed revision surgery because of recurrent ulceration while prolonged bearing of prosthesis due to suboptimal primary stump.

The ultimate goal of amputation is the early rehabilitation of the patient on suitable prosthesis. However, complications during or after primary amputation leads to high morbidity and delayed rehabilitation. Revision amputation is warranted in this situation. In this study we tried to evaluate common indications for revision amputation and found that most of these are preventable.

In our study we found that trauma was the most common cause of initial amputation (43.75%) followed by infection (28.12%), peripheral vascular diseases (12.25), malignancy (9.37%) and leprosy (6.25%). Increasing trend of road traffic accident in developing countries explains the situation. Our findings are supported by the similar study by Schwarz who found almost similar indications for primary amputation but in varying percentage [3]. However, he also found trauma as a most common cause for initial amputation. Evaluation of underlying cause for initial amputation is very important while performing revision surgery because it determines the final outcome and rate of rehabilitation. In one study, amputation following peripheral vascular disease achieved successful prosthetic ambulation in only 66% patients [5], whereas studies of amputation revisions following traumatic amputation report a 100% rate of successful prosthetic rehabilitation [6,7]. Among patients with infected stump or stitch abscess, 40% patients were suffering from diabetes mellitus. Other underlying immunocompromising medical conditions were not noted in the study population except malignant bone tumours. Three patients who were suffering from osteosarcoma of proximal tibia were primarily managed by above knee amputation.

We also noticed that most common indications for revision amputation are formation of bad stump and infection following initial amputation. Inadequate preoperative planning and poor knowledge about subsequent rehabilitation process and prosthesis are the probable reasons for poor stumps. Few studies has concluded that amputations performed by unsupervised trainee surgeons leads to a higher revision rate and a lower rate of successful rehabilitation [8,9]. Successful amputation and subsequent early rehabilitation is utmost important for the patients, their family members as well as our society. Hence amputation surgery should be given equal importance to other complex surgical procedures and preferably should be done or supervised by senior experts.

Bad stumps with poorly covered bone are especially problematic in above knee amputations because they require an end weight bearing prosthesis. Poorly covered bone leads to frequent ulcerations at pressure points. Hence, bone end should be properly covered and every effort should be put to avoid perioperative infection. Two cases required revision amputation due to formation of neuroma following initial amputation. Excision of neuroma was done and nerve was divided at more proximal level. Sharp division of major nerves at level proximal to the amputation are recommended to avoid this complication [2].

In our study two patients had to undergo revision amputation at a higher level from below knee to above knee to obtain a good stump. Following an above knee amputation, 87% more energy is required for ambulation in vascular patients and 33% more in traumatic amputees [4]. Elderly patients may not be able to put this extra energy due to decreased physiological reserve may not rehabilitated despite of good surgical outcome. In these situations revision amputation from low to high level further decreases chances of patient ambulation. Hence level of amputation for stump revision should be kept at the lowest possible level [2] however few studies are not in agreement to this philosophy [10].

A meticulously performed amputation with ideal stump may get necrosed due application of too tight cast in postoperative period. This is a preventable cause for revision surgery and may be avoided with little precaution while applying cast or bandage over stump. Similarly formation of flexion contractures should be prevented by patient education and physiotherapy to avoid any delay in prosthetic rehabilitation.

Revision amputation of lower limbs remains a challenge for both patient and treating surgeon. In our study, poorly formed stump is found to be the most common cause for the revision surgery. We emphasize that amputation should not be taken as undesirable surgery and preferably should be performed or supervised by well trained surgeons. Every effort should be made to form an ideal stump for better and rehabilitation of patients.