Synopsis
Make proportionate lower-limb amputation decisions, select a healing functional level, and coordinate rehabilitation around individual goals and capability.
- Major amputation can relieve pain, remove necrotic or infected tissue, achieve healing and preserve achievable independence.
- NICE says major amputation for chronic limb ischaemia follows vascular multidisciplinary consideration of all revascularisation options.
- Primary amputation may be appropriate for an unsalvageable or non-functional limb, very poor functional status or short life expectancy after shared decision-making.
Key red flags
Wet gangrene, crepitus, rapidly spreading infection, shock or organ dysfunction requires immediate source control and sepsis treatment.
A painful cold limb with fixed mottling, profound anaesthesia or paralysis may be irreversibly ischaemic and needs immediate senior vascular assessment.
Early postoperative hypotension, falling haemoglobin, wound bleeding or expanding swelling suggests haemorrhage.
New stump erythema, purulence, dehiscence, necrosis or systemic illness suggests infection or failure of healing and requires urgent review.
Chest pain, hypoxia, sudden breathlessness, unilateral swelling or collapse raises concern for perioperative cardiac or venous thromboembolic complications.
Irreversible necrosis, absent reconstructible outflow, destroyed weight-bearing foot structures or uncontrollable infection may prevent a functional healed foot.
Investigation priorities
Confirm reconstructibility and identify whether limited revascularisation could preserve a more functional level.
Management branches
A threatened limb may not heal or function despite technically possible reconstruction.
- Clarify urgent source-control needs, pain, tissue loss, infection, vascular anatomy, previous reconstruction and whether the foot can become functional.
- For non-emergency major amputation, ensure a vascular multidisciplinary team has considered every proportionate revascularisation option using adequate imaging.