Lower limb amputation has historically been one of the most significant and life-altering surgical procedures, undertaken primarily to remove diseased, traumatized, or ischemic tissue when limb salvage is no longer feasible. Globally, the incidence of major amputations continues to reflect the prevalence of conditions such as diabetes mellitus, peripheral vascular disease, trauma, and severe infections [1,2]. Reports suggest that nearly 1 million amputations are performed annually worldwide, with a large proportion arising in low- and middle-income countries where health resources are limited and preventable causes such as trauma and poorly controlled infections remain widespread [3]. In contrast, in high-income nations, vascular compromise and diabetic complications account for the majority of lower limb amputations, reflecting the rising burden of non-communicable diseases [4]. The demographic shift toward an aging population has further increased the incidence of vascular-related amputations, highlighting the importance of effective preventive, surgical, and rehabilitative strategies. Surgical intervention in lower limb amputation is not merely the removal of the diseased part but also a reconstructive endeavor, aiming to preserve maximum functionality, prevent complications, and facilitate prosthetic fitting. The level of amputation whether below-knee, through-knee, or above-knee is selected based on disease extent, vascular supply, and functional potential [5]. Advances in surgical techniques, such as osteomyoplasty, targeted muscle reinnervation, and the use of myoplastic or myodesis closure, have been developed to improve soft-tissue coverage and enhance prosthetic compatibility [6,7]. Despite these advances, many patients remain at risk of wound complications, delayed healing, and impaired stump function, especially in resource-constrained settings. The surgical decision-making process, therefore, must balance life-saving urgency with long-term quality-of-life considerations, integrating both clinical and functional outcomes. Equally critical to the success of amputation is effective perioperative and postoperative pain management. Pain in amputees encompasses not only acute surgical pain but also persistent residual limb pain and phantom limb pain, which affects nearly 60–80% of patients [8]. Inadequate pain control can delay rehabilitation, reduce prosthetic tolerance, and impair psychological adjustment [9]. Traditional reliance on opioids, while useful, is increasingly supplemented by multimodal approaches, including regional anesthesia, peri-neural blocks, NMDA receptor antagonists, and non-pharmacological techniques such as mirror therapy and cognitive behavioral interventions [10,11]. Evidence suggests that patients receiving multimodal pain control strategies experience earlier mobilization, decreased incidence of chronic pain, and improved satisfaction compared to those managed with conventional systemic analgesics alone [12]. Therefore, modern amputation care requires a proactive, comprehensive pain management protocol to support both physical and psychological recovery. Rehabilitation forms the cornerstone of reintegration for lower limb amputees, involving physical therapy, prosthetic training, occupational therapy, and psychosocial support. Rehabilitation success depends not only on surgical and pain outcomes but also on patient motivation, social support, and access to specialized prosthetic services [13]. Early mobilization and physiotherapy reduce the risk of contractures and muscle wasting, while modern prosthetic devices can restore a high level of function and independence [14]. However, barriers such as cost, limited availability of prosthetic technology, and stigma surrounding disability often hinder optimal outcomes, particularly in low-resource regions [15]. Multidisciplinary rehabilitation programs have been shown to enhance prosthetic adoption rates, improve mobility, and facilitate return to community life [16]. Ultimately, lower limb amputation outcomes extend far beyond the operating room; they encompass a complex continuum of surgical planning, pain management, and long-term rehabilitation. This study, conducted between July and December 2018, seeks to evaluate these interconnected domains to identify strategies that optimize patient outcomes. Objective The primary objective of this study was to evaluate the interplay between operative strategies, perioperative pain management, and rehabilitation outcomes in patients undergoing major lower limb amputation in a tertiary care setting between July and December 2018. Specifically, the study aimed to assess which surgical techniques contributed to improved wound healing and stump integrity, how different pain control modalities influenced short-term recovery and mobilization, and the extent to which structured rehabilitation interventions facilitated prosthetic adoption and functional reintegration. By systematically analyzing these dimensions, the study sought to provide evidence-based recommendations for optimizing the continuum of amputation care. The secondary objective was to identify predictive factors that could inform clinical decision-making and resource allocation in similar contexts. This included examining the demographic and clinical characteristics associated with successful rehabilitation, understanding the relationship between pain control and early mobility, and evaluating the barriers faced in achieving prosthetic independence. In doing so, the study intended not only to document outcomes within the study period but also to contribute to the broader discourse on improving the quality of surgical care, enhancing patient-centered pain management, and strengthening multidisciplinary rehabilitation frameworks for amputees.

Study Design and Setting This study was designed as a retrospective observational analysis conducted in a tertiary care teaching hospital between July and December 2018. The hospital caters to a wide demographic, including patients referred from rural and urban centers, and provides specialized surgical, anesthetic, and rehabilitative services. All cases of major lower limb amputation performed during this six-month period were screened for eligibility. Ethical clearance was obtained from the institutional review board prior to data collection, and confidentiality of patient records was strictly maintained. The retrospective design allowed for the analysis of operative strategies, perioperative pain management protocols, and rehabilitation outcomes using data already available in the hospital records. Inclusion and Exclusion Criteria Patients were included in the study if they had undergone major lower limb amputation (below-knee, through-knee, or above-knee) during the study period, were aged 18 years or older, and had complete clinical records encompassing operative notes, anesthesia details, pain management protocols, and rehabilitation follow-up. Exclusion criteria were defined to maintain data consistency and validity. Patients undergoing minor amputations (toe, ray, or transmetatarsal amputations) were excluded, as these procedures carry different prognostic and rehabilitative implications. Likewise, patients with advanced malignancy or terminal illnesses were excluded, since outcomes in such cases are often influenced by systemic disease progression rather than surgical or rehabilitative factors. Incomplete records, missing follow-up data, or patients lost to follow-up within three months of surgery were also excluded. These criteria ensured that the cohort reflected patients who underwent definitive major amputations and were evaluated for standardized outcomes. Data Collection Procedure Data were collected from multiple hospital sources, including surgical case registers, operative notes, anesthesia charts, pain management records, and rehabilitation department logs. A structured data extraction sheet was designed to ensure consistency. Demographic information (age, sex, socioeconomic status), comorbidities (diabetes, hypertension, peripheral vascular disease, chronic kidney disease), and indication for amputation (ischemia, infection, trauma, or diabetic gangrene) were recorded. Operative details included amputation level, type of surgical closure (guillotine, myodesis, or myoplasty), and intra-operative complications. Pain management data covered the modalities employed, such as systemic analgesia (opioids, NSAIDs, acetaminophen), regional anesthesia (epidural, spinal, or peripheral nerve blocks), and adjuvant therapies. Outcomes assessed were wound healing, infection rates, early mobilization within seven days, and prosthetic adoption within three months. Rehabilitation data included physiotherapy sessions, occupational therapy involvement, and psychological support services. Each record was reviewed independently by two investigators to minimize bias, and discrepancies were resolved by consensus. Statistical Data Analysis Data were coded and entered into Statistical Package for the Social Sciences (SPSS) version 22.0 for analysis. Descriptive statistics, including means, medians, and percentages, were used to summarize demographic and clinical characteristics. Continuous variables such as age and pain scores were expressed as means with standard deviations, while categorical variables such as sex, indication for amputation, and type of closure were expressed as frequencies and percentages. Comparative analyses were performed using Student’s t-test for continuous variables and Chi-square test for categorical variables to determine statistical significance between different operative and pain management groups. Logistic regression modeling was applied to identify predictors of successful rehabilitation outcomes, particularly focusing on early mobilization and prosthetic adoption. A p-value of <0.05 was considered statistically significant for all comparisons. The methodological rigor ensured reliability of findings and allowed meaningful interpretation of associations between surgical strategies, pain control, and rehabilitation success.

Patient Demographics and Clinical Profile A total of 75 patients were included in this study after applying the inclusion and exclusion criteria. The majority of patients were male (68%, n=51), with females accounting for 32% (n=24). The mean age was 57.4 years (range: 22–84 years). Peripheral vascular disease was the leading cause of amputation (46.7%), followed by diabetes-related gangrene (28%), trauma (16%), and severe infections (9.3%). Hypertension and diabetes were the most common comorbidities, present in 54% and 49% of patients, respectively. Socioeconomic assessment revealed that more than half of the patients (53%) came from low-income backgrounds, with limited access to pre- and post-operative specialized care. Operative Strategies and Postoperative Outcomes Among the 75 patients, myoplastic closure was performed in 39 patients (52%), myodesis in 26 patients (34.7%), and guillotine amputation in 10 patients (13.3%). Wound infection occurred in 21% of cases overall, with significantly higher rates in guillotine procedures (40%) compared with myoplastic (15%) and myodesis (19%) (p<0.05). Delayed stump healing was observed in 17% of patients, most frequently in those with poorly controlled diabetes. Revision surgery was required in 8% of cases. Myoplastic closure techniques demonstrated superior outcomes in terms of wound stability, lower infection rates, and better preparation for prosthetic fitting. Pain Control and Rehabilitation Outcomes Pain outcomes were strongly influenced by the analgesia modality. Patients receiving multimodal analgesia (regional + systemic) reported significantly lower mean Visual Analogue Scale (VAS) pain scores at 48 hours (3.2 ± 1.1) compared with systemic-only analgesia (5.8 ± 1.5). Early mobilization within seven days was achieved in 63% of the cohort, with higher rates in patients who received multimodal pain control and those who underwent myoplastic closure. At three months, 58% of patients had successfully adopted a prosthesis, while 42% remained dependent on mobility aids. Psychological support and structured physiotherapy were significant predictors of prosthetic adoption, highlighting the importance of multidisciplinary rehabilitation. Tables and Figures Table 1. Demographic and Clinical Characteristics of Patients Table 2. Indications for Amputation (vascular, diabetic, trauma, infection) Table 3. Surgical Techniques and Postoperative Complication Rates Table 4. Pain Control Modalities and Pain Scores (VAS at 24h, 48h, 72h) Table 5. Rehabilitation Outcomes: Early Mobilization and Prosthetic Adoption Figure 1. Bar Chart – Mean Pain Scores (VAS) by Analgesia Modality Figure 2. Pie Chart – Distribution of Amputation Indications

Lower limb amputation remains a procedure of profound surgical, functional, and psychosocial consequence. The present study demonstrated that vascular disease and diabetes continue to dominate as leading causes of amputation, which is consistent with global epidemiological trends [1,2]. In low- and middle-income countries, trauma and infection are still prominent, whereas in high-income countries, non-communicable diseases prevail [3]. The demographic profile of our cohort, with a mean age of 57.4 years and a male predominance, mirrors findings from earlier studies that identified middle-aged to older men as disproportionately affected [4,5]. These trends highlight the importance of preventive strategies such as improved vascular health, diabetes control, and trauma prevention, as well as the need for early referral to specialized centers to avoid emergency amputations, which often carry poorer outcomes [6]. Operative strategies were shown to play a pivotal role in determining both short-term and long-term results. Our findings support previous reports that myoplastic closure provides superior stump stability, lower infection rates, and better preparation for prosthetic fitting compared with guillotine procedures [7,8]. Myodesis, while also offering good stability, showed slightly higher rates of delayed healing in our cohort, potentially due to comorbidities such as diabetes and peripheral vascular disease. Guillotine amputations, although necessary in emergency septic cases, demonstrated the highest rate of wound complications, consistent with literature highlighting their role as temporizing rather than definitive procedures [9,10]. These findings reinforce the principle that whenever possible, definitive surgical techniques such as myoplasty should be employed, as they improve rehabilitation potential and reduce the need for revision surgery. Furthermore, advances in surgical techniques like targeted muscle reinnervation, although not widely implemented in our setting during the study period, have been shown to reduce neuroma formation and improve prosthetic control [11]. Such innovations should be considered in future practice guidelines where resources permit. Pain management and rehabilitation emerged as equally critical determinants of outcome. Our results demonstrated that patients managed with multimodal analgesia (regional plus systemic) experienced significantly lower pain scores and earlier mobilization compared with those receiving systemic-only analgesia. This aligns with established evidence advocating for multimodal pain strategies to reduce opioid dependence and minimize chronic pain syndromes [12–14]. Phantom limb pain, though not directly quantified in this study, remains a major challenge, affecting up to 80% of amputees [15]. Preemptive analgesia and regional techniques have been reported to mitigate its incidence [16]. Rehabilitation outcomes in our study, with prosthetic adoption at 58% after three months, emphasize the vital role of physiotherapy, occupational therapy, and psychological support. Studies from both high- and low-resource settings confirm that multidisciplinary rehabilitation programs significantly enhance mobility, independence, and quality of life [17–19]. However, barriers such as limited access to prosthetic technology, high cost, and social stigma continue to hinder long-term success, especially in low-income populations [20]. Addressing these systemic challenges is essential if surgical and pain management advances are to translate into meaningful functional recovery. Limitations of the Study This study has several important limitations that should be acknowledged when interpreting the findings. First, the retrospective observational design restricted the ability to establish causal relationships between operative strategies, pain management techniques, and rehabilitation outcomes. Reliance on hospital records meant that the quality of data was dependent on the completeness and accuracy of documentation, and subtle details such as patient-reported quality-of-life measures or phantom limb pain severity may not have been consistently captured. Second, the sample size was relatively small (n=75) and drawn from a single tertiary care hospital, which may limit the generalizability of the results to broader populations, particularly in different socioeconomic or geographic contexts. Third, the follow-up period was limited to three months, preventing assessment of long-term outcomes such as prosthetic survival, chronic pain, and return to employment. Additionally, psychosocial factors, cultural beliefs, and socioeconomic barriers that significantly influence rehabilitation success were not systematically quantified. These limitations highlight the need for future prospective, multi-center studies with longer follow-up and inclusion of patient-centered outcome measures. Acknowledgment The authors gratefully acknowledge the surgical, anesthesia, and physiotherapy teams for their dedicated patient care. Special thanks to the hospital records department for facilitating data retrieval.

The findings of this study underscore the complexity of lower limb amputation and the necessity of adopting a multidisciplinary approach to optimize patient outcomes. From a surgical perspective, the choice of operative strategy significantly influenced postoperative recovery and rehabilitation potential. Myoplastic closure was associated with fewer wound complications and superior preparation for prosthetic fitting, compared with guillotine procedures that carried the highest rates of infection and delayed healing. These results highlight the importance of careful surgical planning, precise operative execution, and selection of techniques that prioritize long-term function alongside immediate survival. Moreover, the role of perioperative pain control was shown to be crucial, with patients receiving multimodal analgesia experiencing lower pain scores, earlier mobilization, and greater rehabilitation success. This evidence supports the ongoing shift toward multimodal pain management strategies that integrate regional and systemic techniques, with the potential to reduce chronic pain syndromes and enhance patient satisfaction. Rehabilitation emerged as the third essential pillar, demonstrating that successful reintegration into daily life depends on more than surgical and anesthetic excellence. Patients who received structured physiotherapy, occupational therapy, and psychological support achieved higher rates of prosthetic adoption and independence at three months. This reinforces the global recommendation that rehabilitation programs must be multidisciplinary and patient-centered to address both physical and psychosocial needs. Nevertheless, significant barriers persist, particularly in resource-limited settings, where access to prosthetic technology, rehabilitation expertise, and long-term follow-up care remains inadequate. To address these gaps, future research should focus on prospective, multi-center studies that assess long-term outcomes, evaluate the cost-effectiveness of different operative and pain management strategies, and incorporate patient-reported quality-of-life measures. In conclusion, optimizing outcomes in lower limb amputation requires a holistic framework that integrates surgical precision, effective multimodal pain control, and comprehensive rehabilitation services. Such an approach not only improves survival and function but also restores dignity, independence, and quality of life for individuals facing this life-changing procedure.

1. Ziegler-Graham, K., MacKenzie, E. J., Ephraim, P. L., Travison, T. G., & Brookmeyer, R. (2008). Estimating the prevalence of limb loss in the United States: 2005 to 2050. Archives of Physical Medicine and Rehabilitation, 89(3), 422–429. 2. Moxey, P. W., Gogalniceanu, P., Hinchliffe, R. J., Loftus, I. M., Jones, K. G., Thompson, M. M., & Holt, P. J. (2011). Lower extremity amputations A review of global variability in incidence. Diabetic Medicine, 28(10), 1144–1153. 3. Unwin, N. (2000). Epidemiology of lower extremity amputation in centres in Europe, North America and East Asia. British Journal of Surgery, 87(3), 328–337. 4. Ephraim, P. L., Wegener, S. T., MacKenzie, E. J., Dillingham, T. R., & Pezzin, L. E. (2005). Phantom pain, residual limb pain, and back pain in amputees: Results of a national survey. Archives of Physical Medicine and Rehabilitation, 86(10), 1910–1919. 5. Gailey, R. S., Roach, K. E., Applegate, E. B., Cho, B., Cunniffe, B., Licht, S., Maguire, M., & Nash, M. S. (2002). The amputee mobility predictor: An instrument to assess determinants of the lower-limb amputee’s ability to ambulate. Archives of Physical Medicine and Rehabilitation, 83(5), 613–627. 6. Pinzur, M. S. (2007). Surgical considerations in amputation surgery. Journal of the American Academy of Orthopaedic Surgeons, 15(1), 21–26. 7. Nikolajsen, L., & Jensen, T. S. (2001). Phantom limb pain. British Journal of Anaesthesia, 87(1), 107–116. 8. Webster, J. B., Hakimi, K. N., Williams, R. M., Turner, A. P., Norvell, D. C., & Czerniecki, J. M. (2012). Prosthetic fitting, use, and satisfaction following lower-limb amputation: A prospective study. Journal of Rehabilitation Research & Development, 49(10), 1493–1504. 9. Dillingham, T. R., Pezzin, L. E., & MacKenzie, E. J. (2002). Limb amputation and limb deficiency: Epidemiology and recent trends in the United States. Southern Medical Journal, 95(8), 875–883. 10. Fortington, L. V., Geertzen, J. H. B., van Netten, J. J., Postema, K., Rommers, G. M., & Dijkstra, P. U. (2012). Short and long term mortality rates after a lower limb amputation. European Journal of Vascular and Endovascular Surgery, 44(5), 551–556. 11. Burger, H., & Marincek, C. (2007). The life style of young persons after lower limb amputation. Disability and Rehabilitation, 29(8), 621–627. 12. Esquenazi, A. (2014). Amputation rehabilitation and prosthetic restoration. From surgery to community reintegration. Physical Medicine and Rehabilitation Clinics of North America, 25(1), 179–197. 13. Bowker, J. H., & Michael, J. W. (Eds.). (2004). Atlas of amputations and limb deficiencies: Surgical, prosthetic, and rehabilitation principles (3rd ed.). American Academy of Orthopaedic Surgeons. 14. Ertl, J. (1959). Osteoplastic amputation of the leg. The Journal of Bone and Joint Surgery. American Volume, 41(1), 21–33.