Leg amputation in dogs of the hind limb
The original articles originates from:
Canine Pelvic Limb Amputation
James Howard, DVM, MS, DACVS, The Ohio State University
Kristen French-Kim, DVM, The Ohio State University
Stephen C. Jones, MVB, MS, DACVS-SA, The Ohio State University
Nina R. Kieves, DVM, DACVS-SA, DACVSMR, CCRT, The Ohio State University
Article
Last updated: July 2021
Reading time: approx. 10 minutes
Peer Reviewed
Discussion
Hind limb amputations in dogs are palliative salvage procedures used in end-stage diseases, including complex fractures or chronic complications following previous osteosynthesis, appendicular neoplasms, extensive trauma, chronic non-healing wounds, or appendicular neuropathies (e.g., brachial plexus avulsion). Some amputations are unavoidable due to the financial constraints of pet owners. However, surgeons should always exhaust all other treatment options before performing an amputation. At the same time, it is important to fully educate pet owners about the risks, complications, and prognosis for their specific clinical case.
Midfemur amputation protects the male genitalia and offers a good cosmetic result. However, it carries a higher risk of increased muscle atrophy and pressure sores. Coxofemoral disarticulation, on the other hand, reduces the risk of subsequent muscle atrophy and also produces a pleasing cosmetic outcome. This procedure leads to a predictable result, lowers the risk of pressure ulcers, and simplifies postoperative incision management and home care compared to the midfemur technique.
A complete orthopedic and neurological examination is required prior to surgery. Dogs undergoing hind limb amputation compensate for this with an increased range of motion in the contralateral hind limb, as well as increased range of motion in the cervicothoracic and thoracolumbar spine.^(1) It is important to explain to owners that while amputations generally have a good prognosis, an elevated Body Condition Score (BCS) is associated with a lower quality of life rating.^(2) The preoperative surgical procedure varies depending on the size of the patient, but the anatomical reference points to be identified remain the same (see Step 1). Owners should be informed that extensive fur removal will occur prior to surgery and that it may take some time for the coat to regrow.
Preoperative antibiotics (e.g., cefazolin [22 mg/kg IV], ampicillin/sulbactam [30 mg/kg IV]) should be administered routinely at the time of induction and every 90 minutes during surgery. However, since standard amputations are considered clean procedures, the continuation of postoperative antibiotics should be critically reviewed to prevent the development of resistance. In most cases, unless there is obvious pyoderma around the incision site, postoperative antibiotics are not necessary.
Preoperative epidural anesthesia, intraoperative perineural injections, liposomal bupivacaine during wound closure, and/or the placement of a pain catheter in the superficial tissues should be considered. Perioperative analgesia is essential. Additionally, intravenous and oral analgesics should be administered postoperatively for approximately 10 to 14 days, depending on the patient's individual pain tolerance. Injectable opioids (e.g., morphine, methadone, fentanyl) can be administered immediately postoperatively and, following a pain assessment the next day, switched to oral NSAIDs, which should be used throughout the entire recovery period.
Routine postoperative restriction of movement and consistent wound care, including the application of cold and heat, are part of the standard protocol. NSAIDs, additional analgesics, and anxiolytics are typically prescribed for home care.
Step-by-Step: Leg Amputation in Dogs
What you need
- Soft tissue surgery set, including Mayo scissors, Metzenbaum scissors, forceps, various clamps and optional right-angle forceps.
- Electrocautery
- ± Hatt spoon
- Monofilament suture material (size 4-0 to 0, depending on patient size)
- Polydioxanone suture material for vascular ligation, muscle adaptation and deep subcutaneous closure (size 4-0 to 2-0)
- Poliglecapron 25 for superficial subcutaneous closure (size 4-0 to 3-0)
- Non-absorbable, monofilament suture material (e.g., polybutester [4-0])
- Local anesthetic for perineural injections (do not exceed recommended doses)
- Ropivacaine (0.5 % or 0.75 %): 1-3 mg/kg (dog), 1-2 mg/kg (cat)
- Bupivacaine (0.25 % or 0.5 %): 1-2 mg/kg (dog), 1 mg/kg (cat)
- Syringes and needles for perineural injections (syringe volume depending on the recommended dose; a 25-gauge needle is recommended for perineural injections)
- 4x4 or 3x3 gauze and laparotomy sponges for hemostasis
Step 1
Shave the fur from the level of the navel, 2 to 5 cm dorsally beyond the dorsal midline, 5 cm ventrally beyond the ventral midline, in the entire groin and abdominal area, and circumferentially around the affected hind limb down to the hock. Also remove the fur in the perineal area and at the base of the tail. In cases of soft stools or diarrhea, an anal purse-string suture may be placed. Wrap the distal part of the limb (below the hock) with a sterile dressing and position the patient on its side with the hind limb to be operated on at the top. Then, drape the surgical area of the limb with a sterile dressing.
Step 2
Mark the planned incision lines so that sufficient skin remains for later wound closure. The lateral incision (dashed line) begins at the level of the cranial flank fold and extends in a gentle arc distally to approximately the midpoint of the femur, before ending at the caudal flank fold near the ischial tuberosity. The medial incision (solid line) is a mirror image of the lateral incision, but slightly more proximal.
Step 3
Perform the medial dissection by abducting the limb. Use right-angle forceps to open the subcutaneous tissue and the underlying deep fascia of the thigh by sharp and blunt dissection. Palpate the medial aspect of the thigh to locate the short, taut band of the pectineus muscle. This palpable point indicates the femoral triangle.
Author's note
The femoral triangle carries the femoral artery, femoral vein (Figure A; solid arrow), and the saphenous branch of the femoral nerve to the hind limb. When dissecting the vessels, blunt dissection should be performed with curved clamps in the longitudinal direction of the vessels (Figure B) to avoid accidental rupture or injury.
The boundaries of the femoral triangle are:
- Cranial: Caudal portion of the sartorius muscle
- Caudal: M. pectineus (easily palpable to locate the triangle; Figure A, dashed arrow)
- Lateral: M. vastus medialis, M. pectineus and M. iliopsoas
- Media: External sheet of the abdominal muscles (M. obliquus externus abdominis)
Step 4
Dissect the femoral artery, femoral vein (Figure A), and the saphenous branch of the femoral nerve. Each vessel is triple-ligated. Place one transfixing and one circular ligature on the side of the vessel remaining with the patient, and then another circular ligature on the side that will be removed with the severed limb segment to prevent backbleed. Divide the vessel between the transfixing suture remaining with the patient and the circular suture preventing backbleed (Figure B).
To perform a local nerve block, insert the cannula into the perineural sheath and inject a small amount of ropivacaine or bupivacaine. A small bubble will form. Wait 3 minutes and then sever the nerve distal to the injection site.
Author's note
Larger arteries and veins are always ligated with one transfixing and two circular ligatures, especially in medium to large dogs. In smaller dogs and cats, arteries and veins can be ligated with three circular ligatures. Two ligatures always remain on the patient's side, while one ligature extends with the amputated limb segment to prevent re-bleeding.
Step 5
Work your way cranially and caudally to transect the two bellies of the sartorius muscle (cranial and caudal; solid arrows), the pectineus muscle (dashed arrow; can be transected at its origin, in its belly, or at its insertion), the adductor muscle (Ad), and the gracilis muscle (Gr) midway along the femur. Once the medial circumflex femoral artery and vein, or their deep branches*, are encountered, ligate them as described in step 4. (The semimembranosus muscle [Sm] is marked for orientation.)
Palpate the lesser trochanter of the femur and cut the iliopsoas muscle (Ili) either in the muscle belly or at its insertion.
Author's note
Only the extrinsic muscles of the hind limb (i.e., those connecting the limb to the pelvis) need to be divided. Excessive dissection of the quadriceps femoris muscle can prolong the surgery time and increase the risk of complications.
The femoral nerve runs through the iliopsoas muscle before exiting it and entering the rectus femoris and vastus medialis muscles. The femoral nerve can be blocked with ropivacaine or bupivacaine and then transected.
*The vascular bundle lies caudal to the femoral artery and vein, medial to the pectineus muscle and lateral to the iliopsoas muscle (Ili).
Step 6
Palpate the medial joint capsule (dashed arrow) and make a sharp incision along the rim of the acetabulum. Once the joint capsule is opened, divide the ligamentum capitis ossis femoris with a scalpel, Mayo scissors, or a Hatt spoon. (The iliopsoas muscle [Ili] is indicated by the solid arrow for orientation.)
Author's note
The limb should be passively moved (range of motion) to accurately identify the hip joint and to selectively open the joint capsule.
Step 7
Adduct the limb to expose the lateral muscle insertions. Divide the tensor fasciae latae (TFL) muscle at its distal portion and the associated fascia lata (FL) at the level of the mid-femur. Also in this dissection plane, divide the biceps femoris (BF) and caudal crural abductor (CCA) muscles near the mid-femur. The sciatic nerve should be blocked with a local anesthetic before being divided, as neuropathic pain can cause unnecessary postoperative distress for the animal.
Author's note
The biceps femoris muscle originates from the ventrocaudal portion of the sacrotuberous ligament and the ischial tuberosity. The proximal part of the transected muscle belly can be folded dorsally, which facilitates the dissection and division of the semitendinosus (St) and semimembranosus (Sm) muscles.
Step 8
While the dorsal reversal of the biceps femoris muscle exposes the region around the greater and tertius trochanters of the femur (which improves the view of the superficial, medius, and deep gluteus muscles and the deeper piriformis muscle), you separate the aforementioned muscles near their insertion points.
Fold the gluteus superficialis and piriformis muscles dorsally and carefully dissect the underlying fascia to expose the caudal gluteal artery, caudal gluteal vein, and the sciatic nerve (already transected), which lie close together. Ligate the caudal gluteal artery and vein separately with three ligatures each.
Step 9
Locate the gemelli muscles (Ge) at the caudal border of the hip joint; their muscle bellies are divided by the tendon of the obturator internus muscle (IO). Separate the gemelli muscles within their muscle bellies, as well as the tendon of the obturator internus muscle.
Split the muscle bellies of the gemelli muscles dorsally and ventrally to expose the underlying obturator externus muscle, which you then also cut through within its muscle belly. At the same time, only the rectus femoris muscle, the only part of the quadriceps muscle that contacts the pelvis, is detached.
On the dorsal aspect of the acetabulum, incise the remaining part of the joint capsule (curved arrow) along with the small articularis coxae muscle. Ligate the branch of the lateral circumflex femoral artery.
On the caudal section of the limb, isolate the M. abductor cruris caudalis (the scissors are under the muscle in the picture), and separate it in the middle of the muscle belly.
Step 10
Identify the iliopsoas muscle by its close proximity to the main trunk of the femoral nerve. If the saphenous branch of the femoral nerve has not already been divided, divide the main trunk of the femoral nerve now. To release the cranial and ventromedial portions of the limb, abduct the limb, divide any remaining muscle attachments of the iliopsoas muscle, and ligate any remaining branches of the medial circumflex femoral artery and vein.
Caudal to the iliopsoas muscle, isolate the adductor longus and quadratus femoris muscles and separate them midway through the muscle belly.
Complete the ventral incision at the joint capsule. Use monopolar electrocautery to control hemorrhage.
Carefully abduct the limb to expose the femoral head. Sever any remaining portion of the ligamentum capitis ossis femoris to perform complete dislocation at the hip joint (coxofemoral disarticulation). Remove the limb from the body.
Author's note
Smaller branches of the medial circumflex femoral artery run in close proximity to the ventral joint capsule.
Step 11
Before closing the wound, examine the surgical area for any bleeding and plan measures to prevent dead space. Rinse the surgical field with warm saline solution to minimize the risk of postoperative infection.
Step 12
Begin with the deep muscle closure. Bring the muscle bellies together so that the acetabulum and the transection sites of the arteries, veins, and nerves are covered. Use a continuous or interrupted suture technique (arrows) with absorbable suture material (size 3-0 to 0, depending on the patient's size).
Step 13
Close the subcutaneous layer in the usual manner. If desired, a pain soaker catheter can be placed in the superficial tissues for the postoperative administration of local analgesics—but not directly in the incision area. Triangular skin flaps (so-called "dog ears") often develop at the wound edges. If there is excessive skin, it can be removed and closed routinely. Smaller dog ears can be corrected using various geometric techniques, including placing an apical skin suture, removing the excess skin in a fusiform extension of the incision, or making a triangular excision at the incision.
Author's note
Throughout the entire wound closure process, it is essential to ensure that sufficient skin remains for a tension-free closure. Excess skin should be removed to minimize dead spaces.
Step 14
Perform the skin or intradermal closure – optionally using a continuous or interrupted technique (suture size 4-0 to 3-0, depending on patient size).
Author's note
Staples are generally not recommended due to potential pain and increased inflammatory response, but may be considered for longer incisions in large dogs.
If you have any further questions, please feel free to contact our chief surgeon. Susanne Arndt.
Summary: Leg amputation in dogs
Leg amputation in dogs: A surgical procedure for dogs with serious hind limb conditions. It offers a palliative solution for fractures, neoplasms, neuropathies, and more. (40 seconds)
Leg amputation in dogs is a frequently discussed procedure. It often becomes necessary when severe injuries are present. During a leg amputation, the affected leg is surgically removed. Despite limitations, a leg amputation can allow a dog to adapt to life on three legs.
Veterinarians emphasize that leg amputation in dogs is a palliative procedure; however, it is often recommended due to cancer or trauma. Potential complications must be considered before a leg amputation. Special care is essential after a leg amputation. Recovery after a leg amputation in dogs includes pain management, rehabilitation exercises, and close monitoring.
Although leg amputation in dogs often has a positive outcome, it can be emotionally distressing for owners. Nevertheless, the long-term success rate after leg amputation in dogs is high. A leg amputation allows many dogs to continue living an active life. In some cases, a leg amputation may be necessary for financial reasons.
In any case, leg amputation in dogs should only be considered as a last resort. After a thorough examination, leg amputation in dogs is sometimes also considered due to infections. Furthermore, leg amputation in dogs requires careful aftercare. Despite leg amputation, many dogs remain mobile.
Leg amputation is not always the only option for a dog, but it is often the most sensible one. The recovery process after a leg amputation can vary from dog to dog. A leg amputation in a dog requires careful cost planning. Ultimately, a leg amputation can significantly improve a dog's life.
References & further reading
Hogy SM, Worley DR, Jarvis SL, Hill AE, Reiser RF 2nd, Haussler KK. Kinematic and kinetic analysis of dogs during trotting after amputation of a pelvic limb. Am J Vet Res. 2013;74(9):1164-1171.- Dickerson VM, Coleman KD, Ogawa M, et al. Outcomes of dogs undergoing limb amputation, owner satisfaction with limb amputation procedures, and owner perceptions regarding postsurgical adaptation: 64 cases (2005–2012). J Am Vet Med Assoc. 2015;247(7):786-792.
- Hermanson JW, de Lahunta A, Evans HE. Miller and Evans' Anatomy of the Dog. 5th ed. Elsevier; 2020.
- Johnston SA, Tobias KM, eds. Veterinary Surgery: Small Animals. 2nd ed. Elsevier; 2018.
About the authors
James Howard, DVM, MS, DACVS
The Ohio State University
James Howard, DVM, MS, DACVS, is an Assistant Professor of Soft Tissue Surgery at Ohio State University, where he also completed his DVM degree and surgical residency. He also completed a rotation in internal medicine and surgery at the University of Tennessee. His research interests include hepatobiliary and gastrointestinal surgery, as well as endocrinopathies. Dr. Howard is currently working on minimally invasive diagnostic procedures, pharmacokinetic and pharmacodynamic issues, and methods for obtaining hepatobiliary samples.
Kristen French-Kim, DVM
The Ohio State University
Kristen French-Kim, DVM, received her DVM degree from Ohio State University in May 2021. She has a research background in immunology, vaccine research, and anatomical pathology and is pursuing a career in small animal surgery.
Stephen C. Jones, MVB, MS, DACVS-SA
The Ohio State University
Stephen Jones, MVB, MS, DACVS-SA, is an Assistant Professor of Small Animal Orthopedics at Ohio State University. Dr. Jones studied veterinary medicine at University College Dublin in Ireland. He then completed both a surgical rotation and a specialist internship at Hollywood Animal Hospital in Hollywood, Florida, as well as a combined residency in small animal surgery and a Master of Science degree from the University of Florida. Dr. Jones has authored and published numerous scientific articles, book chapters, and abstracts, and lectures internationally. His particular interests include minimally invasive fracture management, the medical and surgical treatment of joint diseases, arthroscopy, and the surgical management of limb deformities.
Nina R. Kieves, DVM, DACVS-SA, DACVSMR, CCRT
The Ohio State Universityty
Nina R. Kieves, DVM, DACVS-SA, DACVSMR, CCRT, is an Associate Professor of Small Animal Orthopedics and Director of the Sports Medicine and Rehabilitation Service at Ohio State University. She received her DVM degree from the University of Minnesota, completed a residency in small animal surgery at Iowa State University, and a fellowship in sports medicine at Colorado State University. Dr. Kieves' research focuses on sports medicine and rehabilitation, as well as surgical therapy using minimally invasive techniques.