Types of Leg Amputation: Below-Knee, Above-Knee & Other Levels Explained

If you've started researching amputation, you've probably come across terms like BKA, AKA, transtibial, transfemoral, knee disarticulation, and hip disarticulation.

It can feel like learning an entirely new language. If you're new to prosthetic terminology, I break down many of the terms you'll hear here.

And while these terms might sound similar, where an amputation occurs makes a big difference. The joints, bones, and amount of limb remaining can affect prosthetic design, mobility, rehabilitation, and the way someone moves through everyday life.

I'm a below-knee amputee, so I know firsthand how different my experience can be from someone with an above-knee amputation or a much higher level of limb loss. I've also spent years working in prosthetics, including patient care, research, and prosthetic design and fabrication, which has given me a pretty good understanding of how much the level of an amputation can affect everything from prosthetic design to everyday mobility.

So let's break down the different levels of leg amputation and what those differences actually mean.

What is an amputation level?

An amputation level describes where the limb was surgically removed.

For a leg amputation, that could mean removing part of the foot, removing the leg below the knee, removing the leg through the knee joint, removing the leg above the knee, or removing the leg at the hip. Because the level of amputation affects what joints, muscles, and limb length remain, it can make a significant difference in prosthetic design, rehabilitation, and everyday mobility. Two people can both be leg amputees and have very different anatomy, prostheses, mobility, and experiences.

And that's important to understand.

The major lower-limb amputation levels

From the foot upward, the major levels include:

• Toe or partial-foot amputation

• Ankle disarticulation, including a Syme amputation

• Below-knee or transtibial amputation

• Knee disarticulation

• Above-knee or transfemoral amputation

• Hip disarticulation

• Hemipelvectomy

Medical sources use slightly different terminology when grouping these levels, but the basic anatomy is the same.

Want more detail? Below, I break down each level, including what remains anatomically, how it affects prosthetic design, and what that can mean for mobility.

Partial-foot and toe amputations

Not every leg amputation involves losing the entire foot or a large portion of the leg.

A person may have one or more toes amputated, part of the foot removed, or an amputation farther back through the foot.

There are several types of partial-foot amputation, including transmetatarsal, Lisfranc, and Chopart amputations.

The exact level matters because even a relatively small difference in where the foot ends can change how someone bears weight and walks.

Some people with partial-foot amputations may use a specialized shoe, insert, or prosthetic device rather than what most people picture as a traditional prosthetic leg.

Ankle disarticulation and Syme amputation

An ankle disarticulation removes the foot through the ankle joint rather than cutting through the tibia and fibula farther up the leg.

A Syme amputation is a type of ankle disarticulation in which the heel pad is generally preserved and repositioned to the end of the residual limb.

One advantage of this level is that the heel pad can allow for some weight bearing through the end of the residual limb after healing.

The shape and size of the residual limb can also make prosthetic fitting different from a typical below-knee amputation.

Below-knee amputation, or BKA

This is my level.

A below-knee amputation (BKA) is also called a transtibial amputation. The amputation occurs through the lower leg, below the knee joint.

The tibia and fibula are the two bones in the lower leg, and both are involved in a typical transtibial amputation. Most importantly, the natural knee joint is preserved.

That knee makes a huge difference.

My prosthesis doesn't need to replace my knee. It has a socket, suspension system, lower-leg components, and a prosthetic foot, but my biological knee is still doing the work of a knee.

I've been a below-knee amputee for about 30 years. I was born with clubfoot and tibia hemimelia, a congenital condition affecting the development of my tibia, and I had my amputation when I was about 4½ years old.

I don't remember having two legs or remember the amputation itself. My experience is obviously different from someone who becomes a BKA as an adult after an accident, illness, or other medical condition.

But anatomically, I still have a knee.

And that distinction matters when comparing amputation levels.

What does having the knee preserved mean?

In general, preserving the knee gives a prosthetic user an important biological joint to work with.

An above-knee prosthesis has to provide an artificial knee. A below-knee prosthesis doesn't.

That doesn't mean being a below-knee amputee is easy. It isn't. Socket fit, skin issues, suspension, residual-limb changes, alignment, component selection, strength, balance, and plenty of other factors can affect how well someone walks.

But there is a significant mechanical difference between having your biological knee and needing a prosthetic one.

Knee disarticulation

A knee disarticulation, sometimes called a through-knee amputation, occurs through the knee joint.

Instead of cutting through the femur above the knee, the lower leg is separated from the femur at the knee joint itself. This preserves the femur and its full length.

This is different from a BKA because the knee joint itself is no longer intact.

It's also different from a traditional above-knee amputation because the femur isn't cut through.

This level has some unique prosthetic considerations, including the shape of the residual limb and the way the prosthesis is designed around the end of the femur.

Above-knee amputation, or AKA

An above-knee amputation (AKA) is also called a transfemoral amputation.

Instead of the amputation occurring through the lower leg, it occurs through the femur, the large bone in the thigh, above the knee. The natural knee joint is therefore gone.

This means an above-knee prosthesis needs to provide an artificial knee in addition to the lower-leg and foot components.

That is a significant difference.

The knee plays a major role in walking. When someone has a transfemoral amputation, they have to control an artificial knee while also managing the socket and the rest of the prosthesis.

This generally makes walking with a prosthesis more mechanically demanding than it is for someone with a transtibial amputation. Walking with a prosthesis also generally requires more energy as the amputation level moves higher.

But again, that doesn't tell you what an individual person can or cannot do.

There are incredibly active people with above-knee amputations. There are also people with below-knee amputations who have significant mobility challenges.

Amputation level is one piece of the picture, not the entire picture.

Hip disarticulation

A hip disarticulation is much higher on the body.

Instead of cutting through the femur, the leg is removed at the hip joint. The femur is therefore no longer present.

A prosthesis for someone with a hip disarticulation needs to account for an artificial hip joint, knee joint, lower leg, and foot.

That's a very different prosthetic system from what I use as a below-knee amputee.

The difference isn't just the number of components, either. The person has lost additional joints and muscles that would normally contribute to controlling the leg.

That can make prosthetic walking significantly more complex and physically demanding.

Hemipelvectomy

A hemipelvectomy goes beyond the hip.

In an external hemipelvectomy, the leg and part of the pelvis are removed. This is one of the highest levels of lower-limb amputation.

Because even more of the body's normal anatomy is involved, the prosthetic and rehabilitation considerations are substantially different from those for a below-knee or above-knee amputation.

This is also a relatively uncommon level of amputation.

Amputation level doesn't tell the whole story

The level of an amputation matters. It tells us where the limb was removed, but it doesn't tell us everything about the anatomy or function a person has left.

I'm a good example of that. I have a below-knee amputation, so I have a biological knee. But I was born without a tibia and I'm missing much of the anatomy and connective tissue that would normally support and stabilize that knee. My knee doesn't fully bend, and it's internally rotated. So while I have the knee that comes with a below-knee amputation, my anatomy and function are very different from someone who had a typical below-knee amputation after having a normally developed leg.

That's why two people can have the same amputation level and still have very different experiences. Residual limb length and shape, muscle strength, joint mobility, skin and sensation, surgical history, overall health, prosthetic fit, rehabilitation, and the activities someone wants to do can all make a difference.

There are also real mechanical differences between amputation levels. A below-knee amputation preserves the biological knee, which generally provides advantages for prosthetic walking compared with an amputation where the knee has been removed. But preserving the knee doesn't automatically mean an easy experience, just as having an above-knee or higher-level amputation doesn't prevent someone from being incredibly mobile and active.

Your amputation level tells you where the limb was removed. It doesn't tell you everything about the person who lives with it.

One amputation level isn't "worse" than another

I've seen people talk about amputation levels as though there's a simple ranking, with some levels being inherently better than others. I don't think that's a particularly helpful way to look at it.

There are real mechanical differences between levels. Preserving the knee, for example, gives someone an important biological joint that a transfemoral amputee doesn't have. Preserving more of the limb can also provide advantages for prosthetic function.

But you can't reduce a person's life to their amputation level. Someone with a below-knee amputation may have significant mobility challenges, while someone with an above-knee amputation may become an incredible athlete.

The level matters. But the person matters too.

Why two people with the same amputation level can still be very different

Even within one level, no two amputations are exactly the same.

Things like:

• Length and shape of the residual limb

• Muscle strength

• Skin condition

• Sensation and nerve issues

• Surgical technique

• Cause of amputation

• Age at amputation

• Other medical conditions

• Activity level

• Prosthetic fit

• Prosthetic components

• Access to rehabilitation and prosthetic care

• Personal goals

can all affect someone's experience.

That's one reason I don't love making blanket statements about what amputees "can" and "can't" do.

I've been an amputee since childhood, and I've also worked on the prosthetic side of the industry. I've seen enough to know that the same label can describe very different people.

If you're facing an amputation, ask about your specific level

If you're reading this because you or someone you love is actually facing an amputation, you may be trying to figure out what life will look like afterward.

It's completely reasonable to have questions.

Ask your medical team:

• Where exactly will the amputation occur?

• Will the knee joint be preserved?

• How much residual limb length is expected?

• What will weight bearing look like?

• What type of prosthesis might eventually be appropriate?

• What will rehabilitation involve?

• What mobility equipment will you use while healing?

• What should you expect during the prosthetic fitting process?

And don't be afraid to ask your prosthetist questions too.

I've written more about preparing for prosthetist appointments and the questions I think amputees should ask in my [Prosthetist Appointment Checklist].

You can also read my [New Amputee Guide] for practical advice from people who have actually lived with limb loss.

The bottom line

The level can affect the prosthesis someone uses, the joints they retain, the mechanics of walking, and the physical demands of prosthetic mobility.

I'm a below-knee amputee, and keeping my biological knee is a major part of how I move through the world with a prosthesis.

But I don't think amputation level should become a competition.

A below-knee amputee and a hip disarticulation amputee may have very different physical challenges. Both deserve to have those differences acknowledged without turning one person's experience into a measure of another person's worth.

If you're new to amputation, you don't need to know all of the terminology on day one.

Start with understanding where your amputation is, what anatomy you have retained, and how that affects your specific goals.

The rest comes with time.

FAQs

• What is the easiest level of amputation to walk with?

  In general, preserving more of the limb and retaining important joints such as the knee can provide mechanical advantages for prosthetic walking. But there isn't one amputation level that guarantees an easy or difficult outcome.

  Residual limb length, muscle strength, joint mobility, overall health, prosthetic fit, rehabilitation, and a person's goals all matter too.

  A below-knee amputation generally has some mechanical advantages over an above-knee amputation because the biological knee is preserved. But that doesn't mean every below-knee amputee will have an easy time walking, or that someone with an above-knee or higher-level amputation can't become highly mobile and active.

• What is the difference between a below-knee and above-knee amputation?

  A below-knee amputation (BKA) removes the leg below the knee, so the biological knee is preserved. An above-knee amputation (AKA) removes the leg above the knee, so the prosthesis needs an artificial knee. Because of this, the two levels involve different prosthetic designs, walking mechanics, and physical demands.

• Can you walk normally after a leg amputation?

  Many people can walk very well with a prosthesis after a leg amputation, but there isn't one definition of “normal” walking. How someone walks depends on their amputation level, residual limb, strength, joint mobility, prosthetic fit, rehabilitation, and other individual factors. Some people walk, run, hike, play sports, and stay highly active after limb loss.

• Does the level of amputation affect the type of prosthetic you use?

  Yes. The level of amputation determines what joints and anatomy are available to the prosthesis, which affects its design. For example, a below-knee prosthesis can use the person's biological knee, while an above-knee prosthesis needs an artificial knee. Other factors, including residual limb shape and length, activity level, and individual needs, also influence the prosthesis you use.

Medical references

• Cleveland Clinic: Prosthetic Leg

• Johns Hopkins Medicine: Amputation