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One hundred and seventy-eight lower extremity amputations performed on 103 diabetic patients were reviewed. Although the healing rate for the above-the-knee amputation was higher, the probability of prosthetic use and ambulation was greater with the mid-leg amputation, particularly if the patient required bilateral amputation. Late breakdown of the mid-leg stump, once healing had occurred, was not a significant problem. We feel that the proper amputation level is best determined by the skin temperature and appearance at the proposed amputation site rather than rigid reliance on the presence of pulses, oscillometry, or arteriography and that every effort should be directed to retaining a functioning knee. DIABETES J9: 189-95, March, 1970. The principal reason for lower extremity amputation is undoubtedly ischemia, frequently associated with diabetes. Diabetic amputees pose particular problems with respect to wound healing, associated disability, survival, and potential functional attainment. As a result, for many years the popular philosophy has been that the first amputation in a diabetic should be the last. The present study was undertaken in part to evaluate the validity of this philosophy. Federal regulations requiring maximum rehabilitation of hospitalized patients, uninhibited by monetary considerations, provide an excellent opportunity to study healing, durability, and functional results in a series of patients. MATERIALThe series totaled 103 diabetic patients on whom 178 amputations were performed from 1952 to 1965. The surgery was performed by the resident staff under the supervision of many different attending surgeons. All of the patients were -male, reflecting the characteristic From the Orthopaedic Service-Bronx Veterans Administra-

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