A Outpatient Management 1 Obtain focused history and performs focused exam evaluate vascular status if severe vascular dysfunction may require revascularization procedure prior to amputation wound healing potential check with nutrition labs: albumin, prealbumin, transferrin, total lymphocyte count soft tissue injury severe soft tissue injury has the highest impact on decision whether to amputate or reconstruct lower extremity in trauma cases infection CRP, ESR neuropathy trauma vascular exam Doppler (ischemic index) ABI transcutaneous oxygen pressure toe pressures need to assess associated injuries and comorbidities (diabetes) documental baseline neurovascular exam traditional short BKA increases baseline metabolic cost of walking by 40% traumatic BKA 25% 2 Appropriately interprets basic imaging studies AP/Lat views of femur MRI of the to look for integrity of soft tissue and infection 3 Appropriately orders and interprets advanced imaging studies CT and MRI w/ or w/o contrast) 4 Makes informed decision to proceed with operative treatment documents failure of nonoperative management describes accepted indications and contraindications for surgical intervention 5 Postoperative Rehabilitation phase 2 (weeks 2-10) goals strengthening lumbar and core stabilization balance cardiovascular conditioning range of motion independence with mobility and ambulation with mobility devices independence of limb care phase 3 goals progress weightbearing and weight shifting exercises perform rehabilitation exercises independently normalize gait return to high level/high impact exercises start vocation specific training 6 Postop: 2-3 Week Postoperative Visit wound management remove sutures on week three diagnose and management of early complications<br /> wound healing infection DVT 7 Postop: ~ 3 month Postoperative Visit diagnosis and management of late complications<br /> 8 Postop: 1 year Postoperative Visit 9 Treat postoperative complications B Advanced Evaluation and Management 1 Provides complex non-operative treatment multiple co-morbidities non-compliant C Preoperative H & P 1 Perform basic medical and orthopaedic history and physical check neurovascular status to determine level of amputation 2 Order basic imaging studies weightbearing images AP/Lat views of femur 3 Perform operative consent describe complications of surgery including phantom limb pain wound breakdown (worse in diabetics, smokers, vascular insufficiency) superficial and deep infections
E Preoperative Plan 1 Radiographic templating 2 Execute surgical workthrough describes the steps of the procedure to the attending prior to the start of the case describe potential complications and steps to avoid them F Room Preparation 1 Surgical instrumentation basic major orthopedic set oscillating saw drill amputation knife silk free and stick ties suction drain 2 Room setup and equipment standard OR table fluoroscopy 3 Patient positioning place patient supine place small bump under ipsilateral hip to internally rotate the leg G Fishmouth Incision 1 Determine the level of amputation amputation level can be at proximal, mid femur or supracondylar 2 Mark the fishmouth incision incision should be at level of amputation mark both the anterior and poster flaps of the incision 3 Make the skin incision make the incision through the skin, superficial fascia and subcutaneous tissue vertical to the skin edges H Deep Dissection 1 Dissect through underlying fascia transect the major muscles using electrocautery this reduces bleeding tack for later use for soft tissue reconstruction 2 Transect muscle the level of the amputation will determine the muscles that are transected In most cases, portions of the quadriceps, hamstrings and adductors are cut at most levels I Neurovascular Dissection 1 Dissect out vascular structures dissect out the deep femoral artery and vein 2 Suture ligate the artery and vein 3 Transect the artery and vein 4 Identify nerves and transect gently pull the nerves approximately 2 cm ligate the nerves with nonabsorbable sutures transect with a knife these sutures can be later used to identify the femoral and sciatic nerves If catheters are not placed the nerves should be allowed to retract back to the muscle mass J Osseous Dissection 1 Cut bone cut the bone using an oscillating or Gigli saw Protect the soft tissues Place a malleable retractor posteriorly to the femur to prevent damage to the posterior soft tissue flap if tumor case, send frozen section of the intramedullary canal once the bone is cut frozen section should be sent from the intramedullary canal if this is a tumor case 2 Smooth the edges bevel the femoral edge using a saw or rasp to smooth the remaining edge and to leave a less prominent point of contact for the prosthesis K Placement of Epineural Catheter 1 Make a small opening into the epineural sheath use a 15 blade to make a small opening into the epineural sheath 2 Place the epineural catheter place an epineural catheter that has been flushed with 0.25% bupivacaine 3 Advance proximally 5 to 7 cm 4 Close the epineural sheath close the neural sheath with 4-0 chromic suture 5 Place the epineural catheter outside of the skin place a 16 gauge angiocatheter into the skin at the desired site of exit for the epineural catheter thread the epineural catheter through the angiocatheter until it is visible beyond the skin bring the angiocatheter that is encasing the epineural catheter through the subcutaneous tissue to exit at the skin tibial bone cut L Myodesis 1 Make drill holes in the femur make drill holes in the femur using a standard drill 2 Thread sutures thread the sutures that were used to tag the adductors through the femoral holes this tenodeses the adductors to the femurs place a plug of PMMA or gelfoam in the distal canal this prevents large hematomas from occurring myodese the remaining quadriceps and hamstring muscles to each other to cover the end of the femur 3 Treat intraoperative complications N Wound Closure 1 Irrigation & Hemostasis irrigate wounds thoroughly recheck for remaining peripheral bleeders 2 Place drains place closed suction drains beneath the fascial layer drains should be brought out of the medial and lateral aspects of the incision 3 Deep closure 0-vicryl for deep fascia subcutaneous with 2-0 vicryl 4 Superficial closure skin closure with 2-0 nylon (vertical/horizontal mattress) do not want to overly tighten skin as this can necrosis edges 5 Dressing and immediate immobilization place a compressive dressing
O Perioperative Inpatient Management 1 Write comprehensive admission orders IV fluids advance diet as tolerated check appropriate labs DVT prophylaxis foley out when ambulating wound care keep dressing on for 1 week remove drain on POD 2 continue postoperative antibiotics until the drain is removed order and interprets basic imaging studies inpatient pt phase 1 bed to wheelchair mobility range of motion exercises edema control appropriate medical management and medical consultation 2 Discharges patient appropriately pain meds wound care outpatient PT schedule follow up in 2 weeks R Complex Patient Care 1 Develops unique, complex post-operative management plans