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Above Knee Amputation

Authors:

Planning

B

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
C

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

Technique

D

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
E

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
F

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
G

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
H

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
I

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

J

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

Patient Care

K

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
L

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
M

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
  • wound healing
  • infection
  • DVT

7

Postop: ~ 3 month Postoperative Visit

  • diagnosis and management of late complications

8

Postop: 1 year Postoperative Visit

9

Treat postoperative complications

N

Advanced Evaluation and Management

1

Provides complex non-operative treatment

  • multiple co-morbidities
  • non-compliant
O

Complex Patient Care

1

Develops unique, complex post-operative management plans

 

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