Amputations Pathway Updated: 10/4/2016
CPT Codes: 47370, Laparoscopy, surgical, ablation of 1 or more liver tumor(s); radiofrequency 33875 Descending thoracic aorta graft, with or without bypass

Above Knee Amputation

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Preoperative Patient Care
Operative Techniques
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
Postoperative Patient Care
 

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