Introduction to Procedure

We know that undergoing any procedure is a scary experience.  We understand the worry and anxiousness that is associated with surgeries and procedures and aim to walk the road to recovery with you every step of the way. We put this information together using the very helpful handbook, ‘Handbook of Surgical Consent” from Rajesh Nair and David J. Holroyd.  We hope that the following information will answer all your questions and help you with the preparation phase for your procedure.

Description of procedure

Amputations of the lower limb are performed for peripheral vascular disease, trauma, tumours, and infection. The level of the amputation is influenced by the viability of soft tissues, functional requirement, cosmesis, and comfort. In lower limb amputations, the level of amputation in relation to the knee influences postoperative mobility.

An equal percentage of patients with below-knee amputations are able to walk with a prosthesis as compared with those with above-knee amputations.

Lower limb amputations include digital, trans-metatarsal, Syme’s, guillotine, through-knee, below-knee, above-knee and hind quarter amputations.

Careful selection of level of amputation, and good surgical technique and postoperative care are essential to ensure a successful outcome.

Operative techniques

Digital lower limb amputations are usually performed for sepsis and therefore the wound should not be closed. The side should be marked preoperatively. A racquet incision is made around the digit, taking care not to encroach on the neurovascular bundle of the adjacent toes. The bone is divided with bone cutters ensuring removal of the articular surface. Haemostasis and saline lavage are performed. A non-adherent dressing is then applied.

Below-knee amputations may be performed using the skew or long posterior flap. The skew flap incisions are made such that two equal flaps are skewed off the midline and centred along the saphenous veins. In the long posterior flap, perforating branches from the gastrocnemius muscles help supply the overlying skin. In both cases, the incisions are taken down to the tibia and fibula, dividing and ligating the major neurovascular bundles. The tibia and fibula are divided ensuring that the bone edges are even. Haemostasis and saline lavage are performed before the wound is closed in layers.

Above-knee amputations are performed using a slightly unequal anterior and posterior flaps so that the suture line is not over the end of the stump. Muscle is divided down to bone, dividing and ligating major neurovascular bundles. The femur is divided ensuring that the bone edge is even. Haemostasis and saline lavage is performed before the wound is closed in layers.

Additional procedures that may become necessary
  • Debridement of further tissue if sepsis and ischaemia are present.
  • Stump revision or a more proximal amputation if the stump fails to heal.
  • Treatment of infection.
  • Removal of a painful or useless limb.
Alternative procedures/conservative measures
  • If gangrene is dry, digits may auto-amputate.
  • Opiate analgesia to control pain.
  • Long-term antibiotics to treat osteomyelitis.
  • Palliation should be considered when a non-viable limb occurs in patient with significant comorbidity.
Serious/frequently occurring risks

Bleeding, wound infection, osteomyelitis or gangrene necessitating further surgery, DVT and pulmonary embolism, myocardial infarction, falls, phantom limb pain.

Blood transfusion necessary

Group and save: The process of determining the patient’s ABO blood group and screening serum for the presence of antibodies to common red cell antigens that can cause transfusion reactions.

Type of anaesthesia/sedation
  • General anaesthesia.
  • Epidural anaesthesia before surgery may help reduce the likelihood of phantom limb pain.

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