Amputations for Ischaemia (Above & below knee)

Preoperative preparation

• The level of amputation is influenced by viability of the soft tissues & functional requirements of the patient. Therefore, informed consent is taken for a more proximal level then you would intend.
• Give prophylactic antibiotics

Anaesthesia

General or spinal.

Procedure

• Prepare the skin & apply the drapes to seal off the infected or necrotic part of the limb.
• Mark the proposed skin flaps with a sterile skin marker.
• For above knee amputations, anterior & posterior myoplastic flaps should be roughly the same lengths with their base at the level of bone section.
• For below knee, a long posterior myoplastic flap is configured to construct the stump.
• Remove all dead muscles leaving behind bleeding, red & contracting edges.
• Ligate & divide major vessels at lower levels & main nerves at higher positions.
• Divide the periosteum & cut the bone with a Gigli or power saw. The fibula is transected higher than the tibia in a below knee amputation.
• The bone ends are rounded & may be sealed with bone wax.

Closure and Drainage

• Suture the flaps together without tension starting with muscle.
• Handle the skin carefully & close with staples or interrupted nylon sutures.
• Insert a suction drain.
• Apply a pressure dressing over the stump.

Postoperative Management

Multi disciplinary care involving nurses, physiotherapists, occupational therapists, prosthetists & social workers brings the best rehabilitation for these patients. Main post operative complications Include flap necrosis, infection & dehiscence of stump. Later on, phantom limb sensation & pain.