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Below‐the-Knee Amputation (BKA)

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  • Nonsalvageable lower extremity infection.
  • Chronic nonhealing lower extremity wounds.
  • Acute lower extremity infection.
  • Trauma with vascular or neurologic injury; open tibia fracture with posterior tibial nerve disruption or warm ischemia > 6 hours.

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Above‐the-Knee Amputation (AKA)

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  • Severe peripheral vascular disease not amenable to bypass graft with popliteal pressures inadequate to heal BKA.
  • Chronic nonhealing BKA wound.
  • Nonreconstructible traumatic injury to the lower extremity involving the knee joint or proximal tibia.

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Below‐the-Knee Amputation

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  • Cardiopulmonary disease and inability to tolerate surgery (relative contraindications).
  • Fixed knee contracture that would cause pressure on the distal stump after amputation (AKA is indicated in these cases).
  • Nonfunctional limbs (an indication for AKA).
  • Paraplegia (relative contraindication).
  • Infection that extends above the knee.
  • Inadequate blood flow to heal a BKA (popliteal artery pressures < 50 mm Hg).

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Above‐the-Knee Amputation

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  • Aortoiliac occlusive disease with inadequate femoral artery flow to heal an AKA wound.
  • Osteomyelitis of the proximal femur, femoral head, or acetabulum.
  • Cardiopulmonary disease and inability to tolerate surgery (relative contraindications).

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Potential Risks

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  • Nonhealing wound.
  • Phantom pain.
  • Chronic pain.
  • Neuroma.
  • Persistent infection.
  • Need for higher amputation.
  • Loss of mobility.
  • Bleeding requiring transfusion.
  • Complications related to general medical condition, including heart attack, stroke, venous thromboembolism, or death.

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  • Tourniquet.
  • Electrocautery and surgical ties for hemostatic control.
  • Bone-cutting saw (either a powered oscillating saw or Gigli saw).
  • Bone rasp.
  • Amputation knife.
  • Standard vascular and soft tissue instruments.

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  • Ankle-brachial index studies (if applicable) and segmental arterial pressures of the lower limb.
    • Popliteal artery pressure of 50 mm Hg is generally considered adequate to heal a BKA.
  • Full vascular evaluation for possible salvage procedures, including angioplasty, stenting, or vascular bypass (see Figure 39–1).
  • Full medical evaluation (given the high incidence of cardiac disease among patients).
    • Consider cardiac optimization with aspirin, a statin, and a β-blocker as tolerated.
  • Preoperative Physical Medicine and Rehabilitation Amputee service consultation.
  • Preoperative anesthesia consultation for spinal or regional block.
  • Discussion among orthopedic, vascular, and plastic surgery services regarding limb viability in patients with traumatic injury.
  • Preoperative type and crossmatch, as appropriate.

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  • For either BKA or AKA, the patient should be supine.

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  • Figure 39–1: Vascular anatomy of the lower extremity, showing locations for skin incision and femoral and tibial transection.

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Below‐the-Knee Amputation

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  • General, epidural, or long-acting spinal anesthesia may be used.
  • The entire leg is prepared circumferentially to the level of the proximal thigh; open wounds should be prepared with povidone-iodine.
  • A sterile thigh tourniquet is applied.
    • Caveat: a tourniquet should not be used in patients with severe vascular occlusive disease.
  • The distal foot is covered with stockinette or Ioban antimicrobial drape to further exclude it from the operative ...

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