Common indications for supracondylar amputation include trauma, poor blood supply, tumor, and progressive gangrene. Amputation should not be performed unless all conservative measures have failed.
Amputation at the level of the thigh is described in detail here. This is a frequent site following failure of reconstructive or bypass arterial procedures or in the presence of circumstances precluding reconstruction, as documented with proximal and distal arteriography.
The preoperative preparation must of necessity vary with the indications for amputation, as outlined in the preceding section. Careful evaluation must be made to determine whether there is a localized arterial obstruction, and arteriography is essential. If localized obstruction is present, a proximal (e.g., an iliac stent or aortofemoral bypass) reconstructive procedure may restore adequate blood inflow, or a distal (e.g., femoropopliteal) bypass arterial graft may eliminate the need for amputation.
When infection is present, aggressive surgical debridement is the most critical step for success. Appropriate antibiotic regimens should be tailored based on documented sensitivities. Should there be a localized skin infection at the proposed level of amputation, the procedure is delayed if improvement is possible. In the presence of an advancing infection, a guillotine or open amputation is done above the level of infection, with a subsequent definitive amputation at a higher point a few days later or when sepsis has cleared.
For elective amputations, preoperative consultation with physical therapy and a prosthetist can help patients be emotionally and physically ready for the rehabilitation required after amputation surgery.
Low spinal anesthesia is used most frequently, although inhalation anesthesia may be administered unless the patient’s condition contraindicates it.
Patients are placed with the hip on the affected side out to the margin of the table to allow full abduction of the thigh by an assistant, and the calf or ankle may be elevated with several sterile towels. The hair is clipped at the operative level.
The skin from the lower abdomen to well below the knee is prepped. A sterile sheet is placed beneath the thigh. The foot and lower leg up to the knee are covered with an impervious stockinette (FIGURE 1). Unless there is evidence of progressive infection, the extremity is elevated by the assistant to encourage venous drainage. If a low amputation is planned, a sterile tourniquet can be applied high on the thigh. Then a time-out is performed.
The type of flap used varies. With progressive infection of the lower leg, a circular incision is made for a guillotine amputation. However, when possible, anterior and posterior flaps are outlined with a sterile marking pen, ensuring an appropriate stump length (FIGURE 1...