Above-knee amputation

Patient and case

1. Name / Age / Sex
2. UHID / IP no. / Ward-Bed
3. Date of surgery / OT no.
4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

1. Operating surgeonname, designation
2. Assistant(s)
3. Supervising consultantpresent in OT / available / not applicable
4. Steps done by the residentwhole procedure / named steps, under whose supervision
5. Anaesthetist
6. Scrub nurse / circulating nurse

Diagnosis and procedure

1. Pre-operative diagnosis
2. Post-operative diagnosis
3. Procedure planned
4. Procedure performedif different from plan, state why
5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
2. Site / side markedYesNot applicable
3. WHO Surgical Safety ChecklistSign inTime outSign out
4. Antibiotic prophylaxisdrug, dose, route, time given before incision
5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

• bleeding and haematoma
• stump infection
• flap necrosis and poor healing
• revision or higher amputation (hip disarticulation)
• phantom limb sensation and phantom pain
• stump neuroma
• hip flexion and abduction contracture
• deep vein thrombosis
• difficulty walking with a prosthesis; may need a wheelchair

Pre-operative details for this operation

1. IndicationGangrene extending above the level for BKAFailed / infected below-knee stumpKnee flexion contracture or non-functional kneeTraumaTumourSepsisstate the extent of gangrene or sepsis and why a below-knee level is not suitable
2. SideRightLeftlimb marked on the thigh
3. Level decided byClinical (skin temperature, colour)Doppler / pressuresTranscutaneous PO2Angiographyrecord the values if measured
4. Ambulatory status before illnessWalking independentlyWalking with supportBed or wheelchair bound
5. Hip movementrange; any fixed flexion
6. Blood sugar, Hb, renal function, cardiac status
7. Blood reservedgroup and units
8. Disposal of the amputated limbrelatives' wish recorded and signed

Anaesthesia and position

1. AnaesthesiaSpinalEpiduralCombined spinal-epiduralGeneral
2. PositionSupine, leg in external rotation
3. TourniquetNot used (ischaemic limb)Used: pressure and time on / off
4. Distal limb isolatedgangrenous part covered and excluded from the field

Operative findings

1. Skin and muscle at the level of sectionHealthy, bleeding wellPale / poorly bleedingInfected / oedematous
2. Femoral vesselspatent, thrombosed or calcified
3. Pus or tracking infectionNonePresent: extent, culture sent
4. Femur and marrowappearance; osteomyelitis?
5. Stump lengthfemur in cm from the tip of the greater trochanter

Procedure (steps)

1. Skin preparation and drapingantiseptic; groin to below the knee prepared
2. Flaps markedEqual anterior and posterior (fish-mouth)Longer anterior flapGuillotine / open amputationlevel of femoral section and flap lengths in cm
3. Skin and fascia incised; great saphenous vein ligated and dividedligature material
4. Anterior muscles dividedsartorius, rectus femoris, vastus muscles
5. Femoral (superficial femoral) artery and veinisolated, suture-ligated and divided separately; double ligature; material
6. Medial and remaining muscles divided to expose femur
7. Femur dividedPower sawGigli sawlevel; periosteum elevated at the cut; edge bevelled and rasped smooth
8. Profunda femoris vesselsligated as encountered near the bone
9. Sciatic nervepulled down gently, ligated with heavy non-absorbable suture and cut cleanly, allowed to retract; accompanying artery ligated separately
10. Posterior muscles divided, limb removed
11. Tourniquet released (if used), haemostasis, wound washedbone wax only if marrow oozes
12. Myoplasty / myodesisQuadriceps sutured to hamstrings (myoplasty)Muscles fixed to femur through drill holes (myodesis)Not done

Closure, drains and dressing

1. Muscle and fasciainterrupted absorbable sutures over the bone end; material and size
2. Skininterrupted, no tension, no dog ears; material and size
3. DrainSuction drainNonesite of exit
4. DressingSoft bulky dressing with crepe bandage
5. Open stump (if guillotine)plan for revision / closure

Specimens and implants

1. Amputated limbSent for HPENot sent, handed to OT staff for disposalHanded to relativesfor tumour always send, with margins marked
2. Pus / tissue for culture and sensitivitySentNot sent

End of procedure

1. Estimated blood lossml
2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
3. Swab, needle and instrument countCorrectIncorrect: action taken
4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

1. Vitals, dressing soakage, drain outputhourly for the first few hours
2. Stump positionno pillow under the stump or between the thighs; lie prone 15 to 30 minutes a day
3. Drainremove at 48 to 72 hours
4. AnalgesiaIV opioid then oral analgesics; drug, dose, frequency
5. Blood sugarfrequency and insulin plan
6. Thromboprophylaxisearly mobilisation, pharmacological prophylaxis as per unit protocol
7. Physiotherapyfrom POD 1: hip extension and strengthening, bed to chair
8. Wound reviewfirst dressing; look for haematoma, flap necrosis, infection
9. Culture report and antibioticsif sepsis was present
10. Prosthesis / wheelchair planrehabilitation referral once the stump has healed

Signature

1. Name and designation of person writing note
2. Medical Council registration no.
3. Signature / date / time of writingwrite before the patient leaves recovery