Above-Knee and Below-Knee Amputation

Introduction

Amputations above and below the knee are common surgical procedures performed by vascular, orthopedic, and general surgeons. The indications for these procedures include infection, irreversible acute ischemia, chronic progressive ischemia, trauma, intractable pain, neuropathy, and non-healing wounds. In developed countries, the primary indications for lower-extremity amputation are complications of peripheral vascular disease and diabetes mellitus.

Preoperative Evaluation

Recognition of the importance of amputation as the first step of the patient’s rehabilitation to recovery of functional status should be emphasized to the patient and health care team. Successful rehabilitation depends on aggressive postoperative physical and occupational therapy. Group amputee therapy can be helpful in patients with psychological issues surrounding the actual amputation.

Preoperative evaluation and optimization prepare the patient for surgery and minimize perioperative complications. Glucose control, nutrition, and cardiopulmonary status should be evaluated and optimized before operating. Occasionally, initial guillotine amputation is indicated to provide source control of deep space infection, with a secondary procedure for definitive closure planned when clinical and infection status have improved.

The level of amputation is predicated on surgical site healing capacity and ambulatory potential of the patient. The below-knee amputation (BKA) requires significantly less energy expenditure for postoperative mobilization, affording patients a higher likelihood of successful rehabilitation with their prosthesis. The above-knee amputation (AKA), although decreasing ambulatory potential, improves the chance of wound healing, reduces need for amputation revision, and eliminates complications from contractures. Physical examination and noninvasive vascular laboratory testing are helpful in determining the appropriate level of amputation for successful healing.