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

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Wound Care

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  • Most surgeons keep the initial dressing in place for 2 days before examining the wound.
  • For both AKA and BKA, the lower extremity stump must be kept strictly elevated at all times to reduce edema.

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Medical Management

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  • A patient-controlled analgesia pump is often used for postoperative pain.
  • Perioperative tight glucose control is essential to decrease the risk of wound infection and optimize healing.
  • Due to concomitant cardiovascular disease in many patients undergoing amputation, perioperative aspirin, statins, and β-blockers should be continued.
  • Patients should be closely monitored for symptoms of cardiac ischemia.

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Rehabilitation

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  • Early physical therapy consultation is required to initiate teaching of transfers and one-legged mobility.
  • If not consulted preoperatively, the Physical Medicine and Rehabilitation service should be consulted after amputation is completed.
  • With BKA, the patient should be monitored closely for any evidence of flexion contracture at the knee.
    • If contracture is developing, a posterior splint can be used to keep the knee straight.
  • Some surgeons prefer to use a rigid removal cast dressing in the initial postoperative period to protect the stump and help prevent flexion contracture.
  • The patient should remain non-weight bearing on the amputated extremity for a minimum of 3 months.
  • A prosthesis may be fit at 6 weeks but should not be used until all wounds have completely healed.

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  • Delayed wound healing.
    • May occur during the first few postoperative weeks secondary to persistent infection or poor vascular inflow.
    • Often managed with antibiotics when indicated and local wound care but can require surgical debridement, revision, or higher amputation
  • Hematomas.
    • Should be drained to prevent future infection.
  • Joint contractures of the knee.
    • Contracture after BKA is often difficult to correct; ...

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