Chapter 11 - Amputations of Lower Extremity

Peter G. Carnesale
Amputations through the lower limb account for 85% of all amputations. The amputation stump and its
prosthesis must assume the walking and weight-bearing functions of the amputated limb. Burgess has
pointed out that a strong and dynamic stump must be created that will function as a motor and sensory
end organ. His concept of such a stump functioning as a footlike end organ with the prosthesis serving as
the shoe on this foot is exciting and challenging.
Modern total-contact prostheses can be fitted satisfactorily on any properly constructed and well healed
lower extremity amputation stump, usually resulting in excellent function.
Rehabilitation after amputation is directly related to the level of limb loss. At least 90% of patients with
transtibial amputations will successfully use a prosthesis, in contrast to a success rate of 25% or fewer of
geriatric transfemoral dysvascular amputees. Although several factors are responsible for this marked
variance, the primary factor is the marked increase in energy required to walk with an above-the-knee
prosthesis. It is obviously desirable to perform amputations of the lower limb at the most distal level
possible if prosthetic ambulation is a goal.
Since peripheral vascular disease, with or without diabetes, is the major cause of lower limb amputations
(approximately 85% of patients), it is necessary to accurately determine the lowest level at which an
amputation will heal. Previously this has been assessed best by clinical judgment of tissue vascularity at
the time of surgery. Now clinical judgment can be augmented by a variety of preoperative testing
methods, the best of which is the transcutaneous measurement of oxygen tension. This technique is
accurate, widely available, easily performed at the bedside, and cost efficient. The value of this test can be
enhanced by comparing the oxygen tension obtained with and without having the patient inhale oxygen.
An increase in tension after oxygen inhalation is a sign of good local tissue perfusion. However, no
preoperative test is capable of providing an absolute indication of wound healing. Rather, such tests
should be correlated with clinical and surgical observations.
Foot and Ankle Amputations
Amputations about the foot and ankle are discussed in Chapter 10 .
Leg Amputations (Transtibial)
Following the reports of Burgess and others who have carried out transtibial amputations successfully in
over 85% of their patients with peripheral vascular disease, this procedure has become the most common
amputation. The importance of preserving the patient's own knee joint in the successful rehabilitation of
the patient with a lower extremity amputation cannot be overemphasized. Although many variations in
technique exist, basically all procedures may be divided into those for nonischemic limbs and those for
ischemic limbs. These two general techniques vary primarily in the construction of skin flaps and in
muscle stabilization techniques. In nonischemic limbs, skin flaps of various design and muscle
stabilization techniques, such as tension myodesis and myoplasty, are commonly used. In tension
myodesis, transected muscle groups are sutured to bone under physiological tension; in myoplasty,
muscle is sutured to soft tissue, such as opposing muscle groups or fascia. In most instances myoplastic
closures are performed, but some have advocated the use of the firmer stabilization provided by myodesis
in young, active people. In ischemic limbs tension myodesis is contraindicated because it may further
compromise an already marginal blood supply. Also, a long posterior myocutaneous flap and a short or
even absent anterior flap are recommended for ischemic limbs because anteriorly the blood supply is less
abundant than elsewhere in the leg.

NONISCHEMIC LIMBS

The ideal level for amputation below the knee is at the musculotendinous junction of the gastrocnemius
muscle. That part of the leg distal to this level, that is, the distal third of the leg, is not satisfactory because
there the tissues are relatively avascular and soft tissue padding is scanty. In this part even stumps that
heal well at first may break down later because of prosthetic use and physiological changes of aging. In
adults the ideal bone length for a below-the-knee amputation stump is 12.5 to 17.5 cm, depending on
body height. A reasonably satisfactory rule of thumb for selecting the level of bone section is to allow 2.5
cm of bone length for each 30 cm of body height. Usually the most satisfactory level is about 15 cm distal
to the medial tibial articular surface. A stump under 12.5 cm long is less efficient. Stumps lacking
quadriceps function are not useful. In a very short stump of 8.8 cm or less in length, it has been
recommended that the entire fibula together with some of the muscle bulk be removed so that the stump
may fit more easily into the prosthetic socket. However, many prosthetists find that retention of the
fibular head is desirable because then the modern total-contact socket can obtain a better purchase on the
short stump. Transecting the hamstring tendons to allow a very short stump to fall deeper into the socket
also may be considered. Although the procedure has the disadvantage of weakening flexion of the knee,
this has not been a serious problem, and genu recurvatum has not been reported.
Amputations in nonischemic limbs result from tumor, trauma, infection, or congenital anomaly. In each,
the underlying lesion dictates the level of amputation and choice of skin flaps. Microvascular techniques
have made preservation of transtibial stumps possible with the use of distant free flaps and spare part
flaps from the amputated limb. A description of the classic transtibial amputation using equal anterior and
posterior flaps follows.
TECHNIQUE 11-1
Place the patient supine on the operating table and use a pneumatic tourniquet for hemostasis. Beginning
proximally at the anteromedial joint line, measure distally the desired length of bone and mark that level
over the tibial crest with a skin marking pen. Outline equal anterior and posterior skin flaps, the length of
each flap being equal to one half the anteroposterior diameter of the leg at the anticipated level of bone
section. Begin the anterior incision either medially or laterally at the intended level of bone section and
swing it convexly distalward to the previously determined level and then proximally to end at a similar
position on the opposite side of the leg. When crossing the tibial crest, deepen the incision and mark the
periosteum with a cut to establish a point for future measurement. Begin the posterior incision at the same
point as the anterior and also carry it first convexly distalward and then proximally as in the anterior
incision ( Fig. 11-1, A ). Deepen the posterior incision down through the deep fascia but do not separate
the skin or deep fascia from the underlying muscle. Reflect as a single layer with the anterior flap the deep
fascia and periosteum over the anteromedial surface of the tibia. Continue this dissection proximally to the
level of intended bone section. Because it contracts, the anterior flap cannot be used to measure the level
of intended bone section. Instead, use the mark already made in the tibial periosteum to measure the
original length of the flap and thus reestablish the level of bone section. With a saw, mark the bone at this
point. Insert a curved hemostat in the natural cleavage plane at the lateral aspect of the tibia so that its tip
follows along the interosseous membrane and passes over the anterior aspect of the fibula to emerge just
anterior to the peroneus brevis muscle. Identify and isolate the superficial peroneal nerve in the interval
between the extensor digitorum longus and peroneus brevis, gently draw it distally, and divide it high so
that it retracts well proximal to the end of the stump. Divide the muscles in the anterior compartment of
the leg at a point 0.6 cm distal to the level of bone section so that they retract flush with the end of the
bone. As these muscles are sectioned, take special care to identify and protect the anterior tibial vessels
and deep peroneal nerve. Isolate these structures and ligate and divide the vessels at a level just proximal
to the level of intended bone section ( Fig. 11-1, B ). Exert gentle traction on the nerve and divide it
proximally so that it retracts well proximal to the end of the stump. Before sectioning the tibia, bevel its
crest with a saw: begin 1.9 cm proximal to the level of the bone section and cut obliquely distalward to
cross this level 0.5 cm anterior to the medullary cavity. Next, section the tibia transversely and section the
fibula 1.2 cm proximally. Grasp their distal segments with a bone-holding forceps so that they may be
pulled anteriorly and distally to expose the posterior muscle mass. Divide the muscles in the deep
posterior compartment 0.6 cm distal to the level of bone section so that they retract flush with the end of
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the bone. This exposes the posterior tibial and peroneal vessels and the tibial nerve lying on the
gastrocsoleus muscle group. Doubly ligate and divide the vessels and section the nerve so that its cut end
retracts well proximal to the end of the bone. With a large amputation knife bevel the gastrocsoleus
muscle mass so that it forms a myofascial flap long enough to reach across the end of the tibia to the
anterior fascia ( Fig. 11-1, C ). Smoothly round the ends of the tibia and fibula with a rasp and irrigate the
wound to remove all bone dust. Release the tourniquet and clamp and ligate or electrocoagulate all
bleeding points. Bring the gastrocsoleus muscle flap over the ends of the bones and suture it to the deep
fascia and the periosteum anteriorly ( Fig. 11-1, D ). Place a plastic suction drainage tube deep to the
muscle flap and fascia and bring it out laterally through the skin 10 to 12 cm proximal to the end of the
stump. Fashion the skin flaps as necessary for smooth closure without tension and suture them together
with interrupted nonabsorbable sutures ( Fig. 11-1, E ).

Figure 11-1 Amputation through middle third of leg for nonischemic limbs. A, Fashioning of equal anterior and posterior skin
flaps, each one half anteroposterior diameter of leg at level of bone section. B, Division and ligation of anterior tibial vessels
and division of deep peroneal nerve. C, Fashioning of posterior myofascial flap. D, Suture of myofascial flap to periosteum
anteriorly. E, Closure of skin flaps.

AFTERTREATMENT.

See aftertreatment for amputation of ischemic limbs, p. 579 .

ISCHEMIC LIMBS

Because the skin's blood supply is much better on the posterior and medial aspects of the leg than on the
anterior or anterolateral sides, transtibial amputation techniques for the ischemic limb are characterized
by skin flaps that favor the posterior and medial side of the leg. The long posterior flap technique
popularized by Burgess is most commonly used, but medial and lateral flaps of equal length as described
by Persson, skew flaps, and long medial flaps are being used. All techniques stress the need for preserving
intact the vascular connections between skin and muscle by avoiding dissection along tissue planes and
by constructing myocutaneous flaps. Also, amputations performed in ischemic limbs are customarily at a
higher level, for example, 10 to 12.5 cm distal to the joint line, than are amputations in nonischemic
limbs. Tension myodesis and the osteomyoplasty procedure of Ertl, which may be of value in young,
vigorous patients, are contraindicated in those with ischemic limbs because the procedures tend to
compromise an already precarious blood supply.

Figure 11-2 Transtibial amputation in ischemic limbs. A, Fashioning of short anterior and long posterior skin flaps. B,
Separation and removal of distal leg. C, Tailoring of posterior muscle mass to form flaps. D, Suture of flap to deep fascia and
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periosteum anteriorly. E, Closure of skin flaps. (Redrawn from Burgess EM, Zettl JH: Artif Limbs 13:1, 1969.)

TECHNIQUE 11-2 (Burgess)

Position the patient supine on the operating table and do not apply a tourniquet. Prepare and drape
the limb so that an amputation above the knee can be performed if bleeding and tissue viability are
insufficient to permit a successful transtibial amputation. For ischemic limbs, Burgess recommends
an amputation 8.8 to 12.5 cm distal to the line of the knee joint. Outline a long posterior flap and a
short anterior one. The posterior flap should measure 1 cm more than the diameter of the leg at the
level of bone division. Fashion the anterior flap at about the level of anticipated section of the tibia
( Fig. 11-2, A ). Reflect as a single layer with the anterior flap the deep fascia and periosteum over
the anteromedial surface of the tibia. Divide the anterolateral muscles down to the intermuscular
septum, ligating and dividing the anterior tibial vessels and peroneal nerves as encountered. Then
section the tibia and, at a level no more than 0.9 to 1.3 cm higher, section the fibula. Dissect the soft
tissues from the posterior aspect of the tibia and fibula distally to the level of the posterior transverse
skin division and separate and remove the leg, ligating and dividing the nerves and vessels ( Fig. 112, B ). Next, carefully round the tibia and form a short bevel on its anterior and medial aspects.
Tension myodesis is not recommended in this instance. Bevel and tailor the posterior muscle mass to
form a flap ( Fig. 11-2, C ) and carry it anteriorly, suturing it to the deep fascia and periosteum ( Fig.
11-2, D ). Obtain meticulous hemostasis. Next, place a plastic suction drainage tube deep to the
muscle flap and fascia and bring it out laterally through the skin 10 to 12.5 cm proximal to the end
of the stump; if preferred a through-and-through Penrose drain may be used, but it is more difficult
to remove. Fashion the skin flaps as necessary to obtain smooth closure without too much tension.
Trim any dog-ears sparingly; otherwise the circulation in the skin may be disturbed. Close the skin
with interrupted nonabsorbable sutures ( Fig. 11-2, E ).

AFTERTREATMENT.

After transtibial amputation for either ischemic or nonischemic conditions, a soft dressing may be applied
and further aftertreatment is carried out according to the technique described on p. 546 . However, use of
a rigid dressing is preferred and can be used regardless of whether early ambulation is prescribed. If
immediate or prompt prosthetic ambulation is not to be pursued, the stump may be dressed in a simple,
well-padded cast that extends proximally to midthigh and is applied in such a manner as to avoid
proximal constriction of the limb. Good suspension of the cast is essential to prevent it from slipping
distally and impairing stump circulation. This may require compressive contouring of the cast in the
supracondylar area, a waist band and suspension strap, or both. The cast should be removed in 5 to 7
days, and if wound healing is satisfactory, a new rigid dressing or prosthetic cast is applied. If immediate
or prompt prosthetic ambulation is pursued, a properly constructed prosthetic cast is best applied by a
qualified prosthetist.
Prosthetic ambulation must always be closely supervised by a therapist knowledgeable in the technique,
and the stump must be protected from excessive weight-bearing until the tissues have completely healed.
Rigid dressings or prosthetic casts should be changed whenever they become loose or at 7- to 10-day
intervals. When the stump is well healed (at about 3 weeks after surgery), one may elect to use the
prosthetic cast during the day and allow the patient to use an elastic stump shrinker at night. If the cast
becomes too loose, additional stump socks may be worn or a new cast may be required. When the stump
is mature, at 6 to 8 weeks after surgery, a preparatory prosthesis incorporating a customized socket with
endoskeletal construction may be used or, in selected instances, a definitive prosthesis may be fitted.
Disarticulation of Knee
Disarticulation of the knee results in an excellent end-bearing stump. Newer socket designs and prosthetic
knee mechanisms that provide swing phase control have eliminated many of the former complaints
concerning this level of amputation. Although the benefit of its use in children and young adults has been
5

proved, its use in the elderly and especially in patients with ischemia has been limited in this country. This
is true in great measure because the long flaps required could instead allow a more functional, short
transtibial amputation to be performed in most instances. Further, these long flaps are subject to necrosis
in ischemic limbs. Nonetheless, knee disarticulation remains a feasible and even desirable level of
amputation in many instances.
Rogers should be credited with popularizing this procedure. He pointed out its advantages in his original
article: (1) the large end-bearing surfaces of the distal femur covered by skin and other soft tissues that are
naturally suited for weight-bearing are preserved, (2) a long lever arm controlled by strong muscles is
created, and (3) the prosthesis used on the stump is stable. Mazet, Schmitter, and Chupurdia, and Burgess
have described techniques for reducing the bulk of bone at the end of the stump to allow more cosmetic
prosthetic fitting while still retaining the weight-bearing, suspension, and rotational control features of the
stump. Jensen, Paulsen, and Krosnick, and Kjble have described modified skin incisions that allow
greater use of this amputation level in patients with ischemia. Pinzur and Bowker have pointed out that
knee disarticulation is ideal for the nonambulating patient requiring amputation because additional length
of the extremity provides adequate sitting support and balance. Knee flexion contractures and associated
distal ulcers all too common with transtibial amputations also are avoided.
TECHNIQUE 11-3 (Batch, Spittler, and McFaddin)
Measuring from the inferior pole of the patella, fashion a long, broad anterior flap about equal in length
to the diameter of the knee ( Fig. 11-3, A ). Then, measuring from the level of the popliteal crease,
fashion a short posterior flap equal in length to one half of the diameter of the knee. Place the lateral ends
of the flaps at the level of the tibial condyles. Deepen the anterior incision through the deep fascia to the
bone and dissect the anterior flap from the tibia and adjacent muscle. Include in the flap the insertion of
the patellar tendon and the pes anserinus ( Fig. 11-3, B ). Then expose the knee joint by dissecting the
capsule from the anterior and lateral margins of the tibia; divide the cruciate ligaments and dissect the
posterior capsule from the tibia ( Fig. 11-3, C ). Identify the tibial nerve, gently pull it distally, and divide
it proximally so that it retracts well proximal to the level of amputation ( Fig. 11-3, D ). Next, identify,
doubly ligate, and divide the popliteal vessels. Free the biceps tendon from the fibula, complete the
amputation posteriorly, and remove the leg. Do not excise the patella or attempt to fuse it to the femoral
condyles. Furthermore, do not disturb the articular cartilage of the femoral condyles and patella. Perform
a synovectomy only if specifically indicated. Next, suture the patellar tendon to the cruciate ligaments
and the remnants of the gastrocnemius muscle to tissue in the intercondylar notch ( Fig. 11-3,E ). Place a
through-and-through Penrose drain in the wound. Close the deep fascia and subcutaneous tissues with
absorbable sutures and the skin edges with interrupted nonabsorbable sutures ( Fig. 11-3, F ). If sufficient
skin for a loose closure is not available, resect the posterior part of the femoral condyles rather than risk
loss of the skin flaps. However, the wound usually heals quickly, and a permanent prosthesis usually can
be fitted in 6 to 8 weeks because shrinkage of the stump is not a factor. If the wound fails to heal
primarily, there is no reason for apprehension or reamputation because it usually granulates and heals
satisfactorily without additional surgery.

Figure 11-3 Disarticulation of knee joint. A, Skin incision. B, Anterior flap elevated, including insertion of patellar tendon and
pes anserinus. C, Cruciate ligaments and posterior capsule divided. D, Tibial nerve divided high. E, Patellar tendon sutured to
7

cruciate ligaments. F, Wound closed over drain.

Mazet and Hennessy recommend a method that features resection of the protruding medial, lateral, and
posterior surfaces of the femoral condyles for creating a knee disarticulation stump for which a more
cosmetically acceptable prosthesis can be constructed. In this case tolerances within the socket are
greater, more adduction of the stump is permitted in the alignment of the prosthesis, and the decreased
bulk of the stump permits greater ease in the application and removal of the prosthesis.
TECHNIQUE 11-4 (Mazet and Hennessy)
Fashion the usual fishmouth skin incision, making the anterior flap longer and extending 10 cm distal
to the level of the knee joint and making the posterior flap shorter and extending only about 2.5 cm
distal to the same level ( Fig. 11-4 ). Reflect the skin and deep fascia well proximal to the femoral
condyles. Then divide the patellar tendon midway between the patella and the tibial tuberosity. Flex
the knee and section the collateral and cruciate ligaments. Then increase flexion of the knee to 90
degrees, identify and ligate the popliteal vessels, and isolate and divide the tibial nerve. Detach the
hamstring muscles from their insertions and remove the leg. Dissect the patella from its tendon and
discard it.
Next, remodel the femoral condyles in the following manner. Drive a wide osteotome vertically in a
proximal direction through the medial femoral condyle to emerge at the level of the adductor
tubercle. Start this cut along a line that extends from the medial articular margin anteriorly to the
midpoint of the distal articular surface posteriorly (the condyle is wider posteriorly). Then discard the
medial half of the condyle. Next resect the lateral part of the lateral femoral condyle in a similar
manner, starting at the junction of the medial two thirds and lateral one third of the distal articular
surface. Then direct attention to the posterior aspect of both condyles. Resect the posterior projecting
bone by a vertical osteotomy in the frontal plane, starting at the point where the condyles begin to
curve sharply superiorly and posteriorly. Smoothly round all bony prominences with a rasp but do not
disturb the remaining articular cartilage. At this point each condyle has a fairly broad weight-bearing
area, whereas the projecting side and posterior aspect of each have been removed and the remaining
bone has been smoothly rounded. Next, suture the patellar tendon to the hamstrings in the
intercondylar notch under slight tension. Insert drains at each end of the wound and close the deep
fascia and the skin in separate layers.

TECHNIQUE 11-5 (Kjble)

By constructing shorter medial and lateral flaps, this technique provides more frequent healing in
ischemic limbs than techniques using long anterior and posterior flaps. Place the patient prone on the
operating table. Outline a lateral flap that is one half the anteroposterior diameter of the knee in length
and a medial flap that is 2 to 3 cm longer to allow adequate coverage of the large medial femoral
condyle ( Fig. 11-5 ). Begin the incision just distal to the lower pole of the patella and extend it distally
to the tibial tuberosity, curving medially from this point for the medial flap and laterally from this
point for the lateral flap. Carry both incisions posteriorly to meet in the midline of the limb at a point
2.5 cm proximal to the joint line. Deepen the incisions through the subcutaneous tissue and fascia
down to bone. Divide the patellar tendon at its insertion and release the medial and lateral hamstring
tendons at their insertions. Divide the collateral ligaments and the cruciate ligaments. Then divide the
posterior joint capsule and expose, doubly ligate, and divide the popliteal vessels. Identify and sharply
transect the peroneal and tibial nerves so that their cut ends retract well proximal to the end of the
stump. Release the gastrocnemius origins from the distal femur and divide any remaining soft tissues.
Suture the patellar tendon and the hamstring tendons to each other and to the cruciate ligaments in the
intercondylar notch. Approximate the skin edges with interrupted nonabsorbable sutures.

Figure 11-4 Mazet and Hennessy disarticulation of knee. A, Anterior view. B, Lateral view. (Redrawn from Mazet R Jr,
Hennessy CA: J Bone Joint Surg 48A:126, 1966.)

Figure 11-5 Kjble disarticulation of knee with medial and lateral skin flaps.
AFTERTREATMENT.

If desired, a soft dressing may be applied and conventional aftercare instituted as previously described ( p.
546 ). Preferable treatment is to apply a rigid dressing or prosthetic cast with or without immediate or
early weight-bearing ambulation. If non-weight-bearing is desired, the rigid dressing need consist only of
a properly padded cast extending to the groin and securely suspended by compressive contouring of the
cast in the supracondylar area or by a waist belt and suspension strap, or both. If weight-bearing
ambulation is pursued, the prosthetic cast should be applied by a qualified prosthetist. Aftertreatment is
then similar to that outlined after transfemoral amputation ( p. 583 ).
Thigh Amputations (Transfemoral)
9

Amputation through the thigh is second in frequency only to transtibial amputation. In this procedure the
patient's knee joint is lost, so it is extremely important for the stump to be as long as possible to provide a
strong lever arm for control of the prosthesis. The conventional, constant friction knee joint used in most
above-the-knee prostheses extends 9 to 10 cm distal to the end of the prosthetic socket, and the bone must
be amputated this far proximal to the knee to allow room for the joint. When the level of amputation is
more distal than this, the knee joint of the prosthesis will be more distal than the knee of the opposite
limb, which is cosmetically undesirable and is especially noticeable when the patient is seated.
Amputation stumps in which the level of bone section is less than 5 cm distal to the lesser trochanter
function as and are prosthetically fitted as hip disarticulations.
In nonischemic limbs, muscle stabilization by myodesis or myoplasty is important when constructing a
strong and sturdy amputation stump. Gottschalk has pointed out that in the absence of myodesis of the
adductor magnus most transfemoral amputations result in at least 70% loss of adduction power. Most
amputations, even at the transfemoral level, are done because of ischemic problems, and myodesis should
not be attempted lest a limited vascular supply be further compromised. However, myoplastic muscle
stabilization is desirable in the ischemic limb to decrease the anterolateral drift of the transected bone end
that often occurs.
NONISCHEMIC LIMBS

TECHNIQUE 11-6
Position the patient supine on the operating table and perform the surgery under tourniquet hemostasis.
Beginning proximally at the anticipated level of bone section, outline equal anterior and posterior skin
flaps. The length of each flap should be at least one half the anteroposterior diameter of the thigh at this
level. Atypical flaps are always preferred to amputation at a higher level. Fashion the anterior flap with
an incision that starts at the midpoint on the medial aspect of the thigh at the level of anticipated bone
section. The incision passes in a gentle curve distally and laterally, crosses the anterior aspect of the
thigh at the level determined as noted above, and then curves proximally to end on the lateral aspect of
the thigh opposite the starting point ( Fig. 11-6, A ). Fashion the posterior flap in a similar manner.
Deepen the skin incisions through the subcutaneous tissue and deep fascia and reflect the flaps
proximally to the level of bone section. Then divide the quadriceps muscle and its overlying fascia along
the line of the anterior incision and reflect it proximally to the level of intended bone section as a
myofascial flap. Identify, individually ligate, and transect the femoral artery and vein in the femoral
canal on the medial side of the thigh at the level of bone section. Incise the periosteum of the femur
circumferentially and divide the bone with a saw immediately distal to the periosteal incision. Next, with
a sharp rasp, smooth the edges of the bone and flatten the anterolateral aspect of the femur to decrease
the unit pressures between the bone and the overlying soft tissues. Identify the sciatic nerve just beneath
the hamstring muscles, ligate it well proximally to the end of the bone, and divide it just distal to the
ligature. Then divide the posterior muscles transversely so that their ends retract to the level of bone
section and remove the leg ( Fig. 11-6, B ). Isolate and section all cutaneous nerves so that their cut ends
retract well proximal to the end of the stump. Irrigate the wound with saline to remove all bone dust.
Through several small holes drilled just proximal to the end of the femur, attach the adductor and
hamstring muscles to the bone with nonabsorbable or absorbable sutures ( Fig. 11-6, C ). The muscles
should be attached under slight tension. At this point, release the tourniquet and attain meticulous
hemostasis. Next, bring the quadriceps apron over the end of the bone and suture its fascial layer to
the posterior fascia of the thigh, trimming any excess muscle or fascia to permit a neat, snug
approximation. Insert plastic suction drainage tubes beneath the muscle flap and deep fascia and bring
them out through the lateral aspect of the thigh 10 to 12.5 cm proximal to the end of the stump.
Approximate the skin edges with interrupted sutures of nonabsorbable material ( Fig. 11-6, D ).

10

TECHNIQUE 11-7 (Gottschalk)

Place the patient supine with a roll under the buttock of the affected side. Develop skin flaps using a
long medial flap in the sagittal plane when possible. Detach the quadriceps just proximal to the patella
retaining part of its tendon. Reflect the vastus medialis off the intermuscular septum. Detach the
adductor magnus from the adductor tubercle and reflect it medially to expose the femur. Identify and
ligate the femoral vessels at Hunter's canal. Divide the gracilis, sartorius, semimembranosus, and
semitendinosus 1 to 2 inches below the intended bone section. Divide the femur 12 cm above the knee
joint. Make drill holes in the lateral, anterior, and posterior aspects of the femur, 1.5 cm from its end.
Hold the femur in maximum adduction and suture the adductor magnus to its lateral aspect using
previously drilled holes ( Fig. 11-7 ). Also, place anterior and posterior sutures to prevent its sliding
backward or forward. Suture the quadriceps to the posterior femur by drawing it over the adductor
magnus, while holding the hip in extension. Suture the remaining posterior muscles to the posterior
aspect of the adductor magnus. Close the investing fascia and skin. Apply a soft dressing.

AFTERTREATMENT.

The simplest initial dressing at the above-the-knee level is probably the soft conventional dressing. After
wound healing is apparent, a change to a rigid dressing with attached pylon and prosthetic foot is
desirable, especially in a stronger, alert, and agile patient. Immediate or prompt postsurgical prosthetic
fitting usually is indicated in adolescents or young patients and should be performed by a qualified
prosthetist. Ambulation in this temporary prosthesis is initiated with the knee joint locked. After good
control of the limb has been achieved, the joint is unlocked and a free-swinging knee gait is permitted.

11

Figure 11-6 Amputation through middle third of thigh. A, Incision and bone level. B, Myofascial flap fashioned from
quadriceps muscle and fascia. C, Adductor and hamstring muscles attached to end of femur through holes drilled in bone. D,
Completed amputation.

Aftertreatment is then similar to that outlined for transtibial amputations ( p. 579 ).

ISCHEMIC LIMBS

TECHNIQUE 11-8
Position the patient supine on the operating table and do not use a tourniquet. Outline equal anterior
and posterior skin flaps beginning proximally at the intended level of bone section. The length of
each flap should be at least one half the anteroposterior diameter of the thigh at this level. Deepen the
incisions through the subcutaneous tissue and deep fascia and reflect the posterior flap to the level of
bone section. Do not reflect the anterior flap; instead, divide the quadriceps muscle and its overlying
fascia along the line of the anterior skin incision and reflect the muscle and its attached overlying
skin and fascia proximally as a myocutaneous flap to the level of anticipated bone section. Identify,
individually ligate, and transect the femoral artery and vein in the femoral canal. Incise the
periosteum of the femur circumferentially and divide the bone with a saw just distal to the periosteal
incision. Smoothly rasp the edges of the bone and flatten the anterolateral aspect of the femur to
decrease the unit pressures between the bone and overlying soft tissues. Then identify the sciatic
nerve, ligate it well proximal to the end of the bone, and sharply divide it just distal to the ligature.
Next, divide the posterior muscles so that their ends retract to the level of bone section and then
remove the leg. Identify and section all cutaneous nerves so that their cut ends retract well proximal
to the end of the stump. Irrigate the wound well to remove all bone dust and clamp and ligate or
electrocoagulate all bleeding points. Next, carry the anterior myocutaneous flap over the end of the
bone and suture its deep fascial layer to the deep posterior fascia of the thigh. Insert plastic suction
drainage tubes deep to the muscles and bring them out through the lateral aspect of the thigh.
Approximate the skin edges with interrupted nonabsorbable sutures.

Figure 11-7 Attachment of adductor magnus to lateral femur. (Redrawn from Gottschalk F: Transfemoral amputations. In
Bowker JH, Michael JW, eds: Atlas of limb prosthetics: surgical, prosthetic, and rehabilitation principles, ed 2, St Louis,
1992, Mosby.)

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AFTERTREATMENT.

In an elderly, ischemic patient or a debilitated patient of any age, the simplest initial dressing at the
above-the-knee level is probably the soft conventional dressing. After wound healing is apparent, a
change to a rigid dressing with attached pylon and prosthetic foot is desirable in a stronger, alert, and
agile patient. Immediate or prompt postsurgical prosthetic fitting is usually indicated in adolescents or
young patients and should be performed by a qualified prosthetist. Ambulation in this temporary
prosthesis is initiated with the knee joint locked. After good control of the limb has been achieved, the
joint is unlocked and a free-swinging knee gait is permitted. Aftertreatment is then similar to that outlined
for transtibial amputations ( p. 579 ).
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