Atlas of General Surgical Techniques (Courtney M. Townsend Jr., B. Mark Evers)

C H A P T E R 94 • Supracondylar Amputation 1049

Skin closure with surgical staples or sutures

FIGURE 94–5

1 0 5 0 S E C T I O N X I I I • A M P U T A T I O N S

STEP 4: POSTOPERATIVE CARE

Complications include hematoma, infection, wound necrosis, and contractures.

A drain may be used if there is persistent oozing.

One of the most immediate postoperative complications can be wound hematoma, which occurs in a small percentage of patients.

Small hematomas can be observed.

Large hematomas may need to be drained.

STEP 5: PEARLS AND PITFALLS

It is imperative to handle tissues gently and attain absolute hemostasis.

Guillotine amputation is used in infected leg or sepsis.

A tourniquet can be used in nonischemic limbs.

A tourniquet is not used in ischemic limbs.

SELECTED REFERENCES

1. Fisher DF: Lower extremity amputations. In Baker RJ, Fischer JE (eds): Mastery of Surgery, 4th ed. Philadelphia, Lippincott Williams & Wilkins, 2001, pp 2191-2198.

2. Carnesale PG: Amputations of lower extremity. In Carnale ST (ed): Campbell’s Operative Orthopaedics, 10th ed. Philadelphia, Mosby, 2002, pp 575-586.

3. Anderson KM: Knee disarticulation and above-knee amputation. Oper Tech Gen Surg 2005;7:90-95.

1 0 5 6 S E C T I O N X I I I • A M P U T A T I O N S

STEP 4: POSTOPERATIVE CARE

A sturdy dressing such as a well-padded cast will help limit postoperative edema and protect the stump. The stump should be inspected at least weekly to assess for viability and infection.

The patient should avoid weight bearing on the extremity until the wound is safely healed.

STEP 5: PEARLS AND PITFALLS

Careful attention to hemostasis, debridement of devitalized tissue, and tension-free closure will help ensure the optimal outcome.

In the setting of a contaminated wound, the stump may be left open to heal by secondary intention or subsequent grafting. Premature closure of a contaminated stump will likely result in further soft tissue loss and necessitate a higher level of amputation.

SELECTED REFERENCES

1. Durham JR, McCoy DM, Sawchuk AP, et al: Open transmetatarsal amputation in the treatment of severe foot infections. Am J Surg 1989;158:127-130.

2. Dwars BJ, van den Broek TA, Rauwerda JA, Bakker FC: Criteria for reliable selection of the lowest possible level of amputation in peripheral vascular disease. J Vasc Surg 1992;15:536-542.

3. McKittrick LS, McKittrick JB, Risley TS: Transmetatarsal amputation for infection or gangrene in patients with diabetes mellitus. Ann Surg 1949;130:826-842.

4. Effeney DJ, Lim RC, Schecter WP: Transmetatarsal amputation. Arch Surg 1977;112:1366-1370.

C H A P T E R 96

HIP DISARTICULATION

Celia Chao and Courtney M. Townsend, Jr.

INDICATION

Hip disarticulation is performed for malignant soft tissue or bony tumors of the proximal thigh region (below the lesser trochanter of the femur) in which negative margins cannot be achieved without a less radical operation. Most sarcomas can be treated with limb-sparing procedures and the use of adjuvant or neoadjuvant therapies. In general, bone and vessels can be resected and replaced with grafts. Sacrifice of a single nerve, either the femoral nerve or the sciatic nerve, would result in some neuromuscular dysfunction but is preferable to amputation. This operation may be appropriate in locally recurrent cases of extensive (unresectable) tumor involvement (usually when adjuvant radiotherapy options have already been exhausted).

This procedure can also be considered for massive trauma and crush injury to the lower extremity or following multiple failed vascular procedures and distal amputations.

STEP 1: SURGICAL ANATOMY

See Figure 96-2 for illustration of key anterior structures. See Figures 96-4 and 96-5 for the posterior lateral anatomy, which must be considered with hip disarticulation.

STEP 2: PREOPERATIVE CONSIDERATIONS

Magnetic resonance imaging of soft tissue tumors of the proximal thigh can delineate the extent of tumor involvement relative to muscular compartments, neurovascular bundles, and bony structures. A bone scan is useful to ensure that the acetabulum and pelvis are not involved with tumor. A Tru-Cut needle biopsy or an open biopsy should have already been performed to confirm the malignant nature of the tumor and the necessity of such a radical operation.

A complete neurologic examination of the involved extremity may reveal significant loss of function and intractable pain preoperatively.

General anesthesia is used.

1057

1 0 5 8 S E C T I O N X I I I • A M P U T A T I O N S

STEP 3: OPERATIVE STEPS

1. INCISION

A Foley catheter is placed in the bladder. The patient is positioned in the lateral decubitus position to provide adequate exposure for both anterior and posterior aspects of the thigh (Figure 96-1). A bean bag may be used to help maintain this position. The skin is prepped from midchest down to the toes. The extremity below the thigh can be covered with a stockinette, such that the entire leg can be manipulated and repositioned intraoperatively to facilitate the resection.

Incision line

FIGURE 96–1