Conversion of Failed Right Leg Below-Knee Amputation to Above-Knee Amputation for Severe Peripheral Arterial Disease

Patients with severe peripheral arterial disease and critical limb-threatening ischemia are at high risk for limb loss. This video presents a 76-year-old male with extensive comorbidities who underwent above-knee amputation after failed healing of a below-knee amputation. Despite patent inflow vessels, poor distal perfusion led to non-healing wounds. The patient tolerated the above-knee amputation well, with an uneventful recovery and discharge to rehabilitation on postoperative day five. This case illustrates the role of above-knee amputation in patients with severe peripheral arterial disease and non-healing below-knee amputation, emphasizing technical steps and perioperative management.

Above-knee amputation; amputation; limb loss.

This patient is a 76-year-old male with an established history of severe peripheral arterial disease (PAD) resulting in critical limb-threatening ischemia (CLTI).¹ Patients with CLTI are at a high risk for limb loss. His past medical history is significant for severe hypertension, diabetes mellitus, hypercholesterolemia, coronary artery heart disease, and severe aortic stenosis. Several years ago, he underwent bilateral lower extremity femoral-to-popliteal artery bypasses for limb salvage. Unfortunately, over the course of years, his right leg bypass thrombosed, but since he had no signs or symptoms of CLTI, he was managed conservatively. A few months ago, he underwent transfemoral aortic valve replacement (TAVR) via right femoral access to treat his severe aortic stenosis. The procedure was complicated by acute embolic stroke and acute right leg ischemia. Unfortunately, due to multiple comorbidities and a large stroke, he was not a candidate for revascularization of the right lower extremity. He also could not receive anticoagulation due to a large embolic stroke. He developed rest pain in his right leg and toe ulcers. Over the course of the next few months, his leg ulcers continued to get worse and now became large, non-healing wounds. His arterial duplex and CTA showed no revascularization options, and he was offered leg amputation. With patent common femoral and profunda femoris arteries, it was deemed that he had adequate blood flow to heal amputation at below-knee level. He underwent a right leg below-knee amputation. Unfortunately, due to poor blood flow related to his heart disease and severe PAD, he did not heal his below-knee amputation site. The amputation incision opened and required surgical debridement. It did not heal.

Due to non-healing of below-knee amputation site, he was offered above-knee amputation with high anticipated healing potential.²

Preoperatively, nerve blocks were placed by the anesthesiologist. The patient was brought to the operating room, and general endotracheal anesthesia was induced by the anesthesiologist. An arterial line was placed for hemodynamic monitoring due to his significant history of heart disease. A Foley catheter was inserted for ensuring accurate urine output. His right leg, including the open below-knee amputation stump were prepped with antiseptic solution and the leg was draped in standard surgical fashion. Since he had established, severe PAD, no tourniquet was applied. He was given preoperative antibiotics and after surgical time out was performed, a fishmouth incision was made in the right mid-thigh area. Skin was incised with scalpel, and subcutaneous tissue was divided with Bovie cautery. Anterior and medial compartment muscles were divided with Bovie cautery. Calcified superficial femoral artery and femoral vein were identified. Careful dissection was performed to isolate them from the surrounding structures. Both artery and vein were clamped separately and divided. Each of them was suture ligated with 2-0 silk suture. Next, periosteum was raised on the femur bone, and the femur bone was divided with an electric bone saw. Next, the posterior compartment muscles were divided with Bovie cautery. Sciatic nerve was identified; it was injected with 1% lidocaine and was sharply divided with scissors. The distal leg was then sent off the table as a specimen. The open wound was then irrigated with warm, antibiotic solution. All small bleeding points on the muscles were controlled with Bovie cautery. The anterior and posterior compartment muscles were brought together and approximated using interrupted 2-0 Vicryl sutures. Skin was closed with staples and sterile dressings were applied. The patient tolerated the operation well and was brought to the recovery room in stable condition. His postoperative course was uneventful, and he was discharged to a rehabilitation facility 5 days after his operation. 

Nothing to disclose.

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.