Complications, risks, and consequences
Estimated frequency
Most significant/serious complications
Infection (overall)
1–5 %
Wound
1–5 %
Bone associated (osteomyelitis)
0.1–1 %
Systemic sepsis
0.1–1 %
Bleeding or hematoma formation
Wound
1–5 %
False aneurysm
0.1–1 %
Arteriovenous fistula
0.1–1 %
Muscle necrosis
1–5 %
Flap necrosis
5–20 %
Rare significant/serious problems
Bone protuberance
0.1–1 %
Deep venous thrombosis/pulmonary embolus
0.1–1 %
Verrucous change chronic edema
0.1–1 %
Chronic wound dressings
0.1–1 %
Gas gangrene/necrotizing fasciitis
<0.1 %
Mortalitya
<0.1 %
Less serious complications
Residual pain/discomfort/tenderness
Short term (<4 weeks)
50–80 %
Longer term (>12 weeks)
0.1–1 %
Fat necrosis
1–5 %
Pressure necrosis
5–20 %
Pressure ulcers
1–5 %
Stump neuroma
1–5 %
Pressure hypertrophy
1–5 %
Wound dehiscence
1–5 %
Seroma/lymphatic fluid leak/lymphocele formation
1–5 %
Mobilization balance problems
50–80 %
Forgetting amputation during mobilization
50–80 %
Phantom pain
50–80 %
Phantom limb
50–80 %
Delayed wound healing (including ulceration)
5–20 %
Wound scarring (poor cosmesis)
5–20 %
Perspective
See Table 5.1. Minor complications are relatively common; however, most of these will usually settle with dressings and antibiotics. These include minor bleeding, oozing, superficial infection, swelling, numbness, minor ulceration, minor dehiscence, and discomfort. Major complications can occur and include osteomyelitis, severe hemorrhage from a slipped femoral arterial ligature, complete wound dehiscence, keloid scarring, and muscle necrosis, all of which may require further surgery or other treatment, including antibiotics. Mobility typically becomes more problematic the higher the amputation is on the limb.
Major Complications
Perhaps the most serious complications after amputation are severe bleeding, complete wound dehiscence and serious infections, including osteomyelitis. Mobility problems can also cause serious chronic disability. Flap necrosis and infection can also cause considerable problems and rarely result in systemic infection, necrotizing infections and even multisystem organ failure, especially in elderly patients, diabetics, and with other comorbidities. Chronic pain can also be a major problem and reduce mobility.
Consent and Risk Reduction
Main Points to Explain
Discomfort/pain
Bleeding
Poor function
Infection
Stiffness
Poor mobilization
Below-Knee Amputation
Description
General anesthesia is usually preferable; however, spinal, regional, or local anesthesia can be used. The aim is to remove the lower limb below the knee joint, usually through the upper 1/3 of the lower limb, although this is dependent on the pathology. The usual indications are necrosis, irreversible ischemia, trauma, tumor, or loss of function of the distal lower limb, not amenable to lower amputation. Preservation of the knee aids locomotion greatly. Skin and muscle flaps are fashioned anteriorly and posteriorly, retaining as much usable tissue as practicable. The tibia and fibula are cut, trimmed, and shaped to reduce tissue trauma from the bone ends, and the vessels and nerves are ligated as high as possible above the bone ends to prevent injury to these during postoperative mobilization. The fibula is cut shorter than the tibia. Typically, the posterior skin flap with the calf muscles is retained longer than the anterior flap, to enable the posterior flap to be brought over the bone ends and sutured more anteriorly.
Anatomical Points
The anatomy of the lower limb is relatively constant; however, the underlying disease process may dictate the type and precise level of amputation. The integrity of the other limb is very important in determining mobility.
Table 5.2
Below-knee amputation estimated frequency of complications, risks, and consequences
Complications, risks, and consequences | Estimated frequency |
|---|---|
Most significant/serious complications
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