1. Knee Amputation
PRESENTED BY
Ms. SAKUN RASAILY
PAEDIATRIC WARD
BPKIHS

2. PRESENTATION OUTLINE
 RELEVENT ANATOMY OF KNEE.
 INTRODUCTION OF KNEE AMPUTATION
 EPIDEMIOLOGY
 CLASSIFICATION
 INDICATIONS
 LEVEL OFAMPUTATION
 PREVENTION
 COMPLICATION
 NURSING DIAGNOSIS
 NURSING MANAGEMENT
 PROSTHESIS
 CONCLUSION
 REFERENCES
 POST TEST

3. RELEVENT ANATOMY
- The Knee Joint is the largest & complex joint in the body .
- It consists of 3 Joints:
1) Medial Condylar Joint : Between the medial condyle “of
the femur” & the medial condyle “of the tibia” .
2) Latral Condylar Joint : Between the lateral condyle “of the
femur” & the lateral condyle “of the tibia” .
3) Patellofemoral Joint : Between the patella & the patellar
surface of the femur.
- The fibula is NOT directly involved in the joint .

4. KNEE ANATOMY IN FIGURE

5. INTRODUCTION
 Amputation is the surgical removal of a limb or
part of a limb by cutting through the shaft of the
bone.
 Through the knee amputations – the removal of
the lower leg and knee joint. The remaining
stump is still able to bear weight as the whole
femur is retained

6. EPIDEMIOLOGY OF DISABILITY
 In 2011, the prevalence of persons with disabilities
in Nepal was 1.9% of the total population.
 This figure comes from the question asked in the
census, "Do you or any other of your family members
have a disability?"
 The National Population and Housing Census 2011
indicated that physical disabilities represented a third
of the total population of persons with disabilities in
Nepal.

7. Levels of Amputation
Through Knee
Amputation
85%
Below Knee Amputation
87%
Above Knee Amputation
93%
Source : Lower Extremity Amputations Around the Knee Joint: A Functional Outcome Study
: Nitesh K Karn1,2, MBBS, (FCPS); at all, BBMed, 2019, 3:39-46
LEVEL OF KNEE AMPUTATION

8. TYPES OF KNEE AMPUTATION
 Below knee amputations-BKA (transtibial) – an
amputation of the leg below the knee that retains the
use of the knee joint.
 Through the knee amputations – the removal of
the lower leg and knee joint. The remaining
stump is still able to bear weight as the whole
femur is retained
 Above knee amputation-AKA (transfemoral) - an
amputation of the leg above the knee joint.

9. INDICATIONS
 Dead (or Dying)
 Gangrene
 PeripheralVascular disease Atherosclerosis
Embolism
SevereTrauma Burns
Frost bite
Bone setters gangrene
 Dangerous limb
 Malignant tumours:Osteosarcoma, Marjolins ulcer
 Potentially lethal sepsis
 Crush Injury
 Damn Nuisance
 Pain
 Gross malformation
 Recurrent Sepsis
 Severe loss of function
 Madura foot
 Elephantiasis
Colloquially 3 D’s
 Dead (or Dying)
 Dangerous limb
 Damn Nuisance

10. LEVEL OF AMPUTATION
 Determined by :
a) Disease process
b)Viability of tissues and
c) Prosthesis available.
 Determination of adequate blood
flow:
Clinical :i.) lowest palpable pulse
ii.) skin colour and temperature
iii.)bleeding at surgery
Others:
 Doppler ultrasonography

11. LEVEL OF AMPUTATION Contd.
 Transcutaneous oxygen measurement >40mmHg.
 Skin perfusion pressure measurement
by infrared thermography or laser
doppler flowmetry.
 Tooshort a stump may tend to slip out of
prosthesis.Too long a stump may have

12. IDEAL STUMP
It Should have
1. Sufficient length to bear prosthesis.
• Below knee 7.5 - 12.5 cm from tibial tuberosity
• Above Knee - 23 cm from greater trochanter
2. Conical and Rounded
3. Tenderness Free
4. Adequate joint movement, blood supply.
5. Heal adequately by 1st intention
6. Scar - thin, placed where it is not exposed to
pressure, freely mobile over underlying tissues - not
interfere with prosthetic function
7. Skin should not be infolded and no redundant soft
tissue.
8. Adequate muscle padding - adequate movement

13. EVALUATION OF PATIENT WHO NEED AMPUTATION
• Check for anemia - correct by blood or packed cells
transfusion
• Infection - control using antibiotic and proper dressing
• Decision of which limb to be amputated
• Decision of level of amputation by :
– Skin temperature
– Arterial doppler
• Informed consent should be taken
• Psychological counselling
• Plan for prosthesis & rehabilitation by physiotherapist &
rehabilitation team.

14. AMPUTATION IN KNEE
ABOVE KNEE (AK) AMPUTATION
• Equal anterior and posterior flaps
• Ideal femur stump should be 25 cms long.
• Minimum stump should be 10cms long.
• It is technically easy, healing chances are
better and faster.
• Cosmetic results poor, prosthesis fitting isnot
• proper, pt limps while walking and need
support

15. B E LO W K N E E A M P U TAT I O N ( B U R G E S S ’ )
• Min. Stump L e n gt h :
• 8 C m From Tibial Tuberosity
(14-17 C m Is Good)
• Long Posterior Flap
• S ca r Anteriorly
AMPUTATION IN KNEE

16. PREVENTION
 Diagnosis and management of diabetes
 Thorough foot exam once per year
 Drive safely:
 Wear your seatbelt
 Drive the speed limit
 Safety at work if using heavy equipment, saws,
explosives, or flammable substances

17. COMPLICATIONS
• Early
 Hemorrhage, Hematoma,
Infection
 Gas gangrene
 Wound dehiscene
 Gangrene of flaps
 DVT → Pulm. Embolism
• Later
• Pain
• Infection, bone spur,scar adherent
to bone, amputation neuroma
• Phantom limb
• Phantom pain
• Ulceration of the stump
• pressure effects of the
prosthesis/↑ ischemia.
 Early Complications
 Late Complications

18. NURSING DIAGNOSIS
 Acute pain r/t surgical amputation
 Risk for infection r/t a site for organism
invasion 2o to surgical amputation
 Impaired skin integrity r/t surgical amputation
 Risk for disturbed sensory perception:
phantom limb pain r/t surgical amputation
 Disturbed body image r/t amputation of a body
part
 Disturbed self-concept r/t loss of a body part
 Risk for anticipatory grieving r/t loss of a body
part
 Risk for dysfunctional grieving r/t loss of a
body part
 Impaired physical mobility r/t loss of extremity
 Self-care deficit: feeding, bathing, hygiene,
dressing, grooming, or toileting r/t loss of
extremity
 Risk for falls r/t loss of lower extremity
 Fear r/t surgery, coping with the loss of limb
after surgery
 Ineffective coping r/t failure to accept loss of a
body part

19. NURSING MANAGEMENT
PREOPERATIVE CARE
 Assessment and resuscitation
 Investigate & address co-morbid conditions in consultation with
physicians, Anaesthetists & Physiotherapist(multidisciplinary).
 FBC,FBS, Se/u/c, urinalysis, chest x-ray,ECG, serum albumin(>3.5g/dl).
 Informed consent –pathology, inevitability of amputation, complications,
availability of prosthesis
 Determine the level of amputation.
 a)Find a place where healing is mostly to be complete.
 b)Tohave an ideal stump for prosthesis fitting.

20.  ANAESTHESIA : GA/Spinal
 POSITION : Supine
 Psychological support is most important to maintain cardiac hemostasis also.
 PREINCISION : prophylactic antibiotics,exsanguinate, tourniquet, skin
prep & draping.
 Irrigation with N/S, Removal of tourniquet to meticulously secure
haemostasis.
 Assist in close skin with interrupted non absorbable sutures.
 Wound dressing- soft or rigid
 Oxygen saturation vital monitoring assessment.
 Assess for bleeding and urine output during operation time.
 If more blood loss infused blood volume.
INTRA-OPERATIVE CARE

21. POST OPERATIVE CARE
 General care: Control of pain, prevention oedema, prevention of
infection, DVT prevention, care of concurrent medical conditions.,
Suture removal.
 Physiotherapy: Muscles exercised, joints keptmobile, patients
taught how to use crutches & prosthesis.
 NUTRITION: high protein,fiber containing
diet,calcium,phosphorous etc.
 Stump dressing
1. Soft dressing: gauze, cotton wool,bandage, Teachpatient or r
elative stump bandaging.
2. Rigid dressing: POP cast can be used with stump socks &
padding.
 Cast changed every 5-7 days for skin care.Within 3-4 wks rigid
dressing can be changed to a removable temporary prosthesis.

22. PROSTHESIS
 Is the substitution of a part of the body to achieve optimum
function .
 The term "prosthesis" refers to an external assistive
device applied to replace an absent limb.

24. REFERENCES
• Surgeryencyclopedia: https://www.surgeryencyclopedia.com/A-
Ce/Amputation.html
• Text book of Medical Surgical Nursing, 6th Edition By GN Mandal, Makalu
Publication,
• American Academy of Orthopaedic Surgeons. 6300 North River Road,
Rosemont, Illinois 60018-4262. Phone (847) 823-7186. http://www.aaos.org .
• Amputation; Stump. (2009). Mosby’s dictionary of medicine, nursing, and health
professions (8th ed.). St. Louis, MO: Mosby Elsevier.
Read more: https://www.surgeryencyclopedia.com/A-
Ce/Amputation.html#ixzz6QDgKeLZu
• Medscape: https://emedicine.medscape.com/article/1232102-overview#a13
• Bailey & Love's Short Practice of Surgery, 27th Edition: International Student's Edition.
Pg 1144.
• Manipal Manual of Surgery 4th Edition; K Rajgopal, Anitha Shenoy.Pg 700-704
• www.google.com
• www.slideshare.com
• www.slidesgo.com

25. POST TEST
{1} Types of amputation includes…..
a. Below knee amputation
b above knee amputation
c. Both of above
d. None of above
{2} Indications of amputation belongs to
a. 3D b.4D c. 5D d. 6D
{3} Complication of amputation…………
a. Hemorrhage
b. Hematoma
c. Pain
d. all
{4} Amputation means……….