646 PART VI AMPUTATIONS

■ Deepen the skin incisions through the subcutaneous

tissue and deep fascia, and reflect the flaps proximally to
the level of bone section.
■ Divide the quadriceps muscle and its overlying fascia

along the line of the anterior incision, and reflect it proxi-

mally 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 peri-
Short osteum of the femur circumferentially, and divide the
transfemoral bone with a saw immediately distal to the periosteal
incision.
■ With a sharp rasp, smooth the edges of the bone, and

Medial flatten the anterolateral aspect of the femur to decrease

transfemoral the unit pressures between the bone and the overlying
soft tissues.
■ Identify the sciatic nerve just beneath the hamstring

Long muscles, ligate it well proximal to the end of the bone,

transfemoral and divide it just distal to the ligature.
■ Divide the posterior muscles transversely so that their
Supracondylar ends retract to the level of bone section, and remove the
leg (Fig. 16-8B).
■ Isolate and section all cutaneous nerves so that their cut

ends retract well proximal to the end of the stump. Irri-

gate 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
FIGURE 16-7 Levels of transfemoral amputations. sutures (Fig. 16-8C). The muscles should be attached
under slight tension.
■ At this point, release the tourniquet and attain meticulous

hemostasis.
■ Bring the “quadriceps apron” over the end of the bone,
in the ischemic limb, however, to decrease the anterolateral and suture its fascial layer to the posterior fascia of the
drift of the transected bone end that often occurs. thigh, trimming any excess muscle or fascia to permit a
neat, snug approximation.
■ Insert plastic suction drainage tubes beneath the muscle

TRANSFEMORAL (ABOVE-KNEE) flap and deep fascia, and bring them out through the
lateral aspect of the thigh 10 to 12.5 cm proximal to the
AMPUTATION OF NONISCHEMIC end of the stump.
LIMBS ■ Approximate the skin edges with interrupted sutures of

nonabsorbable material.
TECHNIQUE 16-6
■ Position the patient supine on the operating table, and
perform the surgery using 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 TRANSFEMORAL (ABOVE-KNEE)
anteroposterior diameter of the thigh at this level. Atypi- AMPUTATION OF NONISCHEMIC
cal flaps always are preferred to amputation at a higher LIMBS
level.
■ Fashion the anterior flap with an incision that starts at TECHNIQUE 16-7
the midpoint on the medial aspect of the thigh at the
level of anticipated bone section. The incision passes in a (GOTTSCHALK)
gentle curve distally and laterally, crosses the anterior
aspect of the thigh at the level determined as noted ■ Place the patient supine with a roll under the buttock of
earlier, and curves proximally to end on the lateral aspect the affected side.
of the thigh opposite the starting point (Fig. 16-8A). ■ Develop skin flaps using a long medial flap in the sagittal

■ Fashion the posterior flap in a similar manner. plane when possible.

 CHAPTER 16 AMPUTATIONS OF THE LOWER EXTREMITY 647

Amputation
level Skin flap
incision

B C

FIGURE 16-8 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. SEE TECHNIQUE 16-6.

■ Detach the quadriceps just proximal to the patella, retain-

ing 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 2.5 to 5 cm below the intended bone

section.
■ Divide the femur 12 cm above the knee joint.

■ Drill holes in the lateral, anterior, and posterior aspects of

the femur, 1.5 cm from its end.

■ Hold the femur in maximal adduction, and suture the

adductor magnus to its lateral aspect using previously

drilled holes (Fig. 16-9). 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, and apply a soft dressing.
FIGURE 16-9 Attachment of adductor magnus to lateral
femur. (Redrawn from Gottschalk F: Transfemoral amputations. In
Bowker JH, Michael JW, editors: Atlas of limb prosthetics: surgical,
prosthetic, and rehabilitation principles, ed 2, St. Louis, 1992, Mosby.)
SEE TECHNIQUE 16-7.
648 PART VI AMPUTATIONS
TRANSFEMORAL (ABOVE-KNEE)
AMPUTATION FOR ISCHEMIC LIMBS
TECHNIQUE 16-8
■ 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 antero-
posterior 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 quad-
riceps 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 myocu-
taneous 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.
■ Identify the sciatic nerve, ligate it well proximal to the end
of the bone, and sharply divide it just distal to the
ligature.
■ Divide the posterior muscles so that their ends retract to
the level of bone section, and 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.
■ Carry the anterior myocutaneous flap over the end of the
bone, and suture its deep fascial layer to the deep pos-
terior 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 nonabsorb-
able sutures.
POSTOPERATIVE CARE Many concepts and strategies
relevant to these patients were discussed earlier under
postoperative care of transtibial amputations. The empha-
sis is on the recognition that patients with ischemic limbs
generally are less healthy than patients with nonischemic
limbs; the rehabilitative program generally progresses
much more slowly and more cautiously. A major obstacle
to rehabilitation after transfemoral amputation is the
loss of the knee joint, which exponentially increases the
energy expenditure for locomotion with a prosthesis. This
has consequences for cardiac patients and patients with
ischemic contralateral limbs. The patient and family must
be aware of the risks involved with a physically demand-
ing rehabilitation program. Many transfemoral amputees
with vascular disease never use a prosthesis consistently.
Patients with bilateral transfemoral amputations fre-
quently elect to use a wheelchair because it is faster, and
oxygen consumption is four to seven times more using
bilateral transfemoral prostheses. Younger patients can
experience progress more rapidly, as discussed under
transtibial postoperative care.
A soft dressing is adequate initially for elderly dysvas-
cular patients, whereas immediate postoperative rigid
dressings and earlier weight bearing with a locked-knee
pylon are appropriate in younger patients. Patients seem
more comfortable if weight bearing is delayed until
sutures or staples are removed. Subsequently, ambulation
can be progressed with an unlocked knee and less upper
extremity support. For the definitive prosthesis, a variety
of prosthetic knee units are available that are lighter and
accommodate constant or variable gait cadences and
provide good stability during weight bearing.
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