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Above-the-knee amputations are performed in patients of all ages for a variety of reasons. The amputation is performed through the femur and allows patients to use a prosthesis for ambulation. This activity reviews the indications and techniques for above-the-knee amputations and highlights the role of the interprofessional team in caring for patients who undergo this procedure. Objectives: Outline the anatomy of the thigh, along with indications and contraindications in regards to above-the-knee amputations. Describe the equipment and general technique in regards to above-the-knee amputations. Review the potential complications and their clinical significance of above-the-knee amputations. Summarize interprofessional team strategies for improving care coordination and outcomes in above-the-knee amputations. Access free multiple choice questions on this topic.

Above-the-knee amputations (AKA) involve removing the leg from the body by cutting through both the thigh tissue and femoral bone. This procedure may be necessary for a wide variety of reasons, such as trauma, infection, tumor, and vascular compromise. There are several known physiologic and psychologic complications that are associated with this procedure. However, an interprofessional approach to caring for these patients may decrease the rate of these complications.

Complications following above-the-knee amputation include muscle atrophy, surgical site wound infections, dehiscence, and wounds from prosthetic wear. One can minimize the complications from skin breakdown when they are caught early by checking the skin daily, especially in patients who have an insensate stump. Additionally, certain pre-operative measures may be used to predict a patient's ability to heal an amputation. Albumin over 3.0g/dL, total lymphocyte count greater than 1500/mm^3, and ankle-brachial index greater than 0.45 have been shown to improve wound healing.[4] Abduction and flexion contractures may also occur as a complication. One study found that 4 of 8 patients who did not have their iliotibial band fixed to the femur to avoid developing an abduction contracture ended up developing a hip flexion contracture; this is believed to have occurred because the gluteus maximus, a hip extensor, inserts in part onto the iliotibial band.[5] The risk of flexion contracture is reducible by having the patient intermittently lie prone post-operatively. Also, myodesis of the quadriceps with the hip in a fully extended position in the OR can reduce this risk. Abduction contracture risk can be decreased by properly performing a myodesis of the adductors to the femur. Phantom limb pain is another complication of an AKA and has been estimated to affect up to 80% of patients who undergo a limb amputation.[6] Post-traumatic stress disorder (PTSD) and depression are known as psychologic complications of amputation. Elderly patients with chronic pain and those who undergo a traumatic amputation demonstrate a higher prevalence of these disorders. Patients who undergo an AKA as a result of chronic illness have lower rates of PTSD.[7]

An above-knee amputation is associated with enormous morbidity; unlike a below-knee amputation, fitting a prosthesis for an above-knee stump is difficult. In fact, most patients cannot adapt to an above-knee prosthesis and eventually succumb to a wheelchair to get around. This leads to other complications like pressure sores, inability to perform daily living activities, and depression. When possible, clinicians need to avoid an above-knee amputation because of the high morbidity; if the procedure is elective, presurgical education of the patient is important. Both the pre and postoperative management of an above-knee amputation is best managed by an interprofessional team because there are functional and physical issues that need to be dealt with. An interprofessional approach is essential in caring for patients who have undergone an amputation. Aside from the physician performing the procedure, specialists in other fields of medicine can play a role in improving a patient's outcome. Internal medicine physicians can control and treat comorbid conditions, which may otherwise slow a patient's progress. Nurses are essential to monitoring vital signs, assisting the patient with daily activities, and delivering medication. The wound care nurse is vital to ensure that the stump is healing; unless the wound has healed, a prosthesis cannot be fitted. Pharmacists help with prescribing appropriate medications to control pain, prevent thrombosis, and decrease infection risk. Physical therapists guide the patient in rehabilitation protocols to restore muscle function and regain mobility in the absence of a limb. Prosthetists ensure the patient has an appropriate, well-fitting prosthetic. Psychologists and psychiatrists can be a valuable asset to the treatment team if the patient develops symptoms of PTSD or depression. One study, which reviewed 233 patients over 5 years, showed that a team approach to the care of amputees could decrease inpatient stay by 20 days, increase the number of patients discharged with a prosthesis by five-fold, and increase the effectiveness of rehabilitation in the long term setting by threefold.[11] [Level 3]

Pharmacists help with prescribing appropriate medications to control pain, prevent thrombosis, and decrease infection risk. Physical therapists guide the patient in rehabilitation protocols to restore muscle function and regain mobility in the absence of a limb. Prosthetists ensure the patient has an appropriate, well-fitting prosthetic. Psychologists and psychiatrists can be a valuable asset to the treatment team if the patient develops symptoms of PTSD or depression. One study, which reviewed 233 patients over 5 years, showed that a team approach to the care of amputees could decrease inpatient stay by 20 days, increase the number of patients discharged with a prosthesis by five-fold, and increase the effectiveness of rehabilitation in the long term setting by threefold.[11] [Level 3] The outcomes of patients with an above-knee amputation depend on the reason why the surgery was necessary. For those with peripheral vascular disease, the outcomes are guarded; many also have associated heart disease, which can often lead to death. For those undergoing amputation for trauma, the prognosis is good. In summary, caring for patients with above-the-knee amputation requires an interprofessional team approach, including physicians, specialists, specialty-trained nurses, physical and occupational therapists, and pharmacists, all collaborating across disciplines to achieve optimal patient results.[12] [Level 5]