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Amputation - Above Knee

 

What is it?

There is not enough blood getting down your leg to keep it alive. The lack of blood causes severe pain and allows serious infection to take hold. The only choice is to take off the damaged part. This must be done high enough to get proper healing of the stump. In your case it means an amputation through the thigh.

The Operation

You will probably have a general anaesthetic, and will be asleep for the whole operation. Sometimes patients are numbed from the waist down with an injection in the back. In this case you will be awake but you will not feel any pain from the waist down. A cut is made so that after removing the diseased part, you end up with a rounded stump made of healthy skin. You should plan to be in the hospital for up to six weeks to cover any delay in healing of the wound. You may well be out before this.

Any Alternatives

An alternative is to amputate lower down, such as through the knee, or at the mid-shin level. But the lower the level, the higher the risk of poor healing, more operations, and a longer stay in hospital. A direct operation on the arteries will not help at this stage. Laser treatment and X-ray guided stretching of the arteries will not work for you. Overall, your best plan is an above-knee amputation.

Before the operation

Stop smoking and try to get your weight down if you are overweight. (See Healthy Living). If you know that you have problems with your blood pressure, your heart, or your lungs, ask your family doctor to check that these are under control. Check the hospital's advice about taking the Pill or hormone replacement therapy (HRT). Check you have a relative or friend who can come with you to the hospital, take you home, and look after you after the operation. Sort out any tablets, medicines, inhalers that you are using. Keep them in their original boxes and packets. Bring them to the hospital with you. On the ward, you may be checked for past illnesses and may have special tests to make sure that you are well prepared and that you can have the operation as safely as possible. Please tell the doctors and the nurses of any allergies to tablets, medicines or dressings. You will have the operation explained to you and will be asked to fill in an operation consent form. Many hospitals now run special preadmission clinics, where you visit for an hour or two, a few weeks or so before the operation for these checks.

After - In Hospital

You may be given oxygen from a face mask for a few hours if you have had chest problems in the past. You will have a fine, thin plastic tube in your arm to give you a blood transfusion (if necessary) or salt solutions. You will have a fine, plastic drainage tube coming out of the skin near the wound, connected to a container. This is to drain any residual blood or other fluid from the area of the operation. You may have a tube draining urine from the bladder to make your nursing easier. There is some discomfort on moving rather than severe pain. You will be given injections or tablets to control this as required. Ask for more if the pain is not well controlled or if it gets worse. Your original pain will have gone, but you may still feel as if the leg is still there. This is called a 'phantom limb' and is something that it is expected and something that most patients experience after an amputation. The feeling fades in time. A general anaesthetic will make you slow, clumsy and forgetful for about 24 hours. The nurses will help you with everything you need until you are able to do things for yourself. Do not make important decisions during this time. By the end of one week the wound should be virtually pain-free. You will be helped out of bed after 24 hours. You should be sitting out of bed comfortably in a week. You should be trying to stand and walk with crutches after a week or so. Your phantom limb may make you forget you have had an amputation. Always have a nurse to help you out of bed, or you may fall and injure yourself. It is important for you to pass urine and empty your bladder after the operation. If you have any difficulty, ask the nurses or doctors. The wound has a dressing on it. The dressing will be changed every two to three days for two weeks to see if the wound is healing well. Any stitches may be taken out after about two weeks. The wound drain is taken out after 48 hours or so. When you first see the wound, the stump will look very bulgy, but this smoothes off in a week or two. The hospital will arrange for you to see the limb fitter once the wound is fully healed. You will have a go at walking with a temporary limb in the physiotherapy department before you see the fitter. You can wash as soon as the dressing has been removed but try to keep the wound area dry until the stitches come out. Soap and warm tap water are entirely adequate. Salted water is not necessary. You can shower or take a bath as often as you want. You will be given an appointment to visit the surgical outpatient Department for a check-up about one month after you leave hospital. The nurses will advise about sick notes, certificates etc.

After - At Home

You may need alterations to your home, e.g. bath handles and ramps which will help you when you return. These will be arranged by the hospital through the social work department. You will need a temporary wheelchair and to learn how to use it. You may even need to think about a change in your housing if your present home is unsuitable for you after the operation. The social workers will advise you here. You may need convalescence. You are likely to feel tired and need to rest two or three times a day for a month or two after the operation. You will gradually improve. The physiotherapists will train you up towards having an artificial limb. The limb fitting centre will see whether you can manage to use one. It often takes three months or more before you have a limb that fits you exactly, since the stump is changing and firming up all the time. How soon you can drive again depends on how quickly you cope with the artificial limb. You may well be able to drive an automatic car or one specially modified for your needs. You will be helped with this. You can restart sexual relations once the wound has healed. How soon you can return to work depends on how quickly you heal up. It is unlikely that you could do a heavy manual job, but many other jobs are perfectly feasible.

Possible Complications

If you have this operation under general anaesthetic, there is a risk of complications related to your heart and lungs. The tests that you will have before the operation will make sure that you can have the operation in the safest possible way and will reduce the chances for such complications. The chance of dying after an amputation is 3 to 10%. The chances are higher for elderly people with other health problems such diabetes, or disease of the arteries that feed the heart with blood. More than 50% of deaths after an amputation are because of heart problems and about 25% because of lung problems.

If you have an anaesthetic injection at the back, there is a very small chance of a blood clot forming on top of your spine which can cause a feeling of numbness or pins and needles in your legs. The clot usually dissolves on its own and this solves the problem. Extremely rarely, the injections can cause permanent damage to your spine. Chest infections may arise, particularly in smokers. Do not smoke. Being as mobile as possible and co-operating with the physiotherapists to clear the air passages is important in preventing chest infections.

Another possible complication is the formation of clots in the deep veins (draining pipes for the blood) of your legs (deep vein thrombosis or DVT). A piece of one of these clots can get detached and “travel” all the way to the blood pipes of your lungs. There it can cause partial or complete obstruction of the blood vessels in the lungs which can be lethal. You will be given injections of blood thinners (heparin) after the operation to prevent a DVT. In addition, being as mobile as possible and co-operating with the nurses and physiotherapists after the operation are very important in preventing a DVT.

Slow healing is sometimes seen and shows up within the first week or two. The doctors will discuss this with you. Rarely, you might need another operation to clean any dying (necrotic) or tissue that is not healing well. Even more rarely, it may be necessary to amputate the leg higher up to be able to get in healthy margins that will heal well when they are stitched together.
Infection sometimes happens. This is usually localised in the wound area and very rarely spreads into your blood stream. You will be given antibiotics to prevent this and you will be given more if an infection actually occurs. The antibiotics take care of the problem in most cases, but there is a chance that you will need another operation to clean the infected tissues.

Another possible complication after this operation is the development of pressure sores (openings in the skin which can be painful). This happens more frequently in areas of the body under pressure from the bed, the lower part of your back and the area close to your back passage being two typical examples. The use of special beds and mattresses as well as being as mobile as possible after the operation with the help of the nurses and the physiotherapists can help a lot in preventing pressure sores.

As we discussed, most patients feel (especially during the early days after the operation) that the limb is still there (phantom limb). In addition, a lot of patients feel pain in the limb area as if the limb was still there (phantom limb pain). This is usually mild to moderate and rarely severe pain and most of the time gets better as time goes by. In some cases the pain can last for a long time. If this happens the doctor will discuss the best way to deal with the problem. Aches and twinges in the wound may be felt for six months or more but will settle down.

Finally, some patients face psychological problems after the operation. The sense of loss and disability can be very frustrating at times. If this happens you will get the necessary psychological support that can effectively help you to overcome this problem.

General Advice

The operation brings a major change to you, but you will end up much better off than before it. Provided you have enough muscle power and good balance, you will have no great difficulty walking on the new limb. The limb fitting process is rather slow and tedious, but will be worth it in the end. These notes will help you through your operation. They are a general guide. They do not cover everything. Also, all hospitals and surgeons vary a little. If you have any queries or problems, please ask the doctors or nurses.

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