PREOPERATIVE DIAGNOSIS: Right below-knee amputation (BKA) stump breakdown and deep infection.
POSTOPERATIVE DIAGNOSIS: Right below-knee amputation (BKA) stump breakdown and deep infection.
SURGICAL PROCEDURE: Right below-knee amputation (BKA) stump revision with removal of several centimeters of bone and surrounding envelope with soft tissue.
INDICATION: That of a diabetic white female with peripheral neuropathy with pressure and chronic pain who has had intermittent bouts of swelling and pain at the end of her distal stump. She has had approximately 1-2 weeks of skin breakdown distally and persistent drainage. Workup with a bone scan has revealed abnormalities within the bone suggestive of osteomyelitis. Given her recurrent symptoms and likelihood of a deep infection, cervical treatment was advised to include a stump revision and likely a shortening of the remaining tibia to resect a portion of the potentially infected bone.
Her consent was obtained after a thorough PAR and Q conference.
TECHNIQUE: The patient was brought to the operating room and placed on the operating room table. After administration of a general anesthetic, a proximal tourniquet was applied to her right upper thigh. She was then prepped and draped in the usual sterile fashion. Of note, she has an approximately 15-20 degree knee flexion contracture. Her leg was not exsanguinated given concerns of that infection. The tourniquet was elevated to 300 mmHg after she was prepped and draped as previously noted.
Using a portion of the old incision, and estimating a 4-cm distal resection of the tibia, a wedge-shaped incision was created, including excision of the posterior draining sinus. This was carried out down through the underlying scar subcu to the periosteum of the bone, and measurements at this time in the anterior tibia of 4 cm proximally allowed for mark for location of the osteotomy. Circumferential dissection around the tibia was completed. The bone was resected with an oscillating saw. The fibula was prominent and approximately 0.5 to 1 cm proximal to the tibia and oblique osteotomy was completed to the fibula. Care was taken not to extend dissection distally from this location in hopes of maintaining a contamination-free wound. The specimen was then passed off to the back table, and copious lavage was completed throughout. No further necrotic or infected tissue was appreciated.
The saw and rasp were then used to smooth and round off the edges of the bone. This was performed on both the tibia and the fibula. The deep fascia was then closed with interrupted #1 suture, and subcu closure was completed as well with interrupted suture. The skin was stapled. Given her prior history of infection, a drain was maintained with Penrose. The wounds were then cleaned and dressed sterilely. She was placed in a soft dressing.
She was then reversed from her general anesthetic and returned to the recovery room in stable condition without complication.