AMPUTATION BELOW KNEE

MICHAEL EDWARDS

Author's note

This information describes what a patient may expect when having the described operation.

The information is specific to the author's practice.

Other surgeons will doubtless differ in their preferences.

The script can be down loaded and edited to suit other surgeons.

Click here for the PDF version of the leaflet

You will need Abobe Acrobat Reader which can be downloaded from http://www.adobe.com/uk/products/acrobat/readermain.html

Your Below Knee Amputation Operation - Some Information

These notes give a guide to your stay in hospital. They also give an idea about what it will be like afterwards. They do not cover everything. If you want to know more, please ask.

What is the problem?

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

What does the operation consist of?

A cut is made so that, after removing the diseased part, you end up with a rounded stump made of healthy skin.

Are there any alternatives?

If you leave things as they are, your leg will certainly get worse. Life threatening infection may start.

An operation to bypass or core out your leg arteries will not work in your case. Laser treatment and x-ray guided stretching of the arteries will not work for you. Injecting the nerve to your blood vessels will not work.

Antibiotics are not enough by themselves.

An alternative to a below knee operation is one higher up, such as through the knee, or at the mid-thigh level. But the higher the level, the greater the risks of the operation, and the smaller the chances of your walking again.

A lower amputation such as through your toe or foot will not heal. Overall, I think your best plan is an above knee amputation.

What happens before the operation?

Welcome to the ward

You will be welcomed to the ward by the nurses or the receptionist. You will have your details checked. You will be shown to your bed and will be asked to change into your nightwear. You will have some basic tests done, such as pulse, temperature, blood pressure and urine examination.

You will be asked to hand in any medicines or drugs you may be taking, so that your drug treatment in hospital will be correct. Please tell the nurses of any allergies to drugs or dressings.

Visits by the surgical team

You will be seen first by the House Surgeon, who will interview and examine you. He, or she, will arrange some special tests such as x-rays and blood samples. The operation will be explained to you. You will be asked to sign your consent for the operation. If you are not clear about any part of the operation, ask for more details from the doctors or from the nurses. They are never too busy to do this.

You will have the operation site marked on you with a skin pencil. You will be seen by the surgeon who will be doing the operation. He will check that all the necessary preparations have been made.

Visits by the anaesthetic team

One or more anaesthetists who will be giving your anaesthetic will interview and examine you. They will be especially interested in chest troubles, dental treatment and any previous anaesthetics you have had plus any anaesthetic problems with the family.

Visit by the physiotherapist

The physiotherapist will show you how to keep your chest clear after the operation and how to keep moving about. You should not smoke. You will also have exercises to strengthen your arms and shoulders for later on.

Diet

You will have your usual diet until 6-12 hours before the operation. Then you will be asked to take nothing by mouth. This will let your stomach empty to prevent vomiting during your operation.

Shaving

Your leg will be shaved to prevent hairs affecting the wound.

Timing of the operation

The timing of your operation is usually arranged the day before. The nurses will tell you when to expect to go to the operating theatre. Do not be surprised, however, if there are changes to the exact timing.

Premedication

You may be given a sedative injection or tablets about 1 hour before the operation.

Transfer to theatre

You will be taken on a trolley to the operating suite by a ward nurse and a theatre porter. You will be wearing a cotton gown. Wedding rings will be fastened with tape. Removable dentures will be left on the ward. There will be several checks on your details on the way to the anaesthetic room where your anaesthetic will begin.

Usually a general anaesthetic is given so that you are asleep during the operation. Sometimes it is better to numb your legs with an injection in your back and for you to have just a strong sedative. The anaesthetist will talk to you about this.

The operation is then performed.

You will have only the haziest memory of this, if at all. You won't have any pain.

What happens after the operation?

Coming round after the anaesthetic

You may spend 24 hours or so on the Intensive Care Ward before coming back to your original ward. Even if you have not had a general anaesthetic you are unlikely to remember anything for several hours due to sedatives. Some people feel a bit sick for up to 24 hours after the operation, but this passes off. You will be given some treatment for sickness if necessary.

You will be given oxygen from a face mask for a few hours if you have had chest problems in the past.

You will have a plastic tube in your arm to give you a blood transfusion or salt solutions. You will have a fine plastic drainage tube coming out of the skin near the wound, connected to a container.

Warning after a General Anaesthetic

The drugs we give for a general anaesthetic will make you clumsy, slow and forgetful for about 24 hours. This happens even if you feel quite alright.

For 24 hours after your general anaesthetic:

Do not make any important decisions.

Will it hurt?

Your original pain will have gone, but you may still feel as if the foot and toes are still there. This is called a "phantom limb" and is quite normal. The feeling fades in 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. The wound is painful. You will be given injections and later tablets to control this. Ask for more if the pain is unpleasant. You should be trying to walk with crutches in a week or so.

Warning

The phantom limb feeling may make you forget you have had an amputation. Always ask a nurse to help you get out of bed, or you may fall and damage your wound.

Drinking and eating

You will be able to drink within an hour or two of the operation provided you are not feeling sick. The next day you should be able to manage small helpings of normal food.

Opening bowels

It is quite normal for the bowels not to open for a day or so after operation. You will need help with a bed pan at first. Later you will find a commode easy, but you will still need help. If you have not opened your bowels after 2 days and you feel uncomfortable, ask the nurses for a laxative.

Passing urine

It is important that you pass urine and empty your bladder within 6-12 hours of the operation. You will need to use a bottle or a bed pan with help from the nurses at first. If you still cannot pass urine let the nurses know and steps will be taken to correct the problem.

Sleeping

You will be offered painkillers rather than sleeping pills to help you to sleep. If you cannot sleep despite the painkillers please let the nurses know.

Physiotherapy

The physiotherapist will check that you are clearing your lungs of phlegm by coughing. You should help your circulation by continuous movement of body and limbs. Also you will have exercises to strengthen your leg muscles and to keep your knee working. You will continue exercises to build up your arms and shoulders for using crutches later.

The wound and stitches

The wound has a simple dressing on it. We will look under the dressing after a week to see that the wound is healing. There are no stitches to be taken out. 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. Once the wound has healed you will have stump bandages to shape the stump into a cone to fit the artificial limb. We will arrange for you to see the limb fitter once the wound is fully healed. But you will be practising walking with a temporary limb in the Physiotherapy Department before you see them.

Injections

You will have tiny injections into the tummy skin twice a day to keep the circulation going.

Washing

You can wash the wound area as soon as the dressing has been removed. Soap and warm tap water are entirely adequate. Salted water is not necessary. You can shower or take a bath as often as you like.

What about informing my relatives and contacts?

With your permission, The nurses will keep your relatives and contacts up to date with your progress.

How long in hospital?

You should plan to be in hospital for a month to cover any delay in healing of the wound. You may well be out before this. The nurses will talk to you about your home arrangements so that a proper time for you to leave hospital can be arranged.

You will be given an appointment to visit the Surgical Out Patient Department for a check up about one month after you leave hospital.

You may need alterations to your home, such as bath handles, and ramps, which will help you when you return. We will start these arrangements with the Social Work Department. You will need to have a temporary wheelchair and learn how to use it.

Sick notes

Please ask the nurses for sick notes, certificates etc. After you leave hospital You are likely to feel tired and need rests 2 or 3 times a day for a month or more after the operation. You will gradually improve.

What about an artificial limb?

You will be in the hands of the Limb Fitters once the wound has healed. It often takes 3 or more months before you have a limb which suits you exactly, since the stump is changing and firming up all the time. The Physiotherapy Department will continue your training.

Driving

This 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. We will help you in this.

What about sex?

You can restart sexual relations once the wound is healed.

Work

This 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. We can help here.

Complications

Slow wound healing is sometimes seen and shows up within the first week or two. The doctors will discuss this with you. Infection sometimes happens. You will be given antibiotics to prevent this. Aches and twinges in the wound may continue for 6 months or more. They settle down.

General advice

The operation is a medium sized one. You will end up much better off than before it. Most patients are able to walk without difficulty on the new limb. The fitting of the new limb is rather tedious and slow but is well worth it in the end. If you have any problems or queries, please ask the nurses or doctors.

Any Questions?

If you have any questions, jot them down here and ask the doctors or nurses for answers.

Any complaints?

If you have any complaints, please contact the doctors or nurses straight away. If this does not solve the problem, please write to your surgeon.

Have you any comments?

We welcome your comments and suggestions covering your illness, your treatment in hospital, and your recovery. Please write below any points you would like to make. If you prefer, you need not give your name.

Full name:

Hospital:

Ward:

Date of stay in hospital:

Operation:

Out patients department:

Your admission arrangements:

Your welcome on the ward:

Nursing staff:

General ward atmosphere:

Medical staff:

Ward orderlies:

Portering staff:

X-ray staff:

ECG staff:

Did you know who was who?:

Bedding:

Food and drink:

Privacy:

Locker space:

Toilets:

Bathrooms:

Other patients:

Noise:

Information:

Telephone/TV/radio/newspapers:

Timing of operation:

Preparations for your operation:

Going into the theatre:

In the operating theatre:

In the recovery room:

Coming back from theatre:

Intensive Care ward:

Recovery on the ward:

Pain control:

Sleeping:

Wound dressings:

Stitches, clips:

Progress reports:

Visiting hours:

Rest room:

Tablets, medicines, injections:

Going-home arrangements:

Out-patient follow up:

Anything else?

Continue comments overleaf if you wish.

Please send this questionnaire to your surgeon.