Figure A shows a below the knee amputation performed in a diabetic patient with significant vascular disease. Busse JW, Jacobs CL, Swiontkowski MF, Bosse MJ, Bhandari M., Evidence-Based Orthopaedic Trauma Working Group. Its proven that a diagnosis of heart disease or ex Healthcare business professionals from around the world came together at REVCON a virtual conference by AAPC Feb. 78 to learn how to optimize their healthcare revenue cycle from experts in the field. All CPT Code 27,880 and 27,881 entries for amputation through tibia and . Which of the following amputations results in an approximate 40% increase in energy expenditure for ambulation? If the MDs do not specifically document high, mid or low, but indicate a point of incision XXX cm from the tibial tuberosity can it be indicative and coded high mid or low based on the distance documented? Beyaz S, Gler , Bar G. The tibial and fibular shafts are cut with an oscillating saw, and the corners beveled with a rongeur or saw. This root operation defines a broad range of common procedures, since it can be used anywhere in the body to treat a variety of conditions, including skin and genital warts, nasal and colon polyps, esophageal varices, endometrial implants, and nerve lesions. The "icd-10 code for below knee amputation unspecified" is a general term that can be used to describe the condition of having an above the knee amputation. supports all conditions were evaluated. Radiographic films must be taken to include an anterior-posterior and lateral view of the extremity, including the foot, ankle, tibia/fibula, and knee, to assess for concomitant fracture, subcutaneous air, intact proximal bone, etc. KadGS>Y-5'b9G)kFdJ*P3e~";cVKEdPX%T'=[nKTp43Ud84INR|bOoEBimThLL:J7FrZ8ov"MJ}c}fq]oc|w1J5 -ya6 723 0 obj <> endobj %%EOF As with all surgical procedures, there are possibleacute complications of uncontrolled bleeding, infection, acute postoperative pain, and broader medical complications, including acute blood loss anemia and stress-induced cardiac ischemia. View the CPT code's corresponding procedural code and DRG. Presence of an acute open fracture and crush injury. Further preoperative evaluation demonstrates a transcutaneous oxygen pressure of 45 and an albumin of 3.4. } !1AQa"q2#BR$3br Audit reveals crisis standards of care fell short during pandemic. If both a revision of below knee amputation and negative pressure wound therapy are performed, would it be appropriate to override the NCCI edit on 27884? The problem of the geriatric amputee. The tibial neurovascular structures lie within the deep compartment. A below-the-knee amputation (BKA) is a transtibial amputation that involves removing the foot, ankle joint, distal tibia, fibula, and corresponding soft tissue structures. Soleus and flexor digitorum longus originate at the posterior aspect of thetibiaon the soleal line. 148 0 obj <>stream Similarly, an MRI may determine the adequacy of soft tissues. CCQ22017p3 provides some additional direction/assistance with this. Additionally,the long-term clinical survival of BKApatients is notably poor in certain populations; patientswithend-stagediabetes mellitus who receive a BKA for foot ulcers have been shown to have an averagepostoperative life expectancy of aroundthree years.[32]. . The sciatic nerve divides proximal to the popliteal fossa into the common peroneal (fibular) and tibial nervethe common peroneal nerve winds around the fibular neck. (OBQ10.145) The anterior tibial artery is the main blood supply to the anterior compartment of the leg with reinforcement by the perforating branch of the peroneal artery. endstream endobj 57 0 obj <. A skin incision is made down to the fascia circumferentially. The Current Procedural Terminology (CPT ) code 27884 as maintained by American Medical Association, is a medical procedural code under the range - Amputation Procedures on the Leg (Tibia and Fibula) and Ankle Joint. Ability to return to work is the strongest factor to predict outcomes following amputation, Amputation results in better Sickness Impact Profile at 2 years, The absence of plantar sensation has the highest impact on surgeon assessment of the need for amputation, Limb salvage results in worse functional outcomes at 2 years, Psychological distress is the strongest factor to predict outcomes following limb salvage. This contraindicates elective or semi-elective procedures until the condition can be optimized. Six months after the amputation he has persistent difficulty with ambulation because his distal femur moves into a subcutaneous position in his lateral thigh. A 45-year-old diabetic woman with a gangrenous foot undegoes a Chopart amputation without tendon transfer or lengthening. Pedersen HE. In contrast, where time and tissue allow, a completed amputation involves all steps outlined below, resulting in a closed, sutured stump ready to apply a stump shrinker and prosthesis planning. In patients in extremis due to sepsis, blood loss, acute major organ failure, or other causes, every attempt should be made to stabilize the patient before starting a major surgical procedure. Lower extremity amputation serves as a life-saving procedure. amputation levels - High, Mid, Low documentation requirements jennifer.cavagnac@baystatehealth.org December 2018 in Clinical & Coding We are wondering what others are practicing regarding below knee amputations and the documentation specificity of high, mid and low. %PDF-1.5 % The patient had a guillotine amputation of the left foot, followed by amputation of the left leg 5 days later. Tisi PV, Than MM. H\Qo@>4(M6afKs8M!'nqharocwkf/Su;}6?qV spat{Hku+%e nBSE\>,Upl1 AMPUTATION, BELOW KNEE AMPUTATION LEG BELOW KNEE *27880 Amputation, leg, through tibia and fibula; Vascular, Orthopedics . View matching HCPCS Level II codes and their definitions. Leg Compartment Release - Single Incision Approach, Leg Compartment Release - Two Incision Approach, Arm Compartment Release - Lateral Approach, Arm Compartment Release - Anteromedial Approach, Shoulder Hemiarthroplasty for Proximal Humerus Fracture, Humerus Shaft ORIF with Posterior Approach, Humerus Shaft Fracture ORIF with Anterolateral Approach, Olecranon Fracture ORIF with Tension Band, Olecranon Fracture ORIF with Plate Fixation, Radial Head Fracture (Mason Type 2) ORIF T-Plate and Kocher Approach, Coronoid Fx - Open Reduction Internal Fixation with Screws, Distal Radius Extra-articular Fracture ORIF with Volar Appr, Distal Radius Intraarticular Fracture ORIF with Dorsal Approach, Distal Radius Fracture Spanning External Fixator, Distal Radius Fracture Non-Spanning External Fixator, Femoral Neck Fracture Closed Reduction and Percutaneous Pinning, Femoral Neck FX ORIF with Cannulated Screws, Femoral Neck Fracture ORIF with Dynamic Hip Screw, Femoral Neck Fracture Cemented Bipolar Hemiarthroplasty, Intertrochanteric Fracture ORIF with Cephalomedullary Nail, Femoral Shaft Fracture Antegrade Intramedullary Nailing, Femoral Shaft Fracture Retrograde Intramedullary Nailing, Subtrochanteric Femoral Osteotomy with Biplanar Correction, Distal Femur Fracture ORIF with Single Lateral Plate, Patella Fracture ORIF with Tension Band and K Wires, Tibial Plateau Fracture External Fixation, Bicondylar Tibial Plateau ORIF with Lateral Locking Plate, Tibial Plafond Fracture External Fixation, Tibial Plafond Fracture ORIF with Anterolateral Approach and Plate Fixation, Ankle Simple Bimalleolar Fracture ORIF with 1/3 Tubular Plate and Cannulated Screw of Medial Malleol, Ankle Isolated Lateral Malleolus Fracture ORIF with Lag Screw, Calcaneal Fracture ORIF with Lateral Approach, Plate Fixation, and Locking Screws, RETIRE Transtibial Below the Knee Amputation (BKA), if severe vascular dysfunction may require revascularization procedure prior to amputation, check with nutrition labs: albumin, prealbumin, transferrin, total lymphocyte count, severe soft tissue injury has the highest impact on decision whether to amputate or reconstruct lower extremity in trauma cases, need to assess associated injuries and comorbidities (diabetes), traditional short BKA increases baseline metabolic cost of walking by 40%, AP/Lat views of foot, ankle, and tibia/fibula, MRI of the to look for integrity of soft tissue and infection, documents failure of nonoperative management, describes accepted indications and contraindications for surgical intervention, independence with mobility and ambulation with mobility devices, progress weightbearing and weight shifting exercises, perform rehabilitation exercises independently, return to high level/high impact exercises, begin shrinker once wounds are closed, healed and dry, transition to liner when prosthetist feels appropriate, diagnose and management of early complications, diagnosis and management of late complications, check neurovascular status to determine level of amputation, describe complications of surgery including, wound breakdown (worse in diabetics, smokers, vascular insufficiency), describes the steps of the procedure to the attending prior to the start of the case, describe potential complications and steps to avoid them, place small bump under ipsilateral hip to internally rotate the leg, mark the anterior incision 10cm distal to tibial tubercle, this incision is also15cm from knee joint line, anterior incision 2/3 total circumference, posterior incision 1/3 total circumference, mark out the posterior flap so that it is 1.5 times the length of the anterior flap, this is extremely important because it allows for redundant posterior flap upon closure, the posterior flap should be distal to the musculotendinous junction of the gastrocnemius, round out the distal ends of the posterior skin flap to reduce redundancy of skin upon closure, incise the entire circumference of the skin incision through the underlying fascia, direct the vertical incison over the anterior crest of the tibia to facilitate exposure of the anterior periosteal flap, identify the superficial and deep peroneal nerves, place gentle traction and resect nerves using sharp dissection, sharply dissect through the anterior compartment musculature at the most proximal end of the wound, this reduces bulk and makes the myodesis easier, identify, isolate and ligate the anterior tibial artery, elevate the perosteal flap using a single blade wide chisel, sharply incise the anterior and posterior margins of the anteriormedial tibia for 8 to 10 cm distally, raise the flap with the bevel positioned superiorly, protect the flap using a moist gauze sponge, isolate the rest of the tibia with a periosteal elevator, divide the interosseus membrane and identify the fibula, perform cut of the fibula several centimeters distal to the tibia cut, the proximal cut of the fibula is at the level of the distal tibia cut, elevate the periosteum of the fibula at this level of the cut and continue elevating for 1 cm distally, cut a notch into the posterolateral tibia to house the fibula, secure the bone bridge with non absorbable suture through holes that are made through the lateral aspect of the fibula, through the medullary canal of the transverse fibula to the medial aspect of the tibia, without a bone bridge approximately 1 cm proximal to the tibia cut at a lateral angle, distance from the lateral tibia to the media fibula, make fibula cut this distance plus 2 cm proximal to the tibia cut, use a power saw with irrigation to make the tibia cut, transect and taper the posterior musculature, this is done to provide a tension free myodesis, this should be performed at the level of the tibial bone cut, identify and dissect the tibial nerve from the vasculature, inject the nerve with 1% lidocaine then sharpy transect under gentle traction, identify and ligate the posterior tibial artery with ligature suture, ligate the veins with vasvular clips or ligature suture, resect remaining posterior compartment to the level of the distal tibia cut, begin the bevel outside of the medullary canal at 45 degree angle, drill holes just anterior to the bone bevel for myodesis, use a locking style Krackow suture through the gastroc apneurosis and secure it to the tibia, secure the borders of the gastrocnemius to the proximal anterior fascia, recheck for remaining peripheral bleeders, skin closure with 2-0 nylon (vertical/horizontal mattress), do not want to overly tighten skin as this can necrosis edges, soft incision dressing well padded to reduce pressure in incision, continue postoperative antibiotics until the drain is removed, order and interprets basic imaging studies, independent gait training with a walker or crutches, return balancing and conditioning to normal, appropriate medical management and medical consultation. The patient's neurovascular status necessitates the amputation demonstrated in figures A through C. One year following the amputation, the patient complains of difficulty with gait and deformity of the ankle. We know we should query MDs to specify the root operation in terms for coding -- but this is a different level of definition. A 40-year-old male who sustained an open pilon fracture 2 weeks ago is scheduled for a below-the-knee amputation (BKA). Which of the following is true of a knee disarticulation as compared to a transtibial amputation? [17], The most significant contraindication to performing a non-urgent BKA is vascular insufficiency at the planned amputation site. Torres AL, Ferreira MC. Outcomes in lower limb amputation following trauma: a systematic review and meta-analysis. X!A%QeKksg4*L;3LL0i$SC*IIa%,'17wI_ xxq:U'MvW$dgj_y:[6tzA;nX AGl%i=CAGz4P!rpU*Ay$i|web=MgbWRqSWLr?D/ Burgess.[8]. endstream endobj 730 0 obj <>stream The anterior tibial compartment lies anterolateral to the spine of the tibia and anterior to the fibula. A through-knee disarticulation has been shown to have what advantage over a traditional above-knee (transfemoral) amputation? right above-knee amputation, distal femur. ICD-10-CM Diagnosis Code S88.111A [convert to ICD-9-CM] Complete traumatic amputation at level between knee and ankle, right lower leg, initial encounter Complete traum amp at lev betw kn and ankl, r low leg, init; Traumatic amputation below right knee; Traumatic right below knee amputation ICD-10-CM Diagnosis Code S88.112A [convert to ICD-9-CM] Shoulder360 The Comprehensive Shoulder Course 2023. Outline the importance of collaboration and coordination amongst the interprofessional team to facilitate safe outcomes for patients requiring below-the-knee amputations. View matching HCPCS Level II codes and their definitions. right below-knee amputation, proximal tibia/fibula. Moreover, several designs for skin flaps have been introduced to cover the amputation stump. The peroneal nerve innervates the posterior lateral lower leg. It allows for eversion and dorsiflexion. Which of the following statements best describes the forces resulting in this deformity? The lymphatic drainage of the tibia and fibula is to the superficial and deep inguinal lymph nodes. The one exception to this is the case of uncontrolled, spreading necrotizing infection, where the source control is often life-saving. The extensor digitorum longus and extensor hallucis longus tendons insert on the medial fibula. Electrocautery was used to excise the wound and again to undermine the wound edges. Horizontal head of semimembranosus muscle inserts on the medial condyle. . Access free multiple choice questions on this topic. Rules-based maps relating CPT codes to and from SNOMED CT clinical concepts. ICD-10: Routine Aftercare Following Amputation (Coding Tip by PPS Plus) - Feb 2016. Please note this question was answered in 2021. . Subscribe to Codify by AAPC and get the code details in a flash. Categories. [20][21], In infectious cases, osteomyelitis is most effectivelyevaluated with MRI. Distally, branches from nerves supplying the overlying muscle innervate the tibia below. El Hage R, Knippschild U, Arnold T, Hinterseher I. A standard orthopedic operative set is essential. (OBQ06.145) A 66-year-old male sustains an open crush injury to his right lower leg with significant skin loss. We are going to work with our surgeons to ensure a consensus appreciation of their anatomic descriptions of the amputation and what should be equivalent for High, Mid and Low. The tibiofibularbone bridge provides a degree of weight bearing.[27][28]. To plug inpatient facility revenue drains, subscribe to, Crosswalk to an anesthesia code and its base units, and calculate payments in a snap! Her ankle-brachial index (ABI) for her right posterior tibial artery is 0.4. Mortality After Nontraumatic Major Amputation Among Patients WithDiabetes and Peripheral Vascular Disease: A Systematic Review. His history is significant for COPD, diabetes controlled with an insulin pump, and testicular cancer treated with bleomycin twenty years ago. Every postoperative patient should have an attentive primary healthcare provider to follow up closely after hospital discharge. This may be sutured or stapled based on surgeon preference. Conversely, in cases of acute hemorrhage, local tourniquets may be applied for several hours while resuscitation occurs. These include urgent cases where source control of necrotizing infections or hemorrhagic injuries outweighs limb preservation. A drain is placed in the wound, and the fascia is approximated, followed by the subcutaneous tissue and, finally, the skin. Z47.81 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. Factors affecting lifespan following below-knee amputation in diabetic patients. To safely perform a BKA, a standard surgical team should be assembled, including the operating surgeon, anesthesiologist, scrub tech, and circulator. The branches of the popliteal artery are the anterior tibial artery, posterior tibial artery, sural artery, medial superior genicular artery, lateral superior genicular artery, middle genicular artery, lateral inferior genicular artery, and medial inferior genicular artery. [29], Chronic complications of BKAs include the development of painful neuromas from transected nerves, highlighting the importance of proper intraoperative technique as described above. A long posterior skin flap and unequal (skewed) anterior and posterior muscle and skin (myocutaneous) flapshave been widely used. [13], The deep peroneal nerve innervates the first and second toe webbed space. The January 2023 update to the HCPCS Level II code file from the Centers for Medicare 38 Medicaid Services CMS inclu Surgical Procedures on the Musculoskeletal System, Surgical Procedures on the Leg (Tibia and Fibula) and Ankle Joint, Amputation Procedures on the Leg (Tibia and Fibula) and Ankle Joint, Copyright 2023. This is the American ICD-10-CM version of Z89.512 - other international versions of ICD-10 Z89.512 may differ. Below Knee Amputation. Which of the following deformities is most common after the amputation shown in Figure A? Preserving the soft-tissue envelope (peroneus brevis, tertius and plantar fascia) around the fifth metatarsal base, Myodesis of the anterior tibialis to the medial and middle cuneiforms, Lengthening of the gastrocsoleus (achilles tendon). hUkOA+Q8WBH endstream endobj 727 0 obj <>/ExtGState<>/Shading<>>>/TilingType 3/Type/Pattern/XStep 853.814/YStep 853.814>>stream The ICD 10 code for below knee amputation is W81. The periosteal sleeve with chips of attached cortical bones should be fashioned to enclose the distal bone ends and filled with bone graft. This is an AAOS Self Assessment Exam (SAE) question. endstream endobj 121 0 obj <> endobj 122 0 obj <> endobj 123 0 obj <>stream AHA Coding Clinic for HCPCS - 2016 Issue 2; Ask the Editor Excision pressure wound from the below-knee amputation stump with complex closure. (OBQ04.235) An anterior skin flap is drawn to include the anterior two-thirds of the leg, while the posterior flap is drawn 150% longer than the anterior flap to allow ample soft tissue for closure. The initial workup of ischemic and infectious limb-compromising diagnoses often begins in the emergency department or local clinic, where prompt assessment, triage, and workup are critical. 3 This is the American ICD-10-CM version of Z89.511 - other international versions of ICD-10 Z89.511 may differ. American Hospital Association ("AHA"), Jury Convicts Physician for Misappropriating $250K From COVID-19 Relief, REVCON Wrap-up: Mastering the Revenue Cycle, OIG Audit Prompts ASPR to Improve Its Oversight of HPP, Check Out All the New Codes for Reporting Services and Supplies to Medicare. In cases of profound vascular insufficiency, bypass grafting or the placement of stents may be necessary before performing a BKA. Lower limb ischemia, peripheral arterial disease, and diabetes mellitus are considered the major causality of limb amputations in more than 50 % of cases. Documenting that a "below-the-knee amputation" took place really isn't sufficient. hb```b``fa`e``1dd@ A+yd85X0abnhwP` |uCE\L0.ePs9NL?gv``8V}{'z49K$^xM//.A2']K6_z(cjfn1G/{VtOw9g-mD3R*eeenSCS7lqyXRt)VbC/Zb3 (OBQ04.11) I would pick 27882. This is the American ICD-10-CM version of, Z codes represent reasons for encounters. In general, below-the-knee amputations are associated with better functional outcomes than above-the-knee amputations. The fascia is incised, and the muscles are carefully divided into the tibia and fibula. 23921 Disarticulation of shoulder; secondary closure or scar revision Shoulder - Amputation CPT Code Defined Ctgy Description 23800 Arthrodesis, glenohumeral joint; 23802 Arthrodesis, glenohumeral joint; with autogenous graft (includes obtaining graft) endstream endobj 728 0 obj <>stream Pathology of Peripheral Artery Disease in Patients With Critical Limb Ischemia. The physician dictated the following: 139 0 obj <>/Filter/FlateDecode/ID[<34F1831025982756D8AB8A2E92B86786><15F3D9AE19388C44911A30AD3602344A>]/Index[120 29]/Info 119 0 R/Length 107/Prev 820316/Root 121 0 R/Size 149/Type/XRef/W[1 3 1]>>stream [15] Adequate resuscitation and stabilization must always have occurred before such a decision, as judged by vital signs, lactate, base deficit, and the management of concomitant injuries. A corresponding procedure code must accompany a Z code if a procedure is performed. Myodesis of which muscle group is most important for optimal outcome after transfemoral amputation? community guidelines. The applicable bodypart is lower leg, left. At this point, the healthcare team includes the surgeon, the patient (who must provide informed consent for a BKA, either personally or via proxy), anesthesia providers in the operating room, operating room management and staff, and the bedside nurses either in the emergency department or on the floor. Which of the following has the most impact on the decision to attempt limb salvage versus amputation? Inflammatory labs, including ESR and CRP, are important in determining the presence, degree, and acuteness of infection. Impact of malnutrition and frailty on mortality and major amputation in patients with CLTI. Adams CT, Lakra A. This will also show the extent of osteomyelitis and associated soft tissue fluid collections if present. These are branches of the deep femoral nerve and the tibial nerve. XCG#7-y~!_ihU2Df$/ ,d{+YF60=Kx,Yk39A t8Bp`p`p`p`A?~#Gg?xyyyyyyyy2STd*3LE2S|v++ge'N(:Qvo7o7o_t!Bi\cL[s~{cFV` 4 While a BKA divides all compartments, a thorough grasp of the relevant anatomy is vital to controlling blood loss intraoperatively and preventing known complications. 2 The 2021 edition of ICD-10-CM Z89.511 became effective on October 1, 2020. Ex: 1000F Category III Codes The procedure code 0Y6J0Z3 is in the medical and surgical section and is part of the anatomical regions, lower extremities body system, classified under the detachment operation. Branches of the anterior tibial artery supply the proximal metaphysis and epiphysisfrom the periphery via periosteal branches. [9], The penetrating branches of theposterior tibial artery supply the distal metaphysis and epiphysis from the periphery.[10]. The tourniquet is inflated. Below Knee Amputation Midfoot Amputation Compartment Syndrome Upper Extremity Shoulder Humerus Elbow Forearm Pelvis Trauma Acetabulum Lower Extremity Femur Knee Tibia & Fibula Ankle and Hindfoot Evolving Concepts in Orthopaedic Trauma 2023 Feb 24 - Feb 26, 2023 Park City, UT Register | 12 Days Left Learn more 3 The fibularis tertius (FT) is a small muscle in the anterior compartment of the leg that inserts on the anterior surface of the distal fibula. If you are a member and have already registered for member area and forum access, you can log in by clicking here. View the CPT code's corresponding procedural code and DRG. hbbd```b``" ed6q0yL2U !DHZ ,d $YsAdv Harris AM, Althausen PL, Kellam J, Bosse MJ, Castillo R., Lower Extremity Assessment Project (LEAP) Study Group. ICD-10-CM Diagnosis Code S88.111A [convert to ICD-9-CM] Complete traumatic amputation at level between knee and ankle, right lower leg, initial encounter Complete traum amp at lev betw kn and ankl, r low leg, init; Traumatic amputation below right knee; Traumatic right below knee amputation ICD-10-CM Diagnosis Code S88.112A [convert to ICD-9-CM] The tibial and deep and superficial peroneal nerves are identified within their respective neurovascular bundles. 33\ 8Xe97F2(v%"hjx^rE?Jg/!ghkgs+;R|gw3# :Z"(0E83ACg^0(w {T@RBhi`T Type of incision for below knee amputation. To view all forums, post or create a new thread, you must be an AAPC Member. hb``d`` $^2F fah@bAF3812Z0;00v c Stahel PF, Oberholzer A, Morgan SJ, Heyde CE. How far below the knee is that? [31], Therefore,for frail or elderly patients, this is a procedure that must be undertaken in conjunctionwith nutritionalguidance and an overall discussion of patient health and mobility. 0x6k0z8. If this is your first visit, be sure to check out the FAQ & read the forum rules. A 34-year-old male is an inpatient at a rehabilitation hospital after sustaining severe lower extremity injuries in a motor vehicle collision. (OBQ12.171) nFZU,I O;KoEdUSFyOO~mKutru!jv7Y{]/s-Wz\weogpR9pDZ4v?R>-oV2j}2E4 ,g6YzgdAiYXM`CN1O{1r"2pG;!"NA >K"OD`RHLWFd]. ICR-18650 2600 mAh; Downloads. 3 Russell Esposito E, Miller RH. @=O\[Y^J]Z?xB{ (@>7D |M'0j3\q6`]kb8IKNS ED#k !mht2" 9Q Which type of deformity is the most likely complication of this procedure? [24]The latter technique has been primarily introduced by Ernest M. Burgess. This blood supply is noteworthy as graft reconstruction surgery of the mandibleoftenuses the proximalfibula. Tight posterior capsule tissues of the ankle, Unopposed pull of gastrocnemius-soleus only, Unopposed pull of gastrocnemius-soleus, posterior tibialis, and peroneus brevis, Unopposed pull of gastrocnemius-soleus and posterior tibialis. Once the patient is prepped and draped, the tibial tubercle and joint line are marked, with the BKA incision marked distally, typically 10 to 15 cm from the tibial tubercle. (SBQ20TR.15) amputations are done urgently and electively to reduce pain, provide independence, and restore function, prevention of adjacent joint contractures, early return of patient to work and recreation, 1.7 million individuals in the United States with an amputation, 80% of amputations are performed for vascular insufficiency, Amputations may be indicated in the following, most common reason for an upper extremity amputation, most common reason for a lower extremity amputation, perform amputations at lowest possible level to preserve function, Syme amputation is more efficient than midfoot amputation, inversely proportional to length of remaining limb, Ranking of metabolic demand (% represents amount of increase compared to baseline), varies based on patient habitus but is somewhere between transtibial and transfemoral, most proximal amputation level available in children to maintain walking speeds without increased energy expenditure compared to normal children, measurement of doppler pressure at level being tested compared to brachial systolic pressure, pressure-sensitive implanted medical device (automatic implantable cardiac defibrillator, pacemaker, dorsal column stimulator, insulin pump), Amputation versus limb salvage and replantation, mangled upper extremity has a far greater impact on overall function than does a lower extremity amputation, upper extremity prostheses have much more difficulty replicating native dexterity and sensory feedback provided by the native limb, results of nerve repair and reconstruction are more successful in upper extremity than lower extremity, superior functional outcomes can be expected in replanted limbs compared with upper extremity amputations, diminishing outcomes from replantation are expected the more proximal the level, especially about the elbow, wrist disarticulation or transcarpal versus transradial amputation, recommended in children for preservation of distal radial and ulnar physes, can be difficult to use with highly functional prosthesis compared to transradial, Although, this may be changing with advancing technology, easier to fit prosthesis (myoelectric prostheses), transhumeral versus elbow disarticulation, indicated in children to prevent bony overgrowth seen in transhumeral amputations, All named motor and sensory branches within operative field should be identified and preserved, can result in improved muscle mass and preserve the ability to create myoelectric signal for targeted reinnervation, myodesis, the process of attaching the muscle-tendon unit directly to bone is recommended, anchor wrist flexor/extensor tendons to carpus, middle third of forearm amputation maintains length and is ideal, residual 5cm of ulna is required for elbow motion, but at this level will have limited pronation/supination, ideal level is 4-5cm proximal to elbow joint, At least 5-7cm of residual length is needed for glenohumeral mechanics, retain humeral head to maintain shoulder contour, designed to improve control of myeolectric prostheses used for amputation, transfer amputated large peripheral nerves to reinnervated functionally expendable remaining muscles to create a new discrete muscle signal for the myoelectric prosthesis control, secondary benefit of alleviating symptomatic neuroma pain, however, ideal cut is 12 cm (10-15cm) above knee joint to allow for prosthetic fitting, 5-10 degrees of adduction is ideal for improved prosthesis function, creates dynamic muscle balance (otherwise have unopposed abductors), provides soft tissue envelope that enhances prosthetic fitting, amputation through the femur near level of adductor tubercle, synovium is excised to prevent postoperative effusion, patella is arthrodesed to the end of femur for improved end bearing, prepatellar soft tissue is maintained without iatrogenic injury, improved outcomes as compared to transfemoral amputation, ambulatory patients who cannot have a transtibial amputation, suture patellar tendon to cruciate ligaments in notch, use gastrocnemius muscles for padding at end of amputation, Consequence of poor soft tissue envelope from loss of gastrocnemius padding, 12-15 cm below knee joint is ideal (10-16cm of residual tibia bone), longer than this gets into the achilles tendon which has a suboptimal blood supply and ability for soft tissue cushioning, need approximately 8-12 cm from ground to fit most modern high-impact prostheses, preventable with well-designed incision lines, preserve blood supply to the posterior flap, designed to enhance prosthetic end-bearing, argument is that the bone bridge will enhance weight bearing through the fibula and increase total surface area for load transfer, increased reoperation rates have been reported, the original Ertl amputation required a corticoperiosteal flap bridge, the modified Ertl uses a fibular strut graft, requires longer operative and tourniquet times than standard BKA transtibial amputation, fibula is fixed in place with cortical screws, fiberwire suture with end buttons, or heavy nonabsorbable sutures, used successfully to treat forefoot gangrene in diabetics, medial and lateral malleoli are removed flush with distal tibia articular surface, the medial and lateral flares of the tibia and fibula are beveled to enhance heel pad adherence, removal of the forefoot and talus followed by calcaneotibial arthrodesis, calcaneus is osteotomized and rotated 50-90 degrees to keep posterior aspect of calcaneus distal, allows patient to mobilize independently without use of prosthetic, Chopart or Boyd amputation (hindfoot amputation), a partial foot amputation through the talonavicular and calcaneocuboid joints, avoid by lengthening of the Achilles tendon and, leads to apropulsive gait pattern because the amputation is unable to support modern dynamic elastic response prosthetic feet, unopposed pull of tibialis posterior and gastroc/soleus, prevent by maintaining insertion of peroneus brevis and performing achilles lengthening, a walking cast is generally used for 4 week to prevent late equinus contracture, Energy cost of walking similar to that of BKA, more appealing to patients who refuse transtibial amputations, almost all require achilles lengthening to prevent equinus, preserves insertion of plantar fascia, sesamoids, and flexor hallucis brevis, reduces amount of weight transfer to remaining toes, prevent with early aggressive mobilization and position changes, trauma-related amputation have an infection rate of around 34%, prevent with proper nerve handling at the time of procedure, a method of guiding neuronal regeneration to prevent or treat post-amputation neuroma pain and improve patient use of myoelectric prostheses, occurs in 53-100% of traumatic amputations, mirror therapy is a noninvasive treatment modality, most common complication with pediatric amputations, prevent by performing disarticulation or using epihphyseal cap to cover medullary canal, Outcomes are improved with the involvement of psychological counseling for coping mechanisms, Involves a close working relationship between rehab physicians, prosthetists, physical therapists, as well as psychiatrists and social workers, High rate of late amputation in patients with high-energy foot trauma, highest impact on decision-making process, 2nd highest impact on surgeon's decision making process, plantar sensation can recover by long-term follow-up, SIP (sickness impact profile) and return to work, mangled foot and ankle injuries requiring free tissue transfer have a worse SIP than BKA, most important factor to determine patient-reported outcome is the ability to return to work, About 50% of patients are able to return to work, study focused on military population in response to LEAP study, slightly better results in regard to patient-reported outcomes for the amputation group with a lower risk of PTSD, more severe limbs were going into salvage pathway, military population with better access to prostheses, higher rates of return to vigorous activity in the amputation group, Descending thoracic aorta graft, with or without bypass, Laparoscopy, surgical, ablation of 1 or more liver tumor(s); radiofrequency. 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