From the Guidelines
Post-operative care after below-knee amputation (BKA) from a vascular surgery perspective typically involves a 5-7 day hospital stay, though this may vary based on patient factors and complications. Immediate post-operative orders include pain management with multimodal analgesia (opioids like hydromorphone 0.5-2mg IV q4h as needed, transitioning to oral medications like oxycodone 5-10mg q4-6h), prophylactic antibiotics (cefazolin 1-2g IV q8h for 24 hours), DVT prophylaxis (enoxaparin 40mg subcutaneously daily or heparin 5000 units subcutaneously q8h), and wound care with dressing changes every 1-2 days. Some key considerations for post-operative care include:
- Resuming antithrombotic therapy, such as vitamin K antagonists (VKAs), within 24 hours of surgery, as suggested by the American College of Chest Physicians clinical practice guideline 1
- Managing pain and preventing complications, such as deep vein thrombosis (DVT) and wound infections
- Initiating physical therapy within 24-48 hours post-surgery to promote mobility and prevent flexion contractures
- Providing nutritional support and glycemic control to optimize wound healing Follow-up care includes:
- Weekly wound checks for the first 2-4 weeks
- Suture removal at 2-3 weeks
- Prosthetic evaluation at 4-6 weeks post-surgery when the residual limb has adequately healed and swelling has decreased
- Compression therapy with elastic bandages or shrinker socks to shape the residual limb for prosthetic fitting
- Long-term follow-up at 3,6, and 12 months to monitor wound healing, prosthetic fit, and functional status, as recommended by the European Society of Cardiology (ESC) guidelines 1 This comprehensive approach addresses both the physical and functional aspects of recovery, aiming to optimize mobility and quality of life after amputation.
From the Research
Post-Operative Care for Below the Knee Amputation
- The average length of stay in the hospital after a below-knee amputation (BKA) is around 10 days, with a range of 6-15 days 2.
- Post-operative orders may include the use of negative pressure wound therapy (NPWT) to help condition the open stump for successful closure 2, 3.
- NPWT is typically applied as a postsurgical dressing over closed fascia and is removed after 5-7 days 3.
- The use of closed incision NPWT may decrease the incidence of wound complications in vascular patients undergoing major lower extremity amputations 3.
Follow-Up Care
- Patients are typically casted for prosthesis in an average of 90 days, with a range of 42-187 days 2.
- The average follow-up time is around 311 days, with a range of 210-440 days 2.
- Follow-up care may involve monitoring for wound complications, such as dehiscence or infection, and assessing the patient's progress with prosthesis fitting and rehabilitation 2, 3, 4.
- Patients who undergo immediate postoperative prosthesis (IPOP) placement may have similar perioperative systemic and wound complication rates compared to those who undergo conventional BKA, but are less likely to require surgical revision 4.
Outcomes and Complications
- Wound complications, such as dehiscence or infection, are a significant concern after BKA and may be reduced with the use of NPWT 2, 3.
- Patients who undergo BKA for chronic lower extremity pain may experience improved physical health and a decrease in pain to a manageable level, despite ongoing pain in the residual limb 5.
- The need for revision surgery may be lower in patients who undergo IPOP placement compared to those who undergo conventional BKA 4.