Pearls & Pitfalls Orthobullets Technique Guides cover information that is "not testable" on ABOS Part I Preparation evaluate vascular status, wound healing potential, soft tissue injury, infection, neuropathy, and trauma standard OR table, sagital saw, and amputation knife Positioning supine with feet at end of bed bump under ipsilateral thigh and thigh tourniquet Approach anterior and posterior approaches to midshaft tibia anterior incision 10cm distal to tibial tubercle and posterior incision long enough to ensure flap coverage Limb Preparation identify anterior tibial, posterior tibial, and peroneal neurovascular bundles tie off vessels and cut nerves proximally Amputation tibial cut 2-3cm proximal from anterior skin edge with sagital saw perpendicular to bone and fibula cut 1cm proximal bevel distal tibia cut at 45° then rasp edges with saw or rasp Soft Tissue Management deflate tourniquet and coagulate or tie off any bleeding vessels need to approximate edges for even soft tissue distribution Postoperative 2 wks non-weight bearing in well padded knee immobilizer or U-shaped splint 3-6 mo fit for prosthesis and advance rehabilitation Planning & Preparation Patient Evaluation evaluate vascular status, wound healing potential, soft tissue injury, infection, neuropathy, and trauma vascular exam with Doppler (ischemic index), ABI, transcutaneous oxygen pressure, toe pressures if severe vascular dysfunction may require revascularization procedure prior to amputation wound healing potential check with nutrition labs: albumin, prealbumin, transferrin, total lymphocyte count infection check with CRP, ESR 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) documental baseline neurovascular exam traditional short BKA increases baseline metabolic cost of walking by 40% traumatic BKA 25% Imaging AP/Lat views of foot, ankle, and tibia/fibula may require MRI to evaluate extent of infection or soft tissue damage Equipment & Positioning Equipment large sagital saw amputation knife 2.5mm drill, 3.5mm cortical screws (Synthes Small Fragment Set) if Ertl osteomyoplastic procedure performed Position patient supine with feet at the end of the bed bump under ipsilateral thigh and thigh tourniquet betadine scrub and prep extremity thoroughly particularly in infection cases OR Setup standard OR table Approaches Anterior and Posterior Approaches to Tibia mark out tibial tubercle and planned anterior and posterior incisions with gradual rounded edges anterior incision 10cm distal to tibial tubercle 15cm from knee joint line anterior incision 2/3 total circumference posterior incision length long enough to ensure adequate flap coverage posterior incision 1/3 total circumference Surgical Technique Approach in infection cases do not exsanguinate limb elevate and inflate tourniquet 10blade through skin down to fascia cauterize fascia circumferentially Limb Preparation on anterior surface need to find anterior tibial neurovascular bundle tie off vessels with 2-0 silk x2 2-0 silk on needle through vessel cut nerve sharply as proximally as it goes for retraction can inject nerve lidocaine/marcaine to reduce phantom pain post-op repeat process above for posterior tibial and lateral peroneal neurovascular bundles Amputation tibial cut 2-3cm proximal from anterior skin edge with sagital saw perpendicular to bone fibula cut at least 1cm proximal to avoid skin irritation bevel distal tibia cut at 45° rasp edges with saw or rasp can perform Ertle procedure to create fibula strut Ertle osteomyoplastic technique creates a weight-bearing strut from the tibia to fibula from a piece of fibula or osteoperiosteal flap secure strut with 2.5mm drill and 3.5mm bicortical screw use amputation knife to cleanly debulk distal extremity trim posterior flap and debulk with knife to ensure adequate closure Soft Tissue Management deflate tourniquet with laps packed into wound for initial hemostasis carefully remove laps one at a time coagulate or tie off any bleeding vessels deep fascia closure with 0-vicryl need to approximate edges for even soft tissue distribution can leave “dog ears” to preserve blood supply to flap avoid excessive stripping of soft tissue as this devascularizes tissue place deep drain bluntly without sharp end to avoid injuring vessels during placement pass drain with hemostats from medial to lateral under fascia Extremity Check check limb length and soft tissue coverage Closure Irrigation & Hemostasis irrigate wounds thoroughly recheck for remaining peripheral bleeders Closure subcutaneous with 2-0 vicryl skin closure with 2-0 nylon (vertical/horizontal mattress) do not want to overly tighten skin as this can necrosis edges Dressing & Splint soft incision dressing well padded to reduce pressure in incision knee immobilizer or U-shaped splint crutches or walker for ambulation Postoperative Care 2 Weeks wound check and remove sutures place in stump shrinker and stump cast if incision healed 3-6 Months remove stump cast and fit for prosthesis advance rehabilitation Complications Document Complications wound breakdown (worse in diabetics, smokers, vascular insufficiency) superficial and deep infections recurrent infection requiring revision amputation or AKA phantom limb pain