Right above-knee amputation for Fontaine stage IV peripheral arterial disease (PAD)

Make a fishmouth incision down to the muscle fascia at the transition from the middle to the distal third of the thigh. Divide the great saphenous vein between ligatures (not shown in the video). Insert the amputation knife laterally at the angle of the incision, down to the femur, passing anteriorly around the femur and exiting medially at the posterior border of the quadriceps. Fashion the anterior skin-muscle flap in a matter of seconds by transecting the musculature anteriorly along the incision with the amputation knife. In doing so, manually pre-stretch the quadriceps.

Tips:

1. The interface between the anterior and posterior flaps is formed by the medial and lateral margins of the quadriceps muscle.

2. Short incisions ("hacking") compromise wound healing. Transection should be rapid and smooth, as a swift, targeted approach results in low blood loss.

3. If necessary, mark the incision line; centre the angle of the fishmouth on the femur.

Locate the femoral vessels medially.

Tip:

If the superficial femoral artery is still partly patent, dissect the femoral vessels and secure them with a suture ligation before dividing the musculature. A suture ligation is not necessary if the vessels are already obliterated because of the underlying disease, as in the video.