A transfemoral amputation, also known as an above-knee amputation, is a surgical procedure to remove a damaged limb. This is most commonly performed due to traumatic injury, cancer, or vascular disease.
Surgical Steps for Transfemoral Amputation
Position the patient supine on the operating table. Use a tourniquet to control bleeding during the procedure.
Begin proximally at the expected level of bone division. Mark equal anterior and posterior skin flaps. Each flap should be at least half the anteroposterior diameter of the thigh at that level. An atypical flap is always preferable to amputating at a higher level.
Create the anterior flap with an incision starting in the middle of the medial side of the thigh at the level of the planned bone cut. The incision curves gently distally and laterally, crosses the front of the thigh at the predetermined level, and curves proximally to end on the lateral side of the thigh opposite the starting point.
Fashion the posterior flap in a similar manner.
Deepen the skin incisions through the subcutaneous tissue and deep fascia. Retract the flaps proximally to the level of the bone section.
Divide the quadriceps muscle and its overlying fascia along the line of the anterior incision. Retract it proximally to the level of the intended bone cut as a myofascial flap.
Identify the femoral artery and vein within the femoral canal on the medial side of the thigh at the level of the bone cut. Ligate and transect them individually. Incise the periosteum of the femur circumferentially and divide the bone with a saw immediately distal to the periosteal cut.
Smooth the bone edges with a sharp rasp. Also smooth the anterolateral side of the femur to reduce pressure between the bone and the overlying soft tissues.
Identify the sciatic nerve directly beneath the hamstring muscles. Ligate it well proximal to the end of the bone and transect it just distal to the ligature.
Divide the posterior muscles transversely so their ends retract to the level of the bone section, then remove the leg.
Isolate and cut all cutaneous nerves so their cut ends retract well proximal to the end of the stump. Irrigate the wound with saline solution to remove all bone dust.
Attach the adductor and hamstring muscles to the bone using non-absorbable or absorbable sutures. Place these sutures through several small holes drilled just proximal to the end of the femur. Attach the muscles under slight tension.
Release the tourniquet at this point and ensure careful hemostasis.
Bring the quadriceps apron over the end of the bone. Suture the fascial layer to the posterior fascia of the thigh, trimming excess muscle or fascia as needed for a clean, firm closure.
Insert plastic suction drainage tubes under the muscle flap and deep fascia. Bring them out through the lateral side of the thigh, 10 to 12.5 cm proximal to the end of the stump.
Close the skin edges with interrupted sutures of non-absorbable material.
References and Further Reading
Campbell's Operative Orthopaedics, 12th Edition.
Bell JC, Wolf EJ, Schnall BL, Tis JE, Potter BK. Transfemoral amputations: is there an effect of residual limb length and orientation on energy expenditure? Clin Orthop Relat Res. 2014 Oct;472(10):3055-61. doi: 10.1007/s11999-014-3630-x. PMID: 24752912; PMCID: PMC4160504.
Bell JC, Wolf EJ, Schnall BL, Tis JE, Tis LL, Benjamin KPM. Transfemoral amputations: the effect of residual limb length and orientation on gait analysis outcome measures. J Bone Joint Surg Am. 2013;95:408–414. doi: 10.2106/JBJS.K.01446. PubMed.
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