General Surgery - Below Knee Amputation

What level will the amputation be?

A below-knee amputation (BKA) is typically at the level of the calf and shin bones, and involves removing the foot, ankle and a portion of the lower leg below the knee. Your consultant will discuss this with you. The level of the amputation depends on several factors including your height, circulation (blood supply), and any problems with healing or presence of infection.

What are the risks of surgery?

All operations carry a risk of medical complications. For below knee amputations, this may include:

• Bleeding, including the need for a blood transfusion, or developing a haematoma (a blood clot) that may require a return to theatre for further management
• Wound infection
• Pain and phantom limb pain
• Risk of developing a neuroma (painful nerve endings)
• Further surgery to correct complications or help relieve pain
• Medical complications:
  ○    General anaesthetic risks (details will be discussed by the anaesthetist)
  ○    Blood clots (in the legs or lungs)
  ○    Pneumonia (chest infection)

What is phantom limb and phantom pain?

Many people who have had an amputation will experience a feeling that their leg is still there after the operation. This is a normal reaction that happens because your brain and the cut nerves still ‘remember’ the limb. These sensations may feel unpleasant or uncomfortable but may improve over time. Sometimes the sensation can feel like tingling, burning, cramping, itching or sharp shooting pain. Different medications can be tried to manage the pain. Please let the staff know if it causes you a lot of discomfort so that you can be further reviewed.

What is a neuroma?

During the surgery, some of your nerves in the limb will have been cut and try to heal itself. As it does not have anything to connect to, it may form a jumbled bundle at the end of the nerve called a neuroma. This can be painful if it is sensitive or pressed on. Not everyone develops a neuroma, and the risks of neuroma pain can be reduced with specific surgical methods.

What is targeted muscle reinnervation (TMR) and its purpose?

Targeted muscle reinnervation (TMR) is an additional procedure that can be done at the same time of your amputation if it is assessed to be suitable in your case. It involves connecting the ends of the cut nerves from the amputation to the nerves of a nearby muscle. As TMR helps to restore the nerve signals to the brain, it can help to reduce the risk of phantom limb pain and neuroma pain.

What is regenerative peripheral nerve interface (RPNI) and its purpose?

Regenerative peripheral nerve interface is another surgical technique that can be used to manage nerve pain after amputation if it is assessed to be suitable in your case. It involves wrapping the cut ends of nerves in nearby muscles. This provides a target for controlled nerve regrowth to help reduce pain and risk of neuroma formation. Your surgical team will discuss whether TMR, RPNI or a combination both would be best for you.

What will the post-operative recovery be like?

When you come back from theatre, you may feel a bit disorientated from the anaesthetic. You will be monitored closely for the first few hours after surgery and you may notice some drips and tubes attached to you, for example for fluids and medication, oxygen, pain relief and urine drainage. The wound may be covered by large dressings or bandages. You may also have a small drainage tube from your wound to remove excess fluid and blood. A nerve infusion catheter may also be present, which is a small tube giving pain relief directly to the nerves.

On the day of the operation, you will normally recover in bed. Some people may feel well enough after this to start sitting in a wheelchair, which the staff can assist you with.

What can I expect soon after the amputation?

After the amputation, you may experience some pain or discomfort around the wound which should improve as it heals. Good pain control with medications is important to help you move towards rehabilitation. Initially this can be through a machine that you can control for delivering painkillers through your veins. You may start taking painkillers by mouth regularly when you feel able to, and all your pain relief medications will be reviewed regularly by the medical staff. When you are in pain, it is important to let the staff know while you’re in hospital or the GP when you are discharged so we can ensure good pain control.

You may also feel phantom limb sensations and phantom limb pain which may improve over time. In the first few months after your surgery, it may be easy to forget that your limb is no longer there, so it is important to take care as people have been known to fall after trying to use the amputated leg.

After the amputation, it will take time for you to recover both physically and emotionally. It is natural to feel different emotions depending on your situation, such as shock, numbness, loss, grief, anger, anxiety and depression. Please share any worries you have and seek help for any ongoing difficulties so that we can support you.

What can I expect in terms of rehabilitation and artificial limbs (prosthesis)?

Throughout your stay in hospital, you will receive physiotherapy and occupational therapy. You are encouraged to mobilise as soon as possible after surgery to prevent complications like blood clots, chest infections and pressure sores. A physiotherapist will teach you exercises to reduce the risk of muscle weakness and joint stiffness. They will work alongside an occupational therapist to teach you safe ways to get in and out of bed and guide you through doing everyday activities safely like washing, dressing, using the toilet and other household tasks.

You may be able to use an artificial limb or prosthesis depending on the level of your amputation, the condition of your remaining limb, your ability to walk before the amputation and other medical conditions you may have. Every patient is different and not everyone will be able to use a prosthesis.

How do I look after my residual limb?

You are encouraged to handle and look after your residual limb which can help with your phantom limb sensation and come to terms with the amputation positively. When sitting, ensure your bottom is at the back of the wheelchair, sit upright, and shift your body weight to alleviate pressure. You should use a stump board to elevate the leg which helps with wound healing, reduces swelling and prevents stiffness and contractures. You may also be provided with a compression sock to help reduce any swelling further to encourage healing and prepare for an artificial limb if you require one.

How do I look after myself after my surgery?

Following amputation, it is important to avoid injury as it can be more difficult to keep your balance, which may lead to falls. You may find the following tips helpful:

• Make sure your home environment is safe, well-lit and clear for ease of moving around. Remove any loose rugs or cables, make sure floors are dry and avoid slippery surfaces
• Make sure your eyes are regularly tested and that you are wearing your glasses if prescribed
• Have regular check-ups with your GP to review your blood pressure and medications
• Wear comfortable, well-fitting shoes with non-slip soles
• Make sure the brakes of your wheelchair are on and that you are close enough when transferring in and out of your wheelchair
• If you have phantom limb sensations, be careful when you try to move from the bed, especially at night or when you first wake up. It may be easy to forget that you have had your leg amputated and you may try to stand on a phantom limb, leading to falls

It is recommended that you stay active, maintain a healthy balanced diet, stay hydrated, stop smoking and limit alcohol intake to maintain your health as you recover from your surgery. Please ask a member of staff if you would like support for this.