Limb Amputation (not tumor)

Auto Text: “Insert Amputation AKA” or “Insert Amputation BKA”

Specimens include AKA (Above the Knee Amputation) and BKA (Below the Knee Amputation). These are usually performed for peripheral vascular disease, diabetes complicated by gangrene, or trauma. Check clinical history / radiology to determine the reason for amputation and if osteomyelitis is suspected.

Triage

  1. Should be cut fresh.
  2. If received late in the day, you can store limbs in the refrigerator until the next working day. Keep the requisition on the counter so that staff knows a limb is awaiting gross examination the next day.
  3. Once grossing is complete, place the dissected limb back in original bag (if not torn) with the patient label visible. Return the limb to the refrigerator.
  4. After Hours: If the OR calls/pages after hours and asks for someone to pick up an amputation specimen, ask them to hold the specimen in the OR specimen refrigerator and send it to surgpath the following morning.

Gross

  1. Describe procedure (AKA or BKA) and note if there has been a prior amputation.
  2. If foot is present, measure length and note side (right or left).
  3. Measure length of leg.
  4. Measure length of thigh if applicable.
  5. Measure length/diameter of bone at resection margin: tibia and fibula for BKA; femur for AKA.
  6. Describe skin, soft tissue, and arteries at resection margin and submit a representative margin section.
  7. Describe and measure any skin lesions: ulceration, gangrene, missing digits, surgical incisions (including grafts and previous surgical amputation sites). Submit representative section of skin lesion(s).
  8. Dissect and serially section the popliteal (if present), posterior and anterior tibial arteries every few millimeters, looking for calcification, luminal narrowing or thrombi. Submit representative section of each.
    • TIPS for dissecting arteries: The posterior tibial artery runs behind the medial malleolus and up the leg, deep to the muscles.  Make a cut posterior to the medial malleolus, identifiy the neurovascular bundle, and continue your cut superiorly.  Or follow it distally from the popliteal artery. The anterior tibial artery runs just against the lateral surface of the tibia, deep to the muscles.  Make a deep cut along the lateral tibia and identify the neurovascular bundle.
  9. If osteomyelitis is suspected (by clinicians, by radiology, or by your gross exam), submit any suspicious bone, following fixation and decalcification. Usually this bone will be softened and/or discolored grey-green. It may be located under a skin ulcer or necrotic soft tissue.
  10. If the osteomyelitis is located in a foot or ankle bone, bone margin need not be submitted. If the osteomyelitis is located in the femur (in an AKA) or tibia/fibula (in a BKA), then bone margin should be submitted, following fixation and decalcification.
  11. If bone is submitted, state “following decalcification” to the relevant cassette(s) in the gross description and add documentation to Copath (add decal “stain” – one decal order per part is adequate).
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