HS317b - Coding and Classification of Health Data
Injury, complication, poisoning
Class Discussion
Admitting diagnosis
ischaemic right leg
Discharge diagnosis
same
This gentleman was admitted with gangrenous ischaemic changes in his right foot and underwent
ileofemoral bypass in July. He unfortunately returned postoperative with a failed graft and a
right groin infection. He required a below knee amputation which unfortunately got infected.
He then had a right above knee amputation which again got infected and the wound dehisced.
This required revision.
He had a prolonged stay in hospital with physiotherapy and mobilization issues. At one point
three days after the second operative episode he experienced abdominal bloating and pain. CT of
the abdomen showed an ileus. Nasogastric tube was inserted for drainage and he was kept on
clear fluids. This cleared up. He did become MRSA positive while in hospital. We were
eventually able to get him strong enough to be discharged. At the time of discharge the wounds
were healing nicely.
Below knee amputation; debridement of right groin incision.
Patient was placed under general anesthesia. His right leg was prepped and draped in the usual
sterile fashion. The skin incision was carried out and then the electrocautery was used for the
major of the amputation. We divided the fascia and the anterior muscle compartments. First we
divided and then suture ligated the anterior tibia vessels. We then came down on the fibula and
cleared this off approximately 2 cm proximal to the skin incision. We then cut the fibula with a
large bone cutter. Following this, we began to develop our posterior flap on the lateral aspect of
the leg. We then came medially, cleared off the tibia just proximal to the skin incision and then
began to divide the medial muscle bellies and down to begin constructing our myocutaneous
flap. Following this, we identified and divided and suture ligated the tibioperoneal trunk. We
then divided the tibia using the saw. This went without incident. Following this, we completed
our posterior myocutaneous flap bevelling the muscle towards the distal skin incision. This went
well. The leg was removed and haemostasis was obtained. The wound was irrigated and then
the fasica and skin closed.
We then turned our attention to the right groin where we with a combination of sharp and blunt
dissection debrided old necrotic tissue and scar tissue from the breakdown of his groin incision.
We packed this with saline soaked gauze and applied pressure dressing.
Pathology: peripheral vascular disease and ischemic necrosis
Right above knee amputation: patient has general anesthetic. His right leg and groin were
prepped and draped in usual manner. We debrided his right groin of muscle and soft tissue back
to healthy bleeding tissue and then packed the wound with saline soaked gauze. We then
performed above knee amputation. Fish mouth incision was made just a few centimetres above
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HS317b - Coding and Classification of Health Data
Injury, complication, poisoning
the upper aspect of the patella. We came down on to the femur anteriorly and then came through
muscle laterally to the apex of the incision. We did this similarly on the medial aspect. We
identified and divided his in-situ vein graft which was still patent. This was oversewn. We
identified his above knee popliteal vessels and these were suture ligated and divided with 0
Vicryl ligature. We then divided the bone after elevating the periosteum up proximally under the
distal aspect of the skin flap. Bone was divided using electric saw. Following this, we
completed our posterior flap and bevelled the myocutaneous flap towards the skin edge distally.
Haemostasis was ensured and wound closed in the usual manner.
Pathology: atherosclerotic peripheral vascular disease with necrotizing inflammation.
Revision of above knee amputation
Under anesthesia fish mouth incision was then made in the upper thigh and incision was taken
down to fascia which was divided. Muscle was divided, taking this down to femur which was
cut high with a saw. Vessels were controlled appropriately. Muscle was well vascularized and
we were certainly above any level of infection. Posterior flap was then completed with
electrocautery. Hemostasis was secure and muscle was closed over the end of the femur.
Dressing applied.
Pathology: atherosclerotic peripheral vascular disease with necrotizing inflammation.
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