Amputation Operative Note (Minor/Major)

Patient: [Patient name] MRN: [MRN] DOB: [DOB] Date of Procedure: [Date] Facility/OR: [Facility and/or OR number] Surgeon: [Surgeon name, credentials] Assistant(s): [Assistant name(s) and credentials] Anesthesia Provider(s): [Name(s) and role] Laterality: [Left / Right / Bilateral] Case Type: [Elective / Urgent / Emergent]

(Do not infer amputation level, laterality, cultures/specimens, drains/devices, tourniquet use, or complications. If not stated, document as "Not specified" and flag for addendum. Omit non-applicable sections rather than writing "None," unless explicitly stated.)

Preoperative Diagnosis

• [Primary diagnosis] (Problem-oriented phrasing; list in descending clinical importance.)
• [Additional diagnosis] (Include only if relevant to the procedure.)

Postoperative Diagnosis

[Same as preoperative diagnosis / Revised diagnosis reflecting intraoperative findings]

Procedures Performed

• [Primary procedure with laterality and anatomic level] (Toe: specify digit and joint level. Ray: specify which ray. TMA: state transmetatarsal. Major: specify transtibial or transfemoral with side.)
• [Additional procedures] (Include adjuncts: debridement, wound VAC placement, TMR/RPNI.)
• [Stage 1: guillotine/open / Stage 2: formalization/closure] (Include only if staged procedure.)

Indication and Level-Selection Rationale

[Indication narrative] (State primary driver: ischemia, infection, trauma, or combined; duration/course, prior limb-salvage attempts, symptoms, and functional goals. If emergent, state explicit reason.)

[Level-selection rationale] (Explain why the chosen level is appropriate based on extent of infection/necrosis, tissue viability at proposed margins, perfusion status, and feasibility of durable soft-tissue coverage. Address why a more distal level was not appropriate and why a more proximal level was not necessary.)

Consent and Safety Verification

• [Informed consent obtained; key risks discussed if stated]
• [Surgical site marked with laterality confirmed] (If applicable.)
• [Time-out performed per protocol; any variance noted]
• [Antibiotic prophylaxis: agent, dose, timing relative to incision]

Anesthesia and Positioning

Anesthesia: [General / Regional / MAC / Local / Combined]

Regional technique: [Block type and location; catheter placed: yes/no] (Include only if regional used.)

Position: [Supine / Prone / Lateral] (Include padding and limb support if stated.)

Tourniquet: [Location, pressure, total time / No tourniquet]

Operative Findings

• [Tissue viability by region: skin, subcutaneous tissue, fascia, muscle]
• [Presence/absence of purulence, abscess, necrotizing features]
• [Bone appearance if relevant: cortical integrity, bleeding bone, sequestrum]
• [Perfusion/bleeding quality at margins; arterial calcification if pertinent]
• [Condition at planned margins: viable vs nonviable; adequacy for closure]

Procedure Description

[Preparation] (Skin prep, draping, limb exsanguination if applicable, incision planning and flap design. For infected cases, note debridement-first approach and irrigation.)

Minor Amputations (Toe/Ray/Transmetatarsal)

(Include this subsection only if a minor amputation was performed.)

• [Exact level and joint: digit, MTP vs interphalangeal; ray number; or transmetatarsal level]
• [Tendon management: tendons transected or tenodesed]
• [Bone resection and contouring: method and technique]
• [Flap creation: design and rationale for coverage]
• [Closure: layered technique and materials, or if left open: packing type and staged plan]
• [Hemostasis: techniques and agents used]
• [Irrigation and debridement: volumes and solutions]

Major Amputations (Transtibial/BKA, Transfemoral/AKA)

(Include this subsection only if a major amputation was performed.)

• [Level definition: landmarks and measurements from tibial tuberosity or femoral condyles]
• [Flap design and rationale: posterior myocutaneous, skew, fishmouth, etc.]
• [Vessel control: identification and ligation of major vessels]
• [Nerve handling: traction neurectomy vs targeted procedure; nerves addressed]
• [Muscle management: myodesis vs myoplasty; muscles involved]
• [Bone management: BKA tibia/fibula lengths and relationship; AKA femoral cut and beveling]
• [Drain placement: type and location] (If used.)
• [Closure: layers and suture materials; tension considerations]
• [Dressing/immobilization: bulky dressing, negative-pressure therapy, knee immobilizer]
• [Adjuncts: additional debridement, hemostatic agents, wound VAC] (If applicable.)

Cultures and Specimens

(Include only if cultures or specimens were obtained. If none obtained in an infected-appearing case, briefly document rationale.)

• Cultures: [Anatomic source] — [Collection method: deep tissue / bone / swab], [Aerobic / Anaerobic / Both]
• Pathology specimens: [Specimen and source, laterality] — [Orientation markers if used], [Special requests: margin evaluation, osteomyelitis assessment] (Identify proximal margin specimen when relevant.)

Drains and Devices

(Include only if applicable.)

• [Drain type and location; removal criteria if specified]
• [Negative-pressure wound therapy: type, settings, dressing interface]
• [Local antibiotic delivery: type and location]

Counts and Complications

• Counts: [Correct / Discrepancy and resolution]
• Estimated blood loss: [mL]
• Tourniquet time: [Total time] (Include only if tourniquet used.)
• Complications: [None / Complication and management]

Disposition

[Patient condition at case end], [Destination: PACU / ICU / Ward], [Weight-bearing status]

Postoperative Plan

• Wound care: [Dressing type; change schedule; VAC change plan if applicable]
• Drains: [Removal criteria and timing] (If applicable.)
• Limb positioning: [Elevation; contracture prevention measures]
• Antibiotics: [Prophylaxis vs treatment; agent(s), route, duration or per ID guidance]
• Pain management: [Multimodal plan; regional catheter plan if placed]
• VTE prophylaxis: [Mechanical and/or pharmacologic]
• Activity and weight-bearing: [Status, restrictions, limb protection]
• Therapies: [PT/OT consult and mobility goals; PM&R or amputee rehab consult]
• Prosthetics: [Consult timing and next steps]
• Follow-up: [Clinic/wound check timing]; [Return precautions: fever, bleeding, worsening pain, concerning drainage]

Signature

[Surgeon name, credentials] — [Date and time]