Lower Extremity Amputation (BKA / AKA)

CPT 27880
Approach Open
Add-on / Variant CPTs
  • 27882 — Amputation, leg, through tibia and fibula, open (guillotine)
  • 27590 — Amputation, thigh, through femur (above-knee)
  • 27592 — Amputation, thigh, open (guillotine)
Preoperative Diagnosis:

Right [left] lower extremity [critical limb ischemia / gangrene / non-healing wound / necrotizing infection] not amenable to revascularization — [below-knee / above-knee] amputation planned

Postoperative Diagnosis:

Same

Procedure Performed:

Right [left] [below-knee (transtibial) / above-knee (transfemoral)] amputation

Attending Surgeon:

[Attending name], MD/DO

First Assistant:

[Resident/PA name]

Anesthesia:

General endotracheal [/ spinal]

Indications:

The patient is a [age]-year-old [male/female] with [critical limb ischemia / non-reconstructible vascular disease / infected gangrene / necrotizing infection] of the right [left] lower extremity not amenable to revascularization, presenting for [below-knee / above-knee] amputation. Vascular surgery evaluated the patient and determined the level of amputation. The risks, benefits, and alternatives were discussed and informed consent was obtained.

Findings:

The limb demonstrated [gangrene / tissue loss / infection / non-viable tissue] to the level of [toes / midfoot / ankle / calf]. Skin and subcutaneous tissue at the planned amputation level were [viable / well-perfused / consistent with adequate healing potential]. [Pulse oximetry / TcPO2 / skin perfusion pressure] at the planned level was [X] mmHg [suggesting adequate healing potential].

Description of Procedure:

[BELOW-KNEE (TRANSTIBIAL):]
The patient was positioned supine. The right [left] leg was prepped and draped. Anterior and posterior skin flaps were marked [or a long posterior flap was designed]. The anterior flap was created at the planned tibia transection level. The posterior flap was made longer to provide adequate soft tissue coverage.

Skin and subcutaneous tissue were divided with electrocautery. The muscles of the anterior compartment were divided. The tibia was divided with a [Gigli saw / oscillating saw] at the planned level. The fibula was divided [1.5–2 cm proximal to the tibial level] with a [nibbler / oscillating saw] and the cut end was beveled. The posterior compartment muscles (gastrocnemius, soleus) were divided to create the posterior myocutaneous flap. Major vessels (anterior tibial artery, posterior tibial artery, peroneal artery) were doubly ligated and divided. The tibial and peroneal nerves were pulled gently, ligated, and divided proximally to allow the nerve ends to retract from the stump.

The tibial crest was beveled with a rasp. The posterior myofascial flap was brought anteriorly and secured to the anterior fascia with [0-Vicryl] interrupted sutures. Skin was closed with [staples / interrupted nylon]. A [soft dressing / rigid cast / compression wrap] was applied.

[ABOVE-KNEE (TRANSFEMORAL):]
Anterior and posterior skin flaps were created at the planned femoral transection level. Muscles were divided with electrocautery. The femur was divided with an oscillating saw. Major vessels (SFA/popliteal) were doubly ligated. The sciatic nerve was ligated and divided to allow proximal retraction. The adductor muscles were secured to the femoral periosteum (myodesis) [or myoplasty performed]. Skin closed with staples.

Complications:

None

Specimens:

Amputated limb sent to pathology [and microbiology for cultures if infected]

Estimated Blood Loss:

[X] mL

Drains:

None / [JP drain in wound]

Disposition:

The patient tolerated the procedure well and was taken to the PACU in stable condition. Rehabilitation medicine was notified for prosthetic planning.

Epic SmartPhrase Version 
PREOPERATIVE DIAGNOSIS: *** lower extremity *** — *** amputation planned
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: *** [BKA/AKA]
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: ***

INDICATIONS: .PTAGE-year-old .PTSEX with *** not amenable to revascularization. Level selected based on ***. Consent obtained.

FINDINGS: Tissue viability at planned level: ***. Perfusion: ***.

PROCEDURE:
Supine. *** leg prepped and draped. [Anterior/posterior flaps OR long posterior flap] designed. Skin and fascia divided. Muscles divided. [Tibia divided at *** level, fibula 1.5 cm proximal, fibula beveled / Femur divided at *** level]. Vessels doubly ligated and divided. [Tibial and peroneal nerves / Sciatic nerve] ligated and divided proximally. [Tibial crest beveled / Myodesis performed]. Posterior flap brought anteriorly, secured with 0-Vicryl. Skin closed with ***. Dressing applied.

EBL: *** mL
SPECIMENS: Amputated limb to pathology
COMPLICATIONS: None
DISPOSITION: PACU, stable. Rehab notified.

Signed: .ME, .MYDEGREE
.TODAY
Variants

Open Guillotine Amputation (Damage Control)

Given [sepsis / hemodynamic instability / grossly infected limb], an open guillotine amputation was performed as a damage control procedure. The limb was amputated at the planned level with perpendicular division of all soft tissues and bone. Vessels were ligated. The wound was left open and packed. A formal revision with stump closure will be performed at a planned second operation after source control and resuscitation.

Charting Tips
  • Document the amputation level selection rationale. TcPO2 >30 mmHg or skin perfusion pressure >40 mmHg at the planned level predicts adequate healing. Document any objective perfusion measurements used to guide level selection.
  • Document nerve management. Specifically note that the nerves were ligated and divided under traction to allow the cut ends to retract proximally away from the stump. Inadequate nerve retraction leads to neuroma formation and chronic stump pain.
  • For diabetic/infected limbs, document cultures sent from the amputated specimen and any intraoperative findings consistent with osteomyelitis. This guides post-operative antibiotic duration and affects whether bone cultures were taken.
Billing Tips
  • BKA (transtibial): 27880 (open/guillotine, 14.99 wRVU) or 27882 (with immediate prosthetic fitting, 9.55 wRVU). Open guillotine amputations followed by delayed closure: bill 27880 for the initial, then 27884/27886 for the revision/closure.
  • AKA (transfemoral): 27590 (open, 13.13 wRVU) or 27592 (closed flap, 10.71 wRVU). Document whether performed open or with flap closure; revision uses 27594/27596.
  • Through-knee amputation: 27598 (10.94 wRVU). Use for true knee disarticulation, not BKA or AKA.
  • Foot/midfoot amputations: 28800 (Lisfranc/midfoot, 8.57 wRVU), 28805 (transmetatarsal, 12.39 wRVU). Document level of transaction through the operative note.
  • Revision/re-amputation: 27882/27884/27886 cover revision of a prior amputation stump. Document the prior level and reason for revision (wound failure, infection, bone overgrowth).
  • Global period is 90 days. Post-op wound care, stump revision, and rehabilitation referral within 90 days are bundled. Re-amputation within the global uses modifier -78.
  • Document indication (CLTI, infection, trauma), level selection rationale, tissue viability assessment, bone level (cm from joint), and method of flap closure. All affect DRG grouping and quality metric reporting.