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How to Perform a Below-Knee Amputation

Article in Acta chirurgica Belgica · May 2003

DOI: 10.1080/00015458.2003.11679416 · Source: PubMed


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3 authors, including:

Frank E Vermassen
Ghent University


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Technical note

Acta chir belg, 2003, 103, 238-240

How to Perform a Below-Knee Amputation

C. Randon, J. Deroose, F. Vermassen
Department of thoracic and vascular surgery, Ghent University Hospital, Belgium.

Key words. Below-knee amputation ; gangrene ; revalidation ; vascular.

Abstract. Eventhough modern techniques have improved patient survival and limb salvage rates in patients with criti-
cal limb ischaemia and end-stage vascular disease, amputation is sometimes the only possible treatment.
In younger patients with traumatic avulsion of a foot, infected gangrene of the foot or a peripheral tumour, amputation
is out of discussion and commonly accepted. In older vascular patients, amputation should rather be considered as the
starting point for revalidation and rehabilitation than as failure of a revascularization technique.
The evolution in prostheses permits a rapid revalidation in most patients. However, an accurate amputation technique is
still required to produce a good quality stump allowing early fitting of prosthetics.

Introduction Table I
HIPPOCRATE of COS (480-377 BC) described in the fifth
– Failed arterial reconstruction or inoperable arterial disease with
century B.C. amputation techniques for gangrene : “He
end-stage ischaemia and non-reconstructable arterial disease
recommended amputation of the gangrenous extremity – Acute ischaemia (thrombosis or embolism) with failed revascu-
at the joint below the boundaries of the blackening as larization
soon as it is fairly dead and has lost its sensitivity and he – Extensive tissue necrosis
advised that care must be taken not to wound the living – Infected gangrene
– Trauma
part. He recommends to wait for the demarcation line
and self amputation of the extremity” (1). CELSE (50 AC)
described in his “De Arte Medica” a flap operation Table II
where the bone must be divided at a higher level. Aims of amputation
There has been a big evolution since HIPPOCRATE, but the
basics in amputation techniques such as the indications – Removal of diseased tissue
(all referring to gangrene), the aims of amputation i.e. – Relief of pain
– Primary healing of the amputation at the chosen level
relief of pain and removal of diseased tissue and the – Construction of a stump and provision of a prosthesis that will
level of amputation above the demarcation line, all permit useful function
The primary advantage of the below-knee amputation
is the maintenance of the patient knee-joint, at least if it amputation to lower the level of an amputation. In case
is still functional and shows less than 15 % flexion con- of trauma complicated by infection or an infective gan-
tracture. This permits a better rehabilitation and ambula- grene, a two-stage operation is performed. The first
tion compared to the above-knee amputation (70% vs stage consists in an open supramalleolar guillotine
10-30%). amputation, combined to appropriate antibiotic treat-
A good psychological support is needed in all ment and irrigation with antiseptics, followed by a
patients. Active participation in decision making and below-knee amputation at a viable level 5 to 7 days later.
acceptance of the amputation as the only treatment The most challenging part of the below-knee amputa-
option is an essential criterium for a rapid revalidation tion is the determination of the level of amputation : it
afterwards. A younger person can walk without help in must be the most distal site that can heal uncompro-
6 weeks with modern prostheses and rehabilitation tech- mised. However, “no objective test can predict the
niques. However, in older patients coexisting morbidity amputation level” (2). Indeed, the experienced surgeon’s
is responsible for a mortality rate of up to 18%.
The indications and aims of amputation as mentioned —————
in Tables I and II are valid for all levels of amputations. Presented at “the third Belgian week of surgery”, may 2th,
An arterial reconstruction can be combined with an 2002, casino Knokke.
How to Perform a Below-knee Amputation 239

Table III
Critera to determine the level of amputation

– Clinical judgment (80% healing)

– Measurements of peripheral pulses at different levels (segmental
Doppler systemic pressure)
– Capillary refill time
– Rubor level
– Condition of the skin (e.g. trauma with skin laceration)
– Level of ischaemic atrophy (gangrene)
– Demarcation line
– Tumour level Fig. 1
– Angiography when a combined revascularization-amputation is skin incision for below-knee amputation

Table IV
The best known and most used technique is the long
Other level predicting tests posterior myocutaneous flap based on the underlying
– Fluorescein dye measurements gastrocnemius muscle as proposed by Burgess. The
– Laser Doppler velocimetry anterior and posterior flaps of equal length (known as
– Laser Doppler measurements of skin perfusion pressure the fishmouth flaps) and the medial and lateral myocu-
– Photoelectric skin perfusion pressures taneous flaps of equal length created through sagittal
– Isotope skin blood flow measurements (xenon 133)
incisions are valuable alternatives. The applied method
– Skin temperature measurements
– Transcutaneous oxygen measurements (tcPO2) relays on the remaining available skin.
– Transcutaneous carbon dioxide measurements (tcPCO2) In this article we describe the long posterior flap tech-
nique. Anatomically the blood supply to the posterior
flap through posterior calf collaterals in the gastrocne-
Table V mius muscle with steal of blood from the other compart-
Amputation methods ments and the soleus muscle is usually better than the
– A long posterior myocutaneous flap (Burgess and Romano)
blood supply to the anterior flap in an ischaemic leg
– The fishmouth flap (Persson) even if there is no recordable arterial pressure at the
– Skew flap (Roehampton) ankle on doppler examination. However, in practice,
– A medially based myocutaneous flap (developed in Dundee) there are no more healing problems with the fishmouth
– The circular method incision.
The skin incision is marked on the affected leg. The
level of transsection of the bone is located 10 to 12 cm
or approximately one hand breadth, including the
clinical judgment is the best predictor for a maximal thumb, below the tibial tuberositas. This incision is
viable stump length. Other methods to establish the most placed 1 cm distal to the planned level of transsection.
distal amputation level able to heal are mentioned in The anterior incision ends 2 cm medially from the tibial
Table III. Measurement of the segmental systolic pres- border. To draw the flap, one can use the 1/3-2/3
sure in diabetic patients is unreliable due to calcifica- method : 2/3 of the circumference of the leg is the hori-
tions in the distal vessels. Some additional tests are men- zontal part of the amputation and the 1/3 of the circum-
tioned in literature but they have a low sensitivity and ference is the length of the flap (Fig. 1). If any doubt,
specificity (Table IV). generous flaps are cut and retrimmed at closure.
Electrocautery should be avoided to prevent damage
Techniques to the surrounding soft tissue . The large vessels should
be ligated. Never use a tourniquet because a residual
Various techniques for transtibial amputation are haematoma can end up in an infection.
described in literature (Table V). Start on the anterior surface down to the tibia and pro-
The oldest method used for infective gangrene as long your incision medially and laterally before turning
mentioned previously is “the circular method or guillo- distally on the drawings. The saphenous vein, if still pre-
tine method“ ; the skin, the muscles and bones are cut sent, is ligated. The muscle of the anterior compartment
circular in the same plane. But due to the retraction of is sharply divided and the anterior neurovascular bundle
the soft tissues, the bone projects outwards. This opera- is ligated. The incision is prolonged through the lateral
tion is always followed by a second operation to correct compartment. The posterior and peroneal neurovascular
these errors. bundles are divided and ligated. The posterior flap
240 C. Randon et al.

noma formation. If prosthetic material is present it

should be removed. The deep muscles are transsected
just distally to the level of the tibia. Remove enough
muscle so that the end of the stump is not bulbous, this
means in most cases resection of the soleus muscle only
leaving the gastrocnemial muscle for the myocutaneous
flap. The avascular plan between the soleus and gastroc-
nemius muscle is easily identified medially and devel-
oped by blunt dissection. The soleus muscle is trans-
sected at the level of the tibia with ligation of the poste-
rior tibial vessels. At that stage, the posterior flap is
retrimmed to avoid “dog ears”.
The stump is rinsed with saline before closure to
remove clots and debris. The use of local antibiotics
shows no better result in recent literature (3). A drain is
usually not needed in an ischaemic limb, but if required,
Fig. 2 use a closed suction drain.
the long posterior flap technique The muscle fascia or aponeurosis of the posterior flap
is sewn without any tension to the anterior fascia with
interrupted absorbable sutures to avoid retraction. The
which consists of the gastrocnemial and soleus muscle is skin is closed atraumatically and without traction, to
sharply and carefully freed from its tibial and fibular avoid dehiscence, with interrupted vertical mattress
attachments. sutures and sterile tapes in between. A stump dressing is
A periosteal elevator is used to mobilize the perio- applied.
steum to a point just proximal to the site of bone divi- Mobilization of the knee joint from the first postoper-
sion. Resection of too much periosteum increases bone ative day is required to avoid deep vein thrombosis
overgrowth and sequester formation. The fibula is trans- (12.5%). The first wound control is performed after
sected 3 to 4 cm proximal to the level of tibial transsec- 48 hours. After the operation, the stump skin retracts :
tion (Fig. 2). Before transsecting the tibia check if any 1/3 of the original size of the flap (4 cm retraction in a
metallic prosthesis for fracture fixation is present. This flap of 12 cm).
should be removed. The tibial bone is transsected at a
level above the flaps but is still longer than the fibular
stump. To avoid seeding of bone dust provoking neocal- References
cifications or osteofits, a Findlay’s metal retractor or
1. VASCONSELOS E. Chapter I (1-20 ; 25-49) and Chapter V (174-181)
even a cloth compress around the stump can be used. In : Modern methods of amputation. New York : Philosophical
The use of bone wax is discouraged as it acts like a for- library, Inc., 1945.
eign body. Smooth contours of the tibial bone are creat- 2. GREENALGH R. M., JAMIESON C. W., NICOLAIDES A. N. Part II,
Chapter 9 - Investigation of critical ischemia (75-84) and Part VI,
ed with a rasp, angulated bone remnants and bony Chapters 33, 34, 35 - Major amputation for vascular disease (361-
prominences are avoided as they cause functional inca- 389). In : GREENALGH R. M., JAMIESON C. W., NICOLAIDES A. N.
pacity. The distal tibia is bevelled at the anterior cortex (eds.). Limb salvage and amputation for vascular disease.
Philadelphia : W.B. Saunders company, 1988.
at an angle of 45° to 60°. 3. ALLCOCK P. A., JAIN A. S. Revisiting transtibial amputation with the
Nerves must be divided without excessive traction at long posterior flap. Br J Surg, 2001, 88 : 683-8.
a level above the bony division to avoid neuralgia and
stump pain due to neurinoma formation at a point of
C. Randon
pressure. The vasa vasorum of the sciatic nerve are lig-
Department of thoracic and vascular surgery
ated to avoid bleeding before ligating the nerve itself. Ghent University Hospital
The nerve can be cauterized or infiltrated with alcohol De Pintelaan 185
90° (HUBER and LEWIS) or chirocaine 2% to avoid neuri- B-9000 Gent, Belgium

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