Townsend Courtney M.Jr., Evers B. Mark. Atlas of General Surgical Techniques: Expert Consult

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1032 Section XIII • Amputations

2. DISSECTION

◆ Divide the anterior compartment with an amputation knife, down to the interosseous

membrane, taking care to ligate the anterior tibial artery (Figure 93-2).

◆ Expose minimal lengths of tibia and ﬁ bula with periosteal elevation, because this compro-

mises the blood supply to bony segments.

CHAPTER 93 • Below-Knee Amputation 1033

Division of anterior compartment

muscles and ligation of the anterior

tibial neuromuscular bundle along the

interosseous membrane

FIGURE 93 –2

1034 Section XIII • Amputations

◆ Divide the tibia and ﬁ bula using a bone saw and beveling the anterior surface, taking the

ﬁ bula more proximally, because this will not be a weight-bearing component of the amputa-

tion stump (Figures 93-3 through 93-6).

Fibula cleared of adjacent tissue and

periosteum with elevator and

divided 1-2 cm proximal from

division line of tibia

FIGURE 93 –3

CHAPTER 93 • Below-Knee Amputation 1035

Beveling the anterior tibia to reduce

a pressure point on skin flaps

FIGURE 93 –5

FIGURE 93 –4

Division of tibia with Gigli saw

Proximal soft tissue flap

protected behind retractors

1036 Section XIII • Amputations

Final inspection for hemostasis

of marrow cavity

FIGURE 93 –6

CHAPTER 93 • Below-Knee Amputation 1037

◆ Identify and ligate posterior compartment vessels short of the wound (Figure 93-7).

◆ Similarly, identify and strip nerves short, and allow retraction to prevent neuromas in the

closed wound.

Posterior tibial vessels are

ligated individually between clamps

FIGURE 93 –7

1038 Section XIII • Amputations

◆ Use the amputation knife to divide the posterior compartment between the level of

dissection and the tip of the posterior ﬂ ap (Figure 93-8).

3. CLOSING

◆ Use absorbable sutures to approximate the fascia of the muscle posteriorly to the pretibial

fascia, closing the deep structures (Figure 93-9).

◆ Close the skin with either surgical staples or nonabsorbable sutures (Figure 93-10).

◆ Closed-suction drains may be used at the discretion of the surgeon.

Creation of posterior flap

accomplished by dividing the

muscles flush with the skin incision

FIGURE 93 –8

CHAPTER 93 • Below-Knee Amputation 1039

Closure of skin with surgical

staples or sutures

Assistant aids in closure by

approximating skin flaps

FIGURE 93 –10

Closure of muscles

by approximation of

investing fascia over

tibia

FIGURE 93 –9

1040 Section XIII • Amputations

STEP 4: POSTOPERATIVE CARE

◆ Use posterior knee extension splints to keep the knee joint in extension for use in

prosthesis (Figure 93-11).

◆ Use “stump shapers” or elastic wraps to shape the amputation stump into a cone shape to

facilitate prosthetic socket ﬁ tment.

◆ Skin sutures or staples are typically left in place for extended periods of time to allow the

wound to adequately heal.

Elastic bandage applied over plastic splint

with knee in full extension and tapered to

cone shape at tip of stump

FIGURE 93 –11

CHAPTER 93 • Below-Knee Amputation 1041

STEP 5: PEARLS AND PITFALLS

◆ Creation of a posterior ﬂ ap initially with excess tissue allows the surgeon to trim and tailor

the ﬂ ap, removing redundant tissue and providing adequate soft tissue coverage.

◆ When the patient is ambulating on the below-knee amputation stump, the socket is typi-

cally designed to not bear weight on the distal tip of the tibia but to distribute the load over

a large area below the knee.

SELECTED REFERENCE

1. Lower-extremity amputation for ischemia. In Wilmore D, Cheung LY, Harken AH, et al (eds): ACS

Surgery Principles & Practice. New York, WebMD, 2002, pp 934-956.