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Updated: Oct 15 2019

Below Knee Amputation

Preoperative Patient Care
Operative Techniques

Preoperative Plan


Radiographic templating


Execute surgical workthrough

  • describes the steps of the procedure to the attending prior to the start of the case
  • describe potential complications and steps to avoid them

Room Preparation


Surgical instrumentation

  • basic major orthopedic set
  • oscillating saw
  • drill
  • amputation knife
  • silk free and stick ties
  • suction drain


Room setup and equipment

  • standard OR table
  • fluoroscopy


Patient positioning

  • place patient supine
  • place small bump under ipsilateral hip to internally rotate the leg
  • place a thigh tourniquet

Mark Out Flap Incision


Mark out the tibial tubercle and the medial joint line

  • mark out tibial tubercle


Mark out anterior incison

  • mark the anterior incision 10cm distal to tibial tubercle
  • this incision is also15cm from knee joint line
  • anterior incision 2/3 total circumference


Mark the posterior incision

  • posterior incision 1/3 total circumference
  • mark out the posterior flap so that it is 1.5 times the length of the anterior flap
  • this is extremely important because it allows for redundant posterior flap upon closure
  • the posterior flap should be distal to the musculotendinous junction of the gastrocnemius
  • round out the distal ends of the posterior skin flap to reduce redundancy of skin upon closure

Anterior Soft Tissue Dissection


Dissect through underlying fascia

  • incise the entire circumference of the skin incision through the underlying fascia
  • direct the vertical incison over the anterior crest of the tibia to facilitate exposure of the anterior periosteal flap


Divide the fascia

  • identify the superficial and deep peroneal nerves
  • place gentle traction and resect nerves using sharp dissection
  • sharply dissect through the anterior compartment musculature at the most proximal end of the wound
  • this reduces bulk and makes the myodesis easier
  • identify, isolate and ligate the anterior tibial artery
  • dissect through the deep musculature

Bone Bridge(optional)


Elevate periosteum

  • elevate the perosteal flap using a single blade wide chisel
  • sharply incise the anterior and posterior margins of the anteriormedial tibia for 8 to 10 cm distally
  • raise the flap with the bevel positioned superiorly
  • protect the flap using a moist gauze sponge
  • isolate the rest of the tibia with a periosteal elevator
  • divide the interosseus membrane and identify the fibula


Osteotomize the fibula

  • prepare the fibula for the osteotomy
  • perform cut of the fibula several centimeters distal to the tibia cut
  • the proximal cut of the fibula is at the level of the distal tibia cut
  • elevate the periosteum of the fibula at this level of the cut and continue elevating for 1 cm distally


Construct bone bridge

  • cut a notch into the posterolateral tibia to house the fibula
  • secure the bone bridge with non absorbable suture through holes that are made through the lateral aspect of the fibula, through the medullary canal of the transverse fibula to the medial aspect of the tibia

Bone Transection


Mark the fibula cut

  • without a bone bridge approximately 1 cm proximal to the tibia cut at a lateral angle
  • with a bone bridge
  • measure the interosseous distance
  • distance from the lateral tibia to the media fibula
  • make fibula cut this distance plus 2 cm proximal to the tibia cut


Cut the tibia

  • use a power saw with irrigation to make the tibia cut

Posterior Soft Tissue Dissection


place a sharp amputation knife and

  • transect and taper the posterior musculature


Dissect through the deep posterior compartment and soleus

  • this is done to provide a tension free myodesis
  • this should be performed at the level of the tibial bone cut


Identify neurovascular structures

  • identify and dissect the tibial nerve from the vasculature
  • inject the nerve with 1% lidocaine then sharpy transect under gentle traction
  • identify and ligate the posterior tibial artery with ligature suture
  • ligate the veins with vasvular clips or ligature suture
  • resect remaining posterior compartment to the level of the distal tibia cut



Obtain hemostasis

  • release the tourniquet
  • obtain hemostasis of the musculature


Bevel Tibia

  • begin the bevel outside of the medullary canal at 45 degree angle
  • rasp and round out the sharp edges


Perform myodesis

  • drill holes just anterior to the bone bevel for myodesis
  • use a locking style Krackow suture through the gastroc apneurosis and secure it to the tibia
  • usually # 2 or #5 suture is used
  • place a submuscular drain
  • secure the borders of the gastrocnemius to the proximal anterior fascia


Treat intraoperative complications


Wound Closure


Irrigation & Hemostasis

  • irrigate wounds thoroughly
  • recheck for remaining peripheral bleeders


Deep closure

  • 0-vicryl for deep fascia
  • subcutaneous with 2-0 vicryl


Superficial closure

  • skin closure with 2-0 nylon (vertical/horizontal mattress)
  • do not want to overly tighten skin as this can necrosis edges


Dressing and immediate immobilization

  • soft incision dressing well padded to reduce pressure in incision
  • knee immobilizer or U-shaped splint
  • crutches or walker for ambulation
Postoperative Patient Care
Private Note

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