Below knee amputation is the surgical removal of part of the leg through the tibia and fibula bones. It is indicated for conditions like trauma, peripheral vascular disease, infection, tumors, or frostbite. The Burgess posterior flap technique is commonly used. It involves making incisions to free and shape muscle and skin flaps, sawing the tibia and fibula bones, and closing the flaps over the bone end to form a stump. Postoperative care focuses on managing edema, pain, and starting early rehabilitation and mobilization.

1. HOW DO I DO BELOW KNEE
AMPUTATION

2. DEFINITION
 Amputation
 “Surgical removal of limb or part of the limb
through a bone or multiple bones”
 Disarticulation
 “Surgical removal of hole limb or part of the
limb through a joint”

3. INDICATION
 Trauma
 Peripheral Vascular Disease
 Infection
 Congenital Limb Deficiency
 Tumours
 Frostbite

4. DDD
 Dead
 Deadly
 Dam Nuisance

5. TRAUMA
 trauma is the leading indication for amputation
in younger age group
 The only absolute indication for primary
amputation is an irreparable vascular injury in an
ischemic limb.
 type IIIc with warm ischaemia more than 6hrs
 Mangled Extremity Severity Score

6. MANGLED EXTREMITY SEVERITY SCORE
<6: salvage
>7: amputation

7. PERIPHERAL VASCULAR
DISEASE
 Most significant predictor of amputation in diabetes:-
peripheral neuropathy
 decrease ankle-brachial blood pressure index
 Vascular surgery consultation

8. INFECTION
 Acute or chronic infection that is unresponsive
to antibiotics and surgical debridement
(Necrotsing Fasciitis/Ascending Infection)

9. CONGENITAL DEFICIENCIES
 failure of partial or complete formation of a
portion of the limb.

10. TUMOURS
 Advances in diagnostic imaging, chemotherapy,
radiation therapy, and surgical technique for
reconstruction now make limb salvage a
reasonable option for most patients with bone or
soft tissue sarcomas.

11. FROSTBITE
Typically occurs when one is trapped in extreme cold
conditions for extended periods
 direct tissue injury- formation of ice crystals in
the extracellular fluid
 Ischaemic injury- vascular endothelium
 wait 2-6 month demarcation

12. SURGICAL TECHNIQUE
 Position :
 patient supine with feet at the end of the bed
 sandbag under ipsilateral thigh and thigh
tourniquet
 Aproach
 Burgress Long Posterior Flap
 Skew Flap (Fish Mouth)

13.  Anatomy

15. THE BURGESS POSTERIOR FLAP BELOW
KNEE AMPUTATION
1. Incision Marking (Flap Design)

17. Anterior Flap Disection
 Skin and subcutaneous tissue are incised with
scalpel. (watchout for greater saphenous vein)
 Divide the anterolateral muscles down to the
intermuscularseptum, ligating and dividing the
anterior tibial vessels and peroneal nerves as
encountered with diathermy blade

18. Fibular Transection
 periosteum of the fibula is elevated proximally, and
the fibula is transected 1-2 cm proximal to the level of
the tibial amputation
 transection of the fibula at a higher level may result
in a conically shaped stump, which can make the tibia
too prominent and can make socket fitting difficult

19. Tibial Transection
 periosteal layer of the tibia is cut sharply 1 cm distal
to the level of the skin and elevated proximally about
1-1.5 cm
 tibia is sectioned w/ gigli saw 1 cm distal to skin edge,
& anterior cortex is beveled obliquely (45 deg)
starting proximally at the level of the skin edge distally
to the edge of the tibia

20. Posterior Flap Disection
 posterior muscle mass is sharply and carefully freed
from its attachments to the tibia and fibula distally to
the level of the posterior skin incision
 Posterior tibial artery & veins ,peroneal artery and
veins, tibial nerve are individually clamped and tied
 soleus muscle is isolated and excised, leaving the
gastrocnemius as sole muscle of the myocutaneous
flap

21. Myoplasty
 trim and tailor the posterior muscle mass to form
a flap and carry it anteriorly, suturing it to the
deep fascia and periosteum

22. Skin Closure
 Using non-absorbable tension free suture

23. POST OP PLAN
 Control of edema
 Control of Postoperative pain
 Prevention of joint contractures
 Rapid rehabilitation
 Early mobilisation

24. REFFERENCE
 Campbell’s Operative Orthopedics 11th Ed
 Wheeles Orthopedic Online