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Below Knee Amputation Video and Steps

Steps for Below Knee Amputation Surgery (Without Bone Bridge)

Following are the gross steps for doing a below knee amputation surgery, for detailed steps please check out these links ( Link1 and Link2 ) .

Marking the incision for flap using following parameters

  • Anterior incision 10cm distal to tibial tubercle
  • Anterior incision 2/3 total circumference
  • Posterior incision 1/3 total circumference
  • 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

Putting the Incision and Anterior Soft Tissue Dissection

  • Incision is deepened in layers
  • Saphenous vein is clamped and ligated;
  • Anterior incision is then carried through all tissues to bone
  • Now one can identify anterior tibial artery and veins, and deep peroneal nerve anterior to interosseous membrane; anterior neurovascular bundle can always be identified by spreading between the tibialis anterior and the EHL muscles
  • Incision is carried out thru lateral compartment, superficial peroneal nerve is identified, ligated proximally and cauterized

Transection of Fibula

  • Fibula is transected 1-2 cm proximal to the level of the tibial transection. Periosteum of the fibula is elevated proximally before transection

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, leaving a layer for suture of the posterior musculature
  • Tibia is sectioned with power saw 1 cm distal to skin edge and anterior cortex is beveled obliquely

Posterior Flap Dissection

  • 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 and the peroneal artery and veins are individually clamped and tied
  • Tibial nerve is pulled, cut proximally and allowed to retract
  • Deep muscles: tibialis posterior, FDL, FHL are transected just distal to the level of the tibia and allowed to retract;
  • Soleus muscle is isolated and excised, leaving the gastrocnemius as sole muscle of the myocutaneous flap
  • Sural nerve is pulled, cut proximally and allowed to retract


  • Drill holes just anterior to the bone bevel for myodesis
  • Use a locking style Krackow suture through the gastrocnemius aponeurosis and secure it to the tibia
  • Place a submuscular drain
  • Secure the borders of the gastrocnemius to the proximal anterior fascia

Final Steps

  • Wound is closed in layers
  • Soft dressing is applied
  • Cast is applied to immobilize the knee  to avoid a postoperative flexion contracture


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