This course provides you the practical knowledge for an individual surgical procedure.
- a clear understanding of the steps to be taken to execute the procedure;
- seen an example of how the procedure is executed;
- a clear understanding of all anatomical structures encountered during the procedure;
- seen an example of how the anatomical structures look within the setting of the procedure.
Step by step
Mark the medial joint line, the patella, the tibial tubercle and the lateral joint line. Then mark the skin both lateral and medial about 15 cm under the joint line (10 cm from tibial tubercle). The length of the posterior flap should be half the circumference of the limb from the heretofore mentioned marking + 3 cm. Mark the medial and lateral endpoints of the posterior flap distally. Then draw a line from medial to lateral connecting the two incision marks. Finally connect the two marking points on the lateral and medial side longitudinally .
Incise the skin following the previously made markings.
Length posterior flap
Make the posterior flap slightly longer than necessary so that it may be trimmed at the time of closure.
Incise the subcutaneous tissue to the level of the muscle fascia to expose the anterior and lateral compartment muscles.
Great saphenous vein
Identify the great saphenous vein, which is positioned on the medial side and anterior to the deep fascia.
Transect the great saphenous vein.
Identify the saphenous nerve running in close proximity to the great saphenous vein.
Transect the saphenous nerve.
Transection of a nerve
Transect a nerve as proximal as possible while keeping it under traction. This reduces the chance of neuromas and pain development.
Anterior and lateral compartments dissection
Fascia of anterior compartment
Incise the fascia of the muscles in the anterior compartment.
Anterior and lateral compartment muscles
Identify the anterior and lateral compartment. The anterior compartment consists of the tibialis anterior, the extensor hallucis longus, the extensor digitorum and the peroneus brevis muscles. Lift the anterior and lateral compartment muscles with a clamp.
Transect the anterior and lateral compartment muscles.
Superficial peroneal nerve
Transect the superficial peroneal nerve.
Anterior neurovascular bundle
Identify the anterior neurovascular bundle. It consists of the anterior tibial artery and vein and the deep peroneal nerve.
Anterior neurovascular bundle identification
The anterior neurovascular bundle can always be identified by dissecting between the tibialis anterior muscle and the extensor hallucis longus muscle.
Transect the anterior tibial artery and vein. The deep peroneal nerve should be isolated and transected.
Dissect and separately ligate the large arteries and veins. This prevents the development of arteriovenous fistulas and aneurysms.
Fibula and tibia transection
Transect the interosseous membranes between the fibula and tibia for a few centimeters.
Transect the fibula 1 cm proximal to the level of the tibia.
Skin irritation prevention
Cut the fibula bone at least 1 cm proximal to the tibial bone to avoid decubitus. A higher level may result in a conically shaped stump with an over-prominent tibia what could make socket fitting difficult.
Dissect the periosteum because this is where the fascia of the gastrocnemius will be attached to later on.
Transect the tibia with a sagittal saw at the level, or a little proximal, of the skin. The first centimeter perpendicular to the bone. Now 1-2 cm proximal to this level create a perpendicular precut and subsequently saw in a 45 degree direction to the first cut. Continue with a transverse cut to finalize the transection.
The saw must not be able to come in contact with the proximal skin to avoid skin damage.
Posterior flap dissection
Tibia and fibula
Dissect along the posterior side of the tibia and the fibula to the level of the posterior skin incision.
Muscles deep and superficial compartment
Transect the muscles of the deep and superficial compartments at the level of the skin incision of the posterior flap.
Identify the peroneal artery and vein running posterolateral.
Transect the peroneal vessels.
Posterior tibial neurovascular bundle
Identify the posterior tibial neurovascular bundle posteromedially which includes the posterior tibial artery, vein and tibial nerve.
Transect the posterior tibial vessels and the tibial nerve as proximal as possible.
Deep posterior compartment muscles
Transect and remove the tibialis posterior, the flexor digitorum longus and the flexor hallucis longus.
Transect the soleus muscle to the level of the gastrocnemius.
The posterior myofascial cutaneous flap can survive very well with the gastrocnemius muscle if its fascia is carefully preserved.
Lesser saphenous vein
Identify the lesser saphenous vein running posteriorly.
Transect the lesser saphenous vein.
Identify the sural nerve running in close proximity to the lesser saphenous vein.
Transect the sural nerve as proximal as possible.
(In case a tourniquet is used, deflate tourniquet and check if initial hemostasis is obtained).
Rasp the tibia to minimize damage caused by sharp edges.
Check whether the posterior flap length is sufficient.
Use a drain on indication. A stump can be drained by a closed suction drainage positioned deep in the muscle flap and brought out laterally through the skin 10 to 12 cm proximal from the stump.
Approximate the fascia to the tibial periosteum with mattress sutures.
Do not separate the muscle from the fascia to prevent ischaemia of the skin flap.
Close the subcutaneous tissue with absorbable braided sutures.
Close skin with tension-free interrupted monofilament vertical mattress sutures to reduce tension on the skin or surgical staples. Avoid dog ears, and when they do occur a correction should be performed.
Bandage the end of the stump.
Leave the bandage on the stump for 3-5 days to prevent oedema.
- Tibial Tuberosity
Muscles and tendons
- Tibialis anterior
- Extensor hallucis longus
- Extensor digitorum longus
- Peroneus brevis
- Tibialis posterior
- Flexor digitorum longus
- Flexor hallucis longus
- Deep Fascia of Leg
- Great Saphenous vein
- Anterior tibial artery
- Anterior tibial veins
- Peroneal artery
- Fibular veins
- Posterior tibial artery
- Posterior tibial veins
- Short saphenous vein
- Saphenous nerve
- Superficial peroneal nerve
- Deep peroneal nerve
- Tibial nerve
- Sural nerve
The surgical objectives of the transtibial leg amputation are to completely remove the foot.
Indications for the procedure include severe trauma to the limb, poor blood flow to the limb, severe and ongoing infections, tumors, severe burns or frostbite and loss of function.  After severe trauma, a transtibial leg amputation may be advocated to prevent further complications (sepsis, infection, severe bleeding) or in the case of a poor functional outcome following pathology. 
Poor blood supply to the leg could cause infarction and/or necrosis, resulting in gangrene of the leg. Both microangiopathy caused by diabetes mellitus or macroangiopathy caused by peripheral atherosclerosis can be the underlying pathophysiology. 
Severe and ongoing infections may also be an indication for an amputation. Initially the treatment of infections is tried conservatively,with appropriate wound care and antibiotics. If conservative treatment fails, the infection may spread rapidly, resulting in sepsis. An amputation may be inevitable in this case. 
Severe burns or frostbite may result in the damage and death of vital tissue leading to an inevitable amputation, performed above the level of the necrotic tissue.
If clinically feasible, amputations below the knee are preferred over knee disarticulations or amputations above the knee due to their advanced functional outcomes. There are no conclusive studies on which surgical technique for an amputation below the knee gives the best results regarding the healing of the stump and the prosthesis for maximum rehabilitation potential. 
The following approaches for a lower leg amputation can be used:
Long posterior flap approach: a long posterior flap is subsequently brought up and sutured to the anterior tibial side over the transected bone. The long posterior flap approach is the preferred approach.
Skew flap approach: the skin flaps are equally skewed creating an anteromedial and posterolateral flap, with a muscle flap remaining in between. The posterior muscle flap is positioned anteriorly over the bone. The skin flaps are approximated and sutured thus closing the wound.
Sagittal approach: two semicircular flaps are created medially and laterally to the knee and are subsequently sutured over the transected bone.
Medial approach: a long medial flap is created, which is positioned laterally over the transected bone.
- The Vascular Society of Great Britain and Ireland. Quality improvement framework for major amputation surgery. 2010. Vascular Society of Great Britain and Ireland.
- Lower limb peripheral arterial disease: diagnosis and management: National Institute for Health and Clinical Excellence. August 2012.
- Norgren L, Hiatt WR, Dormandy JA, et al.; on behalf of the TASC II Working Group. Inter-society consensus for the management of peripheral arterial disease (TASC II). J Vasc Surg 2007; 45(1): S5a–S66a.
- The Rehabilitation of Lower Limb Amputation Working Group, Department of Veterans Affairs and Department of Defense. VA/DoD clinical practice guideline for rehabilitation of lower limb amputation. Version 1.0, 2007.
- Cochrane review. Type of incision used for below knee amputation to create a skin flap that maximises healing. April 2014.
INSTRUMENTS AND MATERIALS
A basic surgical set is required for this procedure, as well as a sagittal saw/bone cutter. A tourniquet is optional. The benefits of a tourniquet include decreased blood loss during the procedure and a shorter operating time. The disadvantage, however, is that already compromised circulation becomes more compromised.
The patient is placed in a supine position.
Infected or necrotic areas should be isolated using a mechanical barrier, such as a surgical glove, plastic sleeve or adhesive skin drapes preoperatively to minimize the chance of stump infection.
Besides general complications, specific complications can occur in a transtibial leg amputation, such as stump and wound complications, phantom pain and flexion contractures. Wound healing complications after a transtibial leg amputation are important because in some cases these determine a patient’s ability to walk with a prosthetic limb. 
A hematoma of the stump acts as a focus for infection. It may cause increased tension in the wound resulting in ischemia of the skin and subsequent delayed wound healing.
Stump edema is usually caused by bandage which is applied too tightly. It may cause pain and could result in delayed wound healing. It is treated by elevating the leg and redressing the wound so it is less tight thereby reducing tension.
Ischaemia of the skin at the incision line is commonly caused by too much tension on the skin edges or a wrong estimation of the viability of the flaps before the surgery. This can result in wound dehiscence soon after surgery or even skin necrosis in the non-viable areas several weeks postoperatively.
Surgical site infection is a very common complication postoperatively. Necrosis which has not been completely resected can lead to severe progressive infections. Hypoxic conditions can promote the growth of anaerobes resulting in sepsis.
Postoperative phantom pain usually improves within the first few weeks after surgery. When pain persists beyond this period it may be a sign of ischemia or ongoing infection of the stump, pressure points, neuroma formation and when all other causes have been ruled out phantom pain may be considered/diagnosed.