Below Knee Amputation
Sai Sajja, MD
B elow knee amputation (BKA) is the most commonly per-
formed major limb amputation. With proper patient se-
lection, primary healing can be expected in more than 90% of
patients following BKA.1 Similarly, nearly 90% of patients
with BKA have a realistic chance to ambulate with a prosthe-
sis, compared with only 25% of patients with above knee
amputation.2 The advantages of BKA accrue primarily from
the many benefits of preserving the patient’s own knee joint.
Indications and
Contraindications
BKA is indicated in patients who have infection, gangrene,
nonhealing ulcers, or severe trauma of an extent that pre-
cludes salvage of a functional foot by any of the methods
discussed in prior chapters. It is also indicated in patients
with severe peripheral vascular disease who have failed arte-
rial reconstruction or have presented with unreconstructible
disease and intractable rest pain. BKA is also sometimes per-
formed for cure or palliation of neoplastic disease, or for limb
deformities that impair overall functional status.
BKA is the procedure of choice for patients meeting the
above indications and having a good prognosis for healing
and prosthetic ambulation. BKA (rather than AKA) can be
considered in nonambulatory patients if there is a reasonable
expectation that preservation of the knee joint would im-
prove functional status (for example, by providing better bal-
ance and ability to transfer). In chronically ill, debilitated,
and/or institutionalized patients, BKA often leads to flexion
contractures of the knee, which in turn impair sitting and
transfer, and predispose to pressure ulceration. Similarly,
BKA should not be performed in patients with preexisting
flexion contracture of the knee exceeding 15°. It is also con-
traindicated in the presence of anything more than minor
ulceration or skin necrosis proximal to the ankle joint. Spas-
tic and rigid lower extremity following a stroke is also a
contraindication for BKA, as muscle spasticity will produce a
fixed flexion deformity.
Penn State Hershey Medical Center, College of Medicine of the Pennsylvania
State University, 500 University Drive, Hershey, PA.
Address reprint requests to Dr. Sai Sajja, Fellow in Vascular Surgery, Penn
State Hershey Medical Center, College of Medicine of the Pennsylvania
State University, 500 University Drive, Hershey, PA 17033-2390. E-
mail: ssajja@psu.edu
82 1524-153X/05/$-see front matter © 2005 Elsevier Inc. All rights reserved.
doi:10.1053/j.optechgensurg.2005.07.004
Technical Principles of
Below Knee Amputation
When BKA is performed for nonischemic causes, the ideal
bone length is 12.5 to 17.5 cm, depending on the patient
height. A general guideline is that 2.5 cm of bone length is
needed for each 30 cm of patient height.2 For ischemic limbs,
transection 10 to 12 cm below the joint line is recommended.
At a recommended minimum, three finger-breadths of tibia
distal to the tibial tuberosity should be preserved to enable
prosthetic fit and function. Amputation through the distal
third of the leg is not advisable, as fitting of the prosthesis
becomes more difficult, soft tissue coverage is inadequate,
and the blood supply is tenuous.
A variety of techniques have been described in the con-
struction of BKA skin flaps, including equal anterior and
posterior flaps, long posterior flaps and medial and lateral or
skew flaps.3,4 Whichever the technique employed, care
should be taken not to dissect skin and deep fascia from the
underlying muscle, at risk of compromising flap viability.
While factors such as location of previous incisions influ-
ence the choice of flap design, the long posterior flap (pos-
terior myoplasty) and skew flap techniques are the most
widely applicable. The method of equal anterior and pos-
terior flaps can be used in patients with trauma or neo-
plasm, but is inadvisable in the setting of ischemia or
diabetic foot disease.
The advantages of posterior myoplasty are the superb soft
tissue coverage and the generally good perfusion afforded by
the calf musculature. Disadvantages include the bulbous
shape of the stump in obese or muscular limbs, and the
tendency to have redundant corners (“dog ears”) that may
lead to delay in rehabilitation. The skew flap technique is an
alternative that provides improved stump contour leading to
earlier prosthetic fitting. In a multicenter randomized control
trial, Ruckley and coworkers found that both techniques are
comparable in terms of healing, prosthetic limb fitting, and
mobility.5 Similar findings were confirmed in a recent Co-
chrane database systematic review.6 The choice of incision is
usually based on familiarity with a particular technique and
personal preference. The therapeutic goal of all the tech-
niques is to produce a well-healed, pain free, and functional
stump that can be fitted with prosthesis. With the availability
of modern prosthetic techniques, a successful prosthesis can
be fitted to any well-healed BKA stump with a good func-
tional outcome.
Below knee amputation
Figure 1 Equal anterior and posterior flap method is commonly used
for nonischemic causes. The ideal bone length in this situation is
12.5 to 17.5 cm. The anteroposterior diameter of the leg at this level
is measured and equal anterior and posterior flaps are marked, each
half the diameter of the leg.
Operative Technique
Method of Equal
Anterior and Posterior Flaps
After appropriate anesthesia, the patient is positioned supine
on the operating room table. A pneumatic tourniquet can be
used to minimize blood loss. The desired length of tibia is
measured below the joint line and marked. The anteroposte-
rior diameter of the leg at this level is measured and equal
anterior and posterior flaps are marked, each half the leg
diameter (Fig. 1). The skin and deep fascia are incised along
the marked incisions. As the anterior incision is being carried
over the anteromedial surface of tibia, the periosteum is in-
83
cised to provide a reference for the level of tibial division. The
level of transection of the tibia is further marked with a bone
saw.
The muscles of the anterior compartment are divided
slightly longer than the anticipated tibial stump length. The
superficial peroneal nerve is identified coursing just beneath
the fascia of the lateral compartment and is sharply divided
after gentle traction. The anterior tibial vessels are doubly
ligated and deep peroneal nerve is sharply divided after gen-
tle traction.
The tibia is then divided with a reciprocating saw, and the
fibula is divided 1 to 2 cm shorter, using either a saw, or a
rongeur and bone cutter. Using a bone hook, the distal tibia
is pulled anteriorly and deep posterior compartment muscles
are divided 1 cm distal to the tibial section. The posterior
tibial and peroneal vessels are then identified, doubly ligated
and divided. Posterior tibial nerve is gently retracted and
sharply divided. The gastrocnemeus and soleus muscles are
divided in a tangential fashion to form a myofascial flap long
enough to reach the anterior fascia across the tibia (Fig. 2).
The anterior crest of tibia is beveled 45 to 60°. Using a rasp or
pneumatic burr, all the sharp edges of the tibia and fibula are
smoothed. The tourniquet is released and hemostasis is se-
cured. The wound is irrigated with antibiotic solution. A
closed suction drain is placed deep to the muscle flap, and
using absorbable sutures, the deep fascia of the posterior flap
is sutured to the deep fascia and periosteum of the anterior
flap. The skin is closed with interrupted nonabsorbable su-
tures.
Method of Long Posterior
Flap (Posterior Myoplasty)
The operative techniques most commonly used in patients
with ischemic limbs are the long posterior flap method pop-
ularized by Burgess and the skew flap technique reported by
Robinson.3,4 The posterior myoplasty method is well estab-
lished and is based on the principle of superior blood supply
of the posterior tissues.
The patient is placed supine on the operating table. A
tourniquet is typically not used on the ischemia extremity.
The anterior incision is marked at the chosen level (8.5 to
12.5 cm below the joint line, or 6 to 10 cm distal to the
tuberosity), and should encompass the anterior hemi-cir-
cumference of the leg. Two methods are available for deter-
mining the desired length of the posterior flap: either 2.5 cm
longer than the antero-posterior diameter of the leg at ante-
rior incision line, or one-third the circumference of the leg at
that level (Fig. 3) Once this length has been determined, the
posterior incision is marked along the posterior hemi-cir-
cumference. The medial and lateral incisions connect the
anterior and posterior ones.
The skin and deep fascia are incised, and the anterior and
lateral muscles are divided with cautery. The anterior tibial
vessels are ligated and the peroneal nerves divided sharply as
they are encountered. If not already done, the medial, lateral,
and posterior incisions are deepened through the fascia. The
posterior incision should include the tendo-calcaneus. The
tibia is now sectioned with a reciprocating saw, and the fibula
is divided one centimeter shorter.
An individual surgeon’s preferred method can be used for
84
Figure 2 After the division of tibia and fibula, the muscles of the deep posterior compartment are divided 1 cm distal to
the tibial division. The gastrocnemeus and soleus muscles are divided in a tangential fashion to form a myofascial flap
long enough to reach the anterior fascia across the tibia.
dividing the soft tissues of the posterior flap. The author
recommends the use of a long very sharp amputation knife.
With the tibia distracted anteriorly with a bone hook, and the
entire specimen on gentle caudal traction, the knife is in-
serted just along the posterior edge of the fibula. With swift
slicing motions, the path of the knife should follow a gentle
downward curve away from the fibula and toward the poste-
rior incision. The result will be a beveled posterior myofascial
flap, with more muscle thickness proximally and less thick-
ness distally (Fig. 4).
With this technique the posterior tibial and peroneal ar-
teries are transected in “uncontrolled” fashion, but blood loss
is rarely significant, and the vessels can be promptly com-
pressed once the specimen is removed. The posterior tibial
nerve will be visible on the flap, and should be distracted
distally, crushed proximally to inhibit neuroma, ligated at the
crush site with a 2-0 or 0 ligature, and then divided sharply so
that the stump retracts into the muscle mass posterior to the
tibia. Likewise, the sural nerve is identified along the distal
margin of the flap, distracted gently, ligated, and sharply
divided. The posterior flap is then sculpted to an optimal
shape and thickness.
The anterior edge of the tibia will lie directly beneath the
skin, covered only by subcutaneous fat and anterior fascia. To
avoid erosion and ulceration, the anterior one-fourth to one-
third of the tibial circumference should be re-cut with a bevel
of 45 to 60°, and the new edge thoroughly smoothed with a
rasp or high-speed pneumatic burr. The posterior flap is then
brought over the tibia and the fascial edges approximated
with a suture of choice. Drains are not usually needed for
amputations in ischemic extremities, but can be employed if
necessary. Skin is closed using interrupted nonabsorbable
sutures.
Skew Flap Method
The skin flaps are of equal length, semicircular, and are based
on a line around the limb at right angles to the long axis. The
circumference of the leg is measured at the chosen level of
S. Sajja
tibial division and skin flaps are one fourth this in length. The
anterior starting point of the incision is 2 cm lateral to the
anterior border of the tibia, over the middle of the anterior
compartment. The posterior point is half way around the
circumference. The incision is extended for about 2 cm an-
teriorly to facilitate beveling of the tibia (Fig. 5). The skin and
deep fascia are divided along the marked incisions. No at-
tempt is made to separate the deep fascia from the underlying
muscle.
Division of the anterior and lateral compartment mus-
cles and neurovascular structures is performed as de-
scribed previously. Tibia is sectioned at the chosen level
and fibula divided 2 cm proximally. It is beveled as de-
scribed previously. A bone hook in the medullary cavity
will help retract tibia anteriorly, and the soft tissues are
separated from the tibia and fibula. The length of the gas-
trocnemeus and soleus muscle flap should be at least equal
to the diameter of the leg. The muscle bulk is thinned and
some of the muscle from the medial and lateral aspects is
removed while leaving the deep fascia intact (Fig 6). After
hemostasis and irrigation, the muscle flap along with the
attached deep fascia is brought anteriorly and sutured to
the deep fascia and periosteum. The skin flaps enclose the
posterior muscle flap and are closed with interrupted non-
absorbable sutures (Fig. 7).
Postoperative Management
Many experienced amputation surgeons employ rigid
dressings, applied in the operating room to help control
postoperative edema, protect the stump and prevent flex-
ion contracture of the knee. Care should be taken to avoid
proximal constriction of the thigh. As the swelling de-
creases, a new rigid dressing may need to be applied. A
trained therapist should closely supervise prosthetic am-
bulation. After two to three weeks, elastic stump socks can
be used to further shape the stump before final prosthetic
fitting.
Below knee amputation 85

Figure 3 The incision is marked 8.5 to 12.5 cm below the joint line, or 6 to 10 cm distal to the tuberosity. It should
encompass the anterior hemi-circumference of the leg. The length of the posterior flap should be 2.5 cm longer than the
antero-posterior diameter of the leg at anterior incision line.
86 S. Sajja

Figure 4 To create the posterior flap, the author recommends the use of a long very sharp amputation knife. With the
tibia distracted anteriorly with a bone hook, and the entire specimen on gentle caudal traction, the knife is inserted just
along the posterior edge of the fibula. With swift slicing motions, the path of the knife should follow a gentle downward
curve away from the fibula and toward the posterior incision. The result will be a beveled posterior myofascial flap, with
more muscle thickness proximally and less thickness distally.
Below knee amputation 87

Figure 5 The incision for skin flaps method is semicircular and is based on a line around the limb at right angles to the
long axis. The circumference of the leg is measured at the chosen level of tibial division and skin flaps are one fourth
this in length. The anterior starting point of the incision is 2 cm lateral to the anterior border of the tibia, over the middle
of the anterior compartment. The posterior point is half way around the circumference. The incision is extended for
about 2 cm anteriorly to facilitate beveling of the tibia.
88 S. Sajja

Figure 6 The length of the gastrocnemeus and soleus muscle flap should be at least equal to the diameter of the leg. The
muscle bulk is thinned and some of the muscle from the medial and lateral aspects may need to be removed.
Below knee amputation
Figure 7 The muscle flap along with the
attached deep fascia is brought anteri-
orly and sutured to the deep fascia and
periosteum. A suction drain is placed be-
neath the muscle layer. The skin flaps
enclose the posterior muscle flap and are
closed with interrupted nonabsorbable
sutures.
Conclusions
Below knee amputation is the most frequently performed
major extremity amputation. If loss of the foot is inevitable,
every attempt should be made to preserve the knee joint so
that patients may be afforded the best opportunity to ambu-
late with prosthesis. In dysvascular extremities, the posterior
myoplasty technique has long been established as a safe and
reliable procedure with excellent functional results. Rigid
stump dressings offer considerable advantages over tradi-
tional soft dressings. An aggressive rehabilitation program
should be started early in the postoperative period with the
help of well-trained physical therapists and orthotists to
achieve functional independence.
89
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