1. BELOW KNEE (TRANSTIBIAL)
AMPUTATION

2. OUTLINE
 INTRODUCTION
 EPIDEMIOLOGY
 RELEVANT ANATOMY
 CLASSIFICATION
 INDICATIONS
 LEVEL OF AMPUTATION
 PREOPERATIVE PREPARATIONS
 INTRAOPERATIVE PROCEDURE

3.  POSTOPERATIVE CARE/REHABILITATION
 COMPLICATIONS
 PROSTHESIS
 SITUATION IN OUR SUBREGION
 CONCLUSION

4. INTRODUCTION
 Amputation is the surgical removal of a limb or part of a limb
by cutting through the shaft of the bone.
 It is the most ancient surgical procedures. Early surgical
amputation was a crude procedure by which a limb was
rapidly severed from an unanaesthesized patient,the open
stump was crushed or dipped in boiling oil to obtain
haemostasis.

5.  Hippocrates 1st to use ligature which was lost during the dark
ages.
 1529:Pare reintroduced it & artery forceps.
 1674:Morel introduced tourniquet.
 With the introduction of general anaesthesia & antiseptic
technique in the late 19th century surgeons could now fashion
a functional stump.

6. EPIDEMIOLOGY
 More than 300,000 patients with amputations live in the U S
according to NCHS and about 65,000 amputations are
performed annually.
 >90% of amputations performed in western world are
secondary to PVDx.
 In younger patient trauma is the leading cause followed by
malignancy.
 1965, AK : BK = 70 : 30

7.  1980, AK : BK = 30 : 70.
 In FMC Owerri,41 BKA were done in the last 2years with M
: F = 1.7 : 1.
 Diabetic foot gangrene 88%, Trauma & TBS 5% each, others
2%

8. RELEVANT ANATOMY

9. CLASSIFICATION
 1) Emergency or Elective.
 2)Provisional or Definitive.
 3)End bearing or Non end bearing.

10. INDICATIONS
Colloquially 3 D’s
 Dead (or Dying)  Dangerous limb
 Gangrene  Malignant tumours
 Peripheral Vascular disease  Osteosarcoma
Atherosclerosis  Marjolins ulcer
Embolism  Melanoma
DM  Potentially lethal sepsis
 Crush Injury
 Damn Nuisance
Severe Trauma
 Pain
Burns
 Gross malformation
Frost bite  Recurrent Sepsis
Bone setters gangrene  Severe loss of function
 Madura foot
 Elephantiasis

12. LEVEL OF AMPUTATION
 Determined by : a) Disease process b) Viability of tissues and
c) Prosthesis available.
 Determination of adequate blood flow: Clinical : i.)
lowest palpable pulse ii.)skin colour and
temperature iii)bleeding at surgery
Others :
.Doppler ultrasonography: Ankle : brachial index > 0.5.

13.  Compression pressure at the calf >65mmHg.
 Transcutaneous oxygen measurement >40mmHg.
 Skin perfusion pressure measurement by infrared
thermography or laser doppler flowmetry.
 Too short a stump may tend to slip out of prosthesis. Too long
a stump may have

14. inadequate circulation & can become painful or ulcerate.

15. PREOPERATIVE PREPARATION
 Assessment and resuscitation
 Investigate & address co-morbid conditions in consultation
with physicians, Anaesthetists &
Physiotherapist(multidisciplinary).
 FBC, FBS, Se/u/c, urinalysis, chest x-ray, ECG, serum
albumin(>3.5g/dl).
 Informed consent –pathology, inevitability of amputation,
complications, availability of prosthesis

16.  Determine the level of amputation. Goal of the
surgeon is to: a)Find a place where
healing is mostly to be complete.
b)To have an ideal stump for prosthesis fitting.

17. QUALITIES OF AN IDEAL STUMP
 1)Should heal adequately.
 2)Should have rounded, gently contour with adequate muscle
padding.
 3)Should have sufficient length to bear prosthesis.
 4)Should have thin scar which does not interfere with
prosthetic function.
 5)Should have adequate adjacent joint movt.

18.  6)Should have adequate blood supply.

19. INTRAOPERATIVE PROCEDURE
 ANAESTHESIA : GA/Spinal
 POSITION : Supine
 PREINCISION : prophylactic antibiotics, exsanguinate,
tourniquet, skin prep & draping.
 PROCEDURE: .An
incision to outline a long posterior flap & a short anterior
one --- combined length 1 ½ times the diameter of the leg at
the level of amputation.

20.  Deepened to the bone. Periosteum raised.
 Section tibia at level of incision, bevel anterior surface.
Fibular 2-3cm proximally. Smoothen round sharp margins.
 Vessels isolated and double ligated,Nerves pulled down & cut
with a sharp knife & allowed to retract into the soft tissue.
 Irrigation with N/S, Removal of tourniquet to meticulously
secure haemostasis.

21.  Myoplasty or Myodesis done over a drain after trimming the
muscle to size.
 Close skin with interrupted non absorbable sutures.
 Wound dressing- soft or rigid.

24. POSTOP CARE/ REHABILITATION
 General care: Control of pain, prevention oedema,
prevention of infection, DVT prevention, care of concurrent
medical conditions., Suture removal.
 Physiotherapy: Muscles exercised, joints kept mobile,
patients taught how to use crutches & prosthesis.

25.  Stump dressing: .Soft
dressing: gauze, cotton wool, bandage. Teach patient or
relative stump bandaging. .Rigid dressing: POP cast
can be used with stump socks & padding. A jig could be
applied that allows attachment and alignment for early pylon
use where limited weight bearing with BAC is possible.

26.  Cast changed every 5-7 days for skin care. Within 3-4 wks
rigid dressing can be changed to a removable temporary
prosthesis.
 Benefits: a)prevention of oedema b)enhanced
wound healing c)early maturation of
stump d)decreased post op pain
e)allow early ambulation f)position
stump to avoid contracture

28.  Rehabilitation of the patient is a multidisciplinary approach.
 Aim is to bring the patient to an optimum of physical ,
mental, emotional, social, vocational, & economic efficiency.

29. COMPLICATIONS
 Early
 Haemorrhage
 Haematoma
 Infection
 Late
 depression
 Stump ulceration
 Flap necrosis
 Painful scar
 Phantom limb
 Phantom pain
 Joint stiffness
 Osteomyelitis
 Osteoporosis & tendency to fracture

30. PROSTHESIS
 Is the substitution of a part of the body to achieve optimum
function. Eg BKA prosthesis A)patellar
tendon bearing B)solid ankle cushion
heel Advantages: i) Cosmesis
ii)Ambulation iii) Function of the part.
Disadvantages:
i)infection ii)pressure ulcer iii) cost

32. SITUATION IN OUR SUBREGION
 Socio-cultural belief a)re-incarnation b)Husband
authority over wife c)Children never have
authority d)Males usually decides
 Traditional bone setters
 Few prosthetic centers
 Poverty
 Few centers for microvascular surgeries.

33. CONCLUSION
 Amputation should be done by surgeons who have
knowledge of amputation surgical principles,postop
rehabilitation, & prosthetic design.
 Improved prosthetic design does not compensate for a poorly
performed surgical procedure.
 Amputation should not be viewed as a failure

34. of treatment but rather as the 1st step towards a patient’s
return to a more comfortable & productive life.