Amputations Below the Knee

Ernest M. Burgess. M.D.

Joseph H. Zettl, C.P.

AHE elective amputation must be consid- amputation. Muscle-to-bone suture does

ered plastic and reconstructive in nature. add operative handling of tissues and en-
The need to create a dynamic and sensory circling sutures carry the potential of
motor end-organ should be foremost in the local muscle constriction. For these reasons
surgeon's mind in planning an amputation, myodesis is not recommended for use in
and is emphasized here once more. The the below-knee amputation for vascular
below-knee stump no longer hangs sus- disease. The new technique developed by
pended in an open-end socket. The vari- the Prosthetics Research Study utilizes
able degrees of pressure and weight-bear- the long posterior myofascial flap sewn an-
ing over the entire stump surface afforded teriorly to anterolateral deep fascia and
by the total-contact patellar-tendon-bearing tibial periosteum and provides a reason-
prosthesis enhance the surgeon's opportu- able degree of muscle fixation without risk
nity to fashion a functional terminal end- of strangulation. Muscle-to-bone suture is
organ. Stump strength created by surgical reserved for the nonischemic patient.
muscle stabilization; pliable, sensitive,
but nontender skin and scar; adequate soft NONISCHEMIC PATIENTS
tissue coverage of bone ends and other The optimum level for a below-knee
pressure-sensitive areas; high ligation and amputation in the presence of adequate
division of nerves to remove neuromata blood supply is at the junction of the mid-
from pressure zones; meticulous rounding dle and lower third of the leg. However,
and tailoring of bone surfaces; all contrib- the level of amputation will often be de-
ute to an ideal organ for substitute limb termined by the causal pathology, includ-
application. The atrophic, wasted, bony, ing infection, the degree of scarring of the
below-knee stump so commonly encoun- tissues, and related factors. The surgeon
tered in years past is no longer acceptable. should save all effective length down to
Stump-muscle stabilization, i.e., the at- optimum level, consistent with providing
tachment of sectioned muscles under ap- a comfortable, nontender stump.
propriate tension to bone (myodesis) and
A cylindrical stump shape is desired.
to opposing muscles (myoplasty), is a
The surgeon should think in terms of pro-
prime requisite for dynamic stump activ-
ducing a "foot-like" organ at the below-
ity. Muscle stabilization is especially
knee level. The total-contact socket is the
needed in the through-knee and the above-
"shoe on the foot." Just as plastic surgical
knee amputee. Our experience also justi-
techniques are required in operating on
fies its routine use in below-knee
the hand and foot, the same techniques of
gentleness in skin and other tissue handling
1
Principal Investigator, Prosthetics Research are applicable to amputation surgery.
Study, Seattle, Wash., and Director of Amputations When viewed in this light, the amputation
and Congenital Defects Service, Children's Ortho- becomes a surgical challenge instead of a
pedic Hospital, Seattle, Wash. This study was con-
distressing surgical exercise. Immediate
ducted under Contract V5261P-438 with the Veterans
Administration.
postsurgical prosthetic fitting not only
2
Director, Prosthetics Research Study, Seattle, supports and augments the dynamic ap-
Wash. proach to rehabilitation, it offers certain

1
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physical advantages, i.e., immobilization, mal to the distal end. Muscles are sec-
appropriate continuous pressure relation- tioned long, the gastrocnemius-soleus is
ships, and comfort. These benefits further left as a myofascial flap sufficiently long
justify its incorporation into the over-all to bring it around the end of the tibia to
management of the below-knee amputee. the anterior surface, and nerves and blood
vessels are ligated and divided, the former
AMPUTATION TECHNIQUE FOR THE NON- well above amputation level, the latter at
ISCHEMIC PATIENT the level of tibial section. The nerves are
The patient is prepared for surgery in ligated high, as indicated, but are not
the usual manner. A pneumatic tourni- pulled down so forcibly that traction-avul-
quet is used. Short, broad fishmouth skin sion injury results proximal to ligation.
flaps are outlined to provide a mediolat- Muscles are now sutured to the bone
eral closure. In the nonischemic patient through the drill holes with medium
the flaps are fashioned approximately braided polyester suture and tying the
equal in length. It is advisable to cut the knots within the medullary cavity of the
flaps long, then trim them at the time of tibia. The loop sutures pass through the
closure to provide correct skin tension body of the major muscle groups and
without puckering or undue tension. Skin through deep fascia. They should be at-
and fascia are reflected together. tached under moderate tension, slightly
Scarring, infection, deformity, or other greater than rest length and therefore ca-
unusual circumstances may necessitate pable of providing maximum function.
modification of the skin closure. Flaps can Muscle groups are now sectioned just be-
be outlined to permit closure in any plane yond the end of the tibia except for the
or direction provided the resulting scar is gastrocnemius-soleus flap which is left
nonadherent, nontender, and able to with- long, beveled, and brought over the end
stand properly and comfortably wearing of the tibia as a thinned myofascial flap
of a total-contact socket. Anterior location and sutured to anterior deep fascia and an-
of the scar, condemned in the past, actu- terior periosteum. Good muscle stability
ally is well tolerated even in elderly pa- and stump contour are provided by this
tients. The application of principles of technique. The moderately bulbous stump
plastic surgery in skin management must will rapidly contour to an ideal cylindrical
prevail. shape in the rigid postsurgical dressing.
In the average adult the tibia is tran- The skin flaps are trimmed and closed
sected 2 1/2 to 3 in. above the distal level with interrupted fine polyester sutures in
of the skin incision. The fibula is divided such a manner that no tension is present,
3/8 to 1/2 in. higher. A reciprocating power yet a firm stump without redundant tissue
saw facilitates clean bone section. The tib- is provided (Fig. 1). Drainage of the stump
ial periosteum is elevated about 3/4 in. is optional. We prefer a through-and-
above the cut end of the tibia and the an- through Penrose drain; however, suction
teromedial angle beveled to provide a drainage is convenient and some wounds
larger radius on the anteromedial aspect. will not require any drainage.
Careful rounding of the edges with a
sharp, fine-tooth file is now done. Bone THE RIGID DRESSING
surfaces must be smooth so as to eliminate The wound is covered with a saline-
the possibility of high unit pressures. dampened nonadherent silk or nylon dress-
When the muscles are to be reattached ing and a small amount of fluffed gauze (2
to bone, a procedure recommended where to 3) is placed over the distal stump end.
it is physiologically feasible, 4 to 6 holes A sterile three-ply Orion Lycra stump sock
not more than 7/64 in. in diameter are is rolled carefully over the stump to avoid
drilled through the lateral and posterior damage to the suture lines. The superior
periphery of the tibia about % in. proxi- portion of the stump sock is held firmly
 3

Fig. 2. Application of distal polyurethane pad.

Other relief pads are already in place.

ing well to its contours, providing a

smooth, effective, rigid dressing.
Before the wrap is started, the tibial
relief and distal relief pads are secured in
Fig. 1. Below-knee stump of nonischemic patient
place with one-and-three-quarter turns of
immediately after closure. elastic plaster bandage (Fig. 3). Firm ten-
sion is applied to the distal portion of the
stump from a posterior-to-anterior direc-
suspended anteriorly and in a proximal di- tion, while the plaster bandage is pulled
rection by an assistant. A simple adjust- almost to the limit of its elasticity. By
able shoulder-suspension harness which is supporting the posterior skin flap, tension
interchangeable for right and left can be on the suture line is reduced and the soft
substituted to achieve the same result. tissues are immobilized. The wrap is then
Relief pads of felt or polyurethane are started on the distal end and carried prox-
glued to appropriate locations on the imally to a level slightly past mid-thigh
stump sock to provide relief for bony prom- while tension is maintained in the band-
inences. Prefabricated pads are available age. A minimum of two layers is required.
in a standard size, right and left, but Circumferential wrapping is carried out
must be trimmed, skived, and beveled in from the lateral to the medial aspect, when
appropriate areas to suit individual re- viewed from the front, in order to avoid an-
quirements. The pads are designed and terior displacement of the gastrocnemius
located to provide relief of pressures over
the patella, the tibial tubercle including
the tibial crest, and the distal-anterior
(bevel) aspect of the tibia. Dow Corning
medical adhesive is used to secure the felt
relief pads in place while the polyure-
thane relief pads are provided with an ad-
hesive backing. A sterile reticulated poly-
urethane distal pad of the proper size is
selected and applied to the distal stump
end over the tibial relief pads (Fig. 2).
For the initial part of the rigid dressing,
elastic plaster bandage is used because,
when pulled within limits of its elasticity, Fig. 3. Beginning the rigid dressing by securing
this bandage provides safe and beneficial the tibial relief and distal relief pads in place with
compression to the stump while conform- elastic plaster bandage.
 4

the cast with a roll of conventional plaster

bandage (Fig. 6). The pylon is sized and
cut to correspond to the length of the
sound extremity. A window is cut out of
the plaster over the patella to insure com-

Fig. 4. Application of the first layers of the rigid

dressing.

(Fig. 4). Tension in the wrap decreases

progressively as the application proceeds
proximally to the level of the knee joint
where it is simply rolled on up to slightly
past mid-thigh. It is important to apply the
dressing with firm tension to the distal
portion of the stump and to avoid proximal
constriction to blood flow. The knee is held
in 5 to 15 deg. of flexion controlled by
longitudinal tension applied to the stump
sock from the proximal end. Owing to the
inherent structural weakness of elastic
plaster bandage, the initial wrap must be
reinforced with conventional plaster band-
age and splints. Two splints are applied
over the distal portion of the rigid dress-
ing.
A minimum of two layers of conventional
plaster bandage is applied starting at the
distal third and wrapping proximally with Fig. 5. Completed rigid dressing. Note alignment
even, overlapping circular wraps (Fig. 5). reference line.
At the proximal border of the cast a sus-
pension strap is incorporated anteriorly.
For an obese patient with excessive soft
tissue over the thigh, a second suspension
strap is applied posterolaterally. With the
plaster of Paris still wet, the cast is gently
compressed with the base of each hand
just proximal to the femoral condyles to
provide an effective built-in suspension
mechanism.
After the plaster has hardened suffi-
ciently, the contoured waistbelt is ap-
plied to the patient and connected to the
Fig. 6 Attachment of upper portion of prosthetic
strap or straps of the rigid dressing. The unit to the rigid dressing. Note alignment reference
prosthetic unit is located and attached to line.
 5

The time and extent of ambulation must

be determined by the responsible sur-
geon. Walking training should be carried
out only under the direction of a physical
therapist or other qualified personnel. Ac-
tivity should be increased daily as the pa-
tient's condition permits. Parallel bars,
walkerettes, crutches, and canes are used
as aids in ambulation. Two bathroom
scales may be used to determine the de-
gree of weight-bearing that is taken on the
amputated side. These measurements pro-
vide a good guide to the clinic team con-
cerning the progress being made by the
patient. The patient should never be al-
lowed to ambulate without supervision.
Furthermore, ambulation should not be
permitted without the prosthesis because
in this case the effect of gravity tends to
pull the socket away from the stump,
thereby reducing the pressure between
stump and socket.
On the second postoperative day (48
hours after surgery) the drain is removed.
If there does not appear to be any reason
for removing the cast, such as elevated
body temperature, extreme discomfort,
or excessive looseness of fit, the cast is
kept in place up to 14 days. If for any rea-
Fig. 7. Window in rigid dressing to provide com- son the cast is removed, whether inten-
plete relief over patella, tionally or unintentionally, it is manda-
tory that, if a new cast is indicated, it be
applied immediately. During the first two
plete relief in this area (Fig. 7). The pros- postoperative weeks edema will form rap-
thetic unit is then disconnected from the idly upon removal of the cast and, unless
cast socket before the patient is taken to a new cast is reapplied within a very short
the recovery room. period, the patient will have to be treated
in the conventional manner. The old cast
POSTSURGICAL CARE should never be reapplied because of the
As a rule, a minimum amount of pain is trauma that is apt to result. When the-
experienced by patients that have been socket is removed purposely, a cast cutter
provided with a rigid dressing. It is un- is used. Often the sutures can be taken
usual for drugs stronger than mild opiates out at the time of removal of the first cast,
and sedatives to be required for relief. A 10 to 14 days after surgery. Sometimes it
slight degree of weight-bearing on the is necessary to wait until removal of the
stump will usually tend to reduce any dis- second cast, 15 to 20 days postoperatively.
comfort that might be present. In many instances the stump will be
The patient should be encouraged to sufficiently mature and stable for use of
stand up and bear some weight on the a definitive prosthesis at the time the sec-
prosthesis as soon after the first 24-hour ond cast is removed. When this is so, a
period postoperatively as is practicable. cast of the stump is taken and appropriate
 6

measurements are recorded so that fabri- ences, separate surgical techniques have
cation of a permanent prosthesis can pro- been developed for the ischemic patient
ceed immediately. When the definitive and for the nonischemic patient.
prosthesis is delivered, a light plaster
socket mobilizing the knee joint is pro- LEVEL OF AMPUTATION
vided for use when the definitive prosthe- The great achievements in surgical re-
sis is removed. Use of a plaster socket has construction of the peripheral vascular
proven to be superior to elastic bandages system represent a leading chapter in med-
to prevent edema. If delays are anticipated ical progress during the past two decades.
in providing the patient with a definitive Continuing basic and clinical research
prosthesis, the prosthetic unit, pylon, and throughout the world supports the hope
foot are applied to the short cast to con- that an even higher percentage of limb sal-
tinue ambulation activities. vage can be expected in the years ahead.
However, despite the practical effective-
THE ISCHEMIC PATIENT ness of modern vascular reconstructive sur-
Throughout the United States and Can- gery, statistics indicate that amputations
ada an estimated 80 per cent of all major, for ischemia are increasing both relatively
elective, civilian amputations result from and absolutely in relation to population
ischemia. All but a relatively few involve throughout the western world.
the lower extremity. Significant advances When acute or chronic compromise of
in surgical and postsurgical management arterial blood supply reaches a level in-
coupled with the use of improved pros- sufficient to support tissue viability and
theses now allow amputation below the when reconstructive surgery and nonsur-
knee in the great majority of these pa- gical supportive measures fail, amputa-
tients. tion will be required.
It is difficult to overestimate the impor- Patients requiring amputation are en-
tance of the knee in amputee rehabilita- titled to comparable medical and surgical
tion, especially in the older, classical is- consideration, comparable team effort, and
chemic patient. Debility, impaired vision, the same high-level rehabilitation man-
poor balance, neuropathy, compromised agement attending similar patients whose
circulation and joint function in the re- ischemic limbs are treated by vascular re-
maining lower limb, and chronic systemic construction. Too often, ablative surgery
illness, all emphasize the critical need to does not command this high estate.
save the knee. The older bilateral leg am- Decision to amputate may be simple and
putee, especially, needs his knees to ap- evident. Gross necrosis of tissue with de-
proach the rehabilitation goal that permits marcation, uncontrollable infection, pain,
a reasonable degree of ambulation and irreversible neuropathy, alone or in com-
self-sufficiency. In a consecutive series of bination, and with results of specific tests
128 unselected major lower-extremity am- to assay circulation, will establish the need
putations for peripheral vascular disease to amputate. When all available informa-
(1964 through 1968), we have been able to tion poses a serious question as to the
obtain primary healing at below-knee possibility of limb salvage by reconstruc-
level in 86 per cent. Once healed, the tive surgery rather than amputation, it
stumps remain healed. With adequate has been common practice to attempt such
prosthetic care, secondary breakdown will surgery, even though extensive. Before
seldom occur. These patients were among questionable extensive reconstructive ar-
the approximately 300 cases requiring am- terial surgery is carried out, the surgeon
putation of the lower extremity that were should consider critically the overriding
used in studying and developing the tech- probability of its failure with mandatory
niques of fitting prostheses immediately subsequent amputation. Will the proposed
after surgery. As a result of these experi- surgery compromise the level of amputa-
 7

tion? Will amputee rehabilitation be ad- knee surgery can then be carried out
ditionally complicated by further deteri- quickly.
oration of general health incident to the Bleeding and tissue viability can be ob-
extensive surgical attempt at limb sal- served directly and the final decision can
vage? On a number of occasions, below- now be made as to the level of amputation.
knee amputations have been performed in Only a few minutes are added to the opera-
ischemic patients who were being consid- tive time should one elect the above-knee
ered for possible vascular surgical treat- or through-knee level.
ment but in whom, after review of all
available information, such surgery might AMPUTATION TECHNIQUE FOR THE ISCHEMIC
well have damaged the existing blood sup- PATIENT
ply to a degree that an above-knee ampu- No tourniquet is used. The leg is draped
tation would then have been required. It free with the patient supine. Open and in-
is important that the responsible surgeon fected areas are walled off and shielded by
understand the great rehabilitation value sterile adherent plastic drapes prior to skin
of the knee and weigh all facts relevant to preparation. The level of amputation is
the rehabilitation potential. 3-1/2 to 5 in. below the knee, i.e., a short
There is no single test or combination of below-knee stump (Fig. 8). It has been rec-
tests now available that will demonstrate ognized for many years that skin over the
specifically the lowest effective amputa- posterior leg has better blood supply than
tion level. Successful below-knee ampu- that anterior and anterolateral, and a long
tations have been obtained repeatedly in posterior and a short anterior skin flap are
patients whose arteriograms indicated now used routinely. A long anterior flap,
complete occlusion of the superficial fem- or even equal anterior and posterior flaps,
oral artery. should be avoided. The anterior scar re-
A careful physical examination is the sulting from use of a long posterior flap
first requisite in determination of the level poses no problem in fitting the prosthesis.
of amputation. Appearance of the soft tis- The modern total-contact below-knee pros-
sues, temperature of the skin, the pres- thetic socket can accept a stump with scar
ence or absence of edema after elevation, placement in any position, provided it is
growth of hair, level of sensation and acu- nonadherent, well-healed, and nontender,
ity, together with palpation of pulses, are and it is now standard policy in the Pros-
all important and cannot be supplanted by thetics Research Study to place the scar
laboratory data. Arteriography, plethys- wherever it will heal most advantageously.
mography, thermography, and a number The anterior skin flap is fashioned ap-
of other objective techniques are useful. proximately at the level of anticipated
These include skin mapping with interar- tibial section. The posterior flap must then
terial fluorescein, the use of radioactive be 5 to 6 in. longer to provide proper skin
Xenon #133, and transcutaneous ultra- coverage without undue tension (Fig. 9).
sonic Doppler recordings. Each adds to the After outlining the skin flaps, dissection
available information and assists in level is carried down through the deep fascia to
determination. Old established guidelines the tibia. The periosteum is incised and
for determining amputation level are not stripped proximally 1 in. The anterolat-
valid when weighed against recent experi- eral muscles are divided down to the in-
ence. termuscular septum; blood vessels and
Unless it is clearly evident that a nerves are ligated appropriately and sev-
through-knee or above-knee amputation ered; and then the tibia and fibula are sec-
will be required, the surgeon should pre- tioned, preferably with a power saw. The
pare the leg for both below-knee and fibula is cut no more than 3/8 to 1/2 in.
above-knee amputation. Incisions through above the level of the tibia. Soft tissues
the skin and muscle preparatory to below- are dissected from the posterior aspect of
 8

Fig. 8. Left, stump of 33-year-old patient on 26th day after amputation because of infection ow-
ing to nonunion of the tibia. Right, permanent prosthesis provided same patient on 26th day post-
operative.

Fig. 9. Outline of skin flaps for below-knee amputation on typical ischemic patient,
 9

the tibia and fibula down to the level of used. An immediate postsurgical rigid
the posterior transverse division of skin. dressing and prosthesis are then applied.
The leg is then separated and removed.
The tibia is very carefully rounded with a POSTSURGICAL CARE
short bevel over its anterior and medial Drains are removed 48 hours after sur-
aspects. It is important that no rough bone gery. If the patient's general condition per-
areas or ridges remain. A long bevel is spe- mits, ambulation with guarded weight-
cifically avoided. Nerves are pulled down bearing is begun 24 to 48 hours following
and sectioned high with a sharp knife. surgery. The advantages of upright activ-
They are not injected, crushed, or cauter- ity with limited stance and gait are obvi-
ized. The major nerves are ligated with a ous. However, only touch-down weight-
fine suture just above the site of division bearing not exceeding 25 lb. is allowed
before the division is made. Encircling su- until the initial cast is changed. Person-
ture controls oozing from the blood supply nel in charge of the patient should be in-
that accompanies the nerve, and it also ap- structed carefully as to their responsibility
pears to localize neuroma formation and in preventing the patient from bearing ex-
to lessen overgrowth and adherence to ad- cessive weight or from falling.
jacent structures. The posterior muscle The postsurgical management with an
mass consisting of the gastrocnemius-soleus immediate prosthesis has resulted in much
and deep flexor group is now beveled and less pain than previously encountered.
tailored to permit the entire muscle flap Postoperative pain is generally of a diffuse
to come forward and be sewn anteriorly to aching type. Complaint of localized pain
the deep fascia of the anterolateral muscle almost always indicates abnormal pressure
group and to the reflected periosteum over and requires inspection of the stump and
the anterior tibia. Contouring and trim- change of the socket. Unless complica-
ming of the gastrocnemius medially and tions develop, i.e., evidence of infection,
laterally gives a smooth musculofascial flap excessive loosening of the socket, or severe
stabilized over the end of the bones. The pain, the initial rigid dressing should be
skin is then brought up and closed with- left intact until the time of anticipated su-
out subcutaneous suture (Fig. 10). Medial ture removal, usually two to two-and-one-
and lateral "dog ears" are contoured mod- half weeks following surgery. The cast is
erately. They should not be taken back then removed, with the patient under se-
sufficiently to disturb skin circulation. The dation but not anesthesia, the wound is
immediate postsurgical socket rapidly inspected, sutures are removed if indi-
shapes the stump including moderate skin cated, and a new temporary prosthesis is
irregularity at the medial and lateral an- applied. By this time the patient is usu-
gles. The wound is drained deep to the ally ready for unsupported crutch ambula-
muscle flap, i.e., to bone. Through-and- tion and discharge from the hospital. A
through drain or suction drainage may be temporary prosthesis is worn continuously
until a definitive limb is provided. Ordi-
narily the final limb can be fabricated, fit-
ted, and worn four to five weeks following
below-knee amputation. Typical ischemic
patients are shown in Figures 11 and 12.
Necrosis of skin flaps can result from
either inadequate blood supply or undue
pressure. If the level of amputation is so
low that the blood supply is insufficient
to support a below-knee amputation, it
Fig. 10. Below-knee stump of typical ische- will be evident at the initial cast change.
mic patient showing position of suture line. The decision then to amputate at a higher
 10

Fig. 11. A 69-year-old, white male had multiple difficulties consisting of arteriosclerosis obliterans with
complete right superficial femoral occlusion, diabetes mellitus, arteriosclerotic heart disease with mitral in-
sufficiency, and coronary occlusion. No reconstructive vascular surgery was considered to be feasible. The
preoperative condition of his foot is indicated on the left. Good stump healing was achieved by the 25th post-
operative day, center. The definitive prosthesis was applied on the 28th postoperative day, right.

Fig. 12. A 73-year-old, white female with severe chronic peripheral vascular disease without diabetes. Two
attempts at femoral popliteal bypass graft had been made in the three weeks prior to "breakdown" of the
graft operative sites. Progressive gangrene of the foot had ensued with demarcation just above the ankle
level. Figure in upper left shows the appearance of the leg prior to amputation. A short below-knee level of
amputation was selected and a long posterior musculocutaneous flap developed, upper right. The appear-
ance of the below-knee stump at 19 and 29 days following surgery is indicated in the lower figures. The
definitive prosthesis was fitted on the 32nd postoperative day.
 11

level should be made promptly. Re-am- membres inferieurs sur la table d'operations,
putation rate in the PRS series to through- paper given at the International Congress of
knee or above-knee over the four-year Physical Medicine, Paris, 1964.
4. Bickel, William H., Amputations below the knee
period has been 9.4 per cent. As experi- in occlusive arterial disease, Surg. Clin. N.
ence and techniques have improved, the Amer., Mayo Clinic Number, August 1943.
re-amputation rate for below-knee cases 5. Bickel, William H., and R. K. Ghormley, Ampu-
with ischemia has continued to decrease. tations below the knee in occlusive arterial
The surgeon, of course, likes to avoid all disease, Proc. Mayo Clinic, 18:361, 1943.
6. Block, M. S., and F. W. Whitehouse, Below knee
re-amputations. However, salvage of the amputation in patients with diabetes mellitus,
knee is of such paramount importance Arch. Surg., 87:682-689, October 1963.
that an occasional re-amputation may be 7. Bradham, R. R., and R. D. Smoak, Amputations
required if we are to save all knee joints of the lower extremity used for arteriosclerosis
possible in view of our inadequate means obliterans, Arch. Surg., 90:60-64, January
1965.
for determining the best level for ampu- 8. Burgess, Ernest M., The below-knee amputation,
tation. Inter-Clinic Inform. Bull., 8:4, January 1969.
9. Burgess, E. M., and R. L. Romano, The manage-
SUMMARY AND CONCLUSIONS ment of lower extremity amputees using im-
mediate postsurgical prostheses, Clin. Orthop.,
Below-knee amputation is statistically 57:137-146, 1968.
10. Burgess, E. M., and R. L. Romano, New day for
by far the most important major amputa- leg amputees, Rehab. R e c , July-August 1965.
tion used today. The vast majority of 11. Burgess, E. M., and J. H. Zettl, Immediate post-
major lower-extremity amputations per- surgical prosthetics, Orthop. Pros. Appl. J.,
formed for ischemia will heal primarily June 1967.
and remain healed at below-knee level. 12. Burgess, Ernest M., Joseph E. Traub, and A.
Bennett Wilson, Jr., Immediate postsurgical
The below-knee amputation for ischemia prosthetics in the management of lower ex-
is short in length, the posterior skin and tremity amputees. Prosthetic and Sensory Aids
myofascial flaps are fashioned long, and Service, U.S. Veterans Administration, 1967.
the technique is precise. The resulting 13. Compere, Clinton L., Early fitting of prosthesis
stump is cylindrical in shape, well-pad- following amputation. Surg. Clin. N. Amer.,
48:1:215-226, 1968.
ded, comfortable, and easily fitted with 14. Dederich, Rolf, Die muskelplastische Stumpfkor-
modern below-knee prostheses of the to- rektur, Zentralbl. Chir., 81:29:1194-1206,
tal-contact type. An immediate postsur- 1956.
gical prosthesis is an integral part of the 15. Dederich, Rolf, Plastic treatment of the muscles
over-all below-knee amputee management and bone in amputation surgery, J. Bone Joint
Surg.,45B:l:60-66, February 1963.
in both the ischemic and nonischemic pa- 16. Eraklis, A., and W. Brownell, Below knee ampu-
tient. Restoration of function and reha- tations in patients with severe arterial insuf-
bilitation of the below-knee amputee, ficiency, New Eng. J. Med., 269:938-942,
both unilateral and bilateral, have im- October 1963.
proved in almost spectacular fashion when 17. Ertl, Johann, Uber Amputationsstumpfe, Chi-
rurg, 20:218-224, May 1949.
the guidelines and management which 18. Glattly, Harold W., A preliminary report on the
have been outlined are followed. amputee census, Artif. Limbs, 7:1:5-10, Spring
1963.
BIBLIOGRAPHY 19. Golbranson, F. L., Charles Asbelle, and Donald
Strand, Immediate postsurgical fitting and
1. Baddeley, R. M., and J. C. Fulford, The use of early ambulation, Clin. Orthop., 56:119-131,
arteriography in conservative amputations for 1968.
lesions of the feet in diabetes mellitus, Brit. 20. Guthrie, G. J., A treatise on gun-shot wounds,
J. Surg., 51:633-658, September 1964. Ed. 2, Burgess and Hill, London, 1820.
2. Berlemont, M., Notre experience de I'appareil- 21. Harris, P. D., S. I. Schwartz, and J. A. DeWeese,
lage precoce des amputes des membres in- Midcalf amputation for peripheral vascular
ferieurs aux Etablissements Helio-Marins disease, Arch. Surg., 82:381-383, March 1961.
de Berck, Ann. Med. Phys., Tome IV, No. 22. Hey, William, Practical observations in surgery,
4, October-November-December 1961. Ed. 3, Cadell and Davies, London, 1814.
3. Berlemont, M., L'appareillage des amputes des 23. Hoar, C. S., Jr., and J. Torres, Evaluation of be-
 12

low-the-knee amputation in the treatment of mechanics Laboratory, University of Califor-

diabetic gangrene, New Eng. J. Med., 266: nia. Berkeley and San Francisco, 1961.
440-443, March 1962. 34. Robb, H. J., L. F. Jacobsen, and B. Jordan,
24. Jansen, Knud, Amputation, a manual of prin- Midcalf amputation in the ischemic extrem-
ciples and methods, World Veterans Federa- ity: Use of lateral and medial flap, Arch.
tion, Paris, 1965. Surg., 91:506-508, September 1965.
25. Kelly, P. J., and J. M. Janes, Criteria for deter- 35. Rosenberg, N., Midleg amputation in patients
mining the proper level of amputation in oc- with necrotic leg muscles, Arch. Surg.,
clusive vascular disease: A review of 232 81:614-617, October 1960.
amputations, J. Bone Joint Surg., 39A:833- 36. Silbert, Samuel, Mid-leg amputations for gan-
891, July 1957. grene in the diabetic, Ann. Surg., 127:503,
26. Kendrick, R. R., Below knee amputation in ar- 1948.
teriosclerotic gangrene, Brit. J. Surg., 44:13- 37. Slocum, D. B., An atlas of amputations, C. V.
17, July 1956. Mosby, St. Louis, 1959.
27. Loon, Henry E., Below-knee amputation surgery, 38. Smith, B. C, Amputation through lower third
Artif. Limbs, 6:1:86-99, June 1962. of leg for diabetic and arteriosclerotic gan-
28. Loon, Henry E., Biological and biomechanical grene, Arch. Surg., 27:267, 1933.
principles in amputation surgery, Prosthetics 39. Tillgren, C., Obliterative arterial disease of the
International, Committee on Prostheses, lower limbs: A study of the course of the dis-
Braces, and Technical Aids, International So- ease, Acta Med. Scand., 178:103-119, July
ciety for the Welfare of Cripples, Copenhagen, 1965.
1960. 40. Manual of below-knee prosthetics, University
29. Mondry, F., Der Muskelkraftige Ober-und Un- of California, San Francisco, Biomechanics
terschenkelstumpf, Chirurg, 23:517-519, No- Laboratory, November 1959.
vember 1952. 41. Weiss, Marian, personal communication and dem-
30. Murphy, Eugene F., and A. Bennett Wilson, Jr., onstration, Konstancin Rehabilitation Hos-
Anatomical and physiological considerations in pital, Poland, 1964.
below-knee prosthetics, Artif. Limbs, 6:2:4-15, 42. Weiss, Marian, Neurological implications of fit-
1962. ting artificial limbs immediately after ampu-
31. Pedersen, Herbert E., Lower extremity amputa- tation surgery. Report of Workshop Panel on
tions for gangrene, The American Academy of Lower-Extremity Prosthetics Fitting, Com-
Orthopaedic Surgeons Instructional Course mittee on Prosthetics Research and De-
Lectures, 15:262, 1958. velopment, National Academy of Sciences,
32. Pedersen, H. E., R. L. LaMont, and R. H. February 1966.
Ramsey, Below-knee amputation for gan- 43. Weiss, Marian, Myoplasty—immediate fitting—
grene, Southern Med. J., July 1964. Re- ambulation, paper presented at the Sessions
printed in Orthop. Pros. Appl. J., 18:281- of the World Commission on Research in Re-
287, December 1964. habilitation, Tenth World Congress of the In-
33. Radcliffe, C. W., and James Foort, The patellar- ternational Society, Wiesbaden, Germany,
tendon-bearing below-knee prosthesis, Bio- September, 1966.