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Amputation: below knee

From Mediwikis



MHDOSMasterscriptHigh Detail Operating System

http://mediwikis.com/wiki/index.php/MHDOS_Masterscript_High_Detail_Operating_System

Amputation: Below Knee

Burgess technique


6 Burgess skin closure.png






and

Robinson technique


Robinson finished operation.png







Author:

Michael Edwards

with assistance from

Professor Jonathan Beard and Mr Wissam Al-Jundi


No information in this masterscript should be used without the approval of a fully trained practising surgeon.

Last amended 28 07 2017

CONTENTS

Chapter 1. MHDOS and layout of Masterscript Chapters, Op Sections and Steps.

Chapter 2. Introduction to the Burgess and Robinson techniques.

Chapter 3. What this script covers and does not cover:

Chapter 4. Indications and contraindications.

Chapter 5. Op Section 1.00. Preliminaries and WHO safe surgery checklists sign in and time out.

Chapter 6. Op Section 2.00.Anaesthesia.

Chapter 7. Op Section 3.00. Applying a tourniquet.

Chapter 8. Op Section 4.00.Position.

Chapter 9 .Op Section 5.00.Stance.

Chapter 10. Op Section 6.00.Skin preparation.

Chapter 11. Op Section 7.00.Towelling up.

Chapter 12. Op Section 8.00. Burgess single posterior flap procedure.

Chapter 13. Op Section 9.00.Cutting the fibula.

Chapter 14. Op Section 10.00.Cutting the posterior muscles.

Chapter 15. Op Section 11.00. Review the operation so far.

Chapter 16. Op Section 12.00.Cutting the tibia.

Chapter 17. Op Section 13.00.Fashioning the amputation stump.

Chapter 18. Op Section 14.00. Robinson skew-flapsand myoplastic flap procedure.

Chapter 20. Op Section 16.00.Cutting the fibula.

Chapter 21. Op Section 17.00.Cutting the tibia.

Chapter 22. Op Section18.00.Fashioning the amputation stump.

Chapter 23. Op Section 19.00. Fashioning the skin flaps.

Chapter 24. Op Section 20.00.Checking haemostasis.

Chapter 25. Op Section 21.00.Suturing the myoplastic flap.

Chapter 26. Op Section 22.00. Suturing the skin

Chapter 27. Op Section 23.00. Final touches and WHO safe surgery checklist and sign out.

Chapter 28. Equipment and materials.

Chapter 29. References and further reading.

Chapter 30. We welcome your comments.


Contents

Chapter 1. MHDOS and Masterscript Chapters, Op Sections and Steps.

• About MHDOS (Masterscript High Detail Operating System) [[1]]

• The Masterscript is divided into Chapters.

• Chapters describing the operation are called Op Sections.

• Unlimited numbers of Op Sections are displayed in sequence.

• Each Op Section is divided into an unlimited number of very small Steps.

• Each Step contains an unlimited amount of supporting information (pantinos).

Chapter 2. Introduction to the Burgess and Robinson techniques.

The Burgess and the Robinson techniques are the most commonly performed procedures for below knee amputatios.

In the Burgess technique, there is a single long posterior flap.

Leg with gangrene burgess 5.png










The flap consists of muscle, mainly soleus and gastrocnemius, and also the skin and fat of the calf. It is therefore a myocutaneous flap.


2a cross section of gangrene left leg.png








It is often called a myoplastic flap because its muscle component will be attached to the cut end of the tibia.

Leg with gangrene burgess cross section skin incision - 2nd copy.png








Burgess posterior flap attached.png








The muscle will remain viable and not undergo disuse atrophy.

The skin of the flap, with its nutrition from arteries in the underlying muscle, is stitched directly to the skin of the front of the amputation stump.

There is in effect no anterior flap.

The tibialis anterior and the peroneal muscles, having been cut across, will undergo atrophy.

The stump remains bulky for two weeks or more, which can delay the fitting of a prosthesis.

The transverse skin suture line can be damaged by pressure from a prosthesis.


The Robinson technique is a development of the Burgess technique.

There are three flaps.


Mini 3 Robinson flaps.png








There is one posterior myoplastic flap, which is as long as the myoplastic flap in the Burgess technique.

It is a little thinner, consisting only of muscle, without any skin or fat.

There are two skin flaps.

They consist of skin and fat, without any muscle.

An antero - medial skin flap preserves the blood supply from arteries related to the long saphenous vein and the saphenous nerve.

A postero - lateral skin flap preserves the blood supply from arteries related to the short saphenous vein and the sural nerve.

The skin flaps, when sutured, lie about 15 degrees out of the sagittal plane (north/south). Hence the name skew-flaps.

Benefits of the Robinson technique include:

Better blood supply to the skin than with the Burgess technique.

Pressure from a prosthesis does not concentrate on the wound.

More tapered stump for earlier fitting of a prosthesis.

Choice between Burgess and Robinson amputations.

Probably no overall difference in healing rates.

Robinson procedure is more popular today.

The Burgess operation is useful if the skin is scarred from previous femoral-distal by-pass grafting on the medial side of the leg.

Chapter 3. What this script covers and does not cover:

This script covers the use of a tourniquet.

Less blood loss using a tourniquet.

No evidence of worse healing with a tourniquet.

This script does not cover primary amputation for trauma.

Chapter 4. Indications and contraindications.

Indications

1 left leg with gangrene of toe.png







• For peripheral vascular disease.

• Irreversible ischaemic changes distal to the malleoli.

• Failed foot or toe amputation.

• Redo below knee amputation.

Absolute contraindications:

• Iliac arterial block.

• Fixed flexion deformity in the knee.

This will prevent an artificial limb being applied.

However, a below knee amputation in a bed-bound patient is better than an above knee one for mobility.

• Irreversible ischaemic changes above the malleoli.

These include:

Ulceration.

Red, blue, purple or black skin.

Ischaemic contracture of shin or calf muscle.

Ischaemic tenderness of shin or calf muscles.

Crepitus in the tissues.

Relative contraindications:

• Oedema.

• Lymphangitis.

Chapter 5. Op Section 1.00. Preliminaries and WHO safe surgery checklists sign in and time out.

Step 1.01. Check you have the correct patient.

Step 1.02. Check you have the correct side.

Step 1.03. Check you have the correct limb.

Step 1.04. Check ischaemic tissue is sealed off.

Use clean occlusive towels fixed with 4 inch adhesive plaster eg Elastoplast.

Step 1.05. Check the other limb is protected.

Protect it from pressure or damage during the operation by means of soft padding, particularly under the heel.

Step 1.06. Check there is no other procedure to do.

Step 1.07. Check antibiotics have been given.

According to earlier sensitivities.

OR: Metronidazole 500mg intravenously tds.

Cefuroxime 750mg intravenously tds.

Step 1.08. Check there is a diathermy pad.

Place this on the opposite thigh or under the opposite buttock.

WHO safe surgery checklists sign in and time out.

Step 1.09 If a tourniquet is not being used:

Go to: Chapter 8 Op Section 4.00. Position.

If a tourniquet will be used:

Read on.

Check the following are present and in working order:

Tourniquet cuffs that will fit the thigh.

Cylindrical cuffs for a cylindrical thigh.

Conical (curved) cuffs for a conical muscular thigh.

Extra large cuffs for very fat thighs.

For details see Chapter 28 Equipment and materials.

Tubing.

Connectors.

Gauges.

Pressure source.

Chapter 6. Op Section 2.00. Anaesthesia.

General, or spinal etc, depending on anaesthetic preferences.

Chapter 7. Op Section 3.00 Applying a tourniquet.

If you will not be using a tourniquet:

Go to Chapter 10 Section 6.00. Skin preparation

If a tourniquet is to be used:

Read on.

Step 3.01 Choose a suitable site on the thigh for the tourniquet.

Ideally centered at the site of maximum circumference of the thigh.

The upper edge of the cuff 8cm. below the groin skin crease.

The lower edge at least 25cm. above the knee joint.

This will allow for an above knee amputation if the below knee amputation has to be abandoned because of lack of tissue below the knee.

Step 3.02 Measure the thigh circumference.

At the centre of the chosen site for the tourniquet.

Use a tape measure.

Step 3.03 Choose a suitable tourniquet cuff.

Ie To comply with the above requirements.

Long enough for overlapping of the cuff by 1/3 of the length of the cuff.

Longer overlap may lead to instability of the cuff.

Little or no overlap may lead to loosening of the cuff and inadequate occlusion of blood vessels.

If a pneumatic tourniquet is not available:

Use a sphygmomanometer or an Esmarch bandage.

Step 3.04 Protect the skin and underlying tissues. Wrap a protective layer of cloth around the thigh at the planned tourniquet site.

Use a dressing towel or a thin cotton wool roll.

Make sure the cloth is not folded or creased.

Apply traction distally to the skin as the cloth is wrapped round.

This will prevent wrinkling, pinching and shearing of skin and fat, particularly in a fat patient.

Step 3.05 Wrap the cuff around the thigh and over the protective cloth.

Check the inflation tubing is facing away from the operation site.

Check the tubing lies on the lateral side of the thigh, away from nerves in the thigh.

Step 3.06 Complete assembling the tourniquet.

Fasten the cuff straps.

Tie off any tapes

Attach the sphygmomanometer tubing.

Check there are no air leaks.

Check the sphygmomanometer reads zero mm. Hg.

Step 3.07 Find the Lowest Occlusion Pressure (LOP).

Pump up the cuff until the popliteal or dorsalis pedis pulses disappear.

Step 3.08 Calculate the correct inflation pressure for the procedure.

LOP plus 100mm.Hg.

If you are unable to find the popliteal or dorsalis pulses:

Plan for an inflation pressure of twice the preoperative systolic blood pressure.

A higher pressure may be needed to occlude sclerotic vessels for satisfactory control of bleeding during the operation.

Step 3.09 Release the pressure in the cuff.

Step 3.10 Exsanguinate the limb.

Have the limb elevated as high as possible, by an assistant holding the foot.

Keep the limb elevated for 1 minute to allow emptying of veins, before applying the Esmarch bandage.

Use a sterile non-latex Esmarch bandage 100mm. wide and 3m. long

Start at the fore-foot, above any dressings covering necrotic tissue.

Wrap the bandage round the foot.

Have a 50% overlap of the bandage layers.

Aim for a tightness of 3/4 full stretch of the bandage.

Use a double tension technique

Ie Pull the bandage laterally over the back of the limb.

Pull the bandage medially over the front of the limb.

Continue wrapping the bandage up to and just over the lower margin of the tourniquet cuff.

Tuck the end of the bandage under an earlier wrapping to secure it.

Step 3.11 Start the clock.

Write down the start time on the anaesthetic documents.

Have the time called out every 30 minutes.

To minimise tourniquet damage to the limb:

Plan for the operation to last no longer than 2 hours.

After 2 hours, release the pressure for 15 minutes and repressurise.

Repeat this every hour.

Step 3.12 Pump up the tourniquet to the planned pressure.

Step 3.13 Unwind the Esmarch bandage and remove.

Chapter 8. Op Section 4.00. Position.

Supine.

Have access from groin to heel.

Chapter 9. Op Section 5.00. Stance.

Stand on the side of the amputation.

Have your one assistant opposite.

Chapter 10. Op Section 6.00. Skin preparation.

Step 6.01. Have the leg held up at 45 degrees.

Have an unscrubbed assistant holding the foot.

Step 6.02. Clean the skin.

Clean the skin from the heel to the groin or the lower margin of the tourniquet.

Use 2 swabs on sticks with eg 0.5%.Chlorhexidine in 70% Propanol and one to dry off.

Make sure the antiseptic does not pool under the tourniquet and damage the skin.

Chapter 11. Op Section 7.00.Towelling up.

Step 7.01. Place a large sheet on the operating table up to the buttock.

Step 7.02. Place an upper sheet down to the mid thigh.

Step 7.03. Clip the upper sheet round the mid thigh.

Use a towel clip.

Step 7.04. Place a sheet on top of the operating table sheet.

Step 7.05 Drop the foot into this sheet.

Step 7.06. Fold the lower sheet over the foot and over any bandages.

Clip the sheet tightly around the lower calf at the level of the malleoli with a towel clip.

Chapter 12. Op Section 8.00. Burgess single posterior flap procedure.

If you are planning a Robinson skew- flap procedure:

GO TO Chapter 18 Op Section 14.00 Robinson skew-flaps and myoplastic procedure.

If you are planning a Burgess procedure:

Read on.

Step 8.01. Mark on the skin, the sites of cutting of the tibia and fibula.

Bone cutting sites.png







Ideally, this will be 15cm. below the level of the tibial plateau for the tibia and 12cm. below the level of the tibial plateau for the fibula.

A stump as short as 8cm. is acceptable for a below knee amputation revision.

Use a marker that will not wash off and will not tattoo the skin.

eg Magic Marker.

Step 8.02 Mark the anterior skin incision.

Burgess marking of skin incisions.png






This is a simple transverse incision through the skin and the fat, 2 cms. below the tibial tubercle and 15 cm. below the tibial plateau.

This is at the level of cutting the tibia.

Run the marking round the front half of the leg's circumference.

Step 8.03 Mark the posterior flap.

The posterior flap will need to fold forward to join the front of the tibia after the amputation without any tightness at all.

This means making a long skin flap extending down to 5cm. above the Achilles tendon, as wide as the posterior half of the calf.

Do not make the incision any higher, or you will be in danger of having too short a flap.

You can always shorten the flap later, but you cannot lengthen it.

Step 8.04 Make the anterior skin incision.

Use a scalpel with a no 22 Swann-Morton blade.

Incise the skin and fat and periosteum of the tibia.

Step 8.05. Cut the posterior flap.

Have the limb elevated 45 degrees.

Have your assistant holding the patient's foot.

Make the flap with parallel sides and a curved lower end.

Incise the skin from the medial end of the anterior incision, parallel to the long axis of the limb until you are 20 cms. from the calcaneum.

Extend the incision in a semi-circle to within 10 cms. of the calcaneum.

Then run back onto the lateral side of the calf to the lateral end of the anterior skin incision.

This flap may look extraordinarily long, but it will contract by at least 30% over the next two weeks.

You cannot make a flap too floppy.

Step 8.06. Clamp and divide the long saphenous vein and cut the saphenous nerve.

Separate the saphenous nerve from the long saphenous vein.

Cut the nerve under tension and let it retract proximally.

Clamp and divide the long saphenous vein.

Use eg 2/0 Vicryl ties (Ethicon W9025).

Step 8.07 Clamp and divide the short saphenous vein and cut the sural nerve.

Separate the sural nerve from the short saphenous vein.

Cut the nerve under tension and let it retract proximally.

Clamp, divide and tie off the short saphenous vein.

Use 2/0 Vicryl ties (Ethicon W9025).

Chapter 13. Op Section 9.00. Cutting the fibula.

Step 9.01. Expose the upper end of the fibula.

Cut through the tibialis anterior and peroneal muscles.

Clamp and divide the anterior tibial artery branches and the peroneal artery.

Identify the anterior tibial and the peroneal nerves.

Cut the nerves under tension and allow to retract into the muscles.

Expose a 2 cm. segment of the fibula 1cm. above the anterior skin incision.

Retract the skin and fat with a Langenbeck retractor.

There should be very little bleeding if the operation is being done for arterio-sclerosis.

Clamp vessels with forceps as necessary.

Step 9.02. Divide the fibula.

Use bone cutters to cut the fibula 1 cm. above the anterior skin incision.

Cut the bone obliquely so that the outer side of the cut bone does not press on the skin.

If you are not strong enough:

Use a Gigli saw.

Trim off sharp edges of the bone with bone nibblers.

Chapter 14. Op Section 10.00. Cutting the posterior muscles.

Step 10.01. Develop the posterior flap.

Use a scalpel with a 22 Swann-Morton blade.

Start by deepening the distal end of the incision into the gastrocnemius and soleus.

Cut down to the posterior surface of the tibia and fibula.

Dissect upwards in this plane to make the posterior flap.

This consists of skin, fat, and most of the calf muscles.

Continue upwards to the level of planned tibial resection.

ie. 2cm. below the tibial tubercle, 15cm. below the tibial plateau.

Do the dissection quickly to avoid excess blood loss.

Avoid your own and your assistant's fingers.

Step 10.02. Control major vessels.

In particular, the popliteal artery, but also lesser arteries, soleal veins, any grafts, and tributaries of the long and short saphenous veins.

Use artery forceps and 2/0 Vicryl ties (Ethicon W9025).

Cut the ends of the sutures 3mm. long.

If there is excessive bleeding:

Check the tourniquet pressure.

Increase the pressure up to twice the patient’s systolic pressure.

Step 10.03. Cut the posterior tibial nerve.

Pull the nerve down into the wound with an artery forcep.

Use a scalpel to cut the nerve straight across, high in the wound.

Let the nerve retract upwards out of danger from postoperative adhesions and amputation neuroma.

Chapter 15. Op Section 11.00. Review the operation so far.

The tibia now should be fully exposed at the level of the anterior skin incision.

The posterior flap of skin and muscles (mainly gastrocnemius and soleus) should be hanging away from the tibia at the level of the anterior skin incision.

The major vessels should, by now, be ligated.

Chapter 16. Op Section 12.00. Cutting the tibia.

There are two saw cuts.

The first makes an oblique slope on the front of the tibia.

The second is transverse to complete the division of the bone.

Step 12.01. Elevate the anterior tibial periosteum.

Use a periosteal elevator to pull the periosteum of the anterior tibia proximally 2cm.

This will expose the tibia, free from periosteum and adventitia, ready for the oblique anterior saw cut.

Step 12.02. Retract skin, fat and muscle.

Use an amputation retractor to protect the proximal tissues.

Step 12.03. Make the first saw cut.

This cut will make an atraumatic oblique front to the tibia.

Use an amputation saw.

Start 12 cm. below the tibial plateau.

Angle the saw 45 degrees downwards towards the heel.

Cut halfway across the tibia.

Step 12.04. Make the second saw cut.

Fifteen cm. below the tibial tubercle, cut right through the thickness of the tibia with the saw held perpendicular to the long axis of the bone.

These 2 cuts remove an anterior wedge of tibia to reduce the pressure on the front of the myoplastic flap.

Round off all the edges of the tibia with bone nibblers and a bone file.

Step 12.05. Complete the amputation.

Cut through residual muscle.

Step 12.06. Discard the amputated part.

Chapter 17 Op Section 13.00. Fashioning the amputation stump.

Leg with gangrene burgess cross section skin incision - 2nd copy.png







Step 13.01. Trim the bone.

Use bone nibblers and a bone file to remove jagged edges and to round off any anterior surfaces on the tibia.

Step 13.02. Examine the stump.

Place a fresh towel on the operating table.

Lay the limb down on the fresh towel.

Plug any medullary bleeding with Horsley's bone wax.

Step 13.03. Trim the muscle.

Use a scalpel to shave the muscle down to a 2cm. layer.

This muscle should fold over the lower end of the tibia to meet the periosteum of the anterior surface of the tibia without any tightness.

Trim the muscle laterally and medially so that it does not bulge out of the wound.

This muscle shaving is of great importance.

Beginners are likely to leave too much muscle, which leads to tight flaps, necrosis and infection.

Step 13.04. Check the length of the SKIN of the posterior flap.

Unlike the muscles of the posterior flap, the skin of the posterior flap will not retract noticeably during the operation.

The skin and fat of the posterior flap should fold forward and overlap the skin of the anterior flap by 3 cms.

This will allow for contraction of the flap in the next week or two.

If it looks as if the skin is twice as long as is needed:

This is about right.

Remove any excess of muscle that might be holding the skin of the posterior flap away from the skin of the anterior flap.

Remove any muscle squashing out at the sides.

Trim away excess skin cautiously:

You probably do not need to do this.

If there is any shortness of the skin:

Thin the muscle more.

If there is still shortness:

Remove more tibia and fibula, (to a minimum of 8cm. of tibia).

If the flap is still too short:

The flap will probably fail.

Consider an above knee amputation.

Step 13.05. Check the length of the MUSCLE of the posterior flap.

The muscular part of the flap will retract by about 3cm. as it is cut.

Nevertheless, it should be long enough to overlap the periosteum of the anterior tibia by 1cm.

Trim off excess length of muscle and aponeurosis.

If there is shortness:

Shave off some more muscle.

If there is still shortness:

Remove more tibia and fibula, (to a minimum of 8cm. tibia).

If there is still shortness:

The flap will probably fail.

Consider an above knee amputation.

Step 13.06. Control bleeding.

Release the tourniquet.

Step 13.07. Check haemostasis in:

Bone ends.

Use Horsley’s bone wax.

Muscles, especially the soleus sinuses.

Use diathermy, or underrun with eg 2/0 Vicryl (Ethicon W9136).

Tie off blood arteries and veins.

Retie with eg 2/0 Vicryl ties (Ethicon W9025),

Bleeding nerve ends.

Tie off with 2/0 Vicryl ties (Ethicon W9025).

If bleeding continues:

Reapply the tourniquet.

Wait 5 minutes.

Release the tourniquet.

Repeat the haemostasis procedures.

Consider detatching the myoplastic flap for better access.

For a Burgess procedure:

GO TO: Chapter 25 Op Section 21.00. Suturing the myoplastic flap.

Chapter 18 Op Section 14.00. Robinson skew-flaps and myoplastic flap procedure

Step 14.01. Mark on the skin, the sites of cutting of the tibia and fibula.

Bone cutting sites.png







Use a sterile tape measure.

Ideally this will be 15cm. below the level of the tibial plateau and 12cm. below the level of the tibial plateau for the fibula.

Cutting the tibia as little as 8cm. below the tibial plateau is acceptable for a below knee amputation revision.

Use a marker that will not wash off and will not tattoo the skin.

eg Magic Marker.

Step 14.02 Mark the skin incisions.

MArking for Robinson skiin flaps.png






Pass a sterile tape measure round the leg at the level of tibial division.

Place the zero of the tape 2cm. lateral to the lateral border of the tibia.

Mark this point.

This will be the anterior junction of the two flaps.

Mark the back of the leg half way round the tape.

This will be the posterior junction of the flaps.

To mark the sites of the apex of each flap:

Mark the leg one quarter and three quarter of the way round the leg.

To mark the length of the flaps:

Measure downwards from the site of cutting the tibia.

Measure 15cm. plus ¼ the diameter of the leg at the level of the tibial resection. (Commonly 20- 25 cm.)

To mark the flaps themselves:

Mark a slightly elliptical flap from the antero-medial junction point, through the apex point and round to the postero-lateral junction point.

If you are unfamiliar with the Robinson technique:

Make the skin flaps 2cm. longer to allow for trimming later.

Repeat for the postero-lateral flap.

Extend the marks of the antero-medial junction of the skin flaps 4cm. proximally.

This will allow easier access to the anterior muscle compartment later.

Chapter 19 Op Section 15.00. Incising and developing the skin flaps.

Step 15.01 Incise the antero-medial skin flap.

9 Robinson skin incisions.png







Use a no 22 Swann-Morton scalpel.

Cut through skin and subcutaneous fat round the skin flap.

On the medial side of the flap, identify and free the saphenous nerve from the long saphenous vein.

Divide the nerve under tension with a scalpel.

Ligate and divide the long saphenous vein.

Step 15.02 Incise the postero-lateral skin flap.

Use a no 22 Swann-Morton scalpel.

Cut through skin and subcutaneous fat round the skin flap.

On the posterior aspect of the skin flap, identify and free the sural nerve from the short saphenous vein.

Divide the nerve under tension with a scalpel.

Ligate and divide the short saphenous vein.

Step 15.03 Develop the antero-medial skin flap.

Leg with gangrene Robinson 4.png






Dissect the skin flap off the deep fascia of the underlying calf muscles and periosteum of the tibia.

Use scissor dissection.

Start at the distal end of the flap.

Continue proximally to the level of division of the tibia.

Step 15.04 Develop the postero-medial skin flap.

Dissect the skin flap off the deep fascia of the underlying calf muscles.

Use scissor dissection.

Start at the distal end of the flap.

Continue proximally to the level of division of the tibia.

Chapter 20 Op Section 16.00. Cutting the fibula.

Step 16.01 Anterior compartment.

Retract the antero-medial flap upwards.

Use a Langenbeck retractor.

If there is difficulty in access:

Incise the skin and fat proximally at the anterior junction of the skin flaps

Divide the muscle of the anterior compartment transversely.

Tibialis anterior.

Use a no 22 Swann- Morton scalpel.

Identify the anterior tibial artery, veins and nerve.

Ligate vessels with eg 2/0 Vicryl ties (Ethicon W9025).

Divide vessels and cut the nerve sharply.

Step 16.02 Peroneal muscles and musculocutaneous nerve.

Cut the peroneus longus and brevis muscles transversely.

Identify the musculo-cutaneous nerve and divide sharply.

Step 16.03. Expose the upper end of the fibula.

Expose a 2 cm. segment of the fibula 1cm. above the anterior skin flap incision.

Retract the skin and fat with a Langenbeck retractor.

There should be very little bleeding if the operation is being done for arterio-sclerosis.

Clamp vessels with forceps as necessary.

Step 16.04. Divide the fibula.

Use bone cutters to cut the fibula 1 cm. above the antero-medial skin flap incision.

Cut the bone obliquely so that the outer side of the cut bone does not press on the skin.

If you are not strong enough:

Use a Gigli saw.

Trim off sharp edges of the bone with bone nibblers.

Chapter 21 Op Section 17.00. Cutting the tibia.

Unlike in the Burgess technique:

The tibia is cut across before the muscles.

Then the deep muscles are approached through the gap between the upper and lower sections of the tibia.

Protect the muscles from the saw blade with Langenbeck or larger retractors.

As in the Burgess technique:

There are two saw cuts.

The first makes an oblique slope on the front of the tibia.

The second is transverse to complete the division of the bone.

Step 17.01. Elevate the anterior tibial periosteum.

Use a periosteal elevator to pull the periosteum of the anterior tibia proximally 2cm.

This will expose the tibia, free from periosteum and adventitia, ready for the oblique anterior part of the saw cut.

Step 17.02. Retract skin, fat and muscle.

Use Langenbeck retractors.

Step 17.03. Make the first saw cut.

Use an amputation saw.

Start 2 cm. below the tibial tubercle and 12 cm. below the tibial plateau.

Angle the saw 45 degrees downwards towards the heel.

Cut halfway across the tibia.

Step 17.04. Make the second saw cut.

At the planned level, cut right through the thickness of the tibia with the saw held perpendicular to the long axis of the bone.

These 2 cuts will remove an anterior wedge of tibia to reduce the pressure on the myoplastic flaps.

Round off all tibial edges with bone nibblers and a bone file.

Step 17.05 Complete the amputation.

Retract the distal cut end of the tibia away from the upper end.

Use a bone hook.

Identify the tibialis posterior through the gap between the ends.

Cut through the transversalis posterior.

Clamp posterior tibial vessel and nerves

Fillet the posterior muscles off the back of the tibia and fibula.

Separate the gastrocnemius and soleus from the amputation specimen.

Cut through these two muscles 12cm. above the calcaneum.

Ie at the same level as for the Burgess posterior myo-cutaneous flap.

Cut through any residual muscles to free the amputation specimen from the patient.

Step 17.06 Discard the amputated part.

Chapter 22 Op Section 18.00. Fashioning the amputation stump.

This is the same procedure as for the posterior flap of the Burgess technique, except that there is no skin and fat to dissect.

Step 18.01. Trim the bone.

Use bone nibblers and a bone file to remove jagged edges and to round off any sharp surfaces on the tibia.

Step 18.02. Examine the stump.

Place a fresh towel on the operating table.

Lay the limb down on the fresh towel.

Plug any cortical bleeding from the tibia with Horsley's bone wax.

Step 18.03. Trim the muscle.

Mini 3 Robinson flaps.png







Use a scalpel to shave the gastrocnemius and soleus down to a thickness of 2cm.

This muscle should fold over the lower end of the tibia to meet the periosteum of the anterior surface of the tibia.

Robinson muscle flap folds over end of tibia.png







Trim the muscle laterally and medially so that it does not bulge out of the wound.

This muscle shaving is of great importance.

Beginners are likely to leave too much muscle, which leads to tight flaps, necrosis and infection.

Taper each side of the flap so that the distal end matches the width of the tibial stump.

Ligate posterior tibial and peroneal vessels as encountered.

Cut the posterior tibial nerve short with a scalpel and allow to retract.

If there is excessive bleeding:

Check the tourniquet pressure.

Increase the pressure up to twice the patient’s systolic pressure.

Step 18.04. Check the length of the posterior flap.

The myoplastic flap should be long enough to overlap the periosteum of the anterior tibia by 1cm. without any tightness.

Trim off excess length and thickness of muscle and aponeurosis.

If there is shortness of the flap:

Shave off some more muscle.

If there is still shortness:

Remove more tibia and fibula, (to a minimum of 8cm. tibia).

If there is still shortness:

The flap will probably fail.

Consider an above knee amputation.

Chapter 23 Op Section 19.00. Fashioning the skin flaps.

Step 19.01. Check the skin flaps.

The skin flaps should fold together, with an overlap of one over the other of 3 cm.

This will allow for contraction of the flaps in the next week or two.

Remove any muscle squashing out at the sides.

Trim away excess skin cautiously:

You probably do not need to do this at all.

f there is any shortness of the skin:

Thin the muscle more.

If there is still shortness:

Remove more tibia and fibula, (to a minimum of 8cm. of tibia).

If the flap is still too short:

The flap will probably fail.

Consider an above knee amputation.

Chapter 24.Op Section 20.00. Checking haemostasis.

Step 20.01 Release the tourniquet.

Step 20.02 Check haemostasis in:

Bone ends.

Use Horsley’s bone wax.

Muscles, especially the soleus sinuses.

Use diathermy, or underrun with eg 2/0 Vicryl (Ethicon W9136).

Tie off blood arteries and veins.

Retie with eg 2/0 Vicryl ties (Ethicon W9025),

Bleeding nerve ends.

Tie off with 2/0 Vicryl ties (Ethicon W9025).

If bleeding continues:

Reapply the tourniquet.

Wait 5 minutes.

Release the tourniquet.

Repeat the haemostasis procedures.

Consider detaching the myoplastic flap for better access.

Chapter 25 Op Section 21.00. Suturing the myoplastic flap.

Step 21.01. Suture the posterior flap.

Robinson amputation


Robinson posterior muscle stitched to anterior tibial stump.png





Burgess amputation

Burgess posterior flap attached.png








Stitch the muscle and aponeurosis of the posterior flap to:

The periosteum of the anterior part of the stump of the tibia.

To the deep fascia and ends of tibialis anterior and peroneal muscles.

Use eg interrupted 1 Vicryl (Ethicon W9251).

Insert the stitches at 1cm. intervals.

Cut the ends 3mm. long.

Trim off any muscle bulging out at the ends of the closure.

Step 21.02. Insert a suction drain.

Robinson amputation

11 Myoplastic flap attached.png








Burgess amputation


Leg with gangrene burgess cross section amptation closed.png






Use eg a Portovac drain.

Run the drain along the space between the muscle and the inferior surface of the tibia.

Bring the drain out laterally 10 cms. proximal to the amputation in healthy tissue, away from contamination by perineal organisms.

Avoid vessels in the subcutaneous tissues.

Step 21.03. Cut the drain to fit into the space.

Use stitch scissors.

Step 21.04. Cut the spike off the drain.

Use stitch scissors to cut the drain at 45 degrees to allow easy insertion into the suction container.

Step 21.05. Tuck the drain into the space.

Check the drain does not knot or press on delicate structures.

Step 21.06. Stitch the drain to the skin.

Use No.1 silk (Ethicon W799).

Tie 4 half hitches at skin level.

Tightly enough to just narrow the drain tube very slightly.

Wrap the tie tightly around the drain 4 times at skin level.

Tie 4 more half hitches to finish.

Cut the silk ends 4 cms. long.

Chapter 26 Op Section 22.00. Suturing the skin.

Step 22.01 Stitch the subcutaneous fat.

Use eg 2/0 Vicryl (Ethicon W 9093).

Step 22.02 Check the swab, needle, and instrument counts.

Step 22.03. Close the skin.

Use eg continuous subcuticular 3/0 Vicryl (Ethicon W9890).

Burgess amputation

3 left leg Burgess skin closure.png







Robinson amputation

Left leg Robinson skin closure.png







Step 22.04. Spray the wound.

Use an acrylic spray (eg Nobecutaine).

Step 22.05. Check there is no other procedure to do.

Step 22.06. Apply a skin dressing.

Use a compliant dressing (eg Mepore).

Step 22.07. Dress the wound drain.

Use a compliant dressing (eg Mepore).

Apply a crepe bandage only if the patient is likely to disturb his wounds.

Continue protecting the other limb from pressure and trauma.

Step 22.08. Connect the suction system.

Step 22.09. Start the suction system.

Compress the vacuum chamber and close the plug on it.

Step 22.10. Remove the tourniquet and under-towel.

Chapter 27. Op Section 23.00. Final touches and WHO safe surgery checklist and sign out.

Step 23.01. Clean the skin surrounding the dressing.

Use eg 0.5% Chlorhexidene in 70% Propanol.

Step 23.02. Give antibiotics if not given previously.

Continue antibiotics for any previously identified organism.

OR

Give Amoxycillin 250MG. and Flucloxacillin 250MG. intravenously or orally for five days unless there is a Penicillin allergy.

Step 23.03. Prescribe calcium heparin.

Give 5000 units subcutaneously b.d. until the patient leaves hospital.

Step 23.04. Check the wound drain is working.

Step 23.05. Write legible operation details.

Step 23.06. Fill in the surgical audit form.

Step 22.07. Dictate an operation letter to the general practitioner:

Plus a copy to the referring Physician.

WHO safe surgery checklist sign out.

End of operation.

===Chapter 28. Equipment and materials===.

Basic pack ortho knee

Cotton wool sheet

Instruments

Sterile tape measure

2 sponge holders

Charnleys p.e.

2 needle holders

Bone file

Periosteal elevator

2 Langenbeck retractors

Bone hook

5 Lanes tissue forceps

Bone cutter

20 curved Jolls forceps

Bone nibbler

Towel clips

Blakes retractor

Assistant’s scissors

Amputation knife

1 nontoothed dissecting forceps

2x no 4 knife handles

1 amputation saw

Large Langenbecks retractors

Amputation retractor

Preparation

Hibitane wet x2, dry x1, ether meth x1

Sutures no material

Ties 2x Ethicon w9052 2/0 vicryl

Fascia 2x Ethicon w9251 1 vicryl

Fat 1x Ethicon w9251 1 vicryl

Skin 1x Ethicon w9890 3/0 vicryl

Drain 1x Ethicon w793 1 silk

Other Blades 2x 22 Swann-Morton

Diathermy

Monopolar, flex, holder, medium forceps

Drains

1x Portovac

Patient's position

Supine

Table fittings

Wound antibiotic 0

Wound infiltration 0

Sprays

Nobecutaine

Catheters 0


Dressings Primapore Tourniquet equipment


Recommended Cuff Size Zimmer ATS Cylindrical Cuff

Limb Circumference Range

8 in. (20 cm) 6.0-7.5 in. (15-19 cm)

12 in. (30 cm) 7.5-11.0 in. (19-28 cm)

18 in. (46 cm) 10.5-16.5 in.(27-42 cm)

24 in. (61 cm) 16.5-23.0 in. (42-58 cm)

30 in. (76 cm) 21.0-28.0 in. (53-71 cm)

34 in. (86 cm) 22.5-32.0 in. (57-81 cm)

42 in (107 cm) 28.0-40.0 in. (71-102 cm)


Chapter 29. References and further reading.

J Beard and W Al-Jundi Lower Limb Amputation Oxford Textbook of Vascular Surgery 2015 .

E M Burgess The Below-Knee Amputation. ICIB 1969 vol 8 4 1-22.

K. J. O'Dwyer and M. H. Edwards The association between lowest palpable pulse and wound healing in below knee amputations. Ann R Coll Surg Engl. 1985 Jul; 67(4): 232–234.

Standards of Practice for Safe Use of Pneumatic Tourniquets ... http://www.ast.org/uploadedFiles/Main_Site/Content/About_Us/Standards%20Pneumatic%20Tourniquets.pdf

Trans tibial surgical techniques. Surgical_technique_TTA.pps in www.austpar.com http://www.austpar.com/portals/acute_care/docs-and-presentations/Surgical_Technique_TTA.pps

Tourniquet technique VBM Medizintechnik http://www.vbm-medical.de/cms/files/blutsperre_leitfaden_2.0_05.09_gb.pdf

Chapter 30. We welcome your comments.