You are on page 1of 24

Transtibial amputation

• Transtibial amputation has become the most
common level.
• The importance of preserving the patient’s
own knee joint in the successful rehabilitation
of a patient with a lower extremity
amputation cannot be overemphasized.

The appropriate level must be determined for each individual patient. .• Transtibial amputations can be divided into three levels.

all procedures may be divided into those for nonischemic limbs and those for ischemic limbs.• Although many variations in technique exist. • These two general techniques vary primarily in the construction of skin flaps and in muscle stabilization techniques. .

transected muscle groups are sutured to bone under physiological tension. such as opposing muscle groups or fascia.• Tension myodesis. muscle is sutured to soft tissue. . • Myoplasty.

. myoplastic closures are performed. but some authors have advocated the use of the firmer stabilization provided by myodesis in young.Nonischemic limbs: • In most instances. active individuals.

• A long posterior myocutaneous flap and a short or even absent anterior flap are recommended for ischemic limbs because anteriorly the blood supply is less abundant than elsewhere in the leg.Ischemic limbs: • Tension myodesis is contraindicated because it may compromise further an already marginal blood supply. .

healthier population with fewer comorbidities. partly because of a younger. . Nonischemic limb • Rehabilitation after transtibial amputations in nonischemic limbs generally is quite successful.

Nonischemic limb • A longer residual limb would have a more normal gait appearance. but stumps extending to the distal third of the leg have been considered suboptimal because there is less soft tissue available for weight bearing and less room to accommodate some energy storage systems. • The distal third of the leg also has been considered relatively avascular and slower to heal than more proximal levels. .

depending on body height.5 to 17. Nonischemic limb • In adults. . the ideal bone length for a below- knee amputation stump is 12.5 cm. • Usually the most satisfactory level is about 15 cm distal to the medial tibial articular surface. • A stump less than 12.5 cm of bone length for each 30 cm of body height. • Rule of thumb: allow 2.5 cm long is less efficient.

Nonischemic limb • Stumps lacking quadriceps function are not useful. In a short stump of 8. .8 cm or less it has been recommended that the entire fibula together with some of the muscle bulk be removed so that the stump may fit more easily into the prosthetic socket.

.

.

.

. unless the patient is immunocompromised. and protects the limb from external trauma. or there are concomitant injuries or medical conditions that preclude early initiation of physical therapy. • An immediate postoperative rigid dressing helps control edema. limits knee flexion contracture. there are skin graft issues. Nonischemic limb Postoperative care: • fairly aggressive.

Nonischemic limb Postoperative care: • fairly aggressive. there are skin graft issues. . unless the patient is immunocompromised. or there are concomitant injuries or medical conditions that preclude early initiation of physical therapy. and protects the limb from external trauma. limits knee flexion contracture. • An immediate postoperative rigid dressing helps control edema.

. The cast is changed every 5 to 7 days for skin care. or crutches. • Within 3 to 4 weeks. a walker. • Weight bearing is limited initially. with bilateral upper extremity support from parallel bars. the rigid dressing can be changed to a removable temporary prosthesis if there are no skin complications.• A prosthetist can be helpful with such casting.

g. • amputations performed in ischemic limbs are customarily at a higher level (e.. Ischemic limb • All techniques stress the need for preserving intact the vascular connections between skin and muscle by avoiding dissection along tissue planes and by constructing myocutaneous flaps.5 cm distal to the joint line) than are amputations in nonischemic limbs. . 10 to 12.

Compared with controls. decreased drop in postoperative hemoglobin levels. revision. examining the effects of an exsanguination tourniquet in transtibial amputation of dysvascular limbs revealed decreased blood loss. or wound breakdown were noted. . • A randomized-controlled trial. no increase in the rates of wound healing. Ischemic limb • Traditionally. however. and a decreased need for blood transfusion. tourniquets have not been used in the amputation of dysvascular limbs to avoid damage to more proximal diseased arteries.

.

.

.

.

. Reference • Campbell 12th ed.