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TRANSTIBIAL (BELOWKNEE) AMPUTATIONS

Amsal P. Sinaga

Transtibial amputations can be divided


into three levels

nonischemic limbs
skin flaps and
muscle design

tension
myodesis
tension
myoplasty

Canale & Beaty: Campbell's Operative Orthopaedics,


11th ed.
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tension
myodesis
: transected muscle
groups are sutured to
bone under
physiological tension
Canale & Beaty: Campbell's Operative Orthopaedics, 11th
ed.

tension
myoplasty
The muscle is sutured
to soft tissue, such as
opposing muscle
groups or fascia
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Amputation through middle third of leg


for nonischemic limbs.
A. Fashioning of equal anterior and posterior
skin flaps, each one half anteroposterior
diameter of leg at level of bone section.

Canale & Beaty: Campbell's Operative Orthopaedics,


11th ed.

B. Division and ligation of anterior tibial


vessels and division of deep peroneal nerve.

C. Fashioning of posterior myofascial flap.

D. Suture of myofascial flap to periosteum


anteriorly.

E. Closure of skin flaps

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AFTER-TREATMENT

fairly aggressive
rigid dressing helps control
edema
limits knee flexion contracture
protects the limb from external
trauma
A prosthetist can be helpful
with such casting
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AFTER-TREATMENT
A jig that allows attachment
and alignment for early pylon
use
The cast can be changed every
5 to 7 days
Within 3 to 4 weeks, the rigid
dressing can be changed to a
removable temporary
prosthesis
Several months, transitions of
temporary prosthetics to the

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ErnestM.Burgess.M.D. JosephH.Zettl,C.P. Principal Investigator, Prosthetics


Research Study,Seattle,Wash.,and Director of Amputations and Congenital
Defects Service,Children's Orthopedic Hospital, Seattle, Wash, V5261P-438

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Ischemic limbs
a long and a short
posterior myocutaneous
flap

tension myodesis
is
contraindicated
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Transtibial amputation in ischemic


limbs.
A, Fashioning of short anterior and
long posterior skin flaps.

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B, Separation and removal of


distal leg.

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C, Tailoring of posterior muscle


mass to form flaps

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D, Suture of flap to deep fascia


and periosteum anteriorly.

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E, Closure of skin flaps.

Redrawn from Burgess EM, Zettl JH: Amputations below the knee. Artif Limbs
13:1, 1969
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AFTER-TREATMENT
A soft dressing
Rigid dressing (early
ambulation)
The cast that extends
proximally to midthigh
The cast should be removed in
5 to 7 days
If wound healing is
satisfactory, a new rigid
dressing or prosthetic cast is
applied

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ErnestM.Burgess.M.D. JosephH.Zettl,C.P. Principal Investigator, Prosthetics


Research Study,Seattle,Wash.,and Director of Amputations and Congenital
Defects Service,Children's Orthopedic Hospital, Seattle, Wash, V5261P-438

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