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Annals of The Royal College of Surgeons of England logoLink to Annals of The Royal College of Surgeons of England
. 2019 Sep 18;102(2):162–163. doi: 10.1308/rcsann.2019.0127

Through-knee amputation: mediolateral fasciocutaneous flaps with the addition of a protective gastrocnemius layer

L Eid-Arimoku 1,✉, M Brooks 1
PMCID: PMC6996440  PMID: 31532224

Background

Despite several biomechanical advantages (enhanced proprioception, a longer lever and an end-weight bearing stump)1 through-knee amputation is performed much less frequently than transfemoral amputations.2 Concerns regarding higher rates of wound complications have recently been evaluated with no significant difference found between the two levels.3 Several approaches to fashioning through-knee flaps have been reported.1 None instructs on mediolateral fasciocutaneous flaps fashioned from specific, predefined measurements that facilitate reproducible results. This technique, together with the use of a gastrocnemius muscle flap to cover bone, is described.

Technique

  • Mark and measure the circumference at the level of the tibial tuberosity (Fig 1).

  • One-quarter the length of the circumference medial and lateral to the tibial tuberosity marks midpoint of base of the flaps.

  • One-sixth the length of the circumference from the midpoints distally marks apex of flaps (Fig 1).

  • Complete markings to define fasciocutaneous flaps (Fig 2).

  • Dissect through the knee joint preserving the patella, hamstring tendons, cruciate ligaments and sciatic nerve.

  • Distract the leg anteriorly; control and transfix the pedicle.

  • Isolate the gastrocnemius muscle.

  • Suture hamstring and patellar tendons to the cruciate ligaments.

  • Secure the gastrocnemius over the femur (Fig 3).

  • Insert a suction drain deep to the muscle flap.

  • Close the fascia and skin (Fig 4).

Figure 1.

Figure 1

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Circumferential skin marking at the level of the tibial tuberosity and one-sixth circumference length to mark apical height of fasciocutaneous flaps.

Figure 2.

Figure 2

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Skin marking of mediolateral fasciocutaneous flaps.

Figure 3.

Figure 3

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The gastrocnemius muscle provides good coverage of femur.

Figure 4.

Figure 4

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Completed through-knee amputation.

Discussion

Through-knee amputation is a rarely performed but safe alternative to above-knee amputation in selected patients.1,2 Wound healing remains problematic in all major amputations.1–4 Preserving the gastrocnemius muscle may aid wound healing in general and facilitates vacuum-assisted wound management in particular.

References

  • 1.Albino F, Seidel R, Brown B et al. Through knee amputation: technique modifications and surgical outcomes. Arch Plast Surg 2014; : 562–570. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Lim S, Javorski M, Halandras P et al. Through-knee amputation is a feasible alternative to above-knee amputation. J Vascular Surg 2018; : 197–203. [DOI] [PubMed] [Google Scholar]
  • 3.Schmiegelow M, Sode N, Riis T et al. Re-amputations and mortality after below-knee, through-knee and above-knee amputations. Dan Med J 2018; : pii: A5520. [PubMed] [Google Scholar]
  • 4.National Vascular Registry 2018 Annual Report. London: Royal College of Surgeons of England; 2018. [Google Scholar]

Articles from Annals of The Royal College of Surgeons of England are provided here courtesy of The Royal College of Surgeons of England

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