Below knee amputation

1.Position the patient supine with foot wrapped in drape/crepe.
2.Make an incision (Burgess) a hands-breadth or 10cm below the tibial tuberosity. Ligate the long saphenous vein.
3.Divide through anterior compartment with anterior tibial artery and deep peroneal nerve situated on the interosseus membrane. Ligate large vessels and nerves. Divide through lateral compartment ligating superficial peroneal nerve in the substance of peroneus longus.
4.Define the level of transection of bone with a periosteal elevator. Divide the fibula at a more proximal level (at least 1.5cm) using bone cutting forceps. Transect the tibia with a Gigli saw and bevel the edges round.
5.Divide through posterior compartment (On entering the popliteal fossa, in the upper part the relationship is AVN(tibial) from medial to lateral whence it arches laterally midway and in the lower part of the fossa reassumes its previous relationship i.e. NVA and crosses the soleal arch) ligating posterior tibial artery and tibial nerve medially with peroneal artery adjacent to the medial aspect of the fibula on the posterior surface of tibialis posterior.
6.Create a long posterior myocutaneous flap, consisting of muscular fibres of gastroecnemius NOT tendon, supplemented with soleal fibres if needed. Ligate short saphenous vein and sural nerve in the subcutaneous tissue at the inferior apex of the flap.
7.Place an epineural catheter near the stump of the tibial nerve and infiltrate bupivacaine.
8.Close in layers using 3/0 vicryl/monocryl.