Right-sided through-the-knee amputation in Fontaine stage IV peripheral arterial disease – Vascular Surgery - vascular surgery

Circular skin incision down to the crural fascia a good one handbreadth inferior to the knee joint/tibial plateau. Fashion a full-thickness skin tube by sharp and blunt dissection until the outline of the joint space up to the patellar ligament appears. First, fashion the anterior skin tube until the patellar ligament is exposed. Dissection will reveal the post-inflammatory soft tissue edema characteristic of PAD stage IV. Divide between clamps the great saphenous vein.

Tip:

The skin around the knee area is highly elastic and retracts more than usual. Skin closure under tension will definitely result in impaired wound healing with skin necrosis.

With a scalpel, transect the patellar ligament, collateral ligaments and joint capsule medially and laterally.

Likewise, transect sharply with the scalpel along the tibial plateau the cruciate ligaments now being exposed. The medial and lateral joint capsule can then be transected further posteriad.

Tip:

This maneuver is simplified by pulling the tibial head anteriad ("anterior drawer sign"), which puts traction on the ligaments and capsule.

Traction on the tibial head will tense the posterior part of the joint capsule  which is then transected sharply. Follow this with transecting in one motion the gastrocnemius heads and popliteal vessels, as well as the posterior tibial nerve. Clamp the ends of the transected popliteal artery.

Tip:

Never resect the gastrocnemius heads any further! They harbor important collateral vessels responsible for the blood supply to the joint capsule and the full-thickness skin tube. These small vessels are essential for wound healing.