Below knee amputation with resection of the gastrocnemius and soleus muscles. (BG)

Abstract

<h3>Introduction</h3> There are many techniques described for below knee amputation. All of these techniquesdescribe a method to cover the end of the tibia with portions of the soleus and gastrocnemius muscles, fascia, subcutaneous tissue and skin. Some lower legs are large and it is difficult to close the fascia and skin over bulky muscle under tension. The commonly used Burgess technique (BT) removes the soleus muscle leaving the gastrocnemius muscle. The circulation in the muscle in the stump may be compromised due to the tension required to close the wound. In the BG technique the gastrocnemius and soleus muscles are removed. Closure is easier and under less tension. Previous cadaver angiographic studies have shown that the blood supply to the posterior calf skin is via subfascial arteries and veins and does not depend on the underlying muscle. Some may argue that muscle and fascia over the end of the tibia is protective, however, weight bearing with a total contact prosthesis is on the proximal tibia and patellar tendon. The end of the tibia only pushes the prosthesis back and forth. The muscle atrophies as seen in older BKA stumps. The objective of this report was to compare BG to BT for wound healing. <h3>Method</h3> A retrospective chart review was done from January 1, 2017 - November 1, 2019. A single surgeon performed 41 below knee amputations on patients 46-84 years old. 26 were BG and 15 BT. Indications for amputation in the BG group were: Osteomyelitis 5, Diabetic foot infection 5, ischemic gangrene 11, wet gangrene 2, chronic pain 1, venous stasis ulcers 1 and open dislocation fracture 1. Indications for amputation in the BT group were: Osteomyelitis 2, diabetic foot infection 3 and ischemicgangrene 10. <h3>Results</h3> In the BG group primary wound healing was observed in 18 patients, 2 patients fell, needing long term care and revision, 2 had infection needing wound care, 2 died within the 1^st month and 2 werelost to follow-up. In the BT group primary healing was observed in 9 patients, 3 had wound issues, 1 died within the 1^st month, 1 required revision of the BKA to AKA and 1 was lost to follow-up. <h3>Conclusion</h3> BG is a technique for BKA that avoids closing the wound under tension. Primary wound healing appears consistent with other techniques. A prospective randomized study comparing BG to other BKA methods would be necessary to prove the benefits of BG over other methods.