Below-Knee Amputation (BKA)
[Right / Left] lower extremity [chronic limb-threatening ischemia with gangrene / infected nonhealing wound / nonsalvageable foot infection]; below-knee amputation planned
Same
[Right / Left] below-knee (transtibial) amputation with long posterior flap and myoplasty
[***, MD/DO]
[Resident/PA name]
[General / Regional / Neuraxial]
The patient is a [age]-year-old with a nonsalvageable [right / left] foot due to [chronic limb-threatening ischemia with gangrene / an infected nonhealing wound / an uncontrolled foot infection]. Limb salvage was not feasible because [reason]. A transtibial level was selected based on functional potential, the proximal extent of nonviable or infected tissue, and clinical and objective perfusion assessment indicating a reasonable likelihood of healing. The risks, benefits, and alternatives were discussed, and informed consent was obtained.
[Gangrene / Tissue loss / Infection] extended to the [toes / forefoot / midfoot / ankle] and remained distal to the planned flap. Skin and muscle at the transtibial level were viable with bleeding edges, and no gross purulence was present at the final proximal tissue or bone planes. The tibia was divided [distance] distal to the tibial tubercle, and the fibula was divided [distance] proximal to the tibial level. The completed posterior flap was well perfused and closed without tension. Preoperative perfusion assessment included [clinical examination / Doppler waveforms / transcutaneous oxygen measurement / skin perfusion pressure] with [result].
The patient was positioned supine with pressure points padded. The [right / left] lower extremity was prepared and draped, and the distal wound was isolated from the operative field. A long posterior myocutaneous flap was marked using viable tissue. The anterior incision was placed at the planned tibial transection level, [distance] distal to the tibial tubercle, and the posterior flap was extended distally to provide durable, tension-free coverage.
Skin, subcutaneous tissue, and fascia were divided. The encountered saphenous veins were ligated and divided. The anterior and lateral compartment muscles were divided at the planned level, the anterior tibial vessels were suture ligated, and the interosseous membrane was divided. The tibial periosteum was elevated proximally, and the tibia was divided with a [Gigli saw / oscillating saw]. The anterior tibial crest and all sharp bone edges were beveled and smoothed. The fibula was divided 1 to 2 cm proximal to the tibial level with a [bone cutter / oscillating saw], without excessive shortening.
The posterior flap was completed in a plane deep to the tibia and fibula while preserving sufficient gastrocnemius and soleus tissue for distal padding. The posterior tibial and peroneal vascular bundles were individually suture ligated and divided. The tibial, superficial and deep peroneal, and sural nerves were identified as encountered, placed under gentle traction, divided sharply, and allowed to retract proximal to the distal weight-bearing surface.
The specimen was passed off for pathology. The wound was irrigated to remove bone dust and debris, and meticulous hemostasis was obtained. The skin, muscle, and bone at the final level remained viable without gross residual infection. A posterior myoplasty was performed by advancing the gastrocnemius-soleus fascia over the tibial end and securing it to the anterior compartment fascia with interrupted absorbable sutures. This provided stable soft-tissue coverage without excess bulk or tension. The subcutaneous tissue was approximated, and the skin was closed with [staples / interrupted monofilament sutures]. A nonadherent dressing, padded compression wrap, and knee immobilizer were applied with the knee in extension.
None
Amputated [right / left] lower leg and foot sent to pathology
[X] mL
[None / Closed-suction drain in the deep space]
The patient tolerated the procedure well and was taken to the PACU in stable condition. Knee-extension positioning, residual-limb protection, rehabilitation, and prosthetic planning were initiated.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: *** lower extremity ***, below-knee amputation planned
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: *** below-knee (transtibial) amputation with long posterior flap and myoplasty
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: ***
INDICATIONS: .PTAGE-year-old .PTSEX with a nonsalvageable *** foot due to ***. Limb salvage was not feasible because ***. The transtibial level was selected based on functional potential, extent of disease, and clinical and objective perfusion assessment. Consent obtained.
FINDINGS: Disease extended to *** and remained distal to the planned flap. Final skin, muscle, and bone planes were viable without gross purulence. Tibia divided *** distal to the tibial tubercle; fibula divided *** proximal to the tibial level. Posterior flap well perfused and closed without tension. Perfusion assessment: ***.
PROCEDURE:
Supine with pressure points padded. *** lower extremity prepared and draped; distal wound isolated. A long posterior myocutaneous flap was marked in viable tissue. Skin, subcutaneous tissue, and fascia were divided. Encountered saphenous veins were ligated. Anterior and lateral compartments were divided, the anterior tibial vessels were suture ligated, and the interosseous membrane was divided. Tibia divided at *** with the anterior crest and sharp edges beveled. Fibula divided 1-2 cm proximal without excessive shortening. Posterior flap completed with sufficient gastrocnemius-soleus padding. Posterior tibial and peroneal vessels were suture ligated. Tibial, superficial and deep peroneal, and sural nerves were divided sharply under gentle traction and allowed to retract. Specimen sent to pathology. Wound irrigated; hemostasis obtained. Final tissue planes were viable without gross infection. Posterior myoplasty secured the gastrocnemius-soleus fascia over the tibia to the anterior fascia without tension. Skin closed with ***. Padded compression dressing and knee immobilizer applied in extension.
EBL: *** mL
SPECIMENS: Amputated below-knee segment to pathology
COMPLICATIONS: None
DISPOSITION: PACU, stable. Rehab notified.
Signed: .ME, .MYDEGREE
.TODAYVariants
Open Guillotine Amputation for Source Control
Because of [sepsis / hemodynamic instability / rapidly progressive infection], an open guillotine lower-leg amputation was performed for urgent source control. A circumferential incision was made at the [ankle / distal lower-leg] level proximal to grossly nonviable tissue. Soft tissue and bone were divided without flap creation, named vessels were suture ligated, and encountered nerves were divided sharply under traction. The specimen was sent to pathology, and [deep tissue / bone] was sent for culture. Hemostasis was obtained, and the wound was left open with a sterile bulky dressing. Formal revision and flap closure are planned after infection control and physiologic stabilization.
Formalization and Closure After Guillotine Amputation
The prior open guillotine amputation site was inspected after source control and stabilization. A definitive long posterior flap was marked proximal to the contaminated wound margin in clinically viable tissue. The prior wound, residual nonviable tissue, and distal tibia and fibula were excised to the planned transtibial levels. The tibia was beveled, the fibula was left 1 to 2 cm shorter, and all sharp edges were smoothed. The final muscle and bone planes were [free of gross infection / sampled separately for culture and pathology]. Vessels and nerves were managed as described in the definitive procedure. After irrigation and hemostasis, a posterior myoplasty provided stable coverage of the tibial end, and the flap was closed without tension over [no drain / a closed-suction drain]. A padded dressing and knee immobilizer were applied in extension.
Gastrocnemius Myodesis to the Tibia
In addition to routine flap preparation, two drill holes were placed in the anterior tibial cortex. Heavy nonabsorbable sutures were passed through the gastrocnemius fascia and secured through the drill holes, advancing stable muscle coverage over the distal tibia without strangulating the flap. The remaining deep fascia and skin were then closed without tension.
Proximal Bone or Deep-Tissue Sampling
After removal of the amputated segment, a separate specimen of [proximal tibial bone / proximal fibular bone / deep soft tissue] was obtained from the final operative plane with fresh instruments and sent for [culture / pathology / culture and pathology]. The operative record distinguishes this proximal sample from cultures taken from the amputated specimen. The final level demonstrated [no gross purulence / viable bleeding bone and soft tissue / residual concern for infection].
Charting Tips
- Document why the selected level was expected to heal using the clinical examination and any vascular laboratory or tissue-perfusion results. A favorable value is supportive rather than a guarantee; record the actual test and result instead of converting one threshold into a categorical prediction.
- Document the exact tibial level, the anterior bevel, the fibular level relative to the tibia, and smoothing of sharp edges. Excessive fibular shortening can create a conical residual limb, while a long fibula or prominent tibial crest can impair prosthetic fit.
- Document which vascular bundles were ligated and which nerves were divided under traction and allowed to retract. The record should support deliberate nerve management rather than merely stating that the limb was removed.
- State whether posterior muscle stabilization was a fascial myoplasty or a true myodesis to bone. If myodesis was performed, document the fixation site and suture construct.
- For infection, distinguish cultures from the amputated specimen from a separately obtained proximal bone or deep-tissue sample. Record the exact source, collection method, gross appearance of the final plane, and whether results will guide antimicrobial management.
- If urgent source control makes definitive closure unsafe, use the guillotine variant and document the staged plan. At the later operation, document excision of the prior open margin, revised bone levels, final tissue viability, and closure. For a transfemoral amputation, use the Above-Knee Amputation note.
Documentation & Reimbursement Considerations
- Report Below-Knee Amputation (BKA) as the primary service when it is the definitive operation performed.
- Use the routine note for an initial definitive closed transtibial amputation. An open guillotine source-control procedure and its later formal revision and closure are separate operative sessions and should each be documented on their own merits.
- For a residual-limb revision, document the prior level, reason for revision, amount of bone and soft tissue removed, and closure performed.
- Major lower-extremity amputation generally carries a 90-day global period. Distinguish a planned staged formalization from an unplanned return to the operating room for a complication.
- Conversion of a failed below-knee amputation to a transfemoral level is a new higher-level amputation rather than a below-knee residual-limb revision; use the Above-Knee Amputation note.
- Document the indication, why limb salvage was not feasible, the level-selection rationale, clinical and objective perfusion evidence, exact bone levels, and flap closure. Perfusion measurements support but do not guarantee healing.