Skew-flap below-knee amputation.

The success of the long posterior flap in obtaining sound healing at below-knee level is widely recognised in patients with ischaemic disease, and since this method was introduced in 1967 by Burgess and Romano, the number of patients with healing below-knee amputations in ischaemic disease has dramatically increased, and with improved methods of level selection this proportion may increase further (1). However, the long posterior flap below-knee stump has several problems. The stump may be wide in the transverse diameter causing difficulties in delay in limb fitting; the scar crossing the tibia may break down with prosthetic use, and to avoid these problems we undertook a review of the basic design of the belowknee amputation stump to utilise the best available blood supply and avoid these difficulties. Haertsch (2) studied the skin blood supply by post-mortem injection studies and McCollum et al. (3) indicated that the dominant vascular supply to the skin at this level is by the saphenous nerve artery and the sural nerve artery. Previously the posterior skin flap had been thought to receive the best blood supply from the gastrocnemius muscle surface by perforating arteries. Dellon and Morgan (4) drew attention to this, although Towne and Condon (5) had previously recognised the role of the sural nerve artery. Fulford (6) reported that the skin over the upper part of the anterior tibial compartment had particularly unsatisfactory blood supply, basing this observation on arteriographic studies. The long posterior flap was first illustrated by Hiester in 1739, while the sagittal flap attributed to Monsieur Lenoer and also myocutaneous sagittal flaps ascribed to Monsieur Sedellot are illustrated by Bougery and Jacob (1835) in the Atlas of Operative Surgery. However, more recent authors, Tracy (7), Alter et al. (8), Termansen in 1977, and Persson in 1974, reported the use of sagittal flaps for below-knee amputation. Persson (9) used myocutaneous flaps cut in one piece to provide a degree of myoplastic function. Bek (10) reported a further series and, more recently, Yamanaha and Kwong reported a similar technique in 1985.