Amputations below the knee.

2 Director, Prosthetics Research Study, Seattle, Wash. AHE elective amputation must be considered plastic and reconstructive in nature. The need to create a dynamic and sensory motor end-organ should be foremost in the surgeon's mind in planning an amputation, and is emphasized here once more. The below-knee stump no longer hangs suspended in an open-end socket. The variable degrees of pressure and weight-bearing over the entire stump surface afforded by the total-contact patellar-tendon-bearing prosthesis enhance the surgeon's opportunity to fashion a functional terminal endorgan. Stump strength created by surgical muscle stabilization; pliable, sensitive, but nontender skin and scar; adequate soft tissue coverage of bone ends and other pressure-sensitive areas; high ligation and division of nerves to remove neuromata from pressure zones; meticulous rounding and tailoring of bone surfaces; all contribute to an ideal organ for substitute limb application. The atrophic, wasted, bony, below-knee stump so commonly encountered in years past is no longer acceptable. Stump-muscle stabilization, i.e., the attachment of sectioned muscles under appropriate tension to bone (myodesis) and to opposing muscles (myoplasty), is a prime requisite for dynamic stump activity. Muscle stabilization is especially needed in the through-knee and the aboveknee amputee. Our experience also justifies its routine use in below-knee amputation. Muscle-to-bone suture does add operative handling of tissues and encircling sutures carry the potential of local muscle constriction. For these reasons myodesis is not recommended for use in the below-knee amputation for vascular disease. The new technique developed by the Prosthetics Research Study utilizes the long posterior myofascial flap sewn anteriorly to anterolateral deep fascia and tibial periosteum and provides a reasonable degree of muscle fixation without risk of strangulation. Muscle-to-bone suture is reserved for the nonischemic patient.