Objective: To make a transtibial stump as long as possible, free from local and phantom pain with a maximum of terminal load bearing. In order to preserve the knee joint, an ultra-short tibial stump of 5-6 cm may be indicated.
Indications: A hindfoot amputation level is not possible to achieve.
Contraindications: In amputations for peripheral vascular diseases, amputations through the distal third of the tibia are not recommended. If they still heal, the level selection might have been too proximal.
Surgical technique: According to Verduyn and Burgess, a long posterior muscular flap covering the stump is attached ventrally to a short anterior flap. Modifications: fibular bone bridge (Guedes), resection of the soleus muscle (Baumgartner), Myodesis (Bowker), and Brückner's procedure. Alternative: rotation plasty according to Borggreve-van Nes-Winkelmann.
Postoperative management: Special diagonal elastic bandaging over the knee that must be changed daily. Early prosthetic fitting (in general after 4-6 weeks) after wound has healed. Physical therapy: gait training with 2 crutches or parallel bars with or without an inflatable "prosthesis". Isometric training of the quadriceps. A stump requires several months until it has achieved its final form. During this time, the prosthesis must be adjusted accordingly. Modifications in the home, workplace, and automobile must be made. Sport for the disabled!
Results: In order to preserve a maximum of stump length, wound healing problems are to be taken into consideration, requiring surgery and sometimes even reamputation through or above the knee joint. If it is possible to preserve the knee joint, the rehabilitation results, even with an ultra-short transtibial stump, are far superior to any more proximal amputation level.