Between 1999 and 2001, 35 consecutive patients with diabetes (mean age, 59.4 years) were treated prospectively with a modified skew-flap below-knee amputation. The technique, results, and follow-up are described. By a mean follow-up of 3.5 years, 3 patients required below-knee amputation of the opposite extremity, 4 expired, and 28 were ambulating with a below-knee prosthesis. The modification has several advantages: A tibialis anterior muscle cushion on the distal end of the tibia prevents bone protrusion; anterior skin flaps made by the initial linear anterior incision prevent tension at the suture line; and oblique myocutaneous flaps avoid muscle trimming and prevent shearing of fascial plexuses at closure, thus improving wound healing.