The long posterior flap amputation designed by Kendrick ( I ) and subsequently widely applied by Burgess and Romano (2) in conjunction with an immediate peroperatively fitted prosthesis or without, as reported by Hunter-Craig (3), has now established the place of below-knee amputation in the treatment of patients with an ischaemic extremity which cannot be salvaged by a vascular surgical procedure.Despite its success in permitting this level of amputation in patients who would otherwise have had their amputation at above-knee level, there are a few drawbacks to the surgical technique. The operation is time consuming as considerable shaping of the soft tissue is required, and even in the hands of an experienced operator the stump can be initially unsatisfactory. While much reduction in prominent soft tissue can occur with use of the immediate peroperatively fitted prosthesis, subsequent bandaging to produce late reshaping of the stump entails a delay before a cast can be made for a patellar tendonbearing socket, which adds to the time that the patient may wait or need to stay in hospital before he or she can receive an initial prosthesis.A method of below-knee amputation is described in which the advantage of the long posterior flap technique is maintained but the operation is simplified to produce a durable stump with parallel sides and a hemispherical end from the conclusion of the operation, so that early casting and the provision of a patellar tendon-bearing socket can be achieved. This has been used in amputation for both ischaemia and orthopaedic conditions. Patients and methodsThe limb is shaved and is prepared by an application ofpovidone iodine solution in the ward 2 h before surgery. The foot and any septic lesion is isolated in a sealed polythene bag. The whole limb is wrapped in a dry sterile sheet. The perineum is covered by a large wool pad held in place with orthopaedic briefs or a T bandage. Penicillin and mptronidazole prophylaxis is used routinely. Benzyl penicillin 600 mg is given intramuscularly 1 h before operation and 6-hourly for 5 days, with metronidazole suppositories I g 4 h before operation and &hourly also for 5 days.The operation is performed under a general anaesthetic with a muscle relaxant or with a regional anaesthetic technique. either spinal or epidural anaesthesia being frequently used in our patients. A tourniquet is not applied in those patients with degenerative vascular disease.The skin flaps are marked on the skin before any incision. (Figs. I and 2). The skin flaps are semicircular. based on a line around the limb at right angles to its long axis, drawn at the plane of bone section 10-12cm from the joint line at the tibial plateau.The circumferential mark is bisected by a diameter rotated by 20 from the vertical axis. achieved by marking a point overlying the middle of the anterior tibial compartment and using a thread or tape to measure the circumference. which is then halved to indicate the opposite point on the posteromedial aspect of the limb. Thc anterior junction bet...

Early results from this anecdotal series are encouraging and a prospective study to determine the application of the PTBO in patients with neuropathic and neuropathic/ischaemic tissue loss is planned.

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