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Modified Below-Knee Amputation with Medial Gastrocnemius Muscle Flap and RPNI
Mare G Kaulakis, BS; Christopher J Fedor, MS; José Antonio Arellano, MD; Hilary Y Liu, BS; Jenny A Ziembicki, MD; Francesco M Egro, MD
University of Pittsburgh Medical Center (UPMC), University of Pittsburgh School of Medicine
2025-01-13
Presenter: Mare Kaulakis
Affidavit:
I agree.
Director Name: Vu T. Nguyen
Author Category: Medical Student
Presentation Category: Clinical
Abstract Category: General Reconstruction
Introduction: Below-knee amputation (BKA) may be required for full-thickness burns when muscle or bone is deemed non-salvageable. Traditional BKA techniques can lead to complications, including inadequate soft tissue coverage and phantom limb pain.
Methods: This case report presents a modified BKA technique incorporating muscle flaps and Regenerative Peripheral Nerve Interfaces (RPNIs) to provide additional padding and mitigate postoperative pain.
Results: We report on a 61-year-old male with full-thickness burns covering 65% Total Body Surface Area (TBSA) from flame injury. Initial management included escharotomies and cadaveric allografts to the lower extremities.
Three weeks post-admission, extensive necrosis and bone/tendon exposure necessitated bilateral BKAs. The procedure transposed bilateral medial gastrocnemius flaps for enhanced padding for prosthetic use and vascularized bed for skin grafts. RPNIs involved suturing three free muscle grafts around dissected nerves, with the left stump receiving superficial peroneal and tibial nerves, and the right stump receiving a tibial nerve.
One-week post-surgery, the patient developed left lower extremity phantom limb which was alleviated by a sciatic nerve block and gabapentin. Seven-months post-amputation, the patient was fitted for prosthetics and began rehabilitation. Intermittent phantom limb pain persisted and was managed with over-the-counter pain medication. One-year post-surgery, the patient had made significant progress in mobility and pain control, with continued efforts toward full-time prosthetic use.
Conclusion: This case demonstrates the successful use of bilateral medial gastrocnemius flaps and RPNIs in bilateral BKAs from burn injury. This innovative approach suggests a potential new standard for complex lower limb amputation management in burn patients.
