Below-knee amputation: what to expect from surgery, healing and walking again

An amputation is the surgical removal of part of the body, such as a leg, according to the NHS. A below-knee amputation, also known as a transtibial amputation, takes away the lower leg and foot while preserving the knee joint. Surgeons try to leave enough healthy tissue to cover the end of the bone and to make a stump that can tolerate a prosthetic socket later.

Most amputations involve removing a section of limb rather than the entire limb. The NHS explains that once the section is removed the surgeon may shorten and smooth the bone so that it is covered by adequate soft tissue and muscle, and stitch the muscle to the bone (myodesis) to strengthen the remaining part. The wound is closed with stitches, covered with a bandage and a tube may be placed under the skin to drain fluid.

The NHS lists severe infection, gangrene often resulting from peripheral arterial disease, complications from diabetes, serious trauma to the limb, and a deformed limb with limited movement and function as the main reasons for amputation. When the damage is limited to the foot and lower leg and the blood supply above is adequate, a below-knee level may be possible. If healing is unlikely at this level, the team may discuss a higher amputation instead.

Unless it is an emergency, the NHS says you will be fully assessed beforehand, including your heart and lungs, the condition of your other limb and your home and work environment. Planned amputations carry a lower risk of serious complications than emergency ones, according to the NHS.

After the operation you may be given oxygen through a mask and fluids through a drip, and you may have a urinary catheter for the first few days, says the NHS. Painkillers will be offered, and NHS inform notes that a small tube may be used to deliver local anaesthetic to the nerves in the stump to reduce pain. Tell staff if pain is not controlled.

Swelling is expected. A compression garment helps with swelling and shape, may reduce phantom pain and is fitted once the wound has healed; it should be worn daily and removed at bedtime. A physiotherapist will teach exercises to prevent blood clots and improve circulation. Slow wound healing and wound infection are listed by the NHS among the possible complications, together with heart problems, deep vein thrombosis, pneumonia and stump or phantom pain.

Check the stump daily. The NHS lists warm, red and tender skin, discharge of fluid or pus and increasing swelling as signs of infection, and says to contact your care team if you think you are developing a skin infection.

Removing one limb places extra strain on the other, as the NHS explains. After a leg or foot amputation it is important to avoid injuring the remaining limb. The NHS recommends avoiding poorly fitting footwear and having an appropriately trained professional such as a podiatrist involved in your foot care, and says you should be offered regular foot review by a foot care team.

This is especially relevant when amputation followed diabetes or peripheral arterial disease, because the other foot may also be at risk. If you notice a blister, sore, colour change or swelling in your remaining foot, seek advice promptly rather than waiting for the next appointment.

The NHS says rehabilitation programmes usually begin the day after the operation with simple exercises, and NHS inform says they may begin a few days after surgery. After a leg amputation you are encouraged to move around as soon as possible using a wheelchair and to learn transfer techniques. Physiotherapists and occupational therapists set realistic goals with you and you may later work in a hospital gym.

Prosthetic limbs are not suitable for everyone, as an extensive course of rehabilitation is required and using one takes considerable energy. The choice of limb depends on the type of amputation, the strength in the remaining limb, general health, the tasks it needs to perform and whether you want it to look as real as possible or you are more concerned with function. Preparation, including skin desensitisation and strengthening exercises, begins before fitting, and NHS inform notes it can be several months before the first prosthetist appointment.

• Keep the stump skin clean, dry and moisturised with unscented products.

• Use the compression garment as directed.

• Do the exercises your physiotherapist gives you, including for the remaining leg.

• Report new pain, skin breakdown or a poor socket fit early.

Stump pain and phantom limb pain are common. The NHS says phantom sensations feel as if they come from the missing limb and range from brief flashes to constant pain, are real rather than imagined, and usually improve over time. Treatments include medicines, adjusting the prosthesis, massage, TENS, mental imagery and mirror therapy.

The NHS also says emotions such as grief, anxiety, depression and denial are common, and that people who lose a limb in an emergency have less time to prepare. Talk to your team about your feelings, especially if you feel depressed or suicidal. Charities including the Limbless Association, the Douglas Bader Foundation, Steel Bones and Blesma are listed by the NHS as sources of support.

Amputation surgery, rehabilitation and limb fitting in the UK are mostly delivered through NHS vascular, orthopaedic, diabetes and limb-fitting services. Some people also see private surgeons or choose private prosthetic services for additional options. Whichever route you use, ask who will coordinate your rehabilitation, how often the stump and socket will be reviewed and how you can reach the team if problems develop.