All amputation procedures were performed with the patient in the supine position, under general anesthesia, sterile conditions, and tourniquet control. Preoperative intravenous antibiotics were administered in all cases. Preoperative measurements of lower limb circumference were made 6 cm and 12 cm distal to the tibial plateau. A standard stair-step incision was made approximately 12 cm distal to the tibial plateau, preserving a posterior fasciocutaneous flap extending to the distal Achilles. Dissection was carried down to the underlying muscle fascia. Each of the leg compartments was explored to identify the tibialis anterior (TA), lateral gastrocnemius, peroneus longus, and tibialis posterior muscles. These muscles were marked at resting tension with the ankle and subtalar joints in their neutral positions using sutures set at 1 cm intervals. All muscles of the anterior, lateral, and posterior (both superficial and deep) compartments were disinserted. The distal ends of the tibial, superficial peroneal, deep peroneal, and sural nerves were identified, isolated, and transected. Dissection was carried down to the level of the periosteum of the tibia and fibula, and osteotomies were made at approximately 12 cm and 10 cm, respectively. The anterior tibial, posterior tibial, and peroneal vessels were ligated. The medial and lateral tarsal tunnels were procured from the distal amputated limb via sharp dissection, including 4–5 cm segments of each tunnel’s native tendon contents, and were affixed to the flat of the residual tibia using multiple unicortical suture anchors. AMIs were constructed via coaptation of the TA and lateral gastrocnemius muscles to either end of the tendon portion passing through the proximally positioned tarsal tunnel, and coaptation of the tibialis posterior and peroneus longus muscles to the distally positioned tarsal tunnel. Radiopaque 1–2 mm tantalum beads were embedded in the center of each tarsal tunnel, and in all 4 AMI muscles. In patients 2 and 3, the distal ends of the tibial, superficial peroneal, deep peroneal, and sural nerves were capped with free muscle grafts harvested from the distal amputated limb to establish neuroma-preventing RPNIs. The soft-tissue envelope was then closed in a layered fashion over a single closed suction drain. Finally, a layered compression dressing and standard knee immobilizer was applied (Figs. 2–4).