North American experience with knee disarticulation with use of a posterior myofasciocutaneous flap. Healing rate and functional results in seventy-seven patients

Knee disarticulation vs. transfemoral amputation after failed transtibial amputation: Surgical outcome and prosthetic fitting in patients with peripheral vascular disease

OBJECTIVE

Our aim was to compare transfemoral amputation (TFA) to knee disarticulation (KD) as a reamputation level after failed transtibial amputation (TTA) in patients with peripheral vascular disease and/or diabetes.

METHODS

We studied 152 patients undergoing reamputation, 86 TFA and 66 KD, after a failed TTA. The primary outcome was reamputation and reoperation, and secondary outcomes were prosthetic fitting and mortality. Logistic regression analyses were performed to identify factors associated with the outcome.

RESULTS

The reamputation rate was 36% after KD and 15% after TFA ( p = 0.004). The multivariable analysis showed that TFA was associated with a significantly reduced risk of reamputation, odds ratio (OR) = 0.31 (95% confidence interval [95% CI], 0.1-0.7). The overall reoperation rate was 38% after KD and 22% after TFA ( p = 0.03). This reduction of risk for TFA was not significant in the multivariable analysis, OR = 0.49 (95% CI, 0.2-1.0). Prosthetic limb fitting was possible in 30% after KD and 19% after TFA ( p = 0.1). Previous amputation in the contralateral leg was the only factor associated with reduced ability for prosthetic fitting in the multivariable analysis, OR = 0.15 (95% CI, 0.03-0.7). Mortality at 30 d was 17% and 53% at 1 year. No independent factors affected 30-d mortality in the multivariable analysis.

CONCLUSIONS

In this study, we found a significantly lower risk of reamputation after TFA compared with KD after a failed TTA. We consider TFA to be the reamputation level of choice, especially when there is a need of reducing risk of further reamputations.

Surgical Techniques for Performing a Through-Knee Amputation: A Systematic Review and Development of an Operative Descriptive System

BACKGROUND

Through-knee amputation (TKA) carries potential biomechanical advantages over above knee amputation (AKA) in patients unsuitable for a below-knee amputation. However, concerns regarding prosthetic fit, cosmesis and wound healing have tempered enthusiasm for the operation. Furthermore, there are many described surgical techniques for performing a TKA. This frustrates attempts to compare past and future comparative data, limiting the opportunity to identify which procedure is associated with the best patient centered outcomes. The aim of this systematic review is to identify all the recognized operative TKA techniques described in the literature and to develop a clear descriptive system to support future research in this area.

METHODS

A systematic review was performed, searching the OVID, PubMed, and Cochrane Library databases, according to Cochrane and PRISMA guidelines. Papers of any design were included if they described an operative technique for a TKA. Key operative descriptions were captured and used to design a classification system for surgical techniques.

RESULTS

A total of 906 papers were identified, of which 28 are included. The most important distinctions in operative technique were the level of division of the femur (disarticulation without bone division, transcondylar amputation, with or without shaving of the medial, lateral, and posterior condyles and supracondylar amputation), management of the patella (kept whole, partially preserved, completely removed), use of a muscular gastrocnaemius flap, and skin incisions. A 4-component classification system was developed to be able to describe TKA operative techniques. A suggested shorthand nomenclature uses the first letter of each component (FPMS; Femur, Patella, Muscular flap, Skin incision), followed by a number, to describe the operation. Patient outcomes were poorly reported, and therefore outcomes for different types of TKA are not addressed in this review.

CONCLUSIONS

A novel descriptive system for describing different techniques for performing a TKA has been developed. This classification system will help in reporting, comparing, and interpreting past and future studies of patients undergoing TKA.

Knee Disarticulation Versus Transfemoral Amputation: The Prosthetist's Perspective

OBJECTIVES

The objective of this study was to survey a broad group of prosthetists on their experience with amputees with knee disarticulation (KD) and transfemoral amputation (TFA) to determine their preference of amputation level, opinions on patient preference, and common problematic issues to guide decision-making for patients and surgeons faced with the decision of a high-level lower extremity amputation.

DESIGN

This is a survey-based study.

INTERVENTION

A blinded electronic mail survey was completed by 102 prosthetists.

MAIN OUTCOME MEASUREMENTS

Each prosthetist was asked (1) what amputation level (KD or TFA) do they prefer and why and (2) which amputation level do they believe patients prefer and why.

RESULTS

There was no consensus among prosthetists regarding amputation level preference. Fifty-four (53%) prosthetists preferred KD and 48 (47%) preferred TFA. Fifty-five (54%) prosthetists believed patients preferred TFA and 47 (46%) believed patients preferred KD. Amputation level preference often depended on age, functional goals, and concerns with cosmesis. The most common benefits given for KD over TFA included distal-end weight-bearing (n = 53), a lower subischial socket (n = 43), and better function (n = 30). The most common disadvantages given for KD over TFA included component limitations due to space available below amputation (n = 56), poor cosmesis (n = 49), an asymmetrical knee axis (n = 42), and difficulties with sitting/standing (n = 13).

CONCLUSION

No consensus exists between prosthetists regarding preference for KD versus TFA. The advantages and disadvantages of KD reported in this study, along with the associated decision tree, can be used for future counseling of patient's faced with high-level lower extremity amputations.

Through-knee versus above-knee amputation for vascular and non-vascular major lower limb amputations

BACKGROUND

Diabetes and vascular disease are the leading causes of lower limb amputation. Currently, 463 million adults are living with diabetes, and 202 million with peripheral vascular disease, worldwide. When a lower limb amputation is considered, preservation of the knee in a below-knee amputation allows for superior functional recovery when compared with amputation at a higher level. When a below-knee amputation is not feasible, the most common alternative performed is an above-knee amputation. Another possible option, which is less commonly performed, is a through-knee amputation which may offer some potential functional benefits over an above-knee amputation.

OBJECTIVES

To assess the effects of through-knee amputation compared to above-knee amputation on clinical and rehabilitation outcomes and complication rates for all patients undergoing vascular and non-vascular major lower limb amputation.

SEARCH METHODS

The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL databases; the World Health Organization International Clinical Trials Registry Platform; and the ClinicalTrials.gov trials register to 17 February 2021. We undertook reference checking, citation searching, and contact with study authors to identify additional studies.

SELECTION CRITERIA

Published and unpublished randomised controlled trials (RCTs) comparing through-knee amputation and above-knee amputation were eligible for inclusion in this study. Primary outcomes were uncomplicated primary wound healing and prosthetic limb fitting. Secondary outcomes included time taken to achieve independent mobility with a prosthesis, health-related quality of life, walking speed, pain, and 30-day survival.

DATA COLLECTION AND ANALYSIS

Two review authors independently reviewed all records identified by the search. Data collection and extraction were planned in line with recommendations outlined in the Cochrane Handbook for Systematic Reviews of Interventions. We planned to assess the certainty of evidence using the GRADE approach.

MAIN RESULTS

We did not identify RCTs that met the inclusion criteria for this review.

AUTHORS' CONCLUSIONS

No RCTs have been conducted to determine comparative clinical or rehabilitation outcomes of through-knee amputation and above-knee amputation, or complication rates. It is unknown whether either of these approaches offers improved outcomes for patients. RCTs are needed to guide practice and to ensure the best outcomes for this patient group.

A review of through-knee amputation

OBJECTIVES

Through-knee amputation is an umbrella term for several different surgical techniques, which may affect clinical and functional outcomes. This makes it hard to evaluate the benefits and need for a through-knee amputation approach. This article seeks to (1) determine the number of through-knee amputation performed compared with other major lower limb amputations in England over the past decade; (2) identify the theoretical concepts behind through-knee amputation surgical approaches and their potential effect on functional and clinical outcomes and (3) provide a platform for discussion and research on through-knee amputation and surgical outcomes.

METHODS

National Health Service Hospital Episodes Statistics were used to obtain recent numbers of major lower limb amputations in England. EMBASE and MEDLINE were searched using a systematic approach with predefined criteria for relevant literature on through-knee amputation surgery.

RESULTS

In the past decade, 4.6% of major lower limb amputations in England were through-knee amputations. Twenty-six articles presenting through-knee amputation surgical techniques met our criteria. These articles detailed three through-knee amputation surgical techniques: the classical approach, which keeps the femur intact and retains the patella; the Mazet technique, which shaves the femoral condyles into a box shape and the Gritti-Stokes technique, which divides the femur proximal to the level of the condyles and attaches the patella at the distal cut femur.

CONCLUSIONS

Through-knee amputation has persisted as a surgical approach over the past decade, with three core approaches identified. Studies reporting clinical, functional and biomechanical outcomes of through-knee amputation frequently fail to distinguish between the three distinct and differing approaches, making direct comparisons difficult. Future studies that compare through-knee amputation approaches to one another and to other amputation levels are needed.

Translating Technique into Outcomes in Amputation Surgeries

The department of surgery at Washington University is putting increased emphasis on outcomes for amputees. This multidisciplinary effort begins with choosing the correct surgery and incorporating the latest technical advances in amputation surgery.

Are Gait Parameters for Through-knee Amputees Different From Matched Transfemoral Amputees?

BACKGROUND

Through-knee amputation is a common amputation level after battlefield injuries during the medical evacuation process. However, there are limited data comparing through-knee amputation with transfemoral amputation as a definitive amputation level in terms of gait parameters.

QUESTIONS/PURPOSES

(1) Does through-knee amputation result in improved gait velocity when compared with matched transfemoral amputees? (2) Do through-knee amputees have a faster gait cadence than matched transfemoral amputees? (3) Do through-knee amputees have a different stride length or stride width than matched transfemoral amputees? (4) Does through-knee amputation result in decreased work of ambulation when compared with matched transfemoral amputees?

METHODS

Between January 2008 and December 2012, six male active-duty military patients who had undergone unilateral through-knee amputations as a result of trauma underwent gait studies at our institution. Of those, four of six underwent gait analysis after being able to walk for at least 3 months without assistive devices, and this group was studied here. Most through-knee amputees who were not included had elective revisions of their amputations from through-knee to a transfemoral amputation before completing 3-month gait data. Each of the amputees studied was matched to a transfemoral amputee based on height, body mass index, and contralateral amputation level resulting in a case-control study of active-duty military male amputee patients. Inclusion required complete gait data collected while walking at a self-selected pace wearing custom prosthetic devices. The through-knee amputees had a median (range) age of 32 years (23-41 years) and the transfemoral amputees had a median age of 24 years (22-27 years). Three-dimensional gait data were collected and analyzed. A power analysis found that to detect a clinically important difference (set at a change in work of ambulation of 1 J/kgm) with a p value of 0.05 and a β set to 0.2, a study population of 56 patients per group would be required; that being said, our results on a much smaller population must be considered exploratory.

RESULTS

With the numbers available, we found no differences in gait velocity when comparing through-knee (1.18 m/sec) and matched transfemoral amputees (1.20 m/sec, difference of medians = 0.02 m/sec; p = 0.964). Likewise, we found no differences in gait cadence when comparing through-knee with transfemoral amputees (104 versus 106 steps/min, respectively, difference of means 2 steps/min, p = 0.971). There was no difference in stride length or stride width when comparing through-knee (70 cm and 18 cm, respectively) with transfemoral amputees (70 cm and 19 cm, respectively; p = 0.948 and p = 0.440). With the numbers available, we did not identify a difference in the work of ambulation for through-knee amputees when compared with matched transfemoral amputees (8.3 versus 7.5 J/kg, respectively; p = 0.396).

CONCLUSIONS

Based on our findings, we are unable to demonstrate any functional advantages of knee disarticulation over transfemoral amputation. Although there are theoretical advantages for maintaining an intact femur during the medical evacuation and serial débridement process, we question the utility of knee disarticulation as a definitive amputation level; however, larger numbers of patients are needed to confirm these results.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Acute femoral shortening for reconstruction of a complex lower extremity crush injury

Traumatic through-knee or transfemoral amputations with concomitant ipsilateral femoral fractures are extremely rare injuries. The initial goal of management is patient resuscitation and stabilization. Subsequent interventions focus on limb salvage and the creation of a residual limb that can be fitted successfully for a functional lower extremity prosthesis. We present the case of a patient who sustained a traumatic through-knee amputation ipsilateral to an open comminuted femoral fracture. Soft tissue injury prohibited initial primary closure over the distal femoral condyles. A functional residual limb was achieved with acute femoral shortening, maintenance of the femoral condyles and fracture stabilization with a short retrograde intramedullary nail. This approach allowed maintenance of muscular attachments to the femur, soft tissue closure and resulted in a residual limb of acceptable length with a broad weight-bearing surface that was fitted with a prosthesis successfully.

Disarticulation of the knee: Analysis of an extended database on survival, wound healing, and ambulation

OBJECTIVE

This study analyzed survival of the amputee patients, wound healing, and ambulation after knee disarticulation (KD).

METHODS

Between July 1989 and October 2015, 153 KDs in 138 patients were performed at Nij Smellinghe Hospital, Drachten. Data were retrieved from hospital medical records. Wound healing was analyzed using nonparametric tests. Ambulation was recorded according to the Special Interest Group Amputation Medicine Workgroup Amputation and Prosthetics mobility scale.

RESULTS

Survival at 1, 6, and 12 months was 86%, 65%, and 55%, respectively. Wounds healed in 91% of patients. Wounds healed primarily in 57% of residual limbs, and healing was delayed in 33%. A transfemoral amputation (TFA) was performed in 10%. Patients with sagittal flaps had significantly poorer primary wound healing and delayed wound healing more often than patients with a dorsal-myocutaneous (dorsomyocutaneous) flap (P < .027). In total, 62% of patients were provided with a prosthesis. Preoperatively, 71% of the patients had intention to ambulate with prosthesis, of which 91% received prosthesis. Of these, 35% walked without the help of others. KD amputee patients who underwent a reamputation at the transfemoral level were significantly less ambulant than amputee patients who did not (P < .021).

CONCLUSIONS

If feasible, the dorsomyocutaneous flap technique seems to be the treatment of choice in KD. Because the wound complication rate of the group with a dorsomyocutaneous flap and the percentage of amputee patients who received prosthesis after KD fell within the same range as TFA amputee patients, KD may be an appropriate alternative when surgeons consider a TFA.

Development of a cosmetic knee disarticulation prosthesis: A single-patient case study

BACKGROUND AND AIM

If a person does not become ambulant after an amputation, a knee disarticulation (KD) shouldbe considered and the person may then benefit from a cosmetic KD prosthesis. The features of a cosmetic KD prosthesis are, however, seldom described. The aim of this clinical note is to describe the development of a cosmeticKD prosthesis.

TECHNIQUE

A non-ambulant person with bilateral KD formulated, together with her physiatrist, the criteria for a cosmetic KD prosthesis. On the basis of these, a lightweight, natural-looking, well-fitting, easy-to-put-on and take-off KD prosthesis, with no thigh lengthening during sitting, was made. This prosthesis was fixed on a wheelchair and does not impede transfer.

DISCUSSION

A newly constructed cosmetic prosthesis for non-ambulant persons with a KD is described in detail. We hope that this will encourage physiatrists and prosthetists to offer non-ambulant persons with a KD a cosmetic prosthesis.

CLINICAL RELEVANCE

A cosmetic leg prosthesis with good cosmetic properties, good sitting comfort, and no restrictions in making transfers is described in detail for non-ambulant persons with a knee disarticulation.

Reoperation after combat-related major lower extremity amputations

OBJECTIVE

Complication rates leading to reoperation after trauma-related amputations remain ill defined in the literature. We sought to identify and quantify the indications for reoperation in our combat-injured patients.

DESIGN

Retrospective review of a consecutive series of patients.

SETTING

Tertiary Military Medical Center.

PATIENTS/PARTICIPANTS

Combat-wounded personnel sustaining 300 major lower extremity amputations from Operations Iraqi and Enduring Freedom from 2005 to 2009.

INTERVENTION

We performed a retrospective analysis of injury and treatment-related data, complications, and revision of amputation data. Prerevision and postrevision outcome measures were identified for all patients.

MAIN OUTCOME MEASUREMENTS

The primary outcome measure was the reoperation on an amputation after a previous definitive closure. Secondary outcome measures included ambulatory status, prosthesis use, medication use, and return to duty status.

RESULTS

At a mean follow-up of 23 months (interquartile range: 16-32), 156 limbs required reoperation leading to a 53% overall reoperation rate. Ninety-one limbs had 1 indication for reoperation, whereas 65 limbs had more than 1 indication for reoperation. There were a total of 261 distinct indications for reoperation leading to a total of 465 additional surgical procedures. Repeat surgery was performed semiurgently for postoperative wound infection (27%) and sterile wound dehiscence/wound breakdown (4%). Revision amputation surgery was also performed electively for persistently symptomatic residual limbs due to the following indications: symptomatic heterotopic ossification (24%), neuromas (11%), scar revision (8%), and myodesis failure (6%). Transtibial amputations were more likely than transfemoral amputations to be revised due to symptomatic neuromata (P = 0.004; odds ratio [OR] = 3.7; 95% confidence interval [95% CI] = 1.45-9.22). Knee disarticulations were less likely to require reoperation when compared with all other amputation levels (P = 0.0002; OR = 7.6; 95% CI = 2.2-21.4).

CONCLUSIONS

In our patient population, reoperation to address urgent surgical complications was consistent with previous reports on trauma-related amputations. Additionally, persistently symptomatic residual limbs were common and reoperation to address the pathology was associated with an improvement in ambulatory status and led to a decreased dependence on pain medications.

Cosmetic effect of knee joint in a knee disarticulation prosthesis

Despite numerous advantages, knee disarticulations (KDs) are rarely performed because of the anticipated KD prosthesis fitting problems that include the positioning of the knee joint distally from the KD socket. This results in lengthening of the thigh and subsequent shortening of the shank. The objective of this study was to assess the cosmetic effect of the knee joint in a KD prosthesis by determining the extent of the lengthening of the thigh and the shortening of the shank. This lengthening and shortening were measured through an experimental setup using laser techniques. These measurements were made of 18 knee joints used in KD prostheses. Lengthening of the thigh varied between 23 and 92 mm, and shortening of the shank varied between 3 and 50 mm. The polycentric knees Medi KH6 and Medi KHF1 showed the least lengthening of the thigh, and the polycentric knees Teh Lin Prosthetic & Orthotic Co. Ltd Graph-Lite and Medi KP5 showed the least shortening of the shank.

Factors affecting outcome after traumatic limb amputation

BACKGROUND

Traumatic leg amputation commonly affects young, active people and leads to poor long-term outcomes. The aim of this review was to describe common causes of disability and highlight therapeutic interventions that may optimize outcome after traumatic leg amputation.

METHODS

A comprehensive search of MEDLINE, Embase and Cumulative Index to Nursing and Allied Health Literature databases was performed, using the terms 'leg injury', 'amputation' and 'outcome'. Articles reporting outcomes following traumatic leg amputation were included.

RESULTS

Studies demonstrated that pain, psychological illness, decreased physical and vocational function, and increased cardiovascular morbidity and mortality were common causes of disability after traumatic leg amputation. The evidence highlights that appropriate preoperative management and operative techniques, in conjunction with suitable rehabilitation and postoperative follow-up, can lead to improved treatment outcome and patient satisfaction.

CONCLUSION

Patients who undergo leg amputation after trauma are at risk of poor long-term physical and mental health. Clinicians involved in their care have many opportunities to improve their outcome using a variety of therapeutic variables. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Gritti-stokes amputations in the trauma patient: clinical comparisons and subjective outcomes

BACKGROUND

The Gritti-Stokes amputation procedure is a modification of the traditional transfemoral amputation, with resection of the bone at a supracondylar femoral level and fixation of the patella to the distal part of the femur as an end-cap. Although well-established in patients with vascular compromise, no evidence exists on its use in the trauma setting.

METHODS

Fourteen consecutive patients who underwent Gritti-Stokes amputation and fifteen consecutive patients who underwent traditional transfemoral amputation by fellowship-trained orthopaedic traumatologists at a level-I trauma center were evaluated at more than fourteen months postoperatively. The Sickness Impact Profile (SIP) questionnaire was also administered to both patient groups at more than thirty-six months postoperatively to assess patient-reported functional outcomes.

RESULTS

Despite the two groups not having significant differences in preoperative variables or demographics, the Gritti-Stokes group had significantly improved SIP questionnaire overall and domain scores. This procedure also left the patients with a significantly longer residual limb (an average of 46.1 cm of residual femoral length versus 34.6 cm for the transfemoral group). The Gritti-Stokes group also had a significantly increased rate of walking without assistive devices (five patients versus none in the transfemoral amputation group).

CONCLUSIONS

The Gritti-Stokes amputation appears to be safe and beneficial when utilized in the trauma population.

[Knee disarticulation and through-knee amputation]

OBJECTIVE

A knee disarticulation or a through-knee stump is superior compared to a transfemoral stump. The thigh muscles are all preserved, and the muscle balance remains undisturbed. The range of motion of the hip joint is not limited. The bulbous shape of the stump allows full weight bearing at the stump end and can easily be fitted with a prosthesis. An amputee with a bilateral knee disarticulation is able to walk "barefoot".

INDICATIONS

A more distal amputation level, e.g., an ultra-short transtibial amputation, is not possible. Important alternative to transfemoral amputations. Possible for any etiology except for Buerger-Winiwarter's disease. New indications are infected and loosened total knee replacements.

CONTRAINDICATIONS

Preservation of the knee joint is possible.

SURGICAL TECHNIQUE

Knee disarticulation is a very atraumatic procedure, compared to transfemoral amputations. Neither bones nor muscles have to be severed, just skin, ligaments, vessels, and nerves. Even the meniscal cartilages may be left in place to act as axial shock absorbers. The cartilage of the femur is not resected, but only bevelled in case of osteoarthritis. There are no tendon attachments or myoplastic procedures necessary. The patella remains in place and is held in position only by the retinacula. Skin closure must be performed without the slightest tension, and if possible not in the weight-bearing area. Transcondylar amputations across the femoral condyles only are indicated when there are not sufficient soft tissues for wound closure of a knee disarticulation. Alternatives as the techniques of Gritti, Klaes, and Eigler, the shortening of the femur and the Sauerbruch's rotation plasty [14] are presented and discussed.

POSTOPERATIVE MANAGEMENT

The risk of decubital ulcers is rather high. Correct bandaging of the stump is, therefore, particularly important. Prosthetic fitting is possible 3-6 weeks after surgery. The type of prosthesis depends on the amputee's activity level.

RESULTS

The superior performance of amputees with knee disarticulations in sports prove the superiority of that amputation level compared to transfemoral amputees. However, because less than 5% of amputations are knee disarticulations, statements about statistical significance cannot be made. On the other hand, one should do everything to preserve an ultra-short transtibial stump.

Traumatic and trauma-related amputations: part I: general principles and lower-extremity amputations

Deliberate attention to the management of soft tissue is imperative when performing an amputation. Identification and proper management of the nerves accompanied by the performance of a stable myodesis and ensuring robust soft-tissue coverage are measures that will improve patient outcomes. Limb length should be preserved when practicable; however, length preservation at the expense of creating a nonhealing or painful residual limb with poor soft-tissue coverage is contraindicated. While a large proportion of individuals with a trauma-related amputation remain severely disabled, a chronically painful residual limb is not inevitable and late revision amputations to improve soft-tissue coverage, stabilize the soft tissues (revision myodesis), or remove symptomatic neuromas can dramatically improve patient outcomes. Psychosocial issues may dramatically affect the outcomes after trauma-related amputations. A multidisciplinary team should be consulted or created to address the multiple complex physical, mental, and psychosocial issues facing patients with a recent amputation.

Recent advances in lower extremity amputations and prosthetics for the combat injured patient

Blast-related extremity trauma represents a serious challenge because of the extent of bone and soft tissue damage. Fragmentation and blast injuries account for 56% of all injuries produced within the Iraqi and Afghan theaters where, as of July 2009, 723 combatants have sustained lower extremity limb loss. If limb salvage is not practical, or fails, then amputation should be considered. Amputation can be a reliable means toward pain relief and improvement of function. Optimizing functional outcome is paramount when deciding on definitive amputation level. Preservation of joint function improves limb biomechanics in many cases. Increased limb length also allows for the benefits associated with articular and distal limb proprioception. Amputees with improved lower extremity function also usually exhibit less energy consumption. Function and length are generally directly correlated, whereas energy consumption and length are inversely related. This article discusses the surgical principles of lower extremity amputation and postoperative management of amputees, and the various prosthetic options available.

Pain and pain-related interference in adults with lower-limb amputation: comparison of knee-disarticulation, transtibial, and transfemoral surgical sites

Pain and pain-related interference with physical function have not been thoroughly studied in individuals who have undergone knee-disarticulation amputations. The principal aim of this study was to determine whether individuals with knee-disarticulation amputations have worse pain and pain-related interference with physical function than do individuals with transtibial or transfemoral amputations. We analyzed cross-sectional survey data provided by 42 adults with lower-limb amputations. These individuals consisted of 14 adults reporting knee-disarticulation amputation in one limb and best-matched cases (14 reporting transfemoral amputation and 14 reporting transtibial amputation) from a larger cross-sectional sample of 472 individuals. Participants were rigorously matched based on time since amputation, reason for amputation, age, sex, diabetes diagnosis, and pain before amputation. Continuous outcome variables were analyzed by one-way analysis of variance. Categorical outcomes were analyzed by Pearson chi-square statistic. Given the relatively small sample size and power concerns, mean differences were also described by estimated effect size (Cohen's d). Of the 42 participants, 83% were male. They ranged in age from 36 to 85 (median = 55.1, standard deviation = 11.0). Most amputations were of traumatic origin (74%), and participants were on average 12.4 years from their amputations at the time of the survey. Individuals with transtibial amputation reported significantly more prosthesis use than did individuals with knee-disarticulation amputation. Amputation levels did not significantly differ in phantom limb pain, residual limb pain, back pain, and pain-related interference with physical function. Estimates of effect size, however, indicated that participants with knee-disarticulation amputation reported less phantom limb pain, phantom limb pain-related interference with physical function, residual limb pain, residual limb pain-related interference with physical function, and back pain-related interference with physical function than did participants with transtibial or transfemoral amputations. This study demonstrated that patients with knee-disarticulation amputation used prostheses significantly less than did patients with transtibial amputation. However, no evidence was found that patients with knee-disarticulation amputation have worse outcomes in terms of pain and pain-related interference with physical function; in fact, they may have more favorable long-term outcomes.

Knee disarticulation: survival, wound healing and ambulation. A historic cohort study

The aim of this study was to analyze survival, wound healing and ambulation after knee disarticulation (KD). A historic cohort study using medical records and nursing home records was performed. Data included demographics, reason for amputation, concomitant diseases, survival, wound healing, re-amputation and ambulation. Data of 80 patients (71 unilateral and nine bilateral amputees) were available for evaluation. Median follow-up was 9.9 years (IQR: 4.1; 14.3 years). Mean age of amputation was 76.9 (+/- 9.6) years. Reason for amputation was gangrene in 72 patients. Most common concomitant (96%) disease was peripheral arterial disease (PAD). Survival after 1, 6 and 12 months was 87%, 65% and 52%, respectively. Delayed wound healing occurred in 42% (n = 16) of the patients with two or three concomitant diseases and in 15% (n = 6) of the patients with no or one concomitant disease. Trans-femoral re-amputation was performed in nine (12%) patients. Of the 61 discharged KD amputees, 36 (59%) were provided with a prosthesis. Eventually 21 (34%) patients became household walkers.

Through-knee amputation in patients with peripheral arterial disease: a review of 50 cases

BACKGROUND

For good rehabilitation candidates, the biomechanical advantages of the end weight-bearing through-knee amputation (TKAmp) compared with the above knee amputation (AKA) are well established. However, the TKAmp has been abandoned by vascular surgeons because of poor wound healing rates related to long tissue flaps and challenges to prosthetic fitting related to the femoral condyles. Since 1998, we have performed the modified "Mazet" technique TKAmp procedure that creates shorter flaps to close the wound and greatly facilitates prosthesis fitting. The purpose of this study is to review our results with TKAmp in patients with peripheral vascular disease who were not candidates for below-knee amputation.

METHODS

The records of all patients who underwent through-knee amputation between 1998 and 2006 were retrospectively reviewed. Mean follow-up was 33 months (range, 38 days to 99 months). Amputations for trauma and malignancy were excluded. Patient survival, maintenance of ambulation, and independent living status were analyzed using Kaplan-Meier survival analysis methods.

RESULTS

Fifty patients underwent TKAmp using a modified Mazet technique. The mean age was 63 years; 50% were men, and 50% had diabetes mellitus. All patients had peripheral arterial disease. Thirty-five patients (70%) had prior revascularization procedures. Those patients averaged 2.2 revascularization procedures prior to amputation. There were three (6%) perioperative deaths. The ipsilateral common femoral artery was patent in 43/50 (86%) of patients at the time of amputation. Forty patients (80%) had open wounds and three patients (6%) had a failed below-knee amputation at the time of TKAmp. Thirty-eight patients (81%) healed their TKAmp wound. Nine patients failed to heal and were revised to an above knee amputation. The cumulative probability of regular prosthetic usage and maintenance of ambulation was estimated to be 0.56 at 3 years and 0.41 at 5 years. The probability of maintaining independent living status at 3 and 5 years was 0.77 and 0.65, respectively. Survival probabilities for patients in this series were 0.60 at 3 years and 0.44 at 5 years.

CONCLUSION

These data show that the TKAmp is associated with an acceptable primary healing rate and satisfactory functional outcomes in patients with peripheral arterial disease. The advantages of TKAmp over AKA make it the preferred alternative for patients with vascular disease who are candidates for prosthetic rehabilitation.

Knee disarticulation and hip release for severe lower extremity contractures

Severe lower extremity contractures cause many problems for patients and their caregivers. Hygiene, skin and perineal care, positioning, and dressing are severely compromised. Surgical management of such deformities is challenging and results have not been published. We treated eight nonambulatory adults with severe and rigid lower extremity contractures with hip release and knee disarticulation of 14 extremities. The patients had neurologic disorders with spasticity. The indications for surgery were fixed contractures of at least 90 degrees at the knee and hip that interfered with passive function and quality of life. All patients were bed-bound secondary to their contractures. The average age at surgery was 57 years; the minimum followup was 6 months (mean, 34 months; range, 6-102 months). The average preoperative flexion contractures were 106 degrees at the hips and 139 degrees at the knees. The average postoperative hip flexion contracture was 6 degrees , and there were no serious complications or recurrent contractures. Positioning and hygiene problems were universally improved, enabling all of the patients to become wheel-chair users, and all patients or their caretakers reported resolution of pain.

Functional outcomes following trauma-related lower-extremity amputation

BACKGROUND

The principal aims of this study were to examine functional outcomes following trauma-related lower-extremity amputation and to compare outcomes according to the amputation levels. We hypothesized that above-the-knee amputations would result in less favorable outcomes than would through-the-knee or below-the-knee amputations. A secondary aim was to examine the factors, in addition to amputation level, that influence outcome, including the type of soft-tissue coverage, selected patient characteristics, and the technological sophistication of the prosthetic device.

METHODS

A cohort of 161 patients who had undergone an above-the-ankle amputation at a trauma center within three months following the injury was followed prospectively at three, six, twelve, and twenty-four months after the injury. The Sickness Impact Profile, a self-reported measure of functional status, was used as the principal measure of outcome. Secondary outcomes included pain; degree of independence in transfers, walking, and climbing stairs; self-selected walking speed; and the physician's satisfaction with the clinical, functional, and cosmetic recovery of the limb. Longitudinal multivariate regression techniques were used to determine whether outcomes differed according to the level of amputation after we controlled for covariates.

RESULTS

There was no significant difference in the scores on the Sickness Impact Profile between the patients treated with above-the-knee and those treated with below-the-knee amputation. However, patients with a below-the-knee amputation performed better than did patients with an above-the-knee amputation on the timed test for walking speed (p = 0.04). Patients with a through-the-knee amputation had worse regression-adjusted Sickness Impact Profile scores (p = 0.05) and slower self-selected walking speeds (p = 0.004) than did patients with either a below-the-knee or an above-the-knee amputation. Differences according to the level of amputation were most pronounced for physical function. In general, physicians were less satisfied with the clinical, cosmetic, and functional recovery of the patients with a through-the-knee amputation. Except for problems encountered with insufficient gastrocnemius coverage of the stump in many patients with a through-the-knee amputation, neither the soft-tissue coverage nor the technological sophistication of the prosthesis correlated with outcome.

CONCLUSIONS

Severe disability accompanies above-the-ankle lower-extremity amputation following trauma, regardless of the level of amputation. Clinicians should critically evaluate the need for a through-the-knee amputation in patients with a traumatic injury. The results of this study also underscore the need for controlled studies that examine the relationship between the type and fit of prosthetic devices and functional outcomes.