Selection of patients for through-the-knee amputation

Forty-six adult patients had a through-the-knee amputation (disarticulation of the knee) in a four-year period. Thirty-four of the patients had peripheral vascular insufficiency and were judged to lack the potential for using a prosthesis functionally, although the evaluation indicated that they had the potential for healing of the wound at the below-the-knee level of amputation. At a minimum follow-up of one year, the amputation wound had healed in thirty of these patients, and no joint contracture had developed. Two patients died in the first postoperative month, and two had failure to heal and needed revision to an above-the-knee amputation. The remaining twelve patients who had a through-the-knee amputation were judged to be potentially able to use a prosthesis functionally, but they did not have the capacity for wound-healing at the below-the-knee level. Therefore, in these patients, a through-the-knee amputation was performed as an alternative to an above-the-knee amputation. The amputation wound healed in eight of these patients, but four (33 per cent) had failure to heal and needed subsequent revision to an above-the-knee amputation. All twelve patients were able to use a prosthesis. The through-the-knee amputation provides good muscular balance and has a low risk for the late development of joint contracture. The residual limb (stump) provides an excellent surface area for sitting balance and a lever-arm for transfer. In a patient who has the potential to use a prosthesis functionally, the residual limb allows direct load-transfer (end weight-bearing).(ABSTRACT TRUNCATED AT 250 WORDS)     

Patient profiles of below knee-amputation following road traffic accidents – An observational study from a level 1 trauma centre in India

BackgroundPrimary amputation below the level of the knee joint is the most frequently performed amputation following trauma; however, data about incidence, patient profiling, and causative factors are seldom available in India.ObjectiveTo evaluate the profile and incidence of trauma-related amputations below the level of the knee joint at a level 1 trauma center.MethodsAn observational study over six months was conducted at a level 1 trauma center of north India. Epidemiological data such as age, sex, occupation, socioeconomic status, mechanism of injury, time of surgery, single or staged procedure, and complications were recorded from the admission files.Observations125/3047 (4.1%) trauma patients underwent amputation, of which 32.8% (41 of 125) had amputation below the level of the knee joint. Unilateral transtibial amputation was the most common (85.3%) involving 40/41 males with a mean age of 37.2 years of low socioeconomic status. Road traffic accidents were the most common cause (85.36% of cases). 39 of 41 cases presented within 24 h of injury and underwent surgery within 24 h of presentation. Secondary surgery was needed in 24.4% of the patients and revision amputation was done in only 2.4% (n = 1/41). No patient developed medical complications, and the average hospital stay was 8.7 days with a range from 2 to 14 days.ConclusionWe have documented a significant amputation rate in trauma cases (4.1%) reflecting on the seriousness of patients seen at our center. Most patients are young males at the peak of their productive lives, and from low socioeconomic status. Road Safety is essential, and specialized services for the amputees may be the need of the hour.     

Amputation of the knee joint in vascular diseases

Reported are 97 extensive amputations in 87 patients from 1975 to 1977. Postoperative early mortality was 47% and depended on the disease and the various factors that made amputation necessary. Amputations in chronic occlusive vascular disease without septicemia had a far lower mortality, 10%. Amputations in patients with septicemia resulted in a mortality of 90%. According to Burgess, amputations of the lower leg, exarticulation in the knee joint, and myeloplastic and open amputation of the thigh should be considered in that order. Exarticulation in the knee joint is only feasible in the presence of an open, deep, femoral artery.     

膝关节周围创伤伴腘窝血管伤的早期诊断与救治

目的 :探讨膝关节周围创伤伴腘窝血管伤的早期诊断与救治。方法 :回顾性分析2007年1月至2013年1月15例膝关节周围骨折、脱位伴腘窝血管损伤患者的临床资料,其中男9例,女6例;年龄26~62岁,平均39.2岁。结合临床症状、体征,运用血氧饱和度监测仪、彩色超声、DSA介入造影及手术探查等方法明确血管损伤,分别采用组合式外固定支架、钢板螺钉股骨髁逆行交锁钉内固定骨折及膝关节脱位,并根据具体情况对损伤血管进行取栓、修补、自体静脉移植重建血循环,分析手术时间、住院天数、保肢指数、输血量、医疗费用及感染发生情况,明确早期诊断及有效救治的作用。结果:本组患者死亡1例,截肢8例,6例手术成功修复腘动脉、胫前及胫后动脉。6例肢体存活患者随访12~60个月,平均28.3个月。保肢成功且关节功能优良4例。结论:膝关节周围创伤伴腘窝血管伤具有伤情复杂且严重、易误漏诊、预后差、保肢风险高等特点,应结合患者的创伤机制、损伤部位局部解剖特点、临床表现及适当的辅助检查来把握膝关节周围创伤伴腘窝血管伤的早期诊断,掌握合适的保肢与截肢指征以高效救治患者。     

Selection of level for lower limb amputation

Selection of level of lower limb amputation following trauma or in dysvascular patients must be based on experience, and a broad knowledge of the early and late problems following amputation and prosthetic fitting. Successful wound healing is important to achieve, so that the patient can be soon fitted with a prosthesis, and become involved in a rehabilitation program with the emphasis on early return to work and/or the home environment. It is helpful if the surgeon concerned has some knowledge of the advantages and limitations of prosthetic use at the various levels in the lower limb - too much information in the past has been relayed by word of mouth or repeated ad nauseam in orthopaedic textbooks. After trauma, it is usually a young male patient who must cope with limited function, loss of body image, difficult relationships with friends and loved ones leading to changes in their pattern of life and future plans.The dysvascular patient, however, is running ‘out of time’. Stewart²¹ reported a mean survival in peripheral vascular disease patients of only four years plus two months, when compared to the diabetic dysvascular patients of only three years plus eight months, after the amputation. If a patient survives for more than three years, there is a high chance that the other limb will be lost during that period. Young diabetic patients without peripheral vascular disease present with significant problems from peripheral neuropathy, osteoarthropathy of the foot and ankle, retinal damage and kidney problems often requiring long-term dialysis. These patients have limited life expectancy and selection of the level of amputation must take into consideration the necessity for early prosthetic fitting and rehabilitation.Diabetic patients with absent foot pulses should not be treated any differently from non-diabetics when the level of amputation is being considered. Similarly, elderly patients with athero sclerosis should be assumed to be diabetic, and this assumption should be verified by appropriate biochemical tests. Both groups should be intensively investigated in the hope that angioplasty or by-pass procedures may prolong limb survival if only for a limited period. There have been suggestions that the level of amputation and need for revision in dysvascular patients may be affected adversely by prior attempts at revascularization, but other studies fail to support this claim.^22,23Unfortunately, one must be both realistic and pessimistic about prosthetic fitting and use, especially in trans-femoral amputees. In a recent publication,²⁴ the authors conclude that only 10% to 15% of dysvascular amputees achieved mobility around the home on their prosthesis, and only 5% rehabilitate well independent of their wheelchair. They emphasize that when amputation is inevitable, more consideration should be given to surgery that optimizes wheelchair rehabilitation. These findings must make a surgeon responsible for performing the amputation continually aware of the importance of preserving the knee joint in the elderly dysvascular patient.     

Mobility one year after unilateral lower limb amputation: a modern, UK institutional report

The aim of this current retrospective study was to assess postoperative mobility one year after above knee (AKA) or below knee amputation (BKA) in a district general hospital. Data on patient demographics, diabetic status, risks for peripheral vascular disease, mortality and mobility at one year were recorded from the vascular database. Seventy-five patients underwent lower limb amputation over a 70-month period (AKA n=31, BKA n=44). Operative mortality was 10% and mortality at one year 13.7%. Fourteen out of the 31 patients (45.1%) who underwent AKA were mobile independently or with a walking stick compared to 54.5% (24/44) in the BKA group (P=0.44). Fifteen patients (48.3%) were diabetic in the AKA group compared to 26 patients (59.1%) in the BKA group (P=0.49). In the under 60 years group and over 60 years group there was no significant difference in type of amputation (P=0.64) or mobility (P=0.69). In this current series, there was no significant rehabilitation benefits in patients undergoing BKA compared to AKA. With an ageing population who inherently have increasing significant medical problems, the perceived benefit in preserving the knee joint may not be as significant as previously reported.     

The very long posterior tibial artery island flap.

Limb salvage procedures utilising tissue which would otherwise be discarded have become a well established practice in the management of trauma. These principles may also be utilised in the treatment of the burn injury. Two patients are presented with severe burns to the lower limbs involving muscle and bone where above knee amputation seemed inevitable. Salvage of the knee joint and conversion to a below knee amputation has been made possible by utilising the remaining skin of the sole of the foot based on a very long posterior tibial neurovascular pedicle ("Fillet of Sole" flap). This has provided full thickness sensate skin over the knee joint and below knee stump and has led to improved functional performance of the patient.     

The fate of bilateral lower limb amputees in end-stage vascular disease.

Sixty-six patients with end-stage peripheral vascular disease who had undergone bilateral major amputation of the lower extremities in our institution during the 10-year period January 1980-December 1989 were reviewed. There were 46 males and 20 females with an age range from 34 to 91 years (mean 67.7 years). A 98.5% follow-up was achieved. Of these patients 25% underwent their second amputation in the first, 50% within the second and 75% within the third postoperative year, notwithstanding the fact that prior attempts at revascularisation had been performed in 62% of all patients. The 30-day hospital mortality was 4.5%. The initial level of amputation was metatarsal in 14.4%, below knee in 66.6%, through knee in 9.9% and above knee in 9.1%. Out of a total of 132 stumps 89 healed by primary intention. Following secondary revisions and amputations the final level of amputation was metatarsal in 7%, below knee in 49%, through knee in 14% and above knee in 30%. Survival rates were 62% after 2 years, 31% after 5 years, and 14% after 8 years. By this time all diabetics had died, while 33% of non-diabetics were still alive (p greater than 0.02). Age, sex and amputation level had no bearing upon survival rate. Forty-three patients (65.1%) were ambulatory after their first amputation, but following contralateral amputation barely more than half (23 patients) were able to walk. In the presence of bilateral stage IV disease it is highly important to rehabilitate the patient immediately following unilateral amputation before considering amputation of the contralateral limb, otherwise the patient will not become ambulatory.     

Functional outcome after excision of heterotopic ossification about the knee in ICU patients

The objective of this study was to evaluate the degree of improvement in the range of movement in the knee joint, sitting ability, and overall ambulation in patients with heterotopic ossification of the knee joint who underwent surgical excision of ectopic bone. Between 1999 and 2006, 14 patients (23 joints) with significant heterotopic ossification of the knee joint that required surgery were evaluated. We compared the range of movement in the knee joint, sitting ability, and overall ambulation in the preoperative and postoperative periods using the Fuller and Keenan classification systems. Range of movement increased in 82% of cases (19 knee joints). Sitting ability improved in 13 patients (93%). Postoperatively, ambulation in eight patients (57%) was remarkably superior. In conclusion, resection of heterotopic ossification may significantly improve the range of movement in the knee joint, sitting ability, and overall ambulation.     

Major stump trauma following below-knee amputation. Outcome and recommendations for therapy.

Injury to the stump of a below-knee amputation (BKA) may require revision to a higher level of amputation. We undertook a retrospective review of BKAs performed during a 14-year period. Twenty-three patients suffered trauma to their stumps. Most (80%) trauma resulted from a fall. The severity of the trauma was graded on a three-part scale. Operative reclosure was attempted in 8 cases with 2 successes. Closure by secondary intent was successful in 7 of the 12 attempts. A total of 11 patients had revision to above-knee amputation (AKA) as the final outcome. The severity of trauma correlated inversely with the likelihood of eventual stump salvage. We conclude that primary reclosure or closure by secondary intent should be considered, since in 53% of attempts this results in knee preservation. Analysis of noninvasive vascular testing prior to the BKA was not helpful in predicting successful salvage of traumatized stumps.     

Chemical Analysis of the Surface of Silicone Modified by Oxygen Plasma Treatment for Cell Adhesion

Objective:  There is no consensus of objective information to determine the indication for lower extremity amputation and the lowest amputation level that will heal. In this report, we studied amputation for the lower extremity ischemia.
Objects and Methods:  We measured transcutaneous oxygen tension (tcPO2) in seven patients who had have ischemic disease of the lower extremity, two patients were in Buerger's disease and five patients were in arteriosclerosis obliterans (ASO). Of these patients, in regard to complications, four patients had diabetes mellitus (DM) and two patients underwent hemodialysis because of chronic renal failure. Six patients of them were men and only one patient was woman, mean age was 59 years old (25∼76 years old).
Results:  Two patients who had Buerger's disease underwent primary amputation. All another five patients who had ASO underwent secondary amputation. Selections of lower extremity amputation levels were above‐knee amputations in three patients, below‐knee amputations in two patients and toe amputation in two patients. There were incurable infections in two patients.
Conclusions:  It is generally said that if patients have had critical limb ischemia without providing hemodynamic improvement, it is necessary for them to be performed lower extremity amputations within 12 months, In concrete terms, segmental Doppler systolic blood pressures are below 50 mmHg and tcPO2 are below 30 mmHg. However in this our study, primary healing rate was 75% when the tcPO2 was above 20 mmHg.     

Minor environmental trauma and lower extremity amputation in high-risk patients with diabetes: incidence, pivotal events, etiology, and amputation level in a prospectively followed cohort

This study determined the incidence, pivotal events, etiology, and levels of amputation in a prospectively followed cohort of 400 people with diabetes and a prior healed foot ulcer who participated in a randomized footwear trial. Participants were seen every 17 weeks for 2 years. Subjects with foot lesions were referred to their healthcare provider for treatment. In this cohort, 11 participants required lower limb amputation (rate 13.8 per 1000 person-years). Pivotal event analysis revealed that only one amputation was related to footwear, six amputations were due to non-footwear-related minor environmental trauma, two were due to progression of vascular disease (dry gangrene from critical ischemia), one was due to a self-care injury while cutting the toenails, and one was due to a decubitus ulcer. Previously proposed strategies to reduce the amputation rates in individuals with diabetes have focused heavily on footwear and education. However, even with this emphasis, amputation rates in the United States are still high. This study suggests that the prevention of minor environmental trauma, including household accidents, merits additional attention. We believe that further efforts to reduce amputation rates for individuals with diabetes will need to emphasize the prevention of minor trauma, especially in those already compromised with neuropathy and vascular disease.     

Patient survival and limb salvage after shark attack with major vascular injury: A case report

Shark attacks are rare unique pathological processes. Some of them represent devastating injuries with a high morbidity and significant mortality. Related published articles are limited. The increased human interaction within the environment of sharks is the cause of rising incidence of such attacks. This study reported a case of level 4 shark injuries (shark-induced trauma scale) in a 33-year-old male patient, who presented with an extensive injury of the right lower limb with the characteristic features of shark bite. At admission the patient was in a state of shock with profuse bleeding that was controlled by tourniquet. The patient was resuscitated according to the advanced trauma life support. Clinical examination showed hard signs of vascular injury with absent pedal pulse, associated neurological deficits and severance at the knee joint. Prompt vascular intervention after resuscitation was performed to manage the major vascular injuries, together with proper washout and debridement of all the necrotic tissues under strong antibiotic coverage to prevent infection. After that, the patient underwent sequenced plastic, orthopedic, and neurological interventions. Strict follow-up was conducted, which showed that the patient was saved and achieved a functioning limb. This study aims to highlight the management of level 4 shark injuries, which are considered serious and challenging with a high fatality rate and a great risk of amputation due to the associated major vascular injuries. Immediate well organized management plan is crucial. Prompt resuscitation and surgical intervention by a highly-skilled medical team are required to improve the chance of patient survival and limb salvage.     

Kinematics of various joint mechanisms for the prosthetic substitution of the knee joint following knee exarticulation]

In the past, long amputation stumps of the thigh after knee disarticulation were difficult to fit with a knee prosthesis. Apart from other difficulties, one essential problem was caused by the fact that in preservation of the femoral length there was little or even no space to assemble a knee prosthesis at the level of the axis of the natural knee joint, that is to say at a position somewhere within the femoral condyles. In the meantime the number of knee disarticulations has increased and thus substituted the conventional above knee amputation. Consequently some new, partly polycentric knee joint mechanisms have been designed for the prosthetic fitting of knee disarticulation stumps as well as for long amputation stumps of the thigh. These mechanisms try to cope with the space problem in different ways and, moreover, some of them can also produce a moving centre of rotation at joint flexion similar to the natural knee joint. The motion pattern in current knee joint mechanisms is investigated by graphical construction of their centrodes and it is compared to the motion pattern of the natural knee joint.     

Above-the-knee amputation after a total knee replacement: prevalence,etiology, and functional outcome

BACKGROUND: Despite modern surgical techniques, salvage of a failed total knee replacement remains a challenge. In certain situations, when other treatment options have been exhausted, patients with a failed total knee replacement may become candidates for above-the-knee amputation. The objective of this study was to assess the prevalence, etiology, and functional outcome of above-the-knee amputation performed proximal to an ipsilateral total knee replacement. METHODS: From 1970 to 2000, 18,443 primary total knee replacements were performed at our institution; sixty-seven (0.36%) were eventually followed by above-the-knee amputation. Forty-two of the amputations were performed for a cause unrelated to the total knee replacement, most commonly peripheral vascular disease (twenty-four knees). The remaining twenty-five above-the-knee amputations were performed for causes related to the total knee replacement: nineteen were done for uncontrollable infection; two, for periprosthetic fracture; two, for pain; one, for severe bone loss; and one, for a vascular complication. RESULTS: The twenty-five above-the-knee amputations performed for causes related to the total knee replacement were done at an average of 8.6 years (range, eight days to 23.6 years) after the replacement. The prevalence of above-the-knee amputations done for causes related to total knee replacement was 0.14%. Complications after the above-the-knee amputation included deep infection in five patients and superficial infection and skin necrosis in one each; there was also one perioperative death. Nine of the twenty-five limbs were fitted with an above-the-knee prosthesis, but only five patients were walking even to a limited degree with the prosthesis at the time of the last follow-up. CONCLUSIONS: The overall prevalence of amputation after total knee arthroplasty at our tertiary care center was 0.36%. The majority (63%) of the amputations were performed for reasons not attributable to complications of the arthroplasty. The functional outcome after amputation performed above a total knee replacement is poor. A substantial percentage of the patients were never fitted with a prosthesis, and those who were seldom obtained functional independence.     

Primary survival and prosthetic fitting of lower limb amputees

During the period 1984-1985 amputation of the lower limb at a level potentially requiring a prosthesis was performed on 577 patients in 16 operative units. The mean age was 75.7 years for females and 68.1 for males. The most common site of the amputation was above the knee (49.9%). The majority of amputations (93.8%) were performed for vascular diseases and diabetes. Survival figures showed that 25.5% of amputees died within 2 months of amputation, 60.7% were alive after one year and 43.2% after two years. Out of a total of 577 patients, 26.9% were fitted with a prosthesis. Out of below-knee and above-knee amputees surviving over 2 months, 61.5% and 27.2% respectively were fitted with a prosthesis. There were markedly fewer prosthetic fittings in the over-60 age group. Diabetic patients of both sexes were fitted with a prosthesis more often than arterio-sclerotic patients. Among tumour patients 82.4% received a prosthesis. In the study area more emphasis must be put on the concept of preserving the knee joint and preoperative assessment of vascular patients for selection of amputation level. Every effort must be made to avoid delay in the postoperative mobilization and rehabilitation. Prosthetic fitting of amputees could be improved by better liaison between surgical unit and specialized rehabilitation unit and by closer team approach of amputee care.     

Lower limb landmine injuries

The medical records of 186 patients seeking treatment for landmine injuries in the authors' region between 1993 and 2001 were evaluated. Of these patients 13 died of accompanying complications. Ten (10) patients with general body trauma and upper limb trauma were excluded from the study. Of 163 patients with lower-limb injuries included in the study, 21 with traumatic amputation underwent surgical amputation at different levels. Patients without traumatic amputation were divided into 2 groups. There were 41 patients (29%) in Group I who were treated by limb salvage procedures. Treatments used in Group I including wound debridement, tendon repair, skin approximation, minimal osteosynthesis, external fixation of long bones and secondary wound coverage. In Group II, there were 101 patients (71%) with primary amputation. Trans-tibial amputation was performed in 52 cases (51.4%), ankle disarticulation in 24 (23.7%), trans-femoral amputation in 9 (8.9%), partial foot amputation in 8 (7.9%), knee disarticulation in 7 (6.9%) and hip disarticulation in 1 case. In Group I, there was infection in 21 patients (51.2%), revision in 27 (65.8%), and amputation in 15 (36.5%). In Group II, there was infection in 28 patients (27.7%), revision in 17 (16.8%), and amputation at a higher level in 8 (7%). In crush injuries such as those resulting from landmines, soft tissue, vascular, and neurological assessment must be performed with utmost care. Even so, the desired success in interventions intended to save a limb is complicated by a high infection rate, soft tissue complications, and high revision amputation rates. Therefore, a decision to amputate in the early term based on an accurate preoperative assessment is crucial.     

Clinical experience in allogeneic vascularized bone and joint allografting

The allotransplantation of vascularized femoral diaphyses and total knee joints is a novel approach in orthopedic surgery. Allogeneic femoral diaphyses were transplanted into three patients suffering from chondrosarcoma or posttraumatic defects. Total knee joints allografts were transplanted in five patients with large bone defects of the knee and loss of the extensor apparatus caused either by major trauma alone or infection after a major trauma. Bone segments and total joints were harvested from multi-organ donors, perfused with UW-solution and transplanted within cold ischemia times of 18-25 h. Patients were immunosuppressed postoperatively primarily with cyclosporine (Cyclosporin A) and azathioprine. Two allografts (1 femur, 1 knee) were lost due to infections. Seven of the eight patients are able to walk with full weight-bearing posttransplant. Two of the patients with transplanted joint allografts subsequently received total knee arthroplasty implantations. Vascularized bone and joint allotransplantation may serve as a last line of defense treatment before considering lower limb amputation.     

The role of non-invasive vascular studies in determining levels of amputation

Various non-invasive vascular studies have been reported to provide valuable data for selection of the optimum level of amputation in limbs in patients who have vascular disease. We evaluated three such methods: (1) measurement of the change in the transcutaneous PO2 after inhalation of oxygen; (2) determination, by the Doppler method, of segmental blood pressure; and (3) measurement of the temperature of the skin. The records of eighty patients (ninety amputations) were retrospectively reviewed for correlations between the results of the vascular studies and the outcome of the amputation. Measurement of transcutaneous PO2 was found to be the most accurate predictor of successful healing of an amputation; the other two measurements were less reliable. The values for transcutaneous PO2 both at rest and after inhalation of oxygen were significantly different (p less than 0.001) for the patients who had a healed amputation compared with those who had a failed amputation. Regardless of the initial value, if, after inhalation of oxygen, the transcutaneous PO2 reached ten millimeters of mercury or more, it predicted healing of the amputation stump with a sensitivity of 98 per cent. When the level of amputation was selected on the basis of clinical judgment at the time of operation, the sensitivity was only 90 per cent.     

Changing patterns in the predisposition for amputation of the lower extremities.

The purpose of this study was to evaluate and determine the role of diabetes and other common predisposing factors in amputation of the lower extremities. A retrospective review of 110 patients with peripheral vascular disease who underwent amputation between 1987 and 1990 at Hahnemann University Hospital (Philadelphia, PA) was performed. Patients who underwent amputations for trauma or cancer were excluded from this analysis. The patients were divided into four groups according to the site of amputation: Above Knee (n = 43), Below Knee (n = 26), Foot (n = 7) and Transmetatarsal (n = 34). The mean age was 60 years. Fifty-five patients (51%) were white. Sixty-four patients (58%) were men. Twenty-nine patients (26%) were cigarette smokers; sixteen smokers (55%) had above-knee amputation. Thirty-five patients (32%) had previous vascular surgery of the lower extremities. The combination of diabetes and hypertension was present in 40 patients (36%). When either diabetes or hypertension alone was present in a patient, hypertension, not diabetes, was more commonly the dominant underlying medical condition in patients with amputation (32 hypertension-alone patients vs. 10 diabetes-alone patients). The high frequency of hypertension suggests that enhanced control of this disease may affect peripheral vascular disease and related amputations in the future.