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Selection of patients for through-the-knee amputation

MS Pinzur, DG Smith, DJ Daluga and H Osterman
J Bone Joint Surg Am. 1988;70:746-750.

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 Copyright 988 by The Journal ofBone and Joint Surgery. incorporated

Selection of Patients for through-the-Knee Amputation*t

BY MICHAEL S. PINZUR, M.D., DOUGLAS G. SMITH, M.D4, DANIEL J. DALUGA, M.D4,
AND HELEN OSTERMAN, R.N.1, MAYWOOD, ILLINOIS

From the STAMP (Special Team for Amputations, Mobility, Prosthetics/Orthotics) Center,
Hines Veterans Administration Hospital, and the Loyola University Medical Center, Maywood

ABSTRACT: Forty-six adult patients had a through- Using Wagner’s experience and guidelines, we devel-
the-knee amputation (disarticulation of the knee) in a oped a similar program. Before considering amputation, we
four-year period. Thirty-four of the patients had pe- routinely employ a multidisciplinary team approach to eval-
ripheral vascular insufficiency and were judged to lack uate the potential for rehabilitation of a patient who has
the potential for using a prosthesis functionally, although peripheral vascular insufficiency. When vascular recon-
the evaluation indicated that they had the potential for struction is deemed inappropriate or unlikely to be suc-
healing of the wound at the below-the-knee level of am- cessful, the capacity for biological healing at a specific level
putation. At a minimum follow-up of one year, the am- of amputation is assessed. We use the ultrasound Doppler
putation wound had healed in thirty of these patients, ischemic index as a measure of arterial inflow, the level of
and no joint contracture had developed. Two patients serum albumin as a measure of tissue nutrition, and the total
died in the first postoperative month, and two had failure lymphocyte count as a measure of immunocompetence.
to heal and needed revision to an above-the-knee am- Combining this information with that gained from the din-
putation. ical examination, we are able to select a level of amputation
The remaining twelve patients who had a through- that has a reasonable potential for wound-healing279’0; we
the-knee amputation were judged to be potentially able term this the biological level. In addition, through objective
to use a prosthesis functionally, but they did not have psychological testing, we have identified the cognitive, mo-
the capacity for wound-healing at the below-the-knee
TABLE I
level. Therefore, in these patients, a through-the-knee
AMBULATORY STATUS*
amputation was performed as an alternative to an above-
the-knee amputation. The amputation wound healed in Level Status
eight of these patients, but four (33 per cent) had failure
VI Unlimited community ambulator
to heal and needed subsequent revision to an above-the- V Limited community ambulator
knee amputation. All twelve patients were able to use a IV Unlimited household ambulator
prosthesis. III Limited household ambulator
The through-the-knee amputation provides good II Supervised household ambulator
muscular balance and has a low risk for the late devel- I Unlimited wheelchair transfers
opment of joint contracture. The residual limb (stump) 0 Bedridden

provides an excellent surface area for sitting balance and * As described by Volpicelli et al.
a lever-arm for transfer. In a patient who has the po-
tential to use a prosthesis functionally, the residual limb tivational, and psychosocial requirements that appear to be
allows direct load-transfer (end weight-bearing). The necessary for the potential to use a prosthesis functionally6.
functional performance of a patient who has a prosthesis We combine this information with the physical therapy eval-
at this level is superior to that of a patient who has a uation, and, when necessary, cardiopulmonary testing, to
prosthesis at the above-the-knee level. determine if a patient has the capacity to walk with a
prosthesis’ ‘ . This projected level of rehabilitation is then
Wagner developed a program for the classification, combined with the predicted biological level to determine
evaluation, and treatment of the foot in patients who have the level of amputation that most closely correlates with a
diabetes or in whom the foot is neuropathic or dysvas- patient’s eventual function. The combination of projected
cular”#{176}. This program was based on years of clinical ob- levels is termed the patient’s rehabilitation potential.
servation and laboratory testing. We evaluate functional ambulatory capacity in accor-
dance with the levels of ambulation that were described by
* No benefits in any form have been received or will be received from Volpicelli et al. (Table I). Distal amputation at the level of
a commercial party related directly or indirectly to the subject ofthis article.
No funds were received in support of this study.
the foot or ankle is reserved for a patient who is evaluated
t Read at the Annual Meeting of The American Academy of Ortho- as having the capacity to walk functionally with a pros-
paedic Surgeons, Atlanta, Georgia, February 6, 1988.
:1:Department of Orthopaedics and Rehabilitation, Loyola University
thesis7. We attempt to avoid amputation at the below-the-
Medical Center, 2160 South First Avenue, Maywood, Illinois 60153. knee level in a patient whom we judge to be incapable of

746 THE JOURNAL OF BONE AND JOINT SURGERY

 SELECTION OF PATIENTS FOR THROUGH-THE-KNEE AMPUTATION 747
using a prosthesis, because, in such a patient, a flexion
contracture of the knee joint often develops, and this may
result in an ulcer from the pressure between the stump and
the patient’s bed (Figs. 1-A and 1-B). An above-the-knee
amputation is also undesirable in a patient who cannot use
a prosthesis. Drummond et al. showed that, while sitting,
a considerable amount of weight is borne by the posterior
aspect of the thigh in a patient who has balanced or unbal-
anced scoliosis. After an above-the-knee amputation, a flex-
ion-adduction contracture of the hip tends to develop due
to muscular imbalance. A flexed hip provides a much
smaller limb-surface area for sitting and a short lever-arm
for wheelchair transfer. In a patient who cannot walk, how-
ever, the through-the-knee amputation (disarticulation of the
knee) provides an excellent posterior surface area for sitting
and an adequately long lever-arm to assist in transfer.
Wagner”#{176} described a small group of patients who had
a through-the-knee amputation who, to the surprise of the
rehabilitation team, retained the functional capacity to use FIG. 1-A
a prosthesis. Waters et al. reported that an above-the-knee Figs. 1-A and 1-B: A patient who had a below-the-knee amputation and
amputation resulted in an increased expenditure of energy was subsequently unable to walk.
Fig. I-A: The knee is in maximum extension.
on walking. An elderly patient who has peripheral vascular
insufficiency is frequently older physiologically than chron-
ologically, because of concomitant coronary or cerebral-
vascular disease. Although the energy that is needed to walk
with an above-the-knee prosthesis may be lacking, a suc-
cessful amputation at or distal to the knee may help to
preserve the patient’s independence5. The through-the-knee
amputation allows direct load-transfer (end weight-bearing),
which simplifies fitting of the prosthetic socket and facili-
tates training of the patient in gaining competence with the
prosthesis. The through-the-knee prosthesis is easy for a
patient to put on and take off, and it tolerates residual fluc-
tuations in the volume of the limb better than does the below
or above-the-knee prosthesis4’9.

Materials and Methods

During a four-year period, forty-six patients had a
through-the-knee amputation (disarticulation of the knee) at
either the Hines Veterans Administration Hospital or the
Loyola University Medical Center. Forty-four amputations
were performed for peripheral vascular insufficiency and
two, for the residual effects of trauma when the soft-tissue
envelope or an infection of the residual portion of the tibia
precluded a below-the-knee amputation. Twenty-seven (59
per cent) of the patients had diabetes. The patients were
divided into two groups, according to the indications for
amputation and the goals for rehabilitation.
Group I comprised thirty-two patients who had gan-
grene of the distal part of the extremity who, when evaluated
FIG. 1-B
by the criteria that were already described, were judged not
There is a large pressure ulcer on the end of the stump.
to be suitable candidates for prosthetic limb-fitting as part
ofthe rehabilitation program. The average age ofthe patients
in this group was sixty-eight years (range, fifty to ninety- Group II comprised twelve patients who were consid-
one years) Two patients
. who would have been in Group I ered to be appropriate candidates for prosthetic limb-fitting
died in the first postoperative month and were therefore and gait-training. The average age of these patients was
excluded from the study. fifty-nine years (range, thirty-one to sixty-nine years). A

VOL. 70-A, NO. 5, JUNE 1988

748 M. S. PINZUR, D. G. SMITH, D. J. DALUGA, AND HELEN OSTERMAN

FIG. 2-A FIG. 2-B FIG. 2-C

Figs. 2-A, 2-B, and 2-C: Surgical technique for through-the-knee amputation.
Fig. 2-A: Sagittal flaps are used, the length of the flaps being equal to one-half of the diameter of the limb at the knee joint. The apex of the flaps
is at a point midway between the inferior pole of the patella and the tibial tubercle.
Fig. 2-B: Before disarticulation.
Fig. 2-C: After disarticulation, the patellar ligament is sutured to the distal stumps of the cruciate ligaments, and the posterior fascia of the gastrocnemius
is sutured to the retinaculum of the knee joint.

prosthesis was not prescribed to assist solely in transfer, but in whom the wound is healing satisfactorily3 (Fig. 3).
only when the evaluation indicated that it would enable a Stretching of the hip-flexor muscles to prevent contracture
patient to walk. Of these twelve patients, ten had peripheral is not necessary, as neither the flexor nor the extensor mus-
vascular insufficiency, six of whom were judged to lack the des are imbalanced by an amputation at this level.
capacity for wound-healing at the below-the-knee level. The
remaining four patients had had a previous attempt at below- Results
the-knee amputation that had been unsuccessful due to in- Group I: In thirty patients (94 per cent), the amputation
fection or failure to obtain wound-healing. The other two wound healed primarily, but in two (6 per cent), it failed
of the twelve patients in Group II had a through-the-knee to heal, necessitating revision to an above-the-knee ampu-
amputation because stiffness of the knee joint resulting from tation. All of the above-the-knee amputation stumps healed
a previous intra-articular fracture precluded a functional be- satisfactorily. At a minimum follow-up of one year, there
low-the-knee amputation. was no flexion or adduction contracture of the hip in any
The surgical technique was described by Wagner. Sag- of these patients.
ittal skin flaps, equal in length to one-half of the diameter Group II: The two amputations that were done for the
of the limb at the knee joint, are created with the apex residual effects of trauma, and six of the ten that were done
midway between the distal pole of the patella and the tibial for peripheral vascular disease, healed primarily. These pa-
tubercle. After disarticulation of the knee joint, the patellar tients were able to return to the preamputation level of
ligament is sutured to the distal stumps of the cruciate hg- walking, using a prosthesis’. The four amputation stumps
aments, and the posterior fascia ofthe gastrocnemius muscle (33 per cent) that did not heal were revised successfully to
is sutured to the retinaculum of the knee joint (Figs. 2-A, the above-the-knee amputation. All four patients were suc-
2-B , and 2-C). The technique is occasionally modified to cessfulhy fitted with an above-the-knee prosthesis and were
accommodate a previous surgical scar or the available soft- trained in its use, but each of them had a decrease of at
tissue envelope. The wound is dressed with rigid plaster, least one functional level of ambulation8.
and suction drainage is continued for twenty-four hours.
The dressing is changed at five days. Weight-bearing with Discussion
a temporary plastic limb is then initiated in Group-Il patients Using the surgical guidelines that were developed by

ThE JOURNAL OF BONE AND JOINT SURGERY

 SELECTION OF PATIENTS FOR THROUGH-THE-KNEE AMPUTATION 749

Wagner, we obtained similar results with through-the-knee

amputation in this series of patients. We identified two
groups of patients who could potentially benefit from
through-the-knee amputation. In the patients who did not
appear to have the capacity to use a prosthesis (Group I),
the goal was primary wound-healing and early rehabilitation
to the patient’s maximum level of independence, without
the late complications of joint contracture or a poor base
for sitting, which may occur after above-the-knee ampu-
tation.
Vascular reconstruction was not attempted in these pa-
tients, because we thought that there was a poor risk-benefit
ratio for this type of operation. Although many of these
patients appeared to have the biological potential for a more
distal amputation wound to heal, we did not think that it
was appropriate to attempt a distal amputation, with its
inherent risks of morbidity and wound failure, because even
if such an amputation were successful, it would not have
improved the poor rehabilitation potential. . ,.1

In a patient who is judged to be a candidate for a

functional prosthesis, the results of through-the-knee am-
putation are clearly functionally superior to those of above-
the-knee amputation. The socket of the through-the-knee
prosthesis allows direct load-transfer and does not rely on
the finely tuned total-contact fit that is needed by the socket
of the above-the-knee prosthesis. The former type of pros-
thesis is easier for an elderly patient to put on and take off,
and it better tolerates fluctuations in the volume of the
stump. It is our clinical impression that the functional walk- .dt;

ing capacity of the elderly patient who has borderline walk-

ing capacity and who has a through-the-knee prosthesis is
very similar to that obtained with a below-the-knee pros-
thesis. It must be emphasized that this type of elderly patient
should not be compared with a young patient, who can use
FIG. 3
the power of the extensors with a below-the-knee prosthesis.
A healed through-the-knee amputation stump. The surgical scar has
An elderly patient who can walk only at the minimum level retracted posteriorly between the femoral condyles.
may benefit more from direct load-transfer (end weight-
bearing) and stability than from preservation of the exten- rehabilitation team both were willing to accept a potentially
sors, which may not have enough strength to be of any use. high rate of failure in exchange for the increased functional
With the development of new technology, stance-phase con- capacity that would be provided by a successful through-
trol and ultimate stability appear to be easier to obtain with the-knee amputation.
the through-the-knee prosthetic system4’9. We are currently In summary, it is our opinion that the through-the-knee
comparing the function of elderly patients in our gait-anal- amputation has two major advantages. In a patient who has
ysis laboratory to establish objective risk-benefit ratios for gangrene and who does not appear capable of becoming a
below-the-knee and through-the-knee amputations in the pa- functional prosthetic-limb user, the through-the-knee am-
tient who has borderline walking capacity. putation has a low risk of morbidity, a high rate of primary
Although our rate of failure of 33 per cent in the patients wound-healing, and a low potential for the development of
who had the apparent capacity for functional use of a pros- joint contracture, which can lead to pressure ulcers or can
thesis (Group II) was admittedly high, we thought that the limit sitting capacity. In a patient who eventually becomes
potential functional benefits of the through-the-knee am- a functional prosthetic-limb user, it is our experience that
putation far outweighed the risk of failure. These patients the through-the-knee amputation enables a more rapid rate
were not good candidates for general anesthesia, and they of rehabilitation and has a functionally superior outcome
usually were given regional anesthesia. The patients and the compared with the above-the-knee amputation.

References
I . DRUMMOND, D. S. ; NARECHANIA, R. G. ; ROSENTHAL, A. N. ; BREED, A. L. ; LANGE, T. A. ; and DRUMMOND, D. K. : A Study of Pressure
Distributions Measured during Balanced and Unbalanced Sitting. J. Bone and Joint Surg., 64-A: 1034-1039, Sept. 1982.

VOL. 70-A, NO. 5, JUNE 1988

750 M. S. PINZUR, D. G. SMITH, D. J. DALUGA, AND HELEN OSTERMAN

2. KOMAN , L. A. : Current Status of Noninvasive Techniques in the Diagnosis of Upper Extremity Disorders. Part I. Evaluation of Vascular Competency.
In Instructional Course Lectures, The American Academy of Orthopaedic Surgeons. Vol. 32, pp. 61-76. St. Louis, C. V. Mosby, 1983.
3. KRAKER, DAVID; PINZUR, M. S. ; DALEY, ROBERT; and OSTERMAN, HELEN: Early Post-Surgical Prosthetic Fitting with a Pre-Fabricated Plastic
Limb. Orthopaedics, 9: 989-992, 1986.
4. MCCOLLOUGH, N. C. , III; HAMPTON, F. L.; and HARRIS, A. R.: Knee Disarticulation. in Atlas of Limb Prosthetics, pp. 369-377. The American
Academy of Orthopaedic Surgeons. St. Louis, C. V. Mosby, 1981.
5. PERRY, JACQUELIN: Scientific Basis of Rehabilitation. in Instructional Course Lectures, The American Academy of Orthopaedic Surgeons. Vol.
34, pp. 385-388. St. Louis, C. V. Mosby, 1985.
6. PINZUR, M. S.; GRAHAM, G.; and OSTERMAN, H.: Psychological Testing in Amputee Rehabilitation. Clin. Orthop. , 229: 236-240, 1988.
7. PINZUR, MICHAEL; KAMINSKY, MYRON; SAGE, RONALD; CRONIN, RICHARD; and OSTERMAN, HELEN: Amputations at the Middle Level of the
Foot. A Retrospective and Prospective Review. J. Bone and Joint Surg. , 68-A: 1061-1064, Sept. 1986.
8. VOLPICELLI, L. J. ; CHAMBERS, R. B.; and WAGNER, F. W. , JR.: Ambulation Levels of Bilateral Lower-Extremity Amputees. Analysis of One
Hundred and Three Cases. J. Bone and Joint Surg. , 65-A: 599-605, June 1983.
9. WAGNER, F. W. , JR. : Management of the Diabetic-Neurotrophic Foot. Part II. A Classification and Treatment Program for Diabetic, Neuropathic,
and Dysvascular Foot Problems. in Instructional Course Lectures, The American Academy of Orthopaedic Surgeons. Vol. 28, pp. 143-165. St.
Louis, C. V. Mosby, 1979.
10. WAGNER, F. W. , JR.: Amputations of the Foot and Ankle. Current Status. Clin. Orthop. , 122: 62-69, 1977.
1 1. WATERS, R. L. ; PERRY, JACQUELIN; ANTONELLI, DANIEL; and HISL0P, HELEN: Energy Cost of Walking of Amputees. The Influence of Level of
Amputation. J. Bone and Joint Surg. , 58-A: 42-46, Jan. 1976.

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