A reappraisal of a modified through-knee amputation in patients with peripheral vascular disease (original) (raw)
Related papers
Through-knee amputation in patients with peripheral arterial disease: A review of 50 cases
Journal of Vascular Surgery, 2008
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. ( J Vasc Surg 2008;48:638-43.)
Through-knee versus above-knee amputation for vascular and non-vascular major lower limb amputations
Cochrane Database of Systematic Reviews, 2021
This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To assess the e ects of through-knee amputation compared to above-knee amputation on clinical and rehabilitation outcomes and complication rates in all patients undergoing vascular and non-vascular major lower limb amputations. Through-knee versus above-knee amputation for vascular and non-vascular major lower limb amputations (Protocol)
Prosthetic vascular graft management in above-knee amputations
Cardiovascular journal of Africa, 2022
OBJECTIVE Critical limb ischaemia (CLI) is the most severe state of peripheral arterial disease and is one of the major causes of lower-limb amputations. One of the treatment choices is prosthetic vascular grafts. Despite treatment, CLI may lead to amputation owing to infection or progressive ischaemia. The aim of this study was to show that multidisciplinary planning and surgery for CLI patients with prosthetic grafts decreased the duration of hospital stay, costs, risk of infection and ascending conversion of the amputation level. METHODS Forty-two above-knee amputation patients with grafts were retrospectively evaluated. Group A patients (n = 24) had partial excision and group B patients ( n = 18) total excision with or without saphenous patch-plasty, according to the patency of the deep femoral artery. Growth in wound culture, antibiotic therapy duration, conversion to hip disarticulation and hospitalisation periods were compared. RESULTS Differences in growth of wound culture (...
2009
Objectives: The objectives of this thesis were to: estimate the overall and age and gender-specific incidence rates of initial amputation, re-amputation and contralateral amputation, performed for peripheral vascular disease, in the at-risk iabetic and nondiabetic general population; investigate the mortality rate after lower limb amputation performed for peripheral vascular disease and after initial trans-tibial amputation; introduce a Swedish version of the Locomotor Capabilities Index and evaluate its reliability and validity in patients who have undergone lower limb amputation; compare a new rigid dressing with conventional Plaster of Paris rigid dressing after transtibial amputation with regard to the number of days to prosthetic fitting and function with a prosthesis; evaluate the outcome of a new standardized treatment strategy in trans-tibial amputation in patients with peripheral vascular disease with regard to rate of prosthetic fitting and function with prosthesis and ana...
PLoS ONE, 2014
Objective: Little is known about long-term outcomes among patients who receive percutaneous angioplasty (PTA) for peripheral artery disease (PAD) then undergo below-knee or above-knee amputations. We sought to determine clinical outcomes associated with below-knee or above-knee amputation, along with possible explanatory factors and treatment strategies. Methods: Using data from Taiwan's National Health Insurance Research Database from 1997 to 2010, 7,568 adult patients were divided into three groups: lower extremity preserved (LE), below-knee amputation (BK) and above-knee amputation (AK). We assessed outcomes including major adverse cardiovascular events (MACE) and associated risk factors. Results: Overall MACE was significantly higher in the AK group compared to the LE and BK groups, over a mean follow-up of 2.45 years (hazard ratio [HR]: 1.81; 95% confidence interval [CI]: 1.50-2.18 for AK vs. LE; HR: 1.67; 95% CI: 1.36-2.06 for AK vs. BK). However MACE were similar for the BK and LE groups (HR: 1.08; 95% CI: 0.98-1.20). Overall mortality was highest in the AK group (HR: 1.65, 95% CI: 1.34-2.04 for AK vs. BK). As for patient characteristics, atrial fibrillation was more prevalent in the AK group than in the BK group (17% vs. 7%). Independent risk factors associated with death after above-or below-knee amputation included advanced age, heart failure, dialysis, male gender and high patient volume. Conclusion: The MACE rate was highest in the AK group, whereas the LE and BK groups were similar in this regard. Furthermore, overall mortality increased with larger area of amputation.
Ain Shams Journal of Surgery, 2014
Background/Aim: Below-knee amputation (BK) is the most proximal amputation that is still associated with a good rehabilitation procedure. All variations of the transtibial amputation are designed to provide adequate distal end padding and produce a cylindrical stump that can be readily suitable for prosthesis. The aim of this study is to compare the skew flap and the long posterior flap below-knee amputation in patients with peripheral vascular disease in terms of stump healing, wound infection, reamputation rate, and mobility with a prosthetic limb as outcome measures. Patients and methods: Fifty patients with chronic atherosclerotic occlusive disease of the lower extremity and critical ischemia (intractable rest pain, ulcer or gangrene) for whom no other treatment options remained and in whom below-knee amputation is indicated are included in the study. Patients were randomized into two groups. Group 1 underwent Skew Flap BKA; Group 2 underwent long posterior flap BKA. The two groups will be compared in terms of stump healing, wound infection, prosthesis fitting rate, and mobility with a prosthetic limb. Statistical analysis by Chi-square and t-test was used to compare two groups as regard quantitative variables in parametric data (SD<25% mean). Results: Regarding the early post-operative outcomes in terms of death in the 30 days postoperative period, incidence of cardiac events within 30 days post-operatively, primary healing after 7 days, wound discharge after 7 days, incidence of minor edge necrosis after 7 days, major flap necrosis after 7 days, revision of stump & post-operative stay period. Comparing the 2 tested groups using the Chi square showed no significant statistical differences between both of them. Regarding the late outcome results including the survival within 6 months, among the 25 patients of group 1, 20 patients survived till 6 months postoperatively (80% survival rate), while among the 25 patients of group 2, 18 patients survived till 6 months postoperatively (72% survival rate). Regarding prosthesis fitted within 6 months, among the 20 patients of group 1, 5 patients used the below knee prosthesis (25%), while among the 18 patients in group 2, 3 patients used the prosthesis (18.18%). Regarding the mobility status of patients with 6 months post-operative: among the 20 patients of group 1, among 20 patients of group 1, 3 patients were immobile (16.67%), 12 patients were dependent (60%), and 5 patients were independent (25%). While among the 18 patients of group 2: 2 patients were immobile (11.11%), 13 patients were dependent (72.22%) and 3 patients were independent (16.67%). By comparing the two groups regarding the mobility status within 6 months post-operative, there was no significant statistical difference using Chi square. Conclusion: The skew flap technique is considered the routine procedure for below knee amputation in many centers around the world. We conclude that the skew flap is just as effective as the long posterior flap. Skew flap is especially useful when below knee amputation is indicated and the posterior skin is inadequate to construct a long posterior flap.
Vascular surgery reduces the frequency of lower limb major amputations
European journal of vascular surgery, 1994
In June 1988 a Department of Vascular Surgery was established in the county of Viborg, Denmark. In this retrospective study of the periods 1986-87 and 1989-90, we have observed a significant rise in the number of patients evaluated by a vascular surgeon before amputation, from 19 to 49%. At the same time the number of major lower limb amputations significantly decreased. This reduction was most marked in 1990 probably due to a rise of 43% in the number of distal reconstructions. The distribution between below knee, through knee and mid-thigh amputation was unaffected by the increased vascular surgical activity. The frequency of major amputations in the county in 1986-87 of 40.9 per 100,000 per year declined by 25% to 30.9 per 100,000 per year in 1989-90. We conclude that vascular surgery reduces the number of major lower limb amputations and consequently all patients threatened with amputation must be evaluated if vascular reconstruction is possible.
Re-amputations and mortality after below-knee, through-knee and above-knee amputations
Danish medical journal, 2018
INTRODUCTION From January 2013, we changed the surgical strategy in our department and ceased to perform the through-knee amputation (TKA). The primary aim of this study was to investigate re-amputation rates ≤ 90 days after non-traumatic major lower-extremity amputations performed before and after this change of practice. Furthermore, we reported mortality before and after the change of practice. METHODS All non-traumatic major lower-extremity amputations performed in a single centre in two study periods (before and after the change of practice); 2009-2012 (cohort A) and 2014-2015 (cohort B) were included. Re-amputations and all-cause mortality ≤ 90 days after the index amputations were analysed. RESULTS Cohort A: Included 180 amputations with 27 below-knee amputations (BKA), 68 TKAs and 85 above-knee amputations (AKA). 86.7% of patients were American Society of Anesthesiologists (ASA) score 3-5. The re-amputation rate ≤ 90 days was 29.6% (95% confidence interval (CI): 12.7-47.3%) ...
Functional outcome in a contemporary series of major lower extremity amputations
Journal of Vascular Surgery, 2003
Purpose: We undertook this study to document the functional natural history of patients undergoing major amputation in an academic vascular surgery and rehabilitation medicine practice. Methods: A retrospective review was conducted of consecutive patients undergoing major lower extremity amputation and rehabilitation in a university and Department of Veterans Affairs hospital. Main outcome variables included operative mortality, follow-up, survival, median time to incision healing, secondary operative procedures for wound management, and conversion from below-knee amputation (BKA) to above-knee amputation (AKA). For surviving patients, quality of life was determined by degree of ambulation, eg, outdoors, indoors only, or no ambulation; use of a prosthesis; and independence, eg, community housing or nursing facility. Results: From August 1997 through March 2002, 154 patients (130 men; median age, 62 years) underwent 172 major amputations, 78 AKA and 94 BKA, because of either critical limb ischemia (87%) or diabetic neuropathy (13%). Thirty-day operative mortality was 10%. Mean follow-up was 14 months. Healing at 100 and 200 days, as determined with the Kaplan-Meier method, was 55% and 83%, respectively, for BKA, and 76% and 85%, respectively, for AKA. Twenty-three BKA and 16 AKA required additional operative revision, and 18 BKA ultimately were converted to AKA. Survival was 78% at 1 year and 55% at 3 years. Function in surviving patients at 10 and 17 months, respectively, was as follows: 21% and 29% of patients ambulated outdoors, 28% and 25% ambulated indoors only, and 51% and 46% of patients were nonambulatory; 32% and 42% of patients used prosthetic limbs; and 17% and 8% of patients who lived in the community before amputation required care in a nursing facility. Conclusions: We were surprised to find that vascular patients in a contemporary setting who require major lower extremity amputation and rehabilitation often remain independent despite infrequent prosthesis use and outdoor ambulation. Although any hope for postoperative ambulation in this population requires salvaging the knee joint, because of the morbidity incurred in both wound healing and rehabilitation efforts, aggressive effort should be reserved for selected patients at good risk. Ability to predict ambulation after BKA in the vascular population is poor. (J Vasc Surg 2003;38: 7-14.)