Knee Disarticulations Versus Transfemoral Amputations: Functional Outcomes

Abstract

Objectives: To determine whether there is a patient-reported functional difference between combat-related knee disarticulations (KDs) and transfemoral amputations (TFAs). Setting: Role 3 Military Trauma Centers. Patients: We identified and contacted all KDs and TFAs performed at the Walter Reed National Military Medical Center, Walter Reed Army Medical Center, and National Naval Medical Center from January 2003 until July 2012 to participate in a retrospective functional cohort analysis. Ten KD patients were available for study completion and were matched against 18 patients in the TFA group. Intervention: Knee disarticulation versus transfemoral amputation. Main Outcome Measurements: The following surveys were obtained from the participants—AAOS Lower Limb Outcome Questionnaire (LLQ), Tegner Activity Scale, SF-36, and Prosthetic Evaluation Questionnaires (PEQs). Results: Ten KD patients agreed to participate in the study, and 18 TFA matched controls were interviewed. Patients were followed up at an average of 66 months (interquartile range 50–79 months) after injury. There were no significant differences with regard to the SF-36, PEQ, LLQ, and Tegner Activity Scale scores. Conclusions: We detected no functional differences measured on the PEQ, LLQ, SF-36, and Tegner Activity Scale scores between KDs and TFAs. In the absence of a proven functional difference, we advocate performing trauma-related amputations at the most distal level the osseous and soft tissue injuries permit. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

A review of through-knee amputation

“…However, the Mazet and Gritti-Stokes surgical techniques claim to reduce volume of the residual limb by shortening the femur and reducing the bulge of the condyles by shaving or removing them completely, although the bulbous condyles can provide a better prosthetic suspension. 15 Few outcome data relating to TKA are reported and coupled with the absence of a standardised surgical technique; comparison of TKA to AKA is not possible. The variations in TKA surgical technique (classical, Mazet or Gritti-stokes, with their own respective modifications) compound this challenge.…”

“…Classical approach. In the classical approach [Figure 1(a)], the femur is left intact, 4,[11][12][13][14][15][16][17][18][19][20] except for the technical modification described by Vaucher and Blanc 21 where the femoral condylar cartilage and corners are excised to reduce the size of the condyles. The menisci are removed, except by Baumgartner (1979) who reported that the menisci could 'add cover' to the weight bearing femoral condyles in non-vascular patients.…”

“…A dorsal flap uses the gastrocnemius to cover the femoral condyles, with the scar lying anteriorly and horizontally away from the weight-bearing area. [14][15][16] A ventral flap, with the scar lying posteriorly and horizontally, allows thicker skin to be used for coverage. 10 'Fish mouth' flaps of equal lengths can be used with the scar lying on the most distal aspect of the residual limb.…”

“…Murakami (2016) reviewed outcomes of TKA in dysvascular patients noting no differences in residual limb health, prosthetic ambulation and mobility, functional outcomes with tests and questionnaires such as the sickness impact profile (perceived health status) between TKA surgical techniques and between TKA and AKA. 5,34 Of the 26 articles presenting TKA surgical techniques, 8 present both operative and functional outcomes, 20,22,[24][25][26][29][30][31] eight present only operative outcomes, 14,16,18,21,27,28,32,33 two present only functional outcomes 15,23 and eight present no outcomes (Table 2). 4,[9][10][11][12][13]17,19 Survival rates between techniques are inconsistent, ranging from 84% to 100% for all techniques.…”

Measures of Hip Function and Symptoms

“…To our knowledge, the AAOS Hip and Knee Questionnaire has not been used in any major clinical trials. It has been used to assess outcomes in patients with slipped capital femoral epiphysis , and the AAOS Lower Limb Questionnaire appears in numerous studies covering a broad range of musculoskeletal topics, including outcomes of limb lengthening and lower ‐ extremity amputation .…”