title: A reappraisal of a modified through-knee amputation in patients with peripheral vascular disease.
abstract: BACKGROUND
  Through-knee amputation provides a longer lever arm and improved muscle control of the limb compared with above-knee amputation. Through-knee amputation also allows use of a total end-bearing prosthesis, which avoids the ischial pressure and suspension belts required of the above-knee amputation prosthesis. Several reports in the European literature tout the superiority of the through-knee amputation over the above-knee amputation in the patient with vascular disease. Through-knee amputation has received little attention in the United States, however, owing to the belief that the long flaps necessary to close a standard through-knee amputation are associated with an unacceptable rate of wound problems and offer no functional ambulatory advantage to above-knee amputation. We reviewed our experience with a modified technique of through-knee amputation in a group of patients with severe lower extremity ischemia who were not candidates for below-knee amputation to determine the incidence of wound complications and their functional outcome.
  
  
  METHODS
  Since 1996, 12 patients with severe lower extremity arterial insufficiency have undergone through-knee amputation utilizing a technique designed to limit flap length and facilitate the fit of a suction prosthesis. Two patients died of myocardial infarction in the immediate postoperative period and were excluded from the study. In the remaining 10 patients (1 man, 9 women; mean age 63 years (range 40 to 86), the below-knee amputation level was precluded because of gangrene or nonhealing wounds of the mid leg in 5 patients, failure of a previous below-knee amputation attempt in 4 patients, and severe ischemia that would compromise below-knee amputation healing in 1 patient. Nine patients had at least one failed vascular reconstruction procedure.
  
  
  RESULTS
  Mean follow-up is 25 months (range 6 to 41). Six (60%) patients had primary healing of their amputations. Two (20%) patients had delayed healing (6 weeks and 8 weeks). Two (20%) patients developed wound infections, which required amputation revision to the above-knee level. Seven (70%) patients were fitted with a suction socket prosthesis and are fully ambulatory. One patient healed but has not ambulated because of ischemia and subsequent ulceration of the contralateral limb.
  
  
  CONCLUSIONS
  These data show that through-knee amputation is associated with an acceptable primary healing rate (80%) and satisfactory functional outcomes (70% ambulation) in a high-risk vascular population. The functional advantages of through-knee amputation over above-knee amputation make it the preferred alternative for patients with vascular disease.
authors.affiliation: Vascular Surgery Service, Department of Surgical Education, Greenville Hospital System, 701 Grove Rd., Greenville, SC 29605, USA.
authors.forename: D L
authors.initials: DL
authors.lastname: Cull
authors.forename: S M
authors.initials: SM
authors.lastname: Taylor
authors.forename: S E
authors.initials: SE
authors.lastname: Hamontree
authors.forename: E M
authors.initials: EM
authors.lastname: Langan
authors.forename: B A
authors.initials: BA
authors.lastname: Snyder
authors.forename: T M
authors.initials: TM
authors.lastname: Sullivan
authors.forename: J R
authors.initials: JR
authors.lastname: Youkey
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001186:Artificial Limbs; D001696:Biomechanical Phenomena; D004188:Disarticulation / Q000379:methods*; D005260:Female; D006801:Humans; D007719:Knee Joint / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D016491:Peripheral Vascular Diseases / Q000601:surgery*; D012189:Retrospective Studies; D013524:Surgical Flaps; D016896:Treatment Outcome; D014945:Wound Healing