From the Society for Vascular Surgery

Through-knee amputation is a feasible alternative to

above-knee amputation
Sungho Lim, MD,a,b Michael J. Javorski, MS,a Pegge M. Halandras, MD,a Bernadette Aulivola, MD,a and
Paul R. Crisostomo, MD,a Maywood, Ill

ABSTRACT
Objective: Through-knee amputation (TKA) is a rare amputation performed in <2% of all major lower extremity
amputations in the United States. Despite biomechanical benefits and improved rehabilitation compared with above-knee
amputation (AKA), TKA has largely been abandoned by vascular surgeons because of concerns for poor wound healing. The
purpose of this study was to evaluate surgical outcomes of TKA.
Methods: The American College of Surgeons National Surgical Quality Improvement Program between 2005 and 2012
was queried using Current Procedural Terminology codes indicating AKA and TKA. Baseline characteristics were
reviewed, and logistic regression analysis was performed to identify predictors of 30-day mortality. Propensity score
matching was used to balance comorbidities between AKA and TKA. Operative variables and postoperative complica-
tions were compared between the groups.
Results: A total of 7469 AKA and 251 TKA patients were identified among 15,932 major lower extremity amputations.
Baseline characteristics were examined. White race, chronic obstructive pulmonary disease, dyspnea, emergent opera-
tion, steroid use, myocardial infarction, congestive heart failure, high American Society of Anesthesiologists score, old age,
preoperative sepsis or septic shock, and dialysis dependency were associated with increased 30-day mortality. Inde-
pendent lifestyle and smoking (within 1 year) were protective against early death. Baseline comorbidities were not
statistically significant after 1:1 propensity score matching. Operative outcomes were similar in both groups (AKA vs TKA).
Wound infection (7.2% vs 11.2%; P ¼ .16), dehiscence rate (1.2% vs 0.8%; P ¼ 1.0), and 30-day mortality (9.6% vs 11.2%; P ¼ .66)
were comparable. Other outcome parameters, including cardiopulmonary and genitourinary complications, were similar
except for a higher likelihood of return to the operating room in the TKA group (27.9% vs 12.4%; P < .01). Postoperative
mortality was not associated with TKA (P ¼ .77) or reoperation (P ¼ .42), but it was associated with the patients’ physi-
ologic conditions (dyspnea, sepsis, emergent operation, high American Society of Anesthesiologists score, and depen-
dent lifestyle). Predictors of reoperation were contaminated wound (hazard ratio [HR], 2.19; confidence interval [CI],
1.17-3.23; P ¼ .015), sepsis or septic shock (HR, 2.63; CI, 1.37-5.05; P ¼ .004), chronic obstructive pulmonary disease (HR, 2.81;
CI, 1.23-6.42; P ¼ .014), and wound infection (HR, 4.91; CI, 2.06-11.70; P < .001). Presence of peripheral vascular disease was
not associated with post-TKA reoperation (P ¼ .073).
Conclusions: TKA demonstrated similar postoperative morbidity and mortality compared with AKA. Wound infection
and risk of dehiscence were equivalent. TKA did demonstrate a higher rate of reoperation; however, neither TKA nor
reoperation predicted postoperative mortality. Patients in stable physiologic condition without active infection can safely
undergo elective TKA to maximize rehabilitation potential. (J Vasc Surg 2018;68:197-203.)

Considerable effort for limb preservation is routinely Severe peripheral arterial disease with or without comor-
made in medical, endovascular, and open surgical inter- bid diabetes mellitus accounts for the majority of
ventions. However, lower extremity amputation remains patients requiring major lower extremity amputations.1
one of the most common vascular surgical procedures. Level of amputation is mainly dictated by the extent
of the disease. Below-knee amputation (BKA) is typi-
From the Division of Vascular Surgery and Endovascular Therapy, Department
cally used once the needed level for amputation
of Surgery,a and One to MAP, Section of Surgical Analytics,b Loyola University
Medical Center. extends beyond the ankle. An above-knee amputation
Author conflict of interest: none. (AKA) is often the next level of amputation in the pres-
Presented in the Interactive Poster Session of the 2017 Vascular Annual Meeting ence of more proximal disease or failed wound healing
of the Society for Vascular Surgery, San Diego, Calif, May 31-June 3, 2017. from a BKA.
Correspondence: Paul R. Crisostomo, MD, Division of Vascular Surgery and
Advantages of through-knee amputation (TKA) over
Endovascular Therapy, Department of Surgery, Loyola University Medical Cen-
ter, 2160 S First Ave, EMS Bldg 110, Rm 3214, Maywood, IL 60153 (e-mail: AKA include the presence of an end-weight-bearing
[email protected]). stump,2,3 enhanced stability from preserved adductor
The editors and reviewers of this article have no relevant financial relationships to muscle insertion,2 reduced metabolic expenditure
disclose per the JVS policy that requires reviewers to decline review of any during ambulation from a longer lever arm,4 and simpli-
manuscript for which they may have a conflict of interest.
fied creation of the prosthetic device given the
0741-5214
Published by Elsevier Inc. on behalf of the Society for Vascular Surgery. decreased number of articulations.4,5 In addition, superior
https://doi.org/10.1016/j.jvs.2017.11.094 rehabilitation potential and improved postoperative

197
198 Lim et al Journal of Vascular Surgery
July 2018

quality of life have been reported.5-7 Despite these bene-

fits, TKA represents only <2% of all major lower extremity ARTICLE HIGHLIGHTS
amputations in the United States.8,9 Among vascular d
Type of Research: Retrospective analysis of prospec-
surgeons, TKA is similarly rarely performed. Fear of poor tively collected National Surgical Quality Improve-
wound healing and potential stump breakdown in longer ment Program data
soft tissue flaps needed to cover epicondyles of the distal d
Take Home Message: Compared with 7469 above-
femur are possible preconceived misconceptions. Histori- knee amputations, 251 through-knee amputations
cally, outcomes after TKA are acceptable, but scarce (TKAs) resulted in similar operative outcomes, wound
vascular literature exists reporting contemporary infection rates, dehiscence rates, and 30-day mortal-
outcomes of TKA.10-12 The purpose of this study was to ity rates. TKA had higher rates of reoperation, pre-
evaluate surgical outcomes of TKA with AKA. dicted by preoperative wound contamination and
sepsis.
METHODS
d
Recommendation: This study suggests that TKAs
Data sources. This study used the American College of can be used as an alternative to above-knee amputa-
Surgeons National Surgical Quality Improvement tions, especially in patients without active infection.
Program (ACS NSQIP) from January 2005 to December
2012. The ACS NSQIP derives data from the patient’s
the groups using the same statistical tests with baseline
chart, not from the insurance claims. It also provides
characteristics. Multivariate logistic regression analysis
in-depth postoperative information to allow analysis of
was again used to identify risk factors for reoperation
surgical outcomes to improve and to prevent complica-
and mortality. P values <.05 were considered statistically
tions. The NSQIP is publicly available, and individuals in
significant. Statistical analysis was performed using SPSS
the NSQIP are deidentified. Thus, this study was
software version 20 (IBM Corp, Armonk, NY).
exempted from Institutional Review Board approval, and
obtaining of informed consent was not required. Per the
ACS NSQIP database guidelines, our data included 30- RESULTS
day postoperative follow-up results from the partici- A total of 7469 AKA and 251 TKA patients were identi-
pating hospitals with <5% inter-rater reliability audit fied among 15,932 major lower extremity amputations.
disagreement rate. Baseline characteristics and demographics of all AKA
We identified patients using Current Procedural Termi- and TKA patients are shown in Table I. Baseline comor-
nology codes for AKA (27590, 27591), TKA (27598), and bidities between groups (AKA vs TKA) differed in age
BKA (27880, 27881). The NSQIP excludes patients (70.7 6 13.2 years vs 64.7 6 16.2 years; P < .01), previous
younger than 18 years. Patients with open amputation stroke (17.8% vs 11.6%; P ¼ .01), preoperative independent
(27592, 27882) or redo amputation (27594, 27596, 27884, functional status (34.3% vs 45.8%; P < .01), emergency
27886) were excluded. Patients who were trauma victims operation (12.9% vs 28.7%; P < .01), preoperative sepsis
or patients with musculoskeletal oncologic disease were or shock (15.1% vs 27.9%; P < .01), and contaminated
also excluded. Baseline characteristics, preoperative wound (17.5% vs 33.1%; P < .01). Predictors of early postop-
comorbidities, operative variables, and postoperative erative mortality (<30 days) were white race (hazard ratio
outcomes were collected. [HR], 1.28; confidence interval [CI], 1.13-1.45), chronic
obstructive pulmonary disease (HR, 1.31; CI, 1.12-1.55),
Interpretation and statistical analysis. Baseline charac-
dyspnea (HR 1.31; CI, 1.13-1.52), emergent operation (HR,
teristics and preoperative comorbidities were compared
1.50; CI, 1.28-1.76), steroid use (HR, 1.62; CI, 1.32-2.00),
between the groups. For continuous variables, t-test was
myocardial infarction (HR, 1.64; CI, 1.32-2.04), congestive
used after confirming normal distribution by Shapiro-
heart failure (HR, 1.66; CI, 1.39-1.97), high (4-5) American
Wilk test. The c2 or Fisher exact test was used for
Society of Anesthesiologists score (HR, 1.95; CI, 1.72-2.21),
categorical variables, depending on variables’ degree of
old age (>80 years; HR, 2.10; CI, 1.83-2.42), preoperative
freedom. Predictors of 30-day mortality were identified
sepsis or septic shock (HR, 2.15; CI, 1.87-2.47), and dialysis
using multivariate backward stepwise binary logistic
dependence (HR, 2.19; CI, 1.91-2.50). Independent lifestyle
regression analysis; we entered all available baseline
(HR, 0.53; CI, 0.47-0.61) and smoking within 1 year of the
characteristic variables and the level of amputation into
operation (HR, 0.76; CI, 0.64-0.89) were protective against
the regression model and removed the least important
early death (Table II).
variable at each step until all remaining variables
demonstrated significant P values. Propensity score-matched groups. As TKA is more
Propensity score matching was performed using all often applied under emergency circumstances with
baseline characteristic variables to balance comorbid- systemic infection, a 1:1 propensity score match was
ities between AKA and TKA. Operative variables and necessary between the AKA and TKA groups to minimize
postoperative complications were compared between the confounding effect of baseline comorbidities.
Journal of Vascular Surgery Lim et al 199
Volume 68, Number 1

Table I. Baseline characteristics Table II. Predictors of mortality

AKA TKA P value HR 95% CI P value
Total No. 7468 251 N/A Independent lifestyle 0.53 0.47-0.61 <.01
Age, years, 6 SD 70.7 6 13.2 64.7 6 16.2 <.01 Smoking within 1 year 0.76 0.64-0.89 <.01
Male 55.5 61.0 .09 White race 1.28 1.13-1.45 <.01
Race Chronic obstructive 1.31 1.12-1.55 <.01
White 60.3 64.1 .39 pulmonary disease
Black 29.9 25.9 Dyspnea 1.31 1.13-1.52 <.01
Others 9.8 10.0 Emergent operation 1.50 1.28-1.76 <.01
Smoking 27.7 29.5 .52 Steroid use 1.62 1.32-2.00 <.01
Ethanol 2.6 2.4 1.0 Myocardial infarction 1.64 1.32-2.04 <.01
Hypertension 83.2 78.9 .07 Congestive heart failure 1.66 1.39-1.97 <.01
Diabetes mellitus 44.8 45.8 .80 ASA class 4-5 1.95 1.72-2.21 <.01

Congestive heart failure 8.3 5.6 .16 Age >80 years 2.10 1.83-2.42 <.01
Myocardial infarction 4.9 3.2 .29 Preoperative sepsis or shock 2.15 1.87-2.47 <.01

Chronic obstructive 15.0 13.5 .59 Dialysis 2.19 1.91-2.50 <.01

pulmonary disease ASA, American Society of Anesthesiologists; CI, confidence interval;
HR, hazard ratio.
Dyspnea 16.0 17.9 .43
Dialysis 19.3 16.7 .33
(8.6 days vs 10.8 days; P ¼ .052) and 30-day mortality
Stroke 17.8 11.6 .01
(9.6% vs 11.2%; P ¼ .66) were also similar after AKA and
Peripheral arterial 53.1 51.4 .61 TKA. Cardiopulmonary and genitourinary complications
occlusive disease
were comparable. Of note, soft tissue infection (7.2% vs
Rest pain 54.5 50.6 .22
11.2%; P ¼ .16) and wound disruption (1.2% vs 0.8%;
Steroid use 5.4 6.4 .57 P ¼ 1.0) were similar between the AKA and TKA groups.
Functional status However, there was a higher likelihood of return to the
Independent 34.3 45.8 <.01 operating room in the TKA group compared with the
Partial or total 65.7 54.2 AKA group, which was statistically significant (12.4% for
dependence AKA vs 29.9% for TKA; P < .01).
Paraplegia or quadriplegia 3.9 5.6 .18 A total of 155 patients had a dirty or infected wound at
ASA class 4-5 48.0 47.2 .90 the time of intervention; 72 patients underwent AKA and
Emergent operation 12.9 28.7 <.01 83 underwent TKA. After contaminated AKA, 14 (19.4%)
Preoperative sepsis 15.1 27.9 <.01 patients required reoperation and 5 (6.9%) patients
or shock died. After contaminated TKA, 33 (39.8%) patients
Wound class required reoperation and 13 (15.7%) patients died.
Clean 63.9 49.4 Multivariate logistic regression analysis was performed
Clean-contaminated 7.2 4.4 <.01 in backward selection. We entered all comorbidity vari-
Contaminated 11.4 13.1 ables described in Table III plus the level of amputation
Dirty or infected 17.5 33.1
into the model. Postamputation mortality was strongly
associated with dependent lifestyle (HR, 7.70; CI, 3.07-
Operating surgeon
19.32; P < .001; Table V). Other predictors of mortality
Vascular surgeon 79.5 76.1 .053
included dyspnea (HR, 2.64; CI, 1.31-5.33; P ¼ .007), preop-
General surgeon 17.1 17.5
erative sepsis or septic shock (HR, 2.68; CI, 1.11-6.49;
Orthopedic surgeon 3.4 6.4 P ¼ .029), emergency operation (HR, 3.27; CI, 1.62-6.58;
AKA, Above-knee amputation; ASA, American Society of Anesthesiol- P ¼ .001), and high American Society of Anesthesiologists
ogists; N/A, not applicable; SD, standard deviation; TKA, through-knee
amputation. score (HR, 4.61; CI, 2.03-10.48; P < .001). Additional multi-
Values are reported as percentage unless otherwise indicated. variate regression analysis using these five variables plus
the level of amputation confirmed that TKA had no
impact on mortality (HR, 1.15; CI, 0.61-2.19; P ¼ .667).
Table III details well-balanced baseline characteristics Logistic regression analysis was employed to predict
after matching between the two groups. the population of patients at minimal risk of reoperation
There was no statistically significant difference between after TKA. The analysis demonstrated that contaminated
the matched AKA and TKA groups for intraoperative vari- wound at the time of intervention (HR, 2.19; CI, 1.17-3.23;
ables such as requirement of general anesthesia and P ¼ .015), sepsis or septic shock (HR, 2.63; CI, 1.37-5.05;
operative time (Table IV). Postoperatively, length of stay P ¼ .004), chronic obstructive pulmonary disease
200 Lim et al Journal of Vascular Surgery
July 2018

Table III. Baseline characteristics (propensity score matched) Table IV. Operative and postoperative outcomes (pro-
pensity score matched)
AKA TKA P value
AKA TKA P value
Total No. 251 251 N/A
Age, years, 6 SD 64.1 6 15.1 64.7 6 16.2 .64 General anesthesia 86.9 86.9 1.0

Male 61.8 61.0 .93 Operative time, 67.8 6 39.7 63.7 6 47.4 .29
minutes, 6 SD
Race
Intraoperative CPR 0 0.4 1.0
White 64.1 64.1 .95
Length of stay, 8.64 6 13.6 10.75 6 10.5 .052
Black 25.1 25.9 days, 6 SD (days
Others 10.8 10.0 from operation to
Smoking 27.9 29.5 .77 discharge)
Ethanol 2.4 2.4 1.0 Soft tissue infection 7.2 11.2 .16
Hypertension 76.1 78.9 .52 Wound disruption 1.2 0.8 1.0
Diabetes mellitus 43.8 45.8 .72 Pneumonia 5.2 6.0 .85
Congestive heart failure 6.4 5.6 .85 Unplanned reintubation 4.0 5.6 .53
Myocardial infarction 2.4 3.2 .79 Intubated >48 hours 6.4 11.6 .06
Chronic obstructive 12.0 13.5 .69 Pulmonary embolism 1.2 0.8 1.0
pulmonary disease Renal failure 2.0 4.8 .14
Dyspnea 19.5 17.9 .73 Urinary tract infection 4.0 5.2 .67
Dialysis 11.1 16.7 .32 Stroke 2.0 2.0 1.0
Stroke 12.7 11.6 .79 Cardiac arrest 2.8 4.0 .8
Peripheral arterial occlusive 49.0 51.4 .66 Blood transfusion 13.9 13.9 .0
disease Sepsis or septic shock 8.8 10.8 .55
Rest pain 46.6 50.6 .42
Return to operating room 12.4 27.9 <.01
Steroid use 6.0 6.4 1.0 30-Day mortality 9.6 11.2 .66
Functional status
AKA, Above-knee amputation; CPR, cardiopulmonary resuscitation;
Independent 46.6 45.8 .93 SD, standard deviation; TKA, through-knee amputation.
Values are reported as percentage unless otherwise indicated.
Partial or total dependence 53.4 54.2
Paraplegia or quadriplegia 4.4 5.6 .68
ASA class 4-5 45.4 47.4 .72 stable physiologic conditions without localized or sys-
Emergency operation 28.7 28.7 1.0 temic infection. After exclusion of patients with preoper-
Preoperative sepsis or shock 8.8 10.8 .55 ative sepsis or septic shock and contaminated or dirty
Wound class wound at the time of intervention, there were 123
Clean 51.0 49.4 propensity-matched patients in the AKA group and 110
Clean-contaminated 6.8 4.4 .55 patients in the TKA group. After AKA, 14 (11.4%) required
Contaminated 13.5 13.1 reoperation and 10 (8.1%) patients died. After TKA, 15
(13.6%) patients required reoperation and 8 (7.3%)
Dirty or infected 28.7 33.1
patients died. Neither variable was statistically significant
Operating surgeon
(P ¼ .60 for reoperation, P ¼ .81 for mortality).
Vascular 76.5 76.1 .31
General 19.9 17.5 DISCUSSION
Orthopedic 3.6 6.4 This study demonstrated that contemporary surgical
AKA, Above-knee amputation; ASA, American Society of Anesthesiol- outcomes of TKA are largely comparable with those of
ogists; N/A, not applicable; SD, standard deviation; TKA, through-knee AKA; 30-day mortality and intraoperative and postopera-
amputation.
Values are reported as percentage unless otherwise indicated. tive complications were similar in both groups. The rate
of surgical site infection and wound disruption of both
procedures also demonstrated similar outcomes.
Reoperation was higher in TKA. However, this param-
(HR, 2.81; CI, 1.23-6.42; P ¼ .014), and wound infection (HR, eter in the NSQIP database does not identify the reason
4.91; CI, 2.06-11.70; P < .001) predispose patients to post- for reoperation, nor does it distinguish between planned
TKA reoperation. Presence of peripheral vascular disease and unplanned return to the operating room. Thus,
(PVD; n ¼ 41 with PVD vs n ¼ 29 without PVD) was not when TKA is performed as a temporizing operation
associated with post-TKA reoperation (P ¼ .073; Table VI). before definitive staged AKA in patients with over-
Additional analysis was performed to evaluate postam- whelming infection, the rate of TKA reoperation mislead-
putation reoperation rate and mortality in patients with ingly increases. Moreover, the Current Procedural
Journal of Vascular Surgery Lim et al 201
Volume 68, Number 1

Table V. Predictors of mortality (multivariate analysis after proprioception after TKA over AKA, which allows better
1:1 propensity score matching) control of balance with prosthetic ambulation. These
HR 95% CI P value findings were reiterated in several retrospective reports.
Dyspnea 2.64 1.31-5.33 .007 In Europe, Stirnemann et al14 reported the outcomes of
Sepsis or septic shock 2.68 1.11-6.49 .029
413 amputations for arterial insufficiency. Of those,
93 were TKAs. Their study demonstrated that mortality
Emergency operation 3.27 1.62-6.58 .001
and prosthetic gait of TKA were nearly equivalent with
ASA class 4-5 4.61 2.03-10.48 <.001
those of BKA. Moran et al15 reported outcomes of 106
Partially or totally 7.70 3.07-19.32 <.001
TKAs, most of which were the result of vascular insuffi-
dependent lifestyle
ciency. The mortality rate was 20%, and more than half
ASA, American Society of Anesthesiologists; CI, confidence interval; HR,
hazard ratio. of the patients (57%) became ambulatory within
130 days. Hagberg et al5 proved increased prosthesis
use in lower level amputation (100% in BKA, 70% in
Table VI. Predictors of reoperation after through-knee TKA, 56% in AKA). All authors of these reports unequivo-
amputation (TKA) cally advocated consideration of TKA as a primary alter-
HR 95% CI P value native to AKA in patients when BKA is not feasible.
PVD 1.75 0.95-3.23 .073 Biomechanical advantages may contribute in part to
the reported superior outcomes of TKA. One study per-
Dirty wound 2.19 1.17-3.23 .015
formed at our institution demonstrated that the level
Sepsis or septic shock 2.63 1.37-5.05 .004
of amputation is associated with walking capacity.4
Chronic obstructive 2.81 1.23-6.42 .014
Cardiac stress and oxygen consumption per meter
pulmonary disease
were highest in AKA compared with lower level amputa-
Wound infection 4.91 2.06-11.70 <.001
tions. Walking speed, cadence, and stride length were
CI, Confidence interval; HR, hazard ratio; PVD, peripheral vascular
disease. adversely related to the level of amputation. This high
metabolic cost at each step of walking inarguably com-
promises rehabilitation potential in our already multiply
Terminology code system does not specify open (guillo- comorbid vascular surgical patients.
tine) TKA vs definitive TKA, whereas open (guillotine) Despite established biomechanical and physiologic
AKA was coded separately and was excluded from the benefits, TKA has not been widely adopted in the United
present study. This may also falsely increase the reopera- States and represents <2% of all major lower extremity
tion rate after TKA. amputation.1 Large retrospective vascular studies in the
In the United States, it is estimated that about 185,000 United States did not include outcomes of TKA.16-18
upper or lower limb amputations have been performed Indeed, TKA is believed to be prone to wound complica-
annually. Prevalence of limb loss (population living with tions. The bulbous femoral condyles require longer
limb loss) is much higher. Although there are no true musculocutaneous flaps.11,19 In addition, the shape of
surveillance data, the National Health Interview Survey the stump is difficult to fit for a prosthesis.20,21 To over-
estimated that about 1.6 million Americans live without come this disadvantage, Mazet and Hennessy22 in 1966
one or more limbs. This surprisingly high prevalence is suggested several modifications, characterized by crea-
expected to increase in parallel with the aging population tion of a conically shaped femoral stump by removal of
and the associated increase in predisposing vascular con- the medial and lateral femoral condyles and posterior
ditions, such as atherosclerosis and diabetes. One epide- surface. This technique is deemed to have an acceptable
miologic study estimated that the projected number of wound healing rate and an increased chance of pros-
Americans living with limb loss will be tripled by 2050.1 thetic gait. Recent studies reported a primary wound
Clearly, an effort should be made for primary preven- healing rate of about 80% after TKA, which is close to
tion of amputation. Improved diabetic control and the outcome after BKA.8,12,22-24
compliance as well as early recognition and treatment Criteria identifying patients who potentially can benefit
of risk factors for vascular disease are paramount. Unfor- from TKA still need further investigation. Our study
tunately, numerous patients present in a delayed fashion suggests that PVD is not a prohibitive factor for TKA.
with critical limb ischemia or severe diabetic foot Postamputation mortality was associated with baseline
gangrene, or they have failed to respond to numerous physiologic condition, whereas the biggest risk factor
surgical interventions with a subsequent nonsalvageable for reoperation was localized or systemic infection at
limb. Future quality of life after amputation is an impor- the time of intervention. This implies that vascular
tant consideration. surgeons may consider TKA a safe alternative to AKA if
In 1940, Rogers published a landmark paper describing their PVD patient is in stable physiologic condition
the advantages of TKA.13 Being a TKA amputee himself, without active infection in the affected extremity.
Rogers reported enhanced stability and increased Another important consideration to determine the level
202 Lim et al Journal of Vascular Surgery
July 2018

of amputation is functionality. Every patient has a condition without active infection can safely undergo
different perception of functional impairment; stratifying TKA to maximize rehabilitation potential and future
the functional outcome can be subjective and compli- independent lifestyle.
cated. In a study from South Carolina, Taylor et al25
analyzed 627 major lower extremity amputations and AUTHOR CONTRIBUTIONS
identified important factors that may affect postamputa- Conception and design: SL, PH, BA, PC
tion quality of life. Patients who were nonambulatory Analysis and interpretation: SL, PC
before surgery had an almost 10 times greater (HR, 9.5; Data collection: SL, MJ, PC
CI, 4.5-20.2) likelihood of not wearing a prosthesis. AKA Writing the article: SL, MJ, PH, BA, PC
also demonstrated one of the strongest associations Critical revision of the article: SL, MJ, PH, BA, PC
with failure of prosthesis use (HR, 4.4; CI, 2.6-7.4), followed Final approval of the article: SL, MJ, PH, BA, PC
by old age ($70 years; HR, 3.0; CI, 1.4-6.2). Risk factors for Statistical analysis: SL
failure to live independently after amputation were old Obtained funding: Not applicable
age ($70 years; HR, 4.0; CI, 1.7-9.5), AKA (HR, 1.8; CI, Overall responsibility: PC
1.2-2.8), and dementia (HR, 1.6; CI, 1.1-2.4). To consider
multidimensional aspects of the postamputation REFERENCES
outcome, multidisciplinary consultation may help in 1. Ziegler-Graham K, MacKenzie E, Ephraim P, Travison T,
understanding and setting up expectations of the Brookmeyer R. Estimating the prevalence of limb loss in the
United States: 2005 to 2050. Arch Phys Med Rehabil
patient, family, and caregivers. Assessment of preopera- 2008;89:422-9.
tive functional status and expected postoperative func- 2. Hughes J. Biomechanics of the through-knee prosthesis.
tional status may be discussed with the physical Prosthet Orthot Int 1983;7:96-9.
therapist. Thorough discussion of the benefits of lower 3. Liedberg E. Amputation för kärlsjukdom [PhD dissertation].
level amputation and potential complications, including Sweden: Lund Univeristy; 1982. p. 24-8.
4. Pinzur M, Gold J, Schwartz D, Gross N. Energy demands for
possibility of higher level revision, should be fully walking in dysvascular amputees as related to the level of
disclosed to patients. amputation. Orthopedics 1992;15:1033-7.
Smoking within 1 year was protective against early 5. Function after through-knee compared with below-knee
death. This curious observation has also been described and above-knee amputation. Prosthet Orthot Int 1992;16:
in other pathologic processes as the “smoker’s paradox” 168-73.
6. Behr J, Friedly J, Molton I, Morgenroth D, Jensen M, Smith D.
(eg, smokers with acute myocardial infarction have lower Pain and pain-related interference in adults with lower-limb
short-term mortality than nonsmokers do). Numerous amputation: comparison of knee-disarticulation, transtibial,
possible explanations of this paradox have been pro- and transfemoral surgical sites. J Rehabil Res Dev 2009;46:
posed, including dynamic state of smoking and age at 963-72.
7. Penn-Barwell J. Outcomes in lower limb amputation
presentation of smokers.
following trauma: a systematic review and meta-analysis.
Limitations of this study include a retrospective design Injury 2011;42:1474-9.
and the use of administrative data that lack detailed 8. Albino F, Seidel R, Brown B, Crone C, Attinger C. Through
patient information. We were not able to assess the knee amputation: technique modifications and surgical
degree of proximal arterial insufficiency, which may influ- outcomes. Arch Plast Surg 2014;41:562-70.
ence the surgical outcome. Aortoiliac occlusive disease 9. Dillingham T, Pezzin L, MacKenzie E. Limb amputation and
limb deficiency: epidemiology and recent trends in the
or concomitant superficial and deep femoral arterial United States. South Med J 2002;95:875-83.
occlusion increases the risks of a nonhealing wound. 10. Jackson A, Coburn G, Morrison D, Mrozinski S, Reidy J.
Reasons for reoperation were also not identifiable. Through-knee amputation in peripheral vascular disease. Br
Furthermore, outcomes in terms of discharge status J Diabetes Vasc Dis 2012;12:26-32.
(rehabilitation vs nursing home vs home) and ambula- 11. Morse B, Cull D, Kalbaugh C, Cass A, Taylor S. Through-knee
amputation in patients with peripheral arterial disease: a
tion were not available but could be considered poten- review of 50 cases. J Vasc Surg 2008;48:638-43.
tial targets for future studies. 12. Cull D, Taylor S, Hamontree S, Langan E, Snyder B, Sullivan T,
et al. A reappraisal of a modified through-knee amputation
CONCLUSIONS in patients with peripheral vascular disease. Am J Surg
Overall outcomes of TKA demonstrated similar 2001;182:44-8.
13. Rogers S. Amputation at the knee joint. J Bone Jt Surg
wound infection, dehiscence risk, and mortality in addi- 1940;22:973-9.
tion to similar cardiopulmonary morbidity. PVD was 14. Stirnemann P, Mlinaric Z, Oesch A, Kirchhof B, Althaus U.
not a prohibitive risk factor for a post-TKA complica- Major lower extremity amputation inpatients with periph-
tion. However, increased risk of reoperation after TKA eral arterial insufficiency with special reference to the
was noted; thus, patients with active infection or transgenicular amputation. J Cardiovasc Surg 1987;28:152-8.
15. Moran B, Buttenshaw P, Mulcahy M, Robinson K. Through-
systemic sepsis may be better candidates for staged knee amputation in high-risk patients with vascular disease:
guillotine amputation or AKA to decrease the risk of indications, complications, and rehabilitation. Br J Surg
reoperation. Otherwise, patients in stable physiologic 1990;77:1118-20.
Journal of Vascular Surgery Lim et al 203
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16. Stone P, Flaherty S, AbuRahma A, Hass S, Jackson J, Hayes J, 22. Mazet R, Hennessy C. Knee disarticulation: a new technique
et al. Factors affecting perioperative mortality and wound- and a new knee-joint mechanism. J Bone Jt Surg Am
related complications following major lower extremity am- 1966;48A:126-39.
putations. Ann Vasc Surg 2006;20:209-16. 23. Bowker J, San Giovanni T, Pinzur M. North American experi-
17. Aulivola B, Hile C, Hamdan A, Sheahan M, Veraldi J, ence with knee disarticulation with use of a posterior myo-
Skillman J, et al. Major lower extremity amputation: fasciocutaneous flap. J Bone Jt Surg Am 2000;82A:1571-4.
outcome of a modern series. Arch Surg 2004;139:395. 24. Kock H, Friederichs J, Ouchmaev A, Hillmeier J,
18. Nehler M, Coll J, Hiatt W, Regensteiner J, Schnickel G, Gumppenberg S. Long-term results of through-knee ampu-
Klenke W, et al. Functional outcome in a contemporary se- tation with dorsal musculocutaneous flap in patients with end-
ries of major lower extremity amputations. J Vasc Surg stage arterial occlusive disease. World J Surg 2004;28:801-6.
2003;38:7-14. 25. Taylor S, Kalbaugh C, Blackhurst D, Hamontree S, Cull D,
19. Jamieson C, Hill D. Amputation for vascular disease. Br J Messich H, et al. Preoperative clinical factors predict post-
Surg 1976;63:683-90. operative functional outcomes after major lower limb
20. McCollough N. The dysvacsular amputee. Orthop Clin North amputation: an analysis of 553 consecutive patients. J Vasc
Am 1972;3:303-21. Surg 2005;42:227-35.
21. Utterback T, Rohren D. Knee disarticulation as an amputa-
tion level. J Trauma 1973;13:116-20. Submitted Jul 4, 2017; accepted Nov 24, 2017.