Through-knee Amputations Research Articles

Mobility Rates After Lower-Limb Amputation for Patients Treated with Physician-Led Collaborative Care Model

Clinical outcomes after major lower-limb amputation have been historically poor. The current care provided to most amputees is often disorganized and without physician supervision. The primary purpose of this study is to examine rates of postamputation mobility achieved with a prosthesis by patients with chronic limb-threatening ischemia and/or diabetes who required major lower-limb amputation and were treated under an established physician-led collaborative care pathway. The secondary purpose is to describe the structure and utilization of the care pathway by multiple independent vascular surgery practices in the United States to enable future exploration of its impact on key clinical outcomes within this patient population. Clinical records of 2,475 patients from 6 vascular practices that adopted this collaborative care pathway between 2017 and 2020 were retrospectively reviewed. Only records with sufficient documented histories of amputation surgeries, prosthetic services, and mobility status were included. Of 2,475 patient records reviewed, 1,787 patients (2,157 major amputations) were eligible for analysis. Sixty-two-point 2 percent (n=1,111) of patients achieved mobility with the collaborative care pathway. Mobility rate varied by amputation level in the study. Prosthetic mobility was achieved in 73.5% of transtibial amputations, 40.4% of transfemoral amputations, and 35.7% of through-knee amputations, regardless of patient laterality, which is superior or equivalent to the best published rates of mobility. The study describes the structure and utilization of a physician-led collaborative care pathway for treating patients who require lower-limb amputation that meets 5 of the 7 recommendations from the 2019 Global Vascular Guidelines on the Management of Chronic Limb Threatening Ischemia. Internal data analysis results suggest that patients treated via this care pathway can potentially achieve improved mobility rates with a prosthesis following amputation. This collaborative care pathway should be further evaluated for its ability to directly improve mobility and other clinically relevant amputation outcomes.

Preoperative Transcutaneous Oxygen Perfusion Measurements in Predicting Atraumatic Wound Healing After Major Lower Extremity Amputation.

This study examined the correlation between preoperative transcutaneous oxygen perfusion (TcPO2) measurement and the success of wound healing after major lower extremity amputation. There is no validated consensus on how to accurately determine appropriate amputation levels. A TcPO2 greater than 30 to 40 mm Hg is widely cited as a positive predictor of postoperative wound healing, but its validity has not been well defined. A retrospective chart review was performed for patients who underwent above-knee amputation (AKA), through-knee amputation, or below-knee amputation (BKA) at a single institution from 2012 to 2018 with preoperative TcPO2 values and a minimum 30-day postoperative clinical follow-up. This review yielded 141 total amputations: 93 BKAs, 6 through-knee amputations, and 42 AKAs. Fifty-five amputations were unsuccessful, defined by postoperative wound dehiscence or infection. Of these, 37 were BKAs, 4 were through-knee amputations, and 14 were AKAs. There was a significant difference in preoperative TcPO2 between the successful and unsuccessful amputations, at 46.2 and 38.3 mm Hg, respectively (P=.02). A TcPO2 of 30 to 40 mm Hg showed a 68.8% success rate, and a TcPO2 of less than 20 mm Hg showed an 18.2% success rate. A receiver operating characteristic curve for TcPO2 predicting amputation success had an area under the curve of 0.53 for AKAs and 0.61 for BKAs; the diagnostic ability is far from prognostic. There is no linear association between TcPO2 and success rate. A TcPO2 of less than 20 mm Hg has a high positive predictive value for failure, but higher levels are not 100% predictive of wound healing success after amputation, as previously reported. [Orthopedics. 2022;45(3):174-180.].

A review of through-knee amputation.

Through-knee amputation is an umbrella term for several different surgical techniques, which may affect clinical and functional outcomes. This makes it hard to evaluate the benefits and need for a through-knee amputation approach. This article seeks to (1) determine the number of through-knee amputation performed compared with other major lower limb amputations in England over the past decade; (2) identify the theoretical concepts behind through-knee amputation surgical approaches and their potential effect on functional and clinical outcomes and (3) provide a platform for discussion and research on through-knee amputation and surgical outcomes. National Health Service Hospital Episodes Statistics were used to obtain recent numbers of major lower limb amputations in England. EMBASE and MEDLINE were searched using a systematic approach with predefined criteria for relevant literature on through-knee amputation surgery. In the past decade, 4.6% of major lower limb amputations in England were through-knee amputations. Twenty-six articles presenting through-knee amputation surgical techniques met our criteria. These articles detailed three through-knee amputation surgical techniques: the classical approach, which keeps the femur intact and retains the patella; the Mazet technique, which shaves the femoral condyles into a box shape and the Gritti-Stokes technique, which divides the femur proximal to the level of the condyles and attaches the patella at the distal cut femur. Through-knee amputation has persisted as a surgical approach over the past decade, with three core approaches identified. Studies reporting clinical, functional and biomechanical outcomes of through-knee amputation frequently fail to distinguish between the three distinct and differing approaches, making direct comparisons difficult. Future studies that compare through-knee amputation approaches to one another and to other amputation levels are needed.

Use of Anatomical Landmarks in Ankle Arthroscopy to Determine Accuracy of Syndesmotic Reduction: A Cadaveric Study.

Background. The aim of this study was to determine the accuracy of ankle arthroscopy as a means for diagnosing syndesmotic reduction or malreduction and to determine anatomical landmarks for diagnosis. Methods. Six matched-pair cadavers (n = 12) with through-knee amputations were studied. Component parts of the syndesmosis and distal 10 cm of the interosseous membrane (IOM) were sectioned in each. The 12 specimens were divided into 2 groups: 6 specimens in the in-situ group fixed with suture button technique and 6 specimens in the malreduced group rigidly held with a 3.5-mm screw. Specimens were randomized to undergo diagnostic arthroscopy by 3 fellowship-trained foot and ankle orthopaedic surgeons in a blinded fashion. Surgeons were asked to determine if the syndesmosis was reduced or malreduced and provide arthroscopic measurements of their findings. Results. Of 36 arthroscopic evaluations, 34 (94%) were correctly diagnosed. Arthroscopic measurement of 3.5 mm diastasis or greater at the anterior aspect of the distal tibiofibular syndesmosis correlated with a posteriorly malreduced fibula. Arthroscopic evaluation of the Anterior inferior tibiofibular ligament (AITFL), IOM, Posterior inferior tibiofibular ligament (PITFL), lateral fibular gutter, and the tibia/fibula relationship were found to be reliable landmarks in determining syndesmotic reduction. An intraclass correlation coefficient (ICC) for interrater reliability of 1.00 was determined for each of these landmarks between 2 surgeons (P < .001). The ICCs between 2 surgeons' measurements and the computed tomography measurements were found to be 0.896 (P value < .001). Conclusions. Ankle arthroscopy is a reliable method to assess syndesmotic relationship when reduced in situ or posteriorly malreduced 10 mm. Levels of Evidence: Level V: Cadaveric.

Ambulation and functional outcome after major lower extremity amputation

ObjectiveMajor lower extremity amputations (MLEAs) remain a significant source of disability. It is unknown whether postamputation functional outcomes and outcome predictability have changed with a population of increasingly aging and obese patients. Accordingly, we sought to evaluate contemporary trends. MethodsA retrospective chart review was performed to identify patients undergoing MLEA using Current Procedural Terminology codes in a university hospital. Demographics, comorbidities, perioperative variables, and outcomes were obtained. Descriptive statistics, t-tests, and χ2 and multivariate logistic regression modeling were used where appropriate. Survival analyses were performed with the Kaplan-Meier method. ResultsFrom October 2005 to November 2016, 206 patients (147 male; mean age, 63 ± 13.5 years) underwent 256 MLEAs (90.9% below-knee amputations, 1.3% through-knee amputations, and 7.8% above-knee amputations [AKAs]) related to acute and critical limb ischemia, infection, or other causes. Mean follow-up was 178.7 ± 266.9 days. Conversion from below-knee amputation to AKA was 3.5%. Estimated 1-year survival was 83%, and it was 15% lower in nonambulatory patients (75% vs 90%; P = .04). Overall 1-year postamputation ambulatory rate was 46.1%. Nonambulatory patients had a higher body mass index (30.9 ± 8.0 vs 25.6 ± 5.4; P < .001), lower preoperative hematocrit (31.0% ± 7.4% vs 33.3% ± 8.1%; P < .05), higher modified frailty index (mFI; 8.4 ± 1.0 vs 5.4 ± 1.2; P < .0001), higher chronic alcohol use (9% vs 1%; P = .01), dependent preoperative functional status (29% vs 2.1%; P < .01), and lack of family support (66.3% vs 17.9%; P < .01); they were less likely to be married (83.2% vs 35.8%; P < .01) and more likely to have an AKA (20% vs 52.6%; P = .004). There were no patients with dementia, on dialysis, or with bilateral MLEAs who were ambulatory after amputation. Factors predictive of nonambulatory status after MLEA with multivariate logistic regression analysis included increased body mass index (odds ratio [OR], 0.88; 95% confidence interval [CI], 0.81-0.98; P = .017) and an increased mFI (OR, 0.23; 95% CI, 0.16-0.34; P < .0001); a higher hemoglobin level was protective (OR, 1.3; 95% CI, 1.03-1.62; P = .019). ConclusionsPatients should be counseled that <50% of patients receiving MLEAs are ambulatory after amputation. Educating patients about the deleterious effects of obesity on ambulatory status after MLEA may motivate patients to improve their level of fitness to achieve successful ambulation. Patients with an elevated mFI, patients with dementia, and those on dialysis should be considered for AKAs.

Are Gait Parameters for Through-knee Amputees Different From Matched Transfemoral Amputees?

Through-knee amputation is a common amputation level after battlefield injuries during the medical evacuation process. However, there are limited data comparing through-knee amputation with transfemoral amputation as a definitive amputation level in terms of gait parameters. (1) Does through-knee amputation result in improved gait velocity when compared with matched transfemoral amputees? (2) Do through-knee amputees have a faster gait cadence than matched transfemoral amputees? (3) Do through-knee amputees have a different stride length or stride width than matched transfemoral amputees? (4) Does through-knee amputation result in decreased work of ambulation when compared with matched transfemoral amputees? Between January 2008 and December 2012, six male active-duty military patients who had undergone unilateral through-knee amputations as a result of trauma underwent gait studies at our institution. Of those, four of six underwent gait analysis after being able to walk for at least 3 months without assistive devices, and this group was studied here. Most through-knee amputees who were not included had elective revisions of their amputations from through-knee to a transfemoral amputation before completing 3-month gait data. Each of the amputees studied was matched to a transfemoral amputee based on height, body mass index, and contralateral amputation level resulting in a case-control study of active-duty military male amputee patients. Inclusion required complete gait data collected while walking at a self-selected pace wearing custom prosthetic devices. The through-knee amputees had a median (range) age of 32 years (23-41 years) and the transfemoral amputees had a median age of 24 years (22-27 years). Three-dimensional gait data were collected and analyzed. A power analysis found that to detect a clinically important difference (set at a change in work of ambulation of 1 J/kgm) with a p value of 0.05 and a β set to 0.2, a study population of 56 patients per group would be required; that being said, our results on a much smaller population must be considered exploratory. With the numbers available, we found no differences in gait velocity when comparing through-knee (1.18 m/sec) and matched transfemoral amputees (1.20 m/sec, difference of medians = 0.02 m/sec; p = 0.964). Likewise, we found no differences in gait cadence when comparing through-knee with transfemoral amputees (104 versus 106 steps/min, respectively, difference of means 2 steps/min, p = 0.971). There was no difference in stride length or stride width when comparing through-knee (70 cm and 18 cm, respectively) with transfemoral amputees (70 cm and 19 cm, respectively; p = 0.948 and p = 0.440). With the numbers available, we did not identify a difference in the work of ambulation for through-knee amputees when compared with matched transfemoral amputees (8.3 versus 7.5 J/kg, respectively; p = 0.396). Based on our findings, we are unable to demonstrate any functional advantages of knee disarticulation over transfemoral amputation. Although there are theoretical advantages for maintaining an intact femur during the medical evacuation and serial débridement process, we question the utility of knee disarticulation as a definitive amputation level; however, larger numbers of patients are needed to confirm these results. Level III, therapeutic study.

Major Lower Limb Amputations: Experience of a Tertiary Care Hospital in Sri Lanka.

To determine the epidemiology and conditions frequently seen in major lower extremity amputation. Observational study. Teaching Hospital Karapitiya, Sri Lanka, from October 2013 to September 2014. Major lower limb amputations were identified according to ICD-10 criteria. Data was retrospectively collected. Type of the amputation, indication for the amputation, gender and age of the patients, and mortality were noted. Eighty-five cases of major lower limb amputations were analyzed, including 43 above-knee amputations, 40 below-knee amputations, and 2 through-knee amputations. Most of the patients were in their 7th (38.8%, n=33) and the 8th (21%, n=18) decade of life. Female to male ratio was 1:1.7. Indications of lower extremity amputation were diabetic foot ulcer (37.6%, n=32), peripheral vascular disease (31.7%, n=27), followed by trauma (n=6), acute limb ischemia and infections (n=5 each), chronic osteomyelitis (n=4), tumors (n=3), elephantiasis, pressure sore and chronic wound (n=1 each). Overall diabetes frequency was 52.9% (n=45). In-hospital mortality rate was 9.4%. Main cause of deaths was septicemia. In the study population, major lower limb amputations were more common in males compared to females, with highest incidence in the 7th and 8th decades. Diabetes mellitus contributed to more than 50% of amputations directly or indirectly, and septicemia was responsible for the most mortality.

Through knee amputation: technique modifications and surgical outcomes.

BackgroundKnee disarticulations (KD) are most commonly employed following trauma or tumor resection but represent less than 2% of all lower extremity amputations performed in the United States annually. KDs provide enhanced proprioception, a long lever arm, preservation of adductor muscle insertion, decreased metabolic cost of ambulation, and an end weight-bearing stump. The role for KDs in the setting of arterial insufficiency or overwhelming infection is less clear. The purpose of this study is to describe technique modifications and report surgical outcomes following KDs at a high-volume Limb Salvage Center.MethodsA retrospective study of medical records for all patients who underwent a through-knee amputation performed by the senior author (C.E.A.) between 2004 and 2012 was completed. Medical records were reviewed to collect demographic, operative, and postoperative information for each of the patients identified.ResultsBetween 2004 and 2012, 46 through-knee amputations for 41 patients were performed. The mean patient age was 68 and indications for surgery included infection (56%), arterial thrombosis (35%), and trauma (9%). Postoperative complications included superficial cellulitis (13%), soft tissue infection (4%), and flap ischemia (4%) necessitating one case of surgical debridement (4%) and four trans-femoral amputations (9%). 9 (22%) patients went on to ambulate. Postoperative ambulation was greatest in the traumatic cohort and for patients less than 50 years of age, P<0.05. Alternatively, diabetes mellitus and infection reduced the likelihood of postoperative ambulation, P<0.01.ConclusionsKnee disarticulations are a safe and effective alternative to other lower extremity amputations when clinically feasible. For patient unlikely to ambulate, a through-knee amputation maximizes ease of transfers, promotes mobility by providing a counterbalance, and eliminates the potential for knee flexion contracture with subsequent skin breakdown.

Case suitability for definitive through knee amputation following lower extremity blast trauma: analysis of 146 combat casualties, 2008–2010

IntroductionAnalysis of recent UK Armed Forces combat casualty data has highlighted a significant number of through joint traumatic amputations (TAs), most commonly through knee (through knee amputations (TKAs)). Previously, a...

Outcomes in lower limb amputation following trauma: A systematic review and meta-analysis

Introduction Lower limb amputation (LLA) is life-changing surgery. Shorter residual limbs are known to place greater physiological strain on patients than longer residual limbs; however, there is ongoing debate as to whether through-knee amputations are preferable to above-knee amputations. This analysis aims to resolve this question by systematically collecting and pooling published and unpublished data on this subject. Methods An exhaustive search of Medline, Embase and Recal databases was made for outcome studies of patients with lower limb amputations following trauma. Studies concerned with amputations of the upper limb or foot and ankle were excluded as were papers reporting outcomes in a population of mixed trauma and non-trauma patients. Authors of studies published in the last 10 years were contacted for unpublished details. Patients were then divided, according to amputation height, into four groups: below-knee amputation (BKA), through-knee amputation (TKA), above-knee amputation (AKA) and bilateral amputation. The primary outcome measure was Physical Component Score (PCS) of the short-form-36 measure of quality of life and secondary outcomes were pain, employment, ability to walk 500 m and proportion of time that prosthesis is worn. Results As many as 27 studies were included, representing a total of 3105 patients, 1855 with a BKA, 104 with a TKA, 888 with an AKA and 258 bilateral amputees. There was progressive and significant lowering of PCS (worsening outcomes) as unilateral amputation height became more proximal from BKA to TKA and AKA. A significantly greater proportion of patients with a BKA or a TKA were able to walk 500 m than those with an AKA or bilateral amputation ( p = 0.0035). However, patients with a TKA wore their prosthesis significantly less, and had significantly more pain than those with an AKA. Conclusion This study describes the impact of LLA of different levels on patients’ lives. The results indicate that patients with a TKA have a better physical quality of life than those with an AKA and, therefore, support the surgical strategy of maintaining maximum length and performing TKA in preference to AKA, where possible.

Amputation de genou dérivée de la technique de Gritti-Stokes pour artériopathie chronique chez le sujet âgé : est-ce faisable et raisonnable ?

Major lower limb amputation in elderly patients is a dreaded event with high mortality and morbidity. Peripheral arterial disease is the nearly exclusive etiology. The aim of this retrospective study was to assess the feasibility of through-knee amputation, and the morbidity and mortality risk in the elderly (>65 years).From January 2000 to October 2010, 65 Gritti-Stokes through-knee amputations were performed in 58 patients (30 women, 28 men; mean age 79 years). Acute limb ischemia was the most common cause (40%). The others indications were: severe peripheral arterial disease with extensive necrotic lesions (19%), diabetic foot ulcers (15%), non-healing below-knee amputation (10%) and vascular graft infection after prosthetic lower extremity bypass surgery (6%).Overall 30-day mortality was 24% (n=14/58). Vascular morbidity was 9% (n=6/65). The mean hospital stay was 31 days (range 3 to 96). The overall healing rate was 78% (n=51/65). Conversion to above-knee amputation for failed Gritti-Stokes amputation was performed in one patient.Gritti-Stokes amputation is feasible in the elderly with an acceptable one-month mortality and a satisfactory overall healing rate. Most amputations are necessitated by complications of acute limb ischemia. For this subpopulation, Gritti-Stokes amputation should be the standard amputation level. The data collected in this study provide important information that can be useful before amputation for this population, their families and primary care physicians. Ambulation is an important postoperative goal and a multidisciplinary approach in specialized centers is required to achieve good wound healing rates.

Functional Results After Through-Knee and Above-Knee Amputations: Does More Length Mean Better Outcome?

The objective was to evaluate our results on functional outcome for both through-knee amputations and above-knee amputations. Functional outcome was measured using the Special Interest Group in Amputee Medicine score, which focuses on walking distance and use of prosthesis. From 1997 to 2006, 39 through-knee amputations (53%) and 34 above-knee amputations (47%) were performed. Eight (21%) of 39 through-knee amputations needed to be converted to above-knee amputations. Fifty patients (24 above-knee amputations, 26 through-knee amputations) were eligible for follow-up. During follow-up, 71% (of above-knee amputations) and 69% (of through-knee amputations) did not walk with a prosthesis, and 29% of above-knee amputations and 27% of through-knee amputations walked more or less than 50 m. In conclusion, only a minority of patients is able to walk with a prosthesis, and a lot of the through-knee amputations need conversion to a higher level. On the basis of this results, it would be preferable to perform a straight above-knee amputation instead of a through-knee amputation if the correct amputation level is in doubt in high-risk patients.

Through-knee amputation in high-risk patients with vascular disease: Indications, complications and rehabilitation

During a 10-year period 104 patients (mean age 72 years) had 106 through-knee amputations. Indications for surgery were: limb gangrene, 67 (64 per cent); ischaemic ulceration, 22 (21 per cent); rest pain, 9; knee contractures, 6. Thirty patients had had previous unsuccessful vascular reconstructive surgery and five had had a failed femoral embolectomy. The through-knee disarticulation used lateral skin flaps. The mortality was 21 (20 per cent). Of the 83 survivors, 59 (71 per cent) underwent uncomplicated primary wound healing; 36 (43 per cent) of the survivors were unsuitable for rehabilitation on a prosthesis. The remaining 47 (57 per cent) were walking before discharge 30-130 days (mean 68 days) after amputation. Through-knee amputation is a rapid, relatively bloodless, amputation and is a useful debridement procedure. The many surgical and functional advantages, in conjunction with the recent reports of better rehabilitation compared with the above-knee or Gritti-Stokes amputation, suggests that the through-knee amputation deserves greater consideration.

An assessment of above- and through-knee amputations

Abstract Above- and through-knee amputations have been performed in 126 patients at St. Mary's Hospital between 1961 and 1970 Whilst there was a higher operative mortality amongst the above-knee amputees, the local complication rate was much higher in the through-knee group. The mortality rate in the two groups following discharge from hospital was high. The through-knee amputation provides a better functional result than the above-knee type but mobility in both groups might be improved by ‘refresher courses’ in walking training.

Below- and through-knee amputations in ischaemic disease.

Abstract Fifty-three below-knee amputations and 22 through-knee amputations were done for ischaemic disease at St. Thomas's Hospital over the past 5 years. It was found that 36 of the below-knee amputations healed satisfactorily, 27 by first intention, 9 after infection. Eleven of the through-knee amputations healed, 4 after infection. The healing was unaffected by the presence or absence of peripheral gangrene. It is suggested that is suggested that in ischaemic disease of the lower limbs a below-knee amputation should be considered as it has a 70 per cent chance of healing, but if it is felt that this amputation is not suitable then an above-knee amputation should be done in preference to a through-knee amputation.

Prospective audit of major amputations for peripheral vascular disease

Abstract Background Primary amputation followed by prosthetic fitting has been proposed as an alternative worth considering if lower limb bypass has poor prospects of patency. This is an outcome audit of major amputations at a single centre where amputations were performed only if limb salvage was not possible. Methods Consecutive major amputations (n = 162) for peripheral vascular disease from January 1996 to December 1998 were studied prospectively. Duration of hospital stay, causes of morbidity and mortality, and reasons for being unsuitable for prosthesis were recorded. Mobility at admission and after rehabilitation was documented using a standard grading system (grades 1–6). Results There were 114 above-knee, 45 below-knee and three through-knee amputations. The 30-day mortality rate was 14 per cent (22 patients), increasing to 29 per cent (47) at 9 months. Some 57 patients (35 per cent) were rehabilitated with a prosthetic limb (30 above knee, 27 below knee). Mobility with prosthesis was better or maintained in 24 patients, worse by one grade in 17, and by two or more grades in the remaining 16. Fifty-eight patients (36 per cent) were unsuitable for an artificial limb; in four this was because of stump-related problems, and the rest because of co-morbidity. Cardiorespiratory events were the most frequent cause of morbidity and mortality. The mean hospital stay after amputation was 37 days in survivors. Conclusion Perioperative and late mortality rates following amputation are high. A large proportion of amputees were not suitable for prosthesis, mainly because of co-morbidity. Of the patients receiving a prosthesis, only 42 per cent (15 per cent of the total) maintained or improved their mobility. The results are unlikely to be different if a policy of selective primary amputation were to be adopted. The outcome of amputation is worse than widely perceived despite the improvements in prostheses and a well executed rehabilitation process.

An open socket technique for through-knee amputations in relation to skin problems of the stump: an explorative study

Objective: To compare the conventional socket for through-knee amputees with an open socket system for skin problems and other relevant items. Design: All data were collected during three visits to the prosthetic clinic. At the second visit the conventional socket was replaced by the open socket. The use of both socket types was evaluated with a questionnaire and stump inspection. Setting: The subjects were evaluated at the Rehabilitation Centre, St Maartenskliniek, Nijmegen, the Netherlands. Subjects: Twenty subjects with a unilateral through-knee amputation were included and 13 subjects had a trial with the open socket. Results: There is a significant decrease of hyperhydrosis when wearing the open socket, there is no significant decrease in skin irritation or ulcers. The open socket also gives more comfort in sitting position. Conclusion: A further trial is needed in a selected group of prosthesis users among through-knee amputees to establish the long-term acceptance and benefits of the prosthesis with an open socket.

An open socket technique for through-knee amputations in relation to skin problems of the stump: an explorative study.

To compare the conventional socket for through-knee amputees with an open socket system for skin problems and other relevant items. All data were collected during three visits to the prosthetic clinic. At the second visit the conventional socket was replaced by the open socket. The use of both socket types was evaluated with a questionnaire and stump inspection. The subjects were evaluated at the Rehabilitation Centre, St Maartenskliniek, Nijmegen, the Netherlands. Twenty subjects with a unilateral through-knee amputation were included and 13 subjects had a trial with the open socket. There is a significant decrease of hyperhydrosis when wearing the open socket, there is no significant decrease in skin irritation or ulcers. The open socket also gives more comfort in sitting position. A further trial is needed in a selected group of prosthesis users among through-knee amputees to establish the long-term acceptance and benefits of the prosthesis with an open socket.

TRAUMA-RELATED MAJOR LOWER LIMB AMPUTATIONS

The annual number of major lower limb amputations in Denmark as a consequence of trauma was constant during the period 1978 through 1990, with about 70 (1.4 per 100,000 population) per year. The mean age of the amputation population was 49.4 years (males, 44.8 years; females, 58.8 years). Analysis of the age distribution shows characteristic differences between male and female patients. The average hospital stay was 49 days, and 56% of patients were discharged to their homes. The most prevalent amputation levels were transtibial and above-knee, which accounted for about 80% of all amputations. The only systematic change during the period under study was the increase in the number of through-knee amputations. The in-hospital mortality was related to sex, level of amputation, and age. The relative number of amputations varied in the different counties of Denmark and a positive correlation between population density and rate of amputation was found.

Prosthetic use in elderly patients with dysvascular above-knee and through-knee amputations.

Fifty-five patients with vascular insufficiency resulting in above-knee (AK) and through-knee (TK) amputations were studied to determine factors related to prosthetic candidacy and functional outcome. Chart review showed that the only difference between patients who were fitted with prostheses and those who were not fitted with prostheses was their respective number of medical complications. Twenty-three of 31 patients with prostheses were evaluated 7 to 35 months after receiving the prostheses. Ten (44%) of these patients wore their prostheses all day every day and used wheelchairs minimally or not at all. Over half of the patients evaluated used their wheelchairs most of the time. Two (9%) of the 23 patients had stopped wearing their prostheses. Patients who demonstrated increased walking distances and velocities at follow-up used their prostheses more and their wheelchairs less than did the other patients. Neither gait factors nor hip range of motion at discharge was predictive of continued prosthetic use. Functional outcome and prosthetic use were limited in this group of elderly patients with dysvascular AK and TK amputations. The results of this study may serve as a basis for clinical determination of prosthetic candidacy and functional goals.