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Commentary & Perspective
Commentary & Perspective on
"Above-the-Knee Amputation After A Total Knee Replacement. Prevalence, Etiology, and Functional Outcome"
by Rafael J. Sierra, MD, et al.
Commentary & Perspective by
Chitranjan S. Ranawat, MD*,
Ranawat Orthopaedic Center, Department of Orthopedic Surgery, Lenox Hill Hospital, New York, NY
According to Sierra et al., the overall prevalence, at their institution, of above-the-knee amputation performed at an average of 8.6 years after ipsilateral total knee replacement was 0.36%. Further stratification of these data showed a prevalence of 0.14% for above-the-knee amputations performed because of complications of the total knee replacement. In this study, the most common reasons for above-the-knee amputation following total knee replacement included peripheral vascular disease, infections, and tumor recurrence; other reasons included severe bone loss, intractable pain, periprosthetic fracture, diabetic neuropathy, and vascular compromise. Predisposing diagnoses were rheumatoid arthritis and post-traumatic arthritis.
After more than 6000 total knee arthroplasties that I have performed during a period of thirty-two years, I have performed five above-the-knee amputations (prevalence, approximately 0.08%). In three of these patients, peripheral vascular disease had progressed several years after total knee replacement; in the other two patients, deep venous thrombosis had caused acute vascular compromise in one, and an occlusion of a femoropopliteal graft had developed in the other.
In this study by Sierra et al., forty-two (63%) of the sixty-seven amputations were performed for causes not directly related to the total knee replacement, such as tumor recurrence around the knee, progression of peripheral vascular disease, or diabetic neuropathy.
According to the literature, patients who are at risk for amputation following total knee arthroplasty include those with diabetes, rheumatoid arthritis, and other disorders associated with immune compromise and also those who have uncontrollable and life-threatening infections, intractable pain, or progressive peripheral vascular disease1-3.
Few patients who have an above-the-knee amputation are actually able to use a prosthetic limb. Many of these patients are elderly and have rheumatoid arthritis or other comorbidities that deplete their strength. A correctly proportioned stump that is free of contractures, and sufficient upper-extremity strength are necessary to enable the patient to use a prosthetic limb after above-the-knee amputation. The patient's motivation is of the utmost importance in learning to use a prosthetic limb.
On the basis of the information in this study and in the literature2, the chances that an amputee with the above-mentioned complications would be able to use an artificial limb to perform activities of daily living are extremely low, unless he or she is young and vigorous, has normal upper extremities, and had walked normally prior to the amputation.
Above-the-knee amputation following total joint arthroplasty is indicated for uncontrollable infection, intractable pain, substantive loss of bone and soft tissue around the knee, progressive peripheral vascular disease, and tumor recurrence. The prevalence of amputation following a total knee replacement for causes related to the replacement is 0.1% to 0.2% (one to two in 1000), and this may rise in the future as the population ages. In older patients with multiple comorbidities, substantial functional limitations may follow amputation. However, in such cases, amputation still saves lives and relieves pain. These patients, with use of a wheelchair, may attain partial independence.
*The author did not receive grants or outside funding in support of his research or preparation of this manuscript. He did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the author is affiliated or associated.
References
1. Isiklar ZU, Landon GC, Tullos HS. Amputation after failed total knee arthroplasty. Clin Orthop. 1994;299:173-8.
2. Pring DJ, Marks L, Angel JC. Mobility after amputation for failed knee replacement. J Bone Joint Surg Br. 1988;70:770-1.
3. Segawa H, Tsukayama DT, Kyle RF, Becker DA, Gustilo RB. Infection after total knee arthroplasty. A retrospective study of the treatment of eighty-one infections. J Bone Joint Surg Am. 1999;81;1434-45.
4. Smith DE, McGraw RW, Taylor DC, Masri BA. Arterial complications and total knee arthroplasty. J Am Acad Orthop Surg. 2001;9:253-7.
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