JBJS | North American Experience with Knee Disarticulation with Use of a Posterior Myofasciocutaneous Flap : Healing Rate and Functional Results in Seventy-seven Patients*

The Journal of Bone & Joint Surgery, Volume 82, Issue 11

Articles | November 01, 2000

North American Experience with Knee Disarticulation with Use of a Posterior Myofasciocutaneous Flap : Healing Rate and Functional Results in Seventy-seven Patients*

John H. Bowker, M.D.†; Thomas P. San Giovanni, M.D.‡; Michael S. Pinzur, M.D.§

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Investigation performed at the Department of Orthopaedics and Rehabilitation, University of Miami School of Medicine, Miami, Florida, and the Department of Orthopaedic Surgery, Loyola University Medical Center, Maywood, Illinois
*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.
†Department of Orthopaedics and Rehabilitation, University of Miami School of Medicine, 1611 N.W. 12th Avenue, Room 303, Miami, Florida 33136. E-mail address: jbowker@med.miami.edu.
‡1085 Kane Concourse, Bay Harbor Islands, Florida 33154.
Â§Department of Orthopaedic Surgery, Loyola University Medical Center, 2160 South First Avenue, Maywood, Illinois 60153.

The Journal of Bone & Joint Surgery. 2000; 82:1571-1571

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Abstract

Background: A method for closure of a knee disarticulation wound with use of the posterior calf skin and gastrocnemius muscle bellies as an integral flap, without destruction of the perforating vessels, was described by Klaes and Eigler in 1985. The purposes of the present study were to report our experience with use of this technique in a prospective series of knee disarticulations and to determine the healing rate and the functional result after use of the flap.

Methods: Eighty knee disarticulations, performed with use of the flap described by Klaes and Eigler, in seventy-seven patients were evaluated in a prospective manner. The patients ranged in age from nineteen to ninety-two years (mean, sixty-four years). Thirty-one patients had diabetes mellitus with peripheral vascular disease, and twenty-nine had peripheral vascular disease alone as the primary cause of gangrene. Fourteen patients had a traumatic injury, two had a sarcoma, and one had Ollier disease.

Results: Five patients died in the early postoperative period, leaving seventy-five stumps available for evaluation. A total of sixty-seven stumps (89 percent) healed; sixty-three (84 percent) of them healed primarily. Major wound dehiscence occurred in seven stumps (9 percent), requiring revision to the transfemoral level. Six of those patients had a serum albumin level of less than thirty millimoles per liter. Twenty-two (81 percent) of the twenty-seven patients who could walk before surgery were able to walk with a prosthesis after it.

Conclusions: This simple technique offers reliable healing of knee disarticulation wounds in properly selected patients with a variety of conditions. It also provides comfortable end-bearing for prosthesis wearers because the distal flap is thick and mobile.

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Introduction

Introduction | Materials and Methods | Results | Discussion | References

A major advantage of knee disarticulation over transfemoral amputation is the potential for substantial end-weight-bearing along normal proprioceptive pathways. The dispersion of normal and shear forces is aided by the construction of a stable, well padded, distal soft-tissue envelope¹⁷. To achieve these goals, we had for many years used the sagittal flaps and gastrocnemius end-pad recommended by Wagner²⁰. These flaps are quite thin and consist of only skin and subcutaneous tissue, having been dissected free from the crural fascia with loss of the blood vessels penetrating this fascia from the gastrocnemius muscle bellies. As a result, despite its wide base, the lateral flap would occasionally partially necrose, delaying healing.

To address the problem of flap necrosis in transtibial amputations, the long posterior myofasciocutaneous flap was proposed by Verduyn⁷ in 1695, was reintroduced by Bickel² in 1943, and was popularized by Burgess⁴ in 1968. An improved rate of survival of the posterior myofasciocutaneous flap is attributed to the maintenance of vascular continuity from muscle to skin. We were stimulated to utilize this concept for knee disarticulation in adults after Van der Eijken¹⁹ reported success with the flap in a young patient with a tumor. A thorough search of the literature revealed that Klaes and Eigler¹¹, in 1985 in the German literature, were the first to report this technique, and they described the early results of twenty-one procedures in dysvascular limbs.

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Fig. 1:: Schematic drawing of the medial aspect of the knee, showing the outline of the posterior myofasciocutaneous flap for a knee disarticulation.

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Fig. 2:: Schematic drawing showing the pendent posterior flap still attached distally. The plane has been opened between the soleus muscle anteriorly and the gastrocnemius muscle (both hatched) posteriorly.

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Fig. 3:: Intraoperative photograph of the completed posterior myofasciocutaneous flap for a knee disarticulation. The patellar tendon has been sutured to the cruciate ligaments to stabilize the quadriceps muscle.

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | References

Eighty knee disarticulations were performed with use of a long posterior myofasciocutaneous flap incorporating the gastrocnemius muscle bellies in seventy-seven patients between March 1992 and November 1997. The patients ranged in age from nineteen to ninety-two years (mean, sixty-four years). There were fifty-five male and twenty-two female patients. Thirty-one patients had diabetes mellitus with varying degrees of peripheral vascular disease, while twenty-nine had peripheral vascular disease alone as the primary cause of gangrene. Many of them were confined to a bed or wheelchair in a nursing home, and the rehabilitation required for use of a prosthesis was not possible. Severe trauma was the cause of amputation in fourteen patients who were nineteen to sixty-eight years old (mean, forty-three years old). Two patients had sarcoma, and one had Ollier disease. Twenty-eight patients (36 percent) were either smokers or had a history of smoking more than twenty packs per year. The level of serum albumin was less than thirty millimoles per liter in thirty-eight patients (49 percent), while the total lymphocyte count was less than 1500 cells per cubic millimeter (1.5 Â¥ 10⁹ per liter) in twenty-nine patients (38 percent). A transcutaneous oxygen (TcPo2) level of thirty millimeters of mercury or more, a Doppler ankle-brachial index of 0.5 or higher, or a pulsatile waveform in a pulse-volume recording in the calf were considered adequate for wound-healing. One of these three criteria was met in all cases¹⁸.

Surgical Technique

The patient is placed supine with the lower limb prepared and draped to the groin. If needed, a sterile pneumatic tourniquet is applied to the thigh and is removed prior to wound closure to allow proper muscle-tensioning. Prior to incision, the flap is outlined on the skin (Fig. 1). A transverse anterior incision is made at the level of the knee joint to the midlateral line on each side. From each end of this incision, the skin is incised longitudinally to the distal level of the gastrocnemius muscle bellies. The two midlateral incisions then are joined posteriorly. The flap is further developed by incising the investing fascia on each side. The plane between the gastrocnemius and soleus muscles is most easily found on the medial side. The two muscles then are separated by blunt digital dissection to the lateral side, where the dense lateral fascia is encountered and incised (Fig. 2). The flap is then freed at the distal end of the gastrocnemius muscle bellies and bluntly developed proximally.

Anteriorly, the distal skin is dissected from the patellar tendon and the tibial tubercle and then is excised for better exposure. The patellar tendon is skived from the tibial tubercle and is reflected proximally to allow excision of the fat pad lying posterior to it. The knee joint capsule, including the collateral ligaments, is divided circumferentially just proximal to the menisci, with care taken to avoid the popliteal neurovascular structures. This maneuver is made easier by flexing the knee and releasing the cruciate ligaments from their tibial attachments while pulling the tibia forward. The medial and lateral hamstring tendons are secured with clamps prior to division to facilitate their reattachment prior to closure. The popliteal vessels are clamped, divided, and doubly ligated. The tibial and peroneal nerves are gently drawn distally, cut, and allowed to retract into the proximal soft tissues. In younger patients following trauma, these nerves are ligated to control bleeding from their vasa nervorum.

At this point, if a patient is expected to be an active user of a prosthesis and the optimal cosmetic result is desired, consideration may be given to patellectomy and distal femoral shortening and narrowing, as advocated by one of us (J. H. B.)³. This distal femoral reshaping is a combination of two different techniques, combined with patellectomy, as originally described by Burgess⁵ and by Mazet and Hennessy¹⁴. It results in a better cosmetic appearance of the limb by raising the center of the prosthetic knee joint closer to the level of the contralateral knee¹⁵. If the patient is not a candidate for a prosthesis, the patellectomy and ostectomies are omitted.

To maintain a fully muscle-balanced thigh, the major muscles that crossed the knee joint should be reattached to the distal soft tissues of the stump. The patellar tendon is sutured to the cruciate ligaments with the hip extended to avoid creating excessive tightness of the rectus femoris and a resultant hip flexion contracture. The medial and lateral hamstring tendons then are sewn to the knee joint capsule to preserve their secondary function as hip extensors⁹. The iliotibial band should be secured to the lateral aspect of the capsule to enhance abductor function in single-limb stance as well as hip extension through the gluteus maximus⁸. As already noted, the tourniquet is deflated before these muscles are reattached to ensure proper muscle-tensioning without redundancy.

Depending upon the relative width of the distal part of the femur and the gastrocnemius muscle bellies, the bellies can be used in their entirety, each one can be partially narrowed, or one belly can be entirely removed to achieve good distal padding without excess medial-lateral bulkiness. They should be trimmed in length to fit without redundancy. The completed disarticulation is shown in Figure 3. After a drain is placed, the deep and superficial gastrocnemius fasciae are sewn to the knee capsule-extensor retinaculum and the patellar tendon.

Simple skin sutures are placed without tension or use of forceps, especially in dysvascular limbs. A lightweight plaster or fiberglass cast is applied to prevent soiling or damage of the wound, which is especially common in senile patients in a nursing home. The cast is changed weekly until the sutures are removed at three weeks. Prospective users of a prosthesis wear an elastic spica shrinker sock after the fourth week until the stump is ready for fitting.

Results

Introduction | Materials and Methods | Results | Discussion | References

Five patients died in the early postoperative period from complications of cardiovascular disease, leaving seventy-two patients (seventy-five stumps) available for evaluation of healing. Sixty-three wounds (84 percent) healed primarily, while two had delayed healing requiring only minor dè¡²idement. One patient had a major hematoma; the wound healed after drainage and operative dè¡²idement. A seroma developed in the wound of another patient, and multiple aspirations were necessary before healing occurred. Thus, a total of sixty-seven wounds (89 percent) healed. One wound was slowly healing by granulation at the time that the patient died from congestive heart failure four months postoperatively. Seven stumps (9 percent) had a major wound dehiscence, requiring revision to the transfemoral level. Six of those patients had a serum albumin level of less than thirty millimoles per liter, three had a total lymphocyte count of less than 1500 cells per cubic millimeter (1.5 Â¥ 10⁹ per liter), two were smokers, and two were diabetic. Twenty-two (81 percent) of the twenty-seven patients who were able to walk prior to surgery resumed walking with a prosthesis postoperatively. One additional patient who had a revision to the transfemoral level after wound dehiscence also was able to walk with a prosthesis.

Discussion

Introduction | Materials and Methods | Results | Discussion | References

Knee disarticulation has several advantages over transfemoral amputation, including surgical simplicity, minimal blood loss, and a stronger, muscle-balanced stump with less tendency for the development of hip flexion contracture. Other functional benefits include weight-bearing in a prosthesis along normal proprioceptive pathways, with less energy consumption compared with that after amputation at the transfemoral level. When there is no potential for rehabilitation, such as when a patient is confined to a bed or a wheelchair in a nursing home, the long stump provides easier sitting balance, mobility in bed, and transfers¹⁸. It also should be noted that, in this subgroup, severe knee flexion contracture with an ulcer on the distal part of the stump often develops after transtibial amputation, necessitating revision to a more proximal level.

The major deficit of the earlier techniques, which involved use of anterior, posterior, sagittal, or circular flaps, was the relatively thin distal soft-tissue envelope, consisting of only skin and subcutaneous tissue, covering a stump that was intended to be end-bearing. The use of a long anterior flap, in particular, has been associated with a rate of reamputation of 30 to 50 percent¹⁰. Wagner²⁰ provided a major advance by padding the distal part of the femur with the gastrocnemius muscle bellies, but the freely dissected sagittal skin flaps occasionally underwent wound-edge necrosis. In 1985, Klaes and Eigler¹¹ emphasized the need to preserve the circulation to the gastrocnemius muscle bellies by protecting the medial and lateral sural branches of the popliteal artery and the need to avoid damage to the perforating arteries passing between the gastrocnemius muscle bellies and the overlying skin, as described by Mathes and Nahai¹³ in their text on musculocutaneous flaps. In their original series, Klaes and Eigler¹¹ reported on nineteen patients with a total of twenty-one knee disarticulations who had a mean age of sixty-eight years. Two patients died in the early postoperative period. Fifteen of the remaining nineteen wounds healed primarily.

Heinz⁶ reported on forty-six knee disarticulations with use of the same technique in patients with peripheral vascular disease. Of the forty-one patients who had survived past the perioperative period, thirty-two (78 percent) had primary healing and the remaining nine (22 percent) had delayed healing. Only 29 percent were fitted with a prosthesis. In 1994, Kock et al.¹² reported on sixty patients (sixty-two knees) with peripheral vascular disease who underwent a knee disarticulation. The mean age of the patients was sixty-nine years. Thirty-eight (70 percent) of the fifty-four patients who survived had primary healing, and five (9 percent) had healing after a soft-tissue revision, for a total rate of healing of 79 percent. Nine patients had a reamputation at the transfemoral level. Twenty-nine (54 percent) of fifty-four patients were able to walk with a prosthesis¹². Also in 1994, Albers et al.¹ reported on six knee disarticulations with use of this flap that were performed because of osteosarcoma of the proximal part of the tibia. Because the gastrocnemius muscle is anatomically separated from the tibia proximally by the popliteus muscle and the semimembranosus tendon and farther distally by the soleus, flexor digitorum longus, and posterior tibial muscles, there was no difficulty in obtaining adequate margins, provided that magnetic resonance imaging showed no tumor involvement of the proximal part of the tibia or the gastrocnemius muscle bellies. The wound healed primarily in five cases and secondarily in one after wound dehiscence during chemotherapy. All six patients, who had a mean age of twenty years, were able to wear a prosthesis successfully¹.

Our results compare favorably with those previously reported in the European literature. Healing was primary in 84 percent of our patients and secondary in 5 percent, for a total healing rate of 89 percent. Revision to the transfemoral level was required in seven stumps (9 percent) because of wound dehiscence. Six of the seven patients with a stump that did not heal had a serum albumin level of less than thirty millimoles per liter, a strong indicator of poor nutritional status. Only 31 percent of our patients were fitted with a prosthesis because the preponderance of them were in poor health. It is of major importance, however, that twenty-two (81 percent) of the twenty-seven patients who were able to walk prior to surgery were able to resume walking with use of a prosthesis.

This simple technique offers reliable healing of knee disarticulation wounds because it preserves the blood supply that passes from the gastrocnemius muscle bellies to the skin. It also provides comfortable end-bearing for prosthesis wearers. In cases of a malignant tumor of the proximal part of the tibia, it offers a more functional amputation level with safe margins as long as the knee joint and gastrocnemius muscle are shown by magnetic resonance imaging to be free of tumor. We hope that the ease of execution and the reliable healing associated with this method will encourage a wider acceptance of knee disarticulation as preferable to transfemoral amputation in appropriate cases.

References

Introduction | Materials and Methods | Results | Discussion | References

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Bickel, W. H.: Amputations below knee in occlusive arterial diseases. Surg. Clin. North America,23: 982-994, 1943.23982 1943

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Heinz, J.: Die transgenikulüre Amputation mit myokutaneum Gastrocnemiuslappen bei der arteriellen Verschlusskrankheit. Zentralbl. Chir.,117: 167-170, 1992.117167 1992 [PubMed]

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Kock, H. J.; Walz, M. K.; Krause, V.; Klaes, W.; and Eigler, F. W.: Ergebnisse der transgeniculüren Amputation mit dorsal Haut-Muskel-Lappenplastik bei Patienten in Endstadium arteriellen Verschlusskrankheit. Chirurg,65: 1028-1033, 1994.651028 1994 [PubMed]

Mathes, S. J., and Nahai, F.: Vascular anatomy of muscle: classification and application. In Clinical Applications for Muscle and Musculocutaneous Flaps, pp. 16-94. Edited by S. J. Mathes and F. Nahai. St. Louis, C. V. Mosby, 1982.

Mazet, R., Jr., and Hennessy, C. A.: Knee disarticulation. A new technique and a new knee-joint mechanism. J. Bone and Joint Surg.,48-A: 126-139, Jan 1966.48-A126 1966

Michael, J. W.: Knee disarticulation: prosthetic management. In Atlas of Limb Prosthetics: Surgical, Prosthetic and Rehabilitation Principles, edited by J. H. Bowker and J. W. Michael. Ed. 2, pp. 487-500. St. Louis, Mosby-Year Book, 1992.

Pinzur, M. S.; Smith, D. G.; Daluga, D. J.; and Osterman, H.: Selection of patients for through-the-knee amputation. J. Bone and Joint Surg.,70-A: 746-750, June 1988.70-A746 1988

Pinzur, M. S.: Knee disarticulation: surgical procedures. In Atlas of Limb Prosthetics: Surgical, Prosthetic and Rehabilitation Principles, edited by J. H. Bowker and J. W. Michael. Ed. 2, pp. 479-486. St. Louis, Mosby-Year Book, 1992.

Pinzur, M. S.; Slosar, P. J., Jr.; Reddy, N. K.; and Osterman, H.: Through-knee amputation in peripheral vascular insufficiency: functional outcome. Contemp. Orthop.,24: 157-160, 1992.24157 1992

Van der Eijken, J. W.: Case report on knee disarticulation in a child with osteosarcoma of the proximal tibia. Read at the International Society for Prosthetics and Orthotics Up-Date Course in Lower Limb Amputations and Related Prosthetics, Groningen, The Netherlands, Jan. 31, 1992.

Wagner, F. W., Jr.: Management of the diabetic-neurotrophic foot. Part II. A classification and treatment program for diabetic, neuropathic, and dysvascular foot problems. In Instructional Course Lectures, American Academy of Orthopaedic Surgeons. Vol. 28, pp. 143-165. St. Louis, C. V. Mosby, 1979.

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