Last Resort Salvage of Failed Below Knee Amputations

• Main Author: Michael Strauss MD
• Format: Article
• Language: English
• Published: SAGE Publishing 2018-09-01
• Series: Foot & Ankle Orthopaedics
• Online Access: https://doi.org/10.1177/2473011418S00466

Category: Other Introduction/Purpose: The consequences of failed transtibial amputations especially if the remaining tibia is less than 5 cm is revision to an above knee amputation (AKA). This has important ramifications regarding mobility, energy requirements for ambulation and function. An innovative management protocol has been employed to maximize the likelihood of healing and maintaining a functional knee joint. Methods: Five severely vasculopathic patients with failed short transtibial (TT) amputations and greater than 60 degree knee flexion contractures were followed progressively using the protocol of resecting the remaining fibula, releasing the hamstring insertions, debridement of bursa & cicatrix, osteotomy & beveling of the distal end of the tibia, creative flap closures, and maintenance of knee extension with pins or external fixation across the knee joint. The patient’s courses were followed prospectively. All patients were referred for more proximal amputations, but wanted everything possible be done to salvage their knee joints and avoid AKAs. Four of the five patients were diabetic; one was a smoker with osteomyelitis at the end of the tibia. Results: Salvage of the knee joint occurred in 4 of 5 patients (80%) even though the remaining tibia lengths were 5 cm or less. Threaded 3/16th inch Steinmann pins placed cross-wise through the knee joints were used in 4 patients and an external fixator in a 5th patient. The pins remained for 3 to 6 weeks. Four of the 5 patients achieved healing with 2 of the 4 having initial minor wound dehiscences. The failed case occurred in a diabetic patient with renal failure and only collateral circulation below the groin. There was insufficient viable muscle/fascia in this patient to cover the tibia. The 4 patients who avoided an AKA were able to be fitted with TT prostheses and use them in a functional capacity. Conclusion: The use of temporary pin fixation across the knee joint and removal of the remaining fibula to salvage “end stage” failed TT amputations served the purposes of maintaining knee extension during the healing period, allowing closure & healing of threatened and/or dehisced flaps and maintaining knee function. Motivated, compliant patients with failed, otherwise considered non salvageable TT amputations should be considered for using our protocol in deference to proceeding to an AKA.