Abstract
In major lower limb amputation, preservation of the knee joint significantly improves outcome. In the severely compromised limb, to preserve the knee joint, high tibial transection may be necessary creating a less than optimal stump. This study reviews the outcome in below knee amputees with stumps 10cm or shorter.
All 209 below knee (BK) amputees attending the New Zealand Artificial Limb Board’s Dunedin Centre were reviewed. The centre is the sole provider of prosthetic services in the southern region. Forty-four amputees (21% of total) had stumps of 10cm or less in length as measured by caliper rule. After a minimum twelve month follow-up these amputees were placed in two groups.
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Group 1: Short Stump (10cm to 8cm)
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Group 2: Ultra Short Stump (7.5cm to 5cm)
Wood-Stanmore Grades were given for walking ability (Hanspal and Fisher 1991). Rehabilitation was further assessed using a modified Houghton Questionnaire (Houghton et al 1992).
Mean stump length for all 209 BK amputees was 12.5 centimeters (range 5 to 25 centimeters).
Group 1. Short Stump (ten to eight centimeters 0 – 37 amputees
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Nineteen amputees – Good to Excellent (Wood – Stanmore Grade V and V1) i.e. walking indoors and outdoors without aids and with near normal gait. (10 trauma, four dysvascular, four tumour, one infection).
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Fourteen amputees-Satisfactory (Grade 1V) i.e. walking aid indoors and outdoors (13 dysvascular, one congenital).
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4 amputees – Fair Only (Grade 111) i.e. mostly indoors with frame (four dysvascular).
Group 2. Ultra Short Stump (7.5cm to 5cm) – seven amputees
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Six amputees – Good to Excellent (Grade V or V1) – (all trauma)
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One amputee – Fair Only (Grade 111) – (dysvascular)
Group one mostly had a posterior myocutaneous flap amputation with retention of the proximal fibula. In Group two, all had resection of the proximal fibula with varied flaps often with skin grafting. The patellar tendon was intact but two patients had lost the hamstring insertion with hyperextension of the knee, one requiring prosthesis with side steels and thigh corset. In group two the best results followed high resection of the common peroneal nerve and careful shaping of the tibial remnant. Cortical bone formed at the transection level allowing total contact prosthetic fitting with some end bearing.
BK amputation is described as optimally 12.5 centimeters to 17.5 centimeters below the knee joint (10 to 12.5 centimeters in vascular disease). Saving the knee should always be considered and with combined surgical and prosthetic skill a stump as short as five centimeters may be fitted satisfactorily particularly in the young and following trauma.
Correspondence should be addressed to Associate Professor N. Susan Stott, Orthopaedic Department, Starship Children’s Hospital, Private Bag 92024, Auckland, New Zealand.
