Below Knee Amputation:

- See: - BKA Prosthesis - Diabetic Foot - Treatment Considerations - Amputations in the Diabetic Patient - Pediatric BKA: - Discussion: - length considerations: - ideal bone length is between 12 to 17 cm as measured from the medial joint line; - in stumps less than 9 cm, consider removing the entire fibula along w/ some muscle bulk; - when stump measures less than less than 5 cm, function is comprimised, therefore consider amputation at next higher level (knee disarticulation or AKA); - gait and energy adaptions: - average BK amputee expends about 40% more kcal/min than non amputees to maintain a normal gait; - since the average BK amputee walks 36% slower, the average rate of oxygen consumption may remain unchanged; - note, however, the net oxygen demand will increase since the total amount of work to walk a given distance will increase; - references: - Below knee amputation and rehabilitation of amputees. - Gait kinematics in below-knee child amputees: a force plate analysis. - vascular considerations: (anastomoses of lower limb arteries) - dominant supply of the skin at this level is provided by the arteries that run w/ the saphenous nerve and the sural nerve (ie sural artery); - references: - Fasciocutaneous blood supply in below-knee amputation. - Anatomical aspects of the blood supply to the skin of the posterior calf: technique of below-knee amputation. - The blood supply to the skin of the leg: a post-mortem investigation. - Segmental transcutaneous measurements of PO2 in patients requiring below-the-knee amputation for peripheral vascular insufficiency. - Cutaneous blood flow and its relation to healing of below knee amputation. - Muscle blood flow after amputation. Increased flow with medullary plugging. - The below-the-knee amputation for vascular disease. - Functional outcome of below-knee amputation in peripheral vascular insufficiency. A multicenter review. - Noninvasive determination of healing of major lower extremity amputation: the continued role of clinical judgment. - An index of healing in below-knee amputation: leg blood pressure by Doppler ultrasound. - indications for BKA w/ chronic foot and ankle pain: - in the report by Honkamp et al, the authors assessed the outcome of below-the-knee amputations performed to relieve intractable foot and ankle pain; - patients with diabetes mellitus, peripheral vascular occlusive disease, or peripheral neuropathy were excluded; - 20 patients met the inclusion criteria, and 18 completed the study; - when asked whether they would have the BKA done again under similar circumstances, 16 patients said yes, one was unsure, and one said no; - same distribution was observed when the patients were asked whether they were satisfied with the outcome: - sixteen said yes, one was unsure, and one said no; - after the amputation, the patients reported a decrease in both pain frequency and pain intensity; - 10 patients discontinued the use of narcotics, and seven decreased the level and/or dosage; - 3 patients worked before the amputation, and eight worked after the amputation; - average walking distance increased from 0.3 to 0.8 mile (p = 0.0034). - ref: Retrospective Review of Eighteen Patients Who Underwent Transtibial Amputation for Intractable Pain Nicholas Honkamp et al. JBJS (Am) 83:1479-1483 (2001) - considerations with gangrene and infection: - references: - Lower extremity amputation: open versus closed. - One-stage versus two-stage amputation for wet gangrene of the lower extremity: a randomized study. - Simplified two-stage below-knee amputation for unsalvageable diabetic foot infections. - Staged below-knee amputations for septic peripheral lesions due to ischaemia. - Guillotine amputation in the treatment of nonsalvageable lower-extremity infections. - Primary closure of below-knee amputation stumps: a prospective study of sixty-two cases. - Below knee amputation in war surgery: a review of 111 amputations with delayed primary closure. - Below-knee amputation for ischaemic gangrene. Prospective, randomized comparison of a transverse and a sagittal operative technique.

BKA Prosthesis
- See: Prosthetic Feet: - PTB sockets: - provide some weight bearing support in the area of patella tendon and medial tibial flare; - BKA Suspension: - important design considerations for both sockets include - support (pressure distribution) - control (based on limb socket interface) - suspension (socket and/or corsete) - alignment (angular and linear) - total contact socket contour suspension is commonly used & can be one of two designs: patella tendon bearing (PTB) or patella tendon supporting (PTS); - ineffective suspension will manifest as pistoning during swing phase of gait; - PTS sockets - cover the condyles of the femur and have a high anterior wall enclosing the the patella; - provides more support anteriorly & add improved stability & suspension; - PTB w/ supracondylar cuff: - advantages include a kinesthetic hyperextension stop; - disadvantages include restriction in sitting, does not provide maximum M-L stability, and poor cosmesis; - addition of a supracondylar wedge of a flexible material to a PTB socket gives more stability by providing locking fit over the condyle (these may be fixed or removable); - PTB w/ sleeve suspension: - advantages include excellent suspension, conceals prosthetic trimlines, available in latex, neoprene ect. - may cause dermatologic problems; - neoprene sleeves can also be used to provide additional skin protection (especially for diabetics); - Liners: - Soft PTB sockets are most commonly prescribed, especially with bony or scarred residual limbs, peripheral vascular disease, volumetrically unstable residual limbs; - Hard sockets may be preferred in warm, humid climates; - Pylete: - TEM: - Standard Prosthetic Alignment: (corsetless prosthesis) - knee flexion moment (and posterior foot placement): - typically, the BKA prosthesis is placed in 12-14 deg of flexion; - increases effective heel lever, producing knee flexion from heel strike to foot flat; - encourages knee flexion between strike and foot flat; - reduces length of keel encouraging knee flexion from midstance to heel off; - places the quadriceps muscle under slight stretch at heel strike, which improves stability and control; - encourages "roll over" between mid stance and heel off; - limits recurvatum (hyperextension) forces during mid-stance to terminal stance phase of gait; - tends to load more pressure tolerant areas of the proximal tibia; - note that when a BKA prosthesis with corsette is required, flexion is removed from the socket, and the prosthesis is translated posteriorly; - excessive knee flexion (at heel strike) may result from: - heel too firm (knee flexes when the heel is fully compressed); - foot too posterior - foot too dorsiflexed - interface too flexed - forward placement of socket - causes increased knee entension - patellar pain - instability is not a problem; - varus alignment: - initial foot placement is 12 mm inset in relation to midpoint of interface; - narrows the base of support - smooths horizontal displacement of center of gravity - makes for efficient gait; - helps load pressure tolerant areas (medial tibial condyle, lateral fibular surface); - excessive varus moment may be caused by: - foot positioned too medially; - M-L interface is too large; - there is laxity of the lateral collateral ligament; - insufficient varus moment may be exhibited by: - foot positioned too laterally; - loading of pressure sensitive areas (such as a load on the fibular head); - in coronal plane fulcrum is about the patellar tendon; - gait is excessivel widened;

- excessive medial shoe wear; - translation of socket: - lateral translation: - excessive translation causes valgus knee strain; - medial translation: (excessive translation causes:) - varus strain on knee; - due to 3 point bending, expect increased pressure distal-laterally and proximal-medially; - anterior translation: - slight anterior translation may be useful to minimize the tendency for knee hyperextension at heel strike (instead encourages knee flexion), assists w/ roll over between mid stance and heel off; - knee but excesssive cause knee to buckle into flexion at heel strike; - posterior translation: - tends to keep knee in hyperextension during stance phase; - when a thigh corsette is used, the socket must be displaced posteriorly; - Skin Tolerance: - pressure tolerant areas: - patellar ligament - anterior compartment - medial flare of the tibia - distal end - shaft of the fibula - gastroc - popliteal fossa - pressure sensitive areas: - anterior distal tibia - fibular head - crest of tibia - peroneal nerve - distal cut fibula - lateral tibial condyle - Common Prosthetic Problems: - pistoning: - pistoning during swing phase of gait is usually caused by ineffective suspension system; - pistoning during the stance phase is due to poor socket fit or volume changes in stump (may require a change in stump sock thickness); - pressure related pain or redness should be corrected w/ relief of the prosthesis in the affected area; - foot related problems: - too soft a foot results in excessive knee extension, while too hard a foot causes knee flexion and lateral rotation of toes; - when a BKA prosthesis w/ corsette is required, then a softer heel cushion is required; - too much knee hyperextension: (at heel off); - foot too anterior or plantar flexed; - insufficient flexion of the socket or posterior displacement of the socket; - too soft heel cushion (knee flexes when the heel is fully compressed); - too long a keel of a SACH foot