38 Frangež, Smrke-Rejec, Smrke / Rehabilitacija - letn. VII, supl. 3 (2008) OUR EXPERIENCES WITH THE BELOW KNEE AMPUTATION I. Frangež, B. Smrke-Rejec, D. M. Smrke I. Frangež, B. Smrke-Rejec, D. M. Smrke University Medical Centre Ljubljana, Slovenia University Medical Centre Ljubljana, Slovenia mon underlying pathologies indicating amputation were diabetes mellitus complicated by vascular occlusive dis- ease and infection. Results and discussion: Postoperative complications occurred in 24% of cases. The majority suffered from infections that required wound revision or reamputation. Among below knee amputees there were 102 (59.3%) of patients with indication for prosthesis and were sent to Institute for Rehabilitation, Republic of Slovenia. Abstract Objective: The aim of this analysis was to evaluate the characteristics and outcome in patients undergoing lower limb amputation in University Medical Centre Ljubljana between January 1 st 1996 and December 31 st 2002. Patients and methods: Among 771 patients with lower limb amputation we focused on 172 (22.3%) patients with below knee amputation. The most com- INTRODUCTION Major amputation is a commonly performed procedure that is indicated in patients with failed attempts at revas- cularization, comorbidity or anatomic factors precluding revascularization efforts, and extensive tissue loss or infection (1). The transtibial level is the most proximal level at which near-normal function can be expected for most patients. Preserving the knee joint allows transtibial amputees to consume much less energy then transfemoral amputees and contributes to more efficient ambulation with pros- thesis (2). The below-the-knee amputation (BKA) is typically per- formed about 15 cm below the knee. A longer muscle flap made up of the thick muscles of the back of the calf is attached to the remaining part of the tibia or to a shorter muscle flap that makes up the front of the calf. This soft tissue is important because it provides padding for the remaining part of the limb at the site where it attaches to the prosthesis. The remaining part of the limb is known as the residual limb or stump. It can have different shapes, but it is somewhat bulbous initially due to postsurgery swelling. In time, it may resemble cylinder or a cone. The length of the residual limb is very important. If it is too short or too long, it may be difficult to fit it with prosthesis (3). Because BKA is a common surgical procedure we attempted to gain a better understanding of the patient population that required BKA, including co-morbid diseases, revascularisa- tion history, indications for amputation, and postoperative complications. METHODS AND SUBJECTS Retrospective analysis was conducted using data from medi- cal records of patients who underwent BKA in University Medical Centre Ljubljana at the Department for surgical infections and Department for Traumatology, between Janu- ary 1 st 1996 and December 31 st 2002. Medical records were reviewed for basic demographic data, underlying pathologies indicating amputation and postoperative complication. Descriptive statistics were obtained for basic demographic characteristics. The main outcome measure was early opera- tive outcome (operative mortality, wound complications and need for revision amputation). RESULTS In our sample women were on average roughly 8 years older than man, and the difference was statistically robust. The distributions of patients by age group, indications and co- morbid conditions are presented in Table 1. Postoperative complications including wound infection, bleeding and dehiscence occurred in 23.1% of patients (Table 2). Secondary operative procedure was necessary in 24.4% of patients. There was cardiac arrest in 2 patients (1.2%), and no cerebrovascular insults, pulmonary embolism or deep vein thrombosis in our group of patients. Among 172 amputees there were 102 of patients with indication for prosthesis and were sent to Institute for Rehabilitation, Republic of Slovenia. Among the remain- ing 70 patients, there were 40 (23.2%) using wheelchair, 14 (8.1%) were immobile and 16 (9.3%) were using crutches. 39 DISCUSSION The majority (68.6%) of the patients were older than 60 years. Many patients had multiple medical co-morbidities. Vascular occlusive disease mostly caused by Diabetes mel- litus was the most common underlying pathology. BKA is associated with higher wound complication and revision rate as above knee amputation (1, 4). In our group of patients, postoperative complications occurred in 23.1%, which was comparable to the findings of other authors. The latter was also true for the need for secondary operative procedure, which was 24.4% (1, 4). Preserving the knee is also important for subsequent pros- thesis use. In our group of patients, 59.3% of patients were candidates to use prosthesis. CONCLUSION In our institution, the majority of BKA are performed in geri- atric patients with vascular occlusive disease. BKA is associ- ated with high level of revision and reamputation rate, which is particularly distressing for both, patient and the surgeon. We recommend this type of operation, since high quality of life can be achieved despite frequent correction rate of previous below knee amputation. R References eferences: 1. Aulivola B, Hile CN, Hamdan AD, Sheahan MG, Veraldi JR, Skillman JJ, Campbell DR, Scovell SD, LoGerfo FW, Pomposelli FB Jr. Major lower extremity ampu- tation: outcome of a modern series. Arch Surg 2004; 139(4):395-9. 2. Smith DG. Atlas of Amputations and Limb Deficiencies. Rosemont: American Academy of Orthopaedic Surgeons 2004: 481-99. 3. Cristian A. Lower Limb Amputation. New Y ork: Demos Medical Publishing, 2006: 17-21. 4. Wong MW. Lower extremity amputation in Hong Kong. Hong Kong Med J 2005; 11(3):147-52. Table 1: Demographic data of patients undergoing lower extremity amputation Total, n=172 Total, n=172 Male, n=108 Male, n=108 Female, n=64 Female, n=64 Mean age (SD) [years] 69. 1 (13.0) 66.2 (13.9) 73.9 (9.5) Age group [n (%)]: 21 - 40 41 - 60 61 - 80 > 80 7 (4.0%) 26 (15. 1%) 1 18 (68.6%) 30 (17 .4%) 6 (55.5%) 24 (22.2%) 68 (62.9%) 16 (14.8) 1 (1.6%) 2 (3. 1%) 50 (78. 1%) 14 (21.8) Indication for amputation [n (%)]: Vascular occlusive disease Infection Trauma Tumour 161 (93.6%) 154 (89.5%) 7 (4.0%) 1 (0.6%) 98 (90.7%) 94 (87 .0%) 7 (6.5%) 1 (0.9%) 63 (98.4%) 60 (93.7%) 0 0 Comorbid conditions [n (%)]: Diabetes mellitus Cardiovascular disease Lung diseases Neurologic diseases Malignancy 1 14 (66.2%) 1 17 (68.0%) 5 (2.9%) 27 (15.7%) 7 (4.0%) 67 (62.0%) 74 (68.5%) 4 (3.7%) 17 (15.7%) 5 (4.6%) 47 (73.4%) 43 (67 .2%) 1 (1.6%) 10 (15,6%) 2 (3. 1%) Table 2: Postoperative complications and secondary operative procedures after BKA Total, n=172 Total, n=172 Male, n=108 Male, n=108 Female, n=64 Female, n=64 Postoperative complications Infection Bleeding Dehiscence Operative mortality Postoperative mortality 31 (18.0%) 2 (1. 1%) 7 (4.0%) 0 3 (1.7%) 17 (15.7%) 1 (0.9%) 6 (5.5%) 0 1(0.9%) 14 (21.9%) 1 (1.6%) 1 (1.6%) 0 2 (3. 1%) Secondary operative procedure Reamputation Revision 32 (18.6%) 10 (5.8%) 20 (18.5%) 7 (6.5%) 12 (18.7%) 3 (4.7%) Frangež, Smrke-Rejec, Smrke / Rehabilitacija - letn. VII, supl. 3 (2008)