Knee Disarticulation Information

Knee Disarticulation Information

Tom Current and Tina Kilbey

11/15/1997

Thank you all for the great responses I have received. Following is the
orginal question and all the responses I received.

Tom Current, CP

I have been working with a gentleman in his early 70's who is a short
BKA with a 45 degree knee flexion contracture. I have offered to fit
him with a bent knee prosthesis but he does not want this.

The gentleman's surgen has recommended a transfemoral amputation, I
recommended he do a knee disarticulation instead. The surgen is
unfamiliar with prosthetic intervention at this level and has asked for
any information I have related to knee disarticulation prosthetic
fitting.

Does anyone know of any articles related to the knee disarticulation?

____________________________________________________________________

Tom,

As far as literature on knee-exarticulation, you can search Medline on
the
net :
<URL Redacted>
A first check on 'knee exarticulation' yielded 52 hits.

Our department (biomechanical engineering) has developed a knee-exart.
fitting a few years ago, since it make sense to preserve the condyles as
a
load-bearing surface if at all possible. The socket consisted of a cup
fitted to the end of the stump, a bent steel tube connected to the
bottom
of the cup and extending medially and upwards along the upper leg, and
at
the top of this tube a half-circular fitting. The top fitting encloses
the
front-part of the leg, while a velcro-strap ties it to the limb. This
way
the patient can sit without being hindered by the prosthesis. Work in
this
area was done by L. Lemmers (phD).

For some reason, however, orthopaedic surgeons are hesitant to amputate
through the knee. Perhaps this is the 'chicken or the egg'-problem :
hardly
anybody amputates through the knee because there are few well-developed
techniques for making knee exart. prostheses, while hardly anybody makes
knee-exart sockets because there are few exart. patients.

Regards,

Edsko Hekman
Laboratory of Biomechanical Engineering
Twente University
PO box 217 tel. 31-53-4893173
7500AE Enschede fax. 31-53-4893471

e-mail <Email Address Redacted>

We looked around in our library for info regarding knee
disarticulation, but without success. In checking with other CPs
about your situation, all suggested that the better solution would
be for the Patient to seek a new Orthopedic Surgeon who does have
significant experience with prosthetic intervention at this level.

Good Luck

Craig

Check out the Special Issue: Through-knee Amputation and Prosthetics
     Prosthetics and Orthotics International, August 1983, Vol. 7, No.
2.

     Also the latest AAOS Atlas of Limb Prosthetics (1992) has a good
     chapter on KD.

     From my experience, height is important. KD's aren't good on
shorter
     people, it just exaggerates the short shank problem. If the person
is
     pushing 6' or taller then a KD is a good choice. Four bar linkage
     knees are a must: Bock & TehLin (Daw) both have good long linkage
     four bars designed for KD's.

     Michael Schuch
     Director, P & O
     Duke University Medical Center

I am a 52 year old knee disarticulation amputee. The knee
disarticulation was done to clean up the results of a motocycle accident
21 years ago. While there is less choice from a mechanical point of
view, the lack of medical problems following this procedure makes it a
wonderful choice. I have NEVER had any medical problem since the
initial surgery and have a stump that looks as though it simply stopped
growing at the end of the femur.
My original prosthesis was made at Rusk Institute (NYU Medical Center)
in New York. For the past 15 years I have used the services of
Precision Orthotics & Prosthetics (Roger Chin) in New York..... the guy
is a genius. For specific information please call him at (212)
614-0633.

Good Luck,

Ed Heere

Best comprehensive resource regarding amputation surgery, prosthetics,
and
rehabilitation that I have ever seen is The Atlas of Limb Prosthetics
edited
by John Bowker, MD and John Michael, CPO, published by the American
Academy of
Orthopedic Surgeons in 1992. It is printed by Mosby.

I can fax the pertinent chapter on Knee disarticulation surgery and
prosthetics to the surgeon if you would like.

I just did a knee disarticulation about two weeks ago in a vascular
patient
with a 110 degree knee flexion contracture and a dead great toe. So far
it is
working great, minimal blood loss. excellent healing.

The chapter in the Atlas written by Michael Pinzur, MD, an orthopedic
surgeon
at the VA in Chicago is excellent!

Give me a call if he wants the chapter faxed to him or wants to talk to
me or
send me an email. \

You are exactly right in my opinion and experience to recommend the KD
rather
than an AK in this instance.

Ed Jeffries, MD, FACS (423)546-2663
Chief, Division of Orthopedic Surgery
Department of Surgery
UT Medical Center, Knoxville
Secretary, Amputee Coalition of America

In regards to your query on K/D. I do not know of any
recent papers or articles on K/D, although I do remember
one my father wrote with Dr. Robert Mazet Jr. Printed
in <italic>The Journal Of Bone And Joint Surgery, Vol. 48-A,
No.1, pp,126-139, January 1966</italic>. This article
was directed to both the prosthetist and surgeon.

Of course the advancements in materials and componentry
has changed, I know that the concept and operative tech-
nics are still valid and worthy of review.

If you have difficulty in locating the article I have a
few copies somewhere and would be happy to share one with
you.

James Hennessy, C.P.
Rehabilitation Management Ldt.
Auckland, New Zealand

Tom, you've probably already checked it, but the AAOS Atlas is probably
the best general yet succinct article, is current, and has the advantage
of being published by the AAOS which will prob. carry more weight with
the
surgeon than an article from one of the O&P journals. I think there's
both an article on the advantages of the amp level
surgically/functionally
and a separate(?) article on fitting problems.

I've got other articles - if you want references, I'll dig 'em out.

The thing to point out would be that since this is an older gent, he'll
prob. be sitting a lot and he might not like the px leg sticking out
farther than the sound side. However I think that KD is better for
preventing hip flexion contractures in someone who sits a lot. If he's
in
pretty good health, well, our best AK walkers when I was in school
were
always these 70 some year old wiry old guys with knee disartics - it's a
real forgiving fit when you can bear some weight on the end.

Cathy
(718) 824-1355

Tom,
The experiences that I have had with Knee disartics have sworn me off
them
for life for the following reasons:
1. Knee centre is never exact.
2. End bearing on what you would expect to be the ideal skeletal
situation
is surprisingly fraught with problems of skin breakdown and exostoses.
Bony
prominences of the condyles are prone to abrasion also.
3. Prosthetic joints (side-irons) are notorious for breakdowns and
wearing
out quickly.
Trans-femoral amps have few of these problems with the benefit of the
surgeon being able to give you an extra long stump to work with. It
sounds
like your surgeon might listen to you if you tell him where you would
like
the residuum to end.
Hope this helps, Richard Ziegeler

E.C.A.T
<Email Address Redacted>

I've gotten burned lately asking questions on cases like this , so
please
if the answer should be obvious don't take this in a critical manner.
Why
not either a contracture release or a corrective osteotony, preserving
the
B-K status?

Vikki Stefans, pediatric physiatrist (rehab doc for kids) and working
Mom of Sarah T. and Michael C., aka <Email Address Redacted>
Arkansas Children's Hospital/ U of A for Medical Sciences, Little Rock
...and EVERY mom is a working mom! (OK, dads too...)

Tom,
I have reservations about suggesting a KD. I happen to be working on
one now
and He has been all aver looking for a better mouse trap. All the limbs
he
has had so far included some type of endo knee placed well below his
anatomical knee center. Not many prosthetists these days are willing to
go
with outside joints. No matter how you cut it the long knee center
looks
lousy. I'm going with outside joints and the Hosmer Dupaco set up(what
a
chore!!). Unless you think your patient is willing to go with either
the
long KC or outside joints with poor swing control maybe a long
transfemoral
amp will function better. I've also had reasonable success fitting very
short BKs especially when activity is low.
Good luck
Keith Cornell CP

Check out the Otto Bock Lower Extremity Prosthetic Compendium for good
graphical information (limited to Otto Bock Components of course). You
can
get this direct from Bock along with an excellent Upper Extremity
Compendium.
 Endolite has a nice carbon fiber knee disarticulation knee as does
Hosmer.
 There is also the USMC 4 bar linkage collection of hardware (I've had
bad
luck with durability and parts compatability with these units).
Although
there is a cosmetic price to pay (and if your patient is very tall the
knee
length may make sitting in planes, theaters, and some cars difficult,
the
functional benefits of having the entire adductor musculature intact as
well
as (one would assume) good attachment of the quadriceps outweigh the
cosmetic
concerns in all but a few patients and povide an excellent gait.
Harry Phillips, C.P.O.

Dear Tom:

Probably there are publications available right here in the US. I am not
so
familiar with them, but I can help you with an important e-mail address:
<Email Address Redacted>
will be able to give you any information and a whole world of experience
with KD's. He is probably the most experienced German Orthopedic Surgeon
in
this special surgical field. Please do not hesitate to ask (his English
is
perfect) and say Hallo from Wieland.

Best regards
ortho-bio-med - marketing education design
Dipl.-Ing Wieland Kaphingst CPO (D)

Tom;

You may be recently certified by ABC so that accounts for my difficulty
in
finding you in the 1997 ABC registry, if so please accept my
curriosity. No
insult intended. I once fit a patient with similar problems with a
step-up
hinge similar to that used for short BE patients. It magnifies what
motion
the patient has to allow full extension and full flexion of the
prosthesis.
 Of course the patients pants will require extensive modification. But
if it
sounds okay to your patient you may find he is more compliant.

BB {;-)>

Hi Tom,
I presently can'y think of any articles off hand, however, I know that
there are many that exist, unfortuantely I'll be away from work for a
few
days, so wont have access to any.
Having being in the game for the last ten years, under normal
circumstances, it is not even questinable that a knee disart. is far
better
than a trans-fem.
Besides the cosmesis, which depanding on the amputee, there is a chance
that you can get away with things, it is most definately the way to go.
If I think of my knee disartic's as opposed to my long trans-fem's. the
knee disartic's out perform the trans fem's.
I'll look up some references and forward them to you ASAP.
Personally I would do anything to discourage the surgeon from performing
the amp. Please be aware that I assume that there is a choice of what
amputation should be performed.
Good luck,
Peter.

Tom--

Late but perhaps this info is of use.

Danny (I forget his last name), Cascade's Head of central fabrication,
has an
excellent design for use of a Mauch SNS type hydraullic system on a knee
disarticulation while still using outside joints so the knee centers are
anatomical.

You might want to give him a call at 800-888-0865

JTA

I suggest you contact Professor Kingsley Robinson, at the Douglas Bader
Amputee management unit in Roehampton, London telephone (0) 181 789
6611,
then ask switchboard for him by name\
He is one of the most experience amputation surgeons in the UK and will
be
able to advise.

--
+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-
SC Hughes,
Director of BioMedical Engineering
School of Mechanical and Materials Engineering,
University of Surrey,
Guildford, Surrey GU2 5XH

<URL Redacted>

email: <Email Address Redacted>
Tel: 01483 259671
Fax: 01483 306039

Dear Mr. Current,

Through Wieland Kaphingst and Tony van der Waarde I received your
request.
I will be happy to provide you reprints -both in German (with
illustrations)
and English if you e-mail your mailing address!
Definitely a through-knee disarticulation is by far superior to any kind
of
even sophisticated AKs!!!

Best regards

Georg Neff