RESULTS OF KNEE JOINT PRESERVATION AFTER TRANSTIBIAL AMPUTATION OF LOWER LIMBS IN OCCLUSIVE ILIAC ARTERIAL LESIONS Koval O.A., Batiskin S.A., Zoloev D.G
Novokuznetsk Scientific and Practical Centre for Medical and Social Expertise and Rehabilitation of Disabled Persons, Novokuznetsk, Russia
The issues of extremity amputation present one of the most difficult fields in surgery. Experienced surgeons consider the extremity amputation as a technically simple manipulation and entrust its realization to physicians without practical experience [1]. Realization of transtibial extremity decreases the life quality as compared to transfemoral one. So, the knee joint preservation influences on the duration and life quality. After transtibial amputations, the probability of assimilation of the prosthesis and restoration of walking function increase as compared to transfemoral amputations of the lower extremities [2, 3].
However the high amount of amputations in critical ischemia of the lower extremity is carried out at the level of the upper or middle one-thirds of the hip. Currently, there are not any regulatory documents regarding the selection of a level of extremity amputation or such documents are only non-regulatory. One of the main criteria for selection of a level of extremity amputation at the hip level in iliac arterial occlusion is surgeons’ drive to achievement of maximally favorable conditions for wound healing with primary tension. After transtibial and transfemoral amputation, the probability of wound healing do not differ significantly – 75-85 % and 85-93 % correspondingly [4].
As the data of wide-scale epidemiological studies show, the mortality in the early period after extremity amputation is 18-26 % [5, 6]. The number of various complications is high [1]. However complications after high level of hip amputation are most dangerous and present the real life threat [7].
Objective – to investigate the knee joint preservation and the mortality rate after transtibial amputations in presence of occlusive involvements of iliac arteries.
MATERIALS AND METHODS
The study included the patients with atherosclerosis, diabetes mellitus, obliterating thromboangiitis, with the lower extremity amputation at the leg level as result of critical ischemia for the period of 1998-2013. The inclusion criteria were the presence of obliterating disease of extremity vessels, confirmed presence or absence of palpated pulsation of the femoral artery. The confirmation of occlusion or stenosis of the aortic and arterial bed of the lower extremities was realized with use of duplex scanning of arteries, for some patients – with contrast angiography. Arterial occlusion was verified on the basis of absent echolocation of the blood flow or arterial contrasting in the iliac segment.
The study included 573 cases of lower extremity amputation at the leg level. The main group included 83 cases of amputation with presence of the proved occlusive lesion of iliac arteries. The comparison group included 490 cases of amputation with preserved patency of iliac arteries. According to nosology, the main group included 72 patients with atherosclerosis, 10 – with diabetic foot, 1 – with thromboangiitis obliterans. The control group included 200, 274 and 43 patients correspondingly. The mean age of patients in the main group was 62.8 ± 1.1, in the control group – 63.6 ± 1.3. The patients with atherosclerotic lesion of arterial bed and thromboangiitis obliterans were mainly men (up to 82 % in both groups), with mean age of 63-68. The mean age of the patient with diabetic foot was 56-60, with more women than men.
Transtibial amputation was primarily carried out at the level of upper and middle one-third of the leg with formation of skin fascial flaps and length of bonesaw-lines of 9-12 cm. After realization of reamputation for this segment, the skin fascial flaps were formed 0.5-1 cm above necrotic tissues, with shortening of bonesaw-lines of femoral bones over the distance sufficient for closure of a wound without tension of flaps. If amputation at hip level was required for patients with ischemia of the formed stump of the leg, the technique of transfemoral amputation was used with formation of the skin fascial flaps on the border between lower and middle one-thirds and the bone-saw line in the middle one third of the hip.
The results of amputation were estimated according to the number of cases with the preserved knee joint and to lethal outcomes on the months 3 and 60 after extremity amputation. Pearson’s χ2 test was used for testing the statistical hypotheses in two independent samples. The level of statistical significance was p < 0.05.
The study was approved by the ethical committee of Novokuznetsk Scientific and Practical Centre for Medical and Social Expertise and Rehabilitation of Disabled Persons (the protocol No.2, 11 February 2019) and corresponded to Ethical Principles for Medical Research with Human Subjects and to the Rules for Clinical Practice in the Russian Federation.
RESULTS
Within the period up to 3 months after leg amputation, the amount of recurrent amputations in the control and main groups was as described below. Among 83 cases of extremity amputation in the main group with iliac artery occlusion, 17 (20.5 %) patients received some recurrent amputations at the primary level (the upper one-third of the leg) at the background of purulent and necrotic changes in soft tissues (20.8 % of patients with atherosclerotic lesion and 20 % of patients with diabetic foot) in the early postsurgical period. In the control group, recurrent amputations at this level were carried out for 53 (10.8 %) patients (26.5 % of patients with atherosclerosis, 8.1 % – with diabetic foot, 16.3 % – thromboangiitis obliterans).
Within the period up to 3 months, the recurrent amputations at the hip level were carried out for 7 (8.4 %) patients with atherosclerotic arterial lesion in the main group, in the control group – for 18 (3.7 %) patients (with atherosclerosis and diabetic foot). The differences were not statistically significant.
As result of the analysis of values of knee joint preservation over the period of five years after leg amputation, it was found that recurrent amputations at the hip level (within the period of 60 months) were carried out for 36 (43.4 %) patients in the main group (34 (47.2 %) patients with atherosclerotic lesion, 1 – with diabetic foot, 1 – thromboangiitis obliterans). Over the same period, the control group received the recurrent amputations at higher level: 87 (17.7 %) patients, including 51 (25.5 %) with atherosclerosis, 27 (10.9 %) – with diabetic angiopathy, 9 (20.9 %) – with thromboangiitis of lower extremity vessels.
The examination of mortality showed that 6 patients with atherosclerotic lesion of the arterial bed had died in the early postsurgical period, 20 patients – within 60 months, including 17 ones with atherosclerotic lesion and 3 with diabetic angiopathy. Therefore, the general mortality in the main group was 7.3 % in the early postsurgical period and 24.1 % in the late one. Three months after amputation, 29 (6 %) patients died in the control group, including 13 patients with atherosclerosis, 16 – with diabetic lesion of the peripheral arterial bed (6.5 % correspondingly). In the late period, the control group showed the lethal outcomes in 72 cases (36 %) with atherosclerosis, in 94 cases (38.1 %) with diabetic foot, in 3 cases (7 %) with thromboangiitis. The total mortality was 169 (34.9 %) patients over 5 years(table).
Table
Re-amputation and survival rates in transtibial amputations
in patients in main and control groups
|
|
Total |
Amount of leg re-amputations within 3 months |
Amount of hip re-amputations within 3 months |
Amount of hip re-amputations within 60 months |
Mortality within 3 months |
Mortality within 60 months |
|
Main group |
||||||
|
Obliterating arterial diseases |
72 |
15 |
7 |
34 |
6 |
17 |
|
Diabetes mellitus |
10 |
2 |
0 |
1 |
0 |
3 |
|
Obliterating thromboangiitis |
1 |
0 |
0 |
1 |
0 |
0 |
|
Total |
83 |
17 |
7 |
36 |
6 |
20 |
|
Control group |
||||||
|
Obliterating arterial diseases |
200 |
26 |
13 |
51 |
13 |
72 |
|
Diabetes mellitus |
247 |
20 |
3 |
27 |
16 |
94 |
|
Obliterating thromboangiitis |
43 |
7 |
2 |
9 |
0 |
3 |
|
Total |
490 |
53 |
18 |
87 |
29 |
169 |
DISCUSSION
In case of necessary amputation of the extremity, one of the important aspects is a possibility for the knee joint preservation. In Russia, the amputations at the leg level are realized for 16.2-18.7 % of patients with critical ischemia of the extremity. In the European countries, transtibial amputations are carried out for 29-86 % of all extensive amputations of the extremity [1]. The postsurgical mortality after the leg amputation is 7-9 %, after the hip amputation – more than 20 %. The 50 % limit after the hip amputation is 18 months, after transtibial amputation – 48 months [1]. The knee joint preservation improves the results of prosthetics and subsequent home and social rehabilitation. The appealability for primary remedial and training prosthetics after the leg amputation significantly exceeds the values of appealability after amputation at the hip level (52 and 23.8 % correspondingly). The recurrent addressing for subsequent stages of prosthetics after production of the leg prosthesis is 89 %, whereas after the hip prosthetics it consists of 51 % [2].
Therefore, the knee joint preservation after lower extremity amputation in patients with critical ischemia of the extremity gives the advantage as compared to transtibial amputation.
The realization of amputation at the leg level allowed preservation of the knee joint in 91.6 % of cases in the early postsurgical period in patients with critical ischemia of the extremity with occlusion of iliac arteries. These results did not show any statistical difference from similar values in patients with arterial patency of the iliac segment – 96.3 % (p > 0.05).
The comparative analysis of cases of recurrent amputation at the leg level did not find any statistical differences in the main and control groups, although these differences are not important for the knee joint preservation. The purulent and necrotic changes in the primary stump of the leg could be caused by basic infection of the foot, and more distal level of extremity amputation.
In the long term five-year period, the percentage of the knee joint preservation in case of iliac artery occlusion was 56.7 %, for distal lesion of the arterial bed – more than 65.5 % (p < 0.05). Even in a half of cases, the knee joint preservation confirms the appropriateness of primary amputations at the leg level.
The mortality was statistically significant both in early and late periods in the compared groups (p < 0.05).
CONCLSUION
On the basis of the above-mentioned facts, one may suppose than transtibial amputation can be the alternative for transfemoral amputation in a case of proved occlusive lesion of iliac arteries since the values of recurrent amputation at the hip level are not statistically different in early and late periods.
The iliac arterial occlusion in amputation at the leg level does not influence on early and late mortality.
Therefore, regardless of presence or absence of patency of the iliac arterial segment in patients with critical ischemia, one can recommend performing the primary amputations of the lower extremity.
Information on financing and conflict of interests
The study was conducted without sponsorship. The authors declare the absence of any clear or potential conflicts of interests relating to publication of this article.