The Journal of Arthroplasty xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
The Journal of Arthroplasty journal homepage: www.arthroplastyjournal.org
Original Article
Total Knee Arthroplasty After Lower Extremity Amputation: A Review of 13 Cases Derek F. Amanatullah, MD, PhD, Robert T. Trousdale, MD, Rafael J. Sierra, MD Department of Orthopedic Surgery, Mayo Clinic, Rochester Minnesota
a r t i c l e
i n f o
Article history: Received 26 February 2014 Accepted 31 March 2014 Available online xxxx Keywords: total knee arthroplasty TKA below knee amputation osteoarthritis lower extremity amputation
a b s t r a c t Below knee amputation protects the ipsilateral knee from osteoarthritis and overloads the contralateral knee predisposing it to symptomatic osteoarthritis. We retrospectively reviewed 13 primary total knee arthroplasty (TKAs) in 12 patients with a prior lower extremity amputation. Twelve TKAs were performed on the contralateral side of the amputated limb while only one TKA was performed on the ipsilateral side. The average clinical follow-up was 6.8 ± 4.8 years. Knee Society Scores improved from 30.4 ± 11.8 to 88.5 ± 4.2 after TKA with a prior contralateral amputation. Three (23.1%) patients with TKA after contralateral amputation had aseptic loosening of the tibial component. Patients experience clinically significant improvement with TKA after lower extremity amputation. Augmentation of tibial fixation with a stem may be advisable during TKA after contralateral amputation. © 2014 Elsevier Inc. All rights reserved.
In the United States there are about 1.6 million individuals living with a lower extremity amputation and 30,000 to 40,000 lower extremity amputations are performed annually [1]. Most lower extremity amputations are performed for complications of peripheral vascular disease and/or diabetes mellitus. Lower extremity trauma, musculoskeletal tumors, infection or sepsis, and congenital etiologies account for the remainder of lower extremity amputations. Lower extremity amputees are subject to increased physical demands as a result of amputation. The level of lower extremity amputation is directly proportional to the increase in oxygen consumption required for ambulation [2,3]. A retrospective cohort study comparing the prevalence of symptomatic knee osteoarthritis in lower extremity amputees and non-amputees found 10-fold less symptomatic knee osteoarthritis in the amputated limb of the amputee population when compared to the prevalence of symptomatic knee osteoarthritis of non-amputee population [4]. Several epidemiologic studies also support a 40% to 80% increase in the prevalence of symptomatic knee osteoarthritis in the non-amputated limb of the amputee population when compared to the prevalence of symptomatic knee osteoarthritis of non-amputee population [4–7]. 88% of lower extremity amputees have radiographic evidence of osteoporosis in the amputated limb after below knee amputation [8]. Hence, below knee amputation may unload the ipsilateral knee protecting it from osteoarthritis and overload the contralateral knee predisposing it to symptomatic osteoarthritis.
The Conflict of Interest statement associated with this article can be found at http:// dx.doi.org/10.1016/j.arth.2014.03.041. Reprint requests: Rafael J. Sierra, MD, 200 First Street SW, Gonda 14, Rochester, MN 55905.
There are only four known cases of total knee arthroplasty (TKA) after ipsilateral lower extremity amputation in the orthopedic literature [9–11]. Additionally, there is no available data regarding the clinical performance of TKA after contralateral lower extremity amputation despite the epidemiologic evidence that contralateral lower extremity amputation may predispose the knee to degenerative joint disease. The clinical and patient reported outcomes of TKA in the amputee population are poorly described in the literature. We present a case of TKA after ipsilateral lower extremity amputation and the first case series of TKA after contralateral lower extremity amputation. Materials and Methods A retrospective review identified a consecutive set of primary TKAs from the authors’ institution over a period between 1988 and 2009. Patients with a minimum of 2 years follow-up after TKA were identified with the use of a total joint registry that has prospectively followed all patients who have undergone a total joint arthroplasty at our institution since 1969. The registry includes patient demographics, date of last evaluation, implant, reoperation, and type of complication. Patients are scheduled for regular clinical evaluations at 1, 2, and 5 years following the arthroplasty and every 5 years thereafter. The institutional review board reviewed and approved this study prior to initiation. Thirteen TKAs performed by 7 surgeons at our institution in 12 patients after lower extremity amputation were identified for inclusion in this study. All TKA implants were cemented and both cruciate-retaining and posterior-stabilized designs were used. The primary endpoint measured was failure defined as revision for any reason. Average age, height, weight, body mass index (BMI) and operative time were recorded (Table 1). The underlying diagnoses for lower extremity amputation were recorded (Table 2). The immediate
http://dx.doi.org/10.1016/j.arth.2014.03.041 0883-5403/© 2014 Elsevier Inc. All rights reserved.
Please cite this article as: Amanatullah DF, et al, Total Knee Arthroplasty After Lower Extremity Amputation: A Review of 13 Cases, J Arthroplasty (2014), http://dx.doi.org/10.1016/j.arth.2014.03.041
2
D.F. Amanatullah et al. / The Journal of Arthroplasty xxx (2014) xxx–xxx
Table 1 Demographics of Lower Extremity Amputees After TKA. Demographic
Table 3 Implant Position with TKA After Amputation.
Average ± Standard Deviation
Age (years) Sex (Male:Female) Height (cm) Weight (kg) Body Mass Index (BMI) Operative Time (minutes)
65 ± 6 7:5 168 ± 11 91 ± 22 32.0 ± 5.8 173 ± 61
post-operative and latest radiographs of all TKAs were reviewed for implant position, lucency, loosening, or failure according to the Knee Society Roentgenographic Evaluation and Scoring System [12]. The operative reports and clinical notes were reviewed to correlate clinical findings. Functional status was evaluated both pre-operatively and post-operatively. Pre-operative and postoperative Knee Society Scores (KSS) were calculated from clinical examinations and patient surveys. Complications were recorded from the clinical and operative record. All values are reported as the mean and errors are reported as standard deviation where applicable. Comparisons of patient-reported outcomes were performed using a t-test, Fischer exact test, or Chi-square analysis as appropriate. Statistical significance was set at P less than 0.05.
Post-Operative Femoral Valgus Tibial Varus Femoral Flexion Tibial Slope
5.3 1.6 1.7 2.2
± ± ± ±
2.3B 1.8B 1.3B 1.4B
Final Follow-Up 5.9 1.3 2.3 4.8
± ± ± ±
1.9B 0.9B 2.2B 5.3B
P-Value 0.603 0.716 0.537 0.195
a below knee amputation (BKA), 6 (46.2%) TKAs were performed contralateral to an above knee amputation (AKA), and 1 (7.7%) TKA was performed ipsilateral to a BKA. Functional Status Pre-operative and post-operative KSS were calculated from clinical examinations and patient surveys. The pre-operative KSS of the patients with a TKA after contralateral lower extremity amputation were 30.4 ± 11.8, ranging from 15 to 48. The post-operative KSS of the patients with a TKA after contralateral lower extremity amputation were 88.5 ± 4.2, ranging from 93 to 78. This 58 point improvement in KSS is statistically significant (P b 0.05). The KSS of the patient with a TKA after ipsilateral BKA improved from 37 to 90. Revision and Complications
Sources of Funding There were no external funding sources for this study. Results Incidence of TKA after Lower Extremity Amputation 20,824 primary TKAs were performed at our institution from 1988 to 2009 with 2 years minimum follow-up. TKA after contralateral lower extremity amputation represents 0.058% of all TKAs, while TKA after ipsilateral lower extremity amputation represents 0.005% of all TKAs.
Three (23.1%) patients with a TKA after contralateral lower extremity amputation had radiographic evidence of aseptic loosening of their tibial components at final follow-up (Table 4). One of these patients required revision TKA (7.7%) 3 years post-operatively for persistent pain and loss of ambulatory status (Fig. 3). The other two patients had evidence of aseptic loosening but remained asymptomatic and have not required additional surgical intervention at our institution or at an outside institution at final follow-up. One (7.7%) patient with a TKA after contralateral lower extremity amputation had a post-operative pulmonary embolism and another patient with a
Follow-Up The average clinical follow-up was 6.8 ± 4.8 years and average radiographic follow-up was 5.2 ± 4.1 years. Three patients had died at final follow-up, 11, 16, and 22 years after TKA in the setting of a contralateral amputation. Their data at the time of final follow-up was included in our analysis. There were no statistically significant changes in the radiographic position of the implants at the time of final follow-up (Table 3, P N 0.05). Time to TKA after Amputation The average time from amputation to TKA was 27.5 ± 24.7 years. Twelve TKAs (92.3%) were performed contralateral to the amputated limb and only one (7.7%) was performed ipsilateral to the amputated limb (Figs. 1 and 2). Six (46.2%) TKAs were performed contralateral to
Table 2 Indication for Amputation. Diagnosis Tumor Osteomyelitis Vascular Congenital Band Syndrome Failed Total Ankle Arthroplasty Unknown
Number of Patients (%) 4 (33.3%) 1 (8.3%) 1 (8.3%) 1 (8.3%) 1 (8.3%) 4 (33.3%)
Fig. 1. (A) Pre-operative anterior-to-posterior weight bearing radiograph of a right lower extremity below knee amputee with bilateral knee osteoarthritis. (B) Pre-operative lateral radiograph of the right knee. (C) Pre-operative lateral radiograph of the left knee.
Please cite this article as: Amanatullah DF, et al, Total Knee Arthroplasty After Lower Extremity Amputation: A Review of 13 Cases, J Arthroplasty (2014), http://dx.doi.org/10.1016/j.arth.2014.03.041
D.F. Amanatullah et al. / The Journal of Arthroplasty xxx (2014) xxx–xxx
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Fig. 2. (A) Anterior-to-posterior weight bearing radiograph of a right lower extremity below knee amputee after ipsilateral and contralateral TKA at final follow-up. (B) Lateral radiograph of the right knee and ipsilateral TKA at final follow-up. (C) Lateral radiograph of the left knee and contralateral TKA at final follow-up.
TKA after contralateral lower extremity amputation (7.7%) had a hematoma. Both resolved without further complication or morbidity. No patient developed a superficial or deep infection, post-operative knee flexion contracture, nerve palsy, or other documented complication.
Discussion TKA after ipsilateral lower extremity amputation is very rare occurring in 0.058% of all TKAs. Prickett and Scanlon were the first to report on TKA after contralateral BKA [13]. The mean KSS improved from 30.4 ± 11.8 to 88.5 ± 4.2 with TKA after contralateral lower extremity amputation. This 58 point improvement in KSS is statistically significant (P b 0.05) indicating a clinically improvement in pain and function after TKA in this population. The 7.7% revision rate for aseptic loosening in the amputee population is well above the 2.3% early revision rate of primary TKA for aseptic loosening in the non-amputee population [14]. This may be related to improper prosthesis fit and force transfer to the endoprosthesis or the same ambulatory forces that predisposed the contralateral limb to knee osteoarthritis initially [4–7]. This observation combined with the 2 cases of radiographic aseptic loosening not yet requiring revision TKA (Table 4) suggests augmentation of tibial fixation with a cemented stem may be advisable during primary TKA after contralateral amputation. TKA after ipsilateral lower extremity amputation is very rare occurring in 0.005% of all TKAs. None of the now five case reports indicate and intra-operative or post-operative complications with TKA after ipsilateral lower extremity amputation. However, it should be noted that component positioning is a serious issue in this patient population because of the loss of anatomic landmarks at the time of TKA. Component malposition may result in post-operative stiffness,
Fig. 3. (A) Anterior-to-posterior weight bearing radiograph of a left lower extremity below knee amputee after contralateral TKA demonstrating aseptic loosening of the tibial component in all zones. (B) Lateral radiograph of the right knee and ipsilateral TKA demonstrating aseptic loosening of the tibial component in all zones. (C) Anteriorto-posterior weight bearing radiograph of a left lower extremity below knee amputee after revision contralateral TKA with fully cemented stemmed implants. (D) Lateral radiograph of a left lower extremity below knee amputee after revision contralateral TKA with fully cemented stemmed implants.
flexion contracture, or instability affecting ambulatory endurance and require revision TKA. Retrospectively analyzed data has several limitations including the fidelity of the record, loss to follow-up, and selection bias. We have utilized a systematic approach to patient selection and a high fidelity electronic medical record in an attempt to minimize any of these inadvertent biases. TKA surgery was performed by 7 different orthopedic surgeons all fellowship trained in total joint arthroplasty but each with differing approaches to the TKA itself. Additionally, the KSS has not been validated in amputees. The KSS may not the
Please cite this article as: Amanatullah DF, et al, Total Knee Arthroplasty After Lower Extremity Amputation: A Review of 13 Cases, J Arthroplasty (2014), http://dx.doi.org/10.1016/j.arth.2014.03.041
4
D.F. Amanatullah et al. / The Journal of Arthroplasty xxx (2014) xxx–xxx
Table 4 Location of Radiolucency and Revision for Aseptic Loosening. Amputation
TKA System
Type
Fixation
Location of Lucency
Follow-Up
Revision TKA
Ipsilateral Contralateral Contralateral Contralateral Contralateral Contralateral Contralateral Contralateral Contralateral Contralateral Contralateral Contralateral Contralateral
PFC Sigma PFC Sigma PFC Sigma PFC Sigma NexGen NexGen PFC Sigma PFC Sigma PFC Sigma PFC Sigma PFC Sigma Genesis Miller-Galante
PS PS PS PS PS PS PS CR PS PS PS PS CR
Cemented Cemented Cemented Cemented Cemented Cemented Cemented Cemented Cemented Cemented Cemented Cemented Cemented
None None None None None Tibia, All Zones None None None None AP Tibia, Zone 1-2 None AP Tibia, Zone 3-4
2 years 2 years 2 years 2 years 2 years 3 years 5 years 5 years 6 years 10 years 10 years 10 years 15 years
No No No No No Yes No No No No No No No
TKA: Total Knee Arthroplasty; AP: Anterior-to-posterior; Implant type received by patient with TKA after ipsilateral lower extremity amputation.
best outcome measure in a patient population with numerous physical and mental reasons for pain, limping, ambulatory aids, limited ambulation, and decreased range of motion. This would diminish the ability of our study to detect a pre-operative and postoperative difference in the challenging patient population. In conclusion, TKA after lower extremity amputation is rare. TKA after lower extremity amputation provides excellent functional and clinical outcomes. Early aseptic loosening is common; hence augmentation of tibial fixation with a cemented stem may be advisable, with TKA after contralateral BKA. References 1. Ziegler-Graham K, MacKenzie EJ, Ephraim PL. Estimating the prevalence of limb loss in the United States: 2005 to 2050. Arch Phys Med Rehabil 2008;89(3):422. 2. Herbert LM, Engsberg JR, Tedford KG, et al. A comparison of oxygen consumption during walking between children with and without below-knee amputations. Phys Ther 1994;74(10):943. 3. Jeans KA, Browne RH, Karol LA. Effect of amputation level on energy expenditure during overground walking by children with an amputation. J Bone Joint Surg Am 2011;93(1):49.
4. Norvell D, Czerniecki J, Reiber G, et al. The prevalence of knee pain and symptomatic knee osteoarthritis among veteran traumatic amputees and nonamputees. Arch Phys Med Rehabil 2005;86(3):487. 5. Hungerford DS, Cockin J. Fate of the retained lower limb joints in second world war amputees. J Bone Joint Surg (Br) 1975;57(1):111. 6. Lemaire ED, Fisher FR. Osteoarthritis and elderly amputee gait. Arch Phys Med Rehabil 1994;75(10):1094. 7. Melzer I, Yekutiel M, Sukenik S. Comparative study of osteoarthritis of the contralateral knee joint of male amputees who do and do not play volleyball. J Rheumatol 2001;28(1):169. 8. Burke M, Roman V, Wright V. Bone and joint changes in lower limb amputees. Ann Rheum Dis 1978;37(3):252. 9. Pasquina P, Dhal E. Total knee replacement in an amputee patient: a case report. Arch Phys Med Rehabil 2000;81(6):824. 10. Crawford JR, Coleman N. Total knee arthroplasty in a below-knee amputee. J Arthroplasty 2003;18(5):662. 11. Karam MD, Willey M, Shurr DG. Total knee replacement in patients with belowknee amputation. Iowa Orthop J 2010;30(5):150. 12. Ewald FC. The Knee Society total knee arthroplasty roentgenographic evaluation and scoring system. Clin Orthop Relat Res 1989;248:9. 13. Prickett NM, Scanlon CJ. Total joint replacement in extremities with below-knee amputations. Phys Ther 1978;56(8):925. 14. Piedade SR, Pinaroli A, Servien E, et al. Revision after early aseptic failures in primary total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2009;17 (3):248.
Please cite this article as: Amanatullah DF, et al, Total Knee Arthroplasty After Lower Extremity Amputation: A Review of 13 Cases, J Arthroplasty (2014), http://dx.doi.org/10.1016/j.arth.2014.03.041
Contents lists available at ScienceDirect
The Journal of Arthroplasty journal homepage: www.arthroplastyjournal.org
Original Article
Total Knee Arthroplasty After Lower Extremity Amputation: A Review of 13 Cases Derek F. Amanatullah, MD, PhD, Robert T. Trousdale, MD, Rafael J. Sierra, MD Department of Orthopedic Surgery, Mayo Clinic, Rochester Minnesota
a r t i c l e
i n f o
Article history: Received 26 February 2014 Accepted 31 March 2014 Available online xxxx Keywords: total knee arthroplasty TKA below knee amputation osteoarthritis lower extremity amputation
a b s t r a c t Below knee amputation protects the ipsilateral knee from osteoarthritis and overloads the contralateral knee predisposing it to symptomatic osteoarthritis. We retrospectively reviewed 13 primary total knee arthroplasty (TKAs) in 12 patients with a prior lower extremity amputation. Twelve TKAs were performed on the contralateral side of the amputated limb while only one TKA was performed on the ipsilateral side. The average clinical follow-up was 6.8 ± 4.8 years. Knee Society Scores improved from 30.4 ± 11.8 to 88.5 ± 4.2 after TKA with a prior contralateral amputation. Three (23.1%) patients with TKA after contralateral amputation had aseptic loosening of the tibial component. Patients experience clinically significant improvement with TKA after lower extremity amputation. Augmentation of tibial fixation with a stem may be advisable during TKA after contralateral amputation. © 2014 Elsevier Inc. All rights reserved.
In the United States there are about 1.6 million individuals living with a lower extremity amputation and 30,000 to 40,000 lower extremity amputations are performed annually [1]. Most lower extremity amputations are performed for complications of peripheral vascular disease and/or diabetes mellitus. Lower extremity trauma, musculoskeletal tumors, infection or sepsis, and congenital etiologies account for the remainder of lower extremity amputations. Lower extremity amputees are subject to increased physical demands as a result of amputation. The level of lower extremity amputation is directly proportional to the increase in oxygen consumption required for ambulation [2,3]. A retrospective cohort study comparing the prevalence of symptomatic knee osteoarthritis in lower extremity amputees and non-amputees found 10-fold less symptomatic knee osteoarthritis in the amputated limb of the amputee population when compared to the prevalence of symptomatic knee osteoarthritis of non-amputee population [4]. Several epidemiologic studies also support a 40% to 80% increase in the prevalence of symptomatic knee osteoarthritis in the non-amputated limb of the amputee population when compared to the prevalence of symptomatic knee osteoarthritis of non-amputee population [4–7]. 88% of lower extremity amputees have radiographic evidence of osteoporosis in the amputated limb after below knee amputation [8]. Hence, below knee amputation may unload the ipsilateral knee protecting it from osteoarthritis and overload the contralateral knee predisposing it to symptomatic osteoarthritis.
The Conflict of Interest statement associated with this article can be found at http:// dx.doi.org/10.1016/j.arth.2014.03.041. Reprint requests: Rafael J. Sierra, MD, 200 First Street SW, Gonda 14, Rochester, MN 55905.
There are only four known cases of total knee arthroplasty (TKA) after ipsilateral lower extremity amputation in the orthopedic literature [9–11]. Additionally, there is no available data regarding the clinical performance of TKA after contralateral lower extremity amputation despite the epidemiologic evidence that contralateral lower extremity amputation may predispose the knee to degenerative joint disease. The clinical and patient reported outcomes of TKA in the amputee population are poorly described in the literature. We present a case of TKA after ipsilateral lower extremity amputation and the first case series of TKA after contralateral lower extremity amputation. Materials and Methods A retrospective review identified a consecutive set of primary TKAs from the authors’ institution over a period between 1988 and 2009. Patients with a minimum of 2 years follow-up after TKA were identified with the use of a total joint registry that has prospectively followed all patients who have undergone a total joint arthroplasty at our institution since 1969. The registry includes patient demographics, date of last evaluation, implant, reoperation, and type of complication. Patients are scheduled for regular clinical evaluations at 1, 2, and 5 years following the arthroplasty and every 5 years thereafter. The institutional review board reviewed and approved this study prior to initiation. Thirteen TKAs performed by 7 surgeons at our institution in 12 patients after lower extremity amputation were identified for inclusion in this study. All TKA implants were cemented and both cruciate-retaining and posterior-stabilized designs were used. The primary endpoint measured was failure defined as revision for any reason. Average age, height, weight, body mass index (BMI) and operative time were recorded (Table 1). The underlying diagnoses for lower extremity amputation were recorded (Table 2). The immediate
http://dx.doi.org/10.1016/j.arth.2014.03.041 0883-5403/© 2014 Elsevier Inc. All rights reserved.
Please cite this article as: Amanatullah DF, et al, Total Knee Arthroplasty After Lower Extremity Amputation: A Review of 13 Cases, J Arthroplasty (2014), http://dx.doi.org/10.1016/j.arth.2014.03.041
2
D.F. Amanatullah et al. / The Journal of Arthroplasty xxx (2014) xxx–xxx
Table 1 Demographics of Lower Extremity Amputees After TKA. Demographic
Table 3 Implant Position with TKA After Amputation.
Average ± Standard Deviation
Age (years) Sex (Male:Female) Height (cm) Weight (kg) Body Mass Index (BMI) Operative Time (minutes)
65 ± 6 7:5 168 ± 11 91 ± 22 32.0 ± 5.8 173 ± 61
post-operative and latest radiographs of all TKAs were reviewed for implant position, lucency, loosening, or failure according to the Knee Society Roentgenographic Evaluation and Scoring System [12]. The operative reports and clinical notes were reviewed to correlate clinical findings. Functional status was evaluated both pre-operatively and post-operatively. Pre-operative and postoperative Knee Society Scores (KSS) were calculated from clinical examinations and patient surveys. Complications were recorded from the clinical and operative record. All values are reported as the mean and errors are reported as standard deviation where applicable. Comparisons of patient-reported outcomes were performed using a t-test, Fischer exact test, or Chi-square analysis as appropriate. Statistical significance was set at P less than 0.05.
Post-Operative Femoral Valgus Tibial Varus Femoral Flexion Tibial Slope
5.3 1.6 1.7 2.2
± ± ± ±
2.3B 1.8B 1.3B 1.4B
Final Follow-Up 5.9 1.3 2.3 4.8
± ± ± ±
1.9B 0.9B 2.2B 5.3B
P-Value 0.603 0.716 0.537 0.195
a below knee amputation (BKA), 6 (46.2%) TKAs were performed contralateral to an above knee amputation (AKA), and 1 (7.7%) TKA was performed ipsilateral to a BKA. Functional Status Pre-operative and post-operative KSS were calculated from clinical examinations and patient surveys. The pre-operative KSS of the patients with a TKA after contralateral lower extremity amputation were 30.4 ± 11.8, ranging from 15 to 48. The post-operative KSS of the patients with a TKA after contralateral lower extremity amputation were 88.5 ± 4.2, ranging from 93 to 78. This 58 point improvement in KSS is statistically significant (P b 0.05). The KSS of the patient with a TKA after ipsilateral BKA improved from 37 to 90. Revision and Complications
Sources of Funding There were no external funding sources for this study. Results Incidence of TKA after Lower Extremity Amputation 20,824 primary TKAs were performed at our institution from 1988 to 2009 with 2 years minimum follow-up. TKA after contralateral lower extremity amputation represents 0.058% of all TKAs, while TKA after ipsilateral lower extremity amputation represents 0.005% of all TKAs.
Three (23.1%) patients with a TKA after contralateral lower extremity amputation had radiographic evidence of aseptic loosening of their tibial components at final follow-up (Table 4). One of these patients required revision TKA (7.7%) 3 years post-operatively for persistent pain and loss of ambulatory status (Fig. 3). The other two patients had evidence of aseptic loosening but remained asymptomatic and have not required additional surgical intervention at our institution or at an outside institution at final follow-up. One (7.7%) patient with a TKA after contralateral lower extremity amputation had a post-operative pulmonary embolism and another patient with a
Follow-Up The average clinical follow-up was 6.8 ± 4.8 years and average radiographic follow-up was 5.2 ± 4.1 years. Three patients had died at final follow-up, 11, 16, and 22 years after TKA in the setting of a contralateral amputation. Their data at the time of final follow-up was included in our analysis. There were no statistically significant changes in the radiographic position of the implants at the time of final follow-up (Table 3, P N 0.05). Time to TKA after Amputation The average time from amputation to TKA was 27.5 ± 24.7 years. Twelve TKAs (92.3%) were performed contralateral to the amputated limb and only one (7.7%) was performed ipsilateral to the amputated limb (Figs. 1 and 2). Six (46.2%) TKAs were performed contralateral to
Table 2 Indication for Amputation. Diagnosis Tumor Osteomyelitis Vascular Congenital Band Syndrome Failed Total Ankle Arthroplasty Unknown
Number of Patients (%) 4 (33.3%) 1 (8.3%) 1 (8.3%) 1 (8.3%) 1 (8.3%) 4 (33.3%)
Fig. 1. (A) Pre-operative anterior-to-posterior weight bearing radiograph of a right lower extremity below knee amputee with bilateral knee osteoarthritis. (B) Pre-operative lateral radiograph of the right knee. (C) Pre-operative lateral radiograph of the left knee.
Please cite this article as: Amanatullah DF, et al, Total Knee Arthroplasty After Lower Extremity Amputation: A Review of 13 Cases, J Arthroplasty (2014), http://dx.doi.org/10.1016/j.arth.2014.03.041
D.F. Amanatullah et al. / The Journal of Arthroplasty xxx (2014) xxx–xxx
3
Fig. 2. (A) Anterior-to-posterior weight bearing radiograph of a right lower extremity below knee amputee after ipsilateral and contralateral TKA at final follow-up. (B) Lateral radiograph of the right knee and ipsilateral TKA at final follow-up. (C) Lateral radiograph of the left knee and contralateral TKA at final follow-up.
TKA after contralateral lower extremity amputation (7.7%) had a hematoma. Both resolved without further complication or morbidity. No patient developed a superficial or deep infection, post-operative knee flexion contracture, nerve palsy, or other documented complication.
Discussion TKA after ipsilateral lower extremity amputation is very rare occurring in 0.058% of all TKAs. Prickett and Scanlon were the first to report on TKA after contralateral BKA [13]. The mean KSS improved from 30.4 ± 11.8 to 88.5 ± 4.2 with TKA after contralateral lower extremity amputation. This 58 point improvement in KSS is statistically significant (P b 0.05) indicating a clinically improvement in pain and function after TKA in this population. The 7.7% revision rate for aseptic loosening in the amputee population is well above the 2.3% early revision rate of primary TKA for aseptic loosening in the non-amputee population [14]. This may be related to improper prosthesis fit and force transfer to the endoprosthesis or the same ambulatory forces that predisposed the contralateral limb to knee osteoarthritis initially [4–7]. This observation combined with the 2 cases of radiographic aseptic loosening not yet requiring revision TKA (Table 4) suggests augmentation of tibial fixation with a cemented stem may be advisable during primary TKA after contralateral amputation. TKA after ipsilateral lower extremity amputation is very rare occurring in 0.005% of all TKAs. None of the now five case reports indicate and intra-operative or post-operative complications with TKA after ipsilateral lower extremity amputation. However, it should be noted that component positioning is a serious issue in this patient population because of the loss of anatomic landmarks at the time of TKA. Component malposition may result in post-operative stiffness,
Fig. 3. (A) Anterior-to-posterior weight bearing radiograph of a left lower extremity below knee amputee after contralateral TKA demonstrating aseptic loosening of the tibial component in all zones. (B) Lateral radiograph of the right knee and ipsilateral TKA demonstrating aseptic loosening of the tibial component in all zones. (C) Anteriorto-posterior weight bearing radiograph of a left lower extremity below knee amputee after revision contralateral TKA with fully cemented stemmed implants. (D) Lateral radiograph of a left lower extremity below knee amputee after revision contralateral TKA with fully cemented stemmed implants.
flexion contracture, or instability affecting ambulatory endurance and require revision TKA. Retrospectively analyzed data has several limitations including the fidelity of the record, loss to follow-up, and selection bias. We have utilized a systematic approach to patient selection and a high fidelity electronic medical record in an attempt to minimize any of these inadvertent biases. TKA surgery was performed by 7 different orthopedic surgeons all fellowship trained in total joint arthroplasty but each with differing approaches to the TKA itself. Additionally, the KSS has not been validated in amputees. The KSS may not the
Please cite this article as: Amanatullah DF, et al, Total Knee Arthroplasty After Lower Extremity Amputation: A Review of 13 Cases, J Arthroplasty (2014), http://dx.doi.org/10.1016/j.arth.2014.03.041
4
D.F. Amanatullah et al. / The Journal of Arthroplasty xxx (2014) xxx–xxx
Table 4 Location of Radiolucency and Revision for Aseptic Loosening. Amputation
TKA System
Type
Fixation
Location of Lucency
Follow-Up
Revision TKA
Ipsilateral Contralateral Contralateral Contralateral Contralateral Contralateral Contralateral Contralateral Contralateral Contralateral Contralateral Contralateral Contralateral
PFC Sigma PFC Sigma PFC Sigma PFC Sigma NexGen NexGen PFC Sigma PFC Sigma PFC Sigma PFC Sigma PFC Sigma Genesis Miller-Galante
PS PS PS PS PS PS PS CR PS PS PS PS CR
Cemented Cemented Cemented Cemented Cemented Cemented Cemented Cemented Cemented Cemented Cemented Cemented Cemented
None None None None None Tibia, All Zones None None None None AP Tibia, Zone 1-2 None AP Tibia, Zone 3-4
2 years 2 years 2 years 2 years 2 years 3 years 5 years 5 years 6 years 10 years 10 years 10 years 15 years
No No No No No Yes No No No No No No No
TKA: Total Knee Arthroplasty; AP: Anterior-to-posterior; Implant type received by patient with TKA after ipsilateral lower extremity amputation.
best outcome measure in a patient population with numerous physical and mental reasons for pain, limping, ambulatory aids, limited ambulation, and decreased range of motion. This would diminish the ability of our study to detect a pre-operative and postoperative difference in the challenging patient population. In conclusion, TKA after lower extremity amputation is rare. TKA after lower extremity amputation provides excellent functional and clinical outcomes. Early aseptic loosening is common; hence augmentation of tibial fixation with a cemented stem may be advisable, with TKA after contralateral BKA. References 1. Ziegler-Graham K, MacKenzie EJ, Ephraim PL. Estimating the prevalence of limb loss in the United States: 2005 to 2050. Arch Phys Med Rehabil 2008;89(3):422. 2. Herbert LM, Engsberg JR, Tedford KG, et al. A comparison of oxygen consumption during walking between children with and without below-knee amputations. Phys Ther 1994;74(10):943. 3. Jeans KA, Browne RH, Karol LA. Effect of amputation level on energy expenditure during overground walking by children with an amputation. J Bone Joint Surg Am 2011;93(1):49.
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Please cite this article as: Amanatullah DF, et al, Total Knee Arthroplasty After Lower Extremity Amputation: A Review of 13 Cases, J Arthroplasty (2014), http://dx.doi.org/10.1016/j.arth.2014.03.041
