Morse Bryan C, Cull David L, Kalbaugh Corey, Cass Anna L, Taylor Spence M
Academic Department of Surgery, Greenville Hospital System University Medical Center, Greenville, SC 29605, USA.
J Vasc Surg. 2008 Sep;48(3):638-43; discussion 643. doi: 10.1016/j.jvs.2008.04.018. Epub 2008 Jun 30.
For good rehabilitation candidates, the biomechanical advantages of the end weight-bearing through-knee amputation (TKAmp) compared with the above knee amputation (AKA) are well established. However, the TKAmp has been abandoned by vascular surgeons because of poor wound healing rates related to long tissue flaps and challenges to prosthetic fitting related to the femoral condyles. Since 1998, we have performed the modified "Mazet" technique TKAmp procedure that creates shorter flaps to close the wound and greatly facilitates prosthesis fitting. The purpose of this study is to review our results with TKAmp in patients with peripheral vascular disease who were not candidates for below-knee amputation.
The records of all patients who underwent through-knee amputation between 1998 and 2006 were retrospectively reviewed. Mean follow-up was 33 months (range, 38 days to 99 months). Amputations for trauma and malignancy were excluded. Patient survival, maintenance of ambulation, and independent living status were analyzed using Kaplan-Meier survival analysis methods.
Fifty patients underwent TKAmp using a modified Mazet technique. The mean age was 63 years; 50% were men, and 50% had diabetes mellitus. All patients had peripheral arterial disease. Thirty-five patients (70%) had prior revascularization procedures. Those patients averaged 2.2 revascularization procedures prior to amputation. There were three (6%) perioperative deaths. The ipsilateral common femoral artery was patent in 43/50 (86%) of patients at the time of amputation. Forty patients (80%) had open wounds and three patients (6%) had a failed below-knee amputation at the time of TKAmp. Thirty-eight patients (81%) healed their TKAmp wound. Nine patients failed to heal and were revised to an above knee amputation. The cumulative probability of regular prosthetic usage and maintenance of ambulation was estimated to be 0.56 at 3 years and 0.41 at 5 years. The probability of maintaining independent living status at 3 and 5 years was 0.77 and 0.65, respectively. Survival probabilities for patients in this series were 0.60 at 3 years and 0.44 at 5 years.
These data show that the TKAmp is associated with an acceptable primary healing rate and satisfactory functional outcomes in patients with peripheral arterial disease. The advantages of TKAmp over AKA make it the preferred alternative for patients with vascular disease who are candidates for prosthetic rehabilitation.
对于适合康复的患者，与大腿截肢（AKA）相比，经膝关节截肢（TKAmp）的终末负重生物力学优势已得到充分证实。然而，由于长组织瓣导致的伤口愈合率低以及与股骨髁相关的假肢适配挑战，血管外科医生已不再采用TKAmp。自1998年以来，我们开展了改良的“马泽特”技术TKAmp手术，该手术可形成更短的皮瓣来闭合伤口，并极大地便利了假肢适配。本研究的目的是回顾我们对不适合膝下截肢的外周血管疾病患者进行TKAmp的结果。
回顾性分析1998年至2006年间所有接受经膝关节截肢患者的记录。平均随访时间为33个月（范围为38天至99个月）。排除因创伤和恶性肿瘤导致的截肢病例。采用Kaplan-Meier生存分析方法分析患者生存率、步行能力维持情况和独立生活状态。
50例患者采用改良马泽特技术进行了TKAmp。平均年龄为63岁；50%为男性，50%患有糖尿病。所有患者均患有外周动脉疾病。35例患者（70%）曾接受过血管重建手术。这些患者在截肢前平均接受了2.2次血管重建手术。围手术期死亡3例（6%）。截肢时，43/50例（86%）患者的同侧股总动脉通畅。40例患者（80%）有开放性伤口，3例患者（6%）在进行TKAmp时膝下截肢失败。38例患者（81%）的TKAmp伤口愈合。9例患者伤口未愈合，改为大腿截肢。估计3年时定期使用假肢和维持步行能力的累积概率为0.56，5年时为0.41。3年和5年时维持独立生活状态的概率分别为0.77和0.65。本系列患者3年生存率为0.60，5年生存率为0.44。
这些数据表明，TKAmp在患有外周动脉疾病的患者中具有可接受的一期愈合率和令人满意的功能结果。TKAmp相对于AKA的优势使其成为适合假肢康复的血管疾病患者的首选替代方案。
