Major lower extremity amputation in patients with peripheral arterial insufficiency with special reference to the transgenicular amputation.

The selection of the proper level for lower extremity amputation in patients with advanced arterial ischemia poses a multiplicity of problems with regard to operative mortality, stump healing, re-amputation rate and rehabilitation status. In a retrospective study all these parameters have been evaluated in 413 patients submitted to below-knee (bk, n = 196), transgenicular (tg, n = 93) and above-knee (ak, n = 124) amputation between 1971 and 1980. As compared to the ak resection, the bk amputation has the following advantages: lower operative mortality (9% vs. 30.5%), higher prosthetic fitting rate (85% vs. 66%) and significantly improved rehabilitation (walking with artificial limb: bk 84%, ak 22%). Regarding surgical mortality (8.5%) and prosthetic gait (66%), the tg amputation was nearly equivalent to the bk resection and turned out to be clearly superior to the ak amputation. As compared to the latter procedure, knee disarticulation and bk amputation had a greater risk of delayed wound healing and re-amputation at a higher level (ak: 13.5 resp. 1%, tg: 22.5 resp. 25%, bk: 35% resp. 16%). The patient with a bk amputation has the best prospect concerning a successful rehabilitation. Whenever the very important knee joint cannot be saved an ak amputation should be avoided in favour of a knee disarticulation.