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Trans-knee amputation with posterior myocutaneous flap in patients with advanced peripheral arterial disease

Background Critical limb ischemia can result in major amputation when revascularization proved to be impossible. Major amputation is sometimes unavoidable in patients with acute lower limb ischemia with irreversible damage (category III). When compared with the above-knee amputation (AKA), trans-knee amputation (TKA) or knee disarticulation has a durable end weight-bearing stump with a long, powerful, active lever arm for control of the prosthesis with excellent muscle attachments. The round distal stump enhances suspension of the prosthesis. Another advantage is decreased operative blood loss with less bony or muscular disruption, less energy consumption, and resistance to infection by maintaining the cartilage barrier to infection. Purpose Our objective is to evaluate the outcomes of TKA with posterior myocutaneous flap in patients with advanced peripheral arterial disease who are not candidates for below-knee amputation (BKA). Patients and methods his prospective interventional study included 24 patients with advanced peripheral arterial disease in need for amputation and BKA is likely to fail. All patients underwent TKA with posterior myocutaneous flap including gastrocnemius muscle. The indication for amputation was critical limb ischemia owing to unreconstructable peripheral arterial disease in 21 (87.5%) patients in whom revascularization options are unavailable or exhausted and irreversible (category III) acute thrombotic lower limb ischemia in three (12.5%) patients. Results The study was conducted on 24 patients, comprising 15 (62.5%) males and nine (37.5%) females. The mean age of patients was 65.8±10.5 years. Overall, four (16.6%) patients had previous contralateral AKA. Three (12.5%) patients died: two patients died in the early 3 postoperative days and one patient died in the same hospital admission after 35 days. For the remaining 21 patients, healing by primary intention was achieved in 15 (71.4%) patients, by delayed primary intention (tertiary intention) in one (4.8%) patient, and by secondary intention in two (9.6%) patients. Major wound dehiscence occurred in three (14.2%) patients requiring AKA. Conclusion TKA with posterior myocutaneous flap is a safe operative method of amputation in patients with advanced peripheral arterial disease with good healing rates and acceptable functional outcomes. If it is not possible to perform BKA, TKA should be considered before AKA.