MEDICINSKI GLASNIK

More documents

Recommendations

Info

278 Medicinski Glasnik, Volumen 6, Number 2, August 2009 of the stump. These modifications have yielded good results in the application of disarticulation prosthesis for the knee. Three patients (of different age but with the same successful therapy results) with knee disarticulation performed are presented in this study ( Figure 1). A skin incision is performed in two directions from the outer side of the medial and lateral condyle using an anterior long semicircular incision at 3-5 cm distally below the tibial tuberosity and posteriorly at the level of the sagittal line along the midline of the popliteal fossa – Procedure I . A skin flap is raised and the knee joint exposed. The exposed collateral ligaments and hamstring tendons are resected . The patellar ligament is cut off at the patellar tip. The patella is placed in the position of “patella alta”, which additionally increases the contact and weight-bearing surface of the stump. A transverse wide capsulotomy is done to expose the knee joint with menisci and ACLs that are resected -Procedure II . The knee joint is flexed, the notch is exposed, the PCL is removed and the femoral condyle surface is left intact. Nerves and blood vessels in the popliteal fossa are exposed, ligated and transsected. Intact cartilage and femoral condyles are covered with the anterior skin flap which is sutured tension - free to the posterior skin flap in the popliteal fossa – Procedure III . A free drain is placed below the fascia along the entire scar length. The drain is removed after two days and sutures after 14 days. Case one: A 61-year-old male patient fell under a motor excavator and a distal third of the right below-knee was crushed. Primary amputation at the level of the middle third of the belowknee was performed. The wound was left open and local therapy instituted. Due to complications in terms of bone protrusion on the fibular and tibial stumps, musculo-cutaneous defect and impossibility of wound closure, reamputation at the proximal third level was indicated. Knee disarticulation was done and after the wound healing the patient was admitted to the rehabilitation and fitted with a disarticulation prosthesis. After the prosthetic rehabilitation the patient was able to use the prosthesis during the whole day, walk independently, use a walking cane for longer walks and work on the land. Case two: A 36-year-old male patient substained a traumatic amputation of distal third of the right below-knee, and a femoral fracture due to a mine explosion. Transtibial amputation was performed at the level of the proximal third and the right femur was treated by internal fixation according to the AO method. After several months of treatment, the stump was in flexion contracture greater than 30 degrees. Prosthetic fitting was not possible so surgeon recommended the knee disarticulation. After the completed healing of the stump, prosthetic rehabilitation began. Following rehabilitation the patient was able to use the prosthesis for all daily activities and to walk unassisted. Case three: A 45-year old male patient was injured in a traffic accident as a car driver and substained an open fracture of the right belowknee. An operative treatment of this complex fracture was attempted but due to infection appearing in the postoperative course the amputation was indicated. The knee disarticulation was performed and prosthetic rehabilitation began (Figure 2). After a rehabilitation the patient wore the prosthesis during the entire day, used a walking cane for longer walks and worked actively. According to American authors, knee dis- Figure 1. Modified technique of knee disarticulation by Baumgartner (R. Poljak–Guberina, 2004., with patient’s permission)
articulation is described as a simple, safe operative procedure, which has advantages in the prosthesis application but which is not widely applied (8). Some authors recommend the Mazet and Hennessy as well as the Burgess or Bowker methods (5,9) . For those methods it is significant that due to cartilage removal a large bone surface is created, which increases the risk for bleeding and consequently associated complications (5). Thus, the end-bearing of the distal stump portion is significantly reduced. In the prosthetic sense, a disarticulation stump of the knee is obtained and it can accept only an above-knee prosthesis with weight-bearing tuberosity of the ischial bone. This is the very reason for application of those methods only for palliative indications where no prosthesis will be applied because patients will use wheel chairs (8). However, according to the International Society for Prosthetics and Orthotics (ISPO) Consensus Conference on Amputation Surgery 1990, knee disarticulation has an absolutely important place in the practice as an amputation technique (10). It is recommended in younger and elderly patients with indications like trauma, tumors, below-knee infections or circulatory problems in diabetics (11). Our ten-year experience (150 transcondylar amputations and 15 knee disarticulations) of the application of knee disarticulation as well as the application of the disarticulation prosthesis for the knee shows the advantage of this technique in relation to transcondylar amputation of the femur. Our patients with knee-disarticulation prosthesis showed in average a 50% increase in walking speed in comparison with patients with above-knee prosthesis. Our conclusions are Figure 2. Knee-disarticulation stump and prostheses (R. Poljak–Guberina, 2004., with patient’s permission) equivalent with results of authors that showed that energy consumption during walk with disarticulation prosthesis was increased by 40% and with the above-knee prosthesis by 70 – 80% (3). The advantages of knee-disarticulation are the simplicity of operative procedures, good quality of stump and successfully application of prosthesis which result in inproved quality of life. ACKNOWLEDGEMENT/DISCLOSURE Written consent was obtained from the patient for publication of the Figure 1 and Figure 2. REFERENCES Case report 1. Murdoch G, Bennett WA, Jr. Amputation- Surgical practice and patient management. Oxford: Butterworth-Heinemann Co, 1996. 2. Baumgartner RF. Knee disarticulationem versus above-knee amputation. Prosthet Orthot Int 1979; 3:15-9. 3. Nader M, Nader HG. Otto-Bock prosthetic compendium: lower extremity prostheses. Berlin: Schiele and Schon GmbH., 2002. 4. Faber David C, Fielding P. Gritti-Stokes (Through-Knee) amputation: should it be reintroduced? South Med J 2001; 94:997-1001. 5. Mazet R, Hennessy CA. Knee disarticulation: a new technique and a new knee joint mechanism. J Bone Joint Surg 1966; 48:126-39. 6. Vaucher J, Blanc Y. Les desarticulation du genou. Technique operatoire-appareillage (Disarticulation of the knee. Surgical and prosthetic techniques.) Rev Chir Orthop1982; 68:385-406. 7. Duerksen F, Rogalsky RJ, Cochrane IW. Knee disorticulation with intercondylar patellofemoral arthrodesis. Clin Orthop1990; 256:50-6. 8. Smith DG, Micheal JW, Bowker JH. Atlas of Amputations and Limb Deficiencies: Surgical, Prosthetics, and Rehabilitation Principles. American Academy of Orthopeadics Surgeons, Rosemont, Illinois, 2004. 9. Murdoch G, Bennett WA, Jr. A primer on amputations and arteficial limbs. New York: Charles Thomas Co., 1998. 10. Jensen SJ, Lyquist E: Through-knee amputations. International Society for Prosthetics and Orthotics ( ISPO) Consensus Conference on Amputation Surgery. University of Strathclyde, Dundee, Scotland, 1990: 69-81. 11. DL, Taylor SM, Hamontree SE, Langan EM, Snyder BA, Sullivan TM, Youkey JR. A reappraisal of a modified through-knee amputation in patients with peripheral vascular disease. Am J Surg 2001;182:44-8. 279
Page 1 and 2:
MEDICINSKI GLASNIK Official publica
Page 3 and 4:
Medicinski Glasnik Official Publica
Page 5:
Case report Erratum 284 227 Influen
Page 8 and 9:
148 Medicinski Glasnik, Volumen 6,
Page 10 and 11:
Page 12 and 13:
Page 14 and 15:
Page 16 and 17:
Page 18 and 19:
Page 20 and 21:
Page 22 and 23:
Page 24 and 25:
Page 26 and 27:
166 ORIGINAL ARTICLE Effect of inoc
Page 28 and 29:
Page 30 and 31:
Page 32 and 33:
Page 34 and 35:
Page 36 and 37:
Page 38 and 39:
Page 40 and 41:
Page 42 and 43:
Page 44 and 45:
Page 46 and 47:
Page 48 and 49:
188 ORIGINAL ARTICLE Evaluacija dij
Page 50 and 51:
Page 52 and 53:
Page 54 and 55:
Page 56 and 57:
Page 58 and 59:
Page 60 and 61:
Page 62 and 63:
Page 64 and 65:
Page 66 and 67:
Page 68 and 69:
Page 70 and 71:
Page 72 and 73:
Page 74 and 75:
Page 76 and 77:
Page 78 and 79:
218 ORIGINAL ARTICLE Smoking is the
Page 80 and 81:
Page 82 and 83:
Page 84 and 85:
Page 86 and 87:
Page 88 and 89: 228 Medicinski Glasnik, Volumen 6,
Page 116 and 117: 256 ORIGINAL ARTICLE Oral health of
Page 144: 284 ERRATUM Quality of the cardiova
show all

MEDICINSKI GLASNIK

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?