The Vascular Society Amputation Special Interest Group (SIG) recently held a remote UK multi-stakeholder meeting, including surgeons, physiotherapists, prosthetists, orthotists, occupational therapists and rehabilitation consultants, to discuss the place of through-knee amputation (TKA) surgery in today’s vascular practice. Robert Hinchliffe (North Bristol NHS Trust, Bristol, UK) and David Bosanquet (Royal Gwent Hospital, Newport, UK), chair and co-chair of the SIG, respectively, give an overview of the meeting for Vascular News.
The TKA carries many potential biomechanical advantages over an above-knee amputation in patients unsuitable for a below-knee amputation, such as a longer leaver and potential for end weight bearing. However, historical concerns regarding prosthetic fit, cosmesis and wound healing have tempered enthusiasm for the operation, and only 7% of all major lower limb amputation in the UK are TKAs.
In collaboration with a team from Hull York Medical School in Hull, UK (George Smith and Dan Carradice, consultant surgeons, and Hayley Craine, specialist physiotherapist), we organised a remote meeting, with the aim of assessing the current utilisation of TKAs in the UK, discussing the perceived benefits and drawbacks of the technique, and what any future research projects in the area might look like.
The meeting began with a summary of recent data from the Nation Vascular Registry (NVR), and the Scottish Physiotherapy Amputee Research Group (SPARG) by Smith, highlighting that more recent observational data does not support the notion that TKAs suffer with increased failure rates, wound breakdown and poor fitting of prosthesis compared with AKAs, with broadly equivalent or even better outcomes in these observational cohorts. Bosanquet then presented a systematic review of all different published TKA operative techniques, which includes variability in managing the femoral condyles, patella, gastrocnemius and skin incision. The group also heard from Craine about her PhD work, which comprised qualitative interviews with surgeons and prosthetists about their views on TKAs, and perceived risks and draw backs of TKAs.
The group was divided into four smaller ‘break-out’ groups for focused discussions arising from these presentations, before a larger group discussion. This focused on what type of vascular patient may gain most benefit from a TKA, the most appropriate surgical technique, and what outcomes are important to assess in any future study evaluating TKAs. There was broad agreement from the group that both patients expected to ambulate, and those not expecting to ambulate, can derive a benefit from a TKA over an AKA, although patients expecting to ambulate should be discussed with a prosthetists prior to surgery as sometimes an AKA is preferable. A disarticulation without division of the condyles was felt to be the preferable surgical technique, possibly with removal of the patella. It was noted that many surgeons are reluctant to consider the TKA as a valid option for major lower limb amputation, despite enthusiasm from physiotherapists and prosthetists, in part due to training of the technique.
The group was very clear that if felt TKAs can play a greater role in the management of patients requiring major lower limb amputation. However, research is needed to further define its role.
If you are interested in future events of the amputation SIG, please contact David Bosanquet (firstname.lastname@example.org).