Transfemoral amputation (Malgaigne technique)
Overview

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Approximately 150,000 lower limb amputations are performed each year in the United States. The most common causes of amputation are diabetes mellitus, peripheral arterial disease, neuropathy and trauma. The extent of the amputation determines the amount of distal tissue lost and the ability to achieve adequate bone coverage. It is important that an interprofessional approach is taken when treating patients for whom lower limb amputation is an option.
The incidence of lower limb amputation is directly proportional to the incidence of peripheral arterial disease, neuropathy and soft tissue sepsis. This correlation is driven by the increasing incidence of diabetes mellitus, which occurs in 82% of all vascular lower limb amputations in the United States. Patients with diabetes mellitus are 30 times more likely to suffer an amputation than patients without diabetes. In 20% of cases, an accident leads to a lower limb amputation, especially if the accident is associated with severe wound contamination or significant loss of soft tissue. In the context of armed conflict, blast injuries lead to amputation in about 90% of cases, and limb amputation is the cause of 2% of deaths related to armed conflict.
Lower limb amputations are categorised into amputations of the thigh, knee, lower leg and a whole range of ankle and foot amputations. The present case demonstrates a transfemoral amputation following trauma. This was preceded by a transtibial amputation, which was complicated by an ascending infection and a lack of blood supply.
There is controversy in the literature about the optimal amputation level. Rene Baumgartner favours the lowest possible amputation line and describes amputation through the knee joint as functionally better compared to transfemoral amputation. Other authors describe an increased likelihood of soft tissue, vascular and nerve complications following knee joint disarticulation compared to transfemoral amputation. This is probably also due to the fact that there are a number of different techniques for the knee joint and therefore probably also a number of different results.
The present case describes the situation of a traumatic bilateral transtibial amputation following a suicide attempt by a 90-year-old female patient who had jumped in front of a train. The transtibial amputation was initially performed during initial treatment. Later, due to septic complications and poor soft tissue and vascularisation, necrosis developed and the thigh had to be amputated. Disarticulation of the knee joint could not be performed in this patient due to her age and the poor soft tissue and vascularisation conditions.
As with any amputation, the rule for the thigh is that every centimetre should be fought for. It is clear that the classic residual limb with good soft tissue coverage can only be achieved from a height that is approximately at the transition from the distal to the middle third. For anatomical reasons, stumps that are longer are less well padded with muscle and show a disadvantageous course with progressive arterial occlusive disease.
In a very good review of the outcome of lower limb amputations, Penn-Barwell analysed 27 studies involving 3105 patients. The main finding of this study was that 3/4 of patients with lower limb or knee amputations were able to walk again with a prosthesis, whereas this was only possible in 55% of patients with transfemoral amputations.
When creating the two flaps, it is extremely important that the wound is as ventral as possible and not in the area of the weight-bearing zone. The edges of the femur can be bevelled with the oscillating saw by about a third of the cortical thickness, taking care not to create a “spear point”, i.e. not too steep. Drill holes can then be made (2×2 continuous transcortical drill holes with a 5 mm drill bit) and the quadriceps muscle around the femur is guided backwards and fixed (as a transosseous myopexy according to Burgess).
OrthOracle readers will also find the following related techniques of interest:
Transfemoral amputation: Peripheral chondrosarcoma
Through-knee amputation with covering of the sole of the foot
Computer-navigated hemipelvectomy for Ewing’s sarcoma
Navigated hemipelvectomy for chondrosarcoma and GraftJacket (Wright Medical) reconstruction
Amputation of the anterior quarter: Chondrosarcoma of the proximal humerus
Hindquarter amputation: with pedicled fillet flap for chondrosarcoma of the proximal femur
Amputation of the posterior quarter: for a soft tissue sarcoma of the pelvis
Author: Professor Peter Biberthaler MD.
Institution: Technical University of Munich, Klinikum rechts der Isar, Munich, Germany.
Clinicians should seek clarification on whether any implant demonstrated is licensed for use in their own country.
In the USA contact: fda.gov
In the UK contact: gov.uk
In the EU contact: ema.europa.eu