Knee disarticulation versus above-knee amputation*
R. F . B A U M G A R T N E R
Balgrist Orthopaedic Hospital, University of Zurich.
Abstract
If below-knee a m p u t a t i o n is impossible, knee
disarticulation should be considered before
above-knee a m p u t a t i o n , regardless of age a n d
etiology. K n e e disarticulation which leaves the
femur a n d patella u n t o u c h e d offers m a n y
advantages. T h e surgical technique is simple
a n d n o n - t r a u m a t i c since n o bone or muscle
tissue is t o b e dissected. T h e thigh muscles a r e
completely preserved a n d t h u s there is n o
muscular imbalance. T h e s t u m p permits total
end bearing a n d its b u l b o u s shape permits easy
a n d firm attachment of t h e prosthesis. A
specially designed double-wall socket a n d
various types of knee joints are presented.
M o d e r n prostheses are superior to above-knee
prostheses with regard t o function, comfort
a n d cosmesis. Results of 72 patients of all age
groups are presented a n d discussed.
Introduction
If it is impossible to obtain a short below-
knee a m p u t a t i o n , knee disarticulation should be
considered before above-knee amputation
regardless of etiology a n d patient's age. There
is n o level of a m p u t a t i o n between the ankle
a n d the hip joint where one can perform an
a m p u t a t i o n which does n o t require separation
of b o n e or muscle tissues. A t knee disarticu­
lation level the surface of the w o u n d is the
smallest possible which minimizes the danger
of h a e m o r r h a g e or infection. I n children, the
distal epiphyseal line of growth is fully pre­
served. I n contrast t o above-knee a m p u t a t i o n
t h e s t u m p resulting from knee disarticulation
permits full endbearing. All the muscles of the
thigh are entirely preserved.
Despite all these advantages, knee disartic­
ulation is still u n p o p u l a r c o m p a r e d with above-
k n e e a m p u t a t i o n . T h e m a i n objection comes
from the prosthetists w h o complain that there
is n o t enough space for t h e prosthetic knee
joint a n d have difficulties in fitting the b u l b o u s
shape of the s t u m p into a regular socket.
F o r this reason m a n y surgical techniques of
through-knee a m p u t a t i o n indicate the removal
of p a r t s o r all of the femoral condyles a n d t h e
patella to facilitate prosthetic fitting (Fig. 1).
However, knee disarticulation leaving t h e
femur a n d patella u n t o u c h e d offers m a n y
advantages, particularly with regard t o surgical
technique, s t u m p qualities a n d finally even
prosthetic fitting. T h e following technique
(Kjolbye, 1970; Vitali et al, 1978) is recom­
mended.
Fig. 1. Some of the most common through-knes
amputations. Except for knee disarticulation they
involve resection of part or all of the femoral
condyles and the patella.
Operative technique
It is preferable t o have t h e patient in a
supine position which gives easy access to the
knee joint a n d also permits an above-knee
a m p u t a t i o n t o be d o n e if necessary, without
changing the patient's position. F u r t h e r m o r e ,
the supine position does n o t give any particular
problems t o the anaesthetist which is of great
importance in p o o r risk cases, such as geriatric
patients. A tourniquet m a y be used except for
vascular patients. However, as there a r e only
a few easily identified vessels a tourniquet is
not an absolute necessity.
*Based on a paper presented at the ISPO Internation­
al Course on Above-knee Prosthetics, Rungsted,
November, 1978.
 T h e knee joint is flexed t o a right angle. A
skin incision is m a d e with respect t o the con­
dition of the particular patient. If possible, an
a t t e m p t should be m a d e t o obtain two lateral
flaps with the scar placed longitudinally at t h e
dorsal side of the femur between the two
condyles. This scar is placed far from the end
bearing area of the s t u m p a n d permits a high
resection of t h e sciatic nerve. This procedure
necessitates a circular incision at a b o u t 50 m m
distally from t h e tibial plateau (Fig. 2). H o w ­
ever, previous operative scars a n d t h e viability
of the tissue might require other types of skin
flaps, such as a long anterior flap. It is important
t o include existing scars into the new skin
incision a n d n o t t o create additional scars
whenever possible.

Fig. 3. Knee disarticulation. Distal-dorsal view of

the stump. 1: femoral condyles, 2: meniscal cartil­
ages, 3: patellar ligament to be sutured to the
posterior cruciate ligament (4), 5: tendons of the
hamstrings which might be connected with the
posterior joint capsule or a cruciate ligament, 6:
the gastrocnemius muscles, 7: sciatic nerve, 8:
popliteal artery and vein, 9: collateral ligaments.

for the end bearing femoral condyles. Before

Fig. 2. A circular skin incision 50 mm distally from
the tibial plateau is necessary to obtain two lateral
flaps with a longitudinal skin closure at the dorsal
side of the femur. The patellar ligament is dis-
inserted at the tibial tuberosity which gives free
access to the tibial plateau.
Disarticulation of the joint begins by re­
moving the patellar ligament from the tibial
tuberosity which gives free access t o the tibial
plateau (Fig. 3). I n the anterior-posterior
direction, the tibial plateau is separated from
t h e meniscal cartilages, the cruciate a n d lateral
ligaments a n d the joint capsule. Finally the
tibial plateau is completely dislocated anter­
iorly. It is then easy t o identify popliteal
vessels a n d nerves, the latter being cut at
least 70 m m proximally from the end of the
s t u m p . T h e procedure is completed with
sectioning of the hamstrings a n d the complete
removal of the gastrocnemius muscles. In
vascular cases, it might be safer t o remove the
meniscal cartilages as well, otherwise they can
be left in place a n d act as an additional cover
closure, the patellar t e n d o n is sutured t o the
cruciate ligaments o r t o the anterior knee
capsule a n d the hamstrings to the posterior
knee capsule. T o avoid granulomas, it is
preferable to use resorbable material for
suturing. I n vascular cases, the a u t h o r h a s
started not t o suture any ligament at all a n d
there is surprisingly little retraction of t h e
patella even if its ligament is not anchored.
Haemostasis a n d drainage are most i m p o r t a n t
at any a m p u t a t i o n level, but particularly so
in the knee disarticulation. There is n o space
for a h a e m a t o m a a n d if one leads t o necrosis
a n d infection, the result might be an above-
knee a m p u t a t i o n . T h e skin flaps are carefully
shaped a n d closed with only a skin suture.
D u e t o the considerable retraction of the skin
in the area of the knee joint, t h e size of t h e
flaps must be large enough to guarantee a skin
closure without any tension (Fig. 4).
Stump qualities
K n e e disarticulation preserves all the muscles
of the thigh. Therefore, there will be n o retrac­
tion of muscles a n d n o muscular imbalance
 which often compromises a good above-knee
stump is impossible in the knee disarticulation.
O n e of the m a i n advantages of the k n e e
disarticulation s t u m p is its total end bearing
quality. Therefore, the ischial seat, which
causes so m a n y p r o b l e m s in above-knee
amputees, becomes superfluous. The r a n g e of
m o t i o n of the hip joint remains completely
free, including flexion a n d rotation m o v e m e n t s
a n d thus permits a m o r e natural, less energy
consuming gait (Table 1).

Post-operative management
There will be considerable shrinking of t h e
s t u m p , even if all the muscles of the thigh a r e
intact. T h e distal part which is n o t covered b y
muscles is extremely sensitive to pressure,
especially the patella a n d the dorsal sides of
the condyles. Therefore, care must be taken t o
avoid pressure sores due t o bandaging, bed
rest, plaster casts o r p o o r prosthetic fitting.
F o r gait training immediately after surgery,
it is therefore preferable t o fit an inflatable
plastic splint. W h e n the patient lies in bed,
the femoral condyles must be relieved by
padding similar t o the well k n o w n procedures
that prevent pressure sores at the heel (Fig. 5).

Fig. 4. Eighteen year old male patient. Knee dis­

articulation following trauma. Anteroposterior flap
with large scar formation at the thigh. The patient
is now fitted with a total end bearing prosthesis, four
bar linkage with hydraulic knee and swing phase
control.

which is unavoidable in above-knee a m p u ­

tation even using myoplastic techniques. I n
above-knee a m p u t a t i o n s parts of t h e adductors
always h a v e t o be sacrificed whilst the abductors
between the iliac b o n e a n d the greater troch­
Fig. 5. The dorsal sides of the femoral condyles and
anter always remain intact. Bony outgrowth the patella are most sensitive to pressure.

Table 1

Fig. 6. Twenty-two year-old male patient. Knee dis­
articulation after motorcycle accident. Local
infection at the medial condyle. Stump revision with
partial resection of the femoral condyles. Healing
occurred within four weeks.
Post-operative complications
A s at any other a m p u t a t i o n level, problems
in w o u n d healing might also occur in knee
disarticulation. A s long as there is only super­
ficial necrosis of soft tissues o n a rather small
surface, healing can be achieved by conservative
treatment within a reasonable time. H o w ­
ever, larger necrosis including ligaments,
cartilage a n d bone requires operative treatment.
In this case, the modified techniques removing
the patella a n d the condyles totally or partially
a r e most suitable as a second line of defence
(Fig. 6).
Prosthetic fitting
T h e objections from the prosthetists against
the shape a n d the length of the s t u m p in knee
disarticulation have almost completely dis­
appeared during the past years. N e w designs
of prostheses are n o w available which are
superior t o the best above-knee prostheses with
regard t o function, comfort a n d cosmesis.
This has led to prosthetists advocating knee
disarticulation even m o r e t h a n the surgeons d o .
T h e two major features are the socket and.
the knee joint.
T h e type of socket used at Balgrist has been
developed by Botta a n d uses the double-wall
technique. There is an inner soft socket m a d e
from polyethylene foam. Its p u r p o s e is t o
provide total contact a n d at the same time t o
transform the b u l b o u s s t u m p into a conic one.
T h e patient p u t s o n this socket first a n d then
h e c a n d o n the outer socket which is m a d e
from laminated plastic. T h e bearing surface
at the distal end must exactly fit the shape of
the femoral condyles a n d avoid pressure on
the patella otherwise pressure sores a r e t h e
inevitable consequence (Fig. 7). T h e rigidity of
the socket decreases gradually distally t o proxi-
mally. T h u s a semi-flexible socket is obtained
which gives m o r e comfort particularly in
sitting, donning a n d doffing the prosthesis.
T h e u p p e r border of the socket follows a line
which is approximately 50 m m below t h e
inguinal ligament. This fact is particularly
appreciated by female patients a n d by double
amputees. D o n n i n g a n d doffing the pros-

Fig. 7. Double wall socket for knee disarticulation. The inner socket, made from polyethylene foam, transforms
the bulbous stump into a conic one. The outer shell is made from laminated plastic. Total contact is most
important especially in the weight bearing areas, left and centre. Otherwise pressure sores at both femoral condyles
are inevitable, right.

Fig. 8. Donning and doffing the prosthesis presents
no problems even to geriatric patients.
thesis is very simple since it does n o t require
any particular effort o r skill which again is
Table 2
REFERENCES
KJØLBYE, J. ( 1 9 7 0 ) . The surgery of the through-knee
amputation 2 5 5 - 2 5 8 . Prosthetic and Orthotic
Practice. Ed. Murdoch, G . , 2 5 5 - 2 5 7 , Edward
Arnold, London.
VITALI, M,, ROBINSON, K . P., ANDREWS, B. G . and
HARRIS, E. E. (1978). Amputations and prostheses,
1 5 8 - 1 6 4 , Bailliere Tindall, London.
especially appreciated by double amputees a n d
by geriatric patients (Fig. 8).
K n e e joints as they a r e c o m m o n l y used in
above-knee prostheses a r e of n o u s e with knee
disarticulations. Joints especially designed for
knee disarticulation a r e n o w available, t h e
first one being developed by Lyquist a t t h e
Orthopaedic Hospital in Copenhagen. O t h e r
types of knee joints have since been developed,
most of t h e m using four b a r linkage mechanisms
a n d permitting knee flexion far in excess of 90°.
They a r e available with o r without swing
phase control. F u r t h e r research is being d o n e
with regard t o improving t h e solidity of t h e
knee mechanism. Prostheses for knee disarticu-
lation a n d above-knee a m p u t a t i o n a r e c o m -
p a r e d in Table 2.
Results
F r o m 1968—1978, t h e a u t h o r h a s performed
72 knee disarticulations, mainly for peripheral
vascular occlusion. F o u r patients presenting
congential deformities corresponding t o knee
disarticulation also have been fitted with t h e
new type of prosthesis. R e - a m p u t a t i o n a t a n
above-knee level was necessary in 7 cases, all
of t h e m being vascular patients. They all h a d
to b e a m p u t a t e d at a high above-knee level
d u e t o advanced tissue necrosis. Local compli-
cations in w o u n d healing occured in 16 cases.
FURTHER READING
BAUMGARTNER, R. (1973). Beinamputationen und
Prothesenversorgung bei arteriellen Durch-
blutungsstörungen, 56-64 and 114-116, Ferdinand
Enke, Stuttgart.
BAUMGARTNER, R . (1977). Amputation und Prothes-
enversorgung beim Kind. Ed. Baumgartner R.
18 and 108-110, Ferdinand Enke, Stuttgart.
BURGESS, E. M. (1977). Disarticulation of knee.
Arch Surg., 1 1 2 1250-1255.