Knee disarticulation is a damage control operation that every vascular surgeon must have in his or her armamentarium. This operation offers a rapid and life-saving way to control sepsis or remove densely ischemic tissue in a gravely ill patient who cannot have a below-knee amputation (BKA). It is also applicable to the patient who has critical limb ischemia but lacks a reconstruction option or is too unstable to undergo a revascularization attempt. For patients who are near the end of life and may not live long enough to heal a BKA or an above-knee amputation (AKA), knee disarticulation is an option for controlling intractable pain from ischemia.

Knee disarticulation is contraindicated in patients who are better served by a BKA or may undergo an AKA immediately.

While some authors are advocates for the use of knee disarticulation as an end weight-bearing stump with a longer lever arm that may decrease the metabolic demand of ambulation, the various techniques utilized to create muscle flaps for wound closure have not gained popularity. This chapter focuses on the use of knee disarticulation as a bridge to an AKA in the unstable patient or as a destination for patients who are undergoing palliative care. It does not describe the different methods advanced in the literature for muscle flap wound closure.

When evaluating a patient, the first question to consider is whether he or she is an appropriate candidate for limb salvage. Factors that affect decision-making include the patient’s vascular anatomy, presence of severe infection or necrosis, premorbid functional status (e.g., ability to ambulate or transfer), and current clinical condition. If limb salvage is not an option, the next decision to make is the level of amputation.

Factors that affect the level of amputation include the degree of ischemia and/or the level of infection as well as the patient’s presumed ability to use a prosthesis in the future. If an AKA is a more appropriate option for the patient, knee disarticulation should be considered if the patient’s stability is in question. For those that cannot tolerate a prolonged operative time or significant blood loss, knee disarticulation offers a rapid procedure with minimal soft tissue trauma and bleeding. Since the limb is
removed through the knee joint, surgery may last minutes without much cut muscle and therefore little blood loss.

Given the implications of the operation, it is important to address the psychosocial aspects of amputation preoperatively. A frank and honest discussion with the patient and his or her family in the preoperative period that allows for questions to be answered will go a long way to clear up misconceptions and calm fears.