CLINICAL ORTHOPAEDICS AND RELATED RESEARCH
Number 319, pp 276-284
Changes in Hip Muscles
-
After Above-Knee Amputation
Sonja M . H. J. Jaegers, MD, PhD*; J. Hans Arendzen, MD, PhD**;
and Henry J. de Jongh, PhD*
To learn about the changes appearing in hip
muscles after an above-knee amputation, 3-di-
mensional reconstructions of the hip and thigh
region of 12 patients with above-knee amputa-
tions were made based on transverse magnetic
resonance images. I n all patients, the amputa-
tions were done at least 2 years before the study
and were necessitated by trauma or osteosar-
coma. The results show that, at higher amputa-
tion levels, the geometry of the once-biarticular
muscles was changed. The cleaved muscles
(40%-60%) and the intact muscles (0-3070) at
the amputated side were atrophied. The amount
of atrophy of the intact muscles at the ampu-
tated side was related to stump length. To avoid
an abduction contracture in 8 patients with am-
putations, the iliotihial tract was not fixed. In 4
of these 8 patients, a flexion contracture was
visible. If the tract was not fixed, the hip exten-
sion torque of the gluteus maximus, which in-
From Departments ol *Anatomy and Embryology and
Rehabilitation, University of Groningen, Groningen,
The Netherlands.
Funding of the magnetic resonance images was pro-
vided by the Research Stimulation Fund of the Univer-
sity Hospital Groningen.
Reprint requests to S. M. H. J. Jaegers, MD, Rehabilita-
tion Centre Beatrixoord, Dilgtweg 5 , 9751 ND Haren,
The Netherlands.
Received: April 14, 1993
Revised: June 18, 1993; October 18, 1993; August 18,
1994; and April I 1, 1995.
Accepted: April 12, 1995.
276
0 1995 Lippincott-Raven Publishers
serts into the tract, decreased. As a result, the
risk of appearance of a flexion contracture in-
creased because the strongest hip flexor (iliop-
soas muscle) was not involved in the amputa-
tion. Abduction contracture could be avoided
only if the hip adductors were fixed accurately,
especially at higher amputation levels.
After an above-knee amputation, the struc-
ture of the muscles around the hip joint at the
amputated side can change.2 The higher the
level of amputation, the more muscles are in-
volved, and probably more changes will ap-
pear in the remaining muscles. The shorter
the amputated femur, the smaller the me-
chanical load of the muscles at the ampu-
tated side. This causes the bones to become
demineralized and the involved muscles to
atrophy.z.8 Sevastikoglou et a18 studied the
changes in the skeleton of the stump, as
shown on radiographs, and compared the
corresponding bones of the leg that was not
amputated. They found that the bones of the
amputation stump atrophied, which seemed
to be permanent. Hubener et a12 studied the
amount of bone demineralization as shown
on computed tomographs and found a 50%
reduction in the density of the femur at the
lower level, 40% reductions of the femur at
the level of the greater trochanter, and 10%
to 25% reduction in density of the hip bone
at the level of the iliosacral joint. Muscular
changes most clearly appeared in muscles
 Number 319
October, 1995 Changes in Hip Muscles After Above-Knee Amputation 277

with hip flexion-extension function. Gottschalkl MATERIALS AND METHODS

described the importance of the adductor
magnus as a hip adductor and extensor, espe-
cially the distal part of the muscle that inserts
at the medial condyle of the femur. He de-
scribed a new technique to fix this part of the
adductor magnus to obtain an optimal adduc-
tor and extensor torque, which obviates a
contracture.
The function of the cleaved muscles is be-
ing investigated: Should the iliotibial tract be
fixed to avoid an abduction contracture, and
what are the advantages of fixing the mus-
cles by myoplasty and myodesis?
The authors studied these questions using
3-dimensional graphical reconstructions of
the bones and muscles of the hip and thigh of
12 patients with above-knee amputations.
They used 2-dimensional traced magnetic
resonance (MR) images. In a previous
study,3 3 healthy persons were studied as a
reference group.
The authors wanted to learn about the struc-
ture of the hip muscles of patients with above-
knee amputations who wear prostheses, espe-
cially with regard to the changes appearing in
the geometry and volumes of the hip muscles
after different amputation methods.
Participants
Twelve healthy men with a unilateral above
knee amputation were studied who satisfied the
following criteria: (1) amputation was done at
least 2 years before this study; (2) amputation
was necessitated by trauma or osteosarcoma;
(3) the participants were optimally fitted with a
prosthesis; and (4) they showed no major gait
deviation.
Table 1 lists the age, stump length, postampu-
tation time, amputation cause, and details of the
socket of the prosthesis. It was possible to obtain
the operation reports of patients who had an am-
putation. The research protocol was approved by
the ethics committee at the authors institution.
Data Processing
Transverse MR images were obtained from all
participants in the supine position from the iliac
crest to the caput of the fibula. A spin echo tech-
nique was used on a Philips Gyroscan (Philips bv,
Eindhoven, The Netherlands). The technique in-
cluded repetition time, 1050 ms; and field of
view, 450 x 1.0 cm with a 256 x 256 matrix. The
slice interval was 5 mm and the slice thickness
was 0.5 mm at all levels. The MR images had to
be made in 2 or 3 series of 57 images each. This

TABLE 1. The Age, Stump Length, Postamputation Time, Amputation Cause, and
Details of the Socket of the Subjects
~~ ~

Stump Postamputation Amputation

Subject Age Length (cm) Time (years) Cause Socket
~ ~

21 55 36.3 35 Trauma Quadrilateral

22 49 34.1 3 Trauma Quadrilateral
23 56 41.8 3 Trauma NML
24 27 30.0 3 Trauma Quadrilateral
25 32 32.5 12 Osteosarcoma Quadrilateral
27 40 34.1 15 Trauma Quadrilateral
29 30 22.1 10 Osteosarcoma Quadrilateral
30 24 10.5 8 Osteosarcoma NML
31 20 11.1 7 Osteosarcoma Quadrilateral
32 28 25.9 7 Trauma Quadrilateral
33 46 16.5 2 Osteosarcoma Quadrilateral
35 51 27.5 8 Trauma Quadrilateral

Quadrilateral = quadrilateral socket with suction system and ischial seat, NML = semiflexible narrow medial lateral socket with
suction system The socket has no ischial seat

278 Jaegers et al
sometimes caused a slight transverse shift be-
tween the successive image series in the 3-dimen-
sional reconstruction.
The program Obex (Cerebrum, Groningen,
The Netherlands) was used in this study. Obex is
an integrated 3-dimensional software package
that can produce 3-dimensional models from 2-
dimensional data sets from MR scans. Obex was
implemented on a Unix system, and the data of
each MR image were loaded into an Apollo
DN3500 computer with a high definition, 20-inch
monitor. The contours of the bones and muscles
of the hip and thigh region were traced inanually
with the help of the computers mouse. The MR
images were all traced by the same investigator
(S.J.). After sections had been entered into the
computer, the reconstructed limbs of each traced
participant could be displayed 3-dimensionally
and viewed from various angles.
Calculation
The area of every traced contour was calculated,
after which the volumes of the bones and muscles
were determined. One-way analysis of variance
was used for testing significant differences be-
tween the muscle volumes of the amputated and
intact sides (p = 0.01). The Pearson correlation
coefficient and regression analysis were used to
test correlation (p = 0.01) between the amount of
atrophy of the muscles and the stump length, and
between the amount of cortical atrophy and the
postamputation time and amputation cause.
Clinical Orthopaedics
and Related Research
The percentage of atrophy of the intact mus-
cles on the amputated side was determined by
comparing the volume of the muscle with the vol-
ume of the same muscle on the intact side. The
percentage of atrophy of the muscles that had
been partly amputated was calculated i n 2 differ-
ent ways:
The percent difference was calculated for the
area of each transverse cross section 3 cm
above and below the thickest part of the mus-
cle belly of the amputated muscle and the in-
tact muscle at the same level. From this the
mean percent difference o f the cross-sec-
tional area of an amputated muscle versus
the intact muscle, the percent atrophy, was
determined; and
First the level of amputation of the femur was
determined. Next the volumes of the muscles
of the amputated and intact legs were calcu-
lated proximal to this amputation level. The
calculated volume of the muscles at the am-
putated side was compared with the calcu-
lated volumes of the muscles at the intact
side. In this way the percentage of atrophy of
the amputated muscles was determined.
RESULTS
In Figures 1 and 2, 3-dimensional reconstruc-
tions of the hip muscles of patients with
above-knee amputations with different stump
lengths are shown in ventral and dorsal views.
Fig 1A-B. Three-dimensional recon-
structions of an above-knee amputa-
tion with a short stump in a ventral (A)
and dorsal view (B). (1, iliacus; 2,
psoas major; 3, sartorius; 4, rectus
femoris; 5, vastus musculature; 6, ten-
sor fasciae latae; 7, gluteus medius; 8,
gluteus maximus; 9, biceps femoris;
10, semitendinosus; 11, semimem-
branosus; 12, pectineus; 13, adductor
longus; 14, adductor magnus; 15, gra-
cilis; *femur.)
Number 319
October, 1995 Chanaes in Hip Muscles After Above-Knee Amputation 279

Fig 2A-8. Three-dimensional recon-

structions of 2 above-knee, low level
amputations in dorsal view. In 1 pa-
tient (A) the iliotibial tract was fixed,
whereas in the other (B) the tract was
not fixed and the gluteus maximus
was retracted. (5, vastus musculature;
7, gluteus medius; 8, gluteus max-
imus;9, biceps fernoris; 10, semitendi-
nosus; 11, semimembranosus; 14,
adductor magnus; 15, gracilis; *femur.

TABLE 2. Means and Standard Deviations of the Volumes of the Bones and
Muscles of Normal Subjects and Patients With Above-Knee Amputations

Patients With Above-Knee Amputation

Volume (em3) Volume (em3) Volume (em3)

Normal Subjects Intact Side Amputated Side

Mean (SO) Mean (SO) Mean (SO)

Bones
0 s coxae 447.6 (53.26) 399.6 (87.23) 421 .O(86.62)
Femur 739 2 (60.13) 713.5 (92.67) 358.7 (99.50)
Muscles
Gluteus rnaxirnus 967 9 (30 00) 1252 4 (283 8) 800 6 (279 95)
Gluteus rnedius 398 9 (60 46) 423 2 (93 2) 331 3 (125 13)
Gluteus rninirnus 120 2 (16 20) 183 5 (107 79) 132 9 (109 83)
Tensor fascia latae 87 0 (16 26) 102 5 (27 32) 65 8 (25 07)
lliopsoas 637 9 (54 93) 471 9 (59 14) 386 6 (62 72)
Sartorius 181 0 (15 65) 169 2 (64 47) 93 1 (46 42)
Rectus fernoris 309 3 (29 78) 288 7 (I18 33) 123 5 (63 82)
Vastus musculature 1872 3 (72 14) I459 6 (279 6) 429 6 (I09 04)
Sernirnembranosus 291 0 (26 17) 282 8 (58 25) 76 2 (61 81)
Sernitendinosus 197 1 (25 46) 204 5 (49 88) 59 4 (44 52)
Biceps fernoris 326 4 (42 15) 399 2 (146 14) 1 12 7 (78 45)
Pectineus 72 8 (12 32) 63 7 (14 59) 59 8 (17 74)
Adductor rninirnus 68 4 (22 78) 80 9 (28 81) 81 6 (28 44)
Adductor brevis 105 2 (5 28) 117 5 (28 96) 106 4 (37 97)
Adductor longus 189 3 (10 22) 168 3 (49 00) 148 6 (64 22)
Adductor rnagnus 514 7 (90 96) 792 2 (157 35) 365 6 (163 57)
Gracilis 1133(1603) 119 5 (25 80) 52 9 (20 60)

SD = standard deviation
 Clinical Orthopaedics
280 Jaegers et al and Related Research

TABLE 3. The Atrophy (YO)of the Volumes and Areas of the Hip Muscles at the
Amputated Side in Comparison With the Intact Side

% Atrophy

Volume Area
Muscles Mean SD Mean SD

Gluteus maximus 36.5 10.8 34.8 15.7

Gluteus medius 27.3 9.1 23.3 11.5
Gluteus minimus 22.0 18.3 23.4 12.2
Tensor fascia latae 49.8 3.5 26.3 17.2
Psoas major 9.5 10.1 13.6 9.3
lliacus 12.0 7.9 17.1 8.1
lliopsoas 21.5 11.3 22.8 14.3
Rectus femoris 58.3 7.7 53.4 7.8
Sartorius 50.8 10.6 40.1 9.8
Biceps femoris 58.8 15.7 32.9 23.6
Semitendinosus 72.8 25.1 44.3 30.0
Semimembranosus 40.8 22.1 30.2 14.5
Pectineus 15.3 8.0
Adductor minimus 11.5 8.3
Adductor brevis 23.6 13.8
Adductor longus 18.0 13.6
Adductor magnus 40.3 20.9 27.5 15.6
Gracilis 54.8 12.7 24.6 29.0

SD = slandard deviation

In patients with a high level of amputation,
the geometry of the once-biarticular muscles
at the amputated side was changed.
Table 2 provides the mean volumes and
standard deviations of all the traced muscles
and bones of the participants with no amputa-
tions and of both legs of those with amputa-
tions. The once-biarticular muscles at the am-
putated side were more atrophied (40%-60%)
than the intact muscles at the amputated side
(0-30%) (Table 3 ) . The amount of atrophy of
the hip muscles increased with decreasing
stump length (Fig 3).
The Skeleton
The volume of the hip bone decreased
slightly (10%) in 1 participant. In 5 partici-
pants there was a slight decrease in volume
of the femur at the level of the trochanter
major (10%-20%). In 10 participants, the
volume of the femoral marrow cavity in-
creased after the amputation (10%-40%).
Based on the MR images, it was evident that
the thickness of the femur had decreased and
cortical atrophy had occurred. No correlation
was found between the amount of cortical at-
rophy and the stump length, postamputation
time, or cause of the amputation.
The Hip Flexors
The strongest hip flexor, the iliopsoas, was
intact in all of the persons studied. However,
the muscle group had atrophied in different
amounts from 4% to 50%. The amount of at-
rophy of the iliopsoas increased with in-
creasing level of amputation (Pearson corre-
lation coefficient, 0.76; p = 0.01). The other
hip flexors (the rectus femoris and sartorius)
are biarticular muscles and were cleaved in
all persons with amputated limbs. At the am-
putated side, the rectus was displaced later-
ally compared with the intact side (Fig 1A).
In amputations leaving a short or medium
stump length, the sartorius was fixed ven-
Number 319
October, 1995 Changes in Hip Muscles After Above-Knee Amputation
75
50
25
0 0
10.5 11.1 16.5 221 25.9 27.5 32.5 33.6 34.1 341 35.3 41.8
A s m LENGTH Icm)
HIP FLEXORS
75 t
B*
50
25
0
10.5 11.1 16.5 22.1 25.9 27.5 32.5 33.6 34.1 34.1 36.3 41.8
C 5IUw LMGIH h 1
Q HIP ABDUCTORS
Fig 3A-D. The total volumes of t h e (A) hip flexors, (B) extensors, (C) abductors, and (D) adductors
of the amputated side in percentages of t h e corresponding muscle volumes of the intact side. (*flex-
ion contracture, 0 = abduction contracture, * = at least 1 hamstring muscles was not fixed, = the ili-
otibial tract was fixed, = t h e adductors were fixed.)
trally to the femur after the amputation, re-
sulting in a vertical course (Fig 1A). As a re-
sult, the sartorius was no longer functional in
external rotation of the thigh. Both muscles
were atrophied in all participants (58% and
35%, respectively) but showed no fatty de-
generation.
The vastus musculature is part of the
quadriceps femoris. It was no longer func-
tional relative to a joint and was extremely
atrophied in all participants. In the few in
whom the vastus musculature had been used
to suture the hamstrings, the sartorius, the
adductors (myoplasty), or all of these, the
musculature showed less atrophy.
The Hip Adductors
The amount of atrophy of the adductors de-
pended on the level of amputation (Fig 3).
281
3
100
Q
75 Q
50
a
10.5 11.1 16.5 22.1 25.9 27.5 32.5 336 34.1 34.1 36.3 4L8
B s m LENGM Id
HIP EXTENSORS
loo
75
i"-
t
-
25
-
n
10.5 11.1 16.5 22.1 25.9 27.5 32.5 33.6 34.1 34.1 36.3 41.8
D s m LENGTH l a 1
HIP RDDUCTORS
The higher the amputation level, the more
the adductor muscles were amputated. The
pectineus and adductor minimus and brevis
were intact in all levels of amputation; they
were atrophied only slightly (10%-15%).
The adductor longus and the part of the ad-
ductor magnus that inserts at the shaft of the
femur were intact only in low level amputa-
tions. The part of the adductor magnus that
inserts at the medial condyle of the femur
was cleaved at all levels of amputation. In 4
persons with amputations, with a short or
medium stump length, the adductor longus
and magnus were fixed and all showed an
abduction contracture (Fig 4B). If the adduc-
tor longus and magnus were well fixed, only
slight atrophy was found in these muscles
and no abduction contracture was visible. In
most patients with an amputation, the once-

282 Jaegers et al
biarticular adductor, the gracilis, was fixed
in a more dorsal position relative to the fe-
mur compared with the intact side. In this
position, the gracilis could barely function as
an internal rotator. In 2 persons with ampu-
tated limbs, the gracilis was not fixed and
showed fatty degeneration.
The Hip Extensors
The strongest hip extensor, the gluteus max-
imus, was atrophied (36%) in all persons with
amputated limbs. The caudal part of the glu-
teus maximus inserts into the iliotibial tract.
The tract was transected in patients with
above-knee amputations, and in 8 patients the
iliotibial tract was not fixed to avoid an ab-
duction contracture. Figure 2B shows that the
gluteus maximus retracted in these patients.
The caudal part of the gluteus maximus
shifted to a more medial position because of
its oblique course. and there was a large
amount of atrophy of the gluteus maximus.
Figure 2A shows a fixed iliotibial tract with
no retraction of the gluteus maximus.
The hamstrings are biarticular hip extensors
and were cleaved in all amputations and se-
verely atrophied (40%-70%). In 5 patients the
semitendinosus were not fixed and they de-
Clinical Orthopaedics
and Related Research
Fig 4A-B. A flexion contracture (A)
and abduction contracture (B) ap-
peared in patients with amputated
limbs whose iliotibial tract (A) or ad-
ductor magnus and longus (B) were
not fixed.
generated into fat. In addition, the adductor
magnus is a hip extensor because of its dorsal
position with respect to the hip joint. In 5 par-
ticipants the iliotibial tract and I or more of the
hamstring muscles were not reattached, and a
flexion contracture was visible (Fig 4A).
The Hip Abductors
The amount of atrophy of the hip abductors,
the gluteus medius and minimus, depended
on the level of amputation (Pearson correla-
tion coefficient, 0.82 and 0.72, respectively;
p = 0.01). The higher the amputation level
the more the muscles were atrophied.
The once-biarticular hip abductor, the ten-
sor fasciae latae, atrophied severely (49%).
The tensor inserts into the iliotibial tract.
When the tract was not fixed, the tensor re-
tracted and shifted to the lateral side. When
the iliotibial tract was fixed, no retraction of
the tensor fasciae latae occurred.
DISCUSSION
The femur can change after an above-knee
amputation. In 10 patients with such an am-
putation, a slight cortical atrophy of the fe-
mur (10%--20%) appeared. Only 3 patients
showed an atrophy of 40%, as reported in the
Number 319
October, 1995 Changes in Hip Muscles After Above-Knee Amputation
study of Hubener et a1.2 The structure of the
remaining thigh musculature changes consid-
erably after an above-knee amputation. The
cleaved and the intact muscles at the ampu-
tated side atrophied (40%-60% and 0-30%,
respectively). When the cleaved muscles are
fixed accurately, they show no fatty degener-
ation and are still functional in human move-
ment. Muscles that are not fixed retract and
can no longer function; rather they degener-
ate into fat. The amount of atrophy of the in-
tact muscles (iliopsoas, gluteus medius, glu-
teus minimus) increases substantially with
increasing level of amputation, although
these muscles have not been directly in-
volved in the amputation. The short stump
provides a short lever arm in the socket,
which makes it more difficult to transfer
forces to and from the prosthesis. The rela-
tionship between the stump length and the
amount of atrophy of the hip joint stabilizing
muscles can be due to the changed position of
the femoral shaft. The muscles are shortened
if there is a flexion/abduction contracture.
The torque of the flexors decreases with pro-
gressive flexion, and the torque of the abduc-
tors decreases with progressive abduction.4-7
Figure 3 shows the crucial decrease in mus-
cle volume in the proximal half of the femur.
In this region the surgeon must be careful in
determining the level of amputation, must
keep the stump length as long as possible, and
must fix the remaining muscles accurately. In
high and medium level amputations, the
course of the once-biarticular muscles is
changed (Fig 1). Several factors change the
geometry. In some persons with amputated
limbs, the femur is in flexion, abduction, ex-
ternal rotation, or a combination of these com-
pared with the intact side. This has conse-
quences for the geometry of the muscles with
respect to the hip joint. This was accounted for
when interpreting the reconstructions.
Some transected muscles were fixed in a
more ventral, dorsal, medial, or lateral posi-
tion relative to the femur compared with the
intact side; as a result, their course was
changed. The changed course of the ampu-
283
tated muscles with respect to the hip joint
was clearly visible in the sartorius and influ-
ences its function and external moment. The
external moment of a muscle is the product
of the internal muscle force times its moment
arm. The moment arm of the muscle with re-
spect to the hip joint changes when the
course of the muscle changes. The transected
muscles must be fixed in an optimal biome-
chanical position with respect to the hip joint
so the muscles can function adequately and
avoid unnecessary loss of function and force.
Because of the small number of persons
who have an above-knee amputation, and the
scarcity of available operation reports, no con-
clusion could be made about which technique
of fixating the muscles, myodesis or my-
oplasty, gave a better result. This study shows
that the myodesis and the myoplasty can give
a good functional stump. Of paramount impor-
tance, however, is that the muscles must be
fixed. If the vastus musculature is used to su-
ture the antagonistic muscle groups (my-
oplasty), the vasti become less atrophied.
If the tensor fasciae latae and gluteus max-
imus are not stretched to their original lengths
before the iliotibial tract is fixed, or if the ili-
otibial tract is not fixed at all, the muscles
show retraction. This was seen in 8 patients
(Fig 2B). Because of the length-force rela-
tionship, the muscle torque decreases when
the muscle is retracted. Alarger amount of at-
rophy of the tensor fasciae latae and gluteus
maximus was found in these patients.
An unfixed iliotibial tract does not always
obviate an abduction contracture, but it in-
creases the risk of a flexion contracture. If
the iliotibial tract is not fixed, the hip exten-
sion torque decreases because the strongest
hip extensor (gluteus maximus) inserts into
the tract. In addition, the extension torque of
the hamstring muscles decreases because
they are involved in the amputation. This re-
sults in an imbalance between the hip exten-
sors and hip flexors, because the iliopsoas al-
ways remains intact after an above-knee
amputation. Therefore a flexion contracture
occurs. An abduction contracture can be

284 Jaegers et al
avoided only if there is a balance in muscle
torque between the hip abductors and adduc-
tors. The higher the amputation level, the
more the adductor longus and magnus are
amputated and their torque decreases. How-
ever, i n all levels of amputation the most im-
portant abductors remain intact (gluteus
medius and minimus). To obtain a balance in
muscle torque, the adductor longus and mag-
nus, especially the part of the adductor mag-
nus that inserts at the medial condyle of the
femur, must be fixed accurately. The results
of this study show that if the cleaved adduc-
tors are not fixed, especially in high level
amputations, an abduction contracture oc-
curs (Fig 4B). In an amputation with fixed
adductor muscles, an abduction contracture
does not occur even with a fixed iliotibial
tract. Gottschalk' described a technique of
fixation, especially of the distal part of the
adductor magnus, that obtains an optimal
muscle force.
Based on this study, the following factors
affect the outcome of the stump and, there-
fore, the surgical technique must be designed
accordingly: ( I ) length of stump, (2) attach-
ment of all hip muscles, ( 3 )attachment of the
iliotibial tract, (4) appropriate tension in
muscles, and ( 5 ) positioning of the femur.
This highlights the importance of the long
stump and its relationship with muscle wast-
ing, not only of resected muscle but also of
the intact muscles. The attachment of the
inuscles to the skeleton requires accurate po-
sitioning so that biomechanical torques act-
ing on the skeleton correspond as closely as
possible to those in the intact limb. To avoid
a flexion/abduction contracture, the iliotibial
tract must be fixed at its original length with
the remaining adductor muscles. Based on
Clinical Orthopaedics
and Related Research
this study, it cannot be determined which fix-
ation method, myodesis or myoplasty, af-
fords a better result after the amputation.
However, the results do show that myodesis
and myoplasty can give a good functional
stump if the muscles are accurately fixed.
Acknowledgments
T h e authors thank the members of the Department
of Magnetic Resonance of the University Hospital
Groningen, especially Dr. B. Mooyaart, for their
help and hospitality, and the study participants.
They also thank R. Dantuma for technical and soft-
ware support and Dr. F. A. Gottschalk of the South-
western Medical School and Dr. A. M . Jain of the
Dundee Limb Fitting Centre for their comments.
References
1. Gottschalk F: Above knee amputation. Report ol
ISPO consensus conference on amputation surgery,
Denmark, International Society of Prouthetics and
Orthotics 60-66. 1 992.
2. Hiibener KH, Ahlemann LM, Weise K: Comptiterto-
mographische Untersuchungen an Reinampulierten.
Z Orthopaedie I I9:336-339. I98 I .
3. Jaegers SMHJ. Dantunia R, de Jongh HJ: Three-di-
mensional reconstructions of the hip musculature on
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