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Amputation alternatives preserving bipedal ambulation
AMPUTATION ALTERNATIVES PRESERVING BIPEDAL AMBULATION HANS-ULRICH STEINAU, MD, DETLEV HEBEBRAND, MD, AND PETER VOGT, MD
The introduction of reconstructive plastic procedures in cases of post-traumatic or resectional defects, neuropathic ulcerations, and infections has considerably decreased the indication for amputation. Conventional parameters for below knee (BK)-ablation like tibial nerve severance, postischemia syndrome, avulsion injuries, chronic osteitis, foot deformities, and sole of the foot defects should be critically revised before mutilating surgery is advised. Interdisciplinary approach for limb salvage is mandatory in cases of high amputation levels, mutilating trauma during childhood, juvenile diabetes, or if iatrogenic factors play a crucial role. In cases of partial foot amputation or oncologically required transverse or sagittal resections, conventional foot stumps, including free tissue transfer and restoration of muscular balance, should be considered to achieve rehabilitation results superior to BK-amputation. Copyright 9 1997by W.B. Saunders Company KEY WORDS: lower leg reconstruction, post-traumatic defects of the foot, malignant tumors of the lower leg, conventional and modified food stump formation
In the past, open comminuted fractures, malignant tumors, neuropathic defects, and cases of peripheral arterial occlusive disease were likely to end up with limb ablation at the proximal level. The introduction of successful techniques for soft tissue replacement, bone stabilization and reconstruction, and limited partial amputation procedures have markedly changed the indication for radical surgery. 1-7 Despite the fact that sophisticated prosthetic supplementation exists, alteration of the patient's lifestyle and selfesteem, problems of professional rehabilitation, and conflicts within the partnership should not be underestimated. Besides parameters of the present situation, futural aspects must be included. Salvage of bipedal ambulation especially allows for self-supplementation and mobility of the aged patient. Table 1 depicts the goals of bipedal ambulation. Therefore, absolute indications for limb salvage procedures exist if high amputation levels should be avoided; trauma, tumor, neurological or infectious diseases in childhood occur; patients with high risk of sequential contralateral secondary amputation like juvenile diabetes or Burger's disease are treated; and in cases with iatrogenic factors whereby the extent of damage should be minimized even with major reconstructive procedures (Table 2). Several attempts have been made to guide the decision for or against amputation with algorithms and scoring s y s t e m s . 3'8-12 However, all of them depend markedly on the
From the Department for Plastic Surgery, Handsurgery, Burn Center, BG-University-Hospital Bergmannsheil, Ruhr-University Bochum, Germany. Address reprint requests to Hans-Ulrich Steinau, MD, Department for Plastic Surgery, Handsurgery, Burn Center, BG-University-Hospital Bergmannsheil Ruhr-University, Bochum, Germany, B0rkle de la Camp-Platz 1, D-44789 Bochum. Copyright 9 1997 by W.B. Saunders Company
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diagnostic and surgical abilities of the treating team. Proper wound assessment, judgement of socio-economic factors, the spectrum of reconstructive procedures, low surgical complication rates, and the early integration of physio-therapy are all individual parameters. In addition, decision making for amputation is likely to be influenced by emotional factors and personal experiences of the surgeon's subspecialty. The outcome must therefore not necessarily correspond with clinical imaginations. Furthermore, the definition of a "useful lower leg remnant" varies within the literature. Amputation recommendations have been given for clinical conditions like tibial nerve severance, late revascularization cases, chronic osteomyelitis, foot deformities, avulsion injuries, sole and heel defects, and segmental gaps of the tibia with concomitant extended soft tissue lOSS.8'10'13'14 To show reconstructive plastic procedures (Table 3) and differential therapeutic aspects, borderline cases between amputation and salvage will serve as examples for tactical approaches, individual modified techniques, distalization methods, and foot-stump formation.
POST-TRAUMATIC LIMB SALVAGE PROCEDURES Iatrogenic factors play a crucial role in ischemia-induced post-traumatic muscle deficiency. Case I (Figs 1 and 2) demonstrates subtotal destruction of lower leg musculature following late revascularization of post-traumatic popliteal artery occlusion. After several debridements, loss of the muscles within the peroneal, anterior, and deep compartment resulted in complete functional deficiency of the upper and lower ankle joint. The remaining part of the lateral gastrocnemius muscle was used to close the exposed knee joint. After intensive discussion of the pros and cons with the patient, a biological stelt could be preserved by covering the defect
Operative Techniques in Plastic and Reconstructive Surgery, Vol 4, No 4 (November), 1997: pp 199-208
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TABLE 1. Salvage of Bipedal Ambulation (Goals) 1. 2. 3. 4. 5.
Long-term functional advantages Occupational and social rehabilitation Self esteem, body image Activities at sports (obesity!) Diminished risk of contralateral amputation (Diabetes, Arterial Occlusive disease) 6. Self-supplementation of the aged patient, prevention of wheel-chair life 7. Reduced costs
with an extended latissimus dorsi flap. Revascularization of the transplant was performed by pulling venous interposition grafts through the interosseus membrane to the superior popliteal segment. The tendons of the anterior tibial muscle, the peroneus longus and the triceps surae, were fixed with transosseous sutures to the distal tibia to keep the foot in plantigrade position. Eight years later, bipedal gait activities are superior to BK-amputation. Provided postischemia syndrome with life-threatening complications could be prevented by early sequential removal of compromised musculature, "empty leg" conditions proved to be better than immediate or secondary ablation of the limb. To keep sufficient perfusion of the foot, the axial arterial and venous pathways must be meticulously dissected step-by-step, occluding the lateral branches within the muscle compartments with clips. In addition, the tibial nerve, which showed temporary postischemic functional loss due to compression injury within the fourth compartment, had to be freed from the soleus arcade down to the tarsal tunnel. During the recovery phase of the nerve, the patient was supplied with longshaft orthopedic footwear which embedded the then a-sensitive sole and heel with full contact. Comparable diseases, like diabetic foot problems, clearly show that neuropathic lower legs are not candidates for amputation but for proper long-time foot care, special shoe inlays, and pressure-reducing sole materials. 1,4 It must be clearly stated that postischemia syndrome should not be underestimated during the clinical course. If the patient at the intensive care unit shows clinical signs of an incipient myonephropathic-metabolic syndrome, immediate amputation is mandatory--life before limb! 6,7 Case II (Figs 3, 4, and 5) shows another important aspect: transfemoral amputation in the aged patient. Following a gun shot injury in the World War II, the 68-year-old male was adjusted to bipedal ambulation despite knee joint fusion and shortening of the leg. Amputation in the elderly has been cited to result in early rehabilitation. If we consider, however, that above knee (AK)-amputation increases energy cost expediture during gait by 50% to 100%, pre-existing or developing cardiorespiratory diseases will exclude the majority of this group from successful prosthetic AK supplementation. This rationale is valid for every age group, because in TABLE 2. Absolute Indication for Limb Salvage 1. 2. 3. 4.
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Prevention of high amputation levels Trauma, tumor, neurological or infectious diseases in childhood Juvenile diabetes, Burger's disease latrogenic factors (late revascularisation)
TABLE 3. Restoration of Bipedal Ambulation Cascade of Reconstructive Plastic Procedures 1. 2. 3. 4. 5. 6.
Functional and esthetic rehabilitation Minor functional and esthetic deficiencies "Empty leg," biologic prosthesis Transverse or sagittal endbearing foot stumps Below-the-knee stump distalization Construction of endbearing full contact in transtibial, transgenicular, transfemoral amputation
modern industrialized countries, average life expectancy has risen to more than 80 years. Therefore limb salvage with preservation of bipedal gait will not only influence the present personal life-style but also the self-supplementation and mobility in the f~ture. 3,12,13,15q7 To achieve successful treatment of the chronic osteitis after 19 attempts at other institutions, radical debridement of infected and avascular structures was followed by free tissue transfer. Because of disadvantageous local factors, atypical routing of the microvessels through a drilled hole in the posterior tibial wall was performed, allowing for end-to-site anastomosis of the thoracodorsal vessels with the popliteal segment. The basic principle of filling infected cavities with well vascularized tissue led to a successful outcome in this case. Despite flatfoot deformity, post-thrombotic syndrome and knee joint fusion, a useful leg remained for the highly satisfied patient for over 6 years. Case III (Figs 6 and 7) shows another important parameter for successful salvage of the lower leg. After complete avulsion injury of the foot, the defect had been covered with split-thickness skin grafts. Loss of the complete sole and heel area is usually an indication for transtibial amputation. Because of the fact that the female patient refused
Fig 1. Twenty-six-year-old male after posterior knee jointdislocation, late revascularization and postischemia-syndrome. After bilateral fasciotomy, serial radical debridements led to removement of 4/5 of the lower leg musculature with exposure of the tibia, fibula, and lateral knee joint structures. To cover the 48 cm defect, the remaining muscle parts of the lateral gastrocnemius could be used to close the knee joint region. A 40 r to 13 cm latissimus dorsi myocutaneous flap was harvested to cover the shaft area. Revascularisation could be performed by insertion of 18 cm vein grafts with end-to-side anastomoses proximal to the poplitea interposition graft.
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Fig 3. Sixty-eight-year-old male suffering from chronic osteitis in the proximal tibial segment. Forty-six years before, a gun-shot wound during World War II led to a knee joint fusion and a reduction of leg length (4 cm). During the past 15 years severe signs of a post-thrombotic syndrome developed. Because of marked skin, subcutaneous tissue atrophy, and fibrosis an endbearing transgenicular amputation could not be recommended. On admission the patient refused transfemoral amputation. In a 2 staged procedure, radical debridement of the tibial cavity was performed removing all avital bone and infected soft tissue structures.
ablation, soft tissue replacement was performed by wrapping a latissimus dorsi-parascapular fat-fascia flap around the distal lower leg. The microsurgical transplant was covered with split-thickness skin grafts using a mesh technique. Seven years later, the patient is able to ambulate with slight limping. Despite successful tissue replacement, ulcerations occurred 3 times because of insufficient foot care. The complication of recurrent lesions within reconstructed soles and heels is very well known in the literature. 14,18-2] The special architecture of fat-compartments, connective tissue bands, and a thick glabrous skin allows for repeated pressure maxima during regular gait and running. 2~ None of the available flaps and grafts are
Fig 2. (A,B) Clinical result 8 years after limb salvage. Despite the fact that radical debridement left an "empty leg," a sensitive biological stelt could be preserved. The patient presents regular gait with minor signs of limping. Up until now, no ulceration or chronic edema could be observed.
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restoration, our patient developed recurrent periods of painfull motility due to osteoarthritis of the lower ankle joints. However, she is highly satisfied with the functional and esthetic outcome and refused secondary amputation. Once limb-sparing in trauma cases is performed, the long-term outcome is influenced by function and form of the reconstructed leg. The result after sophisticated reconstructive procedures should be, in every case, superior to prosthetic supplementation. In addition, the patient who had been satisfied during the initial treatment phase of trauma or tumor will confront the surgeon with questions about secondary contour and scar revisions. To prevent problems, open discussion should be sought about possibilities and limitations of reconstructive methods. Furthermore, socio-economic and psycho-social factors have been cited as playing a crucial role. However, the definite analysis still leaves open questions like the following: Do young alcoholics end up better with immediate BK-prosthetic supplementation or with a basic leg function? What are the long time results of cost-effectiveness, patients" satisfaction, and late sequalae? 2,3,6,16 Employing actual reconstructive procedures, only a minority of the above mentioned post-traumatic conditions should be subjected to ablation of the limb, as secondary amputations
Fig 4. The large defect could be filled with a latissimus dorsi myocutaneous flap while the vascular pedicle was pulled through a drilled hole in the posterior tibial wall, Revascularisation could be performed by end-to-side anastomoses of the thoracodorsal vessels with the popliteal vessels.
therefore able to sufficiently substitute the tissue structures of the sole and heel. Fortunately, the patient develops trick movements to shift weight bearing to the contralateral side, to reduce the contact time, and to avoid pressure distribution on reconstructed areas. 2~ In cases of fixed deformities, neuropathy, repeated soft tissue infections, and osteoarthritis amputation has been recommended as the treatment of choice. However, sufficient footwear supplementation plays a key role in the development of these specific complications. The reconstructive surgeon should check, at intervalls, form and material of shoe inlays. In addition, repeatedly informing the patient should increase his or her compliance to continuously wear specially-designed orthopedic shoes or orthoses and to guarantee proper foot care. Fixed deformities, bony prominences, and muscular dysbalances must be corrected as early as possible to keep the foot in plantigrade position. Provided the reconstructive key points and postoperative treatment modalities are respected, soft tissue transplantation allows for long-time preservation of the foot. Even then, unexpected complications are prone to diminish successful gait rehabilitation. Despite stable soft tissue 202
Fig 5. Clinical result after 6 years. No evidence of fistula formation or bony or soft tissue instability. The patient reached ambulation abilities comparable with his preoperative status. STEINAU, HEBEBRAND, AND VOGT
lower-leg injuries complicated by segmental bone defects clearly demonstrates that interdisciplinary treatment options will reach results far superior to isolated Ilizarow reconstructions. 7 Early use of sufficient, well-vascularized tissues, reduced the time span of transport corticotomy from 68.1 days per cm to 38.4 days per cm, until full endbearing without the aid of additional stabilization methods was possible. The indication for alternative, sophisticated osteoplastic methods, like free fibula transfer or repeated bone grafting, should be compared in relation to this "consolidation index." Applying these data, the potential period of rehabilitation can be estimated and the patient may be able to decide whether socioeconomic factors will interfere. If the patient is faced with multiple reconstructive procedures leading to long-term inability to work, the burden of unemployment plays a crucial role in modern industrialized countries. 2,3 However, amputees are very unlikely to receive a job, because integrity of the body and full-time competitiveness are parameters of selection. Reintegration into the
Fig 6. Fifty-one-year-old female after complete avulsion injury of the soft tissues of the foot distal to the ankle joint. Previous treatment options resulted in split-thickness skin grafts. Because of recurrent ulceration, the complete weightbearing area of the sole, heel, and forefoot could be covered by a 39 to 28 cm primarily thinned latissimus dorsi muscle flap including the parascapular fat-fascia segment. The muscle was covered with thick skin graft meshed with a ratio of 1:3.
are ecceptional. In our own series of 91 consecutive major post-traumatic lower-leg reconstructions between 1982 and 1986, only 2 resulted in secondary BK-stump formation. 6 One case failed to develop stable replacement of a 16 cm bone-gap. The second patient developed severe psychological problems, forcing us to omit further reconstructive procedures.
Segmental Bone and Soft Tissue Loss The introduction of local muscle flaps and microsurgical tissue transplantation markedly extended the indication for limb salvage, however, reconstruction of large segmental bone gaps were likely to produce technical problems, repeated grafting, stress fractures, and elongated treatment phases. 3,5,6,12,13Today, transport-corticotomy (Ilizarow's procedure) in combination with biological bone-fixation and early soft tissue replacement, allows for reduced rehabilitation periods. As Ilizarow's procedure results in a naturally shaped tibial segment, the incidence for these complications decreased significantly. However, soft tissue management plays a key role. In our own institution, retrospective analysis of 134
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Fig 7. (A and B) Seven years later, the patient has developed a slight limp. During the past 4 years, ulcerations occurred 3 times after walking in bare feet or because of foreign body lesion within the stockings. Provided the individually shaped shoe inlays were used continuously, the skin lesions disappeared. Despite sufficient skin and soft tissue coverage, the patient suffers from osteoarthritic pain in the lower ankle joint facets and from pre-existing gonarthrosis and arthritis of the ipsilateral hip joint.
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Fig 8. (A) Sixty-eight-year-old male presenting with the fourth local recurrence of a liposarcoma infiltrating the gastrocnemius muscle and the fourth compartment. Radical resection could be performed sacrificing nearly the whole lower leg musculature. The tibial nerve could be freed by epineurectomy. The foot was supplied solely by the anterior tibial vessels. (B) The large defect could be covered with a latissimus dorsi myocutaneous flap. This figure shows the large resection specimen.
original profession should therefore be a main target of tactical considerations. As a side-effect, reduced rehabilitation periods will considerably diminish the financial problem of private insurance and workers compensation systems.
Fig 9. Thirteen years later at age 81, the patient still uses the lower leg for bipedal ambulation with the aid of a cane. Meanwhile, venous insufficiency has developed within the reconstructed leg and the latissimus dorsi-transplant. Despite an "empty leg," rehabilitation of the patient could be achieved much better than with a comparable transgenicular or transfemoral amputation. No evidence of local recurrence or systemic spread.
eral condition of the patient, pre-existing diseases, the compliance for special treatment options, and potential sequalae of radiochemotherapy should be respected. 27-3~ The most important parameters are the tumor extent and
Malignant Tumors of the Lower Leg and Foot While in the past, malignant tumors of bone and soft tissues of the lower extremity were routinely subjected to amputation, m o d e m reconstructive procedures in combination with radio-chemotherapy, hyperthermic perfusion with cytostatic drugs, and brachytherapy reduced the indication for BK stump-formation to levels below 10% while 5 year survival rates averaged 60% to 70% according to tumor grading. 21,23-27The surgical tactics and techniques are analogous to post-traumatic restorative methods. Provided sufficient oncological requirements were met during primary surgery, (Ro-resection) local relapse dropped to 6 to 8%, a result comparable to other body sites. As local recurrence is not likely to influence the oncological fate of the patient, regional failure can be treated using the above mentioned strategies. Except in cases of palliation, the indication for limb salvage does not correspond with oncological grading and staging. However, the gen-
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Fig 10. Thirty-three-year-old female with a rapidly growing mass at the medial border of the heel. Biopsy resulted in the diagnosis of a clear cell sarcoma (Tumor, No Lymph Nodes, No Metastasis, Grading: 2).
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Fig 11. As the tumor mass clinged to the calcaneus, radical resection, including partial tuber-removement of the calcaneus, was performed resulting in a 3-dimensional safety distance of 2 cm.
local conditions of resectability, including the potential benefits of adjuvant therapies. In low-grade malignancies, the patient will receive a functional limb and a long-time survival prognosis. Cases of high-grade tumors with reduced life expectancy should not be subjected to amputation per se, as increased local radicality will not influence the fatal outcome. In addition, the psychological effects of severe surgical mutilation during the remaining months of life should not be underestimated. Amputation should be the last treatment option. In our own series of 102 patients suffering from lower-leg-andfoot soft tissue sarcomas, only 2 required BK amputation, in 1 patient with multiple lymphway-metatases, AKablation was necessary. Extended sarcoma growths through the intermetatarsal space or within the tarsal sinus led to conventional or modified transverse or sagittal footstump formations in 17 patients. At an average follow-up time of 5 years, only 6 patients developed local recurrence, 2 of them required secondary amputation. Case IV (Figs 8 and 9) shows analogous decision making in tumor cases. Oncologically required radical surgery embedding the fourth local recurrency of a liposarcoma of the lower leg within an uninvolved tissue envelope (Ro-resection), will result in subtotal loss of functional musculature. Following intensive discussion of the problematic aspects with the patient, the indication for preservation of a biological stelt was given. The extended defect with denudation of the tibial nerve and the tibia shaft could be covered by a free latissimus dorsi flap. Thirteen years later, at age 81, the patient uses the leg for bipedal ambulation with the aid of orthopedic footwear. In addition, walking in bare feet at home is possible, as the ankle joint has been stabilized by transosseus tendon fixation. Long-term evaluation shows that despite post-thrombotic skin and subcutaneous tissue changes occuring even within t~e latissimus flap, a useful leg remnant could be achieved. Even major loss of lower leg musculature allows for basic limb function and bipedal ambulation. Especially in aged patients with decreased control of body functions, self supplementation and mobility will be superior without prosthetic supplementation. Case V (Figs 10, 11, and 12) demonstrates the analogous problem of sole of the foot reconstruction in soft tissue AMPUTATIONALTERNATIVES
Fig 12. (A) Defect coverage could be achieved with microsurgical transplantation of a myocutaneous latissimus dorsi flap. Revascularization could be performed by end-to-side anastomoses to the posterior tibial vessels. The muscle flap within the remaining end-bearing areas of the heel was covered with thick split-thickness skin-grafts from the central sole of the foot. (B) Four years later, the patient is able to wear regular footware. Bilateral ambulation is performed without limping. No evidence of ulcerations, pain, or local or systemic relapse.
malignomas. After radical resection of a clear-cell sarcoma localized at the medial border of the calcaneal tuber, the defect could be reconstructed by a primarily trimmed latissimus dorsi flap. The latissimus muscle over posterior heel area was covered with split-thickness skin from the central sole. During the following 4 years, due to proper footcare and excellent compliance, the patient did not develop any soft 205
B
Fig 13. (A) Seventy-one-year-old male suffering from pilon tibial fracture and chronic osteitis over 18 years. A biopsy of the draining sinus resulted in a diagnosis of squamous cell carcinoma. As the patient had a chronic obstructive lung disease and considerable respiratory insufficiency, the indication for hindfoot stump construction was mandatory to avoid increased energy expenditure of transtibial amputation. (B) The historical technique of Rydygier (1888). 3
tissue problems. Trick movements, with weight shifting to the contralateral side, and reduced endbearing over the reconstructed area could be demonstrated by gait analysis. In addition, preference of high-heel shoes led to increased pressure distribution to the forefoot. Our results and the review of literature clearly shows that malignant tumors of the foot are not an indication for transtibial amputation, provided oncological safety margins could be met. Using reconstructive plastic procedures, sufficient tumor management and limb sparing could be obtained.24,25,29,31 Case VI (Figs 13, 14, and 15) demonstrates the borderline between trauma and tumor surgery. After chronic osteitis of 18 years duration after pilon tibial fracture, the former miner developed a squamous cell carcinoma within the draining sinus and tibial cavity. As severe respiratory insufficiency with a dyspnea at rest complicated the general condition, stump distalization was deemed necessary to avoid confinement to a wheelchair for the 71-year-old patient. After wide excision of the tumor and segmental bone resection, the 11 cm gap could be reconstructed by a modified Rydygier technique described as early as 1888. In our case, the first and second ray could be interposed for axial bone restoration. Fixation with plates and screws allowed for immediate endbearing of the stump within a long-shaft orthopedic shoe.
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The preservation of leg length resulted in several advantages for the patient. Energy expediture did not surpass the critical level of a compromised respiratory function by transtibial amputation. 13,15Hindfoot stumps offer bare feet bipedal ambulation at home without technical support, and the guarantee for much more safety in walking on uneven or slippery pavements. In young patients, amelioration of sports activities should be mentioned. Special long-shaft orthosis increase powerful push-off at, eg, soccer or running disciplines. In swimming, a water-resistant prothesis need not be worn. As sports activities play an important role for patients with post-traumatic disorders, diabetes, or malignant tumors to regain self esteem, body image, psychological stability, and weight control, every effort should be undertaken to ameliorate these rehabilitation conditions. Several techniques concerning sagittal and transverse forefoot, midfoot- and hindfoot-stumps have been described and should be integrated into the treatment rationale before transtibial amputation. 3~ The long-term results have been shown to be superior to BK-amputation provided sufficient footwear had been offered. Even patients with axial resection arthroplasty with c~ilcaneo-tibial fusion, according to Pirogov or Spitz)~ or with Symes amputation will benefit from these procedures. 3 Modern reconstructive methods and especially free flap STEINAU, HEBEBRAND,AND VOGT
Fig 14. Using interdisciplinary cooperation segmental resection of the distal tibia, the upper and lower ankle joint was performed. The remaining bone and soft tissue gap of 11 cm could be bridged primarily with a osteomyocutaneous footray-flap. The bony structures could be fixed with osteosyntheses plates and screws allowing for immediate endbearing gait within a shoe-orthosis.
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transfer are able to extend the construction of conventional and modified foot stumps. 6 Successful gait rehabilitation depends, however, on primary restoration of musclebalance avoiding plantar flexion deformity and on the preservation of an endbearing island of original heel or sole structure.
COMMENTARY Every physician performing limb salvage surgery must be knowledgeable of the amputation alternatives that may be used to provide stable wound closure without lower extremity sacrifice. Information regarding the status of the
Fig 15. (A) Sufficient soft tissue coverage of the hindfoot stump 2 years after surgery with no incidence of ulcerations or pain. (B) The radiograph shows stable osteosyntheses of the interposed first and second foot-ray. The remaining cancellous bone of the metatarsals had been filled within the fibular and tibial fusion. Four years later the patient died from coronary heart disease. AMPUTATION ALTERNATIVES
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c o n t r a l a t e r a l l i m b , t h e o v e r a l l m e d i c a l c o n d i t i o n of t h e patient, and their pre-hospital activity level should be f a c t o r e d i n t o the d e c i s i o n p r o c e s s w h e n c o n t e m p l a t i n g limb salvage surgery versus an amputation alternative. As one moves proximally from the midfoot location, the energy expenditure associated with prosthetic ambulation increases. In some patients with associated cardiac and pulmonary disease, an above or below knee amputation m a y r e n d e r t h e m w h e e l c h a i r d e p e n d e n t for t h e r e m a i n d e r of t h e i r lives. This is c e r t a i n l y t r u e if t h e p a t i e n t h a s a l r e a d y u n d e r g o n e a c o n t r a l a t e r a l a m p u t a t i o n . T h e a b i l i t y to p r e serve amputation length using plastic surgical techniques is a m a j o r c o n t r i b u t i o n t h a t o u r s p e c i a l t y h a s o f f e r e d in t h e m a n a g e m e n t of t h e s e p a t i e n t s . D r S t e i n a u a n d h i s coll e a g u e s h a v e d o n e a n e x c e l l e n t j o b at i l l u s t r a t i n g t h e s e points. Their extensive experience in the post-traumatic l o w e r l e g i n j u r e d p a t i e n t is r e f l e c t e d b y t h e i r c a r e f u l l y thought out and rational approach. M o s t i m p o r t a n t is t h e m a n a g e m e n t o f t h e e l d e r l y p a t i e n t w i t h s i g n i f i c a n t c o m o r b i d f a c t o r s s u c h as d i a b e t e s m e l l i t u s , renal failure and/or ischemic cardiomyopathy. Extensive forefoot or midfoot wounds do not necessarily mandate a b e l o w k n e e a m p u t a t i o n . W e d o n o t h a v e to r e s o r t to complex reconstructions with their associated morbidity either, p r o v i d e d w e a r e f a m i l i a r a n d facile w i t h t h e m i d f o o t amputation procedures that permit bipedal ambulation. Lisfranc and Chopart amputations, with appropriate tendoa c h i l l e s l e n g t h e n i n g t e c h n i q u e s , are r e l a t i v e l y s i m p l e a n d straightforward procedures that are extremely useful in this difficult p a t i e n t g r o u p . M y c o n g r a t u l a t i o n s to t h e a u t h o r s for t h e i r i n s i g h t f u l a p p r o a c h to t h e p o s t - t r a u m a t i c lower extremity patient.
REFERENCES 1. Colen LB: Limb salvage in the patient with severe peripheral vascular disease: The role of microsurgical free-tissue transfer. Plast Reconstr Surg 79:389-395, 1987 2. Francel TJ: Improving reemployment rates after limb salvage of acute severe tibial fractures by microvascular soft-tissue reconstruction. Plast Reconstr Surg 93:1028-1034, 1994 3. Hertel R, Strebel N, Ganz R: Amputation versus reconstruction in traumatic defects of the leg: Outcome and costs. J Orthop Trauma 10:223-229, 1996 4. Karp NS, Kasabian AK, Siebert JW, et al: Microvascular free-flap salvage of the diabetic foot: A 5-year experience. Plast Reconstr Surg 94:834-840, 1994 5. Nahai F, Love TR: Lower extremity reconstruction: Management of soft tissue defects, in Cohen M (ed): Mastery of Plastic and Reconstructive Surgery, Vol 3. New York NY, Little, Brown, 1994 pp 1773-1779 6. Steinau HU: Der mikrovascul/ire Latissimus dorsi-Transfer. Klinische Anwendung einschliesslich Versorgung des Hebedefektes. Chirurg 57:126-133, 1986 7. Steinau HU, Hebebrand D, Vogt P, et al: Plastische Weichteildeckung bei Defektfrakturen am Unterschenkel. Chirurg 67:1080-1086, 1996 8. Johansen K, Daines M, Howey TH, et al: Objective criteria accurately predict amputation following lower extremity trauma. J Trauma 30:568-573, 1990 9. Russell WL, Sailors DM, Whittle TB, et al: Limb salvage versus traumatic amputation. Ann Surg 213:473-481, 1991
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10. Sangeorzan BJ, Hansen ST: Early and late post-traumatic foot reconstruction. Clin Orthop 243:86-94, 1989 11. Walton RL, Rothkopf DM: Judgement and approach for management of severe lower extremity injuries. Clin Plast Surg 18:525-543, 1991 12. Yaremchuk MS, Burgess AR, Brumback RJ: Lower Extremity Salvage and Reconstruction: Orthopedic and Plastic Surgical Management. New York, NY, American Elsevier, 1989 13. Baumgartner R, Botta P: Amputation und Prothesenversorgung der unteren Extremit~it. Stuttgart, Enke, 1989 14. Myerson MS, McGarvey WC, Henderson MR, et al: Morbidity after crush injuries to the foot. J Orthop Trauma 8:343-349, 1994 15. Fisher V, Gullickson G: Energy cost of ambulation in health and disability: A literature review. Arch Phys Med Rehabil 59:124-133, 1978 16. Melchiorre PJ, Findley T, Boda W: Functional outcome and comorbidity indexes in the rehabilitation of the traumatic versus the vascular unilateral lower limb amputee. Am J Phys Med Rehabil 75:9-14, 1996 17. Thornhill HL, Jones GD, Bordzka W, et al: Bilateral Below-Knee amputations: Experience with 80 Patients. Arch Phys Med Rehabil 67:159-163, 1986 18. Hidalgo DA, Shaw WW: Reconstruction of foot injuries. Clin Plast Surg 13:663, 1986 19. May JW, Halls MJ, Simon SR: Free microvascular muscle flaps with skin graft reconstrukction of extensive defects of the foot: A clinical and gait analysis study. Plast Reconstr Surg 75:627-636, 1985 20. Rautio J, Kekoni J, H/im~il/iinen H, et al: Mechanical sensibility in free and island flaps of the foot. J Reconstr Microsurg 5:119-125, 1989 21. Steinau HU, Feller AM, H6rl HW, et al: Zur Problematik posttraumatischer Fersenweichteildefekte. Chirurg 60:287-294, 1989 22. Blechschmidt E: Die Architektur des Fersenpolsters. Verh Anat Ges 41:20-42, 1932 23. Arlen M, Marcove RC: Surgical Management of Soft Tissue Sarcomas, Philadelphia, PA, Saunders, 1987, p 321 24. Evans GR, Black JJ, Robb GL, et al: Adjuvant therapy: The effects on microvascular lower extremity reconstruction. Ann Plast Surg 39:141144, 1997 25. Hidalgo DA, Carrasquillo IM: The treatment of lower extremity sarcomas with wide excision, radiotherapy, and free-flap reconstruction. Plast Reconstr Surg 89:96-101, 1992 26. Johnstone PA, Wexler LH, Venzon DJ, et ah Sarcomas of the hand and foot: Analysis of local control and functional result with combined modality therapy in extremity preservation. Int J Radiat Oncol Biol Phys 29:735-745, 1994 27. Owens JC, Shiu MH, Smith R, et al: Soft tissue sarcomas of the hand and foot. Cancer 82:2010-2018, 1985 28. Ormsby MV, Hilaris BS, Nori D, et al: Wound complications of adjuvant radiation therapy in patients with soft-tissue sarcomas. Ann Surg 210:93-102, 1989 29. Selch MT, Kopald KH, Ferreiro GA, et al: Limb salvage therapy for soft tissue sarcomas of the foot. Int J Radiat Oncol Biol Phys 19:41-48, 1990 30. Steinau HU, Ehrl H, Biemer E: Reconstructive plastic surgery in soft tissue sarcomas of the extremities. Eur J Plast Surg 11:99-108, 1988 31. Steinau HU, Gradinger R, Claudi B, et al: Soft tissue sarcomas of the extremities. Limb sparing resection and reconstruction, in Russel RC (ed): PSEF Instructional Courses, Vol 3. St. Louis, Mosby, pp 116-138, 1990 32. Chang BB, Bock DE, Jacobs RL, et al: Increased limb salvage by the use of unconventional foot amputations. J Vasc Surg 19:341-348, 1994 33. Esser JFS: Gestielte Plastiken bei typischen Erfrierungen und bei schlecht geheilten Amputationssttimpfen der unteren Extremit/it. Bruns' Beitr Klin Chit 108:514-541, 1917 34. Gaine WJ, McCreath SW: Syme's amputation revisited: A review of 46 cases. J Bone Joint Surg Br 78:461-467, 1996 35. Letts M, Pyper A: The modified Chopart's amputation. Clin Orthop 256:44-49, 1990 36. Millstein SG, McCowan SA, Hunter GA: Traumatic partial foot amputations in adults. A long-term review. J Bone Joint Surg Br 70:251-254, 1988
STEINAU, HEBEBRAND,AND VOGT
The introduction of reconstructive plastic procedures in cases of post-traumatic or resectional defects, neuropathic ulcerations, and infections has considerably decreased the indication for amputation. Conventional parameters for below knee (BK)-ablation like tibial nerve severance, postischemia syndrome, avulsion injuries, chronic osteitis, foot deformities, and sole of the foot defects should be critically revised before mutilating surgery is advised. Interdisciplinary approach for limb salvage is mandatory in cases of high amputation levels, mutilating trauma during childhood, juvenile diabetes, or if iatrogenic factors play a crucial role. In cases of partial foot amputation or oncologically required transverse or sagittal resections, conventional foot stumps, including free tissue transfer and restoration of muscular balance, should be considered to achieve rehabilitation results superior to BK-amputation. Copyright 9 1997by W.B. Saunders Company KEY WORDS: lower leg reconstruction, post-traumatic defects of the foot, malignant tumors of the lower leg, conventional and modified food stump formation
In the past, open comminuted fractures, malignant tumors, neuropathic defects, and cases of peripheral arterial occlusive disease were likely to end up with limb ablation at the proximal level. The introduction of successful techniques for soft tissue replacement, bone stabilization and reconstruction, and limited partial amputation procedures have markedly changed the indication for radical surgery. 1-7 Despite the fact that sophisticated prosthetic supplementation exists, alteration of the patient's lifestyle and selfesteem, problems of professional rehabilitation, and conflicts within the partnership should not be underestimated. Besides parameters of the present situation, futural aspects must be included. Salvage of bipedal ambulation especially allows for self-supplementation and mobility of the aged patient. Table 1 depicts the goals of bipedal ambulation. Therefore, absolute indications for limb salvage procedures exist if high amputation levels should be avoided; trauma, tumor, neurological or infectious diseases in childhood occur; patients with high risk of sequential contralateral secondary amputation like juvenile diabetes or Burger's disease are treated; and in cases with iatrogenic factors whereby the extent of damage should be minimized even with major reconstructive procedures (Table 2). Several attempts have been made to guide the decision for or against amputation with algorithms and scoring s y s t e m s . 3'8-12 However, all of them depend markedly on the
From the Department for Plastic Surgery, Handsurgery, Burn Center, BG-University-Hospital Bergmannsheil, Ruhr-University Bochum, Germany. Address reprint requests to Hans-Ulrich Steinau, MD, Department for Plastic Surgery, Handsurgery, Burn Center, BG-University-Hospital Bergmannsheil Ruhr-University, Bochum, Germany, B0rkle de la Camp-Platz 1, D-44789 Bochum. Copyright 9 1997 by W.B. Saunders Company
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diagnostic and surgical abilities of the treating team. Proper wound assessment, judgement of socio-economic factors, the spectrum of reconstructive procedures, low surgical complication rates, and the early integration of physio-therapy are all individual parameters. In addition, decision making for amputation is likely to be influenced by emotional factors and personal experiences of the surgeon's subspecialty. The outcome must therefore not necessarily correspond with clinical imaginations. Furthermore, the definition of a "useful lower leg remnant" varies within the literature. Amputation recommendations have been given for clinical conditions like tibial nerve severance, late revascularization cases, chronic osteomyelitis, foot deformities, avulsion injuries, sole and heel defects, and segmental gaps of the tibia with concomitant extended soft tissue lOSS.8'10'13'14 To show reconstructive plastic procedures (Table 3) and differential therapeutic aspects, borderline cases between amputation and salvage will serve as examples for tactical approaches, individual modified techniques, distalization methods, and foot-stump formation.
POST-TRAUMATIC LIMB SALVAGE PROCEDURES Iatrogenic factors play a crucial role in ischemia-induced post-traumatic muscle deficiency. Case I (Figs 1 and 2) demonstrates subtotal destruction of lower leg musculature following late revascularization of post-traumatic popliteal artery occlusion. After several debridements, loss of the muscles within the peroneal, anterior, and deep compartment resulted in complete functional deficiency of the upper and lower ankle joint. The remaining part of the lateral gastrocnemius muscle was used to close the exposed knee joint. After intensive discussion of the pros and cons with the patient, a biological stelt could be preserved by covering the defect
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TABLE 1. Salvage of Bipedal Ambulation (Goals) 1. 2. 3. 4. 5.
Long-term functional advantages Occupational and social rehabilitation Self esteem, body image Activities at sports (obesity!) Diminished risk of contralateral amputation (Diabetes, Arterial Occlusive disease) 6. Self-supplementation of the aged patient, prevention of wheel-chair life 7. Reduced costs
with an extended latissimus dorsi flap. Revascularization of the transplant was performed by pulling venous interposition grafts through the interosseus membrane to the superior popliteal segment. The tendons of the anterior tibial muscle, the peroneus longus and the triceps surae, were fixed with transosseous sutures to the distal tibia to keep the foot in plantigrade position. Eight years later, bipedal gait activities are superior to BK-amputation. Provided postischemia syndrome with life-threatening complications could be prevented by early sequential removal of compromised musculature, "empty leg" conditions proved to be better than immediate or secondary ablation of the limb. To keep sufficient perfusion of the foot, the axial arterial and venous pathways must be meticulously dissected step-by-step, occluding the lateral branches within the muscle compartments with clips. In addition, the tibial nerve, which showed temporary postischemic functional loss due to compression injury within the fourth compartment, had to be freed from the soleus arcade down to the tarsal tunnel. During the recovery phase of the nerve, the patient was supplied with longshaft orthopedic footwear which embedded the then a-sensitive sole and heel with full contact. Comparable diseases, like diabetic foot problems, clearly show that neuropathic lower legs are not candidates for amputation but for proper long-time foot care, special shoe inlays, and pressure-reducing sole materials. 1,4 It must be clearly stated that postischemia syndrome should not be underestimated during the clinical course. If the patient at the intensive care unit shows clinical signs of an incipient myonephropathic-metabolic syndrome, immediate amputation is mandatory--life before limb! 6,7 Case II (Figs 3, 4, and 5) shows another important aspect: transfemoral amputation in the aged patient. Following a gun shot injury in the World War II, the 68-year-old male was adjusted to bipedal ambulation despite knee joint fusion and shortening of the leg. Amputation in the elderly has been cited to result in early rehabilitation. If we consider, however, that above knee (AK)-amputation increases energy cost expediture during gait by 50% to 100%, pre-existing or developing cardiorespiratory diseases will exclude the majority of this group from successful prosthetic AK supplementation. This rationale is valid for every age group, because in TABLE 2. Absolute Indication for Limb Salvage 1. 2. 3. 4.
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Prevention of high amputation levels Trauma, tumor, neurological or infectious diseases in childhood Juvenile diabetes, Burger's disease latrogenic factors (late revascularisation)
TABLE 3. Restoration of Bipedal Ambulation Cascade of Reconstructive Plastic Procedures 1. 2. 3. 4. 5. 6.
Functional and esthetic rehabilitation Minor functional and esthetic deficiencies "Empty leg," biologic prosthesis Transverse or sagittal endbearing foot stumps Below-the-knee stump distalization Construction of endbearing full contact in transtibial, transgenicular, transfemoral amputation
modern industrialized countries, average life expectancy has risen to more than 80 years. Therefore limb salvage with preservation of bipedal gait will not only influence the present personal life-style but also the self-supplementation and mobility in the f~ture. 3,12,13,15q7 To achieve successful treatment of the chronic osteitis after 19 attempts at other institutions, radical debridement of infected and avascular structures was followed by free tissue transfer. Because of disadvantageous local factors, atypical routing of the microvessels through a drilled hole in the posterior tibial wall was performed, allowing for end-to-site anastomosis of the thoracodorsal vessels with the popliteal segment. The basic principle of filling infected cavities with well vascularized tissue led to a successful outcome in this case. Despite flatfoot deformity, post-thrombotic syndrome and knee joint fusion, a useful leg remained for the highly satisfied patient for over 6 years. Case III (Figs 6 and 7) shows another important parameter for successful salvage of the lower leg. After complete avulsion injury of the foot, the defect had been covered with split-thickness skin grafts. Loss of the complete sole and heel area is usually an indication for transtibial amputation. Because of the fact that the female patient refused
Fig 1. Twenty-six-year-old male after posterior knee jointdislocation, late revascularization and postischemia-syndrome. After bilateral fasciotomy, serial radical debridements led to removement of 4/5 of the lower leg musculature with exposure of the tibia, fibula, and lateral knee joint structures. To cover the 48 cm defect, the remaining muscle parts of the lateral gastrocnemius could be used to close the knee joint region. A 40 r to 13 cm latissimus dorsi myocutaneous flap was harvested to cover the shaft area. Revascularisation could be performed by insertion of 18 cm vein grafts with end-to-side anastomoses proximal to the poplitea interposition graft.
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Fig 3. Sixty-eight-year-old male suffering from chronic osteitis in the proximal tibial segment. Forty-six years before, a gun-shot wound during World War II led to a knee joint fusion and a reduction of leg length (4 cm). During the past 15 years severe signs of a post-thrombotic syndrome developed. Because of marked skin, subcutaneous tissue atrophy, and fibrosis an endbearing transgenicular amputation could not be recommended. On admission the patient refused transfemoral amputation. In a 2 staged procedure, radical debridement of the tibial cavity was performed removing all avital bone and infected soft tissue structures.
ablation, soft tissue replacement was performed by wrapping a latissimus dorsi-parascapular fat-fascia flap around the distal lower leg. The microsurgical transplant was covered with split-thickness skin grafts using a mesh technique. Seven years later, the patient is able to ambulate with slight limping. Despite successful tissue replacement, ulcerations occurred 3 times because of insufficient foot care. The complication of recurrent lesions within reconstructed soles and heels is very well known in the literature. 14,18-2] The special architecture of fat-compartments, connective tissue bands, and a thick glabrous skin allows for repeated pressure maxima during regular gait and running. 2~ None of the available flaps and grafts are
Fig 2. (A,B) Clinical result 8 years after limb salvage. Despite the fact that radical debridement left an "empty leg," a sensitive biological stelt could be preserved. The patient presents regular gait with minor signs of limping. Up until now, no ulceration or chronic edema could be observed.
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restoration, our patient developed recurrent periods of painfull motility due to osteoarthritis of the lower ankle joints. However, she is highly satisfied with the functional and esthetic outcome and refused secondary amputation. Once limb-sparing in trauma cases is performed, the long-term outcome is influenced by function and form of the reconstructed leg. The result after sophisticated reconstructive procedures should be, in every case, superior to prosthetic supplementation. In addition, the patient who had been satisfied during the initial treatment phase of trauma or tumor will confront the surgeon with questions about secondary contour and scar revisions. To prevent problems, open discussion should be sought about possibilities and limitations of reconstructive methods. Furthermore, socio-economic and psycho-social factors have been cited as playing a crucial role. However, the definite analysis still leaves open questions like the following: Do young alcoholics end up better with immediate BK-prosthetic supplementation or with a basic leg function? What are the long time results of cost-effectiveness, patients" satisfaction, and late sequalae? 2,3,6,16 Employing actual reconstructive procedures, only a minority of the above mentioned post-traumatic conditions should be subjected to ablation of the limb, as secondary amputations
Fig 4. The large defect could be filled with a latissimus dorsi myocutaneous flap while the vascular pedicle was pulled through a drilled hole in the posterior tibial wall, Revascularisation could be performed by end-to-side anastomoses of the thoracodorsal vessels with the popliteal vessels.
therefore able to sufficiently substitute the tissue structures of the sole and heel. Fortunately, the patient develops trick movements to shift weight bearing to the contralateral side, to reduce the contact time, and to avoid pressure distribution on reconstructed areas. 2~ In cases of fixed deformities, neuropathy, repeated soft tissue infections, and osteoarthritis amputation has been recommended as the treatment of choice. However, sufficient footwear supplementation plays a key role in the development of these specific complications. The reconstructive surgeon should check, at intervalls, form and material of shoe inlays. In addition, repeatedly informing the patient should increase his or her compliance to continuously wear specially-designed orthopedic shoes or orthoses and to guarantee proper foot care. Fixed deformities, bony prominences, and muscular dysbalances must be corrected as early as possible to keep the foot in plantigrade position. Provided the reconstructive key points and postoperative treatment modalities are respected, soft tissue transplantation allows for long-time preservation of the foot. Even then, unexpected complications are prone to diminish successful gait rehabilitation. Despite stable soft tissue 202
Fig 5. Clinical result after 6 years. No evidence of fistula formation or bony or soft tissue instability. The patient reached ambulation abilities comparable with his preoperative status. STEINAU, HEBEBRAND, AND VOGT
lower-leg injuries complicated by segmental bone defects clearly demonstrates that interdisciplinary treatment options will reach results far superior to isolated Ilizarow reconstructions. 7 Early use of sufficient, well-vascularized tissues, reduced the time span of transport corticotomy from 68.1 days per cm to 38.4 days per cm, until full endbearing without the aid of additional stabilization methods was possible. The indication for alternative, sophisticated osteoplastic methods, like free fibula transfer or repeated bone grafting, should be compared in relation to this "consolidation index." Applying these data, the potential period of rehabilitation can be estimated and the patient may be able to decide whether socioeconomic factors will interfere. If the patient is faced with multiple reconstructive procedures leading to long-term inability to work, the burden of unemployment plays a crucial role in modern industrialized countries. 2,3 However, amputees are very unlikely to receive a job, because integrity of the body and full-time competitiveness are parameters of selection. Reintegration into the
Fig 6. Fifty-one-year-old female after complete avulsion injury of the soft tissues of the foot distal to the ankle joint. Previous treatment options resulted in split-thickness skin grafts. Because of recurrent ulceration, the complete weightbearing area of the sole, heel, and forefoot could be covered by a 39 to 28 cm primarily thinned latissimus dorsi muscle flap including the parascapular fat-fascia segment. The muscle was covered with thick skin graft meshed with a ratio of 1:3.
are ecceptional. In our own series of 91 consecutive major post-traumatic lower-leg reconstructions between 1982 and 1986, only 2 resulted in secondary BK-stump formation. 6 One case failed to develop stable replacement of a 16 cm bone-gap. The second patient developed severe psychological problems, forcing us to omit further reconstructive procedures.
Segmental Bone and Soft Tissue Loss The introduction of local muscle flaps and microsurgical tissue transplantation markedly extended the indication for limb salvage, however, reconstruction of large segmental bone gaps were likely to produce technical problems, repeated grafting, stress fractures, and elongated treatment phases. 3,5,6,12,13Today, transport-corticotomy (Ilizarow's procedure) in combination with biological bone-fixation and early soft tissue replacement, allows for reduced rehabilitation periods. As Ilizarow's procedure results in a naturally shaped tibial segment, the incidence for these complications decreased significantly. However, soft tissue management plays a key role. In our own institution, retrospective analysis of 134
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Fig 7. (A and B) Seven years later, the patient has developed a slight limp. During the past 4 years, ulcerations occurred 3 times after walking in bare feet or because of foreign body lesion within the stockings. Provided the individually shaped shoe inlays were used continuously, the skin lesions disappeared. Despite sufficient skin and soft tissue coverage, the patient suffers from osteoarthritic pain in the lower ankle joint facets and from pre-existing gonarthrosis and arthritis of the ipsilateral hip joint.
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Fig 8. (A) Sixty-eight-year-old male presenting with the fourth local recurrence of a liposarcoma infiltrating the gastrocnemius muscle and the fourth compartment. Radical resection could be performed sacrificing nearly the whole lower leg musculature. The tibial nerve could be freed by epineurectomy. The foot was supplied solely by the anterior tibial vessels. (B) The large defect could be covered with a latissimus dorsi myocutaneous flap. This figure shows the large resection specimen.
original profession should therefore be a main target of tactical considerations. As a side-effect, reduced rehabilitation periods will considerably diminish the financial problem of private insurance and workers compensation systems.
Fig 9. Thirteen years later at age 81, the patient still uses the lower leg for bipedal ambulation with the aid of a cane. Meanwhile, venous insufficiency has developed within the reconstructed leg and the latissimus dorsi-transplant. Despite an "empty leg," rehabilitation of the patient could be achieved much better than with a comparable transgenicular or transfemoral amputation. No evidence of local recurrence or systemic spread.
eral condition of the patient, pre-existing diseases, the compliance for special treatment options, and potential sequalae of radiochemotherapy should be respected. 27-3~ The most important parameters are the tumor extent and
Malignant Tumors of the Lower Leg and Foot While in the past, malignant tumors of bone and soft tissues of the lower extremity were routinely subjected to amputation, m o d e m reconstructive procedures in combination with radio-chemotherapy, hyperthermic perfusion with cytostatic drugs, and brachytherapy reduced the indication for BK stump-formation to levels below 10% while 5 year survival rates averaged 60% to 70% according to tumor grading. 21,23-27The surgical tactics and techniques are analogous to post-traumatic restorative methods. Provided sufficient oncological requirements were met during primary surgery, (Ro-resection) local relapse dropped to 6 to 8%, a result comparable to other body sites. As local recurrence is not likely to influence the oncological fate of the patient, regional failure can be treated using the above mentioned strategies. Except in cases of palliation, the indication for limb salvage does not correspond with oncological grading and staging. However, the gen-
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Fig 10. Thirty-three-year-old female with a rapidly growing mass at the medial border of the heel. Biopsy resulted in the diagnosis of a clear cell sarcoma (Tumor, No Lymph Nodes, No Metastasis, Grading: 2).
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Fig 11. As the tumor mass clinged to the calcaneus, radical resection, including partial tuber-removement of the calcaneus, was performed resulting in a 3-dimensional safety distance of 2 cm.
local conditions of resectability, including the potential benefits of adjuvant therapies. In low-grade malignancies, the patient will receive a functional limb and a long-time survival prognosis. Cases of high-grade tumors with reduced life expectancy should not be subjected to amputation per se, as increased local radicality will not influence the fatal outcome. In addition, the psychological effects of severe surgical mutilation during the remaining months of life should not be underestimated. Amputation should be the last treatment option. In our own series of 102 patients suffering from lower-leg-andfoot soft tissue sarcomas, only 2 required BK amputation, in 1 patient with multiple lymphway-metatases, AKablation was necessary. Extended sarcoma growths through the intermetatarsal space or within the tarsal sinus led to conventional or modified transverse or sagittal footstump formations in 17 patients. At an average follow-up time of 5 years, only 6 patients developed local recurrence, 2 of them required secondary amputation. Case IV (Figs 8 and 9) shows analogous decision making in tumor cases. Oncologically required radical surgery embedding the fourth local recurrency of a liposarcoma of the lower leg within an uninvolved tissue envelope (Ro-resection), will result in subtotal loss of functional musculature. Following intensive discussion of the problematic aspects with the patient, the indication for preservation of a biological stelt was given. The extended defect with denudation of the tibial nerve and the tibia shaft could be covered by a free latissimus dorsi flap. Thirteen years later, at age 81, the patient uses the leg for bipedal ambulation with the aid of orthopedic footwear. In addition, walking in bare feet at home is possible, as the ankle joint has been stabilized by transosseus tendon fixation. Long-term evaluation shows that despite post-thrombotic skin and subcutaneous tissue changes occuring even within t~e latissimus flap, a useful leg remnant could be achieved. Even major loss of lower leg musculature allows for basic limb function and bipedal ambulation. Especially in aged patients with decreased control of body functions, self supplementation and mobility will be superior without prosthetic supplementation. Case V (Figs 10, 11, and 12) demonstrates the analogous problem of sole of the foot reconstruction in soft tissue AMPUTATIONALTERNATIVES
Fig 12. (A) Defect coverage could be achieved with microsurgical transplantation of a myocutaneous latissimus dorsi flap. Revascularization could be performed by end-to-side anastomoses to the posterior tibial vessels. The muscle flap within the remaining end-bearing areas of the heel was covered with thick split-thickness skin-grafts from the central sole of the foot. (B) Four years later, the patient is able to wear regular footware. Bilateral ambulation is performed without limping. No evidence of ulcerations, pain, or local or systemic relapse.
malignomas. After radical resection of a clear-cell sarcoma localized at the medial border of the calcaneal tuber, the defect could be reconstructed by a primarily trimmed latissimus dorsi flap. The latissimus muscle over posterior heel area was covered with split-thickness skin from the central sole. During the following 4 years, due to proper footcare and excellent compliance, the patient did not develop any soft 205
B
Fig 13. (A) Seventy-one-year-old male suffering from pilon tibial fracture and chronic osteitis over 18 years. A biopsy of the draining sinus resulted in a diagnosis of squamous cell carcinoma. As the patient had a chronic obstructive lung disease and considerable respiratory insufficiency, the indication for hindfoot stump construction was mandatory to avoid increased energy expenditure of transtibial amputation. (B) The historical technique of Rydygier (1888). 3
tissue problems. Trick movements, with weight shifting to the contralateral side, and reduced endbearing over the reconstructed area could be demonstrated by gait analysis. In addition, preference of high-heel shoes led to increased pressure distribution to the forefoot. Our results and the review of literature clearly shows that malignant tumors of the foot are not an indication for transtibial amputation, provided oncological safety margins could be met. Using reconstructive plastic procedures, sufficient tumor management and limb sparing could be obtained.24,25,29,31 Case VI (Figs 13, 14, and 15) demonstrates the borderline between trauma and tumor surgery. After chronic osteitis of 18 years duration after pilon tibial fracture, the former miner developed a squamous cell carcinoma within the draining sinus and tibial cavity. As severe respiratory insufficiency with a dyspnea at rest complicated the general condition, stump distalization was deemed necessary to avoid confinement to a wheelchair for the 71-year-old patient. After wide excision of the tumor and segmental bone resection, the 11 cm gap could be reconstructed by a modified Rydygier technique described as early as 1888. In our case, the first and second ray could be interposed for axial bone restoration. Fixation with plates and screws allowed for immediate endbearing of the stump within a long-shaft orthopedic shoe.
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The preservation of leg length resulted in several advantages for the patient. Energy expediture did not surpass the critical level of a compromised respiratory function by transtibial amputation. 13,15Hindfoot stumps offer bare feet bipedal ambulation at home without technical support, and the guarantee for much more safety in walking on uneven or slippery pavements. In young patients, amelioration of sports activities should be mentioned. Special long-shaft orthosis increase powerful push-off at, eg, soccer or running disciplines. In swimming, a water-resistant prothesis need not be worn. As sports activities play an important role for patients with post-traumatic disorders, diabetes, or malignant tumors to regain self esteem, body image, psychological stability, and weight control, every effort should be undertaken to ameliorate these rehabilitation conditions. Several techniques concerning sagittal and transverse forefoot, midfoot- and hindfoot-stumps have been described and should be integrated into the treatment rationale before transtibial amputation. 3~ The long-term results have been shown to be superior to BK-amputation provided sufficient footwear had been offered. Even patients with axial resection arthroplasty with c~ilcaneo-tibial fusion, according to Pirogov or Spitz)~ or with Symes amputation will benefit from these procedures. 3 Modern reconstructive methods and especially free flap STEINAU, HEBEBRAND,AND VOGT
Fig 14. Using interdisciplinary cooperation segmental resection of the distal tibia, the upper and lower ankle joint was performed. The remaining bone and soft tissue gap of 11 cm could be bridged primarily with a osteomyocutaneous footray-flap. The bony structures could be fixed with osteosyntheses plates and screws allowing for immediate endbearing gait within a shoe-orthosis.
I'
transfer are able to extend the construction of conventional and modified foot stumps. 6 Successful gait rehabilitation depends, however, on primary restoration of musclebalance avoiding plantar flexion deformity and on the preservation of an endbearing island of original heel or sole structure.
COMMENTARY Every physician performing limb salvage surgery must be knowledgeable of the amputation alternatives that may be used to provide stable wound closure without lower extremity sacrifice. Information regarding the status of the
Fig 15. (A) Sufficient soft tissue coverage of the hindfoot stump 2 years after surgery with no incidence of ulcerations or pain. (B) The radiograph shows stable osteosyntheses of the interposed first and second foot-ray. The remaining cancellous bone of the metatarsals had been filled within the fibular and tibial fusion. Four years later the patient died from coronary heart disease. AMPUTATION ALTERNATIVES
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c o n t r a l a t e r a l l i m b , t h e o v e r a l l m e d i c a l c o n d i t i o n of t h e patient, and their pre-hospital activity level should be f a c t o r e d i n t o the d e c i s i o n p r o c e s s w h e n c o n t e m p l a t i n g limb salvage surgery versus an amputation alternative. As one moves proximally from the midfoot location, the energy expenditure associated with prosthetic ambulation increases. In some patients with associated cardiac and pulmonary disease, an above or below knee amputation m a y r e n d e r t h e m w h e e l c h a i r d e p e n d e n t for t h e r e m a i n d e r of t h e i r lives. This is c e r t a i n l y t r u e if t h e p a t i e n t h a s a l r e a d y u n d e r g o n e a c o n t r a l a t e r a l a m p u t a t i o n . T h e a b i l i t y to p r e serve amputation length using plastic surgical techniques is a m a j o r c o n t r i b u t i o n t h a t o u r s p e c i a l t y h a s o f f e r e d in t h e m a n a g e m e n t of t h e s e p a t i e n t s . D r S t e i n a u a n d h i s coll e a g u e s h a v e d o n e a n e x c e l l e n t j o b at i l l u s t r a t i n g t h e s e points. Their extensive experience in the post-traumatic l o w e r l e g i n j u r e d p a t i e n t is r e f l e c t e d b y t h e i r c a r e f u l l y thought out and rational approach. M o s t i m p o r t a n t is t h e m a n a g e m e n t o f t h e e l d e r l y p a t i e n t w i t h s i g n i f i c a n t c o m o r b i d f a c t o r s s u c h as d i a b e t e s m e l l i t u s , renal failure and/or ischemic cardiomyopathy. Extensive forefoot or midfoot wounds do not necessarily mandate a b e l o w k n e e a m p u t a t i o n . W e d o n o t h a v e to r e s o r t to complex reconstructions with their associated morbidity either, p r o v i d e d w e a r e f a m i l i a r a n d facile w i t h t h e m i d f o o t amputation procedures that permit bipedal ambulation. Lisfranc and Chopart amputations, with appropriate tendoa c h i l l e s l e n g t h e n i n g t e c h n i q u e s , are r e l a t i v e l y s i m p l e a n d straightforward procedures that are extremely useful in this difficult p a t i e n t g r o u p . M y c o n g r a t u l a t i o n s to t h e a u t h o r s for t h e i r i n s i g h t f u l a p p r o a c h to t h e p o s t - t r a u m a t i c lower extremity patient.
REFERENCES 1. Colen LB: Limb salvage in the patient with severe peripheral vascular disease: The role of microsurgical free-tissue transfer. Plast Reconstr Surg 79:389-395, 1987 2. Francel TJ: Improving reemployment rates after limb salvage of acute severe tibial fractures by microvascular soft-tissue reconstruction. Plast Reconstr Surg 93:1028-1034, 1994 3. Hertel R, Strebel N, Ganz R: Amputation versus reconstruction in traumatic defects of the leg: Outcome and costs. J Orthop Trauma 10:223-229, 1996 4. Karp NS, Kasabian AK, Siebert JW, et al: Microvascular free-flap salvage of the diabetic foot: A 5-year experience. Plast Reconstr Surg 94:834-840, 1994 5. Nahai F, Love TR: Lower extremity reconstruction: Management of soft tissue defects, in Cohen M (ed): Mastery of Plastic and Reconstructive Surgery, Vol 3. New York NY, Little, Brown, 1994 pp 1773-1779 6. Steinau HU: Der mikrovascul/ire Latissimus dorsi-Transfer. Klinische Anwendung einschliesslich Versorgung des Hebedefektes. Chirurg 57:126-133, 1986 7. Steinau HU, Hebebrand D, Vogt P, et al: Plastische Weichteildeckung bei Defektfrakturen am Unterschenkel. Chirurg 67:1080-1086, 1996 8. Johansen K, Daines M, Howey TH, et al: Objective criteria accurately predict amputation following lower extremity trauma. J Trauma 30:568-573, 1990 9. Russell WL, Sailors DM, Whittle TB, et al: Limb salvage versus traumatic amputation. Ann Surg 213:473-481, 1991
208
10. Sangeorzan BJ, Hansen ST: Early and late post-traumatic foot reconstruction. Clin Orthop 243:86-94, 1989 11. Walton RL, Rothkopf DM: Judgement and approach for management of severe lower extremity injuries. Clin Plast Surg 18:525-543, 1991 12. Yaremchuk MS, Burgess AR, Brumback RJ: Lower Extremity Salvage and Reconstruction: Orthopedic and Plastic Surgical Management. New York, NY, American Elsevier, 1989 13. Baumgartner R, Botta P: Amputation und Prothesenversorgung der unteren Extremit~it. Stuttgart, Enke, 1989 14. Myerson MS, McGarvey WC, Henderson MR, et al: Morbidity after crush injuries to the foot. J Orthop Trauma 8:343-349, 1994 15. Fisher V, Gullickson G: Energy cost of ambulation in health and disability: A literature review. Arch Phys Med Rehabil 59:124-133, 1978 16. Melchiorre PJ, Findley T, Boda W: Functional outcome and comorbidity indexes in the rehabilitation of the traumatic versus the vascular unilateral lower limb amputee. Am J Phys Med Rehabil 75:9-14, 1996 17. Thornhill HL, Jones GD, Bordzka W, et al: Bilateral Below-Knee amputations: Experience with 80 Patients. Arch Phys Med Rehabil 67:159-163, 1986 18. Hidalgo DA, Shaw WW: Reconstruction of foot injuries. Clin Plast Surg 13:663, 1986 19. May JW, Halls MJ, Simon SR: Free microvascular muscle flaps with skin graft reconstrukction of extensive defects of the foot: A clinical and gait analysis study. Plast Reconstr Surg 75:627-636, 1985 20. Rautio J, Kekoni J, H/im~il/iinen H, et al: Mechanical sensibility in free and island flaps of the foot. J Reconstr Microsurg 5:119-125, 1989 21. Steinau HU, Feller AM, H6rl HW, et al: Zur Problematik posttraumatischer Fersenweichteildefekte. Chirurg 60:287-294, 1989 22. Blechschmidt E: Die Architektur des Fersenpolsters. Verh Anat Ges 41:20-42, 1932 23. Arlen M, Marcove RC: Surgical Management of Soft Tissue Sarcomas, Philadelphia, PA, Saunders, 1987, p 321 24. Evans GR, Black JJ, Robb GL, et al: Adjuvant therapy: The effects on microvascular lower extremity reconstruction. Ann Plast Surg 39:141144, 1997 25. Hidalgo DA, Carrasquillo IM: The treatment of lower extremity sarcomas with wide excision, radiotherapy, and free-flap reconstruction. Plast Reconstr Surg 89:96-101, 1992 26. Johnstone PA, Wexler LH, Venzon DJ, et ah Sarcomas of the hand and foot: Analysis of local control and functional result with combined modality therapy in extremity preservation. Int J Radiat Oncol Biol Phys 29:735-745, 1994 27. Owens JC, Shiu MH, Smith R, et al: Soft tissue sarcomas of the hand and foot. Cancer 82:2010-2018, 1985 28. Ormsby MV, Hilaris BS, Nori D, et al: Wound complications of adjuvant radiation therapy in patients with soft-tissue sarcomas. Ann Surg 210:93-102, 1989 29. Selch MT, Kopald KH, Ferreiro GA, et al: Limb salvage therapy for soft tissue sarcomas of the foot. Int J Radiat Oncol Biol Phys 19:41-48, 1990 30. Steinau HU, Ehrl H, Biemer E: Reconstructive plastic surgery in soft tissue sarcomas of the extremities. Eur J Plast Surg 11:99-108, 1988 31. Steinau HU, Gradinger R, Claudi B, et al: Soft tissue sarcomas of the extremities. Limb sparing resection and reconstruction, in Russel RC (ed): PSEF Instructional Courses, Vol 3. St. Louis, Mosby, pp 116-138, 1990 32. Chang BB, Bock DE, Jacobs RL, et al: Increased limb salvage by the use of unconventional foot amputations. J Vasc Surg 19:341-348, 1994 33. Esser JFS: Gestielte Plastiken bei typischen Erfrierungen und bei schlecht geheilten Amputationssttimpfen der unteren Extremit/it. Bruns' Beitr Klin Chit 108:514-541, 1917 34. Gaine WJ, McCreath SW: Syme's amputation revisited: A review of 46 cases. J Bone Joint Surg Br 78:461-467, 1996 35. Letts M, Pyper A: The modified Chopart's amputation. Clin Orthop 256:44-49, 1990 36. Millstein SG, McCowan SA, Hunter GA: Traumatic partial foot amputations in adults. A long-term review. J Bone Joint Surg Br 70:251-254, 1988
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