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Foot amputations: (2) Hindfoot
Foot amputations: (2) Hindfoot J. Kirkup
Until the 19th century, below-knee amputation a hand’s breadth distal to the patella was the standard solution for advanced pathology of the hindfoot.’ If sporadic partial hindfoot amputations were reported in the 18th century,2 the precise approach of Chopart of Paris was not advocated until near its end, and more proximal hindfoot amputations were not devised until well into the 19th century.
MIDTARSAL DISARTICULATION Chopart’s disarticulation at the level of the talonavicular and calcaneo-cuboid joints, described in 1792, preserved the talus, calcaneum and tendo Achillis insertion but left most other foot tendons detached.3 Originally performed with a long plantar flap, other approaches attempted include equal dorsal and plantar flaps championed by Chelius of Heidelberg, the medioplantar flap by Sedillot of Paris and the dorsal flap by Baudens of Paris.4 The relatively direct transarticular section was modified by preservation of the navicular and/or cuboid, often by mistake, excision of bone from distal calcaneum and talus, and various combinations of these. Although often complicated by marked equinus, due to unopposed action of the tendo Achillis, some maintained this was prevented if secondary attachment of the dorsiflexors was obtained by scarring, as with a dorsal flap. In recommending his own amputation, Syme of Edinburgh remained partisan to Chopart’s classical procedure whenever possible, claiming none of his patients had developed equinus deformity.
SUBTALAR DISARTICULATION TRANSTALAR AMPUTATION
a
C
D
Fig. 1-A) Syme’s stump. Complete excision of the foot, ankle malleoli and a thin section of tibia. (B) Pirigov’s stump. Similar excision to Syme’s but with retention of the tendo Achillis and calcaneal tuberosity applied to the cut tibia1 surface. Often tibia1 shortening greater than Syme’s. (C) Lignerolle’s stump. Subtalar disarticulation with preservation of the ankle and talus. Talar equinus proved unwelcome. (D) Hancock’s stump. Subtalar disarticulation removing head of talus but retaining a sliver of calcaneal tuberosity applied to the subtaloid surface. Tdlar equinus also an obstacle.
the talus proved irksome for it usually assumed an equinus attitude, provoking excess pressure by prostheses on the talar head. In 1864 Hancock6 excised the head and bone protruding below the malleoli and applied a sliver of posterior calcaneum (Fig. lD), after the manner of Pirigov (see below). Nevertheless, suitable indications for subtalar section were uncommon and the results unsatisfactory. In 1924 Elmslie of London, after much surgical experience in the 1914-1918 War, wrote:
AND
Hancock of London stated that this concept was suggested by Lignerolles of Paris, first performed by Textor of Wurzburg in 1841 and promulgated by Malgaine of Paris in 1846’ (Fig. 1C). Lateral, medial, posterolateral and posterior flaps were tried, particularly in France, to ameliorate results but retention of 117
118 The Foot
Subastragaloid amputation consists in a d&articulation of the foot . . . being covered by an internal plantar flap. This amputation is rarely possible, and leaves a stump which is less satisfactory than that of Syme’s amputation7
The procedure is now of historical interest only.
TIBIOTALAR AMPUTATION Removal of the whole foot by disarticulation at ankle joint level was undertaken sporadically before the 19th century. When confirming this in 1796, Bell of Edinburgh’ pointed out that the projecting malleoli made it difficult to obtain good skin cover and in any case the long stump was ill fitted for a prosthesis; formal below-knee amputation was recommended. Farabeuf of Paris maintained that Baudens rehabilitated ankle disarticulation in 1841, although he did not remove tibia1 cartilage and fashioned an anterior flap ill adapted for weight transmission; nevertheless he felt that Baudens should share honours with Syme for this innovation. Syme’s amputation To preserve limbs from amputation, Syme became a protagonist of joint excision for caries, that is bovine tuberculosis,” but found many ankle joints were associated with additional pathology in the subtaloid joint. If talus and calcaneum were diseased, he advised below-knee amputation as the only practical course; at that time, in 1831, he suggested amputation through the tibia at or below its middle, significantly lower routine below-knee secti0n.i’ than Subsequently he conceived the idea of ‘amputation at the ankle-joint’ for talocalcaneal disease, reporting in 1843 on a patient with caries: As the disease extended beyond the limits of Chopart’s operation, it would have been necessary, in accordance with ordinary practice, to remove the leg below the knee, but as the ankle seemed to be sound, I resolved to perform disarticulation there . . .the disarticulation being then readily completed, the malleolar projections were removed by means of cutting pliers.12
Syme did not excise the articular cartilage of the tibia but said if this was diseased, it would be easy to remove by sawing off a slice as the caries penetrated at no great depth into cancellous bone, and later this became his routinei (Fig. 1A). The plantar weightbearing skin of the heel was sutured beneath the stump and his first patient did well, being able to walk up to 30 miles with a simple having performed prosthesis. l4 Syme regretted unnecessary radical operations in the past and concluded: The advantages promised by amputation at the ankle joint, instead of the operation near the knee, are: lst, That the risk of (to) life will be smaller; 2nd, That a
more comfortable stump will be afforded; and, 3rd, That the limb will be more seemly and useful for support and progressive motion.
His conclusions proved correct, especially for younger patients as demonstrated in the Great Wars of this century. Among a variety of approaches to disarticulate the foot, Farabeuf advised a medial flap and Roux of Paris a medioposterior flap but these complicated an otherwise simple approach.15 In a wide ranging survey of Syme’s procedure in 1956, Harris16 emphasized the importance of transection of the tibia just above the articular surface to obtain the largest area of support, of the transection being parallel to the ground when standing and not necessarily at right angles to the tibia1 shaft, of careful subperiosteal dissection of the calcaneum to preserve the hydraulic, elastic adipose compartments of the heel flap intact and careful placement of the flap beneath the tibia using adhesive strapping. Harris believed condemnation of Syme’s amputation, in some quarters, was due to poor operative technique, although he agreed the bulky prosthesis required to accommodate the stump would never be popular with women, unless new prosthetic materials reduced this bulk. Pirogov’s amputation Pirogov of St Petersburg approved of Syme’s amputation but proposed an osteoplastic improvement in 185&l’ to minimize shortening and to facilitate stabilization of the heel pad. This required preservation of the posterior tubercle of the calcaneum with tendo Achillis attachment, or even one-third of the bone which was applied to the cut surface of the tibia in the hope of osseous union (Fig. 1B). However it was not always easy to turn the calcaneal remnant through 90” without further shortening of the tibia which Pirogov was prepared to do, to obtain sound bony contact, thus losing any gain in length over Syme’s operation; bony union was not always obtained. If the calcaneum was diseased then Pirogov’s procedure was not possible. However, Hancock stated that sloughing of the flap was less evident than after Syme’s amputation.18 Pasquier and Le Fort, both of Paris proposed horizontal section of the calcaneum at the superior limit of the tendo Achillis insertion, thus leaving somewhat over half the calcaneum to be applied to the tibia.ig This proved a more difficult procedure demanding a completely healthy calcaneum and it never attracted adherents. It was revived by Boyd of Memphis in 1939, a good result depending on sound tibiocalcaneal arthrodesis.” CONCLUSIONS Many of these foot amputations designed to eradicate joint tuberculosis are now discarded and only
Foot amputations:
disarticulation of toes, disarticulation of rays and Symes amputation are commonly practised.
References I. Heister L. A general system of surgery. London: Innys. 1743: 342. 2. Chelius J M. A system of surgery. Transl by South J F. London: Renshaw. 1847; II: 947. 3. Lafiteau Mons. Observation sur une amputation partielle du pied. In: Fourcroy A F. La medecine eclair&e par les sciences physiques. Paris: Buisson. 1792; IV: 85-88. 4. Farabeuf L-H. Prtcis de manuel operatoire. Paris: Masson, 1885; 466. 5. Hancock H. On the operative surgery of the foot and ankle-joint. London: Churchill, 1873: 191-192. 6. Hancock. ibid. 206-213. 7. Elmslie R C. Amputations. In: Carson H W, ed. Modern operative surgery, 1924; I: 131. 8. Bell B. Cours complet de chirurgie theorique et pratique. Paris: Barrois, 1796; VI: 244. 9. Farabeuf. ibid. 507. IO. Kirkup J. Bone and joint excisions of the foot (history page 3). The Foot 1991; 1: 165-166.
(2) Hindfoot
11. Syme J. Treatise on the excision of diseased joints. Edinburgh: Black, 1831: 144. 12. Syme J. Amputation at the ankle joint. London Edinburgh Monthly J, 1843; 3: 93-96. 13. Syme J. Contributions to the pathology and practice of surgery. Edinburgh: Sutherland & Knox. 1848. 14. Syme J. Observations in clinical surgery, 2nd ed. Edinburgh: Edmonston & Douglas. 1862: 40. 15. Farabeuf. ibid. 5199526. 16. Harris R I. Syme’s amputation. J Bone Joint Surg 1956; 38B: 614-632. 17. Pirogov N I. Kostno-plasticheskoye udlineniye kostei goleni pri vilushtshenii stopi. [Osteoplastic elongation of the bones of the leg in amputation of the foot.] Voyenno-med J 1854; 63: 833100. 18. Hancock. ibid. 182. 19. Farabeuf. ibid. 532. 20. Boyd H B. Amputation of the foot with calcaneotibia1 arthrodesis. J Bone Joint Surg 1939: 21: 997.
The author John R.Kirkup Weston Hill 1 Weston Park East Bath BAl 2XA UK
119
Until the 19th century, below-knee amputation a hand’s breadth distal to the patella was the standard solution for advanced pathology of the hindfoot.’ If sporadic partial hindfoot amputations were reported in the 18th century,2 the precise approach of Chopart of Paris was not advocated until near its end, and more proximal hindfoot amputations were not devised until well into the 19th century.
MIDTARSAL DISARTICULATION Chopart’s disarticulation at the level of the talonavicular and calcaneo-cuboid joints, described in 1792, preserved the talus, calcaneum and tendo Achillis insertion but left most other foot tendons detached.3 Originally performed with a long plantar flap, other approaches attempted include equal dorsal and plantar flaps championed by Chelius of Heidelberg, the medioplantar flap by Sedillot of Paris and the dorsal flap by Baudens of Paris.4 The relatively direct transarticular section was modified by preservation of the navicular and/or cuboid, often by mistake, excision of bone from distal calcaneum and talus, and various combinations of these. Although often complicated by marked equinus, due to unopposed action of the tendo Achillis, some maintained this was prevented if secondary attachment of the dorsiflexors was obtained by scarring, as with a dorsal flap. In recommending his own amputation, Syme of Edinburgh remained partisan to Chopart’s classical procedure whenever possible, claiming none of his patients had developed equinus deformity.
SUBTALAR DISARTICULATION TRANSTALAR AMPUTATION
a
C
D
Fig. 1-A) Syme’s stump. Complete excision of the foot, ankle malleoli and a thin section of tibia. (B) Pirigov’s stump. Similar excision to Syme’s but with retention of the tendo Achillis and calcaneal tuberosity applied to the cut tibia1 surface. Often tibia1 shortening greater than Syme’s. (C) Lignerolle’s stump. Subtalar disarticulation with preservation of the ankle and talus. Talar equinus proved unwelcome. (D) Hancock’s stump. Subtalar disarticulation removing head of talus but retaining a sliver of calcaneal tuberosity applied to the subtaloid surface. Tdlar equinus also an obstacle.
the talus proved irksome for it usually assumed an equinus attitude, provoking excess pressure by prostheses on the talar head. In 1864 Hancock6 excised the head and bone protruding below the malleoli and applied a sliver of posterior calcaneum (Fig. lD), after the manner of Pirigov (see below). Nevertheless, suitable indications for subtalar section were uncommon and the results unsatisfactory. In 1924 Elmslie of London, after much surgical experience in the 1914-1918 War, wrote:
AND
Hancock of London stated that this concept was suggested by Lignerolles of Paris, first performed by Textor of Wurzburg in 1841 and promulgated by Malgaine of Paris in 1846’ (Fig. 1C). Lateral, medial, posterolateral and posterior flaps were tried, particularly in France, to ameliorate results but retention of 117
118 The Foot
Subastragaloid amputation consists in a d&articulation of the foot . . . being covered by an internal plantar flap. This amputation is rarely possible, and leaves a stump which is less satisfactory than that of Syme’s amputation7
The procedure is now of historical interest only.
TIBIOTALAR AMPUTATION Removal of the whole foot by disarticulation at ankle joint level was undertaken sporadically before the 19th century. When confirming this in 1796, Bell of Edinburgh’ pointed out that the projecting malleoli made it difficult to obtain good skin cover and in any case the long stump was ill fitted for a prosthesis; formal below-knee amputation was recommended. Farabeuf of Paris maintained that Baudens rehabilitated ankle disarticulation in 1841, although he did not remove tibia1 cartilage and fashioned an anterior flap ill adapted for weight transmission; nevertheless he felt that Baudens should share honours with Syme for this innovation. Syme’s amputation To preserve limbs from amputation, Syme became a protagonist of joint excision for caries, that is bovine tuberculosis,” but found many ankle joints were associated with additional pathology in the subtaloid joint. If talus and calcaneum were diseased, he advised below-knee amputation as the only practical course; at that time, in 1831, he suggested amputation through the tibia at or below its middle, significantly lower routine below-knee secti0n.i’ than Subsequently he conceived the idea of ‘amputation at the ankle-joint’ for talocalcaneal disease, reporting in 1843 on a patient with caries: As the disease extended beyond the limits of Chopart’s operation, it would have been necessary, in accordance with ordinary practice, to remove the leg below the knee, but as the ankle seemed to be sound, I resolved to perform disarticulation there . . .the disarticulation being then readily completed, the malleolar projections were removed by means of cutting pliers.12
Syme did not excise the articular cartilage of the tibia but said if this was diseased, it would be easy to remove by sawing off a slice as the caries penetrated at no great depth into cancellous bone, and later this became his routinei (Fig. 1A). The plantar weightbearing skin of the heel was sutured beneath the stump and his first patient did well, being able to walk up to 30 miles with a simple having performed prosthesis. l4 Syme regretted unnecessary radical operations in the past and concluded: The advantages promised by amputation at the ankle joint, instead of the operation near the knee, are: lst, That the risk of (to) life will be smaller; 2nd, That a
more comfortable stump will be afforded; and, 3rd, That the limb will be more seemly and useful for support and progressive motion.
His conclusions proved correct, especially for younger patients as demonstrated in the Great Wars of this century. Among a variety of approaches to disarticulate the foot, Farabeuf advised a medial flap and Roux of Paris a medioposterior flap but these complicated an otherwise simple approach.15 In a wide ranging survey of Syme’s procedure in 1956, Harris16 emphasized the importance of transection of the tibia just above the articular surface to obtain the largest area of support, of the transection being parallel to the ground when standing and not necessarily at right angles to the tibia1 shaft, of careful subperiosteal dissection of the calcaneum to preserve the hydraulic, elastic adipose compartments of the heel flap intact and careful placement of the flap beneath the tibia using adhesive strapping. Harris believed condemnation of Syme’s amputation, in some quarters, was due to poor operative technique, although he agreed the bulky prosthesis required to accommodate the stump would never be popular with women, unless new prosthetic materials reduced this bulk. Pirogov’s amputation Pirogov of St Petersburg approved of Syme’s amputation but proposed an osteoplastic improvement in 185&l’ to minimize shortening and to facilitate stabilization of the heel pad. This required preservation of the posterior tubercle of the calcaneum with tendo Achillis attachment, or even one-third of the bone which was applied to the cut surface of the tibia in the hope of osseous union (Fig. 1B). However it was not always easy to turn the calcaneal remnant through 90” without further shortening of the tibia which Pirogov was prepared to do, to obtain sound bony contact, thus losing any gain in length over Syme’s operation; bony union was not always obtained. If the calcaneum was diseased then Pirogov’s procedure was not possible. However, Hancock stated that sloughing of the flap was less evident than after Syme’s amputation.18 Pasquier and Le Fort, both of Paris proposed horizontal section of the calcaneum at the superior limit of the tendo Achillis insertion, thus leaving somewhat over half the calcaneum to be applied to the tibia.ig This proved a more difficult procedure demanding a completely healthy calcaneum and it never attracted adherents. It was revived by Boyd of Memphis in 1939, a good result depending on sound tibiocalcaneal arthrodesis.” CONCLUSIONS Many of these foot amputations designed to eradicate joint tuberculosis are now discarded and only
Foot amputations:
disarticulation of toes, disarticulation of rays and Symes amputation are commonly practised.
References I. Heister L. A general system of surgery. London: Innys. 1743: 342. 2. Chelius J M. A system of surgery. Transl by South J F. London: Renshaw. 1847; II: 947. 3. Lafiteau Mons. Observation sur une amputation partielle du pied. In: Fourcroy A F. La medecine eclair&e par les sciences physiques. Paris: Buisson. 1792; IV: 85-88. 4. Farabeuf L-H. Prtcis de manuel operatoire. Paris: Masson, 1885; 466. 5. Hancock H. On the operative surgery of the foot and ankle-joint. London: Churchill, 1873: 191-192. 6. Hancock. ibid. 206-213. 7. Elmslie R C. Amputations. In: Carson H W, ed. Modern operative surgery, 1924; I: 131. 8. Bell B. Cours complet de chirurgie theorique et pratique. Paris: Barrois, 1796; VI: 244. 9. Farabeuf. ibid. 507. IO. Kirkup J. Bone and joint excisions of the foot (history page 3). The Foot 1991; 1: 165-166.
(2) Hindfoot
11. Syme J. Treatise on the excision of diseased joints. Edinburgh: Black, 1831: 144. 12. Syme J. Amputation at the ankle joint. London Edinburgh Monthly J, 1843; 3: 93-96. 13. Syme J. Contributions to the pathology and practice of surgery. Edinburgh: Sutherland & Knox. 1848. 14. Syme J. Observations in clinical surgery, 2nd ed. Edinburgh: Edmonston & Douglas. 1862: 40. 15. Farabeuf. ibid. 5199526. 16. Harris R I. Syme’s amputation. J Bone Joint Surg 1956; 38B: 614-632. 17. Pirogov N I. Kostno-plasticheskoye udlineniye kostei goleni pri vilushtshenii stopi. [Osteoplastic elongation of the bones of the leg in amputation of the foot.] Voyenno-med J 1854; 63: 833100. 18. Hancock. ibid. 182. 19. Farabeuf. ibid. 532. 20. Boyd H B. Amputation of the foot with calcaneotibia1 arthrodesis. J Bone Joint Surg 1939: 21: 997.
The author John R.Kirkup Weston Hill 1 Weston Park East Bath BAl 2XA UK
119