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The Lisfranc Amputation: A More Reliable Level of Amputation With Proper Intraoperative Tendon Balancing
The Journal of Foot & Ankle Surgery 56 (2017) 824–826
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
The Lisfranc Amputation: A More Reliable Level of Amputation With Proper Intraoperative Tendon Balancing Christopher J. Greene, DPM 1, 2, Christopher Bibbo, DO, DPM, FACFAS 3 1
Surgeon, Foot & Ankle Surgeons of Oklahoma, Oklahoma City, OK Clinical Instructor, Surgical Hospital of Oklahoma/Cleveland Clinic Foundation Podiatric Reconstructive Foot & Ankle Surgery Residency, Oklahoma City, OK 3 Chief of Foot & Ankle Surgery, Orthoplastics, Microsurgery & Limb Savage Service, Rubin Institute for Advanced Orthopaedics/International Limb Lengthening Center, Sinai Hospital of Baltimore, Baltimore, MD 2
a r t i c l e i n f o
a b s t r a c t
Keywords: amputation biomechanics Lisfranc tendon balancing
Traditional transmetatarsal amputations are a reliable level of amputation. However, amputations at the Lisfranc level have met with limited success owing to improper biomechanics resulting from tendon imbalance, ultimately leading to foot deformity positions and an unstable soft tissue envelope with ensuing skin breakdown, infection, and below-the-knee amputation. We describe proper tendon rebalancing that results in improved biomechanics and a more reliable and stable amputation at the more proximal Lisfranc level. Ó 2017 by the American College of Foot and Ankle Surgeons. All rights reserved.
The Lisfranc level of amputation provides a viable surgical option when a transmetatarsal amputation cannot be performed. This level of amputation has been underused owing to its high failure rate. The high failure rate correlates directly with the biomechanical imbalance that is created when the appropriate tendon transfers are not performed. Compared with the more traditional distal transmetatarsal amputation, this more proximal level of amputation can be performed because of infection, peripheral arterial disease, gangrene, osteomyelitis, trauma, neuropathic ulcerations, and, rarely, neoplasms (1). When performing Lisfranc amputation, the insertion of the peroneus longus, peroneus brevis, tibialis anterior, and extensor hallucis longus tendons will be compromised, leading to the high failure rate. The biomechanical influences of these pedal tendons must be addressed for the amputation to be successful. Once these are addressed, the pitfalls of the Lisfranc amputation can be avoided. The other imperative influence that must be addressed is the gastrosoleus complex; therefore, gastrocnemius recession must be performed. If this procedure is negated, the longevity of the stump will not withstand closed kinetic chain motion. The technique we describe provides a functional approach to balancing the pedal stump and avoid the complications of this level of amputation stemming from improper
Financial Disclosure: None reported. Conflict of Interest: None reported. Address correspondence to: Christopher Bibbo, DO, DPM, FACFAS, Rubin Institute for Advanced Orthopaedics/International Limb Lengthening Center, Sinai Hospital, 2401 West Belvedere Avenue, Baltimore, MD 12125. E-mail address: [email protected] (C. Bibbo).
biomechanics, including varus deformation of the stump, equinus, and an antalgic gait (2). All these abnormalities in biomechanics can ultimately lead to ulceration, subsequent infection, and the need for a more proximal amputation. The purpose of the present report is to describe the appropriate tendon transfers to provide the proper biomechanical balance, avoiding the pitfalls of improper biomechanics at the proximal level of the Lisfranc amputation. Surgical Technique The present report was institutional review board exempt. In the presence of arterial disease, it is recommended that vascular
Fig. 1. Peroneus longus tendon identified for later transfer. Black arrow indicates direction of tissue advancement to facilitate wound closure.
1067-2516/$ - see front matter Ó 2017 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2017.01.054
C.J. Greene, C. Bibbo / The Journal of Foot & Ankle Surgery 56 (2017) 824–826
825
Fig. 2. Peroneus longus tendon transferred to the cuboid. Black arrow indicates direction of tissue advancement to facilitate wound closure.
Fig. 4. Dorsal and plantar flaps. Black arrows indicate direction of tissue advancement to facilitate wound closure.
intervention is undertaken before performing the Lisfranc amputation. The patient is placed in the supine position. Depending on the vascular status of the patient, a pneumatic thigh tourniquet can be used. If a tourniquet is used, the lower extremity should be elevated and allowed to exsanguinate with gravity before inflating the tourniquet. The tourniquet should only be inflated to a pressure of no more than 100 mm Hg greater than the systolic blood pressure. However, for patients with vascular compromise, a tourniquet should not be used. The incisions are planned to maximize exposure without jeopardizing the intervening skin bridges. A medial incision is placed that extends from the margin of the proximal medial cuneiform distally along the first metatarsal shaft and then carried plantarly across the digital sulcus. This incision is then extended laterally along the fifth metatarsal shaft, extending to the cuboid. The dorsal and plantar flaps are developed just proximal to the Lisfranc joint line, preserving all major neurovascular structures. The extensor hallucis longus tendon, peroneus brevis tendon, and peroneus longus tendon are all dissected and tagged for later transfer (Fig. 1). Next, the tibialis anterior tendon is identified and removed from the first metatarsal base, preserving its cuneiform insertion. Then, using an osteotome, the metatarsals are disarticulated along the Lisfranc joint. A saw is then used, and the distal aspect of the medial cuneiform is planned, flush with the intermediate cuneiform. A 4.0-mm drill is then used. A pilot hole is first drilled from the lateral proximal cuboid to the plantar distal cuboid. The peroneus longus is then passed through the hole with a tendon passer and secured to the plantar and proximal cortex with no. 2 polyester suture, maintaining the stump in a neutral position (Fig. 2). The peroneus brevis is then anastomosed with the peroneus longus tendon and secured to the periosteal tissue of the cuboid. A pilot hole is then created in the lateral cuneiform from the dorsal to plantar surfaces with the 4.0-mm drill. The extensor hallucis
longus tendon was then transferred to the lateral cuneiform (Fig. 3). The integrity of the tibialis anterior tendon insertion is then visualized and repaired, if necessary. The site was then irrigated with copious amounts of sterile saline, and the dorsal and plantar flaps are contoured to allow advancement of the plantar flap, preserving the plantar fat pad and soft tissue for the stump (Fig. 4). Sequentially, the deep tissues are reapproximated to avoid a dead space, followed by subcutaneous and skin closure. A gastrocnemius recession is performed, and the bandage is applied. Finally, the stump is positioned to a neutral position, and a posterior splint was contoured to the stump (Fig. 5). On discharge, the patient returns for follow-up examinations weekly until the site has healed, and the sutures and staples are removed (Fig. 6). On the sixth week, the patient begins range of motion exercises and allowed to begin weightbearing in a pneumatic boot. At week 8, they are advanced to normal shoe gear, as tolerated.
Fig. 3. Extensor hallucis longus tendon transfer to the lateral cuneiform. Black arrow indicates direction of tissue advancement to facilitate wound closure.
Discussion Traditionally, foot amputation levels above the level of the transmetatarsal level have been met with skepticism. We believe this has mainly resulted from a lack of understanding of biomechanics and the need for tendon balancing to mitigate abnormal pressure forces that result during gait. To this end, a limited number of studies have addressed this issue and not all were specific for the challenging region of the proximal transmetatarsal amputation (2–8). Therefore, we have presented a conceptually simple technique of tendon balancing that produces excellent results. Initially, when the performing this procedure, the anterior tibialis tendon was transferred to the lateral cuneiform. During the course of performing this procedure, the lead author (C.B.) found that preserving most of the tibialis tendon insertion and transferring the extensor hallucis longus tendon to
Fig. 5. Incisions healed before suture removal.
826
C.J. Greene, C. Bibbo / The Journal of Foot & Ankle Surgery 56 (2017) 824–826
proper biomechanical balance. This technique provides a functional approach and balance of the pedal stump to avoid the known complications. References
Fig. 6. Posterior splint contoured to the stump.
the lateral cuneiform assisted in a more plantar-grade stump and balanced range of motion. This surgical maneuver has been proved to improve the outcomes and allow for more durable results. In conclusion, for a proximal Lisfranc amputation to be successful, the appropriate tendon transfers must be performed to provide the
1. Decotiis MA. Lisfranc and Chopart amputations. Clin Podiatr Med Surg 22:385–393, 2005. 2. Clark GD, Lui E, Cook KD. Tendon balancing in pedal amputations. Clin Podiatr Med Surg 22:447–467, 2005. 3. Bibbo C. A modification of the Syme amputation to prevent post-operative heel pad migration. J Foot Ankle Surg 52:766–770, 2013. 4. Krause FG, Pfander G, Henning J, Shafighi M, Weber M. Ankle dorsiflexion arthrodesis to salvage Chopart’s amputation with anterior skin insufficiency. Foot Ankle Int 34:1560–1568, 2013. 5. Roukis TS. Flexor hallucis longus and extensor digitorum longus tendon transfers for balancing the foot following transmetatarsal amputation. J Foot Ankle Surg 48:398–401, 2009. 6. Boffeli TJ, Abben KW. Complete fifth ray amputation with peroneal tendon transferda staged surgical protocol. J Foot Ankle Surg 51:696–701, 2012. 7. Schweinberger MH, Roukis TS. Balancing of the transmetatarsal amputation with peroneus brevis to peroneus longus tendon transfer. J Foot Ankle Surg 46:510–514, 2007. 8. Hamilton GA, Ford LA, Perez H, Rush SM. Salvage of the neuropathic foot by using bone resection and tendon balancing: a retrospective review of 10 patients. J Foot Ankle Surg 44:37–43, 2005.
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
The Lisfranc Amputation: A More Reliable Level of Amputation With Proper Intraoperative Tendon Balancing Christopher J. Greene, DPM 1, 2, Christopher Bibbo, DO, DPM, FACFAS 3 1
Surgeon, Foot & Ankle Surgeons of Oklahoma, Oklahoma City, OK Clinical Instructor, Surgical Hospital of Oklahoma/Cleveland Clinic Foundation Podiatric Reconstructive Foot & Ankle Surgery Residency, Oklahoma City, OK 3 Chief of Foot & Ankle Surgery, Orthoplastics, Microsurgery & Limb Savage Service, Rubin Institute for Advanced Orthopaedics/International Limb Lengthening Center, Sinai Hospital of Baltimore, Baltimore, MD 2
a r t i c l e i n f o
a b s t r a c t
Keywords: amputation biomechanics Lisfranc tendon balancing
Traditional transmetatarsal amputations are a reliable level of amputation. However, amputations at the Lisfranc level have met with limited success owing to improper biomechanics resulting from tendon imbalance, ultimately leading to foot deformity positions and an unstable soft tissue envelope with ensuing skin breakdown, infection, and below-the-knee amputation. We describe proper tendon rebalancing that results in improved biomechanics and a more reliable and stable amputation at the more proximal Lisfranc level. Ó 2017 by the American College of Foot and Ankle Surgeons. All rights reserved.
The Lisfranc level of amputation provides a viable surgical option when a transmetatarsal amputation cannot be performed. This level of amputation has been underused owing to its high failure rate. The high failure rate correlates directly with the biomechanical imbalance that is created when the appropriate tendon transfers are not performed. Compared with the more traditional distal transmetatarsal amputation, this more proximal level of amputation can be performed because of infection, peripheral arterial disease, gangrene, osteomyelitis, trauma, neuropathic ulcerations, and, rarely, neoplasms (1). When performing Lisfranc amputation, the insertion of the peroneus longus, peroneus brevis, tibialis anterior, and extensor hallucis longus tendons will be compromised, leading to the high failure rate. The biomechanical influences of these pedal tendons must be addressed for the amputation to be successful. Once these are addressed, the pitfalls of the Lisfranc amputation can be avoided. The other imperative influence that must be addressed is the gastrosoleus complex; therefore, gastrocnemius recession must be performed. If this procedure is negated, the longevity of the stump will not withstand closed kinetic chain motion. The technique we describe provides a functional approach to balancing the pedal stump and avoid the complications of this level of amputation stemming from improper
Financial Disclosure: None reported. Conflict of Interest: None reported. Address correspondence to: Christopher Bibbo, DO, DPM, FACFAS, Rubin Institute for Advanced Orthopaedics/International Limb Lengthening Center, Sinai Hospital, 2401 West Belvedere Avenue, Baltimore, MD 12125. E-mail address: [email protected] (C. Bibbo).
biomechanics, including varus deformation of the stump, equinus, and an antalgic gait (2). All these abnormalities in biomechanics can ultimately lead to ulceration, subsequent infection, and the need for a more proximal amputation. The purpose of the present report is to describe the appropriate tendon transfers to provide the proper biomechanical balance, avoiding the pitfalls of improper biomechanics at the proximal level of the Lisfranc amputation. Surgical Technique The present report was institutional review board exempt. In the presence of arterial disease, it is recommended that vascular
Fig. 1. Peroneus longus tendon identified for later transfer. Black arrow indicates direction of tissue advancement to facilitate wound closure.
1067-2516/$ - see front matter Ó 2017 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2017.01.054
C.J. Greene, C. Bibbo / The Journal of Foot & Ankle Surgery 56 (2017) 824–826
825
Fig. 2. Peroneus longus tendon transferred to the cuboid. Black arrow indicates direction of tissue advancement to facilitate wound closure.
Fig. 4. Dorsal and plantar flaps. Black arrows indicate direction of tissue advancement to facilitate wound closure.
intervention is undertaken before performing the Lisfranc amputation. The patient is placed in the supine position. Depending on the vascular status of the patient, a pneumatic thigh tourniquet can be used. If a tourniquet is used, the lower extremity should be elevated and allowed to exsanguinate with gravity before inflating the tourniquet. The tourniquet should only be inflated to a pressure of no more than 100 mm Hg greater than the systolic blood pressure. However, for patients with vascular compromise, a tourniquet should not be used. The incisions are planned to maximize exposure without jeopardizing the intervening skin bridges. A medial incision is placed that extends from the margin of the proximal medial cuneiform distally along the first metatarsal shaft and then carried plantarly across the digital sulcus. This incision is then extended laterally along the fifth metatarsal shaft, extending to the cuboid. The dorsal and plantar flaps are developed just proximal to the Lisfranc joint line, preserving all major neurovascular structures. The extensor hallucis longus tendon, peroneus brevis tendon, and peroneus longus tendon are all dissected and tagged for later transfer (Fig. 1). Next, the tibialis anterior tendon is identified and removed from the first metatarsal base, preserving its cuneiform insertion. Then, using an osteotome, the metatarsals are disarticulated along the Lisfranc joint. A saw is then used, and the distal aspect of the medial cuneiform is planned, flush with the intermediate cuneiform. A 4.0-mm drill is then used. A pilot hole is first drilled from the lateral proximal cuboid to the plantar distal cuboid. The peroneus longus is then passed through the hole with a tendon passer and secured to the plantar and proximal cortex with no. 2 polyester suture, maintaining the stump in a neutral position (Fig. 2). The peroneus brevis is then anastomosed with the peroneus longus tendon and secured to the periosteal tissue of the cuboid. A pilot hole is then created in the lateral cuneiform from the dorsal to plantar surfaces with the 4.0-mm drill. The extensor hallucis
longus tendon was then transferred to the lateral cuneiform (Fig. 3). The integrity of the tibialis anterior tendon insertion is then visualized and repaired, if necessary. The site was then irrigated with copious amounts of sterile saline, and the dorsal and plantar flaps are contoured to allow advancement of the plantar flap, preserving the plantar fat pad and soft tissue for the stump (Fig. 4). Sequentially, the deep tissues are reapproximated to avoid a dead space, followed by subcutaneous and skin closure. A gastrocnemius recession is performed, and the bandage is applied. Finally, the stump is positioned to a neutral position, and a posterior splint was contoured to the stump (Fig. 5). On discharge, the patient returns for follow-up examinations weekly until the site has healed, and the sutures and staples are removed (Fig. 6). On the sixth week, the patient begins range of motion exercises and allowed to begin weightbearing in a pneumatic boot. At week 8, they are advanced to normal shoe gear, as tolerated.
Fig. 3. Extensor hallucis longus tendon transfer to the lateral cuneiform. Black arrow indicates direction of tissue advancement to facilitate wound closure.
Discussion Traditionally, foot amputation levels above the level of the transmetatarsal level have been met with skepticism. We believe this has mainly resulted from a lack of understanding of biomechanics and the need for tendon balancing to mitigate abnormal pressure forces that result during gait. To this end, a limited number of studies have addressed this issue and not all were specific for the challenging region of the proximal transmetatarsal amputation (2–8). Therefore, we have presented a conceptually simple technique of tendon balancing that produces excellent results. Initially, when the performing this procedure, the anterior tibialis tendon was transferred to the lateral cuneiform. During the course of performing this procedure, the lead author (C.B.) found that preserving most of the tibialis tendon insertion and transferring the extensor hallucis longus tendon to
Fig. 5. Incisions healed before suture removal.
826
C.J. Greene, C. Bibbo / The Journal of Foot & Ankle Surgery 56 (2017) 824–826
proper biomechanical balance. This technique provides a functional approach and balance of the pedal stump to avoid the known complications. References
Fig. 6. Posterior splint contoured to the stump.
the lateral cuneiform assisted in a more plantar-grade stump and balanced range of motion. This surgical maneuver has been proved to improve the outcomes and allow for more durable results. In conclusion, for a proximal Lisfranc amputation to be successful, the appropriate tendon transfers must be performed to provide the
1. Decotiis MA. Lisfranc and Chopart amputations. Clin Podiatr Med Surg 22:385–393, 2005. 2. Clark GD, Lui E, Cook KD. Tendon balancing in pedal amputations. Clin Podiatr Med Surg 22:447–467, 2005. 3. Bibbo C. A modification of the Syme amputation to prevent post-operative heel pad migration. J Foot Ankle Surg 52:766–770, 2013. 4. Krause FG, Pfander G, Henning J, Shafighi M, Weber M. Ankle dorsiflexion arthrodesis to salvage Chopart’s amputation with anterior skin insufficiency. Foot Ankle Int 34:1560–1568, 2013. 5. Roukis TS. Flexor hallucis longus and extensor digitorum longus tendon transfers for balancing the foot following transmetatarsal amputation. J Foot Ankle Surg 48:398–401, 2009. 6. Boffeli TJ, Abben KW. Complete fifth ray amputation with peroneal tendon transferda staged surgical protocol. J Foot Ankle Surg 51:696–701, 2012. 7. Schweinberger MH, Roukis TS. Balancing of the transmetatarsal amputation with peroneus brevis to peroneus longus tendon transfer. J Foot Ankle Surg 46:510–514, 2007. 8. Hamilton GA, Ford LA, Perez H, Rush SM. Salvage of the neuropathic foot by using bone resection and tendon balancing: a retrospective review of 10 patients. J Foot Ankle Surg 44:37–43, 2005.