transtibial amputation after severe

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Osteocutaneous Pedicle Flap Transfer for Salvage

of Transtibial Amputation After Severe

Lower-Extremity Injury(J Bone Joint Surg Am. 2012;94:447-54)

Hendrik B. MenggaGeneral Surgery Resident, Sam Ratulangi University

Division of Orthopaedic

Journal Reading



Background

• High-energy blunt or penetrating trauma to

the lower extremity may result in loss of limb

• Amputation may be performed on ER :

because of arterial injury / life-threatening

blood loss, or non-reconstructable bone

• Later amputation because of infection,

malunion, nonunion, arthrosis, or pain from

other sources



Background

• Below-the-knee or transtibial amputation is

the most common

• Prosthetic fitting is reliable after transtibial

amputation

• Some injuries generate massive destruction

around the proximal preclude the

performance of a transtibial amputation

• More proximal level is required



Background

• knee disarticulation and transfemoral

amputation increase the energy required to

walk, evenwith a prosthesis

• An alternative technique : ‘‘salvage’’ a

transtibial amputation level by using a

rotational osteocutaneous pedicle flap

transfer from the foot



Background

• Osseous length and soft-tissue coverage can

be augmented with the flap to provide a

functional transtibial amputation

• The neural and vascular structures are

maintained, providing a durable, sensate

surface for prosthetic fitting



Background

• The purpose of this study : examine the

clinical results and functional outcomes of

patients who had salvage of a transtibial

amputation level with a rotational

osteocutaneous pedicle flap from the

ipsilateral foot



Materials and Methods

• 14 patients who had an osteocutaneous

pedicle flap from the ipsilateral foot were

included in the study.

• 12 were followed 24 months (mean, 60.2

months) and evaluated with use of the

Sickness Impact Profile (SIP), Musculoskeletal

Function Assessment (MFA), and a 100-ft(30.48-m) timed walking test



Materials and Methods....

• Surgical Technique

– The osteocutaneous flap is based on the posterior

tibial vascular pedicle with preservation of the deep

plantar arch – Incising the leg on the medial aspect and across the

posterior aspect of the distal part of the tibia and

extending the incision distally to the level of the first

metatarsophalangeal joint. – A full-thickness flap of plantar tissue is developed by

subperiosteal dissection posteriorly and laterally



Surgical Technique....

• The subtalar and calcaneocuboid joints aredisarticulated

• Calcaneus is retained without disruption of

the plantar pad and surrounding medial andlateral soft tissues

• The posterior tibial nerve and tibial artery are

preserved• Resection of the proximal part of the tibia and

debridement of the adjacent soft tissues




• The margins of the proximal part of the tibia areresected and contoured with an oscillating saw

• An oscillating saw is used to remove articular

cartilage from the subtalar joint and to modifythe shape of the calcaneal

• Calcaneus is rotated with the plantar tissuedirected anteriorly

• Secured and compressed against the proximalpart of the tibia with a large-fragment plate (Figs.1-A and 1-B)




• The fibula is resected obliquely to a level

approximately 2 cm proximal to the length of

the retained tibia and calcaneus

• Redundancy in the neurovascular bundle is

controlled

• Weight-bearing is advanced over the first two

months depending on healing of the soft

tissues and bone.



Outcomes

• Patients completed two functional outcomequestionnaires: the Musculoskeletal FunctionAssessment (MFA) and the Sickness Impact

Profile (SIP)• MFA having a greater focus onmusculoskeletal

function

•

The MFA and SIP have been documented to bereliable and valid outcomes instrumentspostinjury



Outcomes....

• 10 categories within the MFA (MusculoskeletalFunction Assessment) :1. Mobility

2. hand and fine motor

3. Housework4. self-care

5. sleep and rest

6. leisure and recreation

7. family relationships

8. cognition and thinking

9. emotional adjustment and adaptation

10. employment



Outcomes....

• Each category is scored independently, and an

overall score can be calculated. Values range

from 0 to 100



Outcomes....

• The SIP (Sickness Impact Profile) has twelve categories:1. Walking

2. Mobility

3. body care and movement

4. social interaction

5. Alertness6. emotional behavior

7. Communication

8. Sleep

9. Eating

10. Work11. Homemanagement

12. Recreation

SIP scores range from 0 to 100 points



Outcomes....

• SIP scores of >10 points indicate substantial

disability

• A 100-ft (30.5-m) timed walking test was

performed



Results

• There were 10 men and 4 women with mean age of 43.2 years.

• The records 14 patients treated at a level-I traumacenter between 1994 and 2006 were retrospectivelyreviewed

• 13 patients had a type-IIIB open tibial fracture, and onehad extensive soft-tissue loss secondary to a burn.

• 4 patients were treated for infection after theprocedure.

• There were no nonunions of the tibia to the calcaneus



• In the early post-reconstruction period, 7 of

the 14 patients required a total of 12additional procedures for wound

debridement, delayed wound closure, or

skingrafting.

• All wounds were healed within 10 weeks.

• Prosthesis usage began at a mean of 11.4

weeks (range, 8-15 weeks)



Results...

• 3 patients underwent late reconstructive

procedures to improve prosthetic fit.

• No patient required subsequent revision to a

more proximal amputation level.

• Mean knee flexion was 1390 (range, 120 to

150).

• 11 patients achieved a walking speed of >4 ft

(1.2 m) per second



Results...

• The MFA scores ranged from 11 to 48 with a

mean score of 35.4moderate functional

disability.

• The SIP scores ranged from 1.6 to 33, with a

mean of 13.0

• 9 of the 12 patients had a SIP score of >10

points substantial residual dysfunction



Discussion

• Conventional transtibial amputation,m inimum 9cm of the proximal part of the tibia must beintact

•

A durable soft-tissue envelope is also essential• In Osteocutaneus pedicle flap transfer vascular

reanastomosis is not required, avoiding freetissue transfer

• Fixation of the calcaneus to the tibia not onlyprovides additional stump length; it also preventsflap instability



Conclusions

• A novel technique has been developed to salvage

a transtibial amputation level with use of a

rotational osteocutaneous flap from the hindfoot.

• In the absence of adequate tibial length and/orsoft-tissue coverage to salvage the entire limb or

to perform a conventional-length transtibial

amputation, this technique is a highly functionalalternative that does not require microvascular

free tissue transfer.



Thank You

transtibial amputation after severe

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