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Pirogoff Amputation for Foot Trauma: An Unusual Amputation LevelA Case Report
F.M. den Bakker, MD1; H.R. Holtslag, PhD2; J.G.H. van den Brand, PhD1
1 Department of Surgery, Medical Centre Alkmaar, P.O. Box 501, 1800 AM Alkmaar, The Netherlands. E-mail address for F.M. den Bakker: f.m.den.bakker@mca.nl
2 Department of Rehabilitation and Sports Medicine, University Medical Centre Utrecht, Heidelberglaan 10, 3584 CX, Utrecht, The Netherlands
View Disclosures and Other Information
Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

Investigation performed at Medical Centre Alkmaar, Alkmaar, and Erasmus Medical Centre, Rotterdam, The Netherlands

Copyright © 2010 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2010 Oct 20;92(14):2462-2465. doi: 10.2106/JBJS.I.01336
5 Recommendations (Recommend) | 3 Comments | Saved by 3 Users Save Case

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Selecting an amputation level involves a choice between maximizing wound-healing potential and optimizing mobility and effective rehabilitation. When leg length is preserved, a patient uses less energy for walking and is more independent and mobile1-3.
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    Sujit K. Tripathy
    Posted on March 19, 2011
    Comment On: Pirogoff's Amputation for Foot Trauma: An Unusual Amputation Level: A Case Report
    Registrar, Department of Orthopaedics, Postgraduate Institute of Medical Education and Research, Chandigarh, India

    Editor's Note: The authors were invited to respond to the letter, but to date, have not done so.

    To the Editor:

    We intend to drop a few lines on our opinion and suggestions regarding the article, “Pirogoff Amputation for Foot Trauma: An Unusual Amputation Level: A Case Report” penned by Bakker et al. and published in your journal (2010;92:2462-5). The article was, indeed, an eye-opener and the laudability of the authors' efforts in foregrounding the effectuality of a rather uncommon variety of distal lower limb amputation (with which they have had considerable success in their patient), and recommending the same to their readers in appropriate situations, is unquestionable. Such articles definitely play an immense role in educating and guiding orthopedic surgeons, thereby facilitating the melioration of scientific, medical research and patient care.

    Pirogoff amputation is a highly successful surgical technique in mangled foot treatment, particularly when forefoot and midfoot is crushed and heel pad is preserved (1). We, however, have a few queries addressed to the authors and a few suggestions regarding the surgical techniques, based on our experience with this same technique in three patients with crush injury foot. Intra-operatively, we observed that as the surgeon attempts to rotate the calcaneum through 90 degrees, the intact Tendo-Achilles with its attachment to the posterior calcaneal tuberosity (that gets stretched during the procedure) prevents a smooth rotation of the heel bone. This poses a significant difficulty intra-operatively (even after removal of the distal tibial articular surface and talectomy that are components of this amputation procedure). A greater amount of anterior calcaneal osteotomy might then become inevitable to rotate the calcaneum through 90 degrees, which in turn would lead to a greater loss of height of the heel. Simple supplementary procedures like lengthening or even a tenotomy of the Tendo Achilles may, in our opinion, preclude any such intra-operative complications/ hurdles. Such a procedure may also, as we believe, obviate post-operative issues like late displacement of the heel pad (with the calcaneum) and delayed pain (due to the constant pull of the taut tendon). The Achilles tendon lengthening or tenotomy also allows the surgeon to resect a very small section of the anterior part of calcaneum, there by preserving the limb length.

    The authors had, in their paper, mentioned that the plantar surface (heel pad area) persists to serve as the weight bearing surface post-operatively. However, we rarely found this to happen with our patients. As the heel pad rotates along with its underlying bone, a majority of the plantar skin rather occupies the anterior surface of the residual stump. The distal weight bearing activity is, in fact, performed by a combination of three surfaces: the soft, posterior creased portion of skin that overlies the Achilles tendon and posterior calcaneum (which normally is a non-weight bearing area), the thick, plantar skin over the heel area with its soft cushion of fat pad underneath and the junction of these two different cutaneous surfaces. These usual nonweight bearing cutaneous portions slowly develop callosities with pressure following weight bearing, gradually transforming into thick surfaces adequate to the task. There have been modifications described in literature that suggest an anterior oblique osteotomy of the calcaneum and rotating the calcaneum through angles of 50 to 70 degrees (1, 2). This has been suggested to provide the following advantages: one, biomechanically, the most advantageous portion of the calcaneum and heel pad form the weight bearing surface; two, height of the heel may be better maintained as the calcaneal osteotomy that may be required to facilitate its rotation (as discussed in previous paragraph) may be curtailed.

    The authors had used external fixation technique to enhance union at the tibio-calcaneal arthrodesis site. We had used simple Steinmann pins (along with POP casts) across the bones after adequate exposure of the subchondral bones to facilitate such union and found the technique quite successful in all our patients. The steinmann pin also could be easily removed as an out-patient procedure at 2 months post-operatively and it had the advantage of minimising the chances of pin-tract infections too. With regard to the issue raised by the authors on the preservation of malleoli in these amputation stumps in order to facilitate easy prosthetic rehabilitation, we are in complete agreement with them. We had preserved the malleoli in all but one patient, in whom the medial malleolus was already fractured, precluding any option of preserving it. These patients, however, do well even without any prosthetic fitting. The authors were extremely right in cautioning the readers on the issue of wound healing and infections in these amputations especially in cases of crush injuries. We had the complication of skin necrosis in two of the three patients, with one of them developing severe wound infection that necessitated multiple debridements.

    Amputations are highly traumatic procedures that wreak havoc to the physical, psychological and social lives of the patients. Every treating surgeon must attempt to maximise the distalisation of the level of amputation, so as to minimise the post-operative disabilities and hardships. It was a commendable work by the authors in this aspect and all their recommendations must be helpful to every orthopedic surgeon in managing similar cases of mangled feet.

    References

    1. Langeveld AR, Oostenbroek RJ, Wijffels MP, Hoedt MT. The Pirogoff amputation for necrosis of the forefoot: a case report. J Bone Joint Surg Am. 2010;92:968-72.

    2. Taniguchi A, Tanaka Y, Kadono K, Inada Y, Takakura Y. Pirigoff ankle disarticulation as an option for ankle disarticulation. Clin Orthop Relat Res. 2003;414:322-8.

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