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.
In 1854, the Russian surgeon Nikolay Ivanovich Pirogoff introduced a technique of foot amputation in which the heel is preserved and used as a base4,5. The forefoot, midfoot, talus, distal part of the calcaneus, and distal tibial articular cartilage are removed. The plantar skin flap is left attached to the calcaneus, which is rotated 90° dorsally to create a sensate weight-bearing surface with minimal loss of leg length, usually <5 cm (Fig. 1).
Since the intact heel pad creates the plantar aspect of the stump, the patient is able to bear full weight on the limb, after bone-healing has occurred, with or without a prosthesis.
Pirogoff's amputation technique and its advantages are not widely appreciated, likely because the original description was written in Russian. Modifications6-9 of the original technique have been introduced, making it difficult to aggregate individual cases.
The Pirogoff technique is not suitable for everyone because of potential wound-healing problems, and it is essential that a patent posterior tibial artery be present. The technique may be most applicable for patients with a traumatic injury.
Because the malleoli are left in place, they remain somewhat prominent in an otherwise cone-shaped stump, and thus a prosthesis may be worn with less friction and be more rotationally stable than the prostheses used following a standard transtibial amputation.
We present a case of a patient who underwent an amputation with the Pirogoff technique following a traumatic injury. The patient was informed that data concerning the case would be submitted for publication, and he consented.
A Medline search for [Pirogov amputation], [Pirogow amputation], or [Pirogoff amputation] was performed, with the following limitations: human and English, Dutch, or German. This search produced thirteen articles, of which ten were relevant3,6-14. A second search for [below tibial amputations] with the same limitations resulted in 226 hits, with no relevant addition to our first search. An extended search in "related articles" also yielded no additional results. No reviews were identified.
The ten articles3,6-14 included a total of sixty-five patients, of whom 85% were male; the duration of follow-up ranged from seven months to fifteen years. One author used multiple amputation techniques in five patients, and the indications for amputation were not clearly stated11; therefore that study was excluded from the analysis. Of the sixty remaining patients eligible for analysis, thirteen (22%) had the amputation because of trauma.
The reasons for choosing a Pirogoff amputation were a rapid recovery and return to functional mobility, either with or without a prosthesis; minimal energy loss when walking because of a minimally shortened limb; minimization of leg-length discrepancy; and a decreased risk of pressure ulceration6,7.
Complications among the sixty patients with a Pirogoff amputation included reamputation at a higher level due to infection (n = 8, 13%), revision of the amputation stump including necrectomy and skin grafting (n = 3, 5%), early failure due to pain and an associated inability to use the limb (n = 11, 18%), and a leg-length discrepancy exceeding 3 cm (n = 1, 2%). All complications occurred within 1.5 years after the amputation, and all except the case of leg-length discrepancy and one local wound infection occurred in patients who had undergone amputation for vascular disease.
The authors of two studies used the Taniguchi rating scale to assess daily functioning of a total of twenty-two patients6,9. Eleven patients (50%) received a score of =60 points (out of 100 points), which was an excellent-to-good rating. One patient had a fair result (a score of 40 to 59 points), and ten patients (45%) had a poor score (=39 points or reamputation). All of the patients with a fair or poor result were dysvascular amputees, and five of these patients subsequently underwent a transtibial amputation.
Because the studies involved small series as well as various modifications of technique and aftercare methods, it is difficult to compare results. However, the literature and our own case suggest that patients with a traumatic injury can have a good outcome after a Pirogoff amputation. The Pirogoff method offers more patient mobility with and without the use of a prosthesis, with complication risks comparable with those of a Syme or transtibial amputation10. The use of an external fixation device instead of cast immobilization postoperatively may improve the chances for osseous union and good stump alignment, but it carries a risk of local infection.
After the acceptance of this report for publication, an additional case report on Pirogoff amputation was published in JBJS15. In our literature review, we found that the failure rate for patients with vascular disease was higher than that in patients with a traumatic injury. We believe that soft-tissue status plays a vital role in the successful outcome of Pirogoff amputations. Our review confirms the conclusions in the previous case report15 that the ability to perform indoor movement without a prosthesis and the small loss of leg length are advantages of this technique over transtibial amputation and that this amputation should be considered more frequently.
We believe that amputation with the Pirogoff method is a suitable and attractive option for patients with localized traumatic injury to the forefoot. Since there is minimal loss of leg length and a stable stump with adequate soft-tissue coverage, normal weight-bearing and mobility with, or even without, a prosthesis is possible.