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Fram BR, Bosse MJ, Odum SM, Reider L, Gary JL, Gordon WT, Teague D, Alkhoury D, MacKenzie EJ, Seymour RB, Karunakar MA. Do Transtibial Amputations Outperform Amputations of the Hind- and Midfoot Following Severe Limb Trauma?: A Secondary Analysis of the OUTLET Study. J Bone Joint Surg Am 2024; 106:776-781. [PMID: 38512987 DOI: 10.2106/jbjs.23.00878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
BACKGROUND The purpose of this study was to compare 18-month clinical and patient-reported outcomes between patients with severe lower-limb injuries treated with a transtibial amputation or a hind- or midfoot amputation. Despite the theoretical benefits of hind- and midfoot-level amputation, we hypothesized that patients with transtibial amputations would report better function and have fewer complications. METHODS The study included patients 18 to 60 years of age who were treated with a transtibial amputation (n = 77) or a distal amputation (n = 17) and who were enrolled in the prospective, multicenter Outcomes Following Severe Distal Tibial, Ankle, and/or Foot Trauma (OUTLET) study. The primary outcome was the difference in Short Musculoskeletal Function Assessment (SMFA) scores, and secondary outcomes included pain, complications, amputation revision, and amputation healing. RESULTS There were no significant differences between patients with distal versus transtibial amputation in any of the domains of the SMFA: dysfunction index [distal versus transtibial], 31.2 versus 22.3 (p = 0.13); daily activities, 37.3 versus 26.0 (p = 0.17); emotional status, 41.4 versus 29.3 (p = 0.07); mobility, 36.5 versus 27.8 (p = 0.20); and bother index, 34.4 versus 23.6 (p = 0.14). Rates of complications requiring revision were higher for distal amputations but not significantly so (23.5% versus 13.3%; p = 0.28). One distal and no transtibial amputees required revision to a higher level (p = 0.18). A higher proportion of patients with distal compared with transtibial amputation required local surgical revision (17.7% versus 13.3%; p = 0.69). There was no significant difference between the distal and transtibial groups in scores on the Brief Pain Index at 18 months post-injury. CONCLUSIONS Surgical complication rates did not differ significantly between patients who underwent transtibial versus hind- or midfoot amputation for severe lower-extremity injury. The average SMFA scores were higher (worse), although not significantly different, for patients undergoing distal compared with transtibial amputation, and more patients with distal amputation had a complication requiring surgical revision. Of note, more patients with distal amputation required closure with an atypical flap, which likely contributed to less favorable outcomes. LEVEL OF EVIDENCE Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Brianna R Fram
- Atrium Health-Carolinas Medical Center, Charlotte, North Carolina
| | - Michael J Bosse
- Atrium Health-Carolinas Medical Center, Charlotte, North Carolina
| | - Susan M Odum
- Atrium Health-Carolinas Medical Center, Charlotte, North Carolina
| | - Lisa Reider
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Joshua L Gary
- Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Wade T Gordon
- Kirk Kerkorian School of Medicine at the University of Nevada, Las Vegas, Nevada
| | | | - Dana Alkhoury
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Ellen J MacKenzie
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Rachel B Seymour
- Atrium Health-Carolinas Medical Center, Charlotte, North Carolina
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Ouchi K, Sato M, Kashiwabara Y, Shimazaki M, Yabuki S. Investigation of walking speed and plantar pressure after chopart amputation. Fukushima J Med Sci 2024; 70:99-102. [PMID: 38494732 DOI: 10.5387/fms.23-00003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2024] Open
Abstract
BACKGROUND In foot amputation, Chopart amputation is considered to have a high risk of deformity, and can result in poor function. We experienced a case in which Chopart amputation combined with tendon transfer and tendon lengthening was performed, and the patient was eventually able to walk independently with a foot prosthesis without experiencing deformity of the foot. We investigated walking speed and plantar pressure after Chopart amputation with and without a foot prosthesis. CASE A 78-year-old man underwent Chopart amputation with tendon transfer and tendon lengthening. As a result, he was able to stand up and walk, both while bearing weight on the heel of the affected foot, but he was unable to push off the ground using that foot. When a foot prosthesis was introduced, the patient's walking speed increased from 0.6 m/s without the prosthesis to 0.8 m/s with the prosthesis, which was an increase of 33%. The plantar pressure at the stump decreased from 129.3 N/cm2 on average without the prosthesis to 51.6 N/cm2 with the prosthesis, which was a 59% decrease. Wearing a foot prosthesis improved the patient's walking speed and decreased plantar pressure at the amputation stump.
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Affiliation(s)
- Kazuo Ouchi
- Department of Rehabilitation Medicine, School of Medicine, Fukushima Medical University
| | - Mari Sato
- Department of Rehabilitation Medicine, School of Medicine, Fukushima Medical University
| | - Yuki Kashiwabara
- Department of Rehabilitation Medicine, School of Medicine, Fukushima Medical University
| | - Mutsumi Shimazaki
- Department of Rehabilitation Medicine, School of Medicine, Fukushima Medical University
| | - Shoji Yabuki
- School of Health Sciences, Fukushima Medical University
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van der Wal GE, Dijkstra PU, Geertzen JH. Lisfranc and Chopart amputation: A systematic review. Medicine (Baltimore) 2023; 102:e33188. [PMID: 36897730 PMCID: PMC9997832 DOI: 10.1097/md.0000000000033188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 02/14/2023] [Indexed: 03/11/2023] Open
Abstract
BACKGROUND Lisfranc and Chopart amputations are historically controversial procedures. To obtain evidence for the pros and cons we performed a systematic review to analyze wound healing, the need for re-amputation at a higher level, and ambulation after a Lisfranc or Chopart amputation. METHODS A literature search was performed in 4 databases (Cochrane, Embase, Medline, and PsycInfo), using database-specific search strategies. Reference lists were studied to include relevant studies that were missed in the search. Of the 2881 publications found, 16 studies could be included in this review. Excluded publications concerned editorials, reviews, letters to the editor, no full text available, case reports, not meeting the topic, and written in a language other than English, German, or Dutch. RESULTS Failed wound healing occurred in 20% after Lisfranc amputation, in 28% after modified Chopart amputation, and 46% after conventional Chopart amputation. After Lisfranc amputation, 85% of patients were able to ambulate without prosthesis for short distances, and after modified Chopart 74%. After a conventional Chopart amputation, 26% (10/38) had unlimited household ambulation. CONCLUSIONS The need for re-amputation because wound healing problems occurred most frequently after conventional Chopart amputation. All 3 types of amputation levels do, however, provide a functional residual limb, with the remaining ability to ambulate without prosthesis for short distances. Lisfranc and modified Chopart amputations should be considered before proceeding to a more proximal level of amputation. Further studies are needed to identify patient characteristics to predict favorable outcomes of Lisfranc and Chopart amputations.
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Affiliation(s)
- Gesiena E. van der Wal
- University of Groningen, University Medical Center Groningen, Department of Rehabilitation Medicine, Center of Rehabilitation, The Netherlands
| | - Pieter U. Dijkstra
- University of Groningen, University Medical Center Groningen, Department of Rehabilitation Medicine, Center of Rehabilitation, The Netherlands
- University of Groningen, University Medical Center Groningen, Department of Oral and Maxillofacial Surgery, The Netherlands
| | - Jan H.B. Geertzen
- University of Groningen, University Medical Center Groningen, Department of Rehabilitation Medicine, Center of Rehabilitation, The Netherlands
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Berli MC. Mid- and Hindfoot Amputations in Diabetic Patients. Foot Ankle Clin 2022; 27:687-700. [PMID: 36096559 DOI: 10.1016/j.fcl.2022.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Several surgical options exist to avoid or at least to delay a below-the-knee amputation (BKA). These are the so-called mid- or hindfoot amputations. They are a valuable treatment option in order to maintain the ability to ambulate without major auxiliary means (eg, a prosthesis). Hence, these amputations allow the patients to maintain certain autonomy. The acceptance of these amputations is significantly higher than a BKA, as the body image is less disturbed. The complication rate in hindfoot amputations in diabetic patients is high due to the comorbidities, in particular peripheral arterial disease and polyneuropathy.
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Affiliation(s)
- Martin C Berli
- Division of Technical Orthopaedics, Department of Orthopaedic Surgery, Balgrist University Hospital, Zurich, Switzerland; Universitätsklinik Balgrist, Forchstrasse 340, 8008 Zurich, Switzerland.
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Reconstruction of Chopart’s Amputation Stump with the Osteomusculocutaneous Latissimus Dorsi-Rib Flap. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2022; 10:e4422. [PMID: 35923985 PMCID: PMC9287272 DOI: 10.1097/gox.0000000000004422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 05/19/2022] [Indexed: 11/26/2022]
Abstract
We present an original technique for reconstruction of the right forefoot after Chopart’s amputation. The case report was of a 20-year-old man who was a nonsmoker without comorbidities. He was referred to our department because of equinus deformity, pain, and prominence of the cuboid under the skin, leading to chronic ulceration at the stump. We performed flow through free latissimus dorsi flap including the eighth and tenth ribs to reconstruct the stump. Results were assessed at 18 months after operation, showing good stability and normal functional outcome of the foot. The patient is satisfied with the results achieved.
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Surgical Management of Patients with Snakebite-Related Musculoskeletal Complication-A Single Institution Experience in Cambodia. World J Surg 2021; 46:54-60. [PMID: 34523046 DOI: 10.1007/s00268-021-06307-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/21/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Snakebite-related injury is a serious public health issue. In Cambodia, it is estimated that up to 21,500 cases of envenoming occurs from snakebites annually. Musculoskeletal disability is a major long-term complication associated with the injury. In this study, we aim to describe surgical management and rehabilitation in snakebite-related musculoskeletal injuries at Children's Surgical Centre, Phnom Penh, Cambodia. METHODS We conducted a retrospective case series analysis of patients with snakebite-related injury who were treated between January 1, 2002 and December 31, 2018. Surgical patients were divided into the early and late presenting groups (= < one year vs. > one year, respectively) based on their time interval from snake bite to time of presentation. RESULTS There were 88 patients who presented with snakebite-related musculoskeletal injury during the cohort study period. Majority of them were male (n = 62, 71%) and had a median age of 24 years old (IQR 17-44). The injuries were all in the upper and lower limbs though lower limb injury was more common in female patients (81% vs. 48%, Fisher's test p = 0.005). The median time interval from snakebite to time of treatment was 3 years (IQR 3 months-11 years). In this study, 65 patients received surgical interventions. An ulcerated wound was the most common symptom among the early presenting group (78% vs. 24%), while scar contracture was most common among the late group (76% vs. 22%) (Fisher's test p < 0.0001). For management, surgical debridement was the most common primary intervention for the early group (52% vs. 19%), and contracture release was the most common for patients in the late group (62% vs. 15%) (Fisher's test p = 0.0004). Overall, the postoperative complication rate was highest in the late presenting group (34% vs. 3%, Fisher's test p = 0.005). CONCLUSION More than half of the patients presented with musculoskeletal injury require surgical correction. Our study demonstrated that scar contracture is the most common complaint among the late presenting group and is associated with high postoperative complication rate.
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Kaib T, Schäfer J, Block J, Heitzmann D, Putz C, Alimusaj M, Wolf SI. Biomechanical analysis of stair ascent in persons with Chopart amputation. Prosthet Orthot Int 2020; 44:164-171. [PMID: 32169005 DOI: 10.1177/0309364619900737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Compared to walking on level ground, ascending stairs requires a large range of motion not only of the hip and knee joint, but also of the ankle joint. The prosthesis often worn by persons with partial foot amputation largely prevents the ankle motion needed during stair ascent. OBJECTIVES Aim of this study was to assess subjects with a Chopart amputation utilizing a clamshell device during stair ascent to identify potential biomechanical deficits. STUDY DESIGN Cross-sectional study with reference group. METHODS Six subjects with unilateral Chopart amputation and 17 unimpaired subjects underwent three-dimensional motion analysis while ascending stairs in a step-over-step manner. RESULTS During weight acceptance, the involved side showed increased external hip-flexing and reduced knee-flexing moments and the sound side a higher ankle power than in the control group. The sound side showed higher external knee-flexing, dorsi-flexing, and hip-adducting moments than the controls during weight acceptance. CONCLUSION The mechanism observed on the involved side differs from that in controls, but is comparable to the mechanisms used by subjects with transtibial amputation reported in the literature. However, compensatory movements on the sound side take place at the ankle and knee joint, differing from subjects with more proximal amputations. CLINICAL RELEVANCE This study underpins the importance of adequate foot leverage and ankle function in cases of partial foot amputation, particularly in transfer situations such as stair ascent. If ankle range of motion is adequate, prosthetic/orthotic devices combining shank leverage with a hinged spring mechanism at the ankle may be promising.
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Affiliation(s)
- T Kaib
- Clinic for Orthopedics and Trauma Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - J Schäfer
- Clinic for Orthopedics and Trauma Surgery, Heidelberg University Hospital, Heidelberg, Germany.,University of Applied Science Koblenz, Remagen, Germany
| | - J Block
- Clinic for Orthopedics and Trauma Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Dww Heitzmann
- Clinic for Orthopedics and Trauma Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - C Putz
- Clinic for Orthopedics and Trauma Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - M Alimusaj
- Clinic for Orthopedics and Trauma Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - S I Wolf
- Clinic for Orthopedics and Trauma Surgery, Heidelberg University Hospital, Heidelberg, Germany
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Greene CJ, Bibbo C. The Lisfranc Amputation: A More Reliable Level of Amputation With Proper Intraoperative Tendon Balancing. J Foot Ankle Surg 2018. [PMID: 28633785 DOI: 10.1053/j.jfas.2017.01.054] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Christopher J Greene
- 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
| | - Christopher Bibbo
- 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.
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Reconstruction of Chopart's Amputation Stump Using Artificial Dermis Combined with Free Anterolateral Thigh Flap. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2016; 3:e558. [PMID: 26893983 PMCID: PMC4727710 DOI: 10.1097/gox.0000000000000547] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Accepted: 09/23/2015] [Indexed: 01/04/2023]
Abstract
A 63-year-old man dropped a metal chunk onto his left foot during his work and suffered a crush injury of the left forefoot. He underwent Chopart’s amputation followed by stump coverage with sole skin at the orthopedic department on the same day. He was referred to our department for reconstruction because of poor vascularization and subsequent necrosis of tissue at the stump. After the necrotic tissue was debrided, exposure of the talus bone was noted. An artificial dermis was then applied to the stump wound, followed by local negative pressure wound therapy. After 3 weeks, the generation of a strong dermis-like tissue was observed at the site of artificial dermis grafting. We then performed flow-through free anterolateral thigh flap grafting to reconstruct the stump wound. This procedure involved suturing of the peroneal muscle group and tibialis anterior muscle, which were cut off during Chopart’s amputation, and suturing the soft tissue surrounding the calcaneus firmly to the fascia lata of the anterolateral thigh flap, followed by suturing of the flap to the skin defect of the left foot. There were neither postoperative complications, such as skin ulcer and equinus/varus deformity, nor need for secondary repair of the grafted flap, so the patient was able to smoothly enter a rehabilitation program including gait training. The current reconstruction technique for the tissue defect following Chopart’s amputation, consisting of artificial dermis grafting, negative pressure wound therapy, and flow-through free anterolateral thigh flap grafting, enabled safe and smooth gait rehabilitation with a forefoot prosthesis.
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