Page 2 P H Y S I O T H E R A P Y DECEMBER, 1970 Amputations around the Ankle and Hind-foot L. P. SEIMON M.B., M.Ch. Orth., F.R.C.S. (Edin.) St. Augustine’s Medical Centre, Durban. Of the various amputations performed around the ankle and hind-foot the majority have been discarded because of numerous problems that have been encountered. In fact many standard texts mention some o f the procedures, only to condemn them. Amputations distal to the metatarsal bases generally present no problem and will not be considered further in this paper. Those through the tarsometatarsal region (Lisfranc) are seldom performed because o f the equinus deformity that is known to occur post-operatively. The Chopart procedure (through the mid-tarsal region) has also been abandoned because o f the severe equino-valgus deformity that results due to the unopposed action o f the gastrosoleus group. Pirigoff’s amputation is one in which the talus is excised, as is most o f the calcaneus. The remaining proximal part o f the calcaneus is then tilted vertically so that its raw distal surface comes up against the distal end o f the tibia. This results in a short stump necessitating a raised prosthesis. Amputation has also been performed through the distal (anterior) end o f the calcaneus. The talus is excised and a straightforward fusion between tibia and calcaneus carried out. This too, results in slight shortening, but the patient has a good end-bearing pad which does not deform, thanks to the arthrodesis. The Syme’s amputation (through the distal quarter-inch o f tibia, and with suture o f the heel pad to cover this raw surface) remains a well-tried and reliable operation. Un- forunately, it too results in a short stump and the prosthesis that is fitted is somewhat bulky and generally unacceptable to most female patients. For various reasons, therefore, many surgeons have been inclined to abandon amputations proximal to the metatarsal bases and distal to the Syme’s level. A n objective o f this paper is to make one reconsider these procedures in the light o f some minor modifications that I have found to be most gratifying. N o one can deny the tremendous benefits to a patient o f having an end-bearing stump that he can get about on, even without the aid o f a prosthesis. Modern prostheses have also been improved considerably and are not as bulky as they were previously. For many o f our patients, notably the lepers, cosmesis is unimportant. The overriding consideration is to enable them to walk again. It has been generally accepted that a solution to the salvage of the grossly deformed foot in these patients is to perform a below-knee amputation. The patient is then dependent on a pylon and frequently has to use crutches or a cane as well. Some unfortunates have no fingers (due to absorption) and cannot manage crutches. Should something go wrong with the pylon, they are, once again, totally incapacitated. The site o f large ulcerated areas over pressure points in grossly deformed feet has usually been enough for most surgeons not to give local amputations in the region a second thought. My own experience proves otherwise, and it is gratifying to note similar views to my own expressed in a recent article by Hart, Williams and Scott.1 Naturally, should there be some other good reason to contra-indicate amputation through the hind-foot, such as a deficient circulation, then obviously the choice must be to go for a more proximal level. Ulcerated areas and evidence o f chronic osteomyelitis are not contra-indications to surgery, but these areas must be adequately excised as part o f the procedure. In all cases my objectives and approach are: 1. To preserve as much length as possible without jeopardising the chances o f survival of the skin flaps. In the mid-tarsal region I would sacrifice some bone on the plantar aspect, rather than dorsally, making the line o f the amputation oblique. The little extra length o f bone on the dorsum o f the foot may make all the difference as to whether the patient requires any prosthesis at all, other than a simple toe-filler in a normal shoe. 2. To anticipate deformity and therefore prevent this by rebalancing the musculature. In tarsometatarsal amputations the long extensor tendons must be trans­ ferred into the medial part o f the cuboid or the lateral cuneiform. This will balance the foot beautifully, and together with the action o f the tibialis anterior, will prevent the occurrence o f an equinus deformity.) Should there be weakness o f the toe extensors, then a tibialis posterior transfer through the interosseus membrane is performed. Where the Achilles’ tendon is already contracted, it is lengthened. The Chopart’s (mid-tarsal) amputation is modified by transferring the tibialis anterior and extensor digitorum longus tendons into the neck o f the talus. This adequately counters the gastrosoleus action. 3. To give the patient a sturdy end-bearing stump that will stand up to the ravages o f daily usage, it is impera­ tive that the weight-bearing surface is normal plantar skin. The ulceration in case (4) is largely due to the fact that, because o f the severe equinus deformity, dorsal skin has become the weight-bearing area. In order to get plantar skin back into an end-bearing position, the procedure must be modified according to the particular case. This is best illustrated by referring to cases (3), (4) and (5). In order to maintain the heel pad in position, I prefer not to excise the os calcis completely as this disrupts the firm union that the pad has to that bone. It is much more practicable to preserve as much o f the os calcis as possible or even a sliver, if most has to be sacrificed, and to get this to fuse to the distal end o f the tibia. Bone heals to bone far better than soft tissue adheres to it. Depending on the dictates o f the particular case, either a modified Syme’s Procedure (retaining a thin piece o f os calcis), or a Pirigoff or straightforward tibio-calcaneal fusion is carried out. When sufficient os calcis is left the fusion is facilitated by using a simple compression device. In the modified Syme’s Procedure, a Steinman’s Pin passed up through the sole into the tibia will hold the position while fusion occurs. 4. To completely excise any ulcer and/or infected bone that is present. Generally the ulcer has resulted due to pressure over a bony prominence. In almost all cases the ulcer has to be excised together with a large underlying wedge o f bone, the latter fortunately also helps to correct the deformity. Results I have been astounded at how well some o f the grossly infected leprosy cases have healed. These patients are usually fitted with a Jumbo boot, but most o f them are able to get about on their stumps without the aid o f any prosthesis at all. When amputation is performed at the tarsometatarsal region, so that a small tongue o f stump projects beyond the line of the anterior margin o f the shin, the patients can frequently get by without having to use any prosthesis at all. I usually recommend a Velskoen-type shoe with a simple sponge rubber toe-filler. ‘Breaking’ o f the shoe at the tarsometatarsal level has not been a problem. When it is, then simple reinforcing o f the sole is usually all that is necessary. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) DECEMBER, 1970 P H Y S I O T H E R A P Y Page 3 I t m ust be r e m e m b e r e d th at a m p u t a t i o n at a h i g h e r level can always be ca rr ie d o u t lat er , s h o u l d t he p r i m a r y p r o c e d u r e fall. T h u s far, onl y t w o ca s es h a v e r e q u i r e d this. OT th es e, one pa ti en t re qu est ed a b e l o w - k n e e a m p u t a t i o n , so t h a t he could be fitted wit h a li m b to m a t c h t h e p r o s t h e s i s o n his other leg. I L L U S T R A T I V E C A S E S Case No. I : T.B.J., age 33 years. This pa t i en t was su ff er in g f r o m p e r o n e a l m u s c u l a r dystrophy. H e d e v e l o p e d bi l at er al pe s c a v u s a n d se ven y e a r s prior to being seen by m e he h a d h ad o p e r a t i o n s p e r f o r m e d on b o th his feet. T h e re sul ts w e r e e x t r e m e l y u n s a t i s f a c t o r y an d the pa ti en t w a l k e d with g r ea t difficulty a n d h a d a t r e m e n ­ dous a m o u n t o f pai n. R ig id c l a w i n g oT t h e t o e s w a s p r es en t with m ul ti p le callos iti es o v e r p r e s s u r e a r e a s , t h e ri gh t b e i n g much worse t h a n t h e left. A t r ip l e a r t h r o d e s i s h a d a l s o been performed o n t h e left a n d t hi s w as s a t is f a c t o r y . T h e soft tissues o f the di stal h a l f o f t h e righ t foo t w er e m a r k e d l y ifibrotic a n d a t r o p h i c , a n d h e a l s o h a d a fixed e q u i n u s ^deformity. H e w as a b l e t o wal k wit h on ly t he u t m o s t difficulty, d u e b o t h t o t h e p a i n a n d th e d e f o r m i t i e s . All the toes o f t he left f o ot we re a m p u t a t e d . O n t h e right a m p u t a t i o n w as c a r r ie d o u t t h r o u g h t h e d i st al h a l f o f th e cuneiforms. T h e E . D . L . t e n d o n s we re t r a n s f e r r e d t o th e lateral c u n e i f o rm a n d t h e A c h i l l e s ’ t e n d o n w as e l o n g a t e d . It is no w t w o a n d a h a l f y e a r s sin c e t h e o p e r a t i o n a n d th e patient has d o n e e x t r e m e l y well. H e w e a r s o r d i n a r y sh o e s with toe-fillers, ha s a m i n i m a l li m p a n d no p a i n w h a t e v e r . Case No. 2: Mrs. R . E . , aged 43 years. This u n f o r t u n a t e l a d y h a d ni ne o p e r a t i o n s p e r f o r m e d o n her right f oo t a f t e r a “ p r o c e d u r e fo r h al l u x v al gu s h a d g o n e wron g". W hen seen sh e w as gr o ss ly i n c a p a c i t a t e d by p a i n , e x t e n d i n g from the m i d -t a r s a l re gi on di sta ll y. S oft t iss ues in t h e a r e a were ex tr em ely fibrotic, a n d fixed d e f o r m i t i e s o f all t h e to es were pre sent. F u r t h e r su r g e r y t o c o r r e c t t h e t o e s w a s o u t o f the qu es tio n a n d in o r d e r t o e r a d i c a t e h er p a i n a n a m p u t a t i o n had to be p e r f o r m e d . S he h ad se v era l o p i n i o n s , all o f w h o m suggested a b e l o w - k n e e a m p u t a t i o n . I n s t e a d I p e r f o r m e d an a m p u t a t i o n i m m e d i a t e l y p r o x i m a l t o t h e t a r s o m e t a t a r s a l joints a n d with t h e b o n e e n d s bev ell ed p o s t e r i o r l y t o w a r d s the p l a n t a r a s p ec t . T h e i n s e r t i o n o f t h e ti bi al is a n t e r i o r w as reinforced m e d i a l l y wit h c h r o m i c s u t u r e s a n d t h e E . D . L . tendons were t r a n s f e r r e d t o t h e lat er al c u n c i f o r m a n d c u b o i d . She has m a d e exce llent p r o g r e s s a n d l e a d s a pe rfe ct ly n o r m a l 'life. At first, v a r i o u s p r o s t h e s e s w er e tr ie d, bu t sh e now' w e a r s or dinary sh oe s wit h a s i m p l e toe-filler. H e r r a n g e o f m o v e ­ ment is well i l l u st r a t e d i n figs. I -6. F ig . 2. C ase 2: M rs. R .E . W E I G H T -B E A R IN G (A N T . V IE W ). F ig. 3. C a se 2: M rs. R .E . A C T IV E D O R S I F L E X I O N . Fig. 1. C ase 2 : M rs. R .E . W E I G H T -B E A R IN G (L A T . VIEW). N ote slight obliquity o f stum p, being longer dorsally. F ig . 4. C a se 2: M rs. R .E . A C T IV E P L A N T A R F L E X I O N R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Page 4 P H Y S I O T H E R A P Y DECEMBER, 1970 Fig. 5. C ase 2 : M rs. R .E . A C T IV E IN V E R S I O N F ig . 6. C a se 2 : M rs. R .E . A C T IV E E V E R S IO N A w ed ge o f sk i n a n d b o n e w a s excis ed f r o m t h e rig h t foo t a n d t h e r e m a i n d e r o f t h e c a l c a n e u s fu sed t o t h e ti bi a, using a c o m p r e s s i o n c l a m p . T h i s b r o u g h t t h e heel p a d i n t o its n o r m a l we ig ht b e a r i n g p o s i t i o n . In t h e left f o ot a tibio- c a l c a n e a l f u si o n was p e r f o r m e d , th e s u p e r i o r s u r f a c e o f t he os c al ci s b e i n g c u t h o r i z o n t a l l y a n d held a g a i n s t t h e tib ia by m e a n s o f a c o m p r e s s i o n c l a m p . Bo th w o u n d s healed p r i m a r i l y a n d ex cel len t w e i g h t - b e a r i n g s t u m p s re su lt ed . C a se N o . 6: M t . S., ag e 35, L epe r. T h i s p a t i e n t p r e s e n t e d wi th se ver e b il at er al e q u i n o - v a r u s d e f o r m i t i e s , a b s o r p t i o n o f t he l at er al f o u r r a y s o f e a c h foot F ig. 7 . C ase 3 : M .S ., L eper. L A T . V IE W L E F T F O O T . N o te how the calcaneus has been pulled up into gross equinus and lies posterior to the tibia. C a se N o . 3 : M . S . , ag e 36. Le per . As c a n be see n in Fig. 7 t h e heel h a s been pu ll ed in to g r o s s e q u i n u s a n d we ig h t is now' t a k e n o n d o r s a l sk in w hi ch c o v e r s t h e di sta l e n d o f t h e ti bi a. A s u b - c u t a n e o u s Ach il les ' t e n o t o m y w a s p e r f o r m e d a n d t h e heel vvas r o t a t e d u n d e r th e ti bi a. T h e o p p o s i n g b o n e s u r f a c e s we re excis ed a n d th e raw e n d s held t o g e t h e r by m e a n s o f a c o m p r e s s i o n c l a m p . T h e w o u n d b e c a m e gro ss ly in fc ct ed b u t t hi s s e ttl ed dow-n r a p i d l y wit h t r e a t m e n t . (Fig . 8.) A g o o d e n d - b e a r i n g s t u m p re sulted. C a se N o . 4: S . K . , a g e 55 y e a r s , L ep er . T h e a p p e a r a n c e o f th i s p a t i e n t ' s feet c a n be seen in Figs. 9 - 1 I. T h e large u l ce r o v e r t h e e n d - b e a r i n g a r e a o f the left s t u m p di d n o t p r e v e n t a p r i m a r y S y m e 's ty pe a m p u t a t i o n b e i n g p e r f o r m e d . T h e ulce r, t o g e t h e r w'ith a w edg e o f b o n e w as ex ci se d , le av in g a p p r o x i m a t e l y h a l f a n inch t h i c k n e s s o f t h e o s calc is. T h i s w as fused t o t h e ti bi a. H e a l i n g w as u n ­ e v e n t f u l bu t u n f o r t u n a t e l y t h e r e s u l t a n t heel w as in mild v a r u s . T h i s w a s c o r r e c t e d s u b s e q u e n t l y by ex cis io n o f a sm a ll l a t e r a l l y b a s e d wed ge. O n t h e righ t side a m i d - t a r s a l a m p u t a t i o n w as first p e r ­ f o r m e d w i t h ex c i s i o n o f t h e l at er al ulcer, usi n g a m ed ia ll y b a s e d flap t o c o v e r th e e n d . A ti b i o - c a lc a n e a l fu si o n was p l a n n e d a s a s e c o n d s t a g e t o be p e r f o r m e d later. C a se N o . 5: N . W . , a g e 58, Le per . T h e a p p e a r a n c e o f t h e feet c a n be cle ar ly vi sua lized by r e f e r r i n g t o Figs. 12 a n d 13. F ig . 8. C ase 3 : M .S . F O U R W E E K S A F T E R T IB IO - C A L C A N E A L F U S I O N . C om pression clam p has just been rem oved. N o te how the heel fat pad has been restored to its norm al position for w eight-bearing. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) DECEMBER, 1970 P H Y S I O T H E R A P Y Page 5 a n d wit h o v e r t in fe cti on e x t e n d i n g d e e p l y i n t o t h e tali. D e s p i t e t h e in f e c t i o n bi la te ra l S y m e ’s ty p e a m p u t a t i o n s were p e r f o r m e d , wi th cxcis ion o f all o b v i o u s l y in fected bo ne . Both s t u m p s he a l e d p er p r i m u m a n d t h e p a t i e n t w as fitted with su rg ica l s t u m p b oo ts . Fig. 9. C ase 4 : S .K ., L eper. T h e left stum p reveals a marked equinus d eform ity with a large ulcer over the abnorm al 11- pressure-bearing area. T he equino-varus deform ity o f the right seen > as foot is a lso depicted. F ig . 12. C ase 4 : S .K . T h e equinus o f the le ft foot is clearly is the fact that the pressure bearing area is now over the anterior end o f the calcaneus. Fig. 10. C ase 4: S .K . S how ing the ex ten t o f the ulceration on the left stum p. S U M M A R Y I llu s tra tiv e cas es reveal t h a t a m p u t a t i o n t h r o u g h th e h i n d- fo ot c a n result in ex cel len t w e i g h t - b e a r i n g s t u m p s a n d th at pr e v i o u sl y e x p e c t e d d e f o r m i t i e s c a n be p r e v e n t e d by an t i c i p a t i n g t h e m a n d by t r a n s f e r r i n g t e n d o n s a c c o r d i n g l y , to r e b a l a n c e t h e fo ot . T h e p r e s e n c e o f u l c e r a t i o n a n d in fe cti o n does no t p r e c l u d e t h is t y p e o f su rg er y. R E F E R E N C E 1- H a r t , R. J., W i l l i am s, H . W . , a n d S c o t t , G . R . L e p ro s y R eview , 40, N o . 1, 59. C ase 5 : N .W ., L eper. N o te the gross equinus deform ity on the right, and equino-varus on the left. F ig . 13. C ase 5 : N .W . R adiographic appearance o f fe e t in F ig . 12. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )