TRANSTIBIAL AMPUTATION General Principles & Update on Surgical Techniques

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1 TRANSTIBIAL AMPUTATION General Principles & Update on Surgical Techniques Douglas G. Smith, MD Harborview Medical Center and University of Washington - Emeritus Prosthetic Research Study Amputee Coalition of America Henry M. Jackson Foundation for Advancement of Military Medicine

2 DISCLOSURES Watson Smith, BS, RDMS No relevant financial relationship reported

3 While we all want to save all or part of the foot ---- Don t Miss the Big Picture Remember to Ask What the Patient Really Wants!

4 Transtibial Amputation Sometimes the Best Solution Prolonged Limb Salvage not always wise Dr Hansen wrote about Saving Limbs and Ruining Lives If you do it - Do it well Padding is Key Early fitting and Rehab still very Important

5 Transtibial Amputation - Flap Design Posterior Flap is Typically Considered Standard - Cylindrical Not Conical Shaped Limb - Tolerates Total Contact Type Fit - More Durable

6 Old Case of Dr. Burgess Here in Seattle

7 IPOP Casting Techniques Foot Attachment Has Value in Some Patients Rigid Dressing Alone Protects the Amputation Site

8 Skew and Sagittal Flaps Skew Flap Anterior/Medial and Posterior/Lateral Cutaneous Flaps Based on Cutaneous Skin Perfusion Studies Long Posterior Muscle Myoplasty over the Tibia ref.: Robinson Sagittal Flaps Anterior/Lateral and Posterior/Medial Musculocutaneous Flaps Based on the Underlying Muscle Groups and Major Vessels Anterior Compartment and Medial Gastrocnemius Muscle Myoplasty over the Tibia ref.: Alter, Persson

9 Dr. Smith - um, we re down here in or #8, and were kind of wondering if, um.., Can you come down here and give use a suggestion on closing this open amputation?

10 Sagittal Flaps

11 Reasonable Length But No Padding In Front

12 Avoid the Term and Technique of guillotine Correct Term is Open Length Preserving Amputation Do Not Remove Valuable Tissue needed for the Flap

13 Equal Anterior and Posterior Fishmouth Flaps Relatively Thin Anterior Skin Typically Results in Poor Distal Padding More Conically Shaped Limbs

14 TT Amputation: General Principles Standard Posterior Flap - Cylindrical Not Conical Shaped Limb - Tolerates Total Contact Type Fit - More Durable Extended Posterior Flap Additional distal coverage and padding

15 TT Amputation: General Principles 1. Pre-Op Plan 2. Skin Incisions / Flaps 3. Nerves 4. Vessels 5. Muscles 6. Bones 7. Closure

16 TT Amputation: General Principles 1. Pre-Op Plan The first decision - where to cut the bone - Historically one hands breadth below tibial tubercle - Now, many recognize value of longer tibia - We Still Avoid the Distal 1/3 to 1/4 of lower leg - Prosthetic components need approx 6 inches space - Practical Length is 1/3 to 1/2 length of the tibia

17 TT Amputation: General Principles 2. Skin Incisions / Flap The Incisions and Flap Design - Long Posterior Flap Most Common - Sagittal and Skew are possible - Avoid equal anterior-posterior flap design - Traditional Posterior Flap is Diameter plus 1 cm - Extended Posterior Flap is LONGER for added Padding over Distal Tibia!

18 TT Amputation: General Principles - Flap Length = Diameter + 1cm - Rotation Point Posterior to Leg - Slight Angle Back to Incisions - Fibula 1 to 2 cm Shorter - Myodesis to Anterior Tibia Periosteum - I Avoid Drill Holes - flap ends up too low

19 TT Amputation: General Principles 3. Nerves Five Nerves Should Be Identified and Managed - Saphenous - Superficial Peroneal - Deep Peroneal - Tibial - Sural Nerves Should Be drawn distally, cleanly divided and allowed to retract back away from areas of scar, pressure, and vessels.

20 Saphenous Superficial Peroneal Deep Peroneal Tibial Sural

21 TT Amputation: General Principles 4. Vessels Three Major Vascular Bundles - Anterior Tibial Vessels - Posterior Tibial Vessels - Peroneal Vessels Large Vascular Bundles: Double ligatation for safety Tip: Avoid ligating deep peroneal N with the anterior tibial vessels, and tibial N with the posterior tibial vessels.

22 TT Amputation: General Principles 5. Muscles Four Compartments: - Anterior Compartment - Transect at level of bone cut - Lateral Compartment - Transect at level of bone cut - Deep posterior Compartment - After isolating vessels, Transect at level of the bone cut - Superficial Posterior Compartment - Preserved with fasciocutaneus flap Leave muscular investing fascia with the solius Do not bevel through the soleus Myodesis of fascia up and over the tibia

23 TT Amputation: General Principles 5. Muscles - TIP OF THE DAY!!! - For Heavy Patients with Leg like Wood - Find Gastec/Soleus Interval - Preserve the Gastroc, but Remove the Soleus as Proximal as Feasible, at least 2 cm proximal to tibial bone cut - Posterior Gastroc based flap can now close

24 TT Amputation: General Principles 6. Bones Tibia: Cut perpendicular to its axis Anterior Bevel of approximately 1/3 But not into the medullary canal Fibula: Cut 1 to 2 cm shorter that the tibia Slight bevel to remove lateral edge Bone Bridging: Will Discuss Briefly at the End of the Talk

25 TT Amputation: General Principles 7. Closure Myodesis of Fascia of Superficial Posterior Muscle: Periosteum Drill Holes in the Bone Fascial Closure: Securely close the fascia Subcutaneous Tissue and Skin Closure: Gentle Technique Longer healing times - use less irritating, long lasting technique

26 What s New Extended Posterior Flap Technique for Transtibial Amputation

27 Extended Posterior Flap

28 Why - Ext Posterior Flap The Standard Posterior Flap Technique -- Popularized by Dr Ernest Burgess -- Very Satisfactory for Most Patients BUT: For Some Patients the Posterior Flap Retracts over Time Troublesome Anterior Distal Pressure Point

29 Case Example 39 Year Old Female Chronic Infected Tibial Non-Union with Osteomyelitis Three Failed Surgical Procedures Desired Amputation and Prosthetic Fitting

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31 Saphenous Nerve Sural Nerve Deep Peroneal Nerve Superficial Peroneal Nerve Tibial Nerve

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33 Prosthetist, Surgeon, Therapist Subjectively Noted Improvement Had Better Than Average Distal Padding!!!

34 Another Case 54 y.o. Female, Transtibial Amputation Surgery 5/2/00 Chronic Osteomyelitis Decreased Sensation on Lower Leg - Old Spine Surgery Extended Flap was More Durable

35 53 y.o. Male, Gun Shot Wound to Right Foot - Hunting Accident R Transtibial Amputation 11/2/00 Photos at 5 weeks Post-Op

36 54 y.o. Male, Infected Total Ankle Arthoplasty R Transtibial Amputation 10/19/00 Photos at 4 Weeks Post-Op Epidermalysis - Healed Uneventfully Successful Prosthetic Fit

37 From - Management of Lower Extremity Amputations August 1969 Burgess, Romano and Zettle Bevel Muscle Flap Separation of Subcutaneous Tissue from Muscle Fascia Closure of Skin

38 New Techniques - Extended Posterior Flap Cannot Bevel the Soleus Muscle Cannot Separate the Subcutaneous Tissue Off of the Muscular Investing Fascia

39 From - Management of Lower Extremity Amputations August 1969 Burgess, Romano and Zettle From Dr Burgess Slides BK with Beveled Muscle Flap OLD VIEW BEVELED THE MUSCLE

40 Think Like a Flap Surgeon Full-Thickness Myocutaneous Flap Do Not Separate Layers The Subcutaneous Tissue Stays with the Muscular Investing Fascia

41 Current Indications Patient Presenting for Transtibial Amputation Healthy Posterior Soft Tissue Reasonable Circulation / Pulses Think Like a Flap Surgeon Diabetes and Peripheral Vascular Disease Case by Case Decision Can assess circulation and flap Intra-op

42 Full Teaching Audio and Video: UW Ortho Limb Loss Education - Traditional Burgess - Extended Posterior Flap Technique - Bone Bridging Transtibial Amputation

43 Tib/Fib Bone Bridge Arthrodesis Ertl Procedure

44 Tib/Fib Bone Bridge Arthrodesis Ertl Procedure PERFORMED WITH INCREASED FREQUENCY Stops tib/fib motion Theory - may lead to less pain Provides broader distal bone surface Theory - may increase end bearing Periosteal Flap used to cover end of tib and fib Theory - more normal intra-osseous pressure

45 Tib/Fib Bone Bridge Arthrodesis Ertl Procedure Improved outcomes have not been proven, but: I still perform Tib/Fib Arthrodesis: Unstable tib/fib from trauma Revision surgery when tib/fib stress is painful Most younger amputees I do not perform Tib/Fib Arthrodesis Presence of infection Geriatric patients with vascular disease Severe diabetes

46 UW Ortho Amputation Education The Limb Loss Education Center: Developing just-in-time training materials for major extremity amputations Douglas G. Smith, MD, Katie Treadwell, and Brian Hafner, PhD Prosthetics Research Study: Seattle, WA

47 Thank You