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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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Wada Y, Masaoka T, Morotomi N, Kawate N. Rehabilitation of a Patient with Pirogoff Amputation and Two-year Follow-up: A Case Report. Prog Rehabil Med 2021; 6:20210004. [PMID: 33521376 PMCID: PMC7835252 DOI: 10.2490/prm.20210004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 01/13/2021] [Indexed: 11/09/2022] Open
Abstract
Background: Pirogoff amputation is a calcaneal amputation invented by Nicolás Pirogoff that involves partial preservation of the calcaneus. Case: A 59-year-old woman was diagnosed with left Lisfranc and Chopart joint fracture-dislocation 9 months after a fall. The patient underwent debridement together with Pirogoff amputation and surgery to place an Ilizarov external fixator. Five months later, the patient was transferred to a rehabilitation hospital. Because of inadequate bone fusion, for 3 months after the amputation the patient underwent gait training with a patellar tendon weight-bearing orthosis to avoid loading the amputated side. After fusion of the bone, the patient was able to walk using a Syme prosthesis and a cane. Three months after discharge from the rehabilitation hospital, the patient was diagnosed with hallux osteomyelitis of the other foot that was associated with the exacerbation of hallux valgus. The patient underwent hallux correction surgery. Three and a half months after the second hospital admission, the patient was again admitted to the rehabilitation hospital. At the end of the rehabilitation program, the patient was able to walk using a cane and a prosthesis. Discussion: Appropriate orthotic treatment and care of the non-amputated limb are of great importance in patients who have undergone a partial foot amputation.
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Affiliation(s)
- Yoshitaka Wada
- Department of Rehabilitation Medicine, Showa University Fujigaoka Rehabilitation Hospital, Kanagawa, Japan
| | - Tomokazu Masaoka
- Department of Rehabilitation Medicine, Showa University Fujigaoka Rehabilitation Hospital, Kanagawa, Japan
| | - Nobuo Morotomi
- Department of Rehabilitation Medicine, Showa University Fujigaoka Rehabilitation Hospital, Kanagawa, Japan
| | - Nobuyuki Kawate
- Department of Rehabilitation Medicine, Showa University Fujigaoka Rehabilitation Hospital, Kanagawa, Japan
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Chiu YC, Chung TC, Wu CH, Tsai KL, Jou IM, Tu YK, Ma CH. Chopart amputation with tibiotalocalcaneal arthrodesis and free flap reconstruction for severe foot crush injury. Bone Joint J 2018; 100-B:1359-1363. [DOI: 10.1302/0301-620x.100b10.bjj-2018-0118.r1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Aims This study reports the outcomes of a technique of soft-tissue coverage and Chopart amputation for severe crush injuries of the forefoot. Patients and Methods Between January 2012 to December 2016, 12 patients (nine male; three female, mean age 38.58 years; 26 to 55) with severe foot crush injury underwent treatment in our institute. All patients were followed-up for at least one year. Their medical records, imaging, visual analogue scale score, walking ability, complications, and functional outcomes one year postoperatively based on the American Orthopedic Foot and Ankle Society (AOFAS) and 36-Item Short-Form Health Survey (SF-36) scores were reviewed. Results The mean length of follow-up was 18.6 months (13 to 28). Two patients had a local infection, flap necrosis was seen in one patient, and one patient experienced a skin graft wound healing delay. Of the 12 patients, one had persistent infection and eventually required below-knee amputation, but pain-free walking was achieved in all the other patients. The mean one-year postoperative AOFAS and SF-36 scores were 75.6 (68 to 80) and 82 (74 to 88), respectively. Conclusion Although our sample size was small, we believe that this treatment method may be a valuable alternative for treating severe foot crush injuries. Cite this article: Bone Joint J 2018;100-B:1359–63.
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Affiliation(s)
- Y-C. Chiu
- Department of Orthopaedic Surgery, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
| | - T-C. Chung
- Department of Orthopaedic Surgery, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
| | - C-H. Wu
- Department of Orthopaedic Surgery, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
| | - K-L. Tsai
- Department of Physical Therapy, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - I-M Jou
- Department of Orthopaedic Surgery, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
| | - Y-K. Tu
- Department of Orthopaedic Surgery, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
| | - C-H. Ma
- Department of Orthopaedic Surgery, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
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Abstract
Foot complications in patients with diabetes mellitus are a challenge to the health care industry. A great deal of expenditure is due to the management of diabetic foot complications. This places a great burden on the health care industry. It also places a great burden on those diabetic patients with foot complications and their families. Therefore, their effective management in an efficient manner is crucial to our patients. To deal with these problems, a dedicated, knowledgeable, and experienced multidisciplinary team is key. Intervention at the earliest possible time yields the best outcome. Prevention is the focus for those with no ulcerations. For those with ulcerations, prompt recognition and treatment is key. The importance of classifying ulcerations according to size, depth, presence or absence of infection, and vascular status can not be overstated. Proper offloading is vital for those with neuropathic lesions. Recognition of patients with a component of ischemia and vascular intervention to increase perfusion will aid in wound healing. Of course deep infection requires immediate drainage. All efforts of those in the multidisciplinary team are directed at the restoration and maintenance of an ulcer-free foot which is important in enabling our patients to maintain their ambulatory status.
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Affiliation(s)
- John M Giurini
- Division of Podiatry, Beth Israel Deaconess Medical Center, Joslin Diabetes Center, Harvard Medical School, Boston, MA 02215, USA
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Blume P, Salonga C, Garbalosa J, Pierre-Paul D, Key J, Gahtan V, Sumpio BE. Predictors for the Healing of Transmetatarsal Amputations: Retrospective Study of 91 Amputations. Vascular 2016; 15:126-33. [PMID: 17573017 DOI: 10.2310/6670.2007.00035] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
This retrospective study reviewed 80 consecutive patients (mean age 62 years; range 21–91 years) who underwent 91 transmetatarsal amputations (TMAs) between 1995 and 2003. The mean follow-up was 12 ± 1.36 months. Sixty-two TMAs healed initially (group 1), whereas 29 TMAs did not heal by 3 months (group 2). At the final examination, in groups 1 and 2, 63 of 91 (69%) limbs were healed. Of the 28 limbs that did not heal, 25 of 28 (89%) required further proximal amputation. Initial healing correlated significantly with the ability to ambulate ( p < .0001) and overall limb salvage ( p < .0001). In group 1, 20 of 27 (74%) limbs that were revascularized healed ( p = .0336). Nonhealing amputations were associated with end-stage renal disease (13 of 19; 68%) ( p = .0209) and leukocytosis (13 of 19; 68%) ( p = .0052).
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Affiliation(s)
- Peter Blume
- Department of Vascular Surgery, Yale University School of Medicine, New Haven, CT 06515, USA.
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Lui TH. Technical tip: percutaneous bone shaving and ulcer endoscopy to manage abnormal pressure point of the sole. Foot (Edinb) 2014; 24:190-4. [PMID: 25241265 DOI: 10.1016/j.foot.2014.08.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Revised: 07/20/2014] [Accepted: 08/06/2014] [Indexed: 02/04/2023]
Abstract
Abnormal plantar pressure can follow post-traumatic foot deformity, Charcot neuroarthropathy and partial foot amputations. Surgery is indicated if the condition does not improve with orthotic treatment. We describe the techniques of percutaneous shaving of the plantar bone prominence and ulcer endoscopy to manage abnormal pressure points under the sole of the foot.
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Affiliation(s)
- T H Lui
- Department of Orthopaedics and Traumatology, North District Hospital, 9 Po Kin Road, Sheung Shui, NT, Hong Kong SAR, China.
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Krause FG, Pfander G, Henning J, Shafighi M, Weber M. Ankle dorsiflexion arthrodesis to salvage Chopart's amputation with anterior skin insufficiency. Foot Ankle Int 2013; 34:1560-8. [PMID: 23780800 DOI: 10.1177/1071100713495380] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND In Chopart-level amputations the heel often deviates into equinus and varus when, due to the lack of healthy anterior soft tissue, rebalancing tendon transfers to the talar head are not possible. Consequently, anterior and lateral wound dehiscence and ulceration may occur requiring higher-level amputation to achieve wound closure, with considerable loss of function for the patients. METHODS Twenty-four consecutive patients (15 diabetes, 6 trauma, and 3 tumor) had Chopart's amputation and simultaneous or delayed additional ankle dorsiflexion arthrodesis to allow for tension-free wound closure or soft tissue reconstruction, or to treat secondary recurrent ulcerations. Percutaneous Achilles tendon lengthening and subtalar arthrodesis were added as needed. Wound healing problems, time to fusion and full weight-bearing in the prosthesis, complications in the prosthesis, and the ambulatory status were assessed. Satisfaction and function were evaluated by the AmpuPro score and the validated Prosthesis Evaluation Questionnaire scale. RESULTS Five patients had successful soft tissue healing and fusions but died of their underlying disease 2 to 46 months after the operation. Two diabetic patients required a transtibial amputation. The other 17 patients were followed for 27 months (range, 13-63). The average age of the 4 women and 13 men was 53.9 years (range, 16-87). Postoperative complications included minor wound healing problems in 8 patients, wound breakdown requiring revision in 4, phantom pain in 3, residual equinus in 1, and adjacent scar carcinoma in 1 patient. The time to full weight-bearing in the prosthesis ranged from 6 to 24 weeks (mean 10). The mean AmpuPro score was 107 points (of 120), and the mean Prosthesis Evaluation Questionnaire scale was 147 points (of 200). No complications occurred with the prosthesis. Twelve patients lost 1 to 2 mobility classes (mean 0.9). The arthrodeses all healed within 2.5 months (range, 1.5 to 5 months). CONCLUSION Adding an ankle arthrodesis to a Chopart's amputation either immediately or in a delayed fashion to treat anterior soft tissue complications was a successful salvage in most patients at this amputation level. It enabled the patients to preserve the advantages of a full-length limb with terminal weight-bearing. LEVEL OF EVIDENCE Level IV, retrospective case series.
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9
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Matamoros R, Riepe G, Drees P. [Minor amputations: a maxi task : Part 2: From transmetatarsal amputation to hindfoot amputation]. Chirurg 2013; 83:999-1012. [PMID: 22895650 DOI: 10.1007/s00104-011-2189-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The definitive aim of a minor amputation is limited resection with retention of feet and legs resulting in a completely loadable extremity, in contrast to the lower leg stump. A shift in the amputation level in the sense of a shortening is inevitably accompanied by a reduction in the stand area, an increase in axial pressure and a disruption of muscle equilibrium in the extent of movement of the rest of the foot. This knowledge forms the central issue for further treatment of minor amputations in addition to the subtle treatment of the skin of the sole for coverage of a tension-free tip of the stump. Advantageous are longitudinal partial amputations of the forefoot and midfoot.
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Affiliation(s)
- R Matamoros
- Zentrum für Gefäßmedizin und Wundbehandlung, Stiftungsklinikum Mittelrhein, Koblenz, Deutschland
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Brown ML, Tang W, Patel A, Baumhauer JF. Partial foot amputation in patients with diabetic foot ulcers. Foot Ankle Int 2012; 33:707-16. [PMID: 22995256 DOI: 10.3113/fai.2012.0707] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Transtibial amputations (TTA) are performed for recalcitrant or infected ulcers of the midfoot, hindfoot, or ankle. This procedure results in decreased ambulatory status caused by increased oxygen demands and energy expenditure. Partial foot amputations have the advantage of being an end-bearing limb and require less work to walk, theoretically suggesting improved functional outcome. The purpose of this research was to examine the longevity, outcome, and mortality of partial foot amputations as an alternative to TTA. METHODS Retrospective chart review identified diabetic patients with transmetatarsal, Chopart's, and calcanectomy amputations for osteomyelitis or nonhealing ulcers. A control group consisted of diabetic patients who underwent TTA. A comparison between groups examined mortality, proximal ipsilateral reamputation, and a validated ambulatory functional outcome measure. RESULTS Eighteen TTA patients were enrolled. The 5-year mortality rate was 0.45, one patient required reamputation, and the mean postoperative ambulatory score was 2.8. Twenty-one transmetatarsal patients were enrolled. The 5-year mortality rate was 0.30, two patients required reamputation, and the mean postoperative ambulatory score was 4.3. Ten Chopart's amputation patients were enrolled. The 5-year mortality rate was 0.36, six patients required reamputation, and the mean postoperative ambulatory score was 4.3. Seventeen partial calcanectomy patients were enrolled. The 5-year mortality rate was 0.69, six patients required reamputation, and the mean postoperative ambulatory score was 4.3. Sixteen total calcanectomy patients were enrolled. The 5-year mortality rate was 0.59, five patients required reamputation, and the mean postoperative ambulatory score was 3.3. CONCLUSION TTA is associated with high morbidity and mortality, which suggests that the advantage of partial foot amputations should be investigated. Only transmetatarsal amputations at 1 and 3 years were statistically lower for mortality than TTA. Partial foot amputations at the other levels failed to show statistically improved survivorship. Transmetatarsal and Chopart's amputations had high ambulatory levels and the longest durability, which suggests that these amputations may provide some ambulatory advantage.
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Affiliation(s)
- Matthew L Brown
- University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
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11
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den Bakker FM, Holtslag HR, van den Brand JGH. Pirogoff amputation for foot trauma: an unusual amputation level: a case report. J Bone Joint Surg Am 2010; 92:2462-5. [PMID: 20962198 DOI: 10.2106/jbjs.i.01336] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- F M den Bakker
- Department of Surgery, Medical Centre Alkmaar, P.O. Box 501, 1800 AM Alkmaar, The Netherlands.
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12
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Schade VL, Roukis TS, Yan JL. Factors associated with successful Chopart amputation in patients with diabetes: a systematic review. Foot Ankle Spec 2010; 3:278-84. [PMID: 20966454 DOI: 10.1177/1938640010379635] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Chopart amputations were first performed for treatment of a non-salvageable distal foot but became unfavorable because of the development of equinovarus contractures and ulcerations. The majority of below-knee amputations today occur in ambulatory patients with diabetes in which a Chopart amputation may be a viable option; however, the durability of the residual limb is questionable. The authors undertook a systematic review of electronic databases and other relevant sources to identify material relating to the factors associated with a successful Chopart amputation in ambulatory patients with diabetes. Studies were eligible for inclusion only if they consecutively enrolled ambulatory patients with diabetes who underwent a Chopart amputation, regardless of etiology, with or without any tendinous or osseous balancing performed and had a mean follow-up of ≥12 months duration. Four studies involving 74 patients/feet were identified that met the inclusion criteria with a weighted mean follow-up of 21.1 months. The efficacy of tendinous and/or osseous balancing could not be assessed because of the lack of comparable techniques. However, review of the included studies supports that a residual functional limb can be maintained for ≥12 months with the use of a properly fitting high-profile prosthetic device for lifelong ambulation.
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Affiliation(s)
- Valerie L Schade
- Limb Preservation Service, Vascular/Endovascular Surgery Service, Department of Surgery, Madigan Army Medical Center, Tacoma, Washington, USA.
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13
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Abstract
Minor amputations are frequently performed for neuroischemic or neuropathic lesions of the diabetic foot. Depending on the definition used, minor amputations can range from toe to Syme amputations. Minor amputations are often combined with necrosectomy and débridement. For early and optimal rehabilitation, as much vital tissue as possible should be conserved, especially considering the skeletal structures of the foot (borderline amputation). Minor amputations are of utmost importance for the prevention of ascending infections and reduce the duration of clinical and outpatient treatment. Minor amputations should be performed only by experienced surgeons and only if arterial perfusion is sufficient. They should be as tissue-conserving as possible and structured interdisciplinary postoperative care is mandatory. Metabolic control should be optimized. Controversial opinions exist with respect to the use of tourniquets, conservation or resection of cartilage and sesamoid bones, open amputation or primary closure of the wound, interdigital spacer function of toes, aseptic proximal transection of tendons, postoperative wound care, negative-pressure wound treatment and antibiotic therapy. In view of these controversies the most important minor amputation techniques are described and discussed.
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Langeveld ARJ, Oostenbroek RJ, Wijffels MPJM, Hoedt MTC. The Pirogoff amputation for necrosis of the forefoot: a case report. J Bone Joint Surg Am 2010; 92:968-72. [PMID: 20360523 DOI: 10.2106/jbjs.h.01890] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- A R J Langeveld
- Department of General Surgery, Albert Schweitzer Hospital, Albert Schweitzerplaats 25, 3318 AT Dordrecht, The Netherlands.
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Loor G, Skelly CL, Wahlgren CM, Bassiouny HS, Piano G, Shaalan W, Desai TR. Is atherectomy the best first-line therapy for limb salvage in patients with critical limb ischemia? Vasc Endovascular Surg 2009; 43:542-50. [PMID: 19640919 DOI: 10.1177/1538574409334825] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To determine the efficacy of atherectomy for limb salvage compared with open bypass in patients with critical limb ischemia. METHODS Ninety-nine consecutive bypass and atherectomy procedures performed for critical limb ischemia between January 2003 and October 2006 were reviewed. RESULTS A total of 99 cases involving TASC C (n = 43, 44%) and D (n = 56, 56%) lesions were treated with surgical bypass in 59 patients and atherectomy in 33 patients. Bypass and atherectomy achieved similar 1-year primary patency (64% vs 63%; P = .2). However, the 1-year limb salvage rate was greater in the bypass group (87% vs 69%; P = .004). In the tissue loss subgroup, there was a greater limb salvage rate for bypass patients versus atherectomy (79% vs 60%; P = .04). CONCLUSIONS Patients with critical limb ischemia may do better with open bypass compared with atherectomy as first-line therapy for limb salvage.
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Affiliation(s)
- Gabriel Loor
- Department of Vascular Surgery, University of Chicago, Chicago, Illinois, USA
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Innere Amputationen beim diabetischen Fußsyndrom. DIABETOLOGE 2009. [DOI: 10.1007/s11428-008-0347-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Abstract
Internal pedal amputation consists of resection of the metatarsals, midtarsal bones, or talus with preservation of the toes and soft-tissue envelope. Although used in the past for the treatment of tuberculosis within the pedal skeleton, internal pedal amputations have become almost forgotten, historical procedures. However, following internal pedal amputations of a diabetic patient, the foot undergoes significant contracture that results in a stable, functional, foreshortened residual foot capable of being protected in custom-molded shoe gear with external or in-shoe orthoses. The author presents the surgical approach and postoperative treatment regime for each form of internal pedal amputation, as well as "pearls" for success.
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Yoho RM, Wilson PK, Gerres JA, Freschi S. Chopart's amputation: a 10-year case study. J Foot Ankle Surg 2008; 47:326-31. [PMID: 18590897 DOI: 10.1053/j.jfas.2008.04.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2007] [Indexed: 02/03/2023]
Abstract
The purpose of this case study was to review the 10-year outcome of a patient with a history of diabetes, pedal osteomyelitis, and peripheral vascular disease, who underwent a Chopart's amputation of the right foot. Key evaluative elements to consider for long-term success of any amputation include the vascular status of the foot, control of infection, adequate soft tissue coverage, biomechanics associated with amputation, the metabolic challenge of amputation, and the psychosocial consequences linked to loss of a limb. The results of the case study show that Chopart's amputation is an excellent limb salvage surgical option that can achieve beneficial long-term outcomes in properly selected patients.
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Affiliation(s)
- Robert M Yoho
- College of Podiatric Medicine and Surgery, Des Moines University, Des Moines, IA 50312, USA
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Einsiedel T, Dieterich J, Kinzl L, Gebhard F, Schmelz A. Extremitätenerhalt durch tibiokalkaneare Arthrodese nach Pirogoff. DER ORTHOPADE 2008; 37:143-52. [DOI: 10.1007/s00132-008-1196-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Stone PA, Back MR, Armstrong PA, Flaherty SK, Keeling WB, Johnson BL, Shames ML, Bandyk DF. Midfoot Amputations Expand Limb Salvage Rates for Diabetic Foot Infections. Ann Vasc Surg 2005; 19:805-11. [PMID: 16205848 DOI: 10.1007/s10016-005-7973-3] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The persistent high incidence of limb loss resulting from advanced forefoot tissue loss and infection in diabetic patients prompted an evaluation of transmetatarsal (TMA) and transtarsal/midfoot amputations in achieving foot salvage at our tertiary vascular practice. Over the last 8 years, 74 diabetic patients required 77 TMAs for tissue loss and/or infection. Twelve (16%) of the patients had a contralateral below-knee amputation (BKA) and 26% (n = 20) had dialysis-dependent renal failure. Thirty-five (45%) limbs had concomitant revascularization (bypass grafting or percutaneous transluminal angioplasty), 32 (42%) had arterial occlusive disease by noninvasive testing and/or arteriography but were not or could not be revascularized, and seven (13%) had normal hemodynamics. Patient factors, arterial testing, operative complications, operative mortality (<60 days), wound healing (at 90 days), limb salvage, functional status, and survival were evaluated during a mean follow-up of 20 months (range 3-48). Operative mortality was 5% (n = 4) after TMA and/or midfoot amputation. Although 32 TMAs initially healed (44%), six BKAs were required 5-38 months later. Of the 41 nonhealing TMAs (56%), progressive infection/tissue loss necessitated major amputation of nine limbs. Chopart (n = 22) or Lisfranc (n = 10) midfoot amputations were done in the remaining 32 nonhealing TMAs. Despite additional wound revisions in 14 patients (44%), major amputation was needed in six limbs. However, functional ambulation was achieved in 23 of 25 (92%) limbs with healed midfoot amputations, and foot salvage was possible in 61% (25/41) of nonhealing TMAs. Overall limb salvage for TMA/midfoot procedures was estimated from Kaplain-Meier life tables to be 73%, 68%, and 62% at 1, 3, and 5 years, respectively, with only 50% of dialysis patients avoiding major amputation. Ankle pressure >100 mm Hg and a biphasic pedal waveform had a positive predictive value (PPV) of 79%, and toe pressure >50 mm Hg had a PPV of 91% for determining healing of TMA/midfoot amputations. One- and 3-year survival rates were only 72% and 69% for the entire cohort from life table estimates. Aggressive attempts at foot salvage are justified in diabetic patients with advanced forefoot tissue loss/infection after assuring adequate arterial perfusion. Transtarsal amputations salvaged over half of nonhealing TMAs with excellent functional results.
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Affiliation(s)
- Patrick A Stone
- Division of Vascular and Endovascular Surgery, University of South Florida, Tampa, FL 33606, USA
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Abstract
The issue of choosing an amputation level can be difficult for physicians. Every attempt should be made to maintain as much pedal length as possible to increase biomechanical function and ambulatory power. When there is excessive soft tissue loss because of trauma, infection, or vascular compromise, a Lisfranc amputation should be considered as a limb-salvage procedure. A more proximal midfoot amputation than Lisfranc is one at Chopart's articulation. This article addresses Lisfranc and Chopart amputations.
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Affiliation(s)
- Mark A DeCotiis
- Podiatry Service, University Hospital, UMDNJ, 150 Bergen Street, A-226, Newark, NJ 07103, USA.
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DeGere MW, Grady JF. A modification of Chopart's amputation with ankle and subtalar arthrodesis by using an intramedullary nail. J Foot Ankle Surg 2005; 44:281-6. [PMID: 16012435 DOI: 10.1053/j.jfas.2005.04.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
This study reports on 7 patients who underwent a new technique for Chopart amputation that includes ankle and subtalar arthrodesis using an intramedullary nail. This method affords rigid control to the rearfoot and appears to avoid the most common complications historically associated with Chopart amputations. All 6 surviving patients achieved successful outcomes within 1 year of their surgery. All are community ambulators who are able to walk short distances within the home without a prosthesis. One patient, who had undergone a previous vascular bypass, died in the early postoperative period after developing an infection that required an above-knee amputation. A second patient developed an infection that resolved with intravenous antibiotics. This new technique reintroduces the Chopart-level amputation as a valuable intermediate between the transmetatarsal and below-knee amputation levels.
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Affiliation(s)
- Michael W DeGere
- VA Chicago Healthcare System-Westside Division of Podiatric Surgical Residency Program, USA.
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Dwyer AJ, Paul R, Gosselin RA. Amputations through the hind foot: a report of three cases using a modified Dwyer and Paul procedure. J Orthop Trauma 2005; 19:286-9. [PMID: 15795580 DOI: 10.1097/01.bot.0000164168.94365.49] [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: 02/02/2023]
Abstract
Salvage of limb length following oblique proximal foot amputations is presented. The technique, results, and follow-up of this procedure are described and compared with other standard procedures. A prospective study was done on 3 adolescents who presented consecutively during years 1999 and 2000. The salvage procedure described was performed on all 3 patients, and they were followed up for an average 3.5 years (range 3-4 years). All patients ambulated soon after surgery using crutches. Union of the graft between the distal tibia and calcaneus was achieved at 6 months, and all patients could walk bare foot as well as using their prosthesis both indoors and outdoors. We conclude that salvage of leg length and preservation of the sole of the foot in its normal plantigrade position by this procedure offers a viable and acceptable option to the surgeon and young patients.
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Affiliation(s)
- Amitabh Jitendra Dwyer
- Department of Orthopedics, Christian Medical College and Hospital, Ludhiana, Punjab, India.
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Mwipatayi BP, Naidoo NG, Jeffery PC, Maraspini CD, Adams MZ, Cloete N. Transmetatarsal Amputation: Three-year Experience At Groote Schuur Hospital. World J Surg 2005; 29:245-8. [PMID: 15645336 DOI: 10.1007/s00268-004-7456-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Transmetatarsal amputation (TMA) for peripheral vascular disease has the reputation of being an operation with a poor outcome. This retrospective study reviewed a 3-year consecutive series of TMA in diabetic and nondiabetic patients. All amputations performed for peripheral vascular disease at Groote Schuur Hospital from January 1999 to December 2002 were reviewed. Data were obtained from hospital records and operating theatre books. The following groups were defined for the purpose of this retrospective study: group 1, TMAs performed in diabetic patients; group 2, TMAs done in nondiabetic patients. Altogether, 43 TMAs were performed: 27 in group 1 and 16 in group 2. Perioperative mortality rates were 7% and 4%, respectively. Overall, the healing rate was 67%: 62% (17/27) in group 1 and 75% (12/16) in group 2. The median times to healing were 8 months in group 1 and 7 months in group 2. Toe pressure and the presence of advanced tibioperoneal disease influenced the outcome of TMA in diabetic patients. Transmetatarsal amputation with a healed stump provided our patients with good mobility. Prediction of healing after operation is unreliable. There was no statistical difference in outcome in diabetic (group 1) versus nondiabetic (group 2) patients.
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Affiliation(s)
- B P Mwipatayi
- Department of Surgery, Vascular Unit, Groote Schuur Hospital/University of Cape Town, Cape Town, South Africa.
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25
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Glass H, Rowe VL, Hood DB, Yellin AE, Weaver FA. Influence of Transmetatarsal Amputation in Patients Requiring Lower Extremity Distal Revascularization. Am Surg 2004. [DOI: 10.1177/000313480407001003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
When a transmetatarsal amputation (TMA) is required, successful long-term limb salvage is questioned. We evaluated the influence of TMA on limb salvage in patients undergoing lower extremity revascularization. Patients who had distal bypasses extending to the infrapopliteal arterial tree and adjunctive TMA were retrospectively reviewed. Limb salvage was determined with life-table analysis. Twenty-four patients (29 limbs) were evaluated: 15 male and 9 female. Average age was 64.2 years old. Gangrene was the indication for bypass and TMA in 25 (86.2%) patients. Seven limbs were lost to follow-up. Nine of the remaining 22 limbs required below-knee (8) or above-knee (1) amputations, seven limbs within the first 3 months. In the group of patients who had major amputations within the first 3 months, graft thrombosis was the cause of leg amputation in six (85.7%) cases. No significant predictors of early major amputation were identified. Limb salvage was 62 per cent at 1 year in the TMA group. In comparison, among historical controls requiring distal revascularization and no adjunctive toe or foot amputations, limb salvage was 76.5 per cent ( P = NS). Long-term limb salvage is dependent on successful lower extremity revascularization. Requirement for TMA should not influence the decision for limb salvage.
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Affiliation(s)
- Holly Glass
- From the Department of Surgery, Division of Vascular Surgery, Keck USC School of Medicine, LAC + USC Medical Center, Los Angeles, California
| | - Vincent L. Rowe
- From the Department of Surgery, Division of Vascular Surgery, Keck USC School of Medicine, LAC + USC Medical Center, Los Angeles, California
| | - Douglas B. Hood
- From the Department of Surgery, Division of Vascular Surgery, Keck USC School of Medicine, LAC + USC Medical Center, Los Angeles, California
| | - Albert E. Yellin
- From the Department of Surgery, Division of Vascular Surgery, Keck USC School of Medicine, LAC + USC Medical Center, Los Angeles, California
| | - Fred A. Weaver
- From the Department of Surgery, Division of Vascular Surgery, Keck USC School of Medicine, LAC + USC Medical Center, Los Angeles, California
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26
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Affiliation(s)
- O Malakhova
- Department of Anatomy and Cell Biology, University of Florida, Gainesville, Florida 32610-0235, USA.
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27
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Nehler MR, Hiatt WR, Taylor LM. Is revascularization and limb salvage always the best treatment for critical limb ischemia? J Vasc Surg 2003; 37:704-8. [PMID: 12618724 DOI: 10.1067/mva.2003.142] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Affiliation(s)
- B Persson
- Department of Orthopaedics, University Hospital, SE 22185 Lund, Sweden
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29
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Abstract
The objective of lower extremity amputation surgery is to create a viable, functional residual limb to maximize patient mobility and independence. When part or all of the forefoot is lost to trauma, infection or gangrene, and the hindfoot is viable, every attempt should be made to preserve as much foot function as possible. The use of the transmetatarsal level is common. In the past, amputations through the Lisfranc and Chopart's joint lines involved significant complication rates. With improvements in patient selection and surgical technique, these two amputation levels are viable options to consider when attempting salvage of the hindfoot structures.
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Affiliation(s)
- J S Early
- Department of Orthopedic Surgery, University of Texas Southwestern Medical School at Dallas 75235-8883, USA
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30
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Steinau HU, Hebebrand D, Vogt P. Amputation alternatives preserving bipedal ambulation. ACTA ACUST UNITED AC 1997. [DOI: 10.1016/s1071-0949(97)80026-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Persson BM, Söderberg B. Pantalar fusion for correction of painful equinus after traumatic Chopart's amputation--a report of 2 cases. ACTA ORTHOPAEDICA SCANDINAVICA 1996; 67:300-2. [PMID: 8686476 DOI: 10.3109/17453679608994696] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- B M Persson
- Department of Orthopedics, Helsingborg Hospital, Sweden
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Darling RC, Shah DM, Chang BB, Lloyd WE, Paty PS, Leather RP. Arterial reconstruction for limb salvage: is the terminal peroneal artery a disadvantaged outflow tract? Surgery 1995; 118:763-7. [PMID: 7570334 DOI: 10.1016/s0039-6060(05)80047-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Arterial reconstructions performed for limb salvage have increasingly used distal perimalleolar and pedal arteries as outflow tracts. However, a paucity of reports comparing the patency and limb salvage rates of these outflow tracts has been published. In this report we examine our experience with distal peroneal artery reconstructions for limb salvage. METHODS During the past 14 years 159 bypasses were performed to the distal peroneal artery (within 5 cm of the malleolus), 157 of which were performed by the medial approach and two by the lateral approach. RESULTS Sixty-three percent of the patients were male, 65% were diabetics, and 43% were smokers; the average age was 72.6 years. Sixty-five percent of the bypasses were performed with the in situ technique. Thirty-one percent of the bypasses were performed with translocated or spliced vein technique, and seven (4%) were performed with prosthetic technique. Secondary patency rates for distal peroneal artery bypass grafts at 1 and 5 years were 86% and 75%. The limb salvage rate for distal peroneal artery bypasses was 87% at 5 years. Four hemodynamic failures occurred in this group. Wound complications requiring revision were seen in one patient with a distal peroneal bypass (0.6%). These results do not differ from our results with other perimalleolar vessels. CONCLUSIONS Arterial reconstruction to the distal peroneal artery has acceptable patency and limb salvage rates. These bypasses are as effective and durable as other perimalleolar bypasses.
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Affiliation(s)
- R C Darling
- Vascular Surgery Section, Albany Medical College, N.Y. 12208, USA
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Abstract
When presented with an ischemic limb with forefoot necrosis of varying amounts, the surgeon often categorizes the need for amputation into toe, ray, transmetatarsal, below-knee, and above-knee. Adherence to this type of algorithm ensures a primary above- or below-knee amputation rate of 10% to 20%. The utility of the more uncommon amputations advocated here is an increase of limbs deemed eligible for revascularization and limb salvage. Furthermore, delaying the amputations until the vascular supply is normalized maximizes tissue salvage and minimizes prolonged hospitalizations with multiple amputations performed as a prelude to major amputation. Although these amputations are often looked upon as an afterthought by many vascular surgeons, careful execution here is as important to effective limb salvage as any distal bypass procedure.
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Affiliation(s)
- B B Chang
- Department of Surgery, Albany Medical College, New York, USA
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Abstract
Our experience and that of others indicate that the number of very distal bypass operations is growing. From the early 1970s, when we performed a few operations per year, our numbers have increased to 60 to 65 operations annually, about 20% of all infrainguinal open revascularizations. Amputation of one leg leaves a patient, should he survive for a few years, with a second limb that is at substantial risk of infection or gangrene. From over 20 years of experience with thousands of diabetic leg problems and approximately 600 paramalleolar bypasses, the following facts have emerged from our clinical practice. Primary pedal arterial arches are virtually never complete. This alone should not deter the surgeon from attempting paramalleolar bypass grafting. Clinical details such as neuropathy, sepsis, and general medical status and even family support should not be overlooked as "risk factors." The order of frequency for pedal distal anastomotic sites will be anterior tibial/dorsalis pedis, posterior tibial/common plantar artery, lateral plantar artery/medial plantar artery, and lateral tarsal artery. In each case the graft should be placed as proximal as possible on the vessel; tibial outflow should be considered. Use short grafts with distal inflow whenever possible. In the rare instance wherein no pedal target site is available, consider the isolated tibial segment. Failure of a very distal bypass procedure seldom results in an amputation that is more proximal than otherwise would have been required if no bypass were attempted. As a corollary, after sepsis is controlled and all lesions and amputations are healed, failure of the graft may spare the limb from further risk of amputation. In diabetics, the presence of a palpable popliteal pulse and absence of foot pulse are tantamount to identifying the paramalleolar bypass graft candidate. Even the presence of palpable pedal pulses does not exclude patients who could achieve limb salvage with pedal bypass. That determination depends upon an angiogram. Pulsation and flow are not equivalent. Just as the obligations of the surgeon who performs an amputation are not discharged until healing and rehabilitation are complete, likewise, the vascular surgeon's duties after paramalleolar bypass must include a return to the ambulatory status. Careful follow-up, ongoing explicit patient and family education about foot care, and orthotics and shoes will enhance the life and life expectancy of the bipedal patient.
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Affiliation(s)
- G Andros
- Vascular Laboratory, Saint Joseph Medical Center, Burbank, California, USA
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Darling RC, Chang BB, Paty PS, Lloyd WE, Leather RP, Shah DM. Choice of peroneal or dorsalis pedis artery bypass for limb salvage. Am J Surg 1995; 170:109-12. [PMID: 7631912 DOI: 10.1016/s0002-9610(99)80266-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Arterial bypasses performed for limb salvage have increasingly used peroneal and pedal arteries as outflow. However, few reports have been published that compare the patency of limb salvage of these alternative outflow tracts. In this report, we have examined our experience with peroneal and dorsalis pedis (DP) artery bypasses for limb salvage. METHODS AND MATERIALS Of more than 3,000 infrainguinal reconstructions performed for limb salvage, 732 were completed to the peroneal artery. During the same period, 238 bypasses were performed to the DP artery. Patient demographics were similar in both groups. The in situ technique was used in 68% of the peroneal bypasses and in 66% of the DP bypasses, respectively. Translocated veins were used in 28% of bypasses, and spliced veins were used in 32%. RESULTS Secondary patency rates for the DP bypass at 1 and 5 years were 89% and 67%, respectively, as compared with 89% and 78% for the peroneal artery bypass. Limb salvage rates for the DP bypass were 94% at 1 year and 86% at 5 years, as compared with 96% and 93% at 1 and 5 years, respectively, for the peroneal artery bypass. No statistical difference was found. Four (1.7%) hemodynamic failures occurred in the DP group and 10 (1.4%) in the peroneal group. Wound complications were seen in 9 (3%) patients in the DP group and in 11 (1.5%) in the peroneal group. CONCLUSION This experience indicates that both peroneal and DP bypasses have acceptable patency and limb salvage rates. Selection of one of these two outflow tracts, where a choice exists, may depend on the conduit limitation and adjacent tissue infection; however, both outflow tracts are durable and hemodynamically effective for limb salvage.
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Affiliation(s)
- R C Darling
- Albany Medical College, Vascular Surgery Section, New York 12208, USA
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