The Pirogoff amputation for necrosis of the forefoot: a case report

Outcome of Modified Pirogoff Amputation for Diabetic Foot Infection: A Single-Center Case Series

INTRODUCTION

Diabetic-related foot condition is one of the most debilitating complications with a higher rate of failure in limb correction, reconstruction, or salvage surgery. Amputation is the final option after other surgical treatments have failed. Major amputation increases energy consumption, resulting in high dependency, decreased mobility, and poor prognosis. Consequently, minor amputation is preferred to resolve these problems but elevated wound complications leading to inadequate prosthesis fit, became a detriment to minor amputation. Strict selection of patients is crucial to ensure success and good functional outcomes as demonstrated in this retrospective study of this case series. Methods: This case series included six patients who underwent Pirogoff amputation with the modification described by Nather and reported the procedure's outcome. The inclusion criteria for subjects were the presence of palpable posterior tibial artery (PTA) or at least biphasic Doppler signal and ankle-brachial systolic index (ABSI) more than 0.70. Other demographic data as well as hematological, inflammatory, and biochemical parameters that may affect wound healing such as Hb, HbA1c, ESR, CRP, WBC, and albumin were recorded as well. The rate and time for wound healing and bone union, presence of complications, and final ambulatory status of patients were determined as the outcome of this study.

RESULTS

All of the patients had diabetic foot infections involving only the forefoot region with the presence of either palpable PTA or biphasic Doppler signal. Although the majority of the cases had deranged blood parameters, soft tissue and bone healing were achieved at variable times. Four had good outcomes as they were able to ambulate. One case was complicated with chronic wound dehiscence and another one had Pirogoff stump infection and required transtibial amputation.

CONCLUSION

With strict selection criteria, Pirogoff amputation may provide a good functional outcome with a lesser degree of complications compared to major amputation.

Results of the modified Pirogoff amputation with cannulated screws for diabetic foot infection

INTRODUCTION

Syme amputation has been shown to have value in patients with diabetic foot infections, but it has inherent drawbacks. A potential alternative is the modified Pirogoff amputation. Our objective was to evaluate the outcome of modified Pirogoff amputation using internal fixation with 6.5-mm cannulated screws in the management of diabetic foot.

METHODS

This is a prospective study of 13 patients admitted from January 2012 to June 2015. Inclusion criteria were infection limited to the forefoot, presence of a palpable posterior tibial pulse and an ankle-brachial index of more than 0.7. Internal fixation of the calcaneum to the tibial was performed using two 6.5-mm cannulated screws under image intensifier control.

RESULTS

In ten cases, the wounds were healed at three weeks. Osseous union was observed in ten cases; the time taken for its occurrence was 2-5 months. Removal of screws was performed in five cases. Five cases developed technical complications of screw tract infection, with two cases having distal screw migration. Good results, defined as cases not requiring a below-knee amputation for two years postoperatively, were obtained in 10 (77%) cases. At the three-year follow-up, three additional cases required proximal amputation, leaving 7 (54%) cases with good outcomes.

CONCLUSION

Our prospective study showed that with careful selection of patients, good postoperative results can be obtained. There is a definite role for modified Pirogoff amputation in the management of diabetic foot problems.

Modifications of the pirogoff amputation technique in adults: A retrospective analysis of 123 cases

BACKGROUND

The Pirogoff amputation (1854) was initially developed to provide full-weight-bearing stumps and therefore allow a short ambulation without prosthesis. Modifications of the original technique including Boyd (1939) and the "Modified Pirogoff" were developed, which further reduced complications and improved the outcome. However, the current evidence regarding the techniques is scarce. The functional outcome, survivorship and complication rates are unknown. It was the purpose of this study to expand the knowledge with a retrospective case series and ultimately summarize and analyze the data with a systematic review.

METHODS

A retrospective study of the Boyd procedures from our institution between 1999 and 2018 was performed. Outcome was determined based on the PLUS-M Score (Prosthetic Limb Users Survey of Mobility). Survivorship (absence of more proximal amputation), postoperative leg-length discrepancy, time to early fusion and time to mobilization were also evaluated. Finally, in the second part of the study, the results were integrated in a systematic review, which followed the Preferred Reporting Items of Systematic Reviews and Meta-analysis (PRISMA) guidelines. The quality of all the studies were then assessed using the Joanna Briggs Institute Critical Appraisal Checklist (JBI CAC).

RESULTS

A total of 123 procedures including 115 patients, with an average follow-up of 45 months (range, 10-300 months) could be included. A very good or good function could be achieved in 85 (69%) patients. The mean survivorship was 82.1% (range 46%-100%). In four studies, including our series, all patients remained with a functional stump at the latest follow-up. The calculated average leg-length discrepancy was 2.5 cm.

CONCLUSION

The "Modified Pirogoff" and Boyd amputation techniques can achieve favourable long-term functional outcome in cases of irreparable foot conditions such as osteomyelitis or trauma. Patency of the posterior tibial artery is an indispensable condition to elect for these surgical techniques. Presence of neuropathy does not preclude this amputation level. With proper patient selection, a maximal survivorship of the stump with treatable minor complications can be achieved.Level of Evidence: IV.

Nikolay Ivanovich Pirogov (1810-1881): A pioneering Russian surgeon and medical scientist

Nikolay Pirogov qualified as a physician from Moscow University in 1828 and then studied surgery and anatomy at University of Dorpat. He developed new surgical techniques, including the eponymous osteoplastic foot amputation. His application of scientifically based techniques extended surgery from a craft to a science. During the Crimean War he initiated the deployment of women as nurses and used triage for dealing with mass casualties. His textbook on field surgery became the standard reference on the subject and his principles remained virtually unchanged until the Second World War. Pirogov died on 5 December 1881 at his estate in Vishnya.

Pirogoff amputation for a bilateral traumatic lower-extremity amputee: indication and technique

Although only a small portion of all lower-extremity amputations in the United States are of traumatic origin, almost half of all living amputees have sustained traumatic amputations. This particular epidemiology is explained by the younger age, and thus longer life expectancy, of traumatic amputees. In this group especially, restoration and lifelong maintenance of ambulation and mobility is essential. The authors present the case of a bilateral traumatic lower-leg amputee whose management included a Pirogoff amputation. Although this amputation technique is not widely used, the authors believe it greatly facilitated stump and soft tissue management in this case and allowed for improved mobility. The indication for and technique of Pirogoff amputation are described, and a brief overview of amputation techniques in the foot is provided.

The modified Pirogoff's amputation in treating diabetic foot infections: surgical technique and case series

BACKGROUND

This paper describes the surgical technique of a modified Pirogoff's amputation performed by the senior author and reports the results of this operation in a single surgeon case series for patients with diabetic foot infections.

METHODS

Six patients with diabetic foot infections were operated on by the National University Hospital (NUH) diabetic foot team in Singapore between November 2011 and January 2012. All patients underwent a modified Pirogoff's amputation for diabetic foot infections. Inclusion criteria included the presence of a palpable posterior tibial pulse, ankle brachial index (ABI) of more than 0.7, and distal infections not extending proximally beyond the midfoot level. Clinical parameters such as presence of pulses and ABI were recorded. Preoperative blood tests performed included a glycated hemoglobin level, hemoglobin, total white blood cell count, C-reactive protein, erythrocyte sedimentation rate, albumin, and creatinine levels. All patients were subjected to 14 sessions of hyperbaric oxygen therapy postoperatively and were followed up for a minimum of 10 months.

RESULTS

All six patients had good wound healing. Tibio-calcaneal arthrodesis of the stump was achieved in all cases by 6 months postoperatively. All patients were able to walk with the prosthesis.

CONCLUSIONS

The modified Pirogoff's amputation has been found to show good results in carefully selected patients with diabetic foot infections. The selection criteria included a palpable posterior tibial pulse, distal infections not extending proximally beyond the midfoot level, ABI of more than 0.7, hemoglobin level of more than 10 g/dL, and serum albumin level of more than 30 g/L.

Distal amputations for the diabetic foot

Minor amputations in diabetic patients with foot complications have been well studied in the literature but controversy still remains as to what constitutes successful or non-successful limb salvage. In addition, there is a lack of consensus on the definition of a minor or distal amputation and a major or proximal amputation for the diabetic population. In this article, the authors review the existing literature to evaluate the efficacy of minor amputations in this selected group of patients in terms of diabetic limb salvage and also propose several definitions regarding diabetic foot amputations.

Ilizarov external frame technique for pirogoff amputations with ankle disarticulation and tibiocalcaneal fusion

BACKGROUND

The high rates of wound failure, persisting infection, and nonunion of the tibiocalcaneal arthrodesis are the main reasons why the Pirogoff ankle disarticulation is rarely used for limb salvage. Use of the Ilizarov external frame has increased our fusion rate. The purpose of this study was to review our experience with the use of the Ilizarov external frame as a technique for Pirogoff amputations with ankle disarticulation and tibiocalcaneal fusion.

METHODS

Twenty-four patients (median age, 57.4 years; range, 29-76 years) underwent a Pirogoff amputation with Ilizarov external frame use between January 2004 and June 2011. The most common indications were gangrene with uncontrollable infection due to Charcot arthropathy or chronic osteomyelitis. Four patients had sustained crush injuries of the foot. All patients were clinically and radiographically followed for a minimum of 12 months. Additionally, 15 patients were evaluated using the Taniguchi rating scale for Pirogoff amputations after a mean follow-up of 44.9 months (range, 12-86 months).

RESULTS

In 21 patients (87.5%), a well-healed Pirogoff stump was achieved after a mean external fixation time of 18.1 weeks (range, 12.7-26.6 weeks). Impaired vascular perfusion was found to be the limiting factor for successful wound healing and an overall successful Pirogoff amputation. According to the Taniguchi scale, 67% of the patients achieved good or excellent functional results. Fair (27%) and poor (6%) results were observed only in the diabetic patients.

CONCLUSION

Using the Ilizarov external frame allowed safe fixation and a high success rate, even in neuropathic feet. The frame allowed for immediate weight-bearing and soft tissue control; however, frame-associated complications were common and could result in revision surgery.

LEVEL OF EVIDENCE

Level IV, case series.