The goal of this chapter is to highlight the principles and concepts that can be applied to the clinical setting across the continuum of care. Socket considerations for the patient with a transtibial. Amputation surgeons have a unique role and responsibility. Extended posterior flap method with bone bridging surgical notes. Improvements in amputation surgical technique and surgical decision making e.
The success of every amputation surgery depends on the balance between these two main goals. The stated goal of the article was to determine the longterm followup of patients who had sustained a battlefield injury. In a study of 50 patients with a transfemoral amputation it was reported that socket shape did not influence the position of the residual femur, that surgical technique was an important factor, and that prosthesis alignment did not seem to influence the position of the residual femoral shaft either. Inpatient rehabilitation and shaping but it requires skilled technique. The ligamentous structures of the joint are the fibrous capsule. Without appropriate application there is the risk of too much proximal compression, tissue strangulation and pressure damage, though these complications are not well documented. A staged amputation with the first surgery providing a drainage amputation may help prevent wound problems at the final level of amputation. Below knee amputation an overview sciencedirect topics. The chapter also covers epidemiology, amputation terminology, functional classification, and implications of. The deep tissues and joint capsule may be closed separately for a more secure closure as well as to prevent a deep space void.
Due to the preservation of the knee joint, many amputees are able to return to or exceed the level of activity prior to their surgery. Finger amputation an overview sciencedirect topics. This book is distributed under the terms of the creative commons. Although many variations in technique exist, basically all procedures may be. For people with a unilateral lowerlimb amputation, the. Amputation is a blind and final method in surgery to save the patients life. Helping inform difficult discussions between patients and practitioners about the level of pfa, or the decision to have a transtibial amputation tta as an alternative, requires an understanding of the current research evidence on a wide range of topics including wound healing, reamputation. Amputation is the removal of a limb by trauma, medical illness, or surgery. Specialized amputee team and shaping but it requires skilled technique. This chapter provides a comprehensive overview of the rehabilitation management for the person with a lower limb amputation. Transtibial surgical technique the fundamental principles of osteomyoplastic transtibial amputation are osseous and softtissue reconstruction that provide a painfree, stable, endbearing residual limb. Long posterior flap burgess technique zdesigned by kendrick 1956 and made popular by burgess 1969. Outcomes of dysvascular partial foot amputation and how.
The ertl technique, an osteomyoplastic transtibial amputation procedure that involves forming a tibiofibular bone bridge to provide a stable tibiofibular articulation that may be capable of some distal weightbearing, may be used to create a highly functional residual limb. Lower limb amputation and gait musculoskeletal key. Transtibial amputation traditional posterior flap bone. The effectiveness of the bone bridge transtibial amputation technique. Along with fasciocutaneous flaps and free flap techniques, skin grafts are a viable option in. The most common indication for amputation of an upper limb is severe trauma. He has chronic pain and dysfunction after several reconstructive surgeries and has requested amputation. Pain and painrelated interference in adults with lower. Muscletobone suture does add operative handling of tissues and en circling sutures carry the potential of local muscle constriction.
As more functional goals for the transtibial amputee have been appreciated, new techniques have been developed in an attempt to enhance function at that level. Proponents of the ertl procedure in which the cut ends of the tibia and fibula are joined with a bone bridge synostosis argue that the residual limb is more stable which confers better prosthetic fit and improved function especially among highperforming individuals. We therefore performed anova both including these participants and excluding their data from further analysis. Its timely publication, in association with the ispo international society for prosthetics andorthotics, coincides with the world conference of the ispo which is held only every 4 years. Principles of amputation zollingers atlas of surgical. A belowknee amputation bka is a transtibial amputation that. Blood vessel disorders such as atherosclerosis, often secondary to diabetes mellitus, account for the greatest percentage of amputations of the lower limb. A novel technique for transtibial amputation in chronic occlusive. Within the first few weeks following amputation, this is mostly a tool for use by a nurse or caregiver.
Removal of the talus and fusion of the distal tibia and fibula. Amputation is the cutting off or the removal of limbextremity or part thereof. An amputation is performed as far above the affected area as is necessary to remove all unhealthy tissue and to leave a portion of sound tissue with which to pad the bone stump. Even though the literature on amputations is becoming. Transtibial amputation, or belowknee amputation, is a surgical procedure performed to remove the lower limb below the knee when that limb has been severely damaged or is diseased. This means sitting with the knee extended and laying without a pillow under the knee. Current level iii evidence supports a bone bridge technique as an equivalent. Background amputation osteomyoplasty, or bone bridging, is a technique developed in 1920 to better correct the residual limb to a normal physiological status 1. The aim of this study was to compare results of transtibial amputations performed using the burgess or modified burgess techniques with those performed using the bruckner technique. A novel technique for transtibial amputation in chronic. Ertle osteomyoplastic technique creates a weightbearing strut from the tibia to fibula from a piece of fibula or osteoperiosteal flap secure strut with 2.
In general, a bka is preferred over an aboveknee amputation aka, as the former has better rehabilitation and functional outcomes. After a few weeks, patients themselves can oftentimes use this device on their own to help put on a. Surgical amputation is currently performed in cases of bone and tissue cancers, gangrene, and uncontrollable infections of the arm or leg. Removal of all or part of a limb, due to infection, disease, tumor, injury or trauma. Rehabiliation following a transtibial amputation in a. Amputation is the removal of a body extremity by trauma or surgery. Redrawn from ruckley cv, stonebridge pa, prescott rj. The new technique developed by the prosthetics research study utilizes. Transtibial, peripheral vascular disease, gait reeducation, balance training.
The patient presented is a 36 year old male who has a 3 month history of a left transtibial amputation. Anesthesia spinal anesthesia is commonly used for major amputation of the lower extremities, inhalation anesthesia for major amputations of the upper extremities, and plexus block or local. Transtibial amputation traditional posterior flap total. This article examines the prevalence of this amputation level, the nomenclature, and the various challenges facing the transfemoral amputee. Short, broad fishmouth skin flaps are outlined to provide a mediolat eral closure.
The transtibial amputation also known as a below the knee or bk is the most common level of lower limb amputation. Amputation osteomyoplasty, or bone bridging, is a technique developed in 1920 to better correct the residual limb to a normal physiological status. In the nonischemic patient the flaps are fashioned approximately equal in length. The long posterior flap technique has become the most frequently recommended technique. Virtually the same findings were reported by sarmiento and warren, who noted a fall in mortality rate from 24% to 10% that was directly related to the reversal of their transtibial totransfemoral ratio from 1. He previously worked as a software designer and is married with a one year old daughter. General principles of amputation surgery uw orthopaedics and. Transtibial amputation outcomes study full text view. The optimal technique for a transtibial amputation in a young, active, and healthy patient is controversial. An amputation is performed as far above the affected area as is necessary to remove all unhealthy tissue and to leave a. The transtibial amputation osteomyoplasty procedure was performed as described by pinzur et al. Surgical practice and patient management provides a complete text for good surgical technique and sensible and practical patient management. Apr 22, 2019 the ertl technique, an osteomyoplastic transtibial amputation procedure that involves forming a tibiofibular bone bridge to provide a stable tibiofibular articulation that may be capable of some distal weightbearing, may be used to create a highly functional residual limb.
Ucsf transtibial amputation trial transtibial amputation. Comparison of functional outcomes following bridge synostosis with nonbonebridging transtibial combatrelated. The wound for total amputation of a digital is also closed with a wellplanned incisional plantar flap technique figs 25. Dec 17, 2019 a belowknee amputation bka is a transtibial amputation that involves removing the foot, ankle joint, and distal tibia and fibula with related soft tissue structures. Long posterior flap burgess technique ztibia cut 1015cm from knee joint line zfibula cut 11. A belowknee amputation bka is a transtibial amputation that involves removing the foot, ankle joint, and distal tibia and fibula with related soft tissue structures. Dysvascular partial foot amputation pfa is a common sequel to advanced peripheral vascular disease. The transfemoral amputation level, part 1 amputee coalition. We present a technique for anterior cruciate ligament acl reconstruction using hamstring tendon autograft with a modi. Previous motorcyle accident, four failed attempts at. Techniques for lower extremity amputation uptodate. As a surgical measure, it is used to control pain or a disease process in the affected limb, such as malignancy or gangrene. Transtibial below knee residual limb edema and shape.
Transtibial below knee residual limb edema and shape management recommendations. Proponents of this technique state that the bone bridging between the tibia and fibula creates a larger and more stable endbearing construct as well as preventing the fibular instability that occurs secondary to loss of the ankle. The total surface bearing socket still may incorporate the weightbearing characteristics of the patella tendon bearing socket, but often will be accompanied by a shock absorbing gel liner. A small pillow may be placed at the distal end of the limb to encourage extension. Another detailed study was made of 25 unilateral transtibial amputees who were all under the age of. This article reports a reproducible technique for transtibial osteomyoplastic amputation.
Despite extensive training and efforts by the vamcs, surgeons have not uniformly adopted any particular dressing techniques. Amputation technique for the non ischemic patient the patient is prepared for surgery in the usual manner. The transtibial amputation is one of the most frequently performed major limb amputations in the united states. Amputation is no longer to be considered as purely the ablation of a useless or debilitating part, but rather as a reconstructive procedure to restore ambulatory function. Smith, md, amputee coalition medical director this is part 1 of a threepart look at the transfemoral aboveknee, or ak amputation level, one of the more frequently performed amputation procedures. Postoperative dressing and management strategies for. Comparing transtibial amputation with ertl and without a tibiafibula synostosis procedure details highenergy open fractures, blast, gunshot wound and crush injuries to the distal tibia, ankle, hind foot and midfoot are common challenges to military and civilian trauma surgeons brown, 2009. As a surgical measure, it is used to control pain or a disease process in the affected limb such as a malignancy, infection or gangrene. To accomplish these goals, osseous reconstruction requires the surgical creation of a.
Tibiofibular bonebridging osteoplasty in transtibial amputation. Proponents of this technique state that the bone bridging between the tibia and fibula creates a larger and more stable endbearing construct as well as preventing the fibular instability that occurs secondary to loss of the ankle mortise 27. Surgical procedures and immediate postsurgical management. Hip and thigh the hip joint is a multiaxial ballandsocket joint. Surgical practice and patient management provides a complete text for good surgical technique for amputation and sensible management of amputees. Transtibial uw orthopaedics and sports medicine, seattle. The primary study objective is to compare functional outcomes and number of revision surgeries to the amputated limb after first amputation for patients undergoing a transtibial amputation and randomized to receive a tibiafibula synostosis ertl procedure versus a standard posterior flap procedure burgess procedure. Below knee amputation bka statpearls ncbi bookshelf. Amputation of the foot at the ankle, part of the calcaneus being left in the lower end of the stump and fused to the distal tibia, 3.
Skewflap versus long posterior flap in belowknee amputations. The study was approved by the university of nebraska medical center irb nonlinear analysis of amputee gait, 02111ep, and by the nebraskawestern iowa veterans affairs medical center irb nonlinear analysis of amputee gait, 00793. Anatomic singlebundle anterior cruciate ligament reconstruction using the modi. Four databases were searched for articles pertaining to surgical strategies specific to a bone bridge technique of the transtibial amputee.
The combined mortality of three studies for transtibial amputation was 9. Transtibial below knee manual after the amputation 6 shrinker donning aid simplify the shrinker donning process with our shrinker donning aid. The ertl procedure is a surgical method in which a bony bridge. In some cases, it is carried out on individuals as a preventative surgery for such problems. Toe amputations still follow textbook rules for either dorsoplantar. Osteomyoplastic and traditional transtibial amputations in. Graphic content traditional reconstructive posterior flap transtibial amputation as described by burgess pathology. For these reasons myodesis is not recommended for use in the belowknee amputation for vascular disease. General principles of amputation surgery uw orthopaedics. Amputation is possible in any age group, but generally it affects or is highest among people aged 65 years and older. In some cases an amputation is carried out on individuals as a preventative surgery for. The reconstructive nature of amputation surgery and the potentially positive impact that proper technique can have on an individuals postamputation function cannot be over emphasized. These are used to prefit a prosthesis before it is made out of a stronger material that is difficult to adjust. We present the operative technique for turnup plasty with a transtibial amputation in three patients with combatrelated open tibial fractures who ultimately required amputation.
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