fibular segment bone bridging in trans-tibial amputation

8/12/2019 Fibular Segment Bone Bridging in Trans-tibial Amputation

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http://poi.sagepub.com/content/28/3/220Theonline version of this article can be foundat:

DOI: 10.3109/03093640409167753

2004 28: 220Prosthet Orthot IntM. A.G.S. Pinto and W. W. Harris

Fibular segment bone bridging in trans-tibial amputation

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Prosthetics and Orthotics International

2004 28 220-224

Fibular segment bone bridging in

trans-tibia1 amputation

M.

. G. S

PINTO and W. W. HARRIS

Centro

Marian W eiss Sdo Paulo Brazil

Abstract

The purpose of this paper is to present

an

alternative method of achieving a synostosis

between tibia and fibula in trans-tibia1

amputations by means of a fibular segment in

place of tibial osteoperibsteal flaps as described

by Ertl, in 1949.

From M ay 1997 through to February 2003, 15

patients were submitted to the proposed

procedure. As a result, all patients produced a

solid synostosis between tibia and fibula and

were rehabilitated with the use of prostheses.

The capacity of these patients for distal

weight-bearing on the stump was remarkable

when compared to patients submitted to the

conventional trans-tibia1 amputation technique.

Introduction

Bone bridging between tibia and fibula in

trans-tibia1 amputations has become desirable

in

the practice of amputation surgery as this

procedure promises a healthier stump and a.

better functional result in prosthetic adaptation.

In 1949, in Germany, the Hungarian surgeon

Janos Ertl published his paper Uber

Amputationsstiimpfe reporting a more

physiological way of performing amputation

surgery of the lower limbs (E d , 1949). He

desFribed the making of a bone bridge between

tibia and fibula in trans-tibia1 amputations

originating from tibial periosteum dissected

from the distal tibia stump. Ossification would

occur in time, resulting in a stable cortical bone

synostosis between both bones.

All correspondence

to

be

addressed

to

Marco Antonio

Guedes de Souza Pinto, Rua Mourato Coelho 1417.

05417-012

SHo

Paulo

S.P.,

Brazil.

A U-shaped bone frame is created, much more

adequate in sustaining distal w eight-bearing than

simple divided stumps of tibia and fibula.

Stabilising the fibula to the tibia by way of a

bone synostosis deters the distal fibula from

dislocating towards the tibia when compressed

by the prosthetic socket during weight-bearing.

In May 1997 the authors revised the trans-

tibial stump of a

38

year old woman with type 1

diabetes. Bone spikes were present at the distal

tibia, and the fibula was longer than the tibia. The

peripheral pulses of this patient w ere palpab le.

During surgery, instead of removing the

excessive fibula, the authors chose to fit i t in a

specially carved groove in the distal tibia. The

segment continued in contact with the remaining

fibula. The m anoeuvre was much less aggressive

and union of the synostosis occurred in a few

months. After a revision done to improve its

shape, radiographic and functional results were

similar to those obtained in bone bridging from

tibial periosteum.

Since then, due to its eff iciency and

simplicity, whenever possible, the authors have

chosen a segment of fibula for bone bridging in

trans-tibial am putations.

Material and method

From May 1997 to February 2003, 15 patients

were consecutively operated according to , the

fibula segment technique. Two

of

them

presented amputation for both lower limbs: one

had an associated trans-femoral amputation and

the other an Ertls bone bridge on the

contralateral limb. Eleven ( 1

I

were males and 4

females. Age varied from 21 to 66 years

(average of 50)at surgery. The causes indicating

surgery and the above data are in Table 1.

220

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Fibular bone bridg e in trans-tibia1amputation 22

1

Fig. la. Leg of a patient with trauma sequel showing

extensive

soft

tissue lesion and osteomyelitis.

Fig.

2

Aspect

of

the tibia

and

fibula stumps after being

sculptured to receive the

fibular

segment.

Fig.

1

b. Skin trimming in order

to

preserve stump length

at its maximum.

Fig. Ic View

of

the stump

after

healing.

All patients but one were operated on by the

same surgeon. All were rehabilitated and

followed-up by the same interdisciplinary team.

The procedure has been refined in the course

of the cases, aiming at

the

viability

of

skin flaps,

the final shape contour of the synostosis, the

vitality of the bone segment obtained from the

fibula and its stability when inserted between the

two distal bone ends.

The description of the technique is as follows:

The skin flaps must

be

of equal dimension

whenever possible. This will preserve stump

length

at

its maximum. However,

i t

is

common to trim the flaps according to

local

conditions, always aiming at maintaining

maximum stump length (Figs. la, Ib and lc).

The flaps must be dissected en bloc with

underlying muscle structures, thus retaining

max imal tissue integrity. If necessary, at the

moment of skin closure, the skin may be

mobilised sufficiently for adequate

accomm odation of the flaps.

Both bones must

be

divided at the same

level

and sculptured

in

such a way

as

o create

a groove to receive the insertion

of

a segment

of fibula between them (Fig.

2 .

The

antenodistal tibia1 crest must be beveled and

carefully rounded together with tibia and

fibula sharp edges to allow better pressure

distribution during gait.

The segment

of

fibula, measuring

approximately 4.5cm, sufficient to be jammed

into the previously carved gro ove under slight

pressure, is obtained from the distal fibula

and. whenever possible, maintained connected

to adjacent musculature

in

an effort

to

preserve its vitality (Fig. 3). About 5m m of the



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222

M A

G. .

into and W. . arris

Fig. 3. The fibula segment is inserted between tibia and

fibula bone stumps.

proximal aspect of this bone segment have to

be removed in order to allow positioning of

the segment in the previously carved groove

without stretching the attached fibular

musculature.

The segment of-fibula is then inserted in the

groove at both bone ends and fastened with

slow absorbable sutures through drilled bone

perforations Fig. 4).

The deep posterior muscles, tibialis posterior,

flexor digitorum, flexor hallucis longus and

soleus, must be divided at the same level as the

tibia. The length of the gastrocnemius is

maintained level to the related skin flap for the

myodesis procedure by fixation to the anterior

tibia1 crest through drilled bone perforations

Mondry, 1952). The remaining pre-tibia1

muscles

are

sutured

to

the fibularis muscles that

remain attached to the fibula fragment and to

the already stabilized gastrocnemius. The

surgical wound is closed in layers, with the skin

tailored to adequate tension. Suction drainilge

in deep and superficial levels was utilised

whenever possible.

Results

Clinical evidence of union

of

the synostosis,

demonstrated by a stable fibula and absence of

pain under limb manipulation, occurred in

14

patients between

8

and 10 weeks. Radiological

evidence of consolidation,

in

most cases,

appeared only at approximately six months after

surgery and a solid synostosis was visible

in

all

cases about one year after surgery Figs.

5a

and b).

n one patient, it was necessary to perform

revision surgery plus bone grafting 6 months

after the first operation, due to mobility between

the fibula and fibular segment. This patient had

Fig. 4. The fibular segment is being fastened

to

the distal

tibia with slow absorbable sutures. Note the preserved

fallen on the stumpon he second post-operative

day,

suffering a dislocation between the distal

fibula and the fibula segment that impaired

primary consolidation at the lateral aspect of the

synostosis. After surgical revision, bone

consolidation was finally achieved.

fibular muscles attached to the fibula segment.

Fig. 5a. Six months after surgery, the radiograph shows

visible proof of bone consolidation.

Fig. 5b. One year after surgery, a solid consolidation of

the synostosis

is

evident.



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Fibular bone bridge in trans tibia1amputation

Table

1

List

of

patients according to gender, age at time

of

surgery and indication

for

amputation.

I 01 I M.H. Fem. I 40

I

Revision in trans-tibia1 diabetes type

1

1

223

02

03

04

E.S. Fern.

59

Revision in trans-tibia1 Hansens disease)

A.R.M. Male 36 Revi sion in trans-tibid car accident)

J.N. Male

47

Osteomyelitis and Charcot diabetes

type 1

I

05

I

A.B.C.

I

Male I

64

Post-traumatic osteo mve litis diabetes tvoe 2

I

06

07

08

A.R. Male 62 Osteomyelitis Hansens disea se)

E.V.C. Male 56

Post-traumatic osteomyelitis

C.L.M. Male 25

Post-traumatic osteomvelitis

One diabetic patient that had been amputated

due to foot melanom a presented a dehiscence of

the skin suture caused by excessive tension of

the skin flaps. It took six months to heal, and

delayed the p rosthetic fitting time. Nevertheless,

the bone bridge presented norm al evolution.

All patients were fitted with prostheses and

began training 4 to

23

weeks after surgery w ith

an average time of 12 weeks (Table 2) which is

similar to the time necessary in fitting patients

operated by the conventional technique at the

authors clinic. Th e decision for prosthetic fitting

was based on limb maturation criteria, and

radiological proof of bon e bridge union was not

a determining factor. All patients but the one who

had a dehiscence of suture

as

a complication,

were ready to be fitted with prostheses between 4

and 10 weeks post-operatively, presenting a

mature enough stump. Nevertheless, the delay in

fitting some of them w as mostly due to financial

reasons, since there is no automatic prosthetic

support fo r amputees in the country.

Fourteen 14) patients are using prostheses all

day long without the aid of any further walking

devices.

One

(1) type 2 diabetic patient, although

successfully trained in prosthetic usage with the

aid of crutches, chose a wheelchair for everyday

activities,

as

he has an significant knee deformity

on the contralateral limb, resulting from a fracture

followed by Charcot osteoarthropathy. He uses

the prosthesis together with the wheelchair and

ambulates only for short distances

at

home and at

work,

or

to get in and out of vehicles.

Discussion

Twenty-three

23)

patients were operated on

using Ertls method from 1987 through 1997.

The results were convincing us as to the

feasibility and advantages of the procedure

regarding better function of the stump (Pinto

et

af. 1998). The bone bridge developed

consistently and

i t

was remarkable to observe

less pain or discomfort while distal weight-

bearing on the stump. With stabilisation of

the

fibula, the resulting bone shape did not alter

when the limb w as compressed by the prosthetic

socket.

How ever, the procedure showed limitations:

the amount of tibia to be sacrificed was about

7cm, whichis prohibitive in most cases with

indication for amputation or revision surgery

at trans-tibia1 level;

blister formation was frequent in the early

post-operative period, suggesting damage to

the skin flaps due to extensive m obilization;

substantial manipulation of bone structures

and soft tissues can only

be

indicated in

cases

with good blood circulation.

The results demonstrate that it is possible to

obtain bone bridge union in trans-tibia1

amputations using a segment of fibula as an

alternative

to

the conventional Ertls

technique.

Even though som e of the cases received a non-

vascularised fibular segment, the synostoses also

developed well. Nevertheless, the preservation

of the blood supply to the segment is desirable,

since, done this way, the relation between the



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224

M.

.

G . S Pinto

and

W . W .

Harris

Pat.

01

02

Table 2. Time elapsed to casting

of

prosthetic socket.

The average time

was 86

days.

Time to casting

103 days

8 days

Pat.

01

02

Time to casting

103 days

8 days

03

04

05

124

days

74 days

117 days

03

04

05

124

days

74 days

117 days

The m ost important features of this alternative

procedure are better preservation of limb length

and a less traumatic operative technique. The

shape of the amputated limb, with both bones

connected distally and parallel to each other,

remained stable over time.

06

07

08

REFERENCES

ERTLJ 1949). Uber Amputationsstiimpfe. Chirurg

20,218.

DEDERICH 1963). Plastic treatment of the muscles

and bone in amputation surgery: a method designed

to produce physiological conditions in the stump.

J Bone Joint urg 45B 1-66.

MEIJER WG,

LINKS

P. SMIT AJ, GROO THOFFW,

EISMAWH

2001).

Evaluation of a screening and

prevention programme for diabetic foot

complications.

Prosrb Ortbot

nr 25 132-137.

MONDRY 1952). Der muskelkraftige

Ober

und

Unterschenkelstiimpf.

Cbirurg

23 5 7-5 18.

PINTOMAGS, ASTUR FILHO NA,

GUEDES

JPB

YAMAHOKAMSO 1998). Ponte sea na

AmputaGBo Transtibial. Rev Bras Orrop

33

525-53 I .

41

days

71 days

68 days

09

10

11

12

13

14

15

75 days

1 9 days

63 days

130 days

70

days

160 days

58 days


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