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Howard Kimmel, DPM, MBA,
Senior Clinical Instructor
Department of Surgery
Case Western Reserve University School of Medicine
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Male Speaker: Okay, now that we talked about the majority of amputations that we do, I asked our next speaker to speak on rearfoot amputations. I’ve asked Dr. Howard Kimmelstein [Phonetic] from Kimmelstein and Wilson’s group to come up and talk to us on rearfoot amputations. Okay, you have 15 minutes.
Howard Kimmelstein: I also tell Dr. Frykberg not to play favorites. It was obvious how much he likes Dr. Nouvong and Dr. Hadi better than I do. But with that being said, this is Dr. Frykberg’s operating room, as you can see, and some of his residents are here and they could tell you what his operating techniques are like. Let’s talk about the principles of rearfoot amputations and really, there’s only basically a couple different rearfoot amputations that we could do. Obviously, I think the thing is you need to treat the procedure as a reconstruction. When you’re doing the amputation, pay attention to try to keep as much function as you can to the limb slash the foot. Obviously, there’s not going to be a lot of foot function with these rearfoot amputations, but it will help as far as bracing them properly. And Dr. Hadi showed a couple good braces with that. And I think a couple of key things that you guys might noticed over the course of the different lectures, how important it is to work with a good orthotist and prosthetist and have them part of your team because obviously, this is going to prevent any further amputation. Think of amputation as a first step to rehab. A lot of times, we tell our patients, we could do this, we could start taking pieces and parts off. But I think you really need to be aggressive in doing the amputations. Dr. Hadi showed all these great results, all these great studies to show that sometimes, we have to be a little bit more aggressive with doing our amputations. Because the less time or the less amount you have to take these patients to the operating room, the better off you are than bone. Think about what you’re doing and what you’re taking with that, try to keep things as anatomical as possible. Try not to have much bulk when you’re doing the amputation. You want to make sure that you have a good padding for your stump, but you want to debulk a lot of the amputations so that you don’t have any excess tissue that has to be remodeled. Think of the yin and yang of muscle, so if you’re doing these amputations, and some of them to talk about going ahead and attaching the tibialis anterior into the top of the foot and the PT to the plantar aspect of the foot. But you have to think, if you’re going to do a Chopart’s amputation, you are going to have obviously some ankle movement. You want to take a look at the muscles that obviously in certain, the rear part of the foot and make sure that you balance them as much as possible with that. Make sure you have some skin. Make sure you’re not fighting the skin. You’re better off to go ahead and do a more proximal amputation because you know if you put much tension on these amputations, they’re going to dehisce and they’re going to go back and go to a further proximal amputation, and obviously the prosthetic devices. Principles of healing, obviously, good blood supply. Sometimes, you’re left with the vascular surgeon says they’re not bypassable. We’re not going to take them. They have an injection fraction of 30. We don’t want to put them on the table. They’ll never survive it, a fem posterior tibial or fem DP. Basically, you guys need to do something to try to save the limb or else, we’ll go ahead and do BK. Sometimes when you’re doing these amputations, some of the key things too is making sure when you’re doing the rearfoot amputations that you find your DP, you find your posterior tibial artery and make sure that you go ahead and tie them off or make sure that you don’t just rip it and be totally aggressive with that because you want to keep as much vascular intact as possible so you get that amputation to heal. Obviously, albumin and prealbumin, you want to take a look at ahead of time. Comorbidities play a large factor into that. Is the infection controlled? Dr. Nouvong talked about go and make sure you look up these tendon sheaths and a lot of times, these things crack up. And you guys will gain from your experience when you go out in practice and you think about what some of your attendings have told you and you don’t do them and then the patient comes back a couple weeks later and then they have a more proximal infection. You have to make sure that you follow these and pull these tendons down and make sure that you get as much as the tendon as possible. And obviously, proper offloading after the surgery and that’s talking about with working with prosthetics. Preoperative planning, make sure you have everything available, incisions, drains, dressings and packing. Know what you want when you’re going to the surgery. If you want a Hemovac, you want a Jackson-Pratt, a TLS drain. I think majority of the amputations need a larger type of drain. TLSs work fine in some scenarios but I think they clog too easily for the larger.
You don’t want to have a large dead space that’s going to be filled with a hematoma because obviously you’re going to set the chance for infection. Obviously, infected cases, Dr. Nouvong talks about what to put in the mix, into your saline, you’re going to use bacitracin, you’re going to use diluted Betadine. Think about delayed primary closure, pulsed lavage, Versajet if you have to. I would say careful handling of the skin. I think this is probably one of the most important things that you’re doing. I go back and forth with my trends on whether or not to use staples or sutures and I’m back to doing sutures again versus staples. I think you could get good closure with staples but I think sutures are a little bit better, number one. And number two, you have to make sure when you’re suturing that you don’t really tug on the sutures that they’re not too tight because they’re going to necrose the skin and that flap is going to break down. Hemostasis obviously is important. Never use a tourniquet, that’s my thought. Always make sure that you tie vessels off. I started recently to do my rearfoot cases with loupes. Either one, I’m getting older with that. But what I found when using loupes is that you really can appreciate the microvascular structures and appreciate a lot of the anatomy and you get less swelling afterwards and less pain especially in your non-diabetic cases. Think about investing in a pair of clip-on loupes. They’re couple hundred dollars, not cheap but I think that will definitely help with the surgery or get a pair of prescription loupes and they’re about 12, 15, $100. But I think it really will help you appreciate a lot of the micro structures in the foot. Don’t burn bones. It’s been long day for everybody. I don’t like to use the Bovie a lot. If it’s going to bleed, put some pressure on there. Just hold that compression down for awhile. I believe the more you burn bone, you’re going to get a high chance of infection and obviously, we talked about removing as much of the tendon as possible. We talked about the drains. Obviously, a lot of these amputations are going to have a lot of space. I feel that you have to use a drain in these, whatever drain you like to use is fine. Keep them in the hospital for a couple days. If the patient is still filling up their Hemovac or their drain after day three, I tend to pull drains at day three. If they’re still filling it up and you wait another day and they’re still being filled up, something is bleeding in there and you’re going to have to take them back. Don’t send these patients home with the drain. Make sure that you remove the drain once there’s not much being filled, if it gets clotted. There’s various tricks and techniques to push that clot to open up the drain again. Excessive tension once again. Be really careful with the skin. I can’t emphasize that enough. PVD patients, don’t put an ACE bandage on them. I have seen a couple of cases where postoperatively a patient comes in, patient leaves before I see them. They have an ACE bandage on. It’s a little too tight. They come back, it’s necrosed. Don’t use any type of compression on that. If you’re going to use some, make sure it’s very limited, and obviously, medical considerations. If we take a look at the slide, and this was taken, I think, out of Campbell’s Orthopaedics, basically there’s different levels of amputation. Obviously, we’re going to concern ourselves basically from level 15, 11 to 15 over here and kind of go through the different amputations. The Chopart amputation, first described in the 1800s by Francois Chopart in Paris with that. The advantage of having a Chopart is that you’re saving at least some part of the foot. Depending on what prosthetist you talk to, sometimes it’s easier to get them in the shoe. I think it’s obviously more functional amputation if you try to balance some of the tendons with that. You do have some limb function with that compared to some of the others. The other key thing too, when you’re looking at these rearfoot amputations, is the amount of cardiac function compared to a more proximal amputation. If these patients are getting a Chopart versus a Syme’s versus a BKA, is their lifespan going to be a little bit longer because it’s less cardiac stress compared to a more proximal amputation. As far as the TAL on this, there hasn’t been much literature to support or not support that. I really personally don’t think you need to do it, but I don’t think it could hurt. That’s up to you. Percutaneous is fine. Here’s an example, using a drain with that. This is just a Jackson-Pratt. My little pearl over here is that if this drain gets filled up or it’s clotted, for lack of a better description, just kind of milk it back and that will sort of get the suction going again.
Sometimes, it’s clotted within the foot and nothing is coming out and you have to pull the drain. Now, the Boyd amputation pretty much is very similar to a Syme’s amputation, but you’re leaving a weightbearing portion of the foot. You’re basically creating an arthrodesis. It’s a calcaneal-tibial arthrodesis, so you’re moving the talus and you’re creating an arthrodesis. Supposedly, it could be better put into a device compared to the Syme’s, because you have more length with that and you have a weightbearing heel pad. I don’t do many of these with that. Now, there is a modification by Pirogoff that removes the anterior two-thirds of the calcaneus, but I really don’t think that’s really going to give you an advantage over Boyd amputation. Like I said, it provides more solid stump, preserves the function of the plantar heel pad because obviously the calcaneus is left [indecipherable] [11:08] to the tibia. It’s weightbearing. Dr. Grady who’s here in Chicago wrote a great paper in JAPMA in 2000, looking at his experience with the Boyd amputation. I think it was between 20 and 40 patients. I don’t recall. He got really good results with that. Definitely think about that as another option, number one. I think some of the concern that people have with doing the Boyd amputation is that you’re putting hardware in either a foot that has just been infected or you’re putting hardware and trying to get a fusion in a foot that’s pretty dysvascular. Here is an example. This is using a [indecipherable] [11:48] external fixator with just a Steinmann pin. If you do have these infected cases, you can use external fixation to try to get that fusion site. For those of you that haven’t used external fixation, you could get a lot of compression and dynamic compression with an external fixator. I know they’re kind of expensive and you have to kind of follow the patients a lot closer than you do with the internal type of fixation, but you could really adjust this compression. Have them come back every week. You could tighten the nuts and bolts and get a lot more compression every time they come in. Think about that when you’re doing these if you are going to do them as an option. Obviously, the Syme’s amputation, the original paper was done by James Syme in 1824. He was basically looking at all the previous amputations done before, all the BKAs and AKAs that were done, and felt that if you just take off the foot, for most of this was frostbite and obviously from the wars, that you could get these patients to walk and would be able to be a benefit to society. When he first described it, a lot of the patient, a lot of the other surgeons discarded the amputation because there’s a high number of wound failures and they thought that some of the stumps were hard to put in a prosthesis. Once again, something to think about when you’re doing these, and we go back and forth with vascular, should we do a Syme, should we do a BK? If we know that this patient had dysvascular foot, we deem it unreconstructable or not salvageable, and let them go ahead and do a BK because it’s not that far away. I don’t think there’s that much decrease on cardiac output personally compared to a BK versus a Syme’s. Wound healing parameters is going to predict whether a patient has immunocompetence, nutritional status, arterial inflow to heal the amputation. Once again, same thing I talked about before. This was actually taken from Dr. Sage who’s coming up next after me over here in Loyola, with Dr. Stock and Dr. Pinzur. They looked at what they considered immunocompetence of having a lymphocyte count of greater than 1,500 and albumin level of greater than 3 to assess minimum tissue nutrition. These might be factors that we take a look at looking at comorbidities and get medicine involved, the internal medicine docs, endocrinologists involved to go ahead and make sure these patients are nutritionally sound to go ahead and do an amputation. Obviously, blood flow, the other thing to describe is greater than 0.5 and looking at TCO2s. Obviously, postop initially is critical for the Syme’s amputation because of dehiscence. We talked about drains and Hematoma and seroma formation that you have to deal with appropriately. Hemostasis, I talked about using loupes and being careful to dissection on the skin. Obviously, I talked about the vascular status. You want to make sure that when you’re dissecting these patients, you look for that posterior tibial artery and you tie it off, and you just don’t go ahead and slash it.
Here’s just an example of the original Syme’s amputation. With that, here’s just an example of a case that I did. Let’s run through real quickly. What I found the best way to take the talus out is I used a McGlamry elevator to kind of go right into the subtalar joint with that. I used it in calcaneus, it was kind of difficult to take out as one, but you do your best with that and go ahead. I suture. I make two drill holes. I take Ethibond, I stop. I get away from FiberWire. I go ahead and pull down the Achilles tendon. What’s ever left of the Achilles tendon and I put that on the articular cartilage, I make sure that I cut off the malleoli, obviously, and also any cartilage on the tibia and go head and suture the Achilles tendon into the bone. Then finally, I’m getting the bye sign from Dr. Frykberg. Here is just a couple examples with that. The braces, like I said, Dr. Sage and Stock and Dr. Pinzur at Loyola, great paper in JBJS with that. In summary, more proximal amputation, more cardiac stress. You’ll look at your vascular status and immunocompetence to see these patients are going to heal. Obviously, rehab and prostheses are probably one of the most important things you could do to increase their lifespan. Thank you.