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Fibular Segment Bone Bridging in Trans-tibial Amputation

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

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    http://poi.sagepub.com/Prosthetics and OrthoticsInternational

    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

    Published by:

    http://www.sagepublications.com

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    International Society for Prosthetics and Orthotics

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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,

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    P. SMIT AJ, GROO THOFFW,

    EISMAWH

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    MONDRY 1952). Der muskelkraftige

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    und

    Unterschenkelstiimpf.

    Cbirurg

    23 5 7-5 18.

    PINTOMAGS, ASTUR FILHO NA,

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    JPB

    YAMAHOKAMSO 1998). Ponte sea na

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