TRANSTIBIAL SURGICAL TECHNIQUE

TRANSTIBIAL SURGICAL TRANSTIBIAL SURGICAL TECHNIQUETECHNIQUE

A Review and Panel DiscussionA Review and Panel Discussion

TRANSTIBIAL AMPUTATION: TRANSTIBIAL AMPUTATION: Surgical Technique Surgical Technique

Most common surgical techniques are:Most common surgical techniques are:1.1. Long Posterior FlapLong Posterior Flap

a)a) Burgess TechniqueBurgess Techniqueb)b) Bruckner TechniqueBruckner Technique

2.2. Anterior/Posterior Fish Mouth flapAnterior/Posterior Fish Mouth flap3.3. Sagittal FlapSagittal Flap4.4. Skewed FlapSkewed Flap5.5. Ertl ProcedureErtl Procedure

TRANSTIBIAL AMPUTATION: TRANSTIBIAL AMPUTATION: Long Posterior Flap – Burgess Long Posterior Flap – Burgess

Technique Technique

Designed by Kendrick 1956 Designed by Kendrick 1956 and made popular by and made popular by Burgess 1969.Burgess 1969.

Most common surgical Most common surgical technique for transtibial technique for transtibial amputation.amputation.


Technique Technique Tibia cut 10-15cm from knee Tibia cut 10-15cm from knee

joint linejoint line Fibula cut 1-1.5cm shorter Fibula cut 1-1.5cm shorter

than tibiathan tibia Long posterior flap marked Long posterior flap marked

with length 5cm longer than with length 5cm longer than the diameter of the calf at the the diameter of the calf at the cut end of the tibiacut end of the tibia


Technique Technique Long posterior flap consisting Long posterior flap consisting

mainly of the lateral and medial mainly of the lateral and medial gastrocnemius muscle and some gastrocnemius muscle and some soleus.soleus.

Debulking the soleus muscle Debulking the soleus muscle may be required.may be required.

To avoid dog years rounding up To avoid dog years rounding up of the perpendicular incisions of the perpendicular incisions has been recommended.has been recommended.


Technique Technique Flap fixed anteriorly by Flap fixed anteriorly by

fascioperiostial suturesfascioperiostial sutures

Skin and subcutaneous tissue Skin and subcutaneous tissue sutured. sutured.

Anterior scar line runs Anterior scar line runs medial/lateral.medial/lateral.

TRANSTIBIAL AMPUTATION: TRANSTIBIAL AMPUTATION: Long Posterior Flap – Bruckner Long Posterior Flap – Bruckner

Technique Technique

Modified long posterior flap Modified long posterior flap technique developed in technique developed in Germany by Bruckner in the Germany by Bruckner in the 1980’s1980’s

Landmarks and skin incisions Landmarks and skin incisions are equivalent to the Burgess are equivalent to the Burgess technique.technique.


Technique Technique

Fibula disarticulated proximally Fibula disarticulated proximally and resectedand resected

Complete resection of the Complete resection of the anterior and lateral anterior and lateral compartments and complete compartments and complete resection of the soleus resection of the soleus muscle.muscle.


Technique Technique

Flap consists mainly of medial Flap consists mainly of medial gastrocnemius with some gastrocnemius with some lateral gastrocnemius if lateral gastrocnemius if neededneeded

Closed in similar fashion to Closed in similar fashion to Burgess techniqueBurgess technique

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TRANSTIBIAL AMPUTATION: TRANSTIBIAL AMPUTATION: AP ‘Fish Mouth’ Flap AP ‘Fish Mouth’ Flap

Early surgical technique for Early surgical technique for transtibial amputation transtibial amputation described by Persson.described by Persson.

Semicircular skin flaps with Semicircular skin flaps with length ¼ the circumference length ¼ the circumference around the cut end of the around the cut end of the tibiatibia

Equal anterior and posterior Equal anterior and posterior flaps.flaps.


Posterior musculocutaneous flap Posterior musculocutaneous flap consisting of gastrocnemius.consisting of gastrocnemius.

Anterior flap consists mainly of Anterior flap consists mainly of skin and subcutaneous tissue.skin and subcutaneous tissue.

Myodesis of posterior Myodesis of posterior musculature to end of tibia.musculature to end of tibia.


Suturing of superficial fascia Suturing of superficial fascia and skin.and skin.

Scar line runs medial/lateral Scar line runs medial/lateral on inferior surface of stump.on inferior surface of stump.

TRANSTIBIAL AMPUTATION: TRANSTIBIAL AMPUTATION: Sagittal Flap Sagittal Flap

First described by Tracey First described by Tracey 1966.1966.

Incision lines for skin flaps Incision lines for skin flaps marked on skin.marked on skin.

Tibia cut 13-15 cm from knee Tibia cut 13-15 cm from knee joint line (A).joint line (A).

Anterior apex of skin flap 1cm Anterior apex of skin flap 1cm lateral to tibial crest(1). lateral to tibial crest(1).


Semicircular flaps Semicircular flaps medial and lateral.medial and lateral.

Inferior margin of flap = Inferior margin of flap = 13-15cm + ¼ 13-15cm + ¼ circumference of the circumference of the calf at the cut end of calf at the cut end of tibia.tibia.


Lateral flap consists of the Lateral flap consists of the anterior and lateral muscles anterior and lateral muscles and overlying skin.and overlying skin.

Medial flap consists mainly of Medial flap consists mainly of medial gastrocnemius and medial gastrocnemius and overlying skin.overlying skin.

Muscle flaps brought over Muscle flaps brought over end of tibia and fibula to form end of tibia and fibula to form a myoplasty.a myoplasty.


Skin and subcutaneous tissue Skin and subcutaneous tissue sutured. sutured.

Scar line runs anterior to Scar line runs anterior to posteriorposterior

TRANSTIBIAL AMPUTATION: TRANSTIBIAL AMPUTATION: Skewed FlapSkewed Flap

First described by First described by Robsinson et al 1982.Robsinson et al 1982.

Incision marks for skin flaps Incision marks for skin flaps marked on skin.marked on skin.

Anterior junction between Anterior junction between the two flaps is at least 2cm the two flaps is at least 2cm from the tibial crestfrom the tibial crest..


Posterior junction 180° from Posterior junction 180° from anterior junction. anterior junction.

Length of skin flaps the same Length of skin flaps the same as for the Sagittal technique.as for the Sagittal technique.


Posterior muscle flap of Posterior muscle flap of gastrocnemius is trimmed gastrocnemius is trimmed and fashioned to cover and fashioned to cover the distal end of the tibia the distal end of the tibia and fibula.and fibula.

Myoplasty of the posterior Myoplasty of the posterior flap to the periostium and flap to the periostium and deep fascia of the deep fascia of the anterior tibial anterior tibial compartment.compartment.


Anteromedial and Anteromedial and posterolateral fasciocutaneous posterolateral fasciocutaneous flaps are closed in an oblique flaps are closed in an oblique fashionfashion

Scar line runs from Scar line runs from anterolateral to posteromedialanterolateral to posteromedial

TRANSTIBIAL AMPUTATION: TRANSTIBIAL AMPUTATION: Ertl ProcedureErtl Procedure

Technique developed by Dr Janos Ertl in Technique developed by Dr Janos Ertl in Hungary in the 1920’s and first described in the Hungary in the 1920’s and first described in the literature in 1939.literature in 1939.

Performed by his three grandsons now in the Performed by his three grandsons now in the USA, mainly on traumatic amputees.USA, mainly on traumatic amputees.

Performed both as primary operation and as a Performed both as primary operation and as a revision. revision.

Designed to seal the medullary cavity of the tibia Designed to seal the medullary cavity of the tibia and fibula to allow end weight bearing. and fibula to allow end weight bearing.

TRANSTIBIAL AMPUTATION: TRANSTIBIAL AMPUTATION: Ertl ProcedureErtl Procedure

Both techniques can be performed with a Both techniques can be performed with a long posterior, sagittal or skewed flap long posterior, sagittal or skewed flap incision.incision.

Two different techniques to seal the Two different techniques to seal the medullary cavity:medullary cavity:

1.1. Periosteal sleeve Periosteal sleeve 2.2. Bony wedge fashioned from removed fibulaBony wedge fashioned from removed fibula

TRANSTIBIAL AMPUTATION: TRANSTIBIAL AMPUTATION: Ertl Procedure: Periosteal SleeveErtl Procedure: Periosteal Sleeve

Long posterior (6cm) and Long posterior (6cm) and short anterior periosteal short anterior periosteal flap created off of the end flap created off of the end of the tibia.of the tibia.

Periosteal flap is taken Periosteal flap is taken with some flakes of bone with some flakes of bone from the posterior surface from the posterior surface of the tibia.of the tibia.


Flaps are sutured over the Flaps are sutured over the tibial osteotomy as a tibial osteotomy as a pouch.pouch.

Bone chips and bone Bone chips and bone slurry placed in the pouch.slurry placed in the pouch.

Same procedure done for Same procedure done for the fibula. the fibula.

Sealing callus develops Sealing callus develops over weeks to monthsover weeks to months


Variation of periosteal sleeve is to suture the Variation of periosteal sleeve is to suture the periosteal flaps of the tibia and fibula together periosteal flaps of the tibia and fibula together to form a tube.to form a tube.

In this technique periosteum is incised anterior In this technique periosteum is incised anterior to posterior creating medial and lateral flaps.to posterior creating medial and lateral flaps.

Medial flap of the tibia sutured to lateral flap of Medial flap of the tibia sutured to lateral flap of the fibula.the fibula.

Lateral flap of the tibia sutured to the medial Lateral flap of the tibia sutured to the medial flap of the fibula.flap of the fibula.

TRANSTIBIAL AMPUTATION: TRANSTIBIAL AMPUTATION: Ertl Procedure: Fibular Bone Block Ertl Procedure: Fibular Bone Block

Consists of a osteotomy Consists of a osteotomy of the fibula of the fibula

Hinged on a lateral Hinged on a lateral periosteal sleeve periosteal sleeve transversely into a notch transversely into a notch on the lateral distal tibia. on the lateral distal tibia.


Sutures through drill Sutures through drill holes are used to secure holes are used to secure the bone block to the the bone block to the distal ends of the tibia distal ends of the tibia and fibula.and fibula.


Bone block covered by perisoteal Bone block covered by perisoteal sleevesleeve

Myoplasty completed by suturing Myoplasty completed by suturing

the posterior to anterior and lateral the posterior to anterior and lateral musclesmuscles

OROR Securing the posterior muscles Securing the posterior muscles

into the osteoperiosteal bridge.into the osteoperiosteal bridge. Skin flaps sutured.Skin flaps sutured.


EVIDENCE COMPARING EVIDENCE COMPARING SURGICAL TECHNIQUESURGICAL TECHNIQUE

Cochrane Review 2007 , ‘Type of incision Cochrane Review 2007 , ‘Type of incision for below knee amputation’for below knee amputation’

Three RCT’s met the criteria.Three RCT’s met the criteria.One trial (Ruckley et al 1991) compared One trial (Ruckley et al 1991) compared

skew flap versus Burgess long posterior skew flap versus Burgess long posterior flap.flap.

One trial (Termansen et al 1977) One trial (Termansen et al 1977) compared sagital versus Burgess long compared sagital versus Burgess long posterior flap.posterior flap.

EVIDENCE COMPARING EVIDENCE COMPARING SURGICAL TECHNIQUESURGICAL TECHNIQUE

Found no significant difference between Found no significant difference between surgical techniques in regard to:surgical techniques in regard to:

1.1. Failed primary stump healingFailed primary stump healing2.2. Post-op infection ratePost-op infection rate3.3. Reamputation at same levelReamputation at same level4.4. Reamputation at higher levelReamputation at higher level5.5. MortalityMortality6.6. LOSLOS7.7. % fit with a prosthesis% fit with a prosthesis

UPCOMING RESEARCHUPCOMING RESEARCH In Oklahoma USA a RCT comparing Ertl In Oklahoma USA a RCT comparing Ertl

procedure to other surgical procedures procedure to other surgical procedures started in January 2006 and will be started in January 2006 and will be completed in December 2008.completed in December 2008.

REFERENCESREFERENCES Ruckley et al 1991, ‘Ruckley et al 1991, ‘Skewflap vs long posterior flap in Skewflap vs long posterior flap in

below knee amputations: Multicenter trial’below knee amputations: Multicenter trial’. Journal of . Journal of Vascular Surgery. 13:3 p423-427.Vascular Surgery. 13:3 p423-427.

Stahel et al 2006, Concepts of transtibial amputation: Stahel et al 2006, Concepts of transtibial amputation: Burgess technique versus modified Bruckner procedure. Burgess technique versus modified Bruckner procedure. ANZ Journal of Surgery. 76: p942-946.ANZ Journal of Surgery. 76: p942-946.

Tisi PV & Callam MJ. ‘Type of incision for below knee Tisi PV & Callam MJ. ‘Type of incision for below knee amputation’, Cochrane Collaboration 2007:3.amputation’, Cochrane Collaboration 2007:3.

Robinson et al 1982, Skew flapRobinson et al 1982, Skew flap www.ErtlReconstruction.comwww.ErtlReconstruction.com www.www.bonebridgebonebridge.com.com

http://www.ertlreconstruction.com/

http://www.bonebridge.com/



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TRANSTIBIAL SURGICAL TECHNIQUE