SLR - September 2014 - Paul A. Osemene
Pirogow’s Amputation: A Modification of the Operation Method
Reference: Bueschges M, Muehlberger T, Mauss KL, Bruck JC, Ottomann C. Pirogow’s Amputation: A Modification of the Operation Method. Adv Orthop. 2013; 2013:460792.
Scientific Literature Review
Reviewed By: Paul A. Osemene, DPM
Residency Program: Englewood Hospital Medical Center
Podiatric Relevance: The objective of early and efficacious treatment of diabetic foot complications is to achieve limb salvage in order to avoid the loss of a limb from major amputation. So-called limited surgical procedures such as transmetatarsal or Chopart/Syme amputations often result in poor clinical outcomes. Prostheses for these stumps are difficult to fit, a fact that reduces mobility for these patients, so reamputations are not rare. Pirogow’s amputation at the ankle presents a valuable alternative to lower leg amputation for patients with the corresponding indications. Although this method offers the ability to stay mobile without the use of prosthesis, it is rarely performed. The reviewed article proposes a modification regarding the operation method of the Pirogow amputation.
Methods: Between the years 2000 and 2006, 27 patients were operated on in the Department of Plastic Surgery in the Martin Luther Hospital in Berlin. 20 of the 27 total patients amputated using the Pirogow method were included in the study 12 months after the operation and were evaluated using the Ankle Score from Taniguchi et al. Five of the seven patients included in the study had to undergo lower leg amputations due to postoperative complications (wound healing dysfunctions), and two patients could no longer be reached at the time of the follow-up 12 months after the amputation. The Ankle Score is based on the Ankle and Hindfoot Score from the American Orthopaedic Foot and Ankle Society (AOFAS) with regard to loss of ankle function and is more heavily weighted for functional and radiological criteria based on Taniguchi. The Ankle Score Questionnaire was given to 10 patients 12 months (plus or minus two weeks) after undergoing the modified amputation based on the Pirogow method. The control group, consisting of 10 patients who underwent the original amputation, was given the same questionnaire in the same time frame.
Results: The maximum value possible is 100 points, and a value above 80 points is rated as an “excellent” result, a value between 60 and 79 points as a “good” result, between 40 and 59 points as a “satisfactory” result, and less than 40 points as an “unsatisfactory” result. 70 percent of those questioned who were amputated following the modified Pirogow method indicated an excellent or very good result in total points whereas in the control group (original Pirogow's amputation) only 40 percent reported excellent or very good result. In addition, the level of pain experienced one year after the completed operation showed different results in favor of the group being operated with the modified way. Furthermore, patients in both groups showed differences in radiological results, postoperative leg length difference, and postoperative mobility.
Conclusions: The modified method compared to the original method is characterized by rotating the calcaneus. The calcaneus is relocated vertically 60°–90° to the plantar level approx. threecm proximal to the calcaneocuboid joint surface. To fix the calcaneus to the tibia, osteosynthesis can be carried out using a Kirschner wire and a 3/0 spongiosa tension screw. For additional modification, the calcaneus is anchored by drilling Steinmann nails cranial and anterior to the calcaneal spur to allow the use of an external fixator. The modified Pirogow amputation presents a valuable alternative to the original amputation method for patients with the corresponding indications. The benefits are found in the significantly reduced pain, difference in reduced radiological complications, the increase in mobility without prosthesis, and the reduction of postoperative leg length difference.