SLR - May 2020 - Keegan Duelfer
Reference: Andronic O, Boeni T, Burkhard M, Kaiser D, Berli M, Waibel F. Modifications of the Pirogoff Amputation Technique In Adults: A Retrospective Analysis Of 123 Cases. Journal of Orthopaedics. 2020 March 15: 5-12.Scientific Literature Review
Reviewed By: Keegan Duelfer, DPM
Residency Program: Regions Hospital/ HealthPartners – St. Paul, MN
Podiatric Relevance: There is a lack of research currently assessing survival rate and stability of amputations proximal to the transmetatarsal level. Based on the increased five and 10 year mortality associated with below knee amputations it is prudent to fully explore the pros and cons of these other amputation levels. This article delves into the Modified Pirogoff and similar Boyd procedures.
Methods: This study can be easily broken into two separate parts with the first consisting of a retrospective review of the Boyd procedure performed at the author’s institution. Between 1998 and 2018, 12 Boyd procedures were performed; however, only seven signed informed consent, so only those were represented in this paper. Average follow up time was 62 months and outcome was determined clinically by assessing function in terms of ambulation and ability to full bear weight without prosthesis and based on the standardized Prosthetic Limb Users Survey of Mobility. Also evaluated postoperative leg-length discrepancy, time to early fusion and time to mobilization.
The second portion of this article involved a systematic review following PRISMA guidelines. Inclusion criteria were: human studies, minimum level IV case series, Modified Pirogoff and Boyd amputation surgical technique, and clinical or radiographic outcome. The quality of the RCTs was evaluated with the Cochrane Risk of Bias assessment tool.
Results: The results for the retrospective review of cases found that fusion occurred at an average of 9.7 weeks using standard radiographs and ambulation with a special predesigned prosthesis achieved at an average of 11.7 weeks postoperatively. Leg length discrepancy was measured in only three patients with an observed mean of 2.7 centimeters.
The systematic review for the Boyd and Pirogoff amputation was based on 10 published reports that met inclusion criteria all of which were level IV clinical evidence. One hundred twenty-three procedures in 115 patients were identified with an average follow-up of 45 months. A “very good” to “good” function was achieved in 85 patients (69 percent). Mean limb length discrepancy was 2.5 centimeters and the mean time to ambulation with prosthesis was 12.7 weeks. Osseous fusion was achieved at 17.2 weeks with mean survivorship of 77 percent.
Conclusions: In the combined retrospective review and systematic review posterior tibial artery patency was the most important factor to consider with multiple papers in the systematic review as well as in their retrospective review reporting survivorship of 100 percent with patency of the posterior tibial artery. The authors also conclude that the increased surface tension resulting from a Pirogoff amputation does not predispose neuropathic patients to revision amputations with 89.5 percent of patients in the systematic review not requiring further amputation. They also state that the Modified Pirogoff and Boyd procedures had very similar outcomes and it was impossible to recommend one over the other. I agree with the author’s conclusion that these amputations are worth considering in the correct patient. The optimal patient selection criteria appears rather narrow for this procedure as removal of the talar body, modification of the calcaneus and introduction of fixation would complicate a potentially infected patient’s course.