Rammelt S, Olbrich A, Zwipp H
Klinik und Poliklinik für Unfall- und Wiederherstellungsschirurgie, Universitätsklinikum Carl Gustav Carus der TU Dresden, Deutschland.
Oper Orthop Traumatol. 2011 Oct;23(4):265-79. doi: 10.1007/s00064-011-0042-x.
Obtaining a durable, weight-bearing stump with minimal or no loss of limb length, and stable soft tissue coverage with preservation of the original sensation of the sole of the foot at the heel.
Complex trauma to the foot with devitalized or nonreconstructable forefoot and midfoot, deep bony and soft tissue infection, infected Charcot foot with threatening sepsis, necrosis or gangrene of the forefoot and midfoot with vasculopathy, malignant tumors, certain infections, gigantism of the forefoot.
Possible reconstruction of the midfoot and forefoot beyond the midtarsal (Chopart) joint, loss or irreversible destruction of the sole of the foot or the distal tibial metaphysis.
The skin incision is designed to retain a long plantar flap with a maximum amount of weight-bearing sole 5-7 cm below amputation level and a shorter anterior flap 1-2 cm below amputation level. Exarticulation or bone resection is performed from anterior to posterior, while preserving the posteromedial vessels to supply the heel flap. The Chopart stump is held in a neutral position avoiding equinus with a tibiotalar external fixator and additional tendon balancing with a noninfected posterior tibialis and one of the peronaeal tendons from medial and lateral through the talar head and Achilles tendon lengthening. Alternatively, a Pirogoff stump with minimal limb length loss (about 2 cm) is achieved with minimal resection at the anterior calcaneal process. The calcaneus is rotated 70-80° and fused to the distal end of the tibia with lag screws or an external frame. Alternatively, a Syme stump is covered with the heel skin after resection of the malleoli flush to the tibial plafond. If anterior wound closure cannot be obtained without tension, temporary vacuum-assisted closure and later definitive coverage with skin grafts, local or free flaps is obtained. In cases of deep infection, the amputation is performed as a staged procedure.
Nonweight bearing until stable scar formation, early mobilization in a total contact cast. Interim prosthesis after 2-4 weeks, fitting of the definitive prosthesis with special shoewear after 2-3 months.
Over a 12-year period, 15 Chopart, 7 Pirogoff, and 2 Syme amputations were performed. A total of 15 patients had sustained a complex foot trauma, 9 had a deep infection, among them 7 in a diabetic Charcot foot. In 16 patients, among them all with deep infection, 1-4 planned revisions were performed. In 5 patients (20.8%), the stumps were revised subacutely to a more proximal amputation level. In 2 patients with Chopart amputation, a hindfoot fusion was performed to correct equinus, while 1 Chopart and 1 Pirogoff stump were subjected to resection of a prominent exostosis. Except for 2 patients with Charcot foot, all patients with hindfoot amputation could walk barefoot over short distances.
获得一个持久、可负重的残端，肢体长度损失最小或无损失，以及稳定的软组织覆盖，并保留足跟处足底的原始感觉。
足部复杂创伤，伴有失活或无法重建的前足和中足，深部骨与软组织感染，感染性夏科氏足伴威胁生命的败血症，前足和中足坏死或坏疽伴血管病变，恶性肿瘤，某些感染，前足巨大症。
中足和前足可能在距下（Chopart）关节以外进行重建，足底或胫骨远端干骺端缺失或不可逆转的破坏。
皮肤切口设计为保留一个长的足底皮瓣，在截肢平面以下5 - 7厘米处保留最大量的负重足底皮肤，以及一个较短的前皮瓣，在截肢平面以下1 - 2厘米处。从前向后进行关节离断或骨切除，同时保留后内侧血管以供应足跟皮瓣。使用胫距外固定器将Chopart残端保持在中立位，避免马蹄足畸形，并通过未感染的胫后肌腱以及一根内侧和外侧的腓骨肌腱经距骨头进行额外的肌腱平衡，同时延长跟腱。或者，通过在前跟骨突处进行最小程度的切除，实现肢体长度损失最小（约2厘米）的皮罗果夫（Pirogoff）残端。将跟骨旋转70 - 80°，并用拉力螺钉或外固定架与胫骨远端融合。或者，在切除内、外踝使其与胫骨平台齐平后，用足跟皮肤覆盖赛姆（Syme）残端。如果无法无张力地进行前侧伤口闭合，则先进行临时负压封闭引流，随后用植皮、局部或游离皮瓣进行确定性覆盖。对于深部感染病例，截肢作为分期手术进行。
在瘢痕形成稳定之前不负重，早期在全接触石膏中活动。2 - 4周后使用临时假肢，2 - 3个月后使用特殊鞋具装配定制假肢。
在12年期间，共进行了15例Chopart截肢、7例皮罗果夫截肢和2例赛姆截肢。共有15例患者遭受了复杂足部创伤，9例有深部感染，其中7例为糖尿病性夏科氏足。16例患者（均为深部感染）进行了1 - 4次计划性翻修。5例患者（20.8%）的残端被亚急性翻修为更高的截肢平面。2例Chopart截肢患者进行了后足融合以纠正马蹄足畸形，同时1例Chopart残端和1例皮罗果夫残端进行了突出骨赘切除。除2例夏科氏足患者外，所有后足截肢患者均可短距离赤脚行走。
