Abstract
Background
The Pirogoff amputation (1854) was initially developed to provide full-weight-bearing stumps and therefore allow a short ambulation without prosthesis. Modifications of the original technique including Boyd (1939) and the “Modified Pirogoff” were developed, which further reduced complications and improved the outcome. However, the current evidence regarding the techniques is scarce. The functional outcome, survivorship and complication rates are unknown. It was the purpose of this study to expand the knowledge with a retrospective case series and ultimately summarize and analyze the data with a systematic review.
Methods
A retrospective study of the Boyd procedures from our institution between 1999 and 2018 was performed. Outcome was determined based on the PLUS-M Score (Prosthetic Limb Users Survey of Mobility). Survivorship (absence of more proximal amputation), postoperative leg-length discrepancy, time to early fusion and time to mobilization were also evaluated. Finally, in the second part of the study, the results were integrated in a systematic review, which followed the Preferred Reporting Items of Systematic Reviews and Meta-analysis (PRISMA) guidelines. The quality of all the studies were then assessed using the Joanna Briggs Institute Critical Appraisal Checklist (JBI CAC).
Results
A total of 123 procedures including 115 patients, with an average follow-up of 45 months (range, 10–300 months) could be included. A very good or good function could be achieved in 85 (69%) patients. The mean survivorship was 82.1% (range 46%–100%). In four studies, including our series, all patients remained with a functional stump at the latest follow-up. The calculated average leg-length discrepancy was 2.5 cm.
Conclusion
The “Modified Pirogoff” and Boyd amputation techniques can achieve favourable long-term functional outcome in cases of irreparable foot conditions such as osteomyelitis or trauma. Patency of the posterior tibial artery is an indispensable condition to elect for these surgical techniques. Presence of neuropathy does not preclude this amputation level. With proper patient selection, a maximal survivorship of the stump with treatable minor complications can be achieved.
Level of Evidence: IV.
Keywords: Pirogoff, Boyd, Amputation, Tibiocalcalneal arthrodesis, Spitzy-pirogoff
1. Introduction
The Pirogoff amputation technique was described by the Russian surgeon Nikolai Pirogoff in 1854.1 The technique is used to treat irreparable midfoot trauma, ischemia or infections.2, 3, 4 The procedure has some advantages in well selected patients, by providing a full-weight-bearing stump and therefore allowing a short ambulation without prosthesis (as for example midnight toilet visits).5,6 Using this technique, the heel pad and the sensation of the sole of the heel are preserved and a tibio-calcaneo osseous continuity is achieved.6 It also needs a reduced limb shortening due to the calcaneal rotation, which makes the prosthesis fitting easier, but is aesthetically not always satisfying.
The main alternatives of partial foot amputation are represented by the transtibial amputation or ankle disarticulation (Syme procedure).7, 8, 9 A recent systematic review by Dillon et al.10 showed that the partial foot amputations have a higher complication rates.10 There is insufficient evidence regarding differences in quality of life in patients with partial foot amputations and transtibial amputations.11
Although the Syme amputation technique also provides a full weight-bearing surface, it has high complication rates represented by heel pad migration, skin problems and also a significantly higher leg length discrepancy.9,12
Modifications to the original Pirogoff technique were described and seemed to improve the functional outcome and to reduce the risk of complications.13 The most popular are the Boyd14,15 technique and the “Modified Pirogoff”,16 the second includes the rotation of the calcaneus in the longitudinal axis including the lengthening of the Achilles tendon to further reduce the leg-length discrepancy.
However, the published reports vary and range from case reports6,17 to case series.18 The quality of life, ultimate outcome, and survivorship are unknown and the results of the modifications of the original Pirogoff technique are poorly described. It is the purpose of this study to expand the knowledge regarding the indications and expected outcomes by reporting all Boyd procedures performed at our institution, including a summary and an analysis of the current literature with a systematic review.
2. Methods
2.1. Patients from our institution
A retrospective study of the Boyd procedures executed at our institution between 1999 and 2018 was performed. From a total of twelve patients, all of them were alive and only seven signed the informed consent and were included. The study has been approved by the local ethical committee (BASEC no 2016–00387) and carried out in accordance with the World Medical Association Declaration of Helsinki.19
The patient pool consisted of 5 men and 2 women. The average follow-up was 62 months (range 10–242 months). The following comorbidities were evaluated: preoperative vascular status, presence of neuropathy or diabetes.
Outcome was determined clinically by assessing function in terms of ambulation and ability to full-weight bear without prosthesis and based on a standardized score (Prosthetic Limb Users Survey of Mobility (PLUS-M).20 Also, postoperative leg-length discrepancy, time to early fusion and time to mobilization were evaluated.
2.2. Surgical technique (current authors)
The following technique carries the name of “Spitzy-Pirogoff”, which is most similar to the Boyd technique, and was performed in all cases at our institution.
The incision runs on the dorsal foot a couple of centimeters distal to the Chopart joint, to plantar, 5–6 cm distal of the Chopart joint in order to create an adequate plantar skin flap. It is followed by the exarticulation of the foot from dorsal to plantar through the Chopart joint with preservation of the posteromedial neurovascular bundle. The talus is released and extracted. A minimal resection of the cuboidal and posterior facets of the calcaneusis performed, as well as an osseous resection of the malleoli including the distal tibial joint surface. The calcaneus is brought anteriorly under the tibia and a tibio-calcaneal arthrodesis is performed with two compression screws (Fig. 1). An alternative osteosynthesis can be achieved by placing an Illizarov external frame. As such, a full weight-bearing stump with minimal loss of limb length and stable soft tissue coverage with preservation of the plantar sensibility of the heel can be achieved (Fig. 2).
Fig. 1.
Postoperative radiographs after Spitzy-Pirogoff/Boyd amputation.
Fig. 2.
Stump appearance at follow-up, 23 months after surgery.
2.3. Systematic review of the literature
2.3.1. Search strategy
The systematic search followed the Preferred Reporting Items of Systematic Reviews and Meta-analysis (PRISMA) Guidelines21 and was a computer-based search of the following databases: MEDLINE, Scopus, CENTRAL (Cochrane Central Register of Controlled Trials), and Web of Science Core Collection. The following key-words and combinations of these were used: “pirogoff”, “spitzy”, “pirogoff-spitzy”, “boyd”, “boyd-spitzy”, “calcaneotibial arthrodesis”, “tibiotalocalcaneal arthrodesis”, with the terms “amputation” or “surgery”. Initially, a blinded and independent process of selection based on title and abstract was made by two authors (O.A. and M.B). Next, a detailed analysis of the chosen studies was performed by screening full texts. All published articles from the beginning until February 1st, 2019 were included in the systematic search. The protocol of this systematic review has been published and registered in the international prospective register of systematic reviews (PROSPERO) under the registration number: CRD42019123411.22
2.3.2. Study selection (inclusion and exclusion criteria)
Studies reporting on the outcome of the original Pirogoff, Boyd or modified Pirogoff amputation technique were included based on predefined eligibility criteria. The inclusion criteria were: (1) Human studies in English or German language; (2) minimum level IV case series studies using Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence23; (3) Pirogoff amputation surgical technique or its modifications, and (4) clinical or radiographic outcomes; The exclusion criteria were: (1) review/hypothesis or oral presentations; (2) non-English/German articles; (3) cadaveric or animal studies, and (4) congenital/pediatric malformations.
2.3.3. Data extraction and quality assessment
The quality of the RCTs was evaluated according to the guidance of the Cochrane Risk of Bias assessment tool.24 The quality of all the studies was then assessed using the Joanna Briggs Institute Critical Appraisal Checklist (JBI CAC).25 A scoring system was then used per study such as studies that answered yes to a question from the checklist scored 2, not clear scored 1 and no scored 0. Each score was then converted into a percentage to harmonize the scoring system.
2.3.4. Data analysis and synthesis
Statistical analysis was performed using SPSS (IBM SPSS Statistics, Version 24.0; Chicago, Illinois). Where applicable, preoperative and postoperative values and clinical scores were compared using the Mann-Whitney U test. Differences between outcomes were analyzed using the students’ t-test. According to all included studies, the alpha level was set at 0.05 and all p values were 2-tailed.
3. Results
3.1. Patients from our institution
A total of seven patients was included in the analysis. The average age of the patients at the time of surgery was 55.3 years (range, 43–77 years). The BMI could be measured in all patients and averaged 25.8 kg/m2. The surgeries had the following indications: five for infection (chronic foot ulcers with osteomyelitis), one for fulminant gangrene of the foot, and one for an unstable scar with persistent ulcers after Chopart amputation (Table 1). Five patients (71%) suffered from diabetes and peripheral neuropathy. Patency of the posterior tibial artery was considered a prerequisite for surgery and was evaluated either clinically by palpating it or by preoperative angiography.
Table 1.
Demographics and etiology (current retrospective study).
| Patient | Age at Surgery (years) | Sex | BMI (kg/m2) | Follow-up (months) | Diagnosis | Surgical Technique (Osteosynthesis method) | Diabetes | Neuropathy | Preoperative Vascular Status |
|---|---|---|---|---|---|---|---|---|---|
| 1 | 43 | M | 23.55 | 85 | chronic ulcers and osteomyelitis (Bona-Jäger stump) | Boyd (Screws) | no | no | Tibialis posterior and dorsalis pedis palpable |
| 2 | 44 | M | 33.58 | 21 | chronic ulcers and osteomyelitis, diabetic foot syndrome | Boyd (Screws) | yes | yes | Tibialis posterior palpable |
| 3 | 48 | F | 26.40 | 42 | unstable scar of the stump after Chopard amputation | Boyd (Screws) | no | no | Tibialis posterior and dorsalis pedis palpable |
| 4 | 66 | M | 25.26 | 22 | osteomyelitis of the navicular bone, diabetic foot syndrome. | Boyd (initially Screws, then Illizarov) | yes | yes | Tibialis posterior and tibialis anterior open |
| 5 | 65 | M | 24.07 | 12 | osteomyelitis and chronic ulcers | Boyd (Illizarov) | yes | yes | Tibialis posterior open (triphasic flow) |
| 6 | 77 | M | 22.23 | 10 | osteomyelitis after Chopard amputation after fulminant gangrene | Boyd (Illizarov) | yes | yes | Tibialis posterior open (angiography) |
| 7 |
44 |
F |
n/a |
242 |
gangrene of the foot |
Boyd (Screws) |
yes |
yes |
Tibialis posterior palpable |
| Total and averages | 55.3 | 5 M (71%) 2 F (29%) |
25.8 | 62 | – | – | 5 (71%) | 5 (71%) | A. Tibialis posterior - open |
In terms of fixation method, five patients had initially undergone screw-osteosynthesis and two patients received an Illizarov external fixator (Table 1). Callus formation and early fusion could be seen at a mean of 9.7 weeks (Table 2) using standard radiographs. This was usually followed by a progressive increase of weight-bearing in an rTCC (removable total contact cast). The ambulation with a special predesigned prosthesis could be achieved at a mean of 11.7 weeks postoperatively. In three patients (43%), the leg-length discrepancy was measured and documented, with a mean of 2.7 cm.
Table 2.
Outcome (current retrospective study).
| Patient | Follow-up (months) | Ability to fully weight-bear without prosthesis (short distance) | Time from surgery to ambulation | Reamputation? | Complications | Functional Outcome (M-Plus Score) | Leg-Length Discrepancy |
|---|---|---|---|---|---|---|---|
| 1 | 85 | Yes | 8 weeks | no | none | Good | n/a |
| 2 | 21 | Yes | 8 weeks | no | none | Good (57.8%) | n/a |
| 3 | 42 | Yes | 12 weeks | no | none | Good | n/a |
| 4 | 22 | Yes | 12 weeks | no | postoperative Screw break and then pin track infection after 3 months | Fair (38.5%) | 2.9 cm |
| 5 | 12 | Yes | 22 weeks | no | late consolidation | Good | n/a |
| 6 | 10 | Yes | 12 weeks | no | none | Very good (86.4%) | 1.9 cm |
| 7 |
242 |
Yes |
8 weeks |
no |
implant removal due to pain and discomfort |
Very good (98.4%) |
3.2 cm |
| Total and averages | 62 | Yes (100%) | 11.7 weeks | 100% Survivorship | 2 (29%) required reoperation | 2 (29%) – very good 4 (57%) – good 1 (14%) – fair |
2.7 cm |
None of the patients required a more proximal amputation until the last follow-up (100% survivorship). Also, all of the study subjects could fully weight-bear for short distances, without the use of a prosthesis. Two patients achieved a very good function and enjoyed a variety of activities such as skiing, four described as having a good level of function, while one patient scored fair on function assessment (Table 2).
In terms of complications, there was an early postoperative screw breakage in one noncompliant patient, where an early full-weight bearing occurred, which required a revision and fixation with Illizarov Osteosynthesis. Another patient required implant removal due to persistent pain in the stump (screw osteosynthesis group). Among the Illizarov group, a late consolidation was noted in one patient. He was able to achieve full weight bearing only 20 weeks after surgery (Table 2).
3.2. Systematic review
3.2.1. Search results
Using combinations of the predefined search keywords, a total of 491 studies was first identified. After duplicates removal and screening of the titles and abstracts, 49 articles were selected for further full text assessment. At this stage, 39 studies were excluded and the reason of exclusion was noted in the PRISMA Flowchart (Fig. 3). Finally, 10 published reports have been included for the systematic review.4,14,16,26, 27, 28, 29, 30, 31, 32 All studies were retrospective case series (level IV evidence). Two of them were written in German,16,30 and eight in English.4,14,26, 27, 28, 29,31,32
Fig. 3.
Flowchart of the systematic search.
There was a significant variation of the scores during the quality assessment process, with a mean of 77% (Table 1s). From these, three studies achieved a maximum score and were therefore considered to be of high quality.4,27,29
As such, 116 Pirogoff amputations have been added through the systematic search and therefore allowed the comparison of a total of 123 procedures including the current retrospective study (Table 2).
3.2.2. Demographics and etiology
A total of 123 procedures including 115 patients, with an average follow-up of 45 months (range, 10–300 months) were analyzed (Table 3). Eighty-one patients were men (70%) and 34 (30%) were women. The average age was 58 years (range, 20–88 years). Ten studies4,14,16,26,27,29,31,32 reported data about the presence of diabetes and only 4 studies specifically documented the percentage of patients suffering from peripheral neuropathy.26,30,31
Table 3.
Demographics (systematic review).
| Author (Year of Study) | No | Avg. Follow-up (range, months) | Sex | Avg. Age (range, years) | Diabetes (%) | Neuropathy (%) | Operative Technique | Quality Assessment Score |
|---|---|---|---|---|---|---|---|---|
| Altindas (2008) | 16 | 38 (4–144) | 11 M (69%) 5 F (31%) |
52 | 16 (100%) | – | Boyd (No Rotation of the Calcaneus) K-Wire Osteosynthesis |
70% |
| Altindas (2012) | 11 | 25 (4–48) | 5 M (45%) 6 F (55%) |
53 (35–68) | 11 (100%) | 11 – Severe (100%) | Boyd (No Rotation of the Calcaneus) K-Wire Osteosynthesis |
75% |
| Einsiedel (2008) | 6 | 46 (6–131) | 5 M (83%) 1 F (17%) |
55 (39–76) | 4 (67%) | 6 – Severe (100%) | Boyd (No Rotation of the Calcaneus) Ilizarov External Frame |
90% |
| Gessmann (2013) | 24 | 28 (12–86) | 19 (79%) M 5 (21%) F |
57 (29–76) | 16 (67%) | – | Modified Pirogoff (Rotation in Longitudinal Axis) Ilizarov External Frame |
100% |
| Kinner (2016) | 6 | – | – | 73 (65–80) | 5 (83%) | – | Modified Pirogoff (Rotation in Longitudinal Axis) Screw Osteosynthesis |
65% |
| Lindqvist (1966) | 4 | n/a (24–300) | 3 (75%) M 1 (25%) F |
n/a (20–40) | – | – | Boyd (No Rotation of the Calcaneus) | 50% |
| Nather (2014) | 6 | 10 | 1 (17%) M 5 (83%) F |
54 (47–67) | 6 (100%) | – | Modified Pirogoff (Rotation in Longitudinal Axis) Screw Osteosynthesis |
100% |
| Taniguchi (2003) | 12 | 67 (25–107) | 10 (91%) M 1 (9%) F |
60 (18–83) | 3 (25%) | – | Modified Pirogoff (Rotation in Longitudinal Axis) Screw Osteosynthesis |
100% |
| Tosun (2011) | 15 | 36 (6–61) | 8 (57%) M 6 (43%) F |
67 (40–88) | 8 (57%) | – | Boyd (No Rotation of the Calcaneus) Screw Osteosynthesis | 60% |
| Warren (1997) | 16 | 96 (12–216) | 14 (88%) M 2 (12%) F |
52 (28–72) | 0% | 16 – Severe (100%) | Boyd (No Rotation of the Calcaneus) Screw/K-Wire Osteosynthesis | 60% |
| Current Study |
7 |
62 (10–242) |
5 M (71%) 2 F (29%) |
55 (43–77) |
5 (71%) |
5 (71%) |
Boyd (No Rotation of the Calcaneus) Screw/Illizarov Osteosynthesis |
– |
| Totals and averages | 123 | 45 (10–300) |
81 (70%) M 34 (30%) F |
58 (20–88) | - | - | - | 77% |
Seven studies used the Boyd/Spitzy-Pirogoff procedure14,26,28,31,32; while in four studies,4,16,27,29 a modified Pirogoff technique with longitudinal rotation of the calcaneus was performed. There were multiple fixation methods using different implants: K-wires; screws and Illizarov external frame.
A bigger diversity could be outlined among etiologies. These included a variety of surgical indications: trauma, chronic ulcers and osteomyelitis, peripheral vascular disease, metastatic tumor, unstable scars, skin decking defects, and other (Table 4).
Table 4.
Etiologies. Outcome. Survivorship.
| Study | No | Etiology | Preoperative Vascular Status | Avg. postop. Leg-Length Discrepancy (range, cm) | Average Time to Ambulation with Prosthesis (range, weeks) | Functional Outcome | Average Time to Bone Fusion (range, weeks) | Complications | Survivorship |
|---|---|---|---|---|---|---|---|---|---|
| Altindas (2008)a | 16 | 16 (100%) - DM | 9 (56%) palpable A. tibialis posterior or dorsalis pedis 14 (88%) palpable A. poplitea |
n/a (5.0–6.0) | – | 15 (94%) - good | – | 2 (12%) Infection, 1 (6%) Necrosis and TTA | 94% |
| Altindas (2012)a | 11 | 11 (100%) - DM | 9 (82%) – A. tib. post. and dorsalis pedis – palpable; 2 (18%) only A. dorsalis pedis palpable |
– | 14 | 11 (100%) - good | 16 (14–24) | 1 (9%) – delayed union | 100% |
| Einsiedel (2008) | 6 | 4 (67%) – DM; 1 (17%) - PVD; 1 (17%) – PN |
– | 1.6 (1.0–3.0) | 15 (13–17) | 1 (17%) – very good; 3 (50%) – good; 2 (34%) – poor; |
15 (13–17) | 2 (33%) TTA at a mean FU of 15 months (2–25 months) | 67% |
| Gessmann (2013) | 24 | 4 (17%) – Trauma; 4 (17%) – COM; 16 (67%) – DM. |
ABI was >0.5 or A. tibialis posterior was opened or there was sufficient collateral perfusion | 2.8 (0–5) | 18.1 (12.7–26.6) | 6 (40%) – very good; 4 (27%) – good; 4 (27%) – fair; 1 (7%) – poor; |
18.1 (12.7–26.6) | 12 (50%) pin track infection, 6 (25%) SSI, 4 (16%) TTA, 1 (4%) TFA |
80% |
| Kinner (2016) | 6 | 5 (83%) – DM; 1 (17%) – PVD |
– | – | – | 5 (83%) – good; 1 (17%) – poor; |
– | 1 (17%) TTA | 83% |
| Lindqvist (1966) | 4 | – | – | – | – | 4 (100%) - good | – | 1 (25%) phantom pain | 100% |
| Nather (2014) | 6 | 3 (50%) – wet gangrene; 1 (17%) – necrotizing fasciitis; 2 (33%) - abscess |
ABI was >0.7 and A. tibialis posterior was opened | – | 12 (8–12) | 6 (100%) – very good | 24 | None | 100% |
| Taniguchi (2003) | 12 | 3 (25%) – Trauma; 3 (25%) – DM; 4 (33%) – PVD; 1 (8%) – MT; 1 (8%) – COM |
Patent A. tibialis posterior or “heel not cold on palpation” | 2.8 (0–3) | 6 | 4 (33%) – very good; 2 (17%) – good; 1 (8%) – fair; 5 (42%) – poor; |
– | 4 (33%) TTA (3 wound dehiscence, 1 calcaneus necrosis) | 67% |
| Tosun (2011) | 15 | 8 (57%) – DM; 5 (36%) – PVD; 1 (7%) – PN; |
9 (60%) – patent A. tibialis posterior | – | 12 | 6 (46%) – good; 7 (54%) – poor; 2 – lost during FU |
12 | 5 (38%) TTA; 2 16%) TFA; | 46% |
| Warren (1997) | 16 | 16 (100%) Leprosy | – | – | – | 4 (29%) – very good; 8 (57%) – good; 1 (7%) – fair; 1 (7%) – poor. |
– | 2 (13%) BKA after a mean of 9 years (8-10) | 87% |
| Current Study |
7 |
5 (72%) – COM, 1 (14%) – wet gangrene, 1 (14%) – unstable scar after Chopard amputation |
Patent A. tibialis posterior |
2.7 (1.9–3.2) |
11.7 |
2 (29%) – very good 4 (57%) – good 1 (14%) – fair |
– |
2 (29%):1 implant removal and 1 early reoperation due to Screw Breakage |
100% |
| Totals and averages | 123 | - | - | 2.5 | 12.7 |
Very good/Good – 85 (69%) Fair/poor – 38 (31%) |
17.2 | - | 82.1% |
Avg. – average; postop – postoperative; COM – chronic osteomyelitis; PVD – peripheral vascular disease; PN – advanced peripheral neuropathy; DM – diabetes mellitus; MT – metastatic tumor; FU – follow up; TTA – transtibial amputation; TFA – transfemoral amputation; BKA – below knee amputation; SSI – surgical site infection.
These studies were performed by the same author and may include patients from the same institution.
Mostly, patency of the posterior tibial artery was considered a prerequisite for surgical treatment. It was either palpable or was patent on imaging studies (angiography, Doppler).
3.2.3. Outcome and survivorship
A very good or good function could be achieved in 85 (69%) patients at an average follow-up of 45 months (range, 10–300 months). There were only 5 studies that reported the range of postoperative leg-length discrepancy.14,27,29,30 The calculated average was 2.5 cm (Table 4). The average time to ambulation with prosthesis was 12.7 weeks, and the mean time to bone fusion was 17.2 weeks. However, significant differences in postoperative management and strategy depending on surgical technique were noted.
The mean survivorship (absence of more proximal amputation) was 77% (range 46%–100%). In four studies, all patients remained with a functional stump at the latest follow-up.4,28,31 In one study, more than half of the patients underwent a transtibial or a transfemoral amputation.32 However, in this cohort, patency of the posterior tibial artery was present in only 60% of the patients preoperatively.32
4. Discussion
Although modifications of the Pirogoff amputation, such as the method described by Kinner with calcaneus rotation16 or the Boyd technique14,32 are rarely described in the literature, these are consistently performed worldwide. Indications, patient and technique selection are the critical steps to influence outcome, although systemic disease is a decisive factor.
A sufficient vascular perfusion of the stump has to be achieved. Hindfoot perfusion is brought mainly by the posterior tibial artery and to a lesser degree by the fibular artery.33 Only 6 out of the 10 reviewed studies reported about patency of the posterior tibial artery.4,14,27,29,31,32
Nather's series included exclusively patients with an open PTA and had a survivorship of 100%.4 Similarly, in our own cohort with a survivorship of 100%, patency of the posterior tibial artery was either assured by a firmly palpable pulse or otherwise secured by angiography prior to surgery. Thus, patency of the PTA is a major requirement to perform the modified Pirogoff or Boyd amputation. In our practice, assessment of the PTA pulse is done first by clinical palpation. In doubt, patients are referred to angiology to secure patency of the PTA. If the PTA is occluded and patency of the PTA can't be restored by interventional angiography, we opt for transtibial amputation.
In terms of peripheral neuropathy, it often leads to neglect of pressure and to plantar ulcers. In theory, the reduction of the footprint after Pirogoff amputations enhances the surface pressure and therefore should elevate the risk for pressure ulcers in patients with neuropathy. Only four studies including our own, reported the prevalence of neuropathy. In one study cohort of 11 subjects, all patients suffered from severe neuropathy and nonetheless achieved a 100% survivorship.31 Warren's series26 of 16 patients included exclusively patients with neuropathy. For the first 8 years, survivorship was 100%. Two patients had secondary amputation due to ulcers and squamous cell carcinoma after 8 and 10 years, respectively.26 Einsiedel30 reported results of six patients, all which had severe peripheral neuropathy. Two of them had secondary transtibial amputation due to recurrent stump ulcers and osteomyelitis after 5 and 25 months, respectively. Our own series included 5 patients with neuropathy. In summary, in 34/38 (89.5%) of patients with peripheral neuropathy, no additional amputation was necessary until final follow-up. This could be explained by the fixed load-bearing stump due to the definitive hindfoot osteosynthesis. In other partial foot amputations (Lisfranc or Chopard), a positional change of the stump due to shortening of the Achilles tendon can be observed, which leads again to an increase of the pressure in the remaining loaded footprint.34 Therefore, the authors do not recommend to decide against the amputation technique in patients only because of peripheral neuropathy.
The Boyd procedure was used in seven of the reviewed studies including our cohort,14,26,28,30, 31, 32 whilst the modified Pirogoff technique with calcaneus rotation was used in the remaining four studies.4,16,27,29 As such, 101/123 (82.1%) patients did not undergo further amputation at final follow-up. Using the modified Pirogoff amputation, survivorship was 79.2% with 10 out of 48 patients undergoing either transtibial or transfemoral amputation. Using the Boyd procedure, survivorship was 84% with 12 out of 75 patients having either transtibial or transfemoral amputation. These survivorship results are similar and are influenced by conditions such as patency of the PTA. An independent students t-test revealed no significant difference between the amputation free survivorship between the two different surgical procedures (p = 0.35). Thus, the authors do not advocate a preference of one surgical procedure by survivorship. Rather, surgeon's expertise and preference should determine the procedure.
The leg shortening is based on the resection of the talus and excision of the distal tibial and the superior or anterior calcaneal joint surfaces. In addition to our cohort, three authors quantified the leg shortening. Performing the Boyd modification, Einsiedel et al.30 reported of a mean shortening of 1.6 cm. In our cohort, mean shortening was 2.7 cm. A huge heterogeneity can be observed when evaluating the reported range in the cohort by Altindas et al.14 (5–6 cm). This is probably due to the lack of a standardized level of resection. On the other hand, using the modified Pirogoff technique described by Kinner with rotation of the calcaneus,16 both Gessmann et al. and Taniguchi et al. reported a mean of 2.8 cm shortening.27,29 A detailed comparison of the leg-shortening is due to the limited available data not. However, leg length compensation of an average of 2.8 cm is technically no challenge for an experienced prosthetist. Thus, in our view, surgeon's expertise and preference should dictate which technique should be used.
Functional outcome was evaluated heterogeneously throughout the reviewed studies. Four out of 11 studies (including our own series) used standardized scores for outcome measurement,27,29,30 whilst the rest used only a subjective assessment of procedural success.4,14,16,26,28,31,32 Overall, in 69% of the patients, the result was deemed as very good or good, while in 31% it was deemed fair or poor. In 56.3% (27/48) of the patients undergoing the modified Pirogoff procedure, a very good or good result was achieved, while 43.7% had fair or poor results. Using the Boyd procedure, 77.3% (58/75) had a very good or good result while 22.7% were judged as fair or poor. An independent students t-test revealed no significant statistical difference between functional outcome (good/very good vs. fair/poor) between the two different surgical procedures (p = 0.29). In theory, the mechanically loadable footprint in patients with a Boyd procedure remains wider and therefore enhances the biomechanical properties of the remaining limb. While this is an assumption, it is also a possible biomechanical explanation for the better functional outcome in patients undergoing the Boyd procedure. Although the Boyd technique seems more advantageous regarding functional outcome, based on heterogeneous measures of functional outcomes reported, a clear recommendation for either Boyd or modified Pirogoff procedure is impossible.
Apart from the retrospective study design and small individual populations of included studies, limitations that were encountered include the following: the heterogeneity of the study subjects, their comorbidities, the difference of the surgical indications, the diversity of the operative techniques, the different methods and measurements of reporting the functional outcome.
To our knowledge, the present study includes the largest number of patients treated with modifications of the original Pirogoff technique, either by the modified Pirogoff or Boyd operative technique.
Ethical approval
The presented study was conducted in accordance with Swiss and international law requirements. Ethical board's approval was obtained from the Ethical Committee of the Canton of Zurich, Switzerland (ID: BASEC Nr. 2016-00387).
Declaration of competing interest
All authors declare that they have no conflict of interest.
Acknowledgments
We sincerely thank Mrs. Kati Sairanen, our Clinical Study Coordinator, for the tremendous support that she provided for the current work.
Footnotes
Supplementary data to this article can be found online at https://doi.org/10.1016/j.jor.2019.10.008.
Appendix A. Supplementary data
The following is the supplementary data to this article:
References
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