Chopart Amputation Research Articles

Klippel-Trenaunay-Weber Syndrome – A case report and review of the literature

Klippel-Trenaunay-Weber syndrome (KTW syndrome), also known as congenital dysplastic angiopathy or angioosteohypertrophy syndrome, is a rare, sporadic, complex malformation that involves congenital malformations of veins, capillaries, and/or lymphatics, which leads to soft tissue hypertrophy and port-wine stains. We report a case of a 37 year old woman with congenital Klippel Trenaunay Weber syndrome. She had many vascular abnormalities from birth which increased in time such that she had many surgical interventions. These abnormalities of veins and capillaries were leading to hypertrophy of the extremities – finger macrosomia. She had orthopedic comorbidities like Chopart amputation of the anterior part of her left foot and dorsal kyphoscoliosis because of the external scars. Studying similar cases from the literature, we found that Klippel-Trenaunay-Weber syndrome could be associated with brain abnormalities. We admitted the patient for additional investigations because some of these patients could have cerebral malformations in the absence of neurologic abnormalities. We considered at that time that it was necessary to look for any unknown vascular abnormality. Management of this syndrome should aim to correct any of the abnormalities present, if technically possible, and if the abnormality is causing symptoms.

Partial Foot Amputation in Patients with Diabetic Foot Ulcers

Transtibial amputations (TTA) are performed for recalcitrant or infected ulcers of the midfoot, hindfoot, or ankle. This procedure results in decreased ambulatory status caused by increased oxygen demands and energy expenditure. Partial foot amputations have the advantage of being an end-bearing limb and require less work to walk, theoretically suggesting improved functional outcome. The purpose of this research was to examine the longevity, outcome, and mortality of partial foot amputations as an alternative to TTA. Retrospective chart review identified diabetic patients with transmetatarsal, Chopart's, and calcanectomy amputations for osteomyelitis or nonhealing ulcers. A control group consisted of diabetic patients who underwent TTA. A comparison between groups examined mortality, proximal ipsilateral reamputation, and a validated ambulatory functional outcome measure. Eighteen TTA patients were enrolled. The 5-year mortality rate was 0.45, one patient required reamputation, and the mean postoperative ambulatory score was 2.8. Twenty-one transmetatarsal patients were enrolled. The 5-year mortality rate was 0.30, two patients required reamputation, and the mean postoperative ambulatory score was 4.3. Ten Chopart's amputation patients were enrolled. The 5-year mortality rate was 0.36, six patients required reamputation, and the mean postoperative ambulatory score was 4.3. Seventeen partial calcanectomy patients were enrolled. The 5-year mortality rate was 0.69, six patients required reamputation, and the mean postoperative ambulatory score was 4.3. Sixteen total calcanectomy patients were enrolled. The 5-year mortality rate was 0.59, five patients required reamputation, and the mean postoperative ambulatory score was 3.3. TTA is associated with high morbidity and mortality, which suggests that the advantage of partial foot amputations should be investigated. Only transmetatarsal amputations at 1 and 3 years were statistically lower for mortality than TTA. Partial foot amputations at the other levels failed to show statistically improved survivorship. Transmetatarsal and Chopart's amputations had high ambulatory levels and the longest durability, which suggests that these amputations may provide some ambulatory advantage.

Outcome of Midfoot Amputations in Diabetic Gangrene

Persistent high incidence of limb loss resulting from advanced foot gangrene in patients with diabetes prompted an aggressive foot salvage surgery as a final attempt before below-the-knee amputation (BKA). The aim of this study was to evaluate the role of transtarsal amputations in achieving limb salvage at our vascular surgery unit, King Fahd Hospital of the University, Saudi Arabia. A prospective study was performed on all patients with diabetes who were admitted to the vascular surgery unit, and underwent transtarsal amputation between November 2005 and October 2010. Patients who had their forefoot removed at the tarsometatarsal level (Lisfranc amputation) or at the midtarsal joint (Chopart amputation) were included in the study. Patient factors, operative complications, operative mortality, wound healing, limb salvage, functional status, and survival rates were evaluated. Over the past 4 years, 32 patients with diabetes were included in this study. Of these, 24 had Lisfranc and 8 had Chopart amputations for advanced gangrene of the foot. A total of 28 patients had evidence of arterial occlusive disease. In all, 24 patients had concomitant revascularization (bypass grafting or percutaneous transluminal angioplasty). Two patients died in the perioperative period (operative mortality: 6%). The stump did not heal in 8 patients (27%) and BKAs had to be performed. Four BKAs and 2 above-the-knee amputations were required 3-28 months later. Functional ambulation at 6 months was achieved in 20 (67%) of 30 patients. Aggressive attempts at foot salvage are justified in patients with diabetes with advanced foot gangrene after assuring adequate arterial perfusion. Transtarsal amputations salvaged about two-thirds of the limbs studied.

Reconstructing Limb Deformities using the VCAM™ External Fixator: A series of 3 cases

External fixation was used almost exclusively for fracture management. It is also used for arthrodesis, management of lower extremity deformities such as Charcot neuroarthropathy, limb lengthening, osteotomy stabilization, osteomyelitis, nonunion or pseudoarthrosis. It has proven extremely useful in the treatment of a number of conditions because it can provide distraction, compression, stabilization and neutralization as needed. Traditional external fixators involve driving pins through the tibia and fibula. The VCAM TM is a unique below the ankle external fixator. The VCAM TM can avoid possible disruptions and complications that are often seen with traditional Ilizarov fixators. The indications for the VCAM TM external fixator are identical to the Ilizarov fixators, such as off-loading, fracture reduction and reconstructive procedures. In our institution, we have used the VCAM TM device to off-load ulcerations and correct limb deformities. In the cases presented in this paper the VCAM TM was used to off-load wounds secondary to Charcot arthropathy and transmetatarsal amputations, as well as to gradually correct a rearfoot deformity such as seen in a Chopart's amputation. The VCAM TM can be constructed into an Ilizarov type frame or a hybrid frame which can be used to achieve gradual triplanar correction. We have seen good results using the VCAM TM for wound care and limb deformities and recommend this approach when tibia and fibula intervention is not necessary.

Factors Associated With Successful Chopart Amputation in Patients With Diabetes

Chopart amputations were first performed for treatment of a non-salvageable distal foot but became unfavorable because of the development of equinovarus contractures and ulcerations. The majority of below-knee amputations today occur in ambulatory patients with diabetes in which a Chopart amputation may be a viable option; however, the durability of the residual limb is questionable. The authors undertook a systematic review of electronic databases and other relevant sources to identify material relating to the factors associated with a successful Chopart amputation in ambulatory patients with diabetes. Studies were eligible for inclusion only if they consecutively enrolled ambulatory patients with diabetes who underwent a Chopart amputation, regardless of etiology, with or without any tendinous or osseous balancing performed and had a mean follow-up of ≥12 months duration. Four studies involving 74 patients/feet were identified that met the inclusion criteria with a weighted mean follow-up of 21.1 months. The efficacy of tendinous and/or osseous balancing could not be assessed because of the lack of comparable techniques. However, review of the included studies supports that a residual functional limb can be maintained for ≥12 months with the use of a properly fitting high-profile prosthetic device for lifelong ambulation.

Preserving Functional Capacity as Opposed to Tissue Preservation in the Diabetic Patient

The authors performed a retrospective review of prospectively collected data of all diabetic patients who underwent transmetatarsal amputation (TMA) for toe gangrene or neuropathic ulceration from May 2006 to June 2009. Twenty-nine TMAs were performed in diabetic patients during the study period, including 24 men and 5 women with a mean +/- SD age of 66.3 +/- 7.5 years. The indications for TMA were gangrene of > or = 2 digits in 12 patients (41%) and neuropathic ulceration with underlying osteomyelitis or abscess and a concomitant dysfunctional forefoot in 17 patients (59%). Of the 12 patients who presented with toe gangrene, 7 (58%) underwent endovascular intervention and 5 (42%) underwent open vascular bypass. Equinus contracture was present in 27 patients (93%), and 26 (96%) of these patients underwent tendo-Achilles lengthening or gastrocnemius recession. Correction of equinus contracture was not performed in 1 patient as it was deemed not feasible. Forefoot varus deformity was present in 22 (76%) patients, and balancing was performed in 17 of these patients (77%) with skeletal stabilization or tendon transfer. Balancing was not performed in the remaining patients as it was not necessary or not feasible. Sixteen patients (55%) healed primarily and 5 patients (17%) developed minor wound separation that healed via secondary intention. An additional 4 patients were able to maintain functional revision procedures confined to the foot (1 TMA revision, 3 Chopart amputations). Three patients (10%) required below-knee amputation, and there were 2 deaths (7%) during the time period. Functional amputation confined to the foot was achieved in 86% of ambulatory diabetic patients. These results support a more aggressive initial approach in ambulatory diabetic patients with multiple digital ulcerations, allowing this patient population to remain functional and avoid multiple reoperations and ultimately major amputation.

Extra-articular Ankle Stabilization

Maintenance of the foot at 90 degrees to the lower leg following posterior calf lengthening or to prevent an equinus contracture in situations in which splint, cast, or external fixation is deemed inappropriate is a challenge. The author presents an observational case series involving 9 extra-articular ankle stabilizations performed in 9 consecutive patients. Each patient underwent his or her index surgery followed by percutaneous placement of 2 smooth 2.8-mm or larger diameter Steinmann pins extra-articular to the ankle joint. There were 6 men and 3 women with a mean age of 56.1 years (range, 31-73 years). Five patients had diabetes with peripheral neuropathy, 2 had critical limb ischemia, 1 had alcohol-induced neuropathy, 1 had lupus, and 1 was an active smoker. Eight patients had posterior calf lengthening, and 1 had open metatarsal fractures with severe soft-tissue disruption with an inability to use splint immobilization. Three patients had a transmetatarsal amputation, 2 patients had Chopart amputations, 2 patients had forefoot plastic surgery reconstructive procedures, 1 had a complex Charcot reconstruction, and 1 had a splittibialis anterior tendon transfer. Extra-articular ankle stabilization fixation was retained for a mean of 5.5 weeks (range, 2-10 weeks). Mean follow-up was 12 months (range, 1-17 months). All extra-articular stabilization procedures were deemed successful. When properly performed, extra-articular stabilization to maintain the foot at 90 degrees to the lower leg represents a safe, simple, reliable, and minimally invasive technique useful in situations in which traditional splint or cast immobilization is not possible and when external fixation is deemed inappropriate.

Chopart's Amputation for Resection of Clear Cell Sarcoma of the Foot: A Case Report and Review of the Literature

Clear cell sarcoma (CCS) is a subset of soft tissue sarcoma that occurs mainly in young Caucasians. Although on initial presentation these growths might not appear to be malignant, CCS has a tendency to disseminate to regional lymph nodes and ultimately develop distant metastasis. We report a case of CCS from our institution, discussing the radiological and pathological findings, surgical treatments, and survival prognoses. To our knowledge, this is the first reported case of using a Chopart's amputation technique in the resection of CCS of the foot. 4.

Chopart's Amputation: A 10-Year Case Study

The purpose of this case study was to review the 10-year outcome of a patient with a history of diabetes, pedal osteomyelitis, and peripheral vascular disease, who underwent a Chopart's amputation of the right foot. Key evaluative elements to consider for long-term success of any amputation include the vascular status of the foot, control of infection, adequate soft tissue coverage, biomechanics associated with amputation, the metabolic challenge of amputation, and the psychosocial consequences linked to loss of a limb. The results of the case study show that Chopart's amputation is an excellent limb salvage surgical option that can achieve beneficial long-term outcomes in properly selected patients.

Achieving Functional Ambulation in a Patient with Chopart Amputation

Chopart amputation provides an interesting functional dilemma for the patient, physiatrist, and prosthetist. This problem is further complicated when the patient develops an equinus contracture from an unbalanced short forefoot lever. Also, genu recurvatum occurs as a consequence of recurrent knee hyperextension from this contracture. There are few reports on the most functional prostheses for this type of patient. We present a case of a pediatric patient with a Chopart amputation who demonstrated genu recurvatum during ambulation. After experimenting with many different types of prostheses, he had persistent lower-limb pain. We prescribed a Chopart prosthesis with a flexible inner socket and a carbon fiber energy-storing keel with posterior calf struts. At his follow-up clinic visit, he no longer had pain, and he was able to play soccer. This device provides a functional alternative for those patients with Chopart amputation who are unable to participate in athletic activities.

Veno-Accompanying Artery Fasciocutaneous (VAF) Flap for Coverage of Skin Defects of the Leg and Ankle

The veno-accompanying artery fasciocutaneous (VAF) flap and veno-neuro-accompanying artery fasciocutaneous (V-NAF) flap are fasciocutaneous flaps receiving arterial blood supply from accompanying arteries of the cutaneous vein and nerve (Nakajima, 1999). These skin flaps can cover skin defects of the extremities as pedicle flaps. These authors reported the results of these flaps used to cover skin defect of the leg. Since 1996, 17 flaps were used in 17 patients. The mean age of 14 men and 3 women was 42 years (range: 3 to 71 years). Cases involved skin defects in 6 patients, traumatic bone and skin defects in 5, and skin defects after tumor resection and after contracture release in 3 patients each. Four patients had combined osteomyelitis and were treated simultaneously with antibiotic-impregnated bone cement. The size of the skin defect ranged from 4 cm × 3.5 cm to 15 cm × 8 cm. The sural or saphenous nerve was used in V-NAF flaps. Currently, the authors spare these nerves, especially the saphenous nerve, in the proximal leg because it runs under the fascia and makes less of a contribution to the blood supply to the leg. There were 13 flaps containing the small saphenous vein and 4 flaps containing the great saphenous vein. Five proximally-based flaps were used to cover proximal skin defects, as proximal as the popliteal fossa and the prepatellar region. Twelve distally-based flaps were used to cover distal skin defects, as distal as the stump of Chopart amputation. Follow-up ranged from 1 year to 6 years (mean: 2 years). All flaps survived completely. The donor sites of these flaps were closed primarily in 6 and with a skin graft in 11 cases. All osteomyelitis cases healed without any problems. Skin defects exposing bone in the leg and ankle are difficult to treat. Free vascularized flaps used to be required in many cases. However, free flap transfer may be difficult in elderly patients or in patients having disease or damage to major arteries of the leg. The VAF and V-NAF flaps are pedicle flaps, relatively easy to dissect and with no need to sacrifice the major arteries of the leg. They are useful for covering skin defects of the leg and ankle.

The Role of Early Surgical Debridement and Revascularization in Patients With Diabetes and Deep Foot Space Abscess: Retrospective Review of 106 Patients With Diabetes

One hundred-six patients underwent emergency debridement of a deep foot space abscess. While 43 patients were admitted after an outpatient visit with immediate surgical debridement (group A), 63 patients were transferred from other hospitals after a mean stay of 6.2+/-7.5 days without debridement (group B). No significant differences were observed in the demographic and clinical features between the 2 groups, except for the following differences in group B: higher blood glucose level on admission (P=.015), lower serum albumin level (P=.005), and a more frequent extension of the infection to the heel (P=.005). Eradication of the infection was obtained in group A without amputation in 9 patients, with an amputation of 1 or more rays in 21, with metatarsal amputations in 12, and with a Chopart amputation in 1. In group B, incision and drainage alone were performed in 4 patients, amputation of 1 or more rays in 21, metatarsal amputations in 10, Chopart amputations in 23, and an above-the-ankle amputation in 5. The amputation level was significantly more proximal in group B (chi2=24.4, P<.001). There was no significant difference in the presence of peripheral arterial occlusive disease between the 2 groups (P=.841). Regression logistic analysis showed a significant relationship between the amputation level and the number of days elapsed before debridement (odds ratio, 1.61; P=.015; confidence interval, 1.10-2.36), but not with the presence of peripheral occlusive disease (odds ratio, 1.73; P=.376; confidence interval, 0.29-15.3). These data show that a delay in the surgical debridement of a deep space abscess increases the amputation level. Accuracy in the diagnosis of peripheral occlusive disease and immediate revascularization yield similar outcomes in patients with or without peripheral occlusive disease.

A Modification of Chopart’s Amputation With Ankle and Subtalar Arthrodesis by Using an Intramedullary Nail

This study reports on 7 patients who underwent a new technique for Chopart amputation that includes ankle and subtalar arthrodesis using an intramedullary nail. This method affords rigid control to the rearfoot and appears to avoid the most common complications historically associated with Chopart amputations. All 6 surviving patients achieved successful outcomes within 1 year of their surgery. All are community ambulators who are able to walk short distances within the home without a prosthesis. One patient, who had undergone a previous vascular bypass, died in the early postoperative period after developing an infection that required an above-knee amputation. A second patient developed an infection that resolved with intravenous antibiotics. This new technique reintroduces the Chopart-level amputation as a valuable intermediate between the transmetatarsal and below-knee amputation levels.

Link-Witzel operation for diabetics

The inner Chopart's amputation for tuberculosis of the tarsal as performed by Link and Witzel at the end of the nineteenth century laid the groundwork for a foot-saving surgical procedure in cases of neuropathic osteoarthropathy with concomitant infection. The question was posed whether such an inner amputation can represent an alternative to the classic hindfoot amputation. Six patients with neuropathic osteoarthropathy, five of whom had diabetes mellitus,who had been operated between 1989 and 2002 were analyzed retrospectively. In all of the cases, surgery had been indicated by chronic osteomyelitis of the tarsal with concomitant, extensive, mainly plantar ulcerations. During the average follow-up period of 55 weeks, no recurrence of an ulcer or infection occurred and therefore no further proximal amputation was necessary. In addition to being provided with orthotics, the remaining five patients could be fitted with made-to-measure orthopedic shoes. In selected cases, the inner Chopart's amputation can represent a solution even in such problematic cases that cannot be solved by a typical hindfoot amputation. The surgical procedure according to Link and Witzel should thus not only be considered as an alternative to Chopart's amputation, but also as a further method to spare diabetics major amputations.

Long-term results of pantalar fusion for correction of equinus deformity after Chopart's amputation: a case report

Painful equinus deformity with subsequent skin breakdown over the anterior portion of the amputation site is one of the major complications of traditional Chopart's amputation. Surgical correction of the deformity is rarely advocated; Syme, Pirogoff or below-the-knee amputations are the preferred treatments. Pantalar arthrodesis is an alternative procedure which corrects the deformity and avoids additional shortening of the limb. We present a case which shows good functional and clinical outcome more than 50 years after the intervention.

Limb salvage with Chopart's amputation and tendon balancing.

For several decades, Chopart's amputation has met with some skepticism owing to reports of significant equinus deformity developing soon after the procedure is performed. However, with appropriate tendon balancing, which generally includes anterior tibial tendon transfer and tendo Achillis lengthening, this level of amputation is often more functional than slightly more distal amputations, such as Lisfranc or short transmetatarsal amputations. The authors offer a rationale for this observation, which includes a discussion of the longitudinal and transverse arch concept of the foot. This concept dictates that the shorter the midfoot-level amputation, the more likely the patient is to develop an equinovarus deformity, thus exposing the fifth metatarsal base and cuboid to weightbearing stress and a high risk of ulceration. Chopart's amputation, in eliminating the cuboid, often obviates the potential varus deformity and thus can have a more acceptable long-term result.

Salvage of foot amputation stumps of Chopart level by free medial plantar flap.

Blast energy-induced traumas usually result in some type of amputations of lower extremities. It is very hard to determine the amputation level of the feet of these cases at first, and secondary amputation stump revisions by bone shortening are often necessary. Among partial foot amputation levels, Chopart level is the most critical. Four male patients (20 to 24 years old) with modified Chopart amputation due to mine explosion injury have had skin-grafted amputation stumps where troublesome, recurrent unstable wounds had developed. These amputation stumps were electively reconstructed with neurosensorial free medial plantar flaps from unaffected feet without any bone shortening. All the transferred flaps survived and adapted to stumps well, and patients were ambulated at the second month by wearing on the original prosthesis after minimal adjustments. At the follow-up period (6 months to 2 years), no skin breakdown of the stumps was evident. Monofilament (Semmes-Weinstein) tests revealed diminished light touch in two patients and diminished protective sensation in another two patients at the sixth month. Temporary donor foot pain, which existed by walking for 3 months, may be due partly to absence of plantar fascia supporting the plantar arc. We suggest that amputation level of Chopart is the most critical of partial foot amputations in young patients and should be reconstructed with flaps if there is not sufficient soft-tissue coverage of amputation stump; free neurosensorial medial plantar flap would be the primary choice with its advantages.

The augmented chopart amputation in children

Provision of a functional weight-bearing stump. Improved stability of ankle and subtalor joints. Prevention of developing an equinus deformity. Severely mangled or malformed foot. Severe bilateral foot and lower limb deformities. Limb length discrepancy. Inadequate plantar skin coverage. Significant loss of tendons. Gross instability at ankle or subtalar joint. Radiographs of foot and ankle. Careful examination of ankle and subtalar joints. Supine. Above knee tourniquet. General anaesthesia. Augmentation of the traditional Chopart amputation with transfer of the tibialis anterior, tibialis posterior, and long toe extensor tendons to the talus and lengthening of the heal cord. Compressive dressing to be changed after 3 weeks. Weight bearing is resumed after 6 weeks. Fitting of a modified Syme's prosthesis after 3 months. Haematoma. Pull out of transferred tendons. Skin flap necrosis. Infection. 6 patients have undergone this amputation, 2 of whom were amputated bilaterally. Follow-up: 5 years. All patients were able to bear full weight. In 1 child the foot drifted into a slight equinus not necessitating a repeat Achilles tendon lengthening.

Increased limb salvage by the use of unconventional foot amputations.

Limb salvage in the presence of ischemic foot necrosis requires revascularization followed by debridement or partial foot amputation. Necrosis extending beyond the toes and metatarsal heads may require the use of unconventional types of amputations. Over a 15-year period 2105 ischemic limbs were treated with infrainguinal revascularization. In 98 cases, extensive foot necrosis was than managed with amputations, including 59 modified Chopart, 14 Lisfranc, 17 Pirogoff and 8 Syme amputations. Patients were not allowed to bear weight for several days to weeks. Skin flap necrosis in 14 cases was managed successfully by debridement and skin grafting. Ambulation required the use of a "clamshell" prosthesis and foot spacer. The overall limb salvage rate in this group was 84% (82 of 98). In general, the modified Chopart amputation most frequently produced ambulatory limb salvage and is technically easier to perform than a Syme amputation. Patient satisfaction and long-term ambulatory function was highest with the modified Chopart. Ischemic foot necrosis extending beyond the limits of conventional transmetatarsal amputation need not be treated with major amputation. This requires the surgeon to be well versed in the use of less common types of partial foot amputations. Acceptable limb salvage and good functional results may be attained by the motivated patient and surgeon with the use of these procedures in the revascularized limb.

Stump problems in traumatic amputation.

Stump problems in amputations resulting from employment related injuries were investigated in 397 cases in the Chugoku and Shikoku districts of Japan between 1987 and 1991. Ninety-seven patients (24%) had stump problems which interfered the prosthetic fitting. Stump problems of the upper extremity were seen in about 9% (17 amputees), two thirds of which were skin troubles. Stump problems of the lower extremity were seen in about 37% (80 amputees). Certain complaints were associated with specific methods of amputation; abnormal keratosis in Syme's amputation, equinus deformity in Chopart's amputation, reduced muscle power in above the knee (A/K) amputation and joint dysfunction in below the knee (B/K) amputation. Adequate prosthetic fitting was achieved by the modification of the socket and alignment in almost all amputees with stump problems. In only two cases, Chopart's amputation required subsequent Syme's amputation due to equinus deformity with abnormal keratosis. In almost every case, stump problems are avoidable by means of surgeons' deliberate evaluation of the affected limb and adequate choice of the amputation level.