BURGESS VERSUS BURGESS VERSUS SKEW FLAPSKEW FLAP

AIMAIM good primary healinggood primary healing

durable stump durable stump

early prosthetic fittingearly prosthetic fitting

EVOLUTION OF B/K AMPUTATIONEVOLUTION OF B/K AMPUTATION

1.1. Kendricks amputation-Kendricks amputation- Ant and Post Ant and Post flaps length 1:2 ratio.flaps length 1:2 ratio.

2.2. BurgessBurgess- long posterior myocutaneous flap- long posterior myocutaneous flap

3.3. Saggital flapSaggital flap technique technique

4.4. SkewSkew flapflap (1982) (1982)

5.5. Medial based flapMedial based flap technique (1995) dr SK technique (1995) dr SK jainjain

Kendricks AmputationKendricks Amputation

• The technique did not gain much favor The technique did not gain much favor

1.1. Failure of stump healing at tibial Failure of stump healing at tibial crest.crest.

2.2. Unhealthy anterior flap in vascular Unhealthy anterior flap in vascular compromised patients.compromised patients.

• So the concept of 1:2 was discounted So the concept of 1:2 was discounted after vascular studies.after vascular studies.

BURGESS AMPUTATIONBURGESS AMPUTATION• Popularized by burgess in 1971Popularized by burgess in 1971• Both in ischemic and non ischemic limbs.Both in ischemic and non ischemic limbs.

• Based on the fact that the blood supply of Based on the fact that the blood supply of the the

Posterio-medial aspt of the leg – goodPosterio-medial aspt of the leg – good

Antero-lateral aspect of leg - poorAntero-lateral aspect of leg - poor

• Avoid dissection between tissue planesAvoid dissection between tissue planes

Cont-Cont-

• Shorter stump 10 – 12.5 cm.Shorter stump 10 – 12.5 cm.

• Create myocutaneous flaps.Create myocutaneous flaps.

• Tension myodesis and osteomyocutaneous Tension myodesis and osteomyocutaneous flaps are contraindicated.flaps are contraindicated.

• Burgess amputation is still very commonly Burgess amputation is still very commonly done in ischemic limbsdone in ischemic limbs

DIS-ADVDIS-ADV

1.1. Delayed primary wound healingDelayed primary wound healing

2.2. Stump edemaStump edema

3.3. Flat stumpFlat stump

4.4. Dog earsDog ears

5.5. Delayed prosthetic fittingDelayed prosthetic fitting

MAIN PROBLEMMAIN PROBLEM

Anterior folding of the burgess flap causes Anterior folding of the burgess flap causes shearing of its layers, mainly the fat – shearing of its layers, mainly the fat –

fascia interface.fascia interface.

This forms the weakest point leading to This forms the weakest point leading to compromised vascularity of the overlying compromised vascularity of the overlying

skinskin

Leading to break down of woundLeading to break down of wound

SAGGITAL FLAP TECHNIQUESAGGITAL FLAP TECHNIQUE• Equal medial and lateral Equal medial and lateral

myocutaneous flaps.myocutaneous flaps.

Diff b/w long post flap and saggital Diff b/w long post flap and saggital flapflap

• SAGGITAL FLAPSAGGITAL FLAP

1.1. Skin cut reduces Skin cut reduces the vulnerable the vulnerable area.area.

2.2. Risk of flap Risk of flap necrosis less as necrosis less as ratio 1:1ratio 1:1

LONG POST LONG POST FLAPFLAP

1.1. Large areaLarge area

2.2. Large post flap Large post flap more risk of more risk of necrosisnecrosis

Diff b/w long post flap and saggital Diff b/w long post flap and saggital flapflap

3.3. Side to side Side to side myoplasty better myoplasty better bone coveragebone coverage

4.4. Oblique cut of Oblique cut of tibia supp tibia supp myoplasty myoplasty prevents post prevents post slidingsliding

3. Ant to post 3. Ant to post myoplastymyoplasty

less effective less effective bonebone

coveragecoverage

4. Posterior sagging 4. Posterior sagging ofof

myoplasty.myoplasty.

Diff b/w long post flap and saggital Diff b/w long post flap and saggital flapflap

• SAGGITAL FLAPSAGGITAL FLAP

5. 5. No dog earsNo dog ears

6. Conical stump6. Conical stump

7. Early healing 7. Early healing

8. Early prosthetic 8. Early prosthetic fittingfitting

• LONG POST LONG POST FLAPFLAP

5. 5. Dog ears presentDog ears present

6. Flat stump6. Flat stump

7. Delay in healing7. Delay in healing

8. Delay in 8. Delay in prosthetic fittingprosthetic fitting

SKEW MODIF OF SAGGITAL FALPSKEW MODIF OF SAGGITAL FALP

• Instead of saggital flapsInstead of saggital flaps

• We fashion antero-medial and postero-lateral We fashion antero-medial and postero-lateral flapsflaps

• The division was based on the knowledge of The division was based on the knowledge of

fasiocutaneous blood supply of a below knee fasiocutaneous blood supply of a below knee stump.stump.

• This keeps the ant part of the scar lateral to This keeps the ant part of the scar lateral to the tibial the tibial

crest which has precarious blood supply.crest which has precarious blood supply.

Adv and disadvAdv and disadv

ADVADV• Simple procedureSimple procedure• Equal flapsEqual flaps• Equal blood supply to both flapsEqual blood supply to both flaps• Improved conical stumpImproved conical stump• Better prosthetic fitting.Better prosthetic fitting.

DISADVDISADV--• Scar still runs across the tibia which lacks Scar still runs across the tibia which lacks

good muscle cushiongood muscle cushion• Bone exposure or protrusion at a later Bone exposure or protrusion at a later

date. date.

CONCEPT OF FASCIO-CUT BLOOD CONCEPT OF FASCIO-CUT BLOOD SUPPLYSUPPLY

• It is no understood that a series of It is no understood that a series of blood vessels pass towards the surface blood vessels pass towards the surface of the skin along fascial septaof the skin along fascial septa

• These septal perforators communicate These septal perforators communicate with vessels of deep fascia forming a with vessels of deep fascia forming a plexusplexus

• So as long as the skin and sub/cut So as long as the skin and sub/cut tissue is not stripped from the fascia it tissue is not stripped from the fascia it will receive axial pattern blood supply.will receive axial pattern blood supply.

MODIF SKEW FLAP (American MODIF SKEW FLAP (American journal of orthopedics 2007)journal of orthopedics 2007)

• In order to counter the problems of skew In order to counter the problems of skew flap where the tibia lacks enough flap where the tibia lacks enough cushioning which could lead to skin cushioning which could lead to skin problems.problems.

• Modification-Modification-

1.1. Proximal 4cm of the anterior incision is Proximal 4cm of the anterior incision is kept linearkept linear

2.2. The dissection proceeds in the plane of The dissection proceeds in the plane of deep fascia in the ant flap till the summit deep fascia in the ant flap till the summit of the flaps.of the flaps.

CONT-CONT-

3. Leaving the tibialis ant rest of the muscles are 3. Leaving the tibialis ant rest of the muscles are cut in a oblique fashion with tibialis post as the cut in a oblique fashion with tibialis post as the centre.centre.

4.4. Muscles in the proximal part are not dissected Muscles in the proximal part are not dissected in order to maintain the blood supply to skin.in order to maintain the blood supply to skin.

5.5. Use of bone hook to hold the bone is avoided.Use of bone hook to hold the bone is avoided.

6.6. The TA muscle is then wrapped around the The TA muscle is then wrapped around the distal tibia and sutured to the thick fascio-distal tibia and sutured to the thick fascio-perosteal flap.perosteal flap.

ADVADV

• Linear incision will provide extra skin to Linear incision will provide extra skin to cover the tibialis anteriorcover the tibialis anterior

• Prevents bulky stump.Prevents bulky stump.• Less tension on suture lineLess tension on suture line• Prevents shearing b/w layers as the myocut Prevents shearing b/w layers as the myocut

flap is not dissected out.flap is not dissected out.• Does not disturb the perforator blood supply.Does not disturb the perforator blood supply.• Muscle cushion prevents skin necrosis and Muscle cushion prevents skin necrosis and

tenting.tenting.• Not using bone hook decreases Not using bone hook decreases

predisposition to infectionpredisposition to infection