The International Journal of Lower Extremity Wounds http://ijl.sagepub.com/
Outcomes After 294 Transtibial Amputations With the Posterior Myocutaneous Flap Benjamin J. Brown, Matthew L. Iorio, Mitchell Klement, Michael R. Conti Mica, Amine El-Amraoui, Peter O'Halloran and Christopher E. Attinger International Journal of Lower Extremity Wounds published online 6 February 2014 DOI: 10.1177/1534734614520706 The online version of this article can be found at: http://ijl.sagepub.com/content/early/2014/02/05/1534734614520706
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IJLXXX10.1177/1534734614520706The International Journal of Lower Extremity WoundsBrown et al
Clinical and Translational Research
Outcomes After 294 Transtibial Amputations With the Posterior Myocutaneous Flap
The International Journal of Lower Extremity Wounds 1–8 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1534734614520706 ijl.sagepub.com
Benjamin J. Brown, MD1, Matthew L. Iorio, MD1, Mitchell Klement, MD1, Michael R. Conti Mica, MD1, Amine El-Amraoui, MD1, Peter O’Halloran, BS1, and Christopher E. Attinger, MD1
Abstract The transtibial amputation is a common operation for which there is little agreement regarding which technique provides the most reliable and resilient outcomes. We performed a retrospective chart review of all transtibial amputations performed by a single surgeon between 2004 and 2011 using the posterior myocutaneous flap with triceps surae myodesis technique. A stepwise logistic regression analysis was performed to evaluate the association between independent variables and dependent outcome variables. A total of 270 patients with 294 transtibial amputations were identified. Ambulation data were available for 192 patients with a mean follow-up 18.4 months. This cohort had an overall ambulation rate of 75%, a 12% incidence of stump wounds, 24% operative revision rate and only 2% required conversion to a transfemoral amputation. The posterior myocutaneous flap provides durable and reliable soft tissue coverage in the setting of a transtibial amputation. Keywords below-knee amputation, transtibial amputation, lower extremity salvage, prosthetic limb Advances in prosthetic technology have allowed transtibial amputees an efficient and functional return to their preinjury level of activity and beyond with some amputees being accused of having an unfair biomechanical advantage compared with their corporeal leg competitors.1 When caring for a patient with a diseased or injured lower extremity, the goal is to salvage the maximum amount of function and for some patients, the best solution may be a properly performed transtibial amputation (TTA). Pell et al2 demonstrated that an amputee’s quality of life is most highly associated with function and mobility, not necessarily lower extremity length.2 Rather than focusing on “limb salvage” or “length salvage,” surgeons should focus on “life salvage” by optimizing each patient’s functional result. Using life salvage as our treatment goal, we have cared for many patients who presented with chronic lower extremity wounds and the attendant complications of pain, multiple hospitalizations, and deconditioning who ultimately become functional following a TTA. In these patients, we used the posterior myocutaneous flap (PMF) with a soleus myodesis and gastrocnemius tenodesis. We have found this technique to be reliable, durable, and favored by prostheticians. The PMF uses the superficial posterior compartment musculature, perfused by the medial and lateral sural arteries, to
provide well-perfused soft-tissue coverage over the transected tibial diaphysis.3 The sural arteries are often spared from peripheral arterial disease, and hence provide a reliable vascularized soft-tissue envelope to cover the distal TTA stump. The resulting tenodesed and myodesed stump keeps the gastrocnemius–soleus complex functionally intact, which helps in knee flexion, venous return, and most important, prevents atrophy from disuse that eventually necessitates multiple prosthesis adjustments and the attendant nonambulatory time periods. The PMF technique was first popularized by Bickel in 1943. Since that time, many surgeons have reported their success with the PMF technique.4-10 The primary advantage of the PMF is that it provides muscle bulk for coverage of the transected diaphyseal ends of the tibia and fibula while moving the suture line away from the distal end of the stump. We agree with Burgess et al11 that removal of the deep posterior compartment allows for a less bulky closure while still 1
Georgetown University Hospital, Washington, DC, USA
Corresponding Author: Christopher E. Attinger, MD, Center for Wound Healing, Department of Plastic Surgery, Georgetown University Hospital, 3800 Reservoir Road NW, 1 Bles, Washington, DC 20007, USA. Email: [email protected]
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preserving adequate soft-tissue bulk that is not dependent on the often diseased crural arteries. The criticism of the PMF technique is that it relies on one long flap in contrast to the clam-shell technique, which relies on 2 smaller flaps of nearly equal length.12,13 Small studies have compared TTA closure techniques and a 2004 Cochrane review found no consensus as to which surgical technique achieves the maximum rehabilitation potential.14-16 To further identify the efficacy of the PMF, we performed a retrospective review of our large series of 294 TTAs performed on 270 patients to determine rates of stump complications and postamputation ambulation in the setting of multiple patient comorbidities. These outcomes were then compared with historic controls in the literature.
Methods We performed a retrospective, institutional review board– approved review of all TTAs performed by the senior author (CEA) between 2004 and 2011. All patients who received a TTA by the senior author were included. All operations were performed at a teaching hospital with significant resident involvement. No patients were excluded. The senior author subspecializes in lower extremity salvage at an urban level 2 trauma center. The vast majority of his patients and referrals are patients with threatened lower extremities as a result of diabetes and vascular disease.
Surgical Technique Most of our patients were diabetics afflicted with chronic infected wounds, so nearly all amputations were performed in 2 stages: drainage amputation followed by completion amputation a minimum of 2 days later.5 At the second operation, 2 sets of instruments were used to minimize contamination of the instruments used for closure. The length of the amputation was discussed, whenever possible, preoperatively with the prosthetist to ensure optimal fitting of the prosthesis. First, the level of the tibial osteotomy was marked. The ideal tibial length in a TTA is a balance between torque and weight bearing. For the average, 6-foot tall patient, the optimal residual tibial length should be between 12 and 18 cm from the tibial tubercle,17 though the surgeon should err on the longer side of this range to allow for the unwanted but occasional revision. Another way to measure is to make sure that the stump has at least 8 inches clearance from the floor to allow for the necessary componentry of the prosthesis. The fibular osteotomy should be 1 to 2 cm shorter than the tibial osteotomy. The skin incision was marked so that anteriorly, over the tibia, the skin was incised 1 cm distal to the planned tibial osteotomy. The skin incision continued transversely at that level, medially and laterally, encompassing the anterior two thirds of the circumference of the leg. Once the posterior third of the leg
Figure 1. Markings for the posterior myocutaneous flap at the second stage of a 2-stage transtibial amputation. The stump was wrapped in Coban after prepping with betadine and before draping in an effort to minimize contamination of the revision wound.
was reached, the incision was carried distally, angling it anteriorly such that at the level of the ankle, the posterior skin flap is half the circumference of the leg. These skin incisions should center the PMF over the superficial posterior compartment maintaining a constant width of the flap as the leg narrowed distally (Figure 1). Then the distal tibia, fibula, anterior compartment musculature, and lateral compartment musculature were removed at the level of the tibial cut and discarded. The deep posterior musculature was then transected at the level of the tibial osteotomy. The posterior tibial, anterior tibial, and peroneal vessels were suture ligated just proximal to this level and the tibial, superficial peroneal, deep peroneal, and saphenous nerves were transected under tension and allowed to retract into the proximal deep tissue. We then beveled the anterior cortex of the tibia in a plane tangent to the top of the patella when the knee was in extension to avoid a point of possible bony protrusion and eventual erosion through the overlying soft tissue. Three 1.5-mm holes were drilled through the anterior tibial cortex for the eventual soleus myodesis (Figure 2). Avoiding the marrow cavity, the wound was pulse lavaged with 3 L of normal saline to remove any bone particulates. Following pulse lavage, new surgical drapes were placed above and below the stump. Gloves were changed and only instruments from the second, “clean,” table were used. A beveled cut was then made through the PMF so that the anterior soleus fascia lined up with the anterior tibial cortex and the Achilles tendon lined up with the anterior crural fasica. (Figures 2 and 3) The surgeon should be careful not to create a plane between the superficial posterior compartment musculature and its overlying skin as this will disrupt cutaneous perforators to the posterior skin flap. The sural nerve was
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Figure 2. Schematic of the posterior myocutaneous flap technique illustrating the axial blood supply, myodesis, and tenodesis. Previously published in Brown et al.18
isolated within the PMF, placed under tension, and transected. For myodesis and tenodesis, we used 0-polydiaxanone suture (Figures 4 and 5). For skin closure, we used 2-0 or 3-0 polypropylene suture in a vertical mattress fashion. To
optimize the stump–prosthesis interface, there should be minimal dog ears and the stump should be nicely tapered. Staples were then placed between the sutures to ensure good skin edge eversion.
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Figure 3. Markings for the beveled cut through the triceps surae so that the anterior soleus fascia lines up with the anterior tibia and the Achilles tendon lines up with the anterior crural fascia.
Figure 4. Myodesis of the anterior soleus fascia to the anterior tibia and the exposure of the anterior crural fascia.
The amputated extremity was then dressed with a dry dressing and placed in a knee immobilizer to help protect the stump as well as prevent a flexion contracture. Nearly all amputees were discharged from the hospital to a rehabilitation facility where they were taught how to safely care for themselves at home using only one leg. Falling onto a fresh amputation is a serious complication that often requires operative revision and sometimes loss of functional osseous length.19 Patients who healed uneventfully had their staples removed at 1 week and sutures removed at 4 weeks. In most cases, the patient was fitted for the initial prosthesis and began ambulating at 4 to 6 weeks postoperatively. After discharge, patients were evaluated in clinic by
Figure 5. Tenodesis of the Achilles tendon to the anterior crural fascia.
the senior author every 2 weeks until they were fitted for a prosthesis. The dependent outcome variables included the need for operative revision, stump wound healing complications, and postoperative ambulation with a prosthesis. We defined “stump wound” as any mention in the clinic notes of an open wound on the stump. This could be due to dehiscence from any cause or a pressure wound from the prosthesis. We defined “ambulation” after amputation as any documentation that the patient successfully ambulated with prosthesis. The independent variables analysed included age, gender, previous lower extremity amputations, tibia length after TTA, perioperative serum creatinine level, perioperative hemoglobin A1c, perioperative serum albumin, operative stages, ipsilateral angioplasty, ipsilateral bypass, ipsilateral débridements, coronary artery disease, prior myocardial infarction, congestive heart failure, cerebrovascular accident, peripheral arterial disease, diabetes mellitus, endstage renal disease, hypertension, active smoking, Charcot arthropathy, and traumatic etiology of lower extremity injury. A multivariate logistic regression analysis was performed to evaluate the association between independent variables and dependent outcome variables. Statistical analyses was performed using IBM SPSS (IBM Corp, Armonk, NY).
Results A total of 294 TTAs were performed on 270 patients. During this same time period, only 67 primary transfemoral amputations (TFAs) were performed. The mean age was 59.5 years and 69% were male. Mean follow-up was 18.4 months
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Brown et al Table 1. Independent Preoperative Variables (y-Axis) and Dependent Outcome Variables (x-Axis).a Ambulation After Amputation DM MI CAD ESRD HTN HLD Charcot Ipsilateral debridement Ipsilateral angioplasty Female Smoker Ipsilateral Bypass CHF Two-stage amputation
Yes 89 (85.58) 18 (69.23) 47 (85.45) 8 (88.89) 87 (85.29) 41 (87.23) 17 (100.00) 79 (84.04) 20 (86.96) 26 (74.29) 23 (82.14) 13 (72.22) 15 (71.43) 69 (87.34)
Operative Revision
Postoperative Wound Healing Complication
No
Yes
No
Yes
No
15 (14.42) 8 (30.77) 8 (14.55) 1 (11.11) 15 (14.71) 6 (12.77) 0 (0.00) 15 (15.96) 3 (13.04) 9 (25.71) 5 (17.86) 5 (27.78) 6 (28.57) 10 (12.66)
78 (33.62) 19 (38.00) 43 (32.82) 7 (36.84) 75 (32.05) 35 (33.02) 13 (39.39) 63 (33.33) 20 (40.00) 27 (31.03) 25 (44.64) 22 (44.90) 21 (32.81) 68 (37.57)
154 (66.38) 31 (62.00) 88 (67.18) 12 (63.16) 159 (67.95) 71 (66.98) 20 (60.61) 126 (66.67) 30 (60.00) 60 (68.97) 31 (55.36) 27 (55.10) 43 (67.19) 113 (62.43)
22 (26.19) 7 (35.00) 13 (29.55) 2 (50.00) 23 (27.71) 13 (31.71) 7 (46.67) 23 (30.26) 5 (27.78) 6 (25.00) 7 (29.17) 5 (27.78) 7 (41.18) 18 (30.00)
62 (73.81) 13 (65.00) 31 (70.45) 2 (50.00) 60 (72.29) 28 (68.29) 8 (53.33) 53 (69.74) 13 (72.22) 18 (75.00) 17 (70.83) 13 (72.22) 10 (58.82) 42 (70.00)
Abbreviations: DM, diabetes mellitus; MI, myocardial infarction; CAD, coronary artery disease; ESRD, end-stage renal disease; HTN, hypertension; HLD, hyperlipidemia; CHF, congestive heart failure. a Values are expresses as n (%).
(range, 6 weeks to 78 months). Only 4.8% (n = 14) of the TTAs were performed on patients with traumatic lower extremity injuries while the remaining 95.2% (n = 280) were suffering from chronic wounds and/or Charcot arthropathy. Additionally, 86% (n = 254) of patients had diabetes and 27% (n = 80) were on dialysis (Table 1). Ambulation outcome data were available on 192 patients. The overall ambulation rate was 75% after TTA, with 78% and 61% of unilateral and bilateral amputees ambulating, respectively. This is 1.6 times higher than the 48% postamputation ambulation rate among our TFA cohort. Independent preamputation variables associated with not ambulating after amputation were serum creatinine level (P = .01, odds ratio [OR] = 0.83, 95% confidence interval [CI] = 0.730.95), prior myocardial infarction (P = .02, OR = 0.38, 95% CI = 0.17-0.87), and female gender (P = .01, OR = 0.24, 95% CI = 0.11-0.51). No independent variables were associated with ambulation following amputation. In all, 24% (n = 71/294) required at least one operative revision with most being due to infection, stump wound, or a fall at an average of 165 days postoperatively (range 1-1230 days; Figure 6). Independent preamputation variables associated with the need for operative revision were prior ipsilateral angioplasty (P = .02, OR = 2.19, 95% CI = 1.12-4.31), prior ipsilateral lower extremity operations (P = .01, OR = 1.06, 95% CI = 1.02-1.10), and younger age (P = .01, OR = 0.97, 95% CI = 0.95-0.99). However, the senior author’s overall TTA to TFA ratio during this time period was 4:1 with only 2% (7/294) of TTAs requiring conversion to TFA at an average of 226 days, all for ischemia and/or infection.
Figure 6. Reasons for operative revision after transtibial amputation.
Twelve percent (36/294) suffered a stump wound during the study period at an average of 400 days postoperatively (range 18-1755 days). Of these, 39% (14/36) required operative intervention. Independent preamputation variables found to be associated with postamputation stump wounds were use of the Ertl technique (P = .01, OR = 3.78, 95% CI = 1.3110.93), Charcot arthropathy (P = .04, OR = 2.65, 95% CI = 1.04-6.77), and prior ipsilateral operations (P = .01, OR = 1.08, 95% CI = 1.03-1.13). The Ertl technique is an eponym
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used to describe the addition of distal tibiofibular bone bridging to a TTA. The only independent preamputation variable found to be associated with not acquiring a postamputation stump wound was hypertension (P = .04, OR = 0.36, 95% CI = 0.13-0.95).
Discussion The goal of an extremity amputation is to retain a residual limb that will interface comfortably with a prosthesis and provide the most efficient gait possible. Unfortunately, the overall complication rate following TTA has been reported to be as high as 43%.20 Because of this high complication rate, some surgeons may have a low threshold for performing a TFA because of its perceived lower complication rate. Keeping the functional result of both in mind, patients with an intact knee joint are able to ambulate much more efficiently than those without a functioning knee joint.21,22 Because a TTA creates a more efficient ambulating extremity compared with a TFA, we strongly feel that the TTA should be performed if there is a reasonable chance that it may heal, except in the case of major medical co-comorbidity precluding a secondary operation.19 This tenet explains the TTA to TFA ratio of 4:1 (294:67) in a primarily diabetic and dysvascular population. The TTA to TFA conversion rate of 2% speaks to the vascular viability of the PMF, even in a morbid patient population. Higher TTA to TFA conversion rates have been reported in the literature, ranging from 7% to 18%.20,23-25 The largest limitation of this study is its lack of a comparative cohort or control. Another limitation is our lack of ambulation data on 29% (78/270) of patients. Moreover, we do not have specific information on the quality or longevity of their ambulation. Our ambulation rate of 78% among unilateral transtibial amputees is higher than that reported in the literature. Ambulation rates following TTA vary greatly and have been reported from 16% to 77%.25-29 It is not surprising to find that prior myocardial infarction and elevated serum creatinine level were associated with a lower likelihood of ambulating postamputation in our cohort. We, however, cannot explain why female gender was associated with a significantly lower likelihood of ambulating after TTA. The need for operative revision of a TTA for any reason is a serious complication that results in a longer nonambulatory period, deconditioning and the possible need for prosthetic refitting. TTA revision rates have been reported to occur in 4% to 30% of patients with an average of 15%.20,23,24,30-35 Our revision rate of 24% is similar to that reported in the literature. The most common reasons for operative revision in our series were infection and stump ulceration (Figure 6). Our higher operative revision rate is likely because of the senior author’s low threshold to explore worrisome amputation stumps in the operating
room. Surprisingly, we did not find diabetes mellitus to be associated with an increased risk for operative revision or wound healing complications and this is consistent with that reported in the literature.24,36 We did find increased age to be associated with a decreased likelihood of operative revision, the corollary of which is that younger age is associated with an increased likelihood of operative revision. This makes intuitive sense since younger patients tend to push the capacity of the amputated limb and have a longer time period of living with their amputation stump. Prior ipsilateral operations and angioplasty were found to be associated with a higher likelihood of operative revision following TTA. This likely results from the confounding relationship between disease severity and the need for angioplasty and other operations, not a direct effect of angioplasty or other prior operations on TTA outcome. Wound healing complications are more detrimental to rehabilitation than most clinicians appreciate since open wounds result in a longer nonambulatory period and subsequent deconditioning. Common precursors that lead to wound healing problems include ischemia, hematoma, and infection. Wound healing complication rates after a TTA have been reported to occur in 13.4% to 30% of patients.20,23,25,37,38 Burgess et al11 reviewed 157 TTAs and found that 74% (n = 66/91) of diabetic patients healed their incision by 60 days compared with a 78% sixty-day healing rate among patients without diabetes. A 6% proximal revision rate was reported in both groups.11 Our wound healing complication rate of 12% is similar to that reported in the literature. Ten percent (30/294) of our population had the Ertl technique performed as a component of their TTA.18 When we initially began performing the Ertl technique, we used a traditional cannulated screw to fixate the interposed vascularized fibular segment between the distal tibia and fibula. The prominent head of cannulated screw often resulted in an overlying wound. On the most recent 12 patients who had the Ertl technique performed, we used a headless compression screw that has significantly reduced subsequent wound healing complications. Since all 30 Ertl cases were included, this analysis found use of the Ertl technique to be associated with a higher likelihood of wound healing complications. Charcot arthropathy is a poorly understood disease and we cannot hypothesize why it is associated with a higher risk for wound healing complications especially in light of the fact that diabetes was not significantly associated with a higher or lower likelihood of wound healing complications. The association of prior ipsilateral operations with an increased likelihood of wound healing complications likely represents the confounding relationship between disease severity and the need for prior ipsilateral operations, not a direct effect of prior operations on TTA outcome. We cannot explain why hypertension, controlled or uncontrolled, was found to be associated with a lower likelihood of wound healing complications.
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Brown et al The TTA is a common operation with a major functional and emotional impact on the patient. As demonstrated by our outcomes, the PMF with myodesis of the triceps surae to the anterior tibial cortex and cural fascia is a reliable and robust technique in the setting of multiple comorbidities. Following below-knee amputation with this technique, most patients will go on to ambulate with a prosthesis and very few will require conversion to a TFA. These results suggest that a surgeon should always consider a TTA using a PMF first in an ambulatory patient and should have a very high threshold for performing a TFA. Acknowledgments We thank Stephen Fernandez, MPH, for his assistance with the statistical analysis and Joyce Lavery for her illustrations.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References 1. Weyand PG, Bundle MW, McGowan CP, et al. The fastest runner on artificial legs: different limbs, similar function? J Appl Physiol. 2009;107:903-911. 2. Pell JP, Donnan PT, Fowkes FG, Ruckley CV. Quality of life following lower limb amputation for peripheral arterial disease. Eur J Vasc Surg. 1993;7:448-451. 3. Taylor GI, Pan WR. Angiosomes of the leg: anatomic study and clinical implications. Plast Reconstr Surg. 1998;102:599616. 4. Kaufman JL. Alternative methods for below-knee amputation: reappraisal of the Kendrick procedure. J Am Coll Surg. 1995;181:511-516. 5. Fisher DF, Clagett GP, Fry RE, Humble TH, Fry WJ. One-stage versus two-stage amputation for wet gangrene of the lower extremity: a randomized study. J Vasc Surg. 1988;8:428-433. 6. Hicks L, McClelland RN. Below-knee amputations for vascular insufficiency. Am Surg. 1980;46:239-243. 7. Burgess EM, Romano RL, Zettl JH, Schrock RD. Amputations of the leg for peripheral vascular insufficiency. J Bone Joint Surg Am. 1971;53:874-890. 8. Hunger-Craig I, Vitali M, Robinson KP. Long posterior-flap myoplastic below-knee amputation in vascular disease. Br J Surg. 1970;57:62-65. 9. Pedersen HE. Lower extremity amputations for gangrene. Instructional Course Lecture, The American Academy of Orthopaedic Surgeons. 1958;15:262. 10. Kendrick RR. Below-knee amputation in arteriosclerotic gangrene. Br J Surg. 1956;44:13-17.
11. Burgess EM, Romano RL, Zettl JH, Schrock RD. Amputations of the leg for peripheral vascular insufficiency. J Bone Joint Surg Am. 1971;53:874-890. 12. Tracy GD. Below-knee amputation for ischemic gangrene. Pac Med Surg. 1966;74:251-253. 13. Persson BM. Sagittal incision for below-knee amputation in ischaemic gangrene. J Bone Joint Surg Br. 1974;56:110-114. 14. Falstie-Jensen N, Christensen KS, Brøchner-Mortensen J. Long posterior flap versus equal sagittal flaps in below-knee amputation for ischaemia. J Bone Joint Surg Br. 1989;71: 102-104. 15. Termansen NB. Below-knee amputation for ischaemic gangrene: prospective, randomized comparison of a transverse and a sagittal operative technique. Acta Orthop. 1977;48: 311-316. 16. Tisi PV, Callam MJ. Type of incision for below knee amputation. Cochrane Database Syst Rev. 2004;(1):CD003749. 17. Pinzur MS, Gottschalk FA, de Pinto MA, Smith DG; American Academy of Orthopaedic Surgeons. Controversies in lowerextremity amputation. J Bone Joint Surg Am. 2007;89: 1118-1127. 18. Brown BJ, Iorio ML, Hill L, Carlisle B, Attinger CE. Belowknee amputation with a vascularized fibular graft and headless compression screw. Plast Reconstr Surg. 2013;131:323-327. 19. Brown BJ, Crone CG, Attinger CE. Amputation in the diabetic to maximize function. Semin Vasc Surg. 2012;25: 115-121. 20. Toursarkissian B, Shireman PK, Harrison A, D’Ayala M, Schoolfield J, Sykes MT. Major lower-extremity amputation: contemporary experience in a single Veterans Affairs institution. Am Surg. 2002;68:606-610. 21. Taylor SM, Kalbaugh CA, Blackhurst DW, et al. Preoperative clinical factors predict postoperative functional outcomes after major lower limb amputation: an analysis of 553 consecutive patients. J Vasc Surg. 2005;42:227-235. 22. Fisher SV, Gullickson GJ. Energy cost of ambulation in health and disability: a literature review. Arch Phys Med Rehabil. 1978;59:124-133. 23. Keagy BA, Schwartz JA, Kotb M, Burnham SJ, Johnson G. Lower extremity amputation: the control series. J Vasc Surg. 1986;4:321-326. 24. Aulivola B, Hile CN, Hamdan AD, et al. Major lower extremity amputation: outcome of a modern series. Arch Surg. 2004;139:395-399. 25. Cruz CP, Eidt JF, Capps C, Kirtley L, Moursi MM. Major lower extremity amputations at a Veterans Affairs hospital. Am J Surg. 2003;186:449-454. 26. Castronuovo JJ Jr, Deane LM, Deterling RA Jr, O’Donnell TF Jr, O’Toole DM, Callow AD. Below-knee amputation: is the effort to preserve the knee joint justified? Arch Surg. 1980;115:1184-1187. 27. Couch NP, David JK, Tilney NL, Crane C. Natural history of the leg amputee. Am J Surg. 1977;133:469-473. 28. Mooney V, Wagner W Jr, Waddell J, Ackerson T. The belowthe-knee amputation for vascular disease. J Bone Joint Surg Am. 1976;58:365-368. 29. Harness N, Pinzur MS. Health related quality of life in patients with dysvascular transtibial amputation. Clin Orthop Relat Res. 2001;(383):204-207.
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30. Haynes IG, Middleton MD. Amputation for peripheral vascular disease: experience of a district general hospital. Ann R Coll Surg Engl. 1981;63:342-344. 31. Creaney MG, Chattopadhaya DK, Ward AS, Morris-Jones W. Doppler ultrasound in the assessment of amputation level. J R Coll Surg Edinb. 1981;26:278-281. 32. Baddeley RM, Fulford JC. A trial of conservative amputations for lesions of the feet in diabetes mellitus. Br J Surg. 1965;52:38-43. 33. Silverman DG, Roberts A, Reilly CA, et al. Fluorometric quantification of low-dose fluorescein delivery to predict amputation site healing. Surgery. 1987;101:335-341. 34. Wutschert R, Bounameaux H. Determination of amputation level in ischemic limbs. Reappraisal of the measurement of TcPo2. Diabetes Care. 1997;20:1315-1318.
35. Yip VS, Teo NB, Johnstone R, et al. An analysis of risk factors associated with failure of below knee amputations. World J Surg. 2006;30:1081-1087. 36. Burgess EM, Romano RL, Zettl JH, Schrock RD Jr. Amputations of the leg for peripheral vascular insufficiency. J Bone Joint Surg Am. 1971;53(5):874-890. 37. Ploeg AJ, Lardenoye J-W, Vrancken Peeters MP, Breslau PJ. Contemporary series of morbidity and mortality after lower limb amputation. Eur J Vasc Endovasc Surg. 2005;29: 633-637. 38. Stone PA, Flaherty SK, Aburahma AF, et al. Factors affecting perioperative mortality and wound-related complications following major lower extremity amputations. Ann Vasc Surg. 2006;20:209-216.
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Outcomes After 294 Transtibial Amputations With the Posterior Myocutaneous Flap Benjamin J. Brown, Matthew L. Iorio, Mitchell Klement, Michael R. Conti Mica, Amine El-Amraoui, Peter O'Halloran and Christopher E. Attinger International Journal of Lower Extremity Wounds published online 6 February 2014 DOI: 10.1177/1534734614520706 The online version of this article can be found at: http://ijl.sagepub.com/content/early/2014/02/05/1534734614520706
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520706
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IJLXXX10.1177/1534734614520706The International Journal of Lower Extremity WoundsBrown et al
Clinical and Translational Research
Outcomes After 294 Transtibial Amputations With the Posterior Myocutaneous Flap
The International Journal of Lower Extremity Wounds 1–8 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1534734614520706 ijl.sagepub.com
Benjamin J. Brown, MD1, Matthew L. Iorio, MD1, Mitchell Klement, MD1, Michael R. Conti Mica, MD1, Amine El-Amraoui, MD1, Peter O’Halloran, BS1, and Christopher E. Attinger, MD1
Abstract The transtibial amputation is a common operation for which there is little agreement regarding which technique provides the most reliable and resilient outcomes. We performed a retrospective chart review of all transtibial amputations performed by a single surgeon between 2004 and 2011 using the posterior myocutaneous flap with triceps surae myodesis technique. A stepwise logistic regression analysis was performed to evaluate the association between independent variables and dependent outcome variables. A total of 270 patients with 294 transtibial amputations were identified. Ambulation data were available for 192 patients with a mean follow-up 18.4 months. This cohort had an overall ambulation rate of 75%, a 12% incidence of stump wounds, 24% operative revision rate and only 2% required conversion to a transfemoral amputation. The posterior myocutaneous flap provides durable and reliable soft tissue coverage in the setting of a transtibial amputation. Keywords below-knee amputation, transtibial amputation, lower extremity salvage, prosthetic limb Advances in prosthetic technology have allowed transtibial amputees an efficient and functional return to their preinjury level of activity and beyond with some amputees being accused of having an unfair biomechanical advantage compared with their corporeal leg competitors.1 When caring for a patient with a diseased or injured lower extremity, the goal is to salvage the maximum amount of function and for some patients, the best solution may be a properly performed transtibial amputation (TTA). Pell et al2 demonstrated that an amputee’s quality of life is most highly associated with function and mobility, not necessarily lower extremity length.2 Rather than focusing on “limb salvage” or “length salvage,” surgeons should focus on “life salvage” by optimizing each patient’s functional result. Using life salvage as our treatment goal, we have cared for many patients who presented with chronic lower extremity wounds and the attendant complications of pain, multiple hospitalizations, and deconditioning who ultimately become functional following a TTA. In these patients, we used the posterior myocutaneous flap (PMF) with a soleus myodesis and gastrocnemius tenodesis. We have found this technique to be reliable, durable, and favored by prostheticians. The PMF uses the superficial posterior compartment musculature, perfused by the medial and lateral sural arteries, to
provide well-perfused soft-tissue coverage over the transected tibial diaphysis.3 The sural arteries are often spared from peripheral arterial disease, and hence provide a reliable vascularized soft-tissue envelope to cover the distal TTA stump. The resulting tenodesed and myodesed stump keeps the gastrocnemius–soleus complex functionally intact, which helps in knee flexion, venous return, and most important, prevents atrophy from disuse that eventually necessitates multiple prosthesis adjustments and the attendant nonambulatory time periods. The PMF technique was first popularized by Bickel in 1943. Since that time, many surgeons have reported their success with the PMF technique.4-10 The primary advantage of the PMF is that it provides muscle bulk for coverage of the transected diaphyseal ends of the tibia and fibula while moving the suture line away from the distal end of the stump. We agree with Burgess et al11 that removal of the deep posterior compartment allows for a less bulky closure while still 1
Georgetown University Hospital, Washington, DC, USA
Corresponding Author: Christopher E. Attinger, MD, Center for Wound Healing, Department of Plastic Surgery, Georgetown University Hospital, 3800 Reservoir Road NW, 1 Bles, Washington, DC 20007, USA. Email: [email protected]
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preserving adequate soft-tissue bulk that is not dependent on the often diseased crural arteries. The criticism of the PMF technique is that it relies on one long flap in contrast to the clam-shell technique, which relies on 2 smaller flaps of nearly equal length.12,13 Small studies have compared TTA closure techniques and a 2004 Cochrane review found no consensus as to which surgical technique achieves the maximum rehabilitation potential.14-16 To further identify the efficacy of the PMF, we performed a retrospective review of our large series of 294 TTAs performed on 270 patients to determine rates of stump complications and postamputation ambulation in the setting of multiple patient comorbidities. These outcomes were then compared with historic controls in the literature.
Methods We performed a retrospective, institutional review board– approved review of all TTAs performed by the senior author (CEA) between 2004 and 2011. All patients who received a TTA by the senior author were included. All operations were performed at a teaching hospital with significant resident involvement. No patients were excluded. The senior author subspecializes in lower extremity salvage at an urban level 2 trauma center. The vast majority of his patients and referrals are patients with threatened lower extremities as a result of diabetes and vascular disease.
Surgical Technique Most of our patients were diabetics afflicted with chronic infected wounds, so nearly all amputations were performed in 2 stages: drainage amputation followed by completion amputation a minimum of 2 days later.5 At the second operation, 2 sets of instruments were used to minimize contamination of the instruments used for closure. The length of the amputation was discussed, whenever possible, preoperatively with the prosthetist to ensure optimal fitting of the prosthesis. First, the level of the tibial osteotomy was marked. The ideal tibial length in a TTA is a balance between torque and weight bearing. For the average, 6-foot tall patient, the optimal residual tibial length should be between 12 and 18 cm from the tibial tubercle,17 though the surgeon should err on the longer side of this range to allow for the unwanted but occasional revision. Another way to measure is to make sure that the stump has at least 8 inches clearance from the floor to allow for the necessary componentry of the prosthesis. The fibular osteotomy should be 1 to 2 cm shorter than the tibial osteotomy. The skin incision was marked so that anteriorly, over the tibia, the skin was incised 1 cm distal to the planned tibial osteotomy. The skin incision continued transversely at that level, medially and laterally, encompassing the anterior two thirds of the circumference of the leg. Once the posterior third of the leg
Figure 1. Markings for the posterior myocutaneous flap at the second stage of a 2-stage transtibial amputation. The stump was wrapped in Coban after prepping with betadine and before draping in an effort to minimize contamination of the revision wound.
was reached, the incision was carried distally, angling it anteriorly such that at the level of the ankle, the posterior skin flap is half the circumference of the leg. These skin incisions should center the PMF over the superficial posterior compartment maintaining a constant width of the flap as the leg narrowed distally (Figure 1). Then the distal tibia, fibula, anterior compartment musculature, and lateral compartment musculature were removed at the level of the tibial cut and discarded. The deep posterior musculature was then transected at the level of the tibial osteotomy. The posterior tibial, anterior tibial, and peroneal vessels were suture ligated just proximal to this level and the tibial, superficial peroneal, deep peroneal, and saphenous nerves were transected under tension and allowed to retract into the proximal deep tissue. We then beveled the anterior cortex of the tibia in a plane tangent to the top of the patella when the knee was in extension to avoid a point of possible bony protrusion and eventual erosion through the overlying soft tissue. Three 1.5-mm holes were drilled through the anterior tibial cortex for the eventual soleus myodesis (Figure 2). Avoiding the marrow cavity, the wound was pulse lavaged with 3 L of normal saline to remove any bone particulates. Following pulse lavage, new surgical drapes were placed above and below the stump. Gloves were changed and only instruments from the second, “clean,” table were used. A beveled cut was then made through the PMF so that the anterior soleus fascia lined up with the anterior tibial cortex and the Achilles tendon lined up with the anterior crural fasica. (Figures 2 and 3) The surgeon should be careful not to create a plane between the superficial posterior compartment musculature and its overlying skin as this will disrupt cutaneous perforators to the posterior skin flap. The sural nerve was
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Figure 2. Schematic of the posterior myocutaneous flap technique illustrating the axial blood supply, myodesis, and tenodesis. Previously published in Brown et al.18
isolated within the PMF, placed under tension, and transected. For myodesis and tenodesis, we used 0-polydiaxanone suture (Figures 4 and 5). For skin closure, we used 2-0 or 3-0 polypropylene suture in a vertical mattress fashion. To
optimize the stump–prosthesis interface, there should be minimal dog ears and the stump should be nicely tapered. Staples were then placed between the sutures to ensure good skin edge eversion.
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Figure 3. Markings for the beveled cut through the triceps surae so that the anterior soleus fascia lines up with the anterior tibia and the Achilles tendon lines up with the anterior crural fascia.
Figure 4. Myodesis of the anterior soleus fascia to the anterior tibia and the exposure of the anterior crural fascia.
The amputated extremity was then dressed with a dry dressing and placed in a knee immobilizer to help protect the stump as well as prevent a flexion contracture. Nearly all amputees were discharged from the hospital to a rehabilitation facility where they were taught how to safely care for themselves at home using only one leg. Falling onto a fresh amputation is a serious complication that often requires operative revision and sometimes loss of functional osseous length.19 Patients who healed uneventfully had their staples removed at 1 week and sutures removed at 4 weeks. In most cases, the patient was fitted for the initial prosthesis and began ambulating at 4 to 6 weeks postoperatively. After discharge, patients were evaluated in clinic by
Figure 5. Tenodesis of the Achilles tendon to the anterior crural fascia.
the senior author every 2 weeks until they were fitted for a prosthesis. The dependent outcome variables included the need for operative revision, stump wound healing complications, and postoperative ambulation with a prosthesis. We defined “stump wound” as any mention in the clinic notes of an open wound on the stump. This could be due to dehiscence from any cause or a pressure wound from the prosthesis. We defined “ambulation” after amputation as any documentation that the patient successfully ambulated with prosthesis. The independent variables analysed included age, gender, previous lower extremity amputations, tibia length after TTA, perioperative serum creatinine level, perioperative hemoglobin A1c, perioperative serum albumin, operative stages, ipsilateral angioplasty, ipsilateral bypass, ipsilateral débridements, coronary artery disease, prior myocardial infarction, congestive heart failure, cerebrovascular accident, peripheral arterial disease, diabetes mellitus, endstage renal disease, hypertension, active smoking, Charcot arthropathy, and traumatic etiology of lower extremity injury. A multivariate logistic regression analysis was performed to evaluate the association between independent variables and dependent outcome variables. Statistical analyses was performed using IBM SPSS (IBM Corp, Armonk, NY).
Results A total of 294 TTAs were performed on 270 patients. During this same time period, only 67 primary transfemoral amputations (TFAs) were performed. The mean age was 59.5 years and 69% were male. Mean follow-up was 18.4 months
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Brown et al Table 1. Independent Preoperative Variables (y-Axis) and Dependent Outcome Variables (x-Axis).a Ambulation After Amputation DM MI CAD ESRD HTN HLD Charcot Ipsilateral debridement Ipsilateral angioplasty Female Smoker Ipsilateral Bypass CHF Two-stage amputation
Yes 89 (85.58) 18 (69.23) 47 (85.45) 8 (88.89) 87 (85.29) 41 (87.23) 17 (100.00) 79 (84.04) 20 (86.96) 26 (74.29) 23 (82.14) 13 (72.22) 15 (71.43) 69 (87.34)
Operative Revision
Postoperative Wound Healing Complication
No
Yes
No
Yes
No
15 (14.42) 8 (30.77) 8 (14.55) 1 (11.11) 15 (14.71) 6 (12.77) 0 (0.00) 15 (15.96) 3 (13.04) 9 (25.71) 5 (17.86) 5 (27.78) 6 (28.57) 10 (12.66)
78 (33.62) 19 (38.00) 43 (32.82) 7 (36.84) 75 (32.05) 35 (33.02) 13 (39.39) 63 (33.33) 20 (40.00) 27 (31.03) 25 (44.64) 22 (44.90) 21 (32.81) 68 (37.57)
154 (66.38) 31 (62.00) 88 (67.18) 12 (63.16) 159 (67.95) 71 (66.98) 20 (60.61) 126 (66.67) 30 (60.00) 60 (68.97) 31 (55.36) 27 (55.10) 43 (67.19) 113 (62.43)
22 (26.19) 7 (35.00) 13 (29.55) 2 (50.00) 23 (27.71) 13 (31.71) 7 (46.67) 23 (30.26) 5 (27.78) 6 (25.00) 7 (29.17) 5 (27.78) 7 (41.18) 18 (30.00)
62 (73.81) 13 (65.00) 31 (70.45) 2 (50.00) 60 (72.29) 28 (68.29) 8 (53.33) 53 (69.74) 13 (72.22) 18 (75.00) 17 (70.83) 13 (72.22) 10 (58.82) 42 (70.00)
Abbreviations: DM, diabetes mellitus; MI, myocardial infarction; CAD, coronary artery disease; ESRD, end-stage renal disease; HTN, hypertension; HLD, hyperlipidemia; CHF, congestive heart failure. a Values are expresses as n (%).
(range, 6 weeks to 78 months). Only 4.8% (n = 14) of the TTAs were performed on patients with traumatic lower extremity injuries while the remaining 95.2% (n = 280) were suffering from chronic wounds and/or Charcot arthropathy. Additionally, 86% (n = 254) of patients had diabetes and 27% (n = 80) were on dialysis (Table 1). Ambulation outcome data were available on 192 patients. The overall ambulation rate was 75% after TTA, with 78% and 61% of unilateral and bilateral amputees ambulating, respectively. This is 1.6 times higher than the 48% postamputation ambulation rate among our TFA cohort. Independent preamputation variables associated with not ambulating after amputation were serum creatinine level (P = .01, odds ratio [OR] = 0.83, 95% confidence interval [CI] = 0.730.95), prior myocardial infarction (P = .02, OR = 0.38, 95% CI = 0.17-0.87), and female gender (P = .01, OR = 0.24, 95% CI = 0.11-0.51). No independent variables were associated with ambulation following amputation. In all, 24% (n = 71/294) required at least one operative revision with most being due to infection, stump wound, or a fall at an average of 165 days postoperatively (range 1-1230 days; Figure 6). Independent preamputation variables associated with the need for operative revision were prior ipsilateral angioplasty (P = .02, OR = 2.19, 95% CI = 1.12-4.31), prior ipsilateral lower extremity operations (P = .01, OR = 1.06, 95% CI = 1.02-1.10), and younger age (P = .01, OR = 0.97, 95% CI = 0.95-0.99). However, the senior author’s overall TTA to TFA ratio during this time period was 4:1 with only 2% (7/294) of TTAs requiring conversion to TFA at an average of 226 days, all for ischemia and/or infection.
Figure 6. Reasons for operative revision after transtibial amputation.
Twelve percent (36/294) suffered a stump wound during the study period at an average of 400 days postoperatively (range 18-1755 days). Of these, 39% (14/36) required operative intervention. Independent preamputation variables found to be associated with postamputation stump wounds were use of the Ertl technique (P = .01, OR = 3.78, 95% CI = 1.3110.93), Charcot arthropathy (P = .04, OR = 2.65, 95% CI = 1.04-6.77), and prior ipsilateral operations (P = .01, OR = 1.08, 95% CI = 1.03-1.13). The Ertl technique is an eponym
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used to describe the addition of distal tibiofibular bone bridging to a TTA. The only independent preamputation variable found to be associated with not acquiring a postamputation stump wound was hypertension (P = .04, OR = 0.36, 95% CI = 0.13-0.95).
Discussion The goal of an extremity amputation is to retain a residual limb that will interface comfortably with a prosthesis and provide the most efficient gait possible. Unfortunately, the overall complication rate following TTA has been reported to be as high as 43%.20 Because of this high complication rate, some surgeons may have a low threshold for performing a TFA because of its perceived lower complication rate. Keeping the functional result of both in mind, patients with an intact knee joint are able to ambulate much more efficiently than those without a functioning knee joint.21,22 Because a TTA creates a more efficient ambulating extremity compared with a TFA, we strongly feel that the TTA should be performed if there is a reasonable chance that it may heal, except in the case of major medical co-comorbidity precluding a secondary operation.19 This tenet explains the TTA to TFA ratio of 4:1 (294:67) in a primarily diabetic and dysvascular population. The TTA to TFA conversion rate of 2% speaks to the vascular viability of the PMF, even in a morbid patient population. Higher TTA to TFA conversion rates have been reported in the literature, ranging from 7% to 18%.20,23-25 The largest limitation of this study is its lack of a comparative cohort or control. Another limitation is our lack of ambulation data on 29% (78/270) of patients. Moreover, we do not have specific information on the quality or longevity of their ambulation. Our ambulation rate of 78% among unilateral transtibial amputees is higher than that reported in the literature. Ambulation rates following TTA vary greatly and have been reported from 16% to 77%.25-29 It is not surprising to find that prior myocardial infarction and elevated serum creatinine level were associated with a lower likelihood of ambulating postamputation in our cohort. We, however, cannot explain why female gender was associated with a significantly lower likelihood of ambulating after TTA. The need for operative revision of a TTA for any reason is a serious complication that results in a longer nonambulatory period, deconditioning and the possible need for prosthetic refitting. TTA revision rates have been reported to occur in 4% to 30% of patients with an average of 15%.20,23,24,30-35 Our revision rate of 24% is similar to that reported in the literature. The most common reasons for operative revision in our series were infection and stump ulceration (Figure 6). Our higher operative revision rate is likely because of the senior author’s low threshold to explore worrisome amputation stumps in the operating
room. Surprisingly, we did not find diabetes mellitus to be associated with an increased risk for operative revision or wound healing complications and this is consistent with that reported in the literature.24,36 We did find increased age to be associated with a decreased likelihood of operative revision, the corollary of which is that younger age is associated with an increased likelihood of operative revision. This makes intuitive sense since younger patients tend to push the capacity of the amputated limb and have a longer time period of living with their amputation stump. Prior ipsilateral operations and angioplasty were found to be associated with a higher likelihood of operative revision following TTA. This likely results from the confounding relationship between disease severity and the need for angioplasty and other operations, not a direct effect of angioplasty or other prior operations on TTA outcome. Wound healing complications are more detrimental to rehabilitation than most clinicians appreciate since open wounds result in a longer nonambulatory period and subsequent deconditioning. Common precursors that lead to wound healing problems include ischemia, hematoma, and infection. Wound healing complication rates after a TTA have been reported to occur in 13.4% to 30% of patients.20,23,25,37,38 Burgess et al11 reviewed 157 TTAs and found that 74% (n = 66/91) of diabetic patients healed their incision by 60 days compared with a 78% sixty-day healing rate among patients without diabetes. A 6% proximal revision rate was reported in both groups.11 Our wound healing complication rate of 12% is similar to that reported in the literature. Ten percent (30/294) of our population had the Ertl technique performed as a component of their TTA.18 When we initially began performing the Ertl technique, we used a traditional cannulated screw to fixate the interposed vascularized fibular segment between the distal tibia and fibula. The prominent head of cannulated screw often resulted in an overlying wound. On the most recent 12 patients who had the Ertl technique performed, we used a headless compression screw that has significantly reduced subsequent wound healing complications. Since all 30 Ertl cases were included, this analysis found use of the Ertl technique to be associated with a higher likelihood of wound healing complications. Charcot arthropathy is a poorly understood disease and we cannot hypothesize why it is associated with a higher risk for wound healing complications especially in light of the fact that diabetes was not significantly associated with a higher or lower likelihood of wound healing complications. The association of prior ipsilateral operations with an increased likelihood of wound healing complications likely represents the confounding relationship between disease severity and the need for prior ipsilateral operations, not a direct effect of prior operations on TTA outcome. We cannot explain why hypertension, controlled or uncontrolled, was found to be associated with a lower likelihood of wound healing complications.
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Brown et al The TTA is a common operation with a major functional and emotional impact on the patient. As demonstrated by our outcomes, the PMF with myodesis of the triceps surae to the anterior tibial cortex and cural fascia is a reliable and robust technique in the setting of multiple comorbidities. Following below-knee amputation with this technique, most patients will go on to ambulate with a prosthesis and very few will require conversion to a TFA. These results suggest that a surgeon should always consider a TTA using a PMF first in an ambulatory patient and should have a very high threshold for performing a TFA. Acknowledgments We thank Stephen Fernandez, MPH, for his assistance with the statistical analysis and Joyce Lavery for her illustrations.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
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