The Pirogoff amputation for necrosis of the forefoot: surgical technique.

The Pirogoff amputation creates a full-weight-bearing stump. It establishes osseous continuity between the tibial plafond and the rotated calcaneus and preserves the heel pad. This advantage is attractive for elderly, low-demand patients who have already undergone a previous contralateral amputation1. A prosthesis does not have to be worn for short walks from room to room or midnight toilet visits, as the patient can use crutches only. In less-developed countries, prosthetic fitting is often unavailable. It is especially in these countries that the Pirogoff amputation can be a good option for patients who have a severe lesion of the forefoot due to trauma. In this group, the Pirogoff calcaneotibial arthrodesis allows painless walking without a prosthesis, with only a slight leg-length discrepancy. In 1854, the Russian surgeon Nikolai Pirogoff first described the amputation that now bears his name2,3. As the number of patients with severe forefoot lesions continues to expand, there has been a resurgence of interest in this procedure. Modifications to the original technique can provide improved functional outcome and reduce the risk of complications. These modifications will be explained in detail. ### Anesthetic Considerations The anesthesiologist decides on the type of anesthesia in accordance with the patient's wishes. Peripheral nerve blocks are associated with minimal hemodynamic disturbance, and, compared with spinal anesthesia, they are a suitable option for high-risk surgical candidates. Preoperative antibiotics are administered thirty minutes prior to the incision. ### Positioning Of The Patient The patient is placed on a radiolucent table in the supine position. A tourniquet is applied to the thigh as a preventive measure and remains uninflated unless there is major unstoppable bleeding. The ipsilateral buttock is raised slightly to ensure that the foot is in neutral rotation; this positioning facilitates the surgical approach. Fluoroscopic imaging in both the anteroposterior and lateral planes will be unimpeded …