Transtibial Amputation Outcomes Study

NCT ID: NCT01821976

Last Updated: 2023-12-01

Study Results

Results pending

The study team has not published outcome measurements, participant flow, or safety data for this trial yet. Check back later for updates.

Basic Information

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Recruitment Status

COMPLETED

Clinical Phase

NA

Total Enrollment

250 participants

Study Classification

INTERVENTIONAL

Study Start Date

2013-03-31

Study Completion Date

2020-03-31

Brief Summary

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The goals of the TAOS study is to determine the best procedures for below the knee amputations. There are two different procedures currently used by surgeons around the county: the Erlt procedure and the Burgess procedure. Proponents of the Ertl procedure advocate that the surgical formation of a tibia to fibula bone bridge provides stability, shape and weight bearing capability to the residual limb that result in less pain and better prosthetic fit and alignment. This procedure is popular especially among the military but it's advantages over the Burgess procedure are not well supported by current research. This study aims to compare the two amputation procedures in an adequately powered randomized trial.

Detailed Description

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High-energy open fractures, blast, gunshot wound and crush injuries to the distal tibia, ankle, hind foot and midfoot are common challenges to military and civilian trauma surgeons (Brown, 2009; Covey, 2002; Ficke, 2007; McGuigan, 2007; Hansen, 2001). Many surgeons believe that an early transtibial amputation provides a better long term functional outcome than limb salvage for these injuries (Hansen, 2001; Myerson, 1994; Sanders, 1992; Turchin,1999; Shawen, 2010;Ellington 2012). If a transtibial amputation is selected as the treatment for the patient, a controversy remains regarding the appropriate amputation technique. Many surgeons advocate for an amputation with a tibia-fibula synostosis technique (Ertl procedure) in young and active patients, believing that this procedure provides a better prosthetic interface, an end bearing capacity and soft tissue stability that improves performance and functional outcomes. (Pinto 2004; Pinzur 2006; Commuri 2010). Others strongly advocate for a standard posterior flap (Burgess procedure) without the synostosis, arguing that patients have similar outcomes with fewer complications and lower costs. (Pinzur 2008; Tindle 2011) To date, the outcomes of the transtibial amputation techniques have not been subjected to an appropriately powered prospective randomized clinical trial.

The primary study objective is to compare functional outcomes and number of revision surgeries to the amputated limb after first amputation for patients undergoing a transtibial amputation and randomized to receive a tibia-fibula synostosis (Ertl procedure) versus a standard posterior flap procedure (Burgess procedure).

The secondary study objectives are to compare levels of impairment for patients undergoing a transtibial amputation and randomized to receive a tibia-fibula synostosis (Ertl procedure) versus a standard posterior flap procedure (Burgess procedure); to compare levels of pain for patients undergoing a transtibial amputation and randomized to receive a tibia-fibula synostosis (Ertl procedure) versus a standard posterior flap procedure (Burgess procedure); and to compare initial hospitalization and overall treatment costs (through the 18 month follow-up) for patients undergoing a transtibial amputation and are randomized to receive a tibia-fibula synostosis (Ertl procedure) versus a standard posterior flap procedure (Burgess procedure). Patients who refuse randomization have the option of participating in a prospective observational study and the type of amputation is decided by the surgeon and patient.

Conditions

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Transtibial Amputation

Study Design

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Allocation Method

RANDOMIZED

Intervention Model

PARALLEL

Primary Study Purpose

TREATMENT

Blinding Strategy

NONE

Study Groups

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Ertl Procedure

Patients randomized to the Ertl Procedure Arm will receive an amputation very similar to the Burgess Procedure, except the surgeon will perform an additional step to make the cut end of the tibia bone heal to the cut end of the fibula bone with a bone bridge. This bone bridge connects the two bones together.

Group Type ACTIVE_COMPARATOR

Ertl Procedure

Intervention Type PROCEDURE

Burgess Procedure

Patients randomized to the Burgess Procedure Arm will receive a below the knee amputation where the bone is cut and skin and muscle from the back of the leg are rotated to cover the cut end of your bone. This provides good soft tissue padding to the bone and a good shape to the leg for later fitting of your prosthesis.

Group Type ACTIVE_COMPARATOR

Burgess Procedure

Intervention Type PROCEDURE

Interventions

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Ertl Procedure

Intervention Type PROCEDURE

Burgess Procedure

Intervention Type PROCEDURE

Eligibility Criteria

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Inclusion Criteria

* Patients requiring a unilateral transtibial amputation following major limb trauma regardless of when the injury occurred
* The injury and its treatment must meet the following criteria:

* The residual fibula is not fractured or if fractured, is stabilized by internal fixation allowing for either the Ertl or Burgess procedure
* Proximal tibia/fibula joint is stabilized
* Soft tissue coverage allows for atypical closure and skin graft \<100 cm2
* Amputation will result in a residual limb that is ≥10 cm from joint line to end of tibia
* Ages 18 and 60 inclusive

Exclusion Criteria

* At time of consent, patient has a Glasgow Coma Scale (GCS) motor score of 0-4 or a GCS motor score of 5 with a significant traumatic brain injury (defined as an AIS code of 5 or 6)
* Patients with wound closure requiring a free tissue transfer
* Fibula fractures proximal to the tibial bone cut that cannot be stabilized
* Late amputation with presence of one of the following conditions: (i) infection within the zone of injury; (ii) chronic regional pain syndrome; (iii) post-traumatic thrombophlebitis
* Patient has a spinal cord deficit
* Patient has a previous leg or foot amputation or is non-ambulatory pre-injury
* Patient has third degree burns on \>10% total surface area affecting the study limb
* Patient has a documented psychiatric disorder
* Patient is unable to speak either English or Spanish
* Severe problems with maintaining follow-up (e.g. patients who are prisoners or homeless at the time of injury or who are intellectually challenged without adequate family support).
* Patient has an amputation to one or both upper extremities (excluding digits)
* Patient is outside hospital's catchment area
* Patient follow-up is planned at another medical center
Minimum Eligible Age

18 Years

Maximum Eligible Age

60 Years

Eligible Sex

ALL

Accepts Healthy Volunteers

No

Sponsors

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Major Extremity Trauma Research Consortium

OTHER

Sponsor Role lead

Responsible Party

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Responsibility Role SPONSOR

Principal Investigators

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Lisa Reider, MHS, PhD

Role: STUDY_DIRECTOR

Johns Hopkins University

Locations

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University of California San Francisco Medical Center

San Francisco, California, United States

Site Status

University of Miami Ryder Trauma Center

Miami, Florida, United States

Site Status

Florida Orthopaedic Institute- Tampa General Hospital

Tampa, Florida, United States

Site Status

Emory University School of Medicine

Atlanta, Georgia, United States

Site Status

Eskenazi Health

Indianapolis, Indiana, United States

Site Status

University of Iowa Hospitals & Clinics

Iowa City, Iowa, United States

Site Status

University of Maryland/R Adams Cowley Shock Trauma Medical Center

Baltimore, Maryland, United States

Site Status

Walter Reed National Military Medical Center

Bethesda, Maryland, United States

Site Status

Hennepin County Medical Center

Minneapolis, Minnesota, United States

Site Status

University of Mississippi Medical Center

Jackson, Mississippi, United States

Site Status

Barnes Jewish Hospital

St Louis, Missouri, United States

Site Status

St. Louis University Medical Center

St Louis, Missouri, United States

Site Status

Carolinas Medical Center

Charlotte, North Carolina, United States

Site Status

Wake Forest University Baptist Medical Center

Winston-Salem, North Carolina, United States

Site Status

MetroHealth Medical Center

Cleveland, Ohio, United States

Site Status

University of Oklahoma

Oklahoma City, Oklahoma, United States

Site Status

Penn State University M.S. Hershey Medical Center

Hershey, Pennsylvania, United States

Site Status

University of Pittsburgh Medical Center

Pittsburgh, Pennsylvania, United States

Site Status

Rhode Island Hospital, Brown University

Providence, Rhode Island, United States

Site Status

Vanderbilt University Medical Center

Nashville, Tennessee, United States

Site Status

San Antonio Miliary Medical Center

Fort Sam Houston, Texas, United States

Site Status

UT Health: The University of Texas Health Science Center at Houston Medical School

Houston, Texas, United States

Site Status

University of Wisconsin School of Medicine and Public Health

Madison, Wisconsin, United States

Site Status

Countries

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United States

Other Identifiers

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W8XWH-10-2-0090

Identifier Type: -

Identifier Source: org_study_id