Do All Amputations Need Tendon Balancing?

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Hello, everyone. My name is John Steinberg. I practice in Washington, DC at MedStar Georgetown University Hospital and MedStar Washington Hospital Center. I'm a Professor in the Department of Plastic Surgery there, and I'm also the Director of Residency Training for the Podiatric Surgery Residency at MedStar Health.
 
Which amputations need tendon balancing?
 
Tendon balancing is important for most amputations, even down to a toe amputation in some instances, but the ones that we really focus on are the midfoot and rearfoot amputations, where particularly if you have gone to a transmetatarsal amputation, we're really worried about the equinus that could result from that. If you've gone to a Lisfranc amputation and lost the insertion of the peroneus brevis, we're worried about a lot of the inversion deformities that can form as well as Choparts amputation being a similar concern with equinus as well.
 
When is tendon balancing contraindicated?
 
If you have a patient who's too high risk for whatever fixation method you are going to use, we try to do as much bone tunneling and as little interference screws and as little hardware left behind as possible. There's usually high risk patients for infection and certainly hardware and foreign material can add to that infection risk. So I think that the main thing is to just watch your patient as far as the wound type. Have you gotten the wound completely clean? Is it safe to go and do additional dissection and procedures to do a tendon balancing procedure? And then perhaps in many of our patients, we want to avoid some of the anchors and other items that would be used that would be for material and infection risk.
 
Do you have any pearls for surgical success with tendon balancing?
 
I think the key thing is we all struggle with—what does physiologic tensioning mean? That's used in a lot of these tendon balancing procedures and you read an article about tendon balancing, it says physiologic tensioning. What does that really mean? I think being critical in the operating room and don't leave there until you're really happy that you have made a difference and you've achieved the correction you're looking for.
 
So don't be afraid to get appropriate tension on that tendon and to use it as a significant tether. I usually go in and exaggerate my correction to some degree, not that you want to go and create the opposite effect way over-tensioning the tendon, but I would say that the common mistakes would be to under-tension and then to make sure that your fixation is secure with whether it's a bone tunnel or you decided to use an anchor, don't be afraid to really tug on that tendon before you leave the OR, because now's the time to check and make sure you've got it secure rather than a week postop when it pops loose.
 
I would just add that tendon balancing procedures are a smart move in general, doesn't apply to every amputation, but I would say that in diabetes and the significant muscle and tendon imbalance that these patients come to the table with, it applies to most amputations from the midfoot and beyond.
 
So we don't do a whole lot for toe amputations or ray amputations, although I would point out that even just sometimes a minor toe amputation, if the other digits have significant flexor contracture already, we will oftentimes go and do a flexor tsunami on those proactively. So I guess I would correct myself and say we even do tendon balancing and toe amputations, but particularly the midfoot amputations, and obviously the workhorse here is whether you're a believer in the tendo-Achilles lengthening versus the gastroc, make sure you do something to alleviate equinus in the typical midfoot or TMA amputation, which is probably one of the more common procedures that we're all doing.