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Duke Orthopaedics
presents
Wheeless' Textbook of Orthopaedics

Foot and Ankle Amputation


- Diabetic Foot - Treatment Considerations

Syme's Amputation
      - Ankle-level amputation.

- Chopart Amputations:
       - The Modified Chopart's Amputation.
       - Resurrection of the amputations of Lisfranc and Chopart for diabetic gangrene.
       - Congenital Chopart amputation. A functional assessment.

- Pirogoff:
      - Pirogoff Amputation for Foot Trauma: An Unusual Amputation Level A Case Report
      - The Pirogoff Amputation for Necrosis of the Forefoot: a case report
      - Pirogoff ankle disarticulation as an option for ankle disarticulation.

- General Considerations:
    - all viable plantar skin with normal or protective sensation should be preserved;
    - intact longitudinal rays in a partial forefoot amputation should be preserved;
    - ankle dorsiflexions should be preserved or transplanted, if necessary, to provide balanced motion at the ankle joint;
    - stump end should be covered with plantar skin to prevent break down with wt bearing and toe off, or the end of the stump should by modified by recognized
              plastic surgical techniques;
    - skin grafting should be applied only to the non weight bearing border or dorsum of the foot;
    - vascular considerations: (Amputations in the Diabetic Patient)
              - Transcutaneous oxygen as a predictor of wound healing in amputations of the foot and ankle.
              - Transcutaneous Doppler ultrasound in the prediction of healing and the selection of surgical level for dysvascular lesions of the toes and forefoot.
              - Survivorship of healed partial foot amputations in dysvascular patients.
              - Minor forefoot amputation in patients with low ankle pressure.
              - Results of minor foot amputations for ischemia of the lower extremity in diabetics and nondiabetics.
              - Partial amputation of the foot for diabetic or arteriosclerotic gangrene. Results and factors of prognostic value.

- Ray Amputations:
    - w/ ray amputations, the first metatarsal ray may be amputated, w/ only moderate loss of foot function;
    - some argue that medial and lateral longitudinal forefoot amputations in diabetics are highly (80%) successful;
    - others (Wagner) argue that only lateral longitudinal amputations are successful and that medial forefoot amputations should be abandoned due to a
             higher rate of recurrent infection;
    - if base of the fifth metatarsal is resected, peroneus brevis insertion should be reinserted into the cuboid;
    - shoe orthotics
             - steel shank to extend the foot lever and prevent deformity at the toe break 
             - rocker sole will help facilitate transition from foot flat to the toe-off phase of gait

- Transmetatarsal Amputation
- Metatarsal Disarticulations:
    - usually need a toe filler to keep the shoe from collapsing;
    - since the arches are intact, wt bearing is sufficient but may be supplemented with an arch support;
    - results in bony anterior section which can be difficult to fit
    - arch often flattens out over time causingn further wt bearing problems;
    - toe filler may be OK, but often molded arch support is added;
    - extended steel shank may add protection during roll over;

- Toe Amputations:
          - usually need no prosthetic treatment;
          - soft filler may be used but does little;
          - loss of great toe eliminates push off, esp. at higher cadences;
          - references:
                - Amputation of the great toe.
                - Amputation of the great toe. A clinical and biomechanical study.

- Prosthetic Considerations at Different Amputation Levels;
    - Longitudinal Ray Amputations:
          - usually lose balance and some wt bearing;
          - in many cases no prosthesis is needed;
          - molded arch support may help distribute wt bearing more evenly;
          - references:
                 - Ray resection in the dysvascular foot. A retrospective review.
                 - Ray resections in the insensitive or dysvascular foot: a critical review.
                 - Sequelae of limited amputation.



Amputations of the foot and ankle. Current status.
Amputations at the middle level of the foot. A retrospective and prospective review.
Amputations through the middle part of the foot.
Traumatic partial foot amputations in adults. A long-term review.
Traumatic partial foot amputation
The feasibility of hind foot amputation in selected sarcomas of the foot.
Partial foot amputations in children. A comparison of the several types with the Syme amputation.


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Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Monday, May 14, 2012 9:56 am