24.amputations of the foot and ankle

Amputation of part or all of the foot is an ancient pro-cedure, if not the oldest form of foot surgery, but sur-geons often abhor foot amputations. Perhaps thereason is the repugnance of removing a body part,perhaps because amputation is seemingly so unaes-thetic, or perhaps because amputation is seen, con-sciously or not, as an admission of failure, a form ofsurgical defeat.

However, in the patient who has a foot that is nolonger either viable or functional, an amputation is apositive procedure because it is the first step on theroad to restored or renewed function. The amputationis therefore the beginning of rehabilitation for thesepatients, many of whom have become debilitated bothphysically and emotionally in the battle to save part orall of a foot. In this process the functions and activi-ties of normal daily life have been held hostage to thehopes and efforts to save the foot, often past the timeof reasonable expectations for good function. To savea poorly functioning foot of marginal viability is tohave won the battle and lost the war, because the goal

is to enhance the function and quality of life for thepatient, not for the limb.

Once a decision to amputate has been made, anumber of challenges remain. These include selectionof the proper level of amputation (Fig. 24–1), methodsof foot salvage to maximize function, proper surgicaltechnique, postoperative management, and footwearmodification and the use of prostheses.

The many causes of partial or complete foot ampu-tation include the following:

1. Diabetes (many diabetic patients also haveperipheral vascular disease)

2. Peripheral vascular disease (in the absence of diabetes)

3. Trauma (most often lawnmower injuries andmotorcycle trauma)

4. Chronic infection (primarily osteomyelitis)5. Tumors6. Congenital abnormalities

Amputations of the Foot and AnkleJames W. Brodsky

1369

C H A P T E R

24

GENERAL CONSIDERATIONSSURGICAL CONSIDERATIONSTourniquetsSoft Tissue PreservationWound ClosureDrainsSkin Grafting and Flap Coverage

Vascular ReconstructionDetermination of Amputation LevelOther Factors Affecting HealingSPECIFIC AMPUTATION LEVELS ANDTECHNIQUES (video clips 3 and 4)SUMMARY

1370 PART VI Diabetes

Amputation of part or all of the foot is correctlyviewed as a procedure of last resort and reflects thesurgeon’s proper desire to save the foot. The term footsalvage emphasizes the contemporary shift from com-plete to partial foot amputations. The goal is to convertmany of the procedures that in the past would havebeen below-knee amputations to partial foot amputa-tions and, in the process, to convert these patients tousers of modified footwear rather than users of pros-thetic limbs.46

GENERAL CONSIDERATIONS

The goals of an amputation are fundamentally greaterin the patient who requires ablative surgery as a resultof trauma than the goals in patients requiring ampu-tation for diabetic foot problems. The diabetic patientor the patient with insensitivity from any cause needsto achieve a plantigrade foot with stable healing of thewounds, and the lowest possible risk for future ulcer-ation. The patient whose amputation is a result oftrauma also needs an extremity that is not painful. Thisis compounded by an increased proclivity of traumaticamputations to develop symptomatic neuromas andcomplex regional pain syndrome (CRPS, reflex sym-

pathetic dystrophy). The advantages and disadvan-tages, as always, are two sides of the same coin. Thetraumatic amputee is not subject to the same fre-quency of recurrent problems and multiple revisionsof the amputation to a higher level (not to mentionrisk to the contralateral leg19) as a diabetic patientbecause the (presumably sensate) limb of the trau-matic amputee has sufficient sensation to prevent neu-ropathic breakdown of the soft tissues.

One of the major goals in amputation surgery of thefoot is to salvage as much of the functioning foot aspossible. The general principle holds true that preser-vation of a greater portion of the limb allows greaterfunction. The classic experimental basis for limbpreservation was documented in a study done atRancho Los Amigos Hospital that showed increasingenergy costs of walking, as evidenced by greater oxygenconsumption, in patients who had higher levels ofamputation.47 The two qualifications of that principleare that the salvaged foot must achieve completehealing with a stable soft tissue envelope, and the footmust be sufficiently plantigrade to be functional.

Partial foot amputations (e.g., transmetatarsal or rayresections) are worthwhile because they allow the useof fairly normal shoes, often with only minor modifi-cations. However, a higher amputation level may bebetter for the patient and yield a more functional result

Syme’sChopart’s

Lisfranc’s

Transmetatarsal

Toe amputationor disarticulation

Metatarso-phalangealdisarticulation

Figure 24–1 Levels of partial foot amputation.

CHAPTER 24 Amputations of the Foot and Ankle 1371

if the patient becomes debilitated because of pro-longed and unsuccessful treatment in an attempt tosave a portion of the foot, for example, a toe or onemetatarsal. In the course of achieving healing of thepartial foot amputation, the patient is non–weightbearing, full time or intermittently, and the upperextremities are occupied with ambulation, therebylimiting the patient’s ability to participate in mostactivities of work and daily living. Thus the goal of footsalvage must be tempered by the functional result andthe time required to achieve the healing. The patientis usually better served with a more proximal but defin-itive and healed amputation that allows walking andresumption of daily routines than if rendered inca-pacitated with protracted wound care in an attempt tosave a portion of the foot that adds little to ultimatefunction.

Although the conversion from below-knee amputa-tion to more distal amputation is still an ongoingprocess with some of the surgical specialties, partialfoot amputations have been clearly shown to result insuperior function, greater mobility, better cosmesis,enhanced lifestyle, lower energy consumption, in-creased sensory input, better weight-bearing surface,and less distortion of body image than transtibialamputations.

SURGICAL CONSIDERATIONS

TourniquetsAlthough the use of tourniquets in amputation surgeryhas often been proscribed in the past, the experimen-tal basis for this prohibition is lacking. A controlled,randomized trial of tourniquet use in foot amputa-tions in diabetic and dysvascular nondiabetic patientsdemonstrated no difference in healing rates betweenpatients with tourniquets and those who did not havetourniquets applied.6 In this series the tourniquet wasreleased once the amputated part was removed, beforebeginning the closure, to check for hemostasis and flapviability.

Use of tourniquets requires three other considera-tions: the location, the type of tourniquet, and thepresence of underlying vascular bypass grafts. Forpartial foot amputations, if a tourniquet is desired orneeded, an Esmarch bandage just above the malleoliis safe and effective.5,6 For more proximal amputations,a thigh tourniquet is required and thus must be apneumatic tourniquet. Although easy to use, thightourniquets can inhibit quadriceps function postoper-atively, which may be a consideration in somepatients. Surgeons are reluctant to place a tourniquetover this area in patients with vascular bypass grafts.

In the case of below-knee amputations, it is reason-able and very often helpful to use a thigh tourniquetto improve visualization, especially for ligature of thevascular bundles. The tourniquet is released prior towound closure to check for hemostasis.

Soft Tissue PreservationThe most important first step in amputation surgery isaggressive debridement of infected and necrotic boneand soft tissue. This must be balanced by the need topreserve the maximum amount of viable skin and softtissue, especially plantar flaps, because they make thebest soft tissue coverage of weight-bearing surfaces.When the amputation is done for gangrene, the initialand preliminary line of resection should be quiteclose, usually a few millimeters, from the edge of thegangrene, in order to save the most soft tissue. At thetime of return to surgery for closure, if the edge provesnot to be viable, it can be cut back farther at that time.Surprisingly, the skin is usually viable because the levelof nonviability has already been demarcated. Taking atoo-generous margin of skin often can force thesurgeon to go to the next higher level of amputation.

The surgeon should not hesitate to make irregularor asymmetric flaps and then to reevaluate the patternof closure once a bleeding edge has been obtained allaround the wound. The surgeon must make the bestuse of the available soft tissue and is encouraged to use“creative” local flaps. The principle is to make use ofthe areas of viable tissue that might not fit the patternof a standard flap for the level of amputation. Forexample, the pattern of locally viable tissue mightallow one to swing a local flap medially to laterallyinstead of using the typical long plantar flap forclosure of a transmetatarsal amputation. The innova-tive use of local tissue in such a situation often is theonly way to achieve closure at that level. Otherwise,the patient has the disadvantage of requiring a moreproximal amputation. This type of local flap is alsopreferable to a skin graft because it is more durableand more sensate. Classically, the ideal length of theflap is approximately half the width of its base.However, the real-life situation of patient care is notalways ideal, and some allowance must be made forthe vagaries of each case if it affords a potential advan-tage to the patient.

Residual local flaps often need to be thinned, espe-cially where they form corners. This is true at all levelsof amputation. As the excessively thick flap is foldedover, it bunches up in the corner and pushes the skinedges away from each other. Thinning the flap exces-sively can disturb the vascularity of the skin edge; someresidual thickness contributes to a natural eversion ofthe edges.


If doubt exists about the viability of an area, the areacan be preserved and observed and then furtherdebrided at the next session in the operating room.Especially with an infected wound, the patient mightrequire two or three sessions in the surgical suite: thefirst time for initial, aggressive debridement; thesecond time, if needed, for redebridement of residualareas of infection or necrosis after a period of inter-vening wound care; and definitive closure at that or asubsequent session. Occasionally it is necessary toexpand the middle step to more than one secondarydebridement. After the debridements, the wound isusually left open to allow drainage and wound care.Surgical redebridement at intervals augments woundcare until the wound is clean or has good granulation.In many cases the focus of infection is sufficientlydistal or localized that the debridement and closurecan be done in a single session (see the discussion ofsurgical treatment of infection in Chapters 23 and 35).

Wound ClosureThe final wound, especially in a partial amputation ofthe foot, must be fashioned to balance the length ofpreserved bone with the available soft tissue to coverit. Wound closure, and thus the ultimate length of the foot, is almost always a function of the amount,location, and shape of the remaining viable soft tissue.If there is deep infection of the bone, the overlying soft tissue is usually compromised by infection as well. Once both are resected to a level proximal to theinfection, the bone length can be balanced to the softtissue.

In many cases it is necessary to sacrifice an addi-tional portion of the osseous structure to achieve thisbalance. With an infected diabetic foot, this can signifyexcision of additional uninfected metatarsals in orderto achieve delayed primary closure of a partial forefootor transmetatarsal amputation. In an example of apartial forefoot amputation, the metatarsal in questionwould have been partially exposed at surgery. Withsubsequent skin closure, the surgeon finds it impossi-ble to completely cover the wound with the remainingviable skin and soft tissue, and skin grafting would notresult in a stable closure. An example of a trans-metatarsal amputation is a patient in whom themedial two or three rays have been partially resectedfor osteomyelitis and the remaining lateral rays createan insufficient platform for weight bearing. Resectionof the uninfected rays allows a better balanced andmore functional foot.

Once a clean, granulating wound is achieved,whether the procedure is a diabetic or a posttraumaticamputation, the wound should be closed. Althoughprimary closure cannot always be achieved, especially

in the dysvascular or diabetic patient, the surgeonshould strive for primary closure of the amputationsite. This can be either immediate primary closure atthe time of resection or delayed primary closure at thesecond or third procedure in the surgical suite. Thiscan be attained in the majority of cases.

Failure to achieve primary or delayed primaryclosure in a large number of cases signifies poor deci-sion making. Leaving large gaping wounds to granu-late inward as the main method of healingamputations, especially in diabetic patients, condemnsthe patient to an unnecessarily and very long recovery(Fig. 24–2). This technique often represents thesurgeon’s failure to make a decision about the viabil-ity of the local tissue and the appropriate final level ofhealing. It is more effective and far more cost-effective,not to mention less debilitating to the patient, toestablish an assessment of the vascularity and healingpotential of the partial foot amputation wound and doa definitive procedure with good, viable local closure.If needed, the limb should first be revascularized bythe vascular surgeon and then redebrided and eventu-ally closed at the new level of viability.

Allowing an entire amputation wound to granulateslowly is an extremely slow process. Large wounds thatare left to granulate very often require skin grafting andproduce an irregular scar or an invaginated skinsurface. The process of wound contracture can be hin-dered by the shape of the wound and the amount ofresidual bone structure beneath. Delayed primaryclosure is valuable, even if it only achieves partialclosure of the wound. It reduces the amount of cover-age to be achieved and speeds healing. In such cases,the wound flaps adhere over part of the wound’slength, and a portion fails to close and continues todrain small amounts. This still reduces the morbiditybecause the residual wound that must be treated and

Figure 24–2 This wound was left open to granulate owingto infection, irregular contours, and nondefinitive debride-ment. This was revised and closed primarily.


that must granulate inward is still only a fraction ofthe original wound’s size. I have advocated this tech-nique previously.11,29 The validity of this concept hasbeen reaffirmed by the advent of negative pressurewound dressings.10,15,30,39

The technique does not work for every case, and itcertainly cannot overcome inadequate debridement orinclusion of nonviable soft tissue. However, primaryclosure, even when partial, is a durable technique formaximizing foot salvage.

A common pattern is adherence and closure of thetwo ends of the suture line, with a small dehiscence inthe middle third. The sutures in the healing areas areusually left in place for a minimum of 4 to 6 weeks,occasionally longer while wound care continues onthe central portion of the wound. This is an importantconsideration because the entire wound in a diabeticor dysvascular patient can take many months to gran-ulate inward. If partial closure is achieved, the time tocomplete healing is greatly reduced.

There are several possible explanations for a woundthat does not appear ready for delayed primary closure.Debridement might have been inadequate, and non-viable tissue remains; the soft tissue flaps might haveinadequate vascularity; or the wound might have hadinsufficient time to begin granulating. Even if it isdecided to cover the wound with a split-thickness skingraft, a good granulating base, or well-vascularizedtissue (e.g., muscle), is necessary first.

In amputation closures, the skin edges are handledas little as possible. Forceps should be used on the sub-cutaneous and deeper layers, rather than on the skinedges. Flaps should be tested at closure by gentlybringing them together manually. This should demon-strate an ability to close the wound without tension. Ifsuch a closure cannot be completed, more of theunderlying bone must be resected to reduce the pres-sure on the flaps. The stump should be palpatedthrough the flaps to make sure that no rough edges,sharp angles, or undesirable bony prominencesremain. The balance of soft tissue to bone discussedearlier is most evident at closure because there shouldbe no tension on the skin edges or suture line. Thesurgeon should inspect the skin for blanching as a signof an overly tight closure. In diabetic amputations thesutures should be left in place an extended time,usually at least twice as long as in a nondiabeticpatient. In most of these patients the nylon skinsutures, which are nonreactive, should be left in placea minimum of 4 weeks, and sometimes longer.

It is not necessary to resect the cartilage from theexposed surfaces at the level of the amputation. Preser-vation of the cartilage, and thus of the underlying sub-chondral bone, can create a barrier to infection of theresidual bone. The clearly defined line of the sub-

chondral bone makes it easier to follow the postoper-ative radiographs for changes such as erosion of thedistal bone.

DrainsDrains are usually used at the time of the delayedprimary closure. Some form of suction drain is prefer-able. The type depends on the surgeon’s judgment, theconfiguration of the wound, and the characteristics ofthe wound closure. Penrose drains, which typically exitthrough the closure and between the sutures, are dis-couraged. They tend to interfere with early adherenceof the wound edges in that location and are less effec-tive than a suction drain in reducing postoperative col-lection of fluid or hematoma. Ideally, the drain shouldexit through a small separate stab wound.

Skin Grafting and Flap CoverageSkin grafting is an acceptable technique for obtainingcoverage (as distinguished from closure) of amputa-tion wounds. Split-thickness grafting is somewhat moresuccessful in traumatic amputations than in thosedone in insensitive diabetic feet. Because of the loss ofprotective sensation, primary closure with local softtissue flaps is still preferable in diabetic patients. Skingrafts often make the difference between salvage and loss of an amputation stump, but they have ahigher rate of recurrent breakdown than local skincoverage.

Free tissue transfer has been a valuable adjunct tolimb salvage, especially in traumatic amputations ofthe foot. The greatest benefit has been in obtainingcoverage over wounds of the ankle, heel, and hindfoot.These areas have relatively little subcutaneous tissue,and the skin, especially in the hindfoot, is fixed andimmobile, which makes rotation of local flaps diffi-cult. Free tissue transfers are difficult, and they addtime, expense, and morbidity to the patient’s recovery.Their use should thus be thoughtfully justified. Ingeneral, the technique is not often applicable to theforefoot and midfoot. However, when appropriatelyindicated for coverage of a soft tissue defect over thehindfoot or heel, a free tissue transfer has the poten-tial to create a great difference in functional outcome.The dramatic effect is attributable to converting thepatient who has no heel from a user of a prosthesis(e.g., Syme’s ankle disarticulation or below-kneeamputee) to a user of a shoe.

Vascular ReconstructionWith an amputation in a diabetic or dysvascular limb,the skin edges should be checked once the final flaps


have been fashioned. If there is not at least a smallamount of visible bleeding, the flaps should probablybe revised to a more proximal level. Typically thesurgeon checks for the presence of punctate bleedingspots in the flaps and especially along the skin edges.When the limb is dysvascular, vascular consultationshould be obtained. Revascularization of the limb canbe done through angioplasty, placement of a proximalstent, endarterectomy, proximal bypass, or distalbypass surgery. Regardless of the technique, revascu-larization is often the key to salvage of the foot. It iscrucial to remember this and to work as a team withvascular surgeons.

Bypass is the most common of these techniques.Balloon angioplasty is applicable primarily to discrete,well-localized (and usually proximal) occlusivelesions, which are relatively uncommon in diabeticpatients and more common above the popliteal arteryin nondiabetic vascular disease. In the nondiabeticpatient, bypass usually takes the form of proximalbypass of a major occlusion at the iliac, femoral, orpopliteal levels. In the dysvascular diabetic patient,similar proximal occlusions or stenoses occur andrespond well to a vascular bypass. In addition, and verycommonly, diffuse occlusions of the arteries distal tothe trifurcation of the popliteal artery can occur in thelower part of the leg. Unlike in the nondiabetic patient,these are not discrete blockages but usually consist ofatherosclerotic involvement diffusely through thevessel. Bypass done down to the level of the ankle mayuse in situ or reversed saphenous vein grafts. Theemphasis should be on doing the revascularizationbefore fashioning the final amputation flaps. Prefer-ably, the final level of amputation is determined oncemaximum tissue perfusion has been achieved.7

The customary surgical techniques described hereare basic guidelines, not absolute requisites, for suc-cessful amputations. No matter what the conscientioussurgeon does, some amputations will fail and willneed to be revised to a higher level. If every amputa-tion heals primarily, the surgeon may be doing someamputations at too proximal a level and not achievingenough salvaged cases from the feet. Often several pro-cedures and revisions are needed before the final resultis obtained, and the revisions do not prejudice thequality of the ultimate result; rather, they make theattempt at foot salvage worthwhile.21,23,27 Healedamputations that result from revision procedures yieldsatisfactory results similar to those that heal after asingle level of amputation. Once partial amputationsof the foot heal, the reported rate of revision is as lowas 10%, thus indicating that these function as defini-tive procedures. The surgeon uses imaging and labo-ratory data, clinical experience, and surgical judgmentto select the level for partial foot amputation.

Determination of Amputation Level

A plethora of tests have been promulgated in the sur-gical and orthopaedic literature as the “best” methodto determine the proper level of amputation. Most arebased on statistical review of ultimate healing of theamputated limb and the correlation with predictedhealing from the test. These procedures include arte-rial Doppler pressure measurements, fluoresceinangiography, transcutaneous oxygen tension measure-ments, and xenon clearance.12,34,37,50

The literature is replete with these reports, althoughall the studies examine levels of healing on the thighand leg. Most of these studies do not address the ques-tion of the proper level of amputation within the foot,that is, the question of the correct level for a partialfoot amputation procedure. For this reason, thesestudies are often difficult or impossible to apply to thedecision-making process of foot salvage, whichdepends greatly on local wound factors of gangrene,infection, and general perfusion of the foot. Differ-ences in vascularity between a transmetatarsal ampu-tation and a Syme ankle disarticulation are at bestdifficult to determine on the basis of most noninva-sive preoperative testing. Even when tests indicate dif-ferences, their reliability for differentiating levels ofviability within the foot has not been clearly proved orwidely accepted. Most of the studies on predictive testsfor amputation healing levels have been aimed atassessing the segmental vascularity of the limb, that is,healing below the ankle, at the ankle, below the knee,or above the knee.

None of the procedures has been demonstrated tohave a clear hegemony in this battle to forecast healingaccurately, at least not in the arena of widespread clin-ical practice. Each of these procedures has clear advan-tages, and a few of these characteristics are mentionedhere, although this is by no means an exhaustivereview of this broad subject.

The most commonly used and widely available testis the arterial Doppler ultrasound. This is most useful asa guideline to general levels of perfusion and is thebest initial screening test to determine whether thepatient needs a vascular surgery consultation and anarteriogram. The Doppler ultrasound is painless,quick, and inexpensive and does not require extensiveinstrumentation. As discussed in the section on vascu-lar evaluation in Chapter 23, the pulse-volume record-ings (waveforms) are reliable indicators of perfusion,but ratios of ankle pressures to arm pressures can be unreliable, especially in the diabetic patient withnoncompliant, calcified vessels that give falsely ele-vated pressures. For healing of distal amputations, themost reliable measures are toe pressures. A forefootamputation is likely to heal with a toe pressure of


40 mm Hg or greater. Distal wound healing in thepresence of toe pressures between 30 and 40 mm Hgis possible but less predictable.3

Some authors advocate transcutaneous oxygen meas-urements. These measurements are clearly much morecumbersome to perform than Doppler studies. Thereadings must be obtained in an environment of con-trolled temperature because they are temperaturedependent, and they are time consuming to perform.On a practical level, an adequate number of readingscannot be done efficiently without multiple simulta-neous probes. No equivalent to Doppler toe pressuresexists; thus this technique does not offer informationabout healing of the most distal procedures. Recentstudies have questioned the reliability of transcuta-neous oxygen measurements. 41 The real question is towhat degree the surgeon finds a correlation of testresults with wound edge bleeding at surgery and withthe healing rate of amputation wounds in that partic-ular institution.

Other Factors Affecting HealingOther factors that affect healing include edema in thelocal tissues, systemic disease, and nutritional factors.Systemic factors include glycemic control in diabeticpatients or vasculitis in patients with inflammatoryarthritides. As noted in Chapter 23, simple indices ofnutritional status can have a predictive value forwound healing after amputation.13 Of course, the adequacy of nutritional status is important to achiev-

ing healing. Published measures of this are the totallymphocyte count, which should be greater than1500/µL; serum albumin 3.5 g/dL or greater; totalprotein 6.2 g/dL or higher; and hemoglobin greaterthan 11 g/dL.

SPECIFIC AMPUTATION LEVELSAND TECHNIQUES

A

BC

ED

Figure 24–3 Terminal Syme’samputation. A, The nail plate isremoved. B, An elliptic incisionis centered over the distalaspect of the distal phalanxencircling the toenail plate. C, The dorsal soft tissue, nailplate, and eponychial folds are excised as a single full-thickness mass. D, The distalphalanx is transected withbone-cutting forceps or a smallsaw and the distal fragment isremoved. E, A single inter-rupted layer of sutures is usedto loosely approximate andevert the skin edges.

AMPUTATION OF THE DISTAL TOE AND NAIL

The terminal Syme amputation, which has beendescribed for severe posttraumatic nail defor-mity, onychomycosis, or recurrent infection ofthe great toenail, can be used for the sameproblems in a lesser toe as well. The key is toremove sufficient bone to allow closure withouttension.

Surgical Technique

1. The nail plate is removed (Fig. 24–3A). Anelliptical incision is centered over the distalaspect of the distal phalanx encircling thetoenail plate. The incision must extend suffi-ciently proximally to include all of the proxi-


mal and lateral eponychial folds to preventpartial nail regrowth (Fig. 24–3B).

2. The dorsal soft tissue, nail plate, and epony-chial folds are excised as a single full-thick-ness mass down to the bone, to expose thedistal phalanx (Fig. 24–3C).

3. The distal phalanx is transected with a bone-cutting forceps or small saw and the distalfragment is removed (Fig. 24–3D). Approxi-mately one third to one half the phalanx isremoved, depending on the amount of softtissue for coverage.

4. The skin flap is shaped to minimize medialand lateral dog ears, although the tissue willshrink and reshape after healing.

5. A single interrupted layer of sutures is usedto loosely approximate and evert the skinedges. A loose skin closure usually allowsadequate drainage and usually obviates theneed for a drain (Fig. 24–3E).

6. A gauze-and-tape dressing is applied.

Postoperative Care

Skin sutures are removed 4 to 8 weeks aftersurgery. Early suture removal is avoided becauseit can lead to dehiscence, especially becausethe flap is thick and stiff.

Pitfalls and Complications

Shaping of the excised ellipse of tissue is impor-tant; a bulbous end can form, and although itusually shrinks to some degree, flaps should besculpted to minimize this. The main complica-tion is dehiscence from a tight closure causedby insufficient resection of bone. In diabeticpatients or nondiabetic dysvascular patients,preoperative vascular studies should be done toscreen for healing potential of this most distalsegment.

Minimum1 cm bone

Sutures

Figure 24–4 Preservation of at least 1 cm of the base of theproximal phalanx in amputations of the hallux is desirable tomaximize the weight-bearing function of the first metatarsal.This patient has two thirds of the proximal phalanx preserved.

intuitive and scientific. The benefits of preserv-ing the base of the phalanx for the subsequentgait of the patient and the pattern of pressureunder the foot have been demonstrated inplantar pressure studies with the pedobaro-graph. The intuitive basis is that by saving thebase of the phalanx, the attachments and thusthe functions of the plantar fascia and flexor hal-lucis brevis tendon are preserved, at least partially. The independent plantar flexion mech-anism of the first ray is not entirely lost, andsome of the weight-bearing function of the firstray may be preserved, possibly reducing thetransfer of pressure to the second and thirdmetatarsal heads.

Surgical Technique

1. A curvilinear skin incision is used to encirclethe dysvascular or infected area and to excisenonviable tissue.

2. The surgeon determines the length of theflaps required for closure of the wound. Atthe base of the phalanx, or at the MTP joint,viable flaps must be present to the level ofthe distal part of the proximal phalanx.

3. Often, sufficient skin is present on the dor-soplantar aspect or mediolateral aspect ofthe hallux to enable the development of fish

AMPUTATION OF THE GREAT TOETHROUGH THE PROXIMAL PHALANX BASE

Although it is technically easier to amputate thegreat toe through a metatarsophalangeal (MTP)disarticulation, there are potential advantagesto saving the base of the proximal phalanx. Theminimum length of the base to save is about 1 cm (Fig. 24–4). This recommendation is both


A B C

Figure 24–5 Racquet-type in-cision for toe amputation. A,Outline of continuous incision.B, After disarticulation. C,Closure.

mouth flaps (an alternative is a racket-typeincision) (Fig. 24–5).

4. A power saw is used to transect the proximalphalanx at its base, leaving a minimum of 1 cm length. Rough edges are beveled witha rongeur.

5. If the base of the phalanx has been pre-served, at least one of the sesamoids mustbe saved because the sesamoid complexattachment to the phalangeal base is the keyto the function of the phalanx if it is to aid inmaintaining some weight-bearing function ofthe first metatarsal.

6. The flaps are approximated with full-thickness, interrupted sutures of a nonreac-tive monofilament.

7. A gauze dressing is applied.

METATARSOPHALANGEALDISARTICULATION OF THE GREAT TOE

In some cases, it is preferable to amputatethrough the MTP joint. There are several impor-tant technical points. It is not necessary toremove the cartilage from the metatarsal head,as noted in the section on wound closure. Themost important technical point is that the flapsmust be viable (bleeding edges, no residualnecrotic tissue) and must be easily closedwithout tension on the skin edges.

It is surprising how distal the flaps must be inorder to achieve closure without tension. Ingeneral, the length of the flaps must be at aminimum, equal to half the length of the proxi-mal phalanx.

Once the proximal phalanx has beenresected, and prior to closure, the sesamoidcomplex should be inspected. As with mostdistal foot amputations, the extensor and flexortendons are resected proximal to the level ofclosure. The flexor hallucis longus passesbetween the sesamoids in a tight sheath. Inmany cases of disarticulation of the hallux, thesesamoids retract. However, if they do not, or ifthe sesamoids are enlarged and arthritic, post-operatively they can create plantar pressureunder the first metatarsal, constituting a risk forulceration in the neuropathic patient. The con-joined tendons of the sesamoid complex are rel-atively avascular, and the thickness can impedemobility of the plantar flap during closure.

For these reasons, sesamoidectomy is often anecessary component of MTP disarticulation.This can take the form of excision of the medialsesamoid only, or of the entire complex of bothsesamoids with the cradle of conjoined tendons.It is not typically necessary to resect the plantarcrista of the first metatarsal head.

Postoperative Care

Routine dressing changes are continued untiladequate healing has occurred. In concept, itwould seem preferable not to allow weight-bearing postoperatively in order to protect thewound and the suture line from shearing forcesthat would pull the wound apart. In reality, manypatients are not physically able to sustainnon–weight bearing for the reasons elaboratedin Chapter 23. A compromise is to allow weightbearing on the hindfoot only, but this is moredifficult to achieve than it appears. The use of


Figure 24–6 Molded insole for healed partial forefoot amputations.

partial shoes that allow the forefoot to hangover the distal edge of the shoe increases thepressure on the heel and hindfoot.

Sutures are removed 4 to 8 weeks aftersurgery. Early suture removal should be avoidedbecause wound dehiscence may occur.

Once a great toe has been amputated, acustom-molded filler in the shoe helps to com-pensate for and diminish sliding of the footinside the shoe (Fig. 24–6).14


The most common short-term complication ofhallux amputation is poor wound healing, oftenbecause of inadequate perfusion at the ampu-tation level. The most common long-term com-plication is the gradual migration of the secondtoe into varus and hyperextension at the MTPjoint. In the diabetic patient with neuropathy,this can lead to pressure ulceration over theproximal or distal interphalangeal joints. As theextension deformity worsens, another ulcerationcan develop under the second metatarsal. Indiabetic patients, an occasional problem is arecurrent ulceration or pressure area near or onthe first metatarsal. Once healing of the halluxamputation has been achieved, the patientneeds to be fitted with an accommodativeinsole to balance the weight-bearing pressureover the forefoot.

AMPUTATION OF THE LESSER TOES

Amputation of the lesser toes can be done as adisarticulation or as a resection through bone. Ifa toe requires amputation because of ischemia,necrosis, or circumscribed distal osteomyelitis,partial amputation is a reasonable alternative,provided that adequate perfusion exists tosupport healing. The advantage of this amputa-tion over disarticulation at the MTP joint is thatthe residual partial toe serves to maintain itsspace and block migration of the two adjacenttoes toward each other into the gap created bythe absent digit (Fig. 24–7).

Surgical Technique

A similar surgical approach is used for resectionof the various lesser toes as for the great toe.

Although preservation of the base of thephalanx in the lesser toes probably produces thesame mechanical advantage, it is less importantthan in the hallux. Regardless of whether theamputation is done distally at the level of thephalanx or as a disarticulation of the entire toeat the MTP joint, the types of closures are thesame. The most important point to remember isthat the two common types of flaps are side-to-side (fish mouth) flaps and racquet flaps. Fishmouth flaps can be fashioned either as medialand lateral flaps or as dorsal and plantar flaps.The racquet incision is the easiest to use, andthe surgeon must decide where to place thehandle of the racquet, that is, the proximal lon-gitudinal extension of the loop. It is most easilyplaced along the dorsum of the ray between the

Figure 24–7 Partial toe amputation. The residual portion ofthe digit blocks migration of the adjacent toes.


zones of the two neurovascular bundles to thedigit (see Fig. 24–5). There are two proximalextensions in the fish mouth flaps. If the flapsare placed dorsally and plantarly, the extensionsrun over the neurovascular structures, makingmedial and lateral flaps preferable (Fig. 24–8).

In a few cases, disarticulation of all the toes atthe MTP joints is a viable alternative, primarilyfor trauma, such as a lawnmower injury to all thetoes. If reasonable soft tissue coverage can beobtained, the foot can be extremely functional.The preservation of length makes footwearmuch easier to fit than with a transmetatarsalamputation because a low quarter shoe will stayon the foot.

If a patient has had more than one toe ampu-tated at different times, as often occurs in dia-betic patients, it is important not to leave thepatient with just one or two remaining toes.These are condemned to experience pressureand ulceration and then to require amputation,because the pressure of footwear and walkingwill be concentrated there. At this point it is bestto remove all the toes, through either MTP dis-articulation or transmetatarsal amputation, toeven out the distal forefoot.

Aftercare

In the immediate postoperative period thepatient is kept in a bulky bandage and a surgi-cal shoe. Splints are required if a concomitantAchilles tendon lengthening or other hindfootprocedure has been done. The surgical shoe orother protective footwear continues to be wornuntil the soft tissue healing is complete, both toprevent pressure on the wound by the shoe andto allow dressing changes.

Toe separators, made of soft foam or Plasti-zote, help to retard drift of the remaining toes

Side-to-sideflaps

Bone resection proximal to orat level of base of flaps

Dorsal-plantarflaps

Racquet-typeincision

A B CFigure 24–8 Types of incisions and flaps for amputation of the lesser toes. A and B are fish-mouth closures. A, Side-to-side ormedial and lateral flaps. B, Dorsal and plantar flaps. C, Racquet-type incision.

into the defect made by the amputated digit. Ifthe patient requires a molded insole, the toeseparator can be built into it, but it is usuallyeasier to keep it separate.


The most common complications are related toinadequate balance of soft tissue and bone. Thisleads to dehiscence of wounds closed undertension. Other complications, as mentionedearlier, include drift of the adjacent toes towardthe defect created by the missing digit. This canbe retarded by the use of a toe separator softpad made of Plastizote or similar materials worninside the sock or stocking. In some cases,resection of the distal second or third metatarsalat the time of disarticulation of the toe allowsimmediate narrowing of the foot and closure ofthe gap between the digits (see following dis-cussion of ray amputations). The drift of thelesser toes is seen most often after amputationof the second toe. The gap closes more natu-rally and with fewer problems after amputationof the fourth toe because of the greater mobil-ity of the fourth metatarsal and the natural varusof the fifth toe.

Disarticulation of the fifth toe at the MTP jointcan leave the fifth metatarsal head exposed topressure of weight bearing, and sometimes itneeds to be resected.

A late deformity of a partial toe amputation isdorsal elevation of the stump caused by ahyperextension contracture at the MTP joint. Inthe lesser toes, this requires resection of the toeremnant back to the MTP joint or release of theextensor tendons and sectioning of the capsuleof the MTP joint on three sides (medially, later-ally, and dorsally).


RAY AMPUTATION AND PARTIALFOREFOOT AMPUTATION

Amputation of a toe with all or part of its corre-sponding metatarsal is the definition of a rayamputation. These are more common than anyother amputation of the foot except simple toeamputations. They are durable and, once theyare healed, are relatively easy to fit in shoes withminor modifications and a molded insole. Narrowing of the foot can create problems of increased pressure under the forefoot or side-to-side movement within the shoe, but this usually can be accommodated by the use ofthe insole. The preservation of foot length isoften an advantage because the longer forefoot makes it easier to keep on a shoe. Rayamputations are typically used to treat traumain healthy patients as well as infection and gan-grene in the dysvascular and diabetic popula-tions (Fig. 24–9).

Dorsal skin

Plantar

Level of boneresection

Figure 24–9 Partial foot amputations. The level of boneresection must be proximal to the level of viable soft tissue toachieve closure without tension on the flaps. Satisfactoryhealing depends on this balance. Shading indicates ampu-tated area.

Border Ray Resection

The easiest single rays to amputate are theborder rays, that is, the first and fifth. Straightmedial and lateral incisions are used, respec-tively. If only a small amount of the distalmetatarsal needs to be resected, the distal endof the incision may loop around the base of thedigit (the racquet). When possible, a longerplantar flap allows for an easier closure when the procedure involves the border of the foot.First-ray and fifth-ray amputations are successfulin preservation of foot length. Fifth-ray am-putations are the most commonly successful ray amputation. Despite some controversy inthe past, first-ray amputations can functionextremely well with a molded insole in the shoethat supports the medial border of the foot andincludes a filler for the absent ray.

Specific surgical techniques in partial forefootamputation can vary greatly. Surgical incisionsand osseous resections must be tailored to theindividual problem area of infection, the magni-tude of soft tissue necrosis, and the extent ofosteomyelitis. Care must be taken to save someof the skin that is over the digit itself, if possi-ble, and always to save more skin than wouldseem necessary. It is obviously easy to trim awayexcess skin, but insufficient soft tissue for closureleads to closure under tension, dehiscence, orwound necrosis (see Fig. 24–2). Failure to saveall possible viable skin and soft tissue is the mostcommon error of the surgeon inexperienced inamputation surgery.

A fillet flap can be created from the toe byremoving the bone subperiosteally and pre-serving the full thickness of the soft tissue, whichis then turned proximally to cover a defect andthen trimmed appropriately (Figs. 24–10 and24–11). Fillet flaps can be done most easily onborder rays.

Central Ray Resection

Single ray amputation of one of the three centralrays (second, third, and fourth) is less familiar tomost surgeons, and it is less often indicatedthan resection of the border rays. The primarytechnical challenge is the approximation of therelatively immobile soft tissue flaps. Often thegap created by the absent ray closes withoutmuch difficulty when the incision is closed. Insome cases the defect allows the two adjacenttoes to drift toward the amputated ray, as occurs


Figure 24–10 The great toe soft tissue has been turnedproximally to cover a defect over the first metatarsal.

Figure 24–11 Healed flap.

Closure can be facilitated by more proximalresection of the central metatarsal, which allowsgreater narrowing of the foot. It is advisable notto disarticulate the base of the metatarsalbecause this will destabilize the midfoot,leading to pain in the traumatic amputee andoften to a Charcot neuropathic midfoot break-down in the insensitive limb.

Multiple Ray Resections: Partial ForefootAmputation

Partial forefoot amputations involve removal oftwo or occasionally three rays from the medialor lateral side of the foot. This is probably moresuccessful in trauma patients but occurs moreoften in diabetic patients because more ampu-tations are done because of diabetes than anyother cause in our population (Fig. 24–13A andB). In most instances, once it becomes neces-sary to amputate three rays, it is easier andyields a more predictably good result to performa transmetatarsal amputation instead. On thewhole, partial forefoot amputations of the lateralside fare better than those on the medial sideof the foot, although there are successful exam-ples of both even in diabetic and dysvascularpatients. Loss of the first ray results in an effec-tive foot less often because the foot does not balance as well, and transferred pressureunder the lesser metatarsals leads to furtherulcerations.

Forefoot, transmetatarsal, and Chopart’samputations are the most common proceduresin which the surgeon may want to use creativeflaps. This signifies using viable local tissue thatis available to close the wound even if it doesnot conform with the ideal flap placement orshape. The goal is to achieve primary closureover the maximum length of bone while stillusing durable local tissues, especially if thisincludes viable plantar skin (Fig. 24–14A to C).

Aftercare

Proper footwear for the healed partial forefootamputation is critical (see Fig. 24–6). The shoemust have additional width and depth in the toebox to accommodate the essential insole. Afiller should be built as a part of the insole toblock side-to-side motion of the remainingnarrow forefoot (i.e., prevent the windshield-wiper motion that can occur with walking).

in a simple toe disarticulation at the MTP joint.The key to successful central ray amputations indiabetic and dysvascular patients, in particular,is to incise the skin and soft tissue that is beingsaved right at the edge of necrosis and infec-tion, in other words, to save maximum softtissue, including skin of the digit (Fig. 24–12A toD).


Deformity of the remaining toes is common andtakes the form of clawing as well as medial orlateral drift toward the absent rays. Footwearalso must accommodate these problems. Insome cases it is necessary to correct these sec-ondary toe deformities surgically subsequent tothe amputation (Fig. 24–15).


The two main complications of the resection ofone or more rays are delayed or poor woundhealing and a functionally compromised resid-ual foot. The latter problem is that the foot bearsweight unevenly, and recurrent pressure ulcera-tion occurs under the residual metatarsal heads(Fig. 24–16). In both cases, the best salvage isrevision to a more proximal level, usually a trans-metatarsal amputation. In the insensitive (usuallydiabetic) patient, another sequela can be the

A B

C DFigure 24–12 A, Plantar ulcer. B, Plantar ulcer is now draining dorsally as well, indicating a deep web-space abscess. C, Footsalvage by web-splitting incision from mid dorsum to mid plantar surface. D, Excision of central metatarsal allowed delayedprimary closure.

development of Charcot’s midfoot joints. Themidfoot collapses and produces a secondarydeformity. This cannot be prevented, but it canbe retarded by preserving the bases of themetatarsals whenever possible.

With a first-ray amputation, an additionalpoint is preservation of the entire attachment ofthe tibialis anterior tendon. In cases that requireresection of the base of the first metatarsal, theinsertion of the anterior tibial tendon should bereattached proximally to the cuneiforms. Thiscan be done through a tunnel in the bone, butit is easier to make a bed in the cancellous boneand attach the tendon with a bone anchor (Fig.24–17).

The same is true for resection of the base ofthe fifth metatarsal, namely, that the peroneusbrevis tendon should be reinserted proximally ifpossible.


A B CFigure 24–14 A, Partial forefoot amputation for abscess and osteomyelitis. B, The maximum amount of soft tissue has beenpreserved, right up to the edge of viable tissue, to achieve closure. C, Healed wound. Patient resumed her original job in themailroom.

A BFigure 24–13 Example of lateral partial forefoot amputation.A, Dorsal view. B, Plantar view.


Figure 24–17 Bone anchor for replantation of tibialis ante-rior tendon.

TRANSMETATARSAL AMPUTATION

Transmetatarsal amputation is a sturdy, practicalsolution to severe gangrene, infection, or tissueloss in the forefoot.32 It is technically easy toperform and has a critical advantage over moreproximal amputations because the insertions ofthe tibialis anterior and peroneus brevis tendonsare preserved (video clip 4). This is important foractive dorsiflexion in walking, and it serves tocounteract the pull of the triceps surae, whichalmost always produces an equinus contracturewhen unopposed or even unbalanced. Oftenconcomitant lengthening of the Achilles tendonis necessary, with or without posterior ankle andsubtalar joint capsulotomies, for an equinus contracture that has developed over a longperiod of non–weight bearing before the amputation.

Subtle equinus, often difficult to recognize, isa cause of failure of this and other partial footamputations. The surgeon should be sensitizedto look for this problem in every patient beforeand after partial foot amputation. Based onstudies of the effect of Achilles tendon length-ening in the treatment of diabetic ulcers, routinelengthening of either the gastrocnemius orAchilles tendon at the time of transmetatarsaland midfoot amputations appears to lower therisk of subsequent ulceration in neuropathicpatients.35

The length of the transmetatarsal amputationcan vary considerably, depending on theamount of soft tissue and the length of bone

Figure 24–15 Molded insole for partial foot amputations.

Figure 24–16 Recurrent ulceration after a partial forefootamputation due to transfer of pressure to the remaining rays.The patient required a transmetatarsal amputation.


that can be retained. Longer stumps have theadvantage of holding onto a shoe better, but ashort stump that heals primarily is better than alonger one that fails to heal or must be left opento granulate.

Whenever possible, it is worthwhile to pre-serve all five metatarsal bases. The traumaticamputee has better balance of the midfoot. Inthe diabetic patient with neuropathy, removal ofone or more metatarsal bases can increase therisk of Charcot breakdown of the midfoot. Thisrisk still exists after any partial foot amputationin a patient with severe neuropathy, even whenall the bases of the metatarsals have beenretained.

Most patients with transmetatarsal amputa-tions can be fit in off-the-shelf footwear or atmost a high-top shoe because of its additionallacing. The shoes generally need to have eitherlace-up closures or hook-and-loop (Velcro) clo-sures. The shoe should have additional depthfor a dual-density molded insole, to which isattached a block or toe filler that holds the shoein the area of the missing forefoot (Fig. 24– 20).


The most common complication of trans-metatarsal amputation is development of recur-rent and recalcitrant ulceration on the stump.This can be caused by the plantar projection ofone of the residual metatarsals or by new boneformation at the distal metatarsal, requiringresection of the prominence.4 Most often, ulcer-ations occur on the distal edge of the stump andresult from an equinus contracture at the ankleand to some extent the transverse tarsal(Chopart) joint.

Treatment consists of Achilles tendon length-ening (occasionally augmented with caspsulo-tomies of the ankle and subtalar joints),resection of the bony prominence, and debride-ment or excision of the ulcer. Postoperativetreatment requires immobilization in a cast,preferably in slight dorsiflexion, because of therisk of recurrent deformity.

When skin grafting is necessary to supple-ment wound closure, which occurs rarely, it canbe used on the dorsum of the foot. On theplantar surface it is much less successful, andcareful consideration should be given to revis-ing to a more proximal level if major skin losshas occurred on the sole.

LISFRANC’S AMPUTATION(TARSOMETATARSAL DISARTICULATION)

Lisfranc’s amputation (tarsometatarsal disarticu-lation) and Lisfranc himself are historic. Lisfranc’swritings preceded the popularization of trans-metatarsal amputations by more than two cen-turies. Lisfranc, a surgeon in Napoleon’s army, isremembered most often nowadays for the appli-cation of his name to the anatomic complex ofthe tarsometatarsal region, and injuries thereof,although he described amputation, not fracturesand dislocations, at this level. This reflects, justas the eponymous Syme amputation, the highmortality associated with amputations that traversed bone in the era prior to antisepsis.Thus the most successful amputations were disarticulations.

The recommended technique for Lisfranc’samputation is essentially that of the trans-metatarsal amputation, including Achilles orgastrocnemius lengthening and reimplantationof the tibialis anterior and peroneus brevistendons.

Surgical Technique (Figs. 24–18 and 24–19)

1. The proposed skin incision is marked preoperatively.

2. The skin incision, as in all amputations of thefoot, is selected by the level of viable skinand soft tissue The incision is curved gentlyproximally in a medial-to-lateral direction tomatch the length of the metatarsals.

3. A full-thickness flap is developed dorsallydown to the metatarsals.

4. The flap from the plantar surface is typicallymade longer so that it wraps dorsallyaround the resected ends of themetatarsals. Although this is not always pos-sible, it is desirable. The use of local dorsalskin is still superior to split-thickness skingrafting and should be used if the plantarskin is insufficient.

5. The tendons are cut back to the proximaledge of the wound.

6. The metatarsals are resected with a smallpower saw.

7. The bones are beveled in a direction fromdorsal–distal to plantar–proximal to preventa sharp plantar edge on the bone that canlead to later pain or ulceration. Themetatarsals are cut in a cascade of length:each successively lateral metatarsal is cut


B CA

ED FFigure 24–18 Surgical technique for transmetatarsal amputation. A, Plantar skin incision. B, Metatarsals divided about 15degrees from the transverse axis. C, Soft tissue divided from the metatarsal necks and heads. D, Toes divided from the plantarflap. E, Tendons drawn down and divided. F, Closure completed by bringing posterior flap dorsally.

Incision

Lateral view

Plantar

Dorsal

Metatarsalbase

Plantar flap

Cascadeof length

Figure 24–19 Incisions and level of bone resection for transmetatarsal amputation.


CHOPART’S AMPUTATION

This disarticulation through Chopart’s joint, thatis, the transtarsal joints of the talonavicular andcalcaneocuboid joints combined, had fallen intodisfavor but has been repopularized by Jacobsand other authors in recent years.8,9,28,33,38

Chopart’s amputation has great and distinctadvantages over both the Syme procedure andthe below-knee amputation. First, it is techni-cally much easier to do than a Syme amputa-tion. Second, when the patient is fittedpostoperatively with an ankle-foot orthosis(AFO), the patient can wear a shoe rather thanthe knee-high prosthesis required both bySyme’s and below-knee amputations (Fig.24–21A to E). Third, Chopart’s amputation doesnot produce as much shortening of the limb.Fourth, as with Syme’s amputation, Chopart’sprocedure is preferable to a below-knee ampu-tation because its distal surface is covered bythe tough weight-bearing skin of the heel: it isa distally weight-bearing amputation. There arenumerous possible variations of the Chopartamputation for which the surgical technique isequivalent and that function equally well. Theseare amputations in which the level of disarticu-lation may pass through the naviculocuneiformjoints medially or the cuboid–metatarsal jointslaterally.Figure 24–20 Shoe insole with toe filler for transmetatarsal

amputation.

approximately 2 to 3 mm shorter than themetatarsal immediately medial to it. Thefifth metatarsal is at a greater incrementcompared to the fourth metatarsal becauseit tends to produce late effects of plantarpressure, presumably because it is the mostmobile of all the metatarsals.

8. Once the bones have been cut, the ampu-tated forefoot is divided from the plantarflap by cutting from proximal to distal justunder the bones down to the plantar skinedge.

9. The plantar flap needs to be thinned toachieve closure without tension. The skin ispreserved for a tension-free closure, and theplantar intrinsic muscles, plantar plates, andsubcutaneous tissue are beveled from prox-imal to distal. Smooth, continuous surfacesare created to prevent multiple tags andtails of devascularized tissue. Excessive oruneven planing of the plantar flap canadversely affect the flap’s viability.

10. The flaps tend to bulge at the medial andlateral edges in particular. Closure in dia-betic patients is done in a single layer withinterrupted nonabsorbable sutures.

11. In an infected foot, presuming that theinfected area has been ablated, primaryclosure is still attempted, usually over asuction drain.

12. The foot is carefully checked for an equinuscontracture, with the knee both extendedand bent. Appropriate lengthening of theAchilles tendon or the gastrocnemius mus-culotendinous juncture (modified Strayerprocedure) is performed.

13. A compression dressing is applied. A care-fully padded posterior splint is applied withthe ankle held in a neutral to mildly dorsi-flexed position. The splint is used to main-tain neutral to slight dorsiflexion if tendonlengthening is performed.

Postoperative Care

Sutures in diabetic patients are left in place aminimum of 4 weeks, but they are often kepttwice this long. The patient is kept non–weightbearing until wound healing is certain. A post-operative cast may be used after the first weekor so, depending on the wound healing andwhether a lengthening of the Achilles or gas-trocnemius was performed.


B CA

E

DFigure 24–21 Bilateral distal gangrene due to embolism. A, Left foot with a more proximal level of gangrene. B, Right footwith gangrene involving the toes. C, Plantar views. D, Right transmetatarsal amputation and left Chopart’s amputation. E, A shoeinsole with a toe filler on the right and an ankle–foot orthosis (AFO) with filler on the left allow the patient to wear low-counterlaced shoes.

Chopart’s amputation can fail because of lateequinus deformities that develop as a result ofthe unbalanced or unopposed pull of theAchilles tendon. Therefore it is necessary to planfor muscle balancing as an integral part of thisprocedure. The surgeon must completely dividethe Achilles tendon at the time of the amputa-tion. Simply lengthening is inadequate becausethe tendency for recurrence of equinus is sogreat. Although recurrence may be diminishedby resection of a segment of the Achilles

tendon, reestablishing anterior tendon functionis probably more important. Second, thetendons of dorsiflexion (anterior tibial, peroneusbrevis) should be transferred proximally to thetalus and anterior process of the calcaneus,respectively, to provide a dynamic force tooppose equinus. Once the ankle is healed, thepatient must be fitted into a polypropyleneAFO, lined with cushioning foam.

Although Chopart’s amputation has severaladvantages over Syme’s amputation, the indica-


Tibialisanteriortendon Peroneus

brevistendon

A

B

C

FED

Figure 24–22 Chopart’s amputation. A, Incisions, lateral view of dorsal and plantar flaps. B, Dorsal view of incision. C and D,Flaps retracted after resection of distal foot. E, Transfer of tibialis anterior tendon through tunnel in neck of talus. Peroneus brevistendon transferred into anterior calcaneus. F, After closure of incisions.

tions for its use are limited. Many patients whohave an insufficient amount of viable soft tissuefor a transmetatarsal amputation do not haveenough for Chopart’s amputation and requireeither a Syme or a below-knee amputation.

Surgical Technique

1. The skin incision is marked preoperatively.2. The flaps are created dorsally and plantarly if

possible; otherwise, available tissue is used.The surgeon takes care to resect the softtissue sufficiently distal to the level of the dis-articulation while remembering that the crosssection of the foot at this level is wide (Fig.24–22A and B; see Fig. 22-1).

3. The skin is retracted and the resection iscarried down directly through the soft tissue,

again leaving sufficient soft tissue to closeover the amputation area.

4. The extensor digitorum longus tendons aresevered and allowed to retract. The anteriortibial and peroneus brevis tendons are tracedout to their most distal insertions, dissectedout, and preserved.

5. Chopart’s joint is located. The dorsal andplantar ligaments of the calcaneocuboid andtalonavicular joints are released (Fig. 24–22Cand D).

6. The Achilles tenotomy or tenectomy is per-formed to prevent the development of anequinus contracture. If the latter is performed,a separate posteromedial incision is made,developing full-thickness flaps from skin toparatenon. A 2- to 3-cm segment of thetendon is excised and the wound is closed.


PARTIAL CALCANECTOMY

Partial calcanectomy can be considered a formof below-knee amputation, and some authorsclassify it as such because it is an amputation ofthe back of the foot rather than the front.43 Tech-nique and indications are discussed in Chapter23. Partial calcanectomy is a method of sal-vaging the foot by removing the nonviableportion. A few case reports2,18,48 and several sub-stantial series of patients12,24,43,49 indicate goodresults with this technique as an alternative tobelow-knee amputation for salvage of the footwith calcaneal osteomyelitis. As with otheramputations, it requires special postoperativeorthotic management, in this case in the form ofa foam-lined posterior-shell AFO.

SYME’S AMPUTATION

The Syme amputation, or ankle disarticulation,is named for James Syme, professor of clinicalsurgery at the University of Edinburgh, who firstdescribed it in 1843. Invented in the era beforeantisepsis, antibiotics, or anesthesia,20 the greatadvantage of this amputation was that it did nothave the 25% to 50% mortality of the below-knee amputation, which often became infectedfrom contamination in a large wound that con-tained the transected medullary cavities of thetibia and fibula.

Although advances in medicine have negatedmany of the advantages of the first century ofuse of this procedure, it still retains the othermajor advantage originally ascribed to it: inSyme’s words, a stump of “greater comfort andutility” when compared with the below-kneeamputation. This advantage derives from theresidual limb’s being longer,36 the amputation’sbeing partially weight bearing on its end, andthe end-bearing stump’s being covered with the special skin and pad of the heel, which withstands this weight well. The remainder of the weight is borne through the flare of the tibial metaphysis near the top of the pros-thesis. This amputation is indicated in trauma,gangrene, and infection and has also been successfully used in patients with congenitallimb deformities and deficiencies such as fibular hemimelia, proximal focal femoral defi-

7. The anterior tibial and peroneus brevistendons are transferred into the neck of thetalus and the anterior process of the calca-neus, respectively (Fig. 24–22E).

8. A soft compression dressing is applied, fol-lowed by either well-molded splints or apostoperative cast to hold the ankle in aslightly dorsiflexed position.

Postoperative Care

The patient is maintained in a postoperativesplint or cast that is changed intermittently tomonitor wound healing. Sutures are removed 4to 8 weeks after surgery depending on woundhealing. Early suture removal should he avoidedto prevent wound dehiscence. The patient iskept non–weight bearing during the healingprocess. An AFO with a built-in molded insoleis fitted after completion of healing to stabilizethe ankle joint and to assist with ambulation by providing a rigid level within the shoe for progression of weight transfer from heel to toe.The distal part of the foot plate of the AFOshould have a filler attached of molded foammaterial to hold the residual foot and preventcollapse of the distal part of the shoe. The shoeshould be modified to have a rigid sole with a roller or rocker plantar surface in order toreduce pressure on the distal surface of thestump.


The primary surgical pitfall in the Chopart ampu-tation is failure to fashion the flaps properly forcoverage. Although it is seldom a problem touse irregular flaps or flaps based to one side (asa result of the limited available tissue), theproblem is that this proximal part of the foot has a wide cross-sectional area. The length ofthe flaps must be proportionate to cover this,and the surgeon can easily err in making thisjudgment.

The primary technical error is failure to rebal-ance the extensor tendons by transferring theanterior tibial and peroneus brevis tendons intothe hindfoot.

The primary complication is the developmentof an equinus contracture leading to recalcitrantulcerations and osteomyelitis. As with otheramputations, poor soft tissue healing is theother major complication.


B C

DA

Figure 24–23 Technique for Syme’s amputation. A, Incisions for Syme’s amputation. The two incisions connect points at 1 cmanterior and 1 cm distal to the tip of each malleolus. B, Incision is carried directly to the bone; subperiosteal dissection of theos calcis is begun. C, Bone hook in the talus for traction. Subperiosteal dissection to the os calcis continues, and the top of theos calcis is dissected. A bone hook in the talus aids in peeling the os calcis out of the soft tissue envelope. D, Skin closure withnylon or other nonabsorbable suture. Note closed incision with dog-ears and a good base of the posterior skin.

ciency, and congenital pseudarthrosis of thetibia.1,16,22,25

The literature reflects that Syme’s amputationcan be done in one or two stages.45 There islittle difference except for a slight shift in theposition of the initial skin incisions 1.5 cm moredistally and anteriorly in the two-stage proce-dure in order to cover the malleoli, which are notresected in the first stage. At this time, mostauthors and surgeons who are experienced inthis technique almost exclusively do Syme’samputation in one stage. Little evidence existsat this time to demonstrate an advantage or aneed for the delayed resection of the malleoli.In the one-stage procedure, the malleoli are cutat the time of the amputation.

The malleoli should not be resected in chil-dren unless severe pressure problems arise, andthen they should be resected below the physealline.

Surgical Technique

1. The anterior incision is along a line that con-nects two points placed 1 to 1.5 cm belowand 1 to 1.5 cm anterior to the midpoint ofthe tip of each malleolus. The two malleo-lar points are then connected by an incision

across the sole and perpendicular to itsplane (Fig. 24–23A and video clip 3).

2. The plantar incision is carried all the way down to bone (i.e., down to the calcaneus).

3. The dorsal incision is carried down to thedome of the talus.

4. The anterior tendons are pulled down witha clamp and divided so that they retract.The anterior tibial artery is ligated or electrocoagulated.

5. The collateral ligament attachments on thetalus are divided by alternating back andforth medially to laterally while pulling thetalus forward and down (Fig. 24–23B).

6. Great care is taken to avoid the neurovas-cular bundle on the medial side. This is oneof the two critical points of the procedure,as was well described by Syme. The bundlelies between the flexor hallucis longus andflexor digitorum longus tendons and can beaccidentally severed. The guide is the flexordigitorum longus tendon because thebundle lies just behind it (Fig. 24–23B).

7. Once the bone is seen, blunt dissection isused (e.g., with a broad Key elevator) toseparate the bone from the entire soft tissueenvelope.


8. A bone hook in the talus assists in the dis-section by applying traction to the interfaceof bone and soft tissue as the calcaneus isdissected out (Fig. 24–23C).

9. This is the second major danger point in theprocedure: the subcutaneous attachment ofthe Achilles tendon. Penetrating or button-holing through the skin at this point usuallydooms the procedure and leads to failure ofthe Syme stump because of damage to theheel pad. The alternating use of sharp andblunt dissection with scalpel and periostealelevator works best (Fig. 24–23C). Thisportion of the procedure is responsible formaking Syme’s procedure the most techni-cally difficult foot amputation.

10. The subperiosteal dissection alternatesfrom above at the Achilles tendon and fromthe undersurface and sides of the calcaneusuntil the bone is free from the soft tissue.This leaves the hollow of the stump readyfor final shaping and closure. The bundlewithin the flap is avoided so as not todamage the blood supply to the heel pad.

11. Before performing the closure, the malleoliare cut off flush with the level of the tibialplafond with a saw or with osteotomes.

12. It is not necessary to remove the cartilagefrom the distal end of the tibia. If the padappears to be too mobile at closure, addi-tional tissue should be resected from thedistal (plantar) edge of the heel pad.

13. Stabilization of the stump can be accom-plished using one or several methods. Thedeep layer of the plantar pad (the plantarfascia included) can be sutured to the anterior edge of the tibia. Alternatively, the plantar fascia can be sutured to thedeep fascia over the anterior tibia. Tenodesis of the Achilles tendon has beendescribed.42

14. The closure is done in layers over a suctiondrain that is brought out proximally througha separate tiny stab wound (Fig. 24–23D).

15. The skin is closed with nylon sutures.16. A bulky, soft dressing is applied, usually fol-

lowed with a cast.

Postoperative Care

A cast is usually applied to protect the stumpand leg. If the patient is diabetic, non–weight- Figure 24–24 Note medial and lateral dog-ears. The dog-

ears can be excised with an ellipse of skin and soft tissue.

bearing ambulation is maintained for 6 weeks.Earlier ambulation in the cast can sometimes beallowed in nondiabetic patients, depending onthe progression of wound healing.

Although resection of the malleoli to the levelof the tibial plafond is required, narrowing themedial–lateral flare of the tibial metaphysis is contraindicated. The flare is required to give a wider base to the bulbous stump. Theflare is the main structure that holds the prosthesis on and keeps it from slipping up and down.

In a two-stage procedure done for infectedcases, the second stage is performed about 6weeks after the initial amputation, provided thatsatisfactory healing has occurred. At the secondstage the dog-ears of soft tissue are reducedmedially and laterally and the malleoli areresected through these elliptic incisions (Fig.24–24). Care must be taken not to excessivelyresect the dog-ears so as not to damage theblood supply to the pad. However, this is not ascritical as in a one-stage procedure, because thissecond stage is not done until the primarysuture line is totally healed.

The reported success rate of Syme’s amputa-tions has varied from 50% to 90%.17,26,31,44,45 Atthis time, most centers report about a 70%success rate for healing of Syme’s amputationsin diabetic and dysvascular patients. The vastmajority of failures in this population occur early


Figure 24–27 One type of Syme’s prosthesis using a wrap-around Plastizote sleeve for the narrow part of the leg abovethe distal bulb.

as the result of failure to achieve primary woundhealing, usually because of vascular insufficiencyof the heel pad, which is supplied by branchesof the posterior tibial artery (Fig. 24–25).

Late failure of Syme’s amputation usuallyresults from peripheral vascular disease that pro-gresses to gangrenous changes of the entirelower-limb segment rather than from mechani-cal complications inherent within the Syme’sstump. However, some patients can developpressure lesions over the distal bony promi-nences that can lead to proximal revision. Mobil-ity of the stump can lead to pressure areas overthe distal fibula or tibia (Fig. 24–26). The treat-ment is resection of the fibula more proximally,or smoothing the tibial edge, and, in a neuro-pathic patient, debridement or resection of theulcer as well. As with all neuropathic ulcerations,measures are taken to resect enough bone torelieve pressure and tension on the skin and todebride the soft tissue.

An experienced prosthetist must fit the pros-thesis on the Syme stump. The challenge is thata snug fit is required but the wide, bulbous endof the stump must pass through a very narrowportion of the prosthesis corresponding to the

width of the distal end of the tibia. This fittingproblem has been handled in several differentways, including placing a hinged window in theprosthesis, placing a wraparound filler abovethe bulb (Fig. 24–27), and using an elastic

Figure 24–25 Failed Syme’s amputation due to early gan-grene and failure of soft tissue to heal. This was revised to abelow-knee amputation.

Figure 24–26 Ulceration over the distal portion of the fibuladue to stump mobility 6 years after a Syme’s amputation. Theulcer healed after resection of the bony prominence.


A BFigure 24–28 This patient has the absolute contraindication for a Syme’s amputation: soft tissue breakdown over the heel. A, Lateral view. B, Plantar view.

double-wall construction for the distal part ofthe prosthesis. The best method is the one withwhich the prosthetist is most familiar and expe-rienced. A disadvantage of Syme’s amputationcompared with a below-knee amputation is that the cosmesis of a Syme stump is re-duced because of the wide ankle portion of the prosthesis.

In many other ways, the Syme’s prosthesis ispreferable to a below-knee amputation. TheSyme’s stump is partially end bearing and hasfewer problems with skin breakdown over theproximal portion of the leg. The mechanicaladvantage of a full lower-leg segment is enor-mous and gives great leverage to the quadri-ceps. Even more important, patients with Syme’samputation need minimal prosthetic trainingcompared to patients with a below-knee ampu-tation, because functionally the Syme’s proce-dure is a partial foot amputation, and walking inthe prosthesis is similar to walking in a cast,which most of the patients have used previously.Syme’s amputation is functionally superior toproximal procedures such as below-knee andabove-knee amputations as demonstrated bystudies showing lower energy cost (oxygen con-sumption per meter) and higher gait velocityand stride length.47


The most common complication of the Syme’sprocedure in diabetic and dysvascular patientsis a failure of healing. Some of these complica-tions cannot be prevented if the goal of sal-

vaging as much of the limb as possible is to bepursued.

The second most common problem with thisprocedure is mobility and displacement of thesoft tissue stump. This is addressed through cau-tious resection of excess soft tissue and by sta-bilizing the stump.

Aggressive resection of the dog-ears on themedial and lateral corners of the stump is apitfall that results in a dangerously narrowedbase to the heel flap. This can reduce the per-fusion of the distal pad of the stump and causethe procedure to fail. It is best to leave thisexcess medial and lateral soft tissue, because itwill shrink as the wound heals and the patientassumes use of a prosthesis.

In Syme’s amputations done for trauma, amoderate number of failures are caused by painof two types. The first cause is neuroma forma-tion at or above the level of the ankle joint, wherethe major nerves have been transected. Selectiveinjection is helpful in diagnosis before surgicalexcision or burying of the neuromas. The secondcause is recalcitrant heel pain, seen in patientswho have sustained crushing trauma to the heeland hindfoot at the original accident, most ofwhich is industrial in nature. These may need tobe revised to a long below-knee amputation.

The absolute contraindication to the use of aSyme’s amputation in any patient is the lack ofan intact and viable heel pad. Patients withulceration or even small gangrenous spots onthe heel are not candidates for this procedureand should have a below-knee amputationinstead (Fig. 24–28A and B).


Pirogoff’samputation

Os calcis

Lines of boneresection

Figure 24–29 Technique for Pirogoff’s amputation.

BELOW-KNEE AMPUTATIONS

Below-knee amputations are sometimes thenecessary treatment when foot salvage amputa-tions fail. When a below-knee amputation isdone for foot disease, consideration should begiven to the level of the below-knee resection.The ideal below-knee stump is a minimum of 15 cm (about 6 inches) below the level of theknee joint. Although a slightly longer or shorterstump can be used, variations in length must betaken into consideration in working with theprosthetist in the postoperative manufacture ofthe below-knee prosthesis. Longer below-kneestumps can afford a longer lever and thusgreater power to the musculature about theknee. Longer stumps are favored by me andother authors when a longer stump is appropri-ate to the tissue healing of an individualpatient.40

The amputation stump can be closed with alonger posterior flap or with side-to-side flaps.A long posterior flap is easiest and most pre-dictable because it provides excellent distalpadding under the resected end of the tibia.Proper shaping of the flaps for a posterior flapclosure is usually overlooked. Most surgeonslearn as interns to cut a square posterior flap.This is easy to remember but leads to a stumpwith large dog-ears on both sides that fits poorlywithin a temporary prosthesis. This slows bothhealing and rehabilitation. If surgical techniqueis deemed important to the patient’s outcomein other forms of surgical reconstruction, thisshould be no exception.

The technique for proper shaping of the stumpis subtle but simple. Shaping is important becauseit allows the surgeon to make an amputationstump that is tapered. This allows earlier pros-thetic fitting because less shrinkage of the stumpis necessary. The healing of soft tissue is enhancedas well because the skin edges come togetherbetter. The key is to shape the posterior flap tocorrespond to the cross-sectional shape of thelimb. This requires rounding the flaps. Moreimportantly, it requires tapering the flap bymaking the midportion of the flap widest to cor-respond to the diameter of the leg and makingthe distal part of the flap narrow to correspond tothe anterior width of the limb (Fig. 24–30).

Pirogoff’s amputation is a variation on theSyme procedure in which varying amounts ofthe tubercle of the calcaneus are preserved andthen internally fixed to the distal cut end of thetibia (Fig. 24–29). Longer soft tissue flaps arerequired. The purported advantage of this pro-cedure is its longer length because Syme’samputation results in mild shortening, althoughthat can be accommodated in the prosthesis.Pirogoff’s procedure obviates the technical diffi-culty of dissecting the Achilles tendon off thecalcaneus. However, fixation of the calcanealtubercle to the distal tibia has its own technicaldifficulties, as well as the risk of symptomaticnonunion. It is not widely practiced in the UnitedStates at this time.


SUMMARY

Although amputation of the foot is an unfortunatenecessity for some patients, attention to detail, both indiagnostic evaluation and in surgical technique,improves the surgeon’s ability to assist patients suc-cessfully in this major step toward rehabilitation offunction and ambulation.

All photographs in this chapter are copyrighted by James W.Brodsky, MD.

REFERENCES

1. Anderson L, Westin GW, Oppenheim WL: Syme amputation inchildren: Indications, results, and long-term follow-up. J PediatrOrthop 4:550-554, 1984.

2. Anderson RB, Foster MD, Gould JS, et al: Free tissue transfer andcalcanectomy as treatment of chronic osteomyelitis of the oscalcis: A case report. Foot Ankle 11:168-171, 1990.

3. Apelqvist J, Castenfors J, J L, et al: Prognostic value of systolicankle and of blood pressure levels in outcome of diabetic footulcer. Diabetes Care 12:373-378, 1989.

4. Armstrong DG, Hadi S, Nguyen HC, et al: Factors associatedwith bone regrowth following diabetes-related partial amputa-tion of the foot. J Bone Joint Surg Am 81:1561-1565, 1999.

5. Biehl WC 3rd, Morgan JM, Wagner FW Jr, et al: The safety of theEsmarch tourniquet. Foot Ankle 14:278-283, 1993.

6. Brodsky JW: Amputations of the foot and ankle. In Mann RA,Coughlin MJ (eds): Surgery of the Foot and Ankle, ed 6. St. Louis,Mosby, 1993.

7. Burgess EM, Marsden FW: Major lower extremity amputationsfollowing arterial reconstruction. Arch Surg 108:655-660, 1974.

8. Chang BB, Bock DE, Jacobs RL, et al: Increased limb salvage bythe use of unconventional foot amputations. J Vasc Surg 19:341-348; discussion 348-349, 1994.

AI

BI

B

A

LEG

FLAP

Level and shape of tibial resection

Skin incisions for a tapered BKA stump

Figure 24–30 A long below-knee amputation (BKA) has mechanical advantages and is often possible when done for footdisease that does not extend above the ankle. Lines A and A! and B and B! are, respectively, the matching widths of the leg andof the posterior flap that produce a tapered BKA stump. A square posterior flap always produces dog-ears, which slow theshaping of the BKA stump for fitting the first prosthesis.


9. Christie J, Clowes CB, Lamb DW: Amputations through themiddle part of the foot. J Bone Joint Surg Br 62:473-474, 1980.

10. Clare MP, Fitzgibbons TC, McMullen ST, et al: Experience withthe vacuum assisted closure negative pressure technique in thetreatment of non-healing diabetic and dysvascular wounds. FootAnkle Int 23:896-901, 2002.

11. Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed7. St. Louis, Mosby, 1999.

12. Crandall RC, Wagner FW, Jr.: Partial and total calcanectomy: Areview of thirty-one consecutive cases over a ten-year period. JBone Joint Surg Am 63:152-155, 1981.

13. Dickhaut SC, DeLee JC, Page CP: Nutritional status: Importancein predicting wound-healing after amputation. J Bone Joint SurgAm 66:71-75, 1984.

14. Due TM, Jacobs RL: Molded foot orthosis after great toe ormedial ray amputations in diabetic feet. Foot Ankle 6:150-152,1985.

15. Eginton MT, Brown KR, Seabrook GR, et al: A prospective ran-domized evaluation of negative-pressure wound dressings fordiabetic foot wounds. Ann Vasc Surg 17:645-649, 2003.

16. Fergusson CM, Morrison JD, Kenwright J: Leg-length inequalityin children treated by Syme’s amputation. J Bone Joint Surg Br69:433-436, 1987.

17. Francis H 3rd, Roberts JR, Clagett GP, et al: The Syme amputa-tion: Success in elderly diabetic patients with palpable anklepulses. J Vasc Surg 12:237-240, 1990.

18. Giacalone VF, Gregory JL, Krych SM: Calcanectomy for the treat-ment of calcaneal osteomyelitis. A case report. J Am Podiatr MedAssoc 81:88-92, 1991.

19. Goldner MG: The fate of the second leg in the diabetic amputee.Diabetes 9:100-103, 1960.

20. Harris RI: Syme’s amputation; the technical details essential forsuccess. J Bone Joint Surg Br 38:614-632, 1956.

21. Harris WR, Silverstein EA: Partial amputations of the foot: Afollow-up study. Can J Surg 41:6-11, 1964.

22. Herring JA, Barnhill B, Gaffney C: Syme amputation. An evalu-ation of the physical and psychological function in youngpatients. J Bone Joint Surg Am 68:573-578, 1986.

23. Hodge MJ, Peters TG, Efird WG: Amputation of the distalportion of the foot. South Med J 82:1138-1142, 1989.

24. Isenberg JS, Costigan WM, Thordarson DB: Subtotal calcanec-tomy for osteomyelitis of the os calcis: A reasonable alternativeto free tissue transfer. Ann Plast Surg 35:660-663, 1995.

25. Jacobsen ST, Crawford AH, Millar EA, et al: The Syme amputa-tion in patients with congenital pseudarthrosis of the tibia. JBone Joint Surg Am 65:533-537, 1983.

26. Jany RS, Burkus JK: Long-term follow-up of Syme amputationsfor peripheral vascular disease associated with diabetes melli-tus. Foot Ankle 9:107-110, 1988.

27. Larsson U, Andersson GB: Partial amputation of the foot for dia-betic or arteriosclerotic gangrene. Results and factors of prog-nostic value. J Bone Joint Surg Br 60:126-130, 1978.

28. Lieberman JR, Jacobs RL, Goldstock L, et al: Chopart amputa-tion with percutaneous heel cord lengthening. Clin Orthop RelatRes 296:86-91, 1993.

29. Mann RA, Coughlin MJ (eds): Surgery of the Foot and Ankle, ed6. St. Louis, Mosby, 1993.

30. McCallon SK, Knight CA, Valiulus JP, et al: Vacuum-assistedclosure versus saline-moistened gauze in the healing of post-

operative diabetic foot wounds. Ostomy Wound Manage 46:28-32, 34, 2000.

31. McElwain JP, Hunter GA, English E: Syme’s amputation inadults: A long-term review. Can J Surg 28:203-205, 1985.

32. McKittrick LS, McKittrick JB, Risley TS: Transmetatarsal ampu-tation for infection or gangrene in patients with diabetes mel-litus. J Am Podiatr Med Assoc 83:62-78, 1949.

33. Millstein SG, McCowan SA, Hunter GA: Traumatic partial footamputations in adults. A long-term review. J Bone Joint Surg Br70:251-254, 1988.

34. Moore WS: Determination of amputation level. Measurementof skin blood flow with xenon Xe 133. Arch Surg 107:798-802,1973.

35. Mueller MJ, Sinacore DR, Hastings MK, et al: Effect of Achilles tendon lengthening on neuropathic plantar ulcers. Arandomized clinical trial. J Bone Joint Surg Am 85:1436-1445,2003.

36. Nakhgevany KB, Rhoads JE, Jr.: Ankle-level amputation. Surgery95:549-552, 1984.

37. Oishi CS, Fronek A, Golbranson FL: The role of non-invasivevascular studies in determining levels of amputation. J Bone JointSurg Am 70:1520-1530, 1988.

38. Roach JJ, Deutsch A, McFarlane DS: Resurrection of the ampu-tations of Lisfranc and Chopart for diabetic gangrene. Arch Surg122:931-934, 1987.

39. Saltzman CL: Salvage of diffuse ankle osteomyelitis by single-stage resection and circumferential frame compressionarthrodesis. Iowa Orthop J 25:47-52, 2005.

40. Smith DG: Principles of partial foot amputations in the diabetic.Instr Course Lect 48:321-329, 1999.

41. Smith DG, Boyko EJ, Ahroni JH, et al: Paradoxical transcuta-neous oxygen response to cutaneous warming on the plantarfoot surface: A caution for interpretation of plantar foot TcPO2

measurements. Foot Ankle Int 16:787-791, 1995.42. Smith DG, Sangeorzan BJ, Hansen ST Jr, et al: Achilles tendon

tenodesis to prevent heel pad migration in the Syme’s amputa-tion. Foot Ankle Int 15:14-17, 1994.

43. Smith DG, Stuck RM, Ketner L, et al: Partial calcanectomy forthe treatment of large ulcerations of the heel and calcanealosteomyelitis. An amputation of the back of the foot. J Bone JointSurg Am 74:571-576, 1992.

44. Spittler AW, Brennan JJ, Payne JW: Syme amputation performedin two stages. J Bone Joint Surg Am 36:37-42; passim, 1954.

45. Wagner F: The diabetic foot and amputations of the foot. InMann R (ed): Surgery of the Foot. St. Louis, Mosby–Year Book,1986.

46. Wagner FW, Jr: Amputations of the foot and ankle. Currentstatus. Clin Orthop Relat Res Jan-Feb(122):62-69, 1977.

47. Waters RL, Perry J, Antonelli D, et al: Energy cost of walking ofamputees: The influence of level of amputation. J Bone Joint SurgAm 58:42-46, 1976.

48. Weisenfeld LS, Flannery D, Luzzi A, et al: Partial calcanectomyfor the treatment of osteomyelitis of the os calcis. J Foot Surg29:226-230, 1990.

49. Woll TS, Beals RK: Partial calcanectomy for the treatment ofosteomyelitis of the calcaneus. Foot Ankle 12:31-34, 1991.

50. Wyss CR, Harrington RM, Burgess EM, et al: Transcutaneousoxygen tension as a predictor of success after an amputation. JBone Joint Surg Am 70:203-207, 1988.

24.amputations of the foot and ankle

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