Amputations of the Foot and Ankle

Amputations of the Foot and Ankle

Maria Romano McGann, DO

Bryan Van Dyke, DO

G. Alex Simpson, DO

Terrence M. Philbin, DO

Dr. Philbin or an immediate family member has received royalties from Arthrex, Inc., Biomet, Crossroads, Paragon 28, and Wright Medical Technology, Inc.; is a member of a speakers’ bureau or has made paid presentations on behalf of Arthrex, Inc., Crossroads, DJ Orthopaedics, Medline, Tissue Tech, and Zimmer Biomet; serves as a paid consultant to or is an employee of Artelon, Arthrex, Inc., Crossroads, DJ Orthopaedics, Medline, Tissue Tech, and Zimmer Biomet; has stock or stock options held in Tissue Tech; has received research or institutional support from Biomimetic and DJ Orthopaedics; and serves as a board member, owner, officer, or committee member of the American Osteopathic Academy of Orthopedics. None of the following authors or any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this chapter: Dr. McGann, Dr. Van Dyke, and Dr. Simpson.


Amputations of the foot and ankle are procedures that have been described for centuries. Amputations can be thought of as a function-restoring procedure, as they are usually indicated once a limb is deemed nonfunctioning or nonviable. In the United States, common reasons for foot and ankle amputations include complications that result from diabetes and vascular disease. More than 60% of nontraumatic lower limb amputations occur in people with diabetes, while only approximately 3% of patients with symptomatic peripheral artery disease require.1,2 Other reasons for amputation of the foot and ankle include severe trauma, chronic pain infection, congenital abnormality, and malignancy.

Amputations are deemed a reconstructive procedure that will assist the patient in locomotion and sensory feedback.3 Treatment by means of amputation should be considered the first step in a patient’s rehabilitation, not as a failure of treatment.4 The goals of all amputations are to heal the wound, avoid further infections, and return a patient to a preamputation ambulatory level. Furthermore, goals include adequate balancing of the remaining muscles to avoid contractures and retain residual limb control.5 Amputations of the foot and ankle range from simple phalangeal amputations to those of the midfoot, hindfoot, ankle disarticulations, and transtibial amputations. Those amputations of the midfoot and hindfoot may preserve the ability for ambulation, which may decrease patient morbidity.6

A well-organized, multidisciplinary team must care for patients undergoing major amputations. The surgeon performing the amputation must be well versed in the surgical technique, postoperative treatment of patients, and the knowledge of prosthetics and footwear modification.

Preoperative Management

Patients in need of an amputation commonly have medical comorbidities, such as diabetes and vascular disease. A thorough preoperative evaluation of the extremity’s color, temperature, pulses, sensation, and tissue quality should be performed to give the patient the best chance for a good
outcome. Radiographs and advanced imaging studies are ordered to evaluate bony structure and determine the extent of any underlying osteomyelitis. Evaluation should also include their functional ability, social environment, nutritional and immune status, and mental state. Preoperative evaluation, including laboratory and vascular studies can aid in determining the potential wound healing of patients undergoing amputation. Predictors of wound healing include serum albumin level, total lymphocyte count, transcutaneous oxygen pressures, and ankle brachial indices.7,8

Every patient must have a good rapport with their medical specialists including an orthopedic surgeon, vascular surgeon, medical doctor, therapists, social worker, physiatrist, and mental health professional. A psychiatric evaluation is an important preoperative tool, as an amputation can be a major life-changing event.9

Level of Amputation

The ultimate goal of an amputation is to restore function to the residual limb, all while maintaining the greatest residual limb length in hopes of returning a patient’s maximum function.32 Furthermore, patient mobility and functional independence should be maintained. The level of amputation will affect how much energy is exhausted by the patient, so maintaining length, whenever possible, is important.32,33 The overall length of the residual limb is affected by the preoperative condition of the limb, associated pathology, and general intraoperative findings. Coverage of residual osseous structures is important to prevent tissue breakdown; therefore it is important to maintain thick myocutaneous flap coverage. In instances of blast trauma, the residual tissue available for wound closure greatly affects the level of amputation.34

Amputations may either be through a joint, disarticulation, or through bone, transosseous. Disarticulations are end bearing, in that loads are directly transmitted through the joint surface and metaphyseal bone. Alternatively, transosseous amputations have a smaller residual cross-sectional area, through which the weight is transferred indirectly. In transosseous amputations, load transfer is through the entire limb via a total contact prosthesis.35

In adults, the energy required for ambulation is drastically different depending upon which level of amputation is performed. As the amputation level becomes more proximal, an increased amount of energy is required to ambulate. Alternatively, recent studies have shown that in children having undergone a Syme, transtibial, or bilateral below-the-knee amputation, no increase was documented in their energy cost of walking, no significant gait difference or function, and they walk at similar speeds compared with their peers.36,37

Types of Amputations

Toe Amputations

Great Toe Amputations

This amputation is indicated in cases where there is pathology of the distal aspect of the hallux or chronic conditions of the nail plate. The benefits of this amputation over a disarticulation of the metatarsal phalangeal joint include maintenance of the plantar flexion mechanism of the first ray. Also, some preservation of the weight-bearing function of the hallux exists, which will decrease the transfer stress of the adjacent rays. When completing this amputation, it is important to save at least 1 cm of the proximal phalangeal base.38

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Feb 27, 2020 | Posted by in ORTHOPEDIC | Comments Off on Amputations of the Foot and Ankle

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