Amputations of the foot can be divided into nonemergency and emergency procedures. Non-emergency amputations allow some flexibility in the creation of skin flaps, selection of level and wound closure. These cases generally include neuropathic feet that are structurally or functionally impaired, with satisfactory circulation and controlled infection. They are characterized by moderate to severe forefoot deformities with associated chronic non-healing ulcers that are recalcitrant to conservative medical and surgical management. In some cases, the presenting deformities are the residua of prior infection, tissue necrosis and chronic non-healing wounds.
Emergency amputations include those performed for gangrene, severe soft tissue infection, osteomyelitis, peripheral vascular disease, tumours or trauma. The main consideration in determining the level of amputation in these cases is the extent of healthy tissue. When infection is the primary issue, an open or guillotine amputation may be necessary. In most cases, adequacy of blood supply to the foot ultimately determines the level at which successful amputation can be performed. Although noninvasive laboratory methods have been proposed for evaluating wound healing potential, clinical experience and judgement are most often relied upon.
Preoperative physical examination should include a quantitative assessment of ankle joint dorsiflexion. Contracture of the Achilles tendon is generally more apparent prior to amputation of the forefoot, and suggests the need for tendon lengthening at the time of amputation. The procedure is performed as necessary, in the presence of equinus or excessive spasticity. In many cases equinovarus deformity is a complication of Lisfranc and Chopart amputations. A longitudinal open procedure or percutaneous approach can be utilized according to the surgeon's preference.
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