Anthony J. Cavallo, DPM Sentara Podiatry Specialists 4/27/2018. Lose a toe, Save a Limb: The Value of Complex Foot Reconstructions
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1 Anthony J. Cavallo, DPM Sentara Podiatry Specialists 4/27/2018 Lose a toe, Save a Limb: The Value of Complex Foot Reconstructions
2 Objectives Review the morbidity and mortality associated with amputation Discuss important anatomic considerations and the effects on function following amputation Discuss long-term salvage rates with various amputation levels Presenter name Identify indications for complex reconstruction and its role in limb salvage
3 Who gets amputations? Epidemiology Overwhelming majority due to sequelae of diabetes and peripheral vascular disease 9.4% (30.3 million Americans) have diabetes from 2015 ADA data Diabetes accounts for 63-69% of amputations performed in the US Presenter name Smith, DG. Amputation. Preoperative assessment and lower extremity surgical techniques. Foot and ankle clinics 6(2): , 2001.
4 Presenter name
5 Amputation Terminology Commonly Performed Pedal Amputations Toe Amputation Ray Amputation Midfoot Amputations (TMA and LisFranc) Chopart s Amputation Presenter name
6 Toe Amputation Presenter name Boffeli, TJ and Gossm MS. Distal syme amputation for tip of toe wounds and gangrene complicated by osteomyelitis of the distal phalanx: surgical technique and outcome in consecutive cases. Journal of foot and ankle surgery 56: 2-6, December 2017.
7 Presenter name Boffeli, TJ and Gossm MS. Distal syme amputation for tip of toe wounds and gangrene complicated by osteomyelitis of the distal phalanx: surgical technique and outcome in consecutive cases. Journal of foot and ankle surgery 56: 2-6, December 2017.
8 Smith, DG. Amputation. Preoperative Presenter assessment name and lower extremity surgical techniques. Foot and ankle clinics 6(2): , 2001.
9 Presenter name Smith, DG. Amputation. Preoperative assessment and lower extremity surgical techniques. Foot and ankle clinics 6(2): , 2001.
10 11 year review of 59 partial first ray amputations 69% developed mean of 3.1 subsequent foot ulcerations at a mean of 10.5 months 36% required ancillary surgical procedures Presenter name
11 Presenter name
12 Transmetatarsal Amputation (TMA) Presenter name Smith, DG. Amputation. Preoperative assessment and lower extremity surgical techniques. Foot and ankle clinics 6(2): , 2001.
13 Transmetatarsal Amputation Presenter name
14 Presenter name
15 Presenter name
16 Presenter name
17 Presenter name
18 Presenter name
19 Presenter name
20 Presenter name
21 LisFranc/Chopart s Amputations Lose attachment of peroneus brevis and tibialis anterior, causes imbalance within foot and equinovarus deformity from gastroc-soleal complex and PT tendon Presenter name Smith, DG. Amputation. Preoperative assessment and lower extremity surgical techniques. Foot and ankle clinics 6(2): , 2001.
22 Prospective study of 32 amputations for foot gangrene 24 LisFranc, 8 Chopart s 8 patients (27%) with non-healing stump 4 BKA, 2 AKA required 3-28 months later Functional ambulation achieved in 20/30 (67%) of patients at 6 months Presenter name Elsharawy, MA. Outcome of midfoot amputations in diabetic gangrene. Ann Vasc Surg 25: , 2011.
23 Presenter name DeGere, MW and Grady, JF. A modifcation of chopart s amputation with ankle and subtalar arthrodesis by using an intramedullary nail. Journal of foot and ankle surgery 44(4): , 2005.
24 Mortality of Amputations Approximately 40% at 1 year, 80% at 5 years Despite the development and more widespread availability of new diagnostic procedures and peripheral vascular interventions, the rates of amputation and subsequent survival have remained relatively unchanged over the last few decades Presenter name Wrobel,JS et al. The high-low amputation ratio: A deeper insight into diabetic foot care? The journal of foot and ankle surgery 45(6): , Feinglass J, Pearce WH, Martin GJ, et al. Postoperative and late survival outcomes after major amputation: findings from the Department of Veterans Affairs national surgical quality improvement program. Surgery 2001; 130: 21-9.
25 198 amputations (91 AKA, 107 BKA, 10 bilateral) Overall mortality (AKA + BKA) 30 day: 16.7% 1 year: 44% 1 year mortality: 58% AKA versus 33% BKA AKA with higher cardiovascular complication rate 33.7% AKA versus 18.8% BKA Presenter name Rosen, N, et al. Mortality and reoperation following lower limb amputation. IMAJ 16: 83-87, 2014.
26 Summary Unfortunately, the rate of amputation and mortality remain relatively unchanged over the past few decades Energy expenditure during ambulation and muscle imbalance increase with the more proximal amputation that is performed Losing all toes in certain circumstances can provide a highly functional result and long term limb preservation Presenter name Complex reconstruction in the form of amputations, tissue transfers, tendon balancing, or osseous procedures play integral roles in efforts to preserve function and salvage limb
27 References Boffeli, TJ and Gossm, MS. Distal syme amputation for tip of toe wounds and gangrene complicated by osteomyelitis of the distal phalanx: surgical technique and outcome in consecutive cases. Journal of foot and ankle surgery 2-6, December Borkosky, SL and Roukis, TS. Incidence of repeat amputation after partial first ray amputation associated with diabetes mellitus and peripheral neuropathy: An 11-Year Review. Journal of foot and ankle surgery 52: , DeGere, MW and Grady, JF. A modifcation of chopart s amputation with ankle and subtalar arthrodesis by using an intramedullary nail. Journal of foot and ankle surgery 44(4): , Elsharawy, MA. Outcome of midfoot amputations in diabetic gangrene. Ann Vasc Surg 25: , Feinglass J, Pearce WH, Martin GJ, et al. Postoperative and late survival outcomes after major amputation: findings from the Department of Veterans Affairs national surgical quality improvement program. Surgery 130:21-29, Presenter name Murdoch, DP et al. The natural history of great toe amputations. Journal of foot and ankle surgery 36(3): , Rosen, N, et al. Mortality and reoperation following lower limb amputation. IMAJ 16: 83-87, Smith, DG. Amputation. Preoperative assessment and lower extremity surgical techniques. Foot and ankle clinics 6(2): , Wrobel, JS et al. The high-low amputation ratio: A deeper insight into diabetic foot care? The journal of foot and ankle surgery 45(6): , 2006.
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