Increased limb salvage by the use of unconventional foot amputations

Abstract

Limb salvage in the presence of ischemic foot necrosis requires revascularization followed by debridement or partial foot amputation. Necrosis extending beyond the toes and metatarsal heads may require the use of unconventional types of amputations. Methods: Over a 15-year period 2105 ischemic limbs were treated with infrainguinal revascularization. In 98 cases, extensive foot necrosis was then managed with amputations, including 59 modified Chopart, 14 Lisfranc, 17 Pirogoff and 8 Syme amputations. Patients were not allowed to bear weight for several days to weeks. Results: Skin flap necrosis in 14 cases was managed successfully by debridement and skin grafting. Ambulation required the use of a "clamshell" prosthesis and foot spacer. The overall limb salvage rate in this group was 84% (82 of 98). In general, the modified Chopart amputation most frequently produced ambulatory limb salvage and is technically easier to perform than a Syme amputation. Patient satisfaction and long-term ambulatory function was highest with the modified Chop art. Conclusions: Ischemic foot necrosis extending beyond the limits of conventional transmetatarsal amputation need not be treated with major amputation. This requires the surgeon to be well versed in the use of less common types of partial foot amputations. Acceptable limb salvage and good functional results may be attained by the motivated patient and surgeon with the use of these procedures in the revascularized limb.

Factors Associated With Successful Chopart Amputation in Patients With Diabetes

“…" information for inclusion even after contacting the authors for missing information. 6,[40][41][42] Three of the 4 references did not clearly state if the patients who underwent a Chopart amputation had a diagnosis of diabetes. 6,40,41 Two of the 4 references did not state the postoperative follow-up time.…”

“…6,[40][41][42] Three of the 4 references did not clearly state if the patients who underwent a Chopart amputation had a diagnosis of diabetes. 6,40,41 Two of the 4 references did not state the postoperative follow-up time. 40,41 One of the references also did not report if the patients returned to ambulation postoperatively in a prosthetic device or if any complications occurred.…”

“…3,4 Chopart amputations fell into disrepute because of the development of distal ulceration that occurred secondary to the equinovarus contracture that developed from the loss of the tendinous insertions of all antagonists of the superficial and deep posterior muscle compartments. 1,[5][6][7][8][9][10][11][12] As a result, since the 1920s, various tendinous and osseous surgical balancing techniques have been described as adjunctive procedures to prevent or treat equinovarus contracture following Chopart amputations. [13][14][15][16][17][18][19][20][21][22][23][24] In addition to the musculoskeletal contractures, shoeing of the residual limb was difficult as loss of the midfoot and forefoot did not allow for return to normal shoe gear without some form of bracing that involved the lower leg.…”

Pantalar fusion for correction of painful equinus after traumatic Chopart's amputation–a report of 2 cases

“…This shortening makes barefoot walking difficult. Burgess (1966) and Chang et al (1994) also suggested an achilles tenotomy to improve balance. Our alternative method, consisting of fusion of the talus both to the tibia and the calcaneus with a simultaneous correction of the equinus and varus contracture, preserves leg length for better barefoot walking and creates stability of shape inside a prosthetic socket.…”

Nikolay Ivanovich Pirogoff (1810–1881)

“…The main advantage of Pirogoff's amputation is its excellent weightbearing without prosthesis, and recent data (Nakhgevany and Rhoads, 1984;Ham et al, 1992;Rijken and Raaymakers, 1995) indicate good long term outcomes. Pirogoff himself described the surgical procedure thus: "the tuberosity of the calcaneus remaining in the posterior flap can extend to the end of the bones of the leg, and by doing this, the leg is lengthened by at least 1 1 ⁄3 inches and it can serve as the most important point of weight bearing since it is almost on the same plane with the sole of the healthy foot" (Chang et al, 1994).…”